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1.
Health Secur ; 18(S1): S105-S112, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32004125

RESUMO

Long-standing cultural, economic, and political relationships among Benin, Nigeria, and Togo contribute to the complexity of their cross-border connectivity. The associated human movement increases the risk of international spread of communicable disease. The Benin and Togo ministries of health and the Nigeria Centre for Disease Control, in collaboration with the Abidjan Lagos Corridor Organization (a 5-country intergovernmental organization) and the US Centers for Disease Control and Prevention, sought to minimize the risk of cross-border outbreaks by defining and implementing procedures for binational and multinational public health collaboration. Through 2 multinational meetings, regular district-level binational meetings, and fieldwork to characterize population movement and connectivity patterns, the countries improved cross-border public health coordination. Across 3 sequential cross-border Lassa fever outbreaks identified in Benin or Togo between February 2017 and March 2019, the 3 countries improved their collection and sharing of patients' cross-border travel histories, shortened the time between case identification and cross-border information sharing, and streamlined multinational coordination during response efforts. Notably, they refined collaborative efforts using lessons learned from the January to March 2018 Benin outbreak, which had a 100% case fatality rate among the 5 laboratory-confirmed cases, 3 of whom migrated from Nigeria across porous borders when ill. Aligning countries' expectations for sharing public health information would assist in reducing the international spread of communicable diseases by facilitating coordinated preparedness and responses strategies. Additionally, these binational and multinational strategies could be made more effective by tailoring them to the unique cultural connections and population movement patterns in the region.

2.
MMWR Morb Mortal Wkly Rep ; 69(1): 10-13, 2020 Jan 10.
Artigo em Inglês | MEDLINE | ID: mdl-31917781

RESUMO

Tailoring communicable disease preparedness and response strategies to unique population movement patterns between an outbreak area and neighboring countries can help limit the international spread of disease. Global recognition of the value of addressing community connectivity in preparedness and response, through field work and visualizing the identified movement patterns, is reflected in the World Health Organization's declaration on July 17, 2019, that the 10th Ebola virus disease (Ebola) outbreak in the Democratic Republic of the Congo (DRC) was a Public Health Emergency of International Concern (1). In March 2019, the Infectious Diseases Institute (IDI), Uganda, in collaboration with the Ministry of Health (MOH) Uganda and CDC, had previously identified areas at increased risk for Ebola importation by facilitating community engagement with participatory mapping to characterize cross-border population connectivity patterns. Multisectoral participants identified 31 locations and associated movement pathways with high levels of connectivity to the Ebola outbreak areas. They described a major shift in the movement pattern between Goma (DRC) and Kisoro (Uganda), mainly through Rwanda, when Rwanda closed the Cyanika ground crossing with Uganda. This closure led some travelers to use a potentially less secure route within DRC. District and national leadership used these results to bolster preparedness at identified points of entry and health care facilities and prioritized locations at high risk further into Uganda, especially markets and transportation hubs, for enhanced preparedness. Strategies to forecast, identify, and rapidly respond to the international spread of disease require adapting to complex, dynamic, multisectoral cross-border population movement, which can be influenced by border control and public health measures of neighboring countries.


Assuntos
Surtos de Doenças , Doença pelo Vírus Ebola/epidemiologia , Migração Humana/estatística & dados numéricos , Participação da Comunidade , República Democrática do Congo/epidemiologia , Surtos de Doenças/prevenção & controle , Doença pelo Vírus Ebola/prevenção & controle , Humanos , Ruanda/epidemiologia , Uganda/epidemiologia
3.
MMWR Morb Mortal Wkly Rep ; 69(1): 14-19, 2020 Jan 10.
Artigo em Inglês | MEDLINE | ID: mdl-31917783

RESUMO

On August 1, 2018, the Democratic Republic of the Congo (DRC) declared its 10th Ebola virus disease (Ebola) outbreak in an area with a high volume of cross-border population movement to and from neighboring countries. The World Health Organization (WHO) designated Rwanda, South Sudan, and Uganda as the highest priority countries for Ebola preparedness because of the high risk for cross-border spread from DRC (1). Countries might base their disease case definitions on global standards; however, historical context and perceived risk often affect why countries modify and adapt definitions over time, moving toward or away from regional harmonization. Discordance in case definitions among countries might reduce the effectiveness of cross-border initiatives during outbreaks with high risk for regional spread. CDC worked with the ministries of health (MOHs) in DRC, Rwanda, South Sudan, and Uganda to collect MOH-approved Ebola case definitions used during the first 6 months of the outbreak to assess concordance (i.e., commonality in category case definitions) among countries. Changes in MOH-approved Ebola case definitions were analyzed, referencing the WHO standard case definition, and concordance among the four countries for Ebola case categories (i.e., community alert, suspected, probable, confirmed, and case contact) was assessed at three dates (2). The number of country-level revisions ranged from two to four, with all countries revising Ebola definitions by February 2019 after a December 2018 peak in incidence in DRC. Case definition complexity increased over time; all countries included more criteria per category than the WHO standard definition did, except for the "case contact" and "confirmed" categories. Low case definition concordance and lack of awareness of regional differences by national-level health officials could reduce effectiveness of cross-border communication and collaboration. Working toward regional harmonization or considering systematic approaches to addressing country-level differences might increase efficiency in cross-border information sharing.


Assuntos
Surtos de Doenças , Doença pelo Vírus Ebola/diagnóstico , Doença pelo Vírus Ebola/epidemiologia , Vigilância em Saúde Pública/métodos , República Democrática do Congo/epidemiologia , Humanos , Ruanda/epidemiologia , Sudão do Sul/epidemiologia , Fatores de Tempo , Uganda/epidemiologia
4.
J Bone Joint Surg Am ; 102(2): 110-118, 2020 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-31644523

RESUMO

BACKGROUND: Increased scrutiny of health-care costs and inpatient length of stay has resulted in many orthopaedic procedures transitioning to outpatient settings. Recent studies have supported the safety and efficiency of outpatient fracture procedures. The aim of the present study was to reduce unnecessary inpatient hospitalizations for healthy patients awaiting surgical treatment of a fracture by 80% by June 30, 2017, with a focus on timely, efficient, and patient-centered care. METHODS: The study design was a time series using statistical process control methodology. Baseline data from October 2014 to June 2016 were compared with the intervention period from July 2016 to December 2018. The Model for Improvement was used as the framework for developing and implementing interventions. The main interventions were a policy change to allow booking of outpatient urgent-room cases, education for patients and nurses, and the development of a standardized outpatient pathway. RESULTS: One hundred and eighty-seven patients during the pre-intervention period and 308 patients during the intervention period were eligible for the ambulatory pathway. The percentage of patients managed as outpatients increased from 1.6% pre-intervention to 89.1% post-intervention. The length of stay was reduced from 2.8 to 0.2 days, a decrease of 94.0%. Patient satisfaction remained high, and there were no safety concerns while patients waited at home for the surgical procedure. CONCLUSIONS: The outpatient fracture pathway vastly improved the efficiency and timeliness of care and reduced health-care costs. A patient-centered culture and support from hospital administration were integral in producing sustainable improvement. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

5.
J Arthroplasty ; 35(2): 364-370, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31732370

RESUMO

BACKGROUND: Total knee arthroplasty (TKA) is the second most common surgery performed in Canada. Understanding and improving quality metrics associated with such high-volume procedures is of utmost importance to maximize value within the healthcare system, which is a balance between cost and quality. Although rates and predictors of hospital readmission and emergency department (ED) visits following TKA have previously been described in privatized healthcare settings, few studies have evaluated trends in length of stay (LOS), hospital readmissions, and ED visits following TKA in a universal single-payer system. METHODS: Using data from a provincially held and validated registry, the Institute for Clinical and Evaluative Sciences, we undertook a review of all 205,152 TKAs performed in the province of Ontario, Canada, between 2003 and 2016. We determined temporal trends in utilization, LOS, readmissions, and ED visits and evaluated patient and provider predictors of hospital readmissions and ED visits using multivariate logistic regression modeling. We also grouped and described the most common reasons for readmission and ED visits based on the available International Classification of Diseases, Ninth Revision and Tenth Revision coding information. RESULTS: LOS decreased significantly over the study period (P < .0001), from a median of 5 days (10th percentile 3 days, 90th percentile 8 days) in 2003 to a median of 3 days (10th percentile 2 days, 90th percentile 4 days) in 2016. All-cause 30-day readmissions did not change significantly over the study period, but the rate of ED visits increased significantly over time. Predictors of 30-day readmission following TKA included older age, male gender, lower income quartile, not having a postoperative visit with a primary care physician (PCP), increased comorbidities, longer LOS, urgent or revision surgery, admission to a teaching hospital, and discharge to an inpatient rehabilitation facility. Variables that predicted increased odds of an ED visit included older age, male gender, lower income quartile, not having a postop visit with a PCP, increasing comorbidities, year of surgery, longer LOS, and revision surgery. Admission to a teaching hospital and discharge to an inpatient rehabilitation facility showed a trend toward increased odds of an ED visit. CONCLUSIONS: We identified a significant increase in ED visits following TKA in Ontario between 2003 and 2016, with no corresponding increase in hospital readmissions despite a significant temporal trend toward shorter LOS. Predictors of ED visits and readmissions were similar, including male gender, lower income, higher comorbidities, and lacking a PCP visit postoperatively. Increased rates of ED visits following TKA in Ontario represent a quality problem, as they are associated with increased cost to the public healthcare system without any substantial benefit. Interventions aimed at redirecting patients from the ED for minor postoperative concerns should be investigated, as this is likely to improve care by reducing costs, improving efficiency, and enhancing patient experience.

6.
J Arthroplasty ; 2019 Nov 04.
Artigo em Inglês | MEDLINE | ID: mdl-31784362

RESUMO

BACKGROUND: A number of articles have been published reporting on the clinical outcomes of various acetabular reconstructions for the management of chronic pelvic discontinuity (PD). However, no systematic review of the literature has been published to date comparing the outcome and complications of different approaches to reconstruction. METHODS: The US National Library of Medicine (PubMed/MEDLINE) and EMBASE were queried for publications from January 1980 to January 2019 using keywords pertinent to total hip arthroplasty, PD, acetabular dissociation, clinical or functional outcomes, and revision total hip arthroplasty or postoperative complications. RESULTS: Overall, 18 articles were included in this analysis (569 cases with chronic PD). The overall survival rate of the acetabular components used for the treatment of chronic PD was 84.7% (482 of 569 cases) at mid-term follow-up, whereas the most common reasons for revision were aseptic loosening (54 of 569 hips; 9.5%), dislocations (45 of 569 hips; 7.9%), periprosthetic joint infection (30 of 569 hips; 5.3%), and periprosthetic fractures (11 of 569 hips; 1.9%). Both pelvic distraction technique (combined with highly porous shells) and custom triflanges resulted in less than 5% failure rates (96.2% and 95.8%, respectively) at final follow-up. Also, highly effective in the treatment of PD were cup-cages and highly porous shells with and/or without augments with 92% survivorship free of revision for aseptic loosening for both reconstruction methods. Inferior outcomes were reported for conventional cementless shells combined with acetabular plates (72.7%) as well as ilioischial cages and reconstruction rings (66.7% and 60.6% survivorship, respectively). CONCLUSION: The current literature contains moderate quality evidence in support of the use of custom triflange implants and pelvic distraction techniques for the treatment of chronic PD, with a less than 5% all-cause revision rate and low complication rates at mean mid-term follow-up. Cup-cages and highly porous shells with or without augments could also be considered for the treatment of PD because both resulted in greater than 90% survival rates. Finally, there is still no consensus regarding the impact of different types of acetabular reconstruction methods on optimizing the healing potential of PD, and further studies are required in this area to better understand the influence of PD healing on construct survivorship and functional outcomes with each reconstruction method.

7.
Artigo em Inglês | MEDLINE | ID: mdl-31793237

RESUMO

The ability to safely and precisely deliver genetic materials to target sites in complex biological environments is vital to the success of gene therapy. Numerous viral and nonviral vectors have been developed and evaluated for their safety and efficacy. This study will feature progress in synthetic polymers as nonviral vectors, which benefit from their chemical versatility, biocompatibility, and ability to carry both therapeutic cargo and targeting moieties. The combination of synthetic gene carrying constructs with advanced delivery techniques promises new therapeutic options for treating and curing genetic disorders. This article is characterized under: Therapeutic Approaches and Drug Discovery > Nanomedicine for Oncologic Disease Therapeutic Approaches and Drug Discovery > Emerging Technologies.

8.
Data Brief ; 26: 104400, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31667218

RESUMO

Data of Cardiopulmonary Resuscitation performed on a mannequin was collected via wearable instrumentation (using the MYO device). The data were collected for both "good" CPR and for performance of CPR with common errors introduced intentionally for this study. The data are labelled according to the error, and contain a variety of derived measurements. Data collected were used toward "Development of a novel cardiopulmonary resuscitation measurement tool using real-time feedback from wearable wireless instrumentation' (Ward et al., 2019) in which full context is available'. The data are available at Mendeley Data, doi:10.17632/pvjghfjmy4.1 (Ward et al., 2019).

9.
Open Forum Infect Dis ; 6(11): ofz452, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31737739

RESUMO

Background: Prosthetic hip and knee joint infections (PJIs) are challenging to eradicate despite prosthesis removal and antibiotic therapy. There is a need to understand risk factors for PJI treatment failure in the setting of prosthesis removal. Methods: A retrospective cohort of individuals who underwent prosthesis removal for a PJI at 5 hospitals in Toronto, Canada, from 2010 to 2014 was created. Treatment failure was defined as recurrent PJI, amputation, death, or chronic antibiotic suppression. Potential risk factors for treatment failure were abstracted by chart review and assessed using a Cox proportional hazards model. Results: A total of 533 individuals with prosthesis removal were followed for a median (interquartile range) of 814 (235-1530) days. A 1-stage exchange was performed in 19% (103/533), whereas a 2-stage procedure was completed in 88% (377/430). Treatment failure occurred in 24.8% (132/533) at 2 years; 53% (56/105) of recurrent PJIs were caused by a different bacterial species. At 4 years, treatment failure occurred in 36% of 1-stage and 32% of 2-stage procedures (P = .06). Characteristics associated with treatment failure included liver disease (adjusted hazard ratio [aHR], 3.12; 95% confidence interval [CI], 2.09-4.66), the presence of a sinus tract (aHR, 1.53; 95% CI, 1.12-2.10), preceding debridement with prosthesis retention (aHR, 1.68; 95% CI, 1.13-2.51), a 1-stage procedure (aHR, 1.72; 95% CI, 1.28-2.32), and infection due to Gram-negative bacilli (aHR, 1.35; 95% CI, 1.04-1.76). Conclusions: Failure of PJI therapy is common, and risk factors are not easily modified. Improvements in treatment paradigms are needed, along with efforts to reduce orthopedic surgical site infections.

11.
J Pediatr Urol ; 15(5): 495-502, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31630935

RESUMO

Quality improvement and patient safety (QIPS) can trace its origin back to the court of Hammurabi (circa 1700BC). However, it did not begin its evolution into its present methodology until the mid-19th century. It was through the application of quantitative parameters around the time of World War I that the field of QIPS has matured and gained a significant presence in the practice of medicine. Herein, the authors present a historical overview of this increasingly important field and correlate the current pediatric urology literature that has arisen from it. Because QIPS research is likely to contribute to efficient, streamlined health care through rapid changes to routine clinical practices, it would behoove pediatric urologists to familiarize themselves with its history and fundamental concepts.

12.
Cancer Epidemiol ; 62: 101591, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31494463

RESUMO

AIMS: The aim of this study was to examine factors including family history, medical history and comorbidities associated with the risk of colorectal cancer (CRC) in young (18-49 years) and middle-age (50-69 years) individuals. METHODS: State records were used to identify individuals born in Western Australia between 1945 and 1996, and their first-degree relatives. Individuals in the cohort and their relatives were linked to State cancer registry, hospital and mortality data to identify diagnoses of CRC and other risk factors. The associations between CRC and identified risk factors were examined using multivariable logistic regression. RESULTS: For both young and middle-aged patients, family history of CRC, and a history of smoking, inflammatory bowel disease, liver disease and non-CRC cancer were associated with a significant increase in odds of CRC. In middle-aged patients, having a colonoscopy in the previous 10 years was associated with a reduced odds of CRC regardless of the detection of polyps. However, in young patients only the absence of polyps as confirmed by colonoscopy was associated with a decreased risk of CRC (OR: 0.38, 95%CI: 0.26 - 0.54, p < 0.001). CONCLUSIONS: Many of the risk factors associated with CRC were similar in young and middle-aged persons, and should be used to identify high risk young patients for screening. The association between colonoscopy and polyps with CRC was modified by age, likely as the result of routine screening in middle-aged patients.

13.
Int J Colorectal Dis ; 34(10): 1673-1680, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31471697

RESUMO

BACKGROUND: Survival following colorectal cancer (CRC) survival may be influenced by a number of factors including family history, individual medical history, and comorbidities. The impact of these factors may vary based on the patient's age. METHODS: The study cohort consisted of individuals born in Western Australia between 1945 and 1996, who had been diagnosed with CRC prior to 2015 (n = 3220). Hospital, cancer, and mortality data were extracted for each patient from state health records and were used to identify potential risk factors associated with CRC survival. Family linkage data, in combination with cancer registry data, were used to identify first-degree family members with a history of CRC. The association between survival following CRC diagnosis and identified risk factors was examined using Cox proportional hazard models. RESULTS: Age and sex were not significantly associated with survival in young patients. However, in middle-aged patients increasing age (HR 1.03, 95% CI 1.01-1.05, p = 0.003) and being male (HR 0.72, 95% CI 0.60-0.87, p < 0.001) were associated with reduced survival. Being diagnosed with polyps and having a colonoscopy prior to CRC diagnosis were associated with improved survival in both young and middle-aged patients, while a history of non-CRC and liver disease was associated with reduced survival. In middle-aged patients, having diabetes-related hospital admissions (HR 1.53, 95% CI 1.15-2.03, p = 0.004) was associated with reduced survival. CONCLUSIONS: In both young and middle-aged patients with CRC, factors associated with early screening and detection were associated with increased CRC survival while a history of liver disease and non-CRC was associated with decreased CRC survival.

14.
Ann Thorac Surg ; 2019 Aug 31.
Artigo em Inglês | MEDLINE | ID: mdl-31479635

RESUMO

BACKGROUND: Despite guideline recommendations, rates of concomitant tricuspid valve repair are suboptimal, possibly due to fear of complications. We reviewed morbidity, mortality, recurrent tricuspid regurgitation, and right ventricular remodeling after guideline-directed concomitant tricuspid valve repair. METHODS: We performed guideline-directed concomitant tricuspid valve repair on 171 consecutive patients who underwent left-sided valve surgery (degenerative mitral surgery or aortic valve replacement) between May 2012 and March 2016. Exclusion criteria included functional mitral regurgitation, rheumatic disease, active endocarditis, and concomitant coronary artery bypass grafting or complex aortic surgery. RESULTS: Mean age was 68 ± 12 years, and 47% (81 of 171) were women. Preoperative atrial fibrillation was present in 57% (98 of 171), and preoperative tricuspid regurgitation was moderate or higher in 64% (108 of 171). The rate of de novo pacemaker placement was 4.1% (7 of 171), and the 30-day mortality rate was 0.6% (1 of 171). Estimated survival was 95% ± 4% at 1 year and 92% ± 5% at 5 years. Freedom from moderate or worse residual/recurrent tricuspid regurgitation was 93% ± 6% at 6 months and 89% ± 8% at 3 years. Quantitative echocardiography found no significant increase in right ventricular dimensions or area at 1 year in subgroup analysis. Mean echocardiographic follow-up was 14.1 months, and mean clinical follow-up was 33.9 months. CONCLUSIONS: Guideline-directed concomitant tricuspid valve repair resulted in excellent safety end points and survival. At 14 months, freedom from moderate or worse tricuspid regurgitation was high, right ventricular performance did not worsen, and the pacemaker rate was comparable to rates after isolated mitral repair. Given these findings, adherence to current guidelines regarding functional tricuspid regurgitation should be encouraged.

15.
Biomacromolecules ; 20(9): 3385-3391, 2019 Sep 09.
Artigo em Inglês | MEDLINE | ID: mdl-31424203

RESUMO

Some synthetic polymers can block cell death when applied following an injury that would otherwise kill the cell. This cellular rescue occurs through interactions of the polymers with cell membranes. However, general principles for designing synthetic polymers to ensure strong, but nondisruptive, cell membrane targeting are not fully elucidated. Here, we tailored biomimetic phosphorylcholine-containing block copolymers to interact with cell membranes and determined their efficacy in blocking neuronal death following oxygen-glucose deprivation. By adjusting the hydrophilicity and membrane affinity of poly(2-methacryloyloxyethyl phosphorylcholine) (polyMPC)-based triblock copolymers, the surface active regime in which the copolymers function effectively as membrane-targeting cellular rescue agents was determined. We identified nonintrusive interactions between the polymer and the cell membrane that alter the collective dynamics of the membrane by inducing rigidification without disrupting lipid packing or membrane thickness. In general, our results open new avenues for biological applications of polyMPC-based polymers and provide an approach to designing membrane-targeting agents to block cell death after injury.

16.
Phys Ther Sport ; 39: 126-135, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31351340

RESUMO

OBJECTIVE: Determine if augmented feedback (AF) used during jump landing training can improve ACL biomechanical injury risk factors. METHODS: Articles that used AF in jump landing training were identified through database searches. Pre-identified ACL injury risk parameters were compared between AF and control groups for immediate and delayed (>24 h) post-tests. Standardised effect sizes were determined when kinematic or kinetic data were available. RESULTS: Fourteen articles were included; four studies using 2D kinematic data were excluded from the meta-analysis as they did not provide kinematic data that were consistent with each other or with the remaining 3D studies. During immediate post-test, peak knee and hip flexion angles (KFA, HFA) and vertical ground reaction force (vGRF) were significantly different between AF and control groups. At retention, peak KFA and vGRF remained significantly different. No significant differences between groups were observed in other parameters. High levels of heterogeneity were detected, likely caused by differences in sex, movement or AF types. CONCLUSIONS: Jump landing training combined with AF was useful in reducing ACL injury parameters related to peak KFA, HFA and vGRF, but had little effect on frontal plane biomechanics. Future work should investigate how different types of AF may affect different participants.


Assuntos
Lesões do Ligamento Cruzado Anterior/prevenção & controle , Terapia por Exercício , Retroalimentação , Humanos
17.
Adv Cancer Res ; 144: 95-135, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31349905

RESUMO

Esophageal squamous cell carcinoma (ESCC) is among the most deadly forms of human malignancy characterized by late stage diagnosis, metastasis, therapy resistance and frequent recurrence. Clinical management of ESCC remains challenging and the disease presently lacks approved targeted therapeutics. However, emerging data from recent clinical and translational investigations hold great promise for future progress toward improving patient outcomes in this deadly disease. Here, we review current clinical perspectives in ESCC epidemiology, pathophysiology, and clinical care, highlighting recent advances with potential to impact ESCC prevention, diagnosis and management. We further provide an overview of recent translational investigations contributing to our understanding of the molecular mechanisms underlying ESCC development, progression and therapy response, including insights gained from genetic studies and various murine model systems. Finally, we discuss future perspectives in the clinical and translational realms, along with remaining hurdles that must be overcome to eradicate ESCC.

18.
Water Res ; 162: 200-213, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31276984

RESUMO

Greywater recycling and rainwater harvesting have the potential to increase the resilience of water management and reduce the need for investment in conventional water supply schemes. However, their water-savings would partly depend on the location and built-form of urban development and hence its household sizes and rainwater per dwelling. We have therefore tested how spatial planning options would affect the future viability of alternative water supply in the Greater South East of England. Our integrated modelling framework, for the first time, forecasts the future densities and variability of built-form to provide inputs to the modelling of alternative water supply. We show that using projections of the existing housing stock would have been unsound, and that using standard dwelling types and household sizes would have substantially overestimated the water-savings, by not fully representing how the variability in dwelling dimensions and household-sizes would affect the cost effectiveness of these systems. We compare the spatial planning trend over a 30 year period with either compaction at higher densities within existing urban boundaries, or market-led more dispersed development. We show how the viability of alternative water supply would differ between these three spatial planning options. The water-savings of rainwater harvesting would vary greatly at a regional scale depending on residential densities and rainfall. Greywater recycling would be less affected by spatial planning but would have a finer balance between system costs and water-savings and its feasibility would vary locally depending on household sizes and water efficiency. The sensitivity of the water savings to differences in rainfall and water prices would vary with residential density. The findings suggest that forecasts of residential densities, rainfall and the water price could be used in conjunction with more detailed local studies to indicate how spatial planning would affect the future water saving potential of alternative water supply.


Assuntos
Conservação dos Recursos Naturais , Abastecimento de Água , Planejamento de Cidades , Inglaterra , Habitação , Chuva , Reciclagem
19.
J Orthop Trauma ; 33(10): 497-502, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31188261

RESUMO

OBJECTIVES: To determine whether the Clinical Frailty Scale (CFS), a validated frailty tool, was associated with discharge destination. Secondary objectives were to determine whether the CFS was associated with in-hospital complications and length of stay. DESIGN: This is a 5-year retrospective cohort study. SETTING: The study took place at an academic Level 1 trauma center. PATIENTS/PARTICIPANTS: All patients 65 years of age and older admitted with an isolated hip fracture were included (N = 423). INTERVENTION: Preadmission CFS was determined as part of routine clinical care prospectively and abstracted from the chart. MAIN OUTCOME MEASUREMENTS: We collected demographic and process data associated with adverse outcomes (age, sex, time to surgery, and mode of anesthesia) and used multivariable logistic regression to determine the association between CFS with discharge destination, in-hospital complications, and length of stay. RESULTS: Preadmission frailty was independently associated with adverse discharge destination (adjusted odds ratio 23.0; 95% confidence interval, 3.0-173.5) and in-hospital complications (adjusted odds ratio 4.8; 95% confidence interval, 2.1-10.8) in greater magnitude than traditional risk factors such as age, male sex, time to surgery, and mode of anesthesia. There was a dose-response relationship between increasing frailty and length of stay (P < 0.001). CONCLUSIONS: Preadmission frailty as quantified by the CFS is associated with discharge destination, in-hospital complications, and length of stay. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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