Interhospital Transfer for Emergency General Surgery: A Contemporary National Analysis.

BACKGROUND: Patients undergoing emergency general surgery (EGS) often require complex management and transfer to higher acuity facilities, especially given increasing national efforts aimed at centralizing care. We sought to characterize factors and evaluate outcomes associated with interhospital transfer using a contemporary national cohort. METHODS: All adult hospitalizations for EGS (appendectomy, cholecystectomy, laparotomy, lysis of adhesions, small/large bowel resection, and perforated ulcer repair) ≤2 days of admission were identified in the 2016-2020 National Inpatient Sample. Patients initially admitted to a different institution and transferred to the operating hospital comprised the Transfer cohort (others: Non-Transfer). Multivariable models were developed to consider the association of Transfer with outcomes of interest. RESULTS: Of ∼1 653 169 patients, 107 945 (6.5%) were considered the Transfer cohort. The proportion of patients experiencing interhospital transfer increased from 5.2% to 7.7% (2016-2020, P < .001). On average, Transfer was older, more commonly of White race, and of a higher Elixhauser comorbidity index. After adjustment, increasing age, living in a rural area, receiving care in the Midwest, and decreasing income quartile were associated with greater odds of interhospital transfer. Following risk adjustment, Transfer remained linked with increased odds of in-hospital mortality (AOR 1.64, CI 1.49-1.80), as well as any perioperative complication (AOR 1.33, CI 1.27-1.38; Reference: Non-Transfer). Additionally, Transfer was associated with significantly longer duration of hospitalization (ß + 1.04 days, CI + .91-1.17) and greater costs (ß+$3,490, CI + 2840-4140). DISCUSSION: While incidence of interhospital transfer for EGS is increasing, transfer patients face greater morbidity and resource utilization. Novel interventions are needed to optimize patient selection and improve post-transfer outcomes.

Data-driven determination of zooplankton bioregions and robustness analysis.

Identifying biogeographic regions through cluster analysis of species distribution data is a common method for partitioning ecosystems. Selecting the appropriate cluster analysis method requires a comparison of multiple algorithms. In this study, we demonstrate a data-driven process to select a method for bioregionalization based on community data and test its robustness to data variability following these steps: •We aggregated and curated zooplankton community observations from expeditions in the Northeast Pacific.•We determined the best bioregionalization approach by comparing nine cluster analysis methods using ten goodness of clustering indices.•We evaluated the robustness of the bioregionalization to different sources of sampling and taxonomic variability by comparing the bioregionalization of the overall dataset with bioregionalizations of subsets of the data. The K-means clustering of the log-chord transformed abundance was selected as the optimal method for bioregionalization of the zooplankton dataset. This clustering resulted in the emergence of four bioregions along the cross-shelf gradient: the Offshore, Deep Shelf, Nearshore, and Deep Fjord bioregions. The robustness analyses demonstrated that the bioregionalization was consistent despite variability in the spatial and temporal frequency of sampling, sampling methodology, and taxonomic coverage.

Choreographed expansion of services results in decreased patient burden without compromise of outcomes: An assessment of the Ontario experience.

Background: Neuro-oncology care in Ontario, Canada has been historically centralized, at times requiring significant travel on the part of patients. Toward observing the goal of patient-centered care and reducing patient burden, 2 additional regional cancer centres (RCC) capable of neuro-oncology care delivery were introduced in 2016. This study evaluates the impact of increased regionalization of neuro-oncology services, from 11 to 13 oncology centers, on healthcare utilization and travel burden for glioblastoma (GBM) patients in Ontario. Methods: We present a cohort of GBM patients diagnosed between 2010 and 2019. Incidence of GBM and treatment modalities were identified using provincial health administrative databases. A geographic information system and spatial analysis were used to estimate travel time from patient residences to neuro-oncology RCCs. Results: Among the 5242 GBM patients, 79% received radiation as part of treatment. Median travel time to the closest RCC was higher for patients who did not receive radiation as part of treatment than for patients who did (P = .03). After 2016, the volume of patients receiving radiation at their local RCC increased from 62% to 69% and the median travel time to treatment RCCs decreased (P = .0072). The 2 new RCCs treated 35% and 41% of patients within their respective catchment areas. Receipt of standard of care, surgery, and chemoradiation (CRT), increased by 11%. Conclusions: Regionalization resulted in changes in the healthcare utilization patterns in Ontario consistent with decreased patient travel burden for patients with GBM. Focused regionalization did not come at the cost of decreased quality of care, as determined by the delivery of a standard of care.

Patient-specific left atrium contraction quantification associated with atrial fibrillation: A region-based approach.

BACKGROUND AND OBJECTIVES: Atrial fibrillation (AF) is a widespread cardiac arrhythmia that significantly impacts heart function. AF disrupts atrial mechanical contraction, leading to irregular, uncoordinated, and slow blood flow inside the atria which favors the formation of clots, primarily within the left atrium (LA). A standardized region-based analysis of the LA is missing, and there is not even any consensus about how to define the LA regions. In this study we propose an automatic approach for regionalizing the LA into segments to provide a comprehensive 3D region-based LA contraction assessment. LA global and regional contraction were quantified in control subjects and in AF patients to describe mechanical abnormalities associated with AF. METHODS: The proposed automatic approach for LA regionalization was tested in thirteen control subjects and seventeen AF patients. After dividing LA into standard regions, we evaluated the global and regional mechanical function by measuring LA contraction parameters, such as regional volume, global and regional strains, regional wall motion and regional shortening fraction. RESULTS: LA regionalization was successful in all study subjects. In the AF group compared with control subjects, results showed: a global impairment of LA contraction which appeared more pronounced along radial and circumferential direction; a regional impairment of radial strain which was more pronounced in septal, inferior, and lateral regions suggesting a greater reduction in mechanical efficiency in these regions in comparison to the posterior and anterior ones. CONCLUSION: An automatic approach for LA regionalization was proposed. The regionalization method was proved to be robust with several LA anatomical variations and able to characterize contraction changes associated with AF.

Validation of a measure of hospital maternal level of care for the United States.

BACKGROUND: Lack of a validated assessment of maternal risk-appropriate care for use in population data has prevented the existing literature from quantifying the benefit of maternal risk-appropriate care. The objective of this study was to develop a measure of hospital maternal levels of care based on the resources available at the hospital, using existing data available to researchers. METHODS: This was a secondary data analysis. The sample was abstracted from the American Hospital Association Annual Survey Database for 2018. Eligibility was limited to short-term acute general hospitals that reported providing maternity services as measured by hospital reporting of an obstetric service level, obstetric services, or birthing rooms. We aligned variables in the database with the ACOG criteria for each maternal level of care, then built models that used the variables to measure the maternal level of care. In each iteration, the distribution of hospitals was compared to the distribution in the CDC Levels of Care Assessment Tool Validation Pilot, assessing agreement with the Wilson Score for proportions for each level of care. Results were compared to hospital self-report in the database and measurement reported with another published method. RESULTS: The sample included 2,351 hospitals. AHA variables were available to measure resources that align with ACOG Levels 1, 2, and 3. Overall, 1219 (51.9%) of hospitals reported resources aligned with Maternal Level One, 816 (34.7%) aligned with maternal level two, and 202 (8.6%) aligned with maternal level Three. This method overestimates the prevalence of hospitals with maternal level one compared to the CDC measurement of 36.1% (Mean 52.9%; 95% CI47.2%-58.7%), and likely includes hospitals that would not qualify as level one if all resources required by the ACOG guidelines could be assessed. This method underestimates the prevalence of hospitals with maternal critical care services (Level 3 or 4) compared to CDC measure of 12.1% (Mean 8.1%; 95%CI 6.2% - 10.0%) but is an improvement over hospital self-report (24.7%) and a prior published method (32.3%). CONCLUSIONS: This method of measuring maternal level of care allows researchers to investigate the value of perinatal regionalization, risk-appropriate care, and hospital differences among the three levels of care. This study identified potential changes to the American Hospital Association Annual Survey that would improve identification of maternal levels of care for research.

Patient Survey Regarding Non-Medical Burdens of Care at a Parental Fetal Care Center.

Recognizing the paucity of literature describing the non-medical effects of care at a tertiary parental fetal care center upon families, the purpose of the study was to better examine the potential barriers that our patients face related to care in a parental fetal care center. An anonymous survey was sent via email to patients who received care from 2015 to 2021. The survey included questions regarding demographics, fetal diagnoses, non-medical expenses related to care, and the impact of care on patient relationships, employment, and other children. 453 patients (15.9%) responded out of the 2684 emails sent. 58.3% of patients traveled >100 miles to reach our referral center, with 20% traveling >300 miles. 42.6% of patients reported non-medical expenditures exceeding $1000, with nearly 1 in 10 reporting expenditures of >$5000 (8.6%). Overall, 38.2% of women reported moderate to severe financial burdens related to receiving care at the parental fetal care center. This study illuminates the financial and social burdens that care at a tertiary parental fetal care center imposes upon families. By acknowledging these barriers, we can strive to minimize them to best provide equitable access to high-quality fetal care services.

A phylogenetic approach identifies patterns of beta diversity and floristic subregions of the Qinghai-Tibet Plateau.

Patterns of taxonomic and phylogenetic beta diversity and their relationships with environmental correlates can help reveal the origin and evolutionary history of regional biota. The Qinghai-Tibet Plateau (QTP) harbors an exceptionally diverse flora, however, a phylogenetic perspective has rarely been used to investigate its beta diversity and floristic regions. In this study, we used a phylogenetic approach to identify patterns of beta diversity and quantitatively delimit floristic regions on the Qinghai-Tibet Plateau. We also examined the relationships between multifaceted beta diversity, geographical distance, and climatic difference, and evaluated the relative importance of various factors (i.e., climate, topography and history) in shaping patterns of beta diversity. Sørensen dissimilarity indices indicated that patterns of species turnover among sites dominated the QTP. We also found that patterns of both taxonomic and phylogenetic beta diversity were significantly related to geographical distance and climatic difference. The environmental factors that contributed most to these patterns of beta diversity include annual precipitation, mean annual temperature, climatic gradients and climatic instability. Hierarchical dendrograms of dissimilarity and non-metric multidimensional scaling ordination based on phylogenetic beta diversity data identified ten floristic subregions in the QTP. Our results suggest that the contemporary environment and historical climate changes have filtered species composition among sites and eventually determined beta diversity patterns of plants in the QTP.

Racial and Geographic Variation of Prenatal Care Coordination Receipt in the State of Wisconsin, 2010-2019.

Medicaid-funded obstetric care coordination programs supplement prenatal care with tailored services to improve birth outcomes. It is uncertain whether these programs reach populations with elevated risks of adverse birth outcomes-namely non-white, highly rural, and highly urban populations. This study evaluates racial and geographic variation in the receipt of Wisconsin Medicaid's Prenatal Care Coordination (PNCC) program during 2010-2019. We sample 250,596 Medicaid-paid deliveries from a cohort of linked Wisconsin birth records and Medicaid claims. We measure PNCC receipt during pregnancy dichotomously (none; any) and categorically (none; assessment/care plan only; service receipt), and we stratify the sample on three maternal characteristics: race/ethnicity, urbanicity of residence county; and region of residence county. We examine annual trends in PNCC uptake and conduct logistic regressions to identify factors associated with assessment or service receipt. Statewide PNCC outreach decreased from 25% in 2010 to 14% in 2019, largely due to the decline in beneficiaries who only receive assessments/care plans. PNCC service receipt was greatest and persistent in Black and Hispanic populations and in urban areas. In contrast, PNCC service receipt was relatively low and shrinking in American Indian/Alaska Native, Asian/Pacific Islander, and white populations and in more rural areas. Additionally, being foreign-born was associated with an increased likelihood of getting a PNCC assessment in Asian/Pacific Islander and Hispanic populations, but we observed the opposite association in Black and white populations. Estimates signal a gap in PNCC receipt among some at-risk populations in Wisconsin, and findings may inform policy to enhance PNCC outreach.

Biogeographic survey of soil bacterial communities across Antarctica.

BACKGROUND: Antarctica and its unique biodiversity are increasingly at risk from the effects of global climate change and other human influences. A significant recent element underpinning strategies for Antarctic conservation has been the development of a system of Antarctic Conservation Biogeographic Regions (ACBRs). The datasets supporting this classification are, however, dominated by eukaryotic taxa, with contributions from the bacterial domain restricted to Actinomycetota and Cyanobacteriota. Nevertheless, the ice-free areas of the Antarctic continent and the sub-Antarctic islands are dominated in terms of diversity by bacteria. Our study aims to generate a comprehensive phylogenetic dataset of Antarctic bacteria with wide geographical coverage on the continent and sub-Antarctic islands, to investigate whether bacterial diversity and distribution is reflected in the current ACBRs. RESULTS: Soil bacterial diversity and community composition did not fully conform with the ACBR classification. Although 19% of the variability was explained by this classification, the largest differences in bacterial community composition were between the broader continental and maritime Antarctic regions, where a degree of structural overlapping within continental and maritime bacterial communities was apparent, not fully reflecting the division into separate ACBRs. Strong divergence in soil bacterial community composition was also apparent between the Antarctic/sub-Antarctic islands and the Antarctic mainland. Bacterial communities were partially shaped by bioclimatic conditions, with 28% of dominant genera showing habitat preferences connected to at least one of the bioclimatic variables included in our analyses. These genera were also reported as indicator taxa for the ACBRs. CONCLUSIONS: Overall, our data indicate that the current ACBR subdivision of the Antarctic continent does not fully reflect bacterial distribution and diversity in Antarctica. We observed considerable overlap in the structure of soil bacterial communities within the maritime Antarctic region and within the continental Antarctic region. Our results also suggest that bacterial communities might be impacted by regional climatic and other environmental changes. The dataset developed in this study provides a comprehensive baseline that will provide a valuable tool for biodiversity conservation efforts on the continent. Further studies are clearly required, and we emphasize the need for more extensive campaigns to systematically sample and characterize Antarctic and sub-Antarctic soil microbial communities. Video Abstract.

Spatial-temporal redundancy evaluation of the municipal solid waste incineration treatment capacity: the case study of China.

In the process of marketization, the lack of redundancy evaluation of the MSW incineration treatment capacity leads to the regional imbalance of treatment capacity and waste of resources. Therefore, this study aimed to develop a spatial-temporal redundancy evaluation method for the MSW incineration treatment capacity based on the accurate MSW generation prediction using artificial intelligence. To achieve this aim, this study first proposed and finalized a prediction model of the provincial MSW generation by applying the artificial neuron network (ANN) technology and using the statistical data of Jiangsu Province of China from 1990 to 2020. In the finalized model, the input variables consist of three demographic variables, three social variables, and five economic variables; the model structure that includes four hidden layers and 16 neurons in each hidden layer performed best with a coefficient of determination (R2) of 0.995 on the training samples and an R2 of 0.974 on the test set, respectively. Using the finalized model and statistical data of all provinces in China, this study proposed a redundancy evaluation method for the MSW incineration treatment capacity and evaluated the spatial and temporal redundancy status of China. The results first confirm the effectiveness of the proposed method to model and quantify the redundancy problem. Second, according to the evaluation results, even if no new treatment plant will be built before 2025, 10 of China's 31 provinces still have redundancy problems, indicating the severity of this problem. This study first contributes to the body of knowledge by modeling the redundancy problem of the MSW incineration treatment capacity. Moreover, this study provides a tool to quantify temporal and spatial redundancy using advanced technology and publicly available data. Furthermore, the results can help waste-related authorities and organizations make optimal strategies and actions to better match MSW treatment capacity and MSW generation volume.

Omernik's Ecoregion Framework: a Legacy for Understanding Regional Patterns in Attainable Resource Quality.

An initial and comprehensive map of ecological regions across the conterminous United States was provided by Omernik in 1987. Because that paper was the most-cited published by the Annals of the American Association of Geographers, we sought to assess and quantify its contribution to science. To do so, we conducted a scientometric analysis to address the following main questions: 1) What are the temporal and spatial citation trends? We expected that Omernik's paper would still be employed 36 years after its publication, and mostly in the United States of America. 2) For what types of environments and organisms has it been applied? Based on its generality, we expected that it had been applied to both terrestrial and aquatic ecosystems. 3) What are the main applications of Omernik's article? We predicted that it would mostly be used for describing and delineating study sites and management areas, as well as for selecting regional reference sites. The number of citations presented a positive temporal increase, indicating its continued applicability. Most papers dealt with aquatic environments, mainly in streams carried out predominantly in the United States of America, as was one of its earliest applications. The usefulness of ecoregions for assessing and managing biotic and abiotic patterns and distributions were the main topics addressed by scientists. Ecoregions have offered a general framework for developing regional expectations and rational regional management policies across large areas, as was their original intent. In addition, ecoregion maps were used for communicating patterns-or the lack of them-to interested scientists, citizens, and decision-makers. That comprehensiveness of Omernik's ecoregion approach has led to its widespread applicability and continued usefulness to a diverse set of scientific and management disciplines.

In France, the organization of perinatal care has a direct influence on the outcome of the mother and the newborn: Contribution from a French nationwide study.

OBJECTIVE: To investigate maternal and neonatal outcomes after a delivery in France in 2019, according to hospital characteristics and the impact of distance and time of travel on mother and newborn. METHODS: All parturients above 18 years of age who delivered in 2019 and were identified in the French health insurance database were included, with their newborns, in this retrospective cohort study. Main outcome measures were Severe Maternal Morbidity score and the Neonatal Adverse Outcome Indicator (NAOI). RESULTS: Among the 733 052 pregnancies included, 10 829 presented a severe maternal morbidity (1.48%) and 77 237 had a neonatal adverse outcome (10.4%). Factors associated with an unfavorable maternal or neonatal outcome were Obstetric Comorbidity Index, primiparity, and cesarean or instrumental delivery. Prematurity was associated with less severe maternal morbidity but more neonatal adverse outcomes. Time of travel above 30 min was associated with a higher NAOI rate. CONCLUSIONS: Results suggest the efficiency of regionalization of perinatal care in France, although a difference in both outcomes persists according to unit volume, suggesting the need for a further step in concentrating perinatal care. Perinatal care organization should focus on mapping the territory with high-level, high-volume maternity throughout the territory; this suggests closing down high-volume units and improving low-volume ones to maintain coherent mapping.

Running, jumping, hunting, and scavenging: Functional analysis of vertebral mobility and backbone properties in carnivorans.

Carnivorans are well-known for their exceptional backbone mobility, which enables them to excel in fast running and long jumping, leading to them being among the most successful predators amongst terrestrial mammals. This study presents the first large-scale analysis of mobility throughout the presacral region of the vertebral column in carnivorans. The study covers representatives of 6 families, 24 genera and 34 species. We utilized a previously developed osteometry-based method to calculate available range of motion, quantifying all three directions of intervertebral mobility: sagittal bending (SB), lateral bending (LB), and axial rotation (AR). We observed a strong phylogenetic signal in the structural basis of the vertebral column (vertebral and joint formulae, length proportions of the backbone modules) and an insignificant phylogenetic signal in most characteristics of intervertebral mobility. This indicates that within the existing structure (stabilization of which occurred rather early in different phylogenetic lineages), intervertebral mobility in carnivorans is quite flexible. Our findings reveal that hyenas and canids, which use their jaws to seize prey, are characterized by a noticeably elongated cervical region and significantly higher SB and LB mobility of the cervical joints compared to other carnivorans. In representatives of other carnivoran families, the cervical region is very short, but the flexibility of the neck (both SB and LB) is significantly higher than that of short-necked odd-toed and even-toed ungulates. The lumbar region of the backbone in carnivorans is dorsomobile in the sagittal plane, being on average ~23° more mobile than in artiodactyls and ~38° more mobile than in perissodactyls. However, despite the general dorsomobility, only some representatives of Canidae, Felidae, and Viverridae are superior in lumbar flexibility to the most dorsomobile ungulates. The most dorsomobile artiodactyls are equal or even superior to carnivorans in their ability to engage in dorsal extension during galloping. In contrast, carnivorans are far superior to ungulates in their ability to engage ventral flexion. The cumulative SB in the lumbar region in carnivorans largely depends on the mode of running and hunting. Thus, adaptation to prolonged and enduring pursuit of prey in hyenas is accompanied by markedly reduced SB flexibility in the lumbar region. A more dorsostable run is also a characteristic of the Ursidae, and the peculiar maned wolf. Representatives of Felidae and Canidae have significantly more available SB mobility in the lumbar region. However, they fully engage it only occasionally at key moments of the hunt associated with the direct capture of the prey or when running in a straight line at maximum speed.

Aspects that facilitate access to care for viral hepatitis: An evaluative research

ABSTRACT BACKGROUND: Viral hepatitis is a major public health concern worldwide. OBJECTIVES: This study aimed to analyze the factors that facilitate access to care for viral hepatitis. DESIGN AND SETTING: Using a sequential mixed method, this evaluation research was conducted in the state of Mato Grosso, Brazil. METHODS: Mapping of references and selection of regions were made based on the quantity and heterogeneity of services. The stakeholders, including the managers of the State Department of Health and professionals from reference services, were identified. Nine semi-structured interviews were conducted using content analysis and discussions guided by the dimensions of the analysis model of universal access to health services. RESULTS: In the political dimension, decentralizing services and adhering to the Intermunicipal Health Consortium are highly encouraged. In the economic-social dimension, a commitment exists to allocate public funds for the expansion of referral services and subsidies to support users in their travel for appointments, medications, and examinations. In the organizational dimension, the availability of inputs for testing, definition of user flow, ease of scheduling appointments, coordination by primary care in testing, collaboration following the guidelines and protocols, and engagement in extramural activities are guaranteed. In the technical dimension, professionals actively commit to the service and offer different opening hours, guarantee the presence of an infectious physician, expand training opportunities, and establish intersectoral partnerships. In the symbolic dimension, professionals actively listen to the experiences of users throughout their care trajectory and demonstrate empathy. CONCLUSIONS: The results are crucial for improving comprehensiveness, but necessitate managerial efforts to enhance regional governance.

Patient and Hospital Characteristics Associated With the Interhospital Transfer of Adult Patients With Sepsis.

IMPORTANCE: The interhospital transfer (IHT) of patients with sepsis to higher-capability hospitals may improve outcomes. Little is known about patient and hospital factors associated with sepsis IHT. OBJECTIVES: We evaluated patterns of hospitalization and IHT and determined patient and hospital factors associated with the IHT of adult patients with sepsis. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: A total of 349,938 adult patients with sepsis at 329 nonfederal hospitals in California, 2018-2019. MAIN OUTCOMES AND MEASURES: We evaluated patterns of admission and outward IHT between low sepsis-, intermediate sepsis-, and high sepsis-capability hospitals. We estimated odds of IHT using generalized estimating equations logistic regression with bootstrap stepwise variable selection. RESULTS: Among the cohort, 223,202 (66.4%) were initially hospitalized at high-capability hospitals and 10,870 (3.1%) underwent IHT. Nearly all transfers (98.2%) from low-capability hospitals were received at higher-capability hospitals. Younger age (< 65 yr) (adjusted odds ratio [aOR] 1.54; 95% CI, 1.40-1.69) and increasing organ dysfunction (aOR 1.22; 95% CI, 1.19-1.25) were associated with higher IHT odds, as were admission to low-capability (aOR 2.79; 95% CI, 2.33-3.35) or public hospitals (aOR 1.35; 95% CI, 1.09-1.66). Female sex (aOR 0.88; 95% CI, 0.84-0.91), Medicaid insurance (aOR 0.59; 95% CI, 0.53-0.66), home to admitting hospital distance less than or equal to 10 miles (aOR 0.92; 95% CI, 0.87-0.97) and do-not-resuscitate orders (aOR 0.48; 95% CI, 0.45-0.52) were associated with lower IHT odds, as was admission to a teaching hospital (aOR 0.83; 95% CI, 0.72-0.96). CONCLUSIONS AND RELEVANCE: Most patients with sepsis are initially hospitalized at high-capability hospitals. The IHT rate for sepsis is low and more likely to originate from low-capability and public hospitals than from high-capability and for-profit hospitals. Transferred patients with sepsis are more likely to be younger, male, sicker, with private medical insurance, and less likely to have care limitation orders. Future studies should evaluate the comparative benefits of IHT from low-capability hospitals.

Regionalization of pancreatic surgery in California: Benefits for preventing postoperative deaths and reducing healthcare costs.

Introduction: Pancreatic cancer (PC) surgery has been associated with improved outcomes and value when performed at high-volume centers (HVC; ≥20 surgeries annually) compared to low-volume centers (LVC). Some have used these differences to suggest that regionalization of PC surgery would optimize patient outcomes and expenditures. Methods: A Markov model was created to evaluate 30-day mortality, 30-day complications, and 30-day costs. The differences in these outcome measures between the current and future states were measured to assess the population-level benefits of regionalization. A sensitivity analysis was performed to evaluate the impact of variations of input variables in the model. Results: Among 5958 new cases of pancreatic cancer in California in 2021, a total of 2443 cases (41 %) would be resectable; among patients with resectable PC, a total of 977 (40 %) patients would undergo surgery. In aggregate, HVC and LVC 30-day postoperative complications occurred in 364 patients, 30-day mortality in 35 patients, and healthcare costs expended managing complications were $6,120,660. In the predictive model of complete regionalization to only HVC in California, an estimated 29 fewer complications, 17 fewer deaths, and a cost savings of $487,635 per year would occur. Conclusions and relevance: Pancreatic cancer (PC) surgery has been associated with improved outcomes and value when performed at high-volume centers (HVC; ≥20 surgeries annually) compared to low-volume centers (LVC). Complete regionalization of pancreatic cancer surgery predicted benefits in mortality, complications and cost, though implementing this strategy at a population-level may require investment of resources and redesigning care delivery models.

Risk-based regionalization approach for area-wide management of HLB vectors in the Mediterranean Basin.

Huanglongbing (HLB) is one of the most devastating citrus diseases worldwide. It is associated with the non-culture bacteria Candidatus Liberibacter spp., which can be transmitted by grafting and/or the psyllid vectors Diaphorina citri (ACP) and Trioza erytreae (AfCP). Although HLB has not been reported in the Mediterranean Basin to date, both vectors are present, and thus represent a serious threat to the citrus industry in this region. Resistant citrus cultivars or effective therapeutic treatments are not currently available for HLB. Nevertheless, area-wide pest management via coordinated management efforts over large areas has been implemented in Brazil, China and the USA for HLB control. This study proposes an open access flexible methodology to address area-wide management of both HLB vectors in the Mediterranean Basin. Based on a risk-based approach which considers climatic information and other variables that may influence vector introduction and spread, such as conventional, organic, abandoned and residential citrus areas as well as transportation corridors, an area-wide management division in pest management areas (PMAs) is proposed. The size and location of these PMAs were estimated by means of a hierarchical clustering algorithm with spatial constraints whose performance was assessed under different configuration scenarios. This proposal may assist policymakers and the citrus industry of the citrus-growing areas of the Mediterranean Basin in risk management planning in the case of the spread of HLB vectors or a possible introduction of the disease. Additionally, it may be a valuable resource to inform opinion dynamic models, enabling the identification of pivotal factors for the success of control measures.

Large scale spatio-temporal modelling of risk factors associated with tuberculosis exposure at the wildlife-livestock interface.

The management of animal tuberculosis (TB) is a priority for European Union animal health authorities. However, and despite all the efforts made to date, a significant part of Spain has as yet been unable to obtain the officially tuberculosis-free (OTF) status. Information regarding wildlife disease status is usually scarce, signifying that the role played by wildlife is usually ignored or poorly assessed in large-scale TB risk factor studies. The National Wildlife Health Surveillance Plan in Spain now provides information on infection rates in wildlife reservoirs at a national level, but there are limitations as regards the sample size, the spatio-temporal distribution of the samples, and the lack of homogeneity of the diagnostic techniques employed. The objective of the study described herein was, therefore, to employ a Bayesian approach with the intention of identifying the risk factors associated with four TB rates in cattle: prevalence, incidence, maintenance and persistence in Spain during the period 2014-2019. The modeling approach included highly informative spatio-temporal latent effects with which to control the limitations of the data. Variation partitioning procedures were carried out, and the pure effect of each factor was mapped in order to identify the most relevant factors associated with TB dynamics in cattle in each region. This made it possible to disclose that the movement of cattle, particularly from counties with herd incidence > 1%, was the main driver of the TB dynamics in cattle. The abundance of herds bred for bullfighting was retained in all four models, but had less weight than the movements. After accounting for farm-related factors, the TB prevalence in wild boar was retained in all the models and was significantly related to incidence, maintenance and persistence. With regard to the incidence, variation partitioning revealed that wildlife was the most explicative factor, thus suggesting that it plays a role in the introduction of the pathogen into uninfected herds, and consequently highlighting its importance in breakdowns. These results show, for the first time on a national scale, that wild ungulates play a relevant role in the spatio-temporal variability of TB in cattle, particularly as regards their disease status. Moreover, the spatial representation of the pure effect of each factor made it possible to identify which factors are driving the disease dynamics in each region, thus showing that it is a valuable tool with which to focus efforts towards achieving the OTF status.

Spiny but photogenic: Amateur sightings complement herbarium specimens to reveal the bioregions of cacti.

PREMISE: Cacti are characteristic elements of the Neotropical flora and of major interest for biogeographic, evolutionary, and ecological studies. We tested global biogeographic boundaries for Neotropical Cactaceae using specimen-based occurrences, coupled with data from visual observations, as a means to tackle the known collection biases in the family. METHODS: Species richness and record density were assessed for preserved specimens and human observations, and a bioregional scheme tailored to Cactaceae was produced using the interactive web application Infomap Bioregions, based on data from 261,272 point records cleaned through automated and manual steps. RESULTS: We found that areas in Mexico and southwestern USA, in eastern Brazil, and along the Andean region have the greatest density of records and the highest species richness. Human observations complement information from preserved specimens substantially, especially along the Andes. We propose 24 cactus bioregions, among which the most species-rich are northern Mexico/southwestern USA, central Mexico, southern central Mexico, Central America, Mexican Pacific coast, central and southern Andes, northwestern Mexico/extreme southwestern USA, southwestern Bolivia, northeastern Brazil, and Mexico/Baja California. CONCLUSIONS: The bioregionalization proposed shows biogeographic boundaries specific to cacti and can thereby aid further evolutionary, biogeographic, and ecological studies by providing a validated framework for further analyses. This classification builds upon, and is distinctive from, other expert-derived regionalization schemes for other taxa. Our results showcase how observation data, including citizen-science records, can complement traditional specimen-based data for biogeographic research, particularly for taxa with specific specimen collection and preservation challenges and those that are threatened or internationally protected.