Potentially avoidable 30-day hospital readmissions in medical patients: derivation and validation of a prediction model

IMPORTANCE Because effective interventions to reduce hospital readmissions are often expensive to implement, a score to predict potentially avoidable readmissions may help target the patients most likely to benefit. OBJECTIVE To derive and internally validate a prediction model for potentially avoidable 30-day hospital readmissions in medical patients using administrative and clinical data readily available prior to discharge. DESIGN Retrospective cohort study. SETTING Academic medical center in Boston, Massachusetts. PARTICIPANTS All patient discharges from any medical services between July 1, 2009, and June 30, 2010. MAIN OUTCOME MEASURES Potentially avoidable 30-day readmissions to 3 hospitals of the Partners HealthCare network were identified using a validated computerized algorithm based on administrative data (SQLape). A simple score was developed using multivariable logistic regression, with two-thirds of the sample randomly selected as the derivation cohort and one-third as the validation cohort. RESULTS Among 10 731 eligible discharges, 2398 discharges (22.3%) were followed by a 30-day readmission, of which 879 (8.5% of all discharges) were identified as potentially avoidable. The prediction score identified 7 independent factors, referred to as the HOSPITAL score: h emoglobin at discharge, discharge from an o ncology service, s odium level at discharge, p rocedure during the index admission, i ndex t ype of admission, number of a dmissions during the last 12 months, and l ength of stay. In the validation set, 26.7% of the patients were classified as high risk, with an estimated potentially avoidable readmission risk of 18.0% (observed, 18.2%). The HOSPITAL score had fair discriminatory power (C statistic, 0.71) and had good calibration. CONCLUSIONS AND RELEVANCE This simple prediction model identifies before discharge the risk of potentially avoidable 30-day readmission in medical patients. This score has potential to easily identify patients who may need more intensive transitional care interventions.

Climatic variability during the last interglacial inferred from geochemical proxies in the Lake El'gygytgyn sediment record

The Last Interglacial Period (LIP) is often regarded as a good analogue for potential climatic conditions under predicted global warming scenarios. Despite this, there is still debate over the nature, duration and frequency of climatic changes during this period. One particularly contentious issue has been the apparent evidence of climatic instability identified in many marine cores but seemingly lacking from many terrestrial archives, especially within the Arctic, a key region for global climate change research. In this paper, geochemical records from Lake El'gygytgyn, north-eastern Russia, are used to infer past climatic changes during the LIP from within the high Arctic. With a sampling resolution of ~20–~90 years, these records offer the potential for detailed, high-resolution palaeoclimate reconstruction. This study shows that the LIP commenced in central Chukotka ~129 thousand years ago (ka), with the warmest climatic conditions occurring between ~128 and 127 ka before being interrupted by a short-lived cold reversal. Mild climatic conditions then persisted until ~122 ka when a marked reduction in the sedimentation rate suggests a decrease in precipitation. A further climatic deterioration at ~118 ka marks the return to glacial conditions. This study highlights the value of incorporating several geochemical proxies when inferring past climatic conditions, thus providing the potential to identify signals related to environmental change within the catchment. We also demonstrate the importance of considering how changes in sedimentation rate influence proxy records, in order to develop robust palaeoenvironmental reconstructions.

Intraoperative fabrication of patient-specific moulded implants for skull reconstruction: single-centre experience of 28 cases

BACKGROUND Intraoperatively fabricated polymethylmethacrylate (PMMA) implants based on computer-designed moulds were used to improve cosmetic results after hard tissue replacement. To assess the implant's cosmetic and functional results we performed both subjective and objective assessments. METHODS This retrospective analysis was performed using a cohort of 28 patients who received PMMA implants between February 2009 and March 2012. The cosmetic and functional results were assessed using a patient questionnaire. Furthermore an objective volumetric subtraction score (0-100) was applied and implant thickness, as well as gaps and tiers, were measured. RESULTS Patients mainly judged their cosmetic result as "good". Two of the 28 patients found their cosmetic result unfavourable. The functional result and stability was mainly judged to be good. Measurements of implant thickness showed a very high correlation with the thickness of the contralateral bone. Volumetric subtraction led to a median quality of 80 on a scale from 0 to 100. Median gaps around the margins of the implant were 1.5 mm parietally, 1.7 mm frontally and 3.5 mm fronto-orbitally, and median tiers were 1.2 mm, 0 mm and 0 mm respectively. The overall rate of surgical revisions was 10.7 % (three patients). Two patients suffered from wound healing disturbances (7.1 %). The overall complication rate was comparable to other reports in the literature. CONCLUSIONS Implantation of intraoperatively fabricated patient-specific moulded implants is a cost-effective and safe technique leading to good clinical results with a low complication rate.

Swiss tree rings reveal warm and wet summers during medieval times

We present a 1200 year drought reconstruction for the European Alpine region based on carbon isotope variations of tree rings from living larch trees and historic timber. The carbon isotope fractionation at the study site is sensitive to summer precipitation, temperature, and irradiance, resulting in a stable and high correlation with a drought index for interannual to decadal frequencies and possibly beyond (r(2)=0.58 for 1901-2004, July/August). When combining this information with maximum latewood density-derived summer temperature, a strongly reduced occurrence of summer droughts during the warm A.D. 900-1200 period is evident, coinciding with the Medieval Climate Anomaly (MCA), with a shift to colder and drier conditions for the subsequent centuries. The warm-wet MCA contrasts strongly with the climate of the drought-prone warm phase of the recent decades, indicating different forcing mechanism for these two warm periods and pointing to beneficial conditions for agriculture and human well-being during the MCA in this region.

The basel cocktail for simultaneous phenotyping of human cytochrome P450 isoforms in plasma, saliva and dried blood spots.

BACKGROUND AND OBJECTIVE Phenotyping cocktails use a combination of cytochrome P450 (CYP)-specific probe drugs to simultaneously assess the activity of different CYP isoforms. To improve the clinical applicability of CYP phenotyping, the main objectives of this study were to develop a new cocktail based on probe drugs that are widely used in clinical practice and to test whether alternative sampling methods such as collection of dried blood spots (DBS) or saliva could be used to simplify the sampling process. METHODS In a randomized crossover study, a new combination of commercially available probe drugs (the Basel cocktail) was tested for simultaneous phenotyping of CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6 and CYP3A4. Sixteen subjects received low doses of caffeine, efavirenz, losartan, omeprazole, metoprolol and midazolam in different combinations. All subjects were genotyped, and full pharmacokinetic profiles of the probe drugs and their main metabolites were determined in plasma, dried blood spots and saliva samples. RESULTS The Basel cocktail was well tolerated, and bioequivalence tests showed no evidence of mutual interactions between the probe drugs. In plasma, single timepoint metabolic ratios at 2 h (for CYP2C19 and CYP3A4) or at 8 h (for the other isoforms) after dosing showed high correlations with corresponding area under the concentration-time curve (AUC) ratios (AUC0-24h parent/AUC0-24h metabolite) and are proposed as simple phenotyping metrics. Metabolic ratios in dried blood spots (for CYP1A2 and CYP2C19) or in saliva samples (for CYP1A2) were comparable to plasma ratios and offer the option of minimally invasive or non-invasive phenotyping of these isoforms. CONCLUSIONS This new combination of phenotyping probe drugs can be used without mutual interactions. The proposed sampling timepoints have the potential to facilitate clinical application of phenotyping but require further validation in conditions of altered CYP activity. The use of DBS or saliva samples seems feasible for phenotyping of the selected CYP isoforms.

Patient-reported outcomes in borderline personality disorder.

Patient-reported outcome (PRO) refers to measures that emphasize the subjective view of patients about their health-related conditions and behaviors. Typically, PROs include self-report questionnaires and clinical interviews. Defining PROs for borderline personality disorder (BPD) is particularly challenging given the disorder's high symptomatic heterogeneity, high comorbidity with other psychiatric conditions, highly fluctuating symptoms, weak correlations between symptoms and functional outcomes, and lack of valid and reliable experimental measures to complement self-report data. Here, we provide an overview of currently used BPD outcome measures and discuss them from clinical, psychometric, experimental, and patient perspectives. In addition, we review the most promising leads to improve BPD PROs, including the DSM-5 Section III, the Recovery Approach, Ecological Momentary Assessments, and novel experimental measures of social functioning that are associated with functional and social outcomes.

Mindfulness-based cognitive therapie for depression (MBCT) in clinical practice - baseline patient characteristics, process and outcome

Introduction: Mindfulness based cognitive therapy for depression (MBCT) has shown to be effective for the reduction of depressive relapse. However, additional information regarding baseline patient characteristics and process features related to positive response could be helpful both for the provision of MBCT in clinical practice, as well as for its further development. Method: Baseline characteristics, process data, and immediate outcome (symptom change, change in attitudes and trait mindfulness) of 108 patients receiving MBCT in routine care were recorded. A newly developed self-report measure (Daily Mindfulness Scale, DMS) was applied daily during the MBCT program. Additionally, patients filed daily reports on their mindfulness practice. There was no control group available. Results: Patients with more severe initial symptoms indicated greater amounts of symptom improvement, but did not show great rates of dropout from the MBCT intervention. Younger age was related to higher rates of dropout. Contradictory to some previous data, patients with lower levels of initial trait mindfulness showed greater improvement in symptoms, even after controlling for initial levels of symptoms. Adherence to daily mindfulness practice was high. Consistent with this result, the duration of daily mindfulness practice was not related to immediate outcome. Process studies using multivariate time series analysis revealed a specific role of daily mindfulness in reducing subsequent negative mood. Conclusions: Within the range of patient present in this study and the given study design, results support the use of MBCT in more heterogeneous groups. This demanding intervention was well tolerated by patients with higher levels of symptoms, and resulted in significant improvements regarding residual symptoms. Process-outcome analyses of initial trait mindfulness and daily mindfulness both support the crucial role of changes in mindfulness for the effects of MBCT.

Song Choices of Swiss Sathya Sai Baba Devotees

The charismatic and controversial Indian guru Sathya Sai Baba is the centre of attention and devotion for a great number of adherents from various national, religious, and ethnic backgrounds. Due to its global spread, the Sathya Sai Baba movement is an ideal case for examining displaced religious practices. Singing is a vital part of the religious practice of Sai devotees. In this article I will discuss the contents and usage of the songbook that Swiss devotees compiled. We can observe the extent to which Indian contents are carried over and how they are supplemented with Swiss songs, but also with songs perceived as being part of a universal spiritual treasury of songs (e.g. Native American, Hebrew or International Christian songs). I will suggest that the concept of de- and reterritorialization helps us to analyze the practices of this global religious community. Additionally, I will argue that the devotees’ choice of songs and their singing practices are indeed a manifestation of their claim to universalism as well as their need to be rooted locally. I will further argue that a globalized religious movement is limited in dealing with the encounter of diverse cultural contents by the strategy of reterritorialization, but beyond that creates a new and supraterritorial cultural context.

Carbon storage versus albedo change: radiative forcing of forest expansion in temperate mountainous regions of Switzerland

In this study, we assess the climate mitigation potential from afforestation in a mountainous snow-rich region (Switzerland) with strongly varying environmental conditions. Using radiative forcing calculations, we quantify both the carbon sequestration potential and the effect of albedo change at high resolution. We calculate the albedo radiative forcing based on remotely sensed data sets of albedo, global radiation and snow cover. Carbon sequestration is estimated from changes in carbon stocks based on national inventories. We first estimate the spatial pattern of radiative forcing (RF) across Switzerland assuming homogeneous transitions from open land to forest. This highlights where forest expansion still exhibits climatic benefits when including the radiative forcing of albedo change. Second, given that forest expansion is currently the dominant land-use change process in the Swiss Alps, we calculate the radiative forcing that occurred between 1985 and 1997. Our results show that the net RF of forest expansion ranges from −24 W m−2 at low elevations of the northern Prealps to 2 W m−2 at high elevations of the Central Alps. The albedo RF increases with increasing altitude, which offsets the CO2 RF at high elevations with long snow-covered periods, high global radiation and low carbon sequestration. Albedo RF is particularly relevant during transitions from open land to open forest but not in later stages of forest development. Between 1985 and 1997, when overall forest expansion in Switzerland was approximately 4%, the albedo RF offset the CO2 RF by an average of 40%. We conclude that the albedo RF should be considered at an appropriately high resolution when estimating the climatic effect of forestation in temperate mountainous regions.

HOMO Stabilisation in π-Extended Dibenzotetrathiafulvalene Derivatives for Their Application in Organic Field-Effect Transistors

Three new organic semiconductors, in which either two methoxy units are directly linked to a dibenzotetrathiafulvalene (DB-TTF) central core and a 2,1,3-chalcogendiazole is fused on the one side, or four methoxy groups are linked to the DB-TTF, have been synthesised as active materials for organic field-effect transistors (OFETs). Their electrochemical behaviour, electronic absorption and fluorescence emission as well as photoinduced intramolecular charge transfer were studied. The electron-withdrawing 2,1,3-chalcogendiazole unit significantly affects the electronic properties of these semiconductors, lowering both the HOMO and LUMO energy levels and hence increasing the stability of the semiconducting material. The solution-processed single-crystal transistors exhibit high performance with a hole mobility up to 0.04 cm2 V−1 s−1 as well as good ambient stability.

Triple-peptide receptor targeting in vitro allows detection of all tested gut and bronchial NETs.

UNLABELLED A high proportion of gut and bronchial neuroendocrine tumors (NETs) overexpresses somatostatin receptors, especially the sst2 subtype. It has also recently been observed that incretin receptors, namely glucagonlike peptide 1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP) receptors, can be overexpressed in gut and bronchial NETs. However, because not all tumors can express these receptors in sufficient amounts, in vivo imaging with a single radioligand may not always be successful. We therefore evaluated with in vitro methods whether a cocktail of radioligands targeting these 3 receptors would improve tumor labeling. METHODS In vitro receptor autoradiography was performed on 55 NETs, comparing in each successive section of tumor the binding with a single radioligand, either (125)I-Tyr(3)-octreotide, (125)I-GLP-1(7-36)amide, or (125)I-GIP(1-30), with the binding using a cocktail of all 3 radioligands, given concomitantly under identical experimental conditions. RESULTS Using the cocktail of radioligands, all tumors without exception showed moderate to very high binding, with a receptor density corresponding to 1,000-10,000 dpm/mg of tissue; conversely, single-ligand binding, although identifying most tumors as receptor-positive, failed to detect receptors or measured only a low density of receptors below 1,000 dpm/mg in a significant number of tumors. In addition, the cocktail of radioligands always provided a homogeneous labeling of the whole tumor, whereas single radioligands occasionally showed heterogeneous labeling. CONCLUSION The study suggests that the use of a cocktail of 3 radioligands binding to somatostatin receptors, GLP-1 receptors, and GIP receptors would allow detecting virtually all NETs and labeling them homogeneously in vivo, representing a significant improvement for imaging and therapy in NETs.

In vitro effects of 3 % hypertonic saline and 20 % mannitol on canine whole blood coagulation and platelet function.

BACKGROUND: Hyperosmolar therapy, using either mannitol or hypertonic saline (HTS), is considered the treatment of choice for intracranial hypertension. However, hyperosmolar agents may impair coagulation and platelet function, limiting their use in patients at risk for hemorrhage. Despite this, studies evaluating the effects of mannitol compared to other hyperosmolar agents in dogs are largely lacking. The aim of this study was to compare the in vitro effects on global hemostasis and platelet function of 20 % mannitol and 3 % HTS on canine blood. METHODS: Citrated whole blood from 15 healthy dogs was diluted with 0.9 % saline, 20 % mannitol and 3 % HTS in ratios of 1:16 and 1:8. Rotational thromboelastometry (ROTEM) was used to assess clotting time (CT), clot formation time (CFT) and maximal clot firmness (MCF) following extrinsic activation (Ex-tem) and after platelet inhibition (Fib-tem). A platelet function analyzer (PFA-100) was used to assess closure time (CtPFA). RESULTS: No significant differences were observed between untreated whole blood and samples diluted with saline. Samples diluted with both mannitol and HTS were hypocoagulable compared to untreated whole blood samples. At a dilution of 1:16, no significant differences were found between any measured parameter in samples diluted with saline compared to mannitol or HTS. At a 1:8 dilution, CtPFA was prolonged in samples diluted with mannitol and HTS compared to saline, and CtPFA was prolonged more with mannitol than HTS. Ex-tem CT was increased at a 1:8 dilution with mannitol compared to HTS. Ex-tem CFT was prolonged at a 1:8 dilution with both agents compared to saline, and was prolonged more with mannitol than HTS. Ex-tem MCF was reduced at a 1:8 dilution with both agents compared to saline. DISCUSSION AND CONCLUSIONS: Data in this study indicate that both mannitol and HTS affect canine platelet function and whole blood coagulation in vitro in a dose-dependent fashion. The most pronounced effects were observed after high dilutions with mannitol, which impaired platelet aggregation, clot formation time, clot strength, and fibrin formation significantly more than HTS. Further in vivo studies are necessary before recommendations can be made

What’s the best method? Comparison of different short forms oft he Pathological Narcissism Inventory

Recent research emphasizes the various facets of narcissism. As a consequence, newly developed questionnaires for narcissism have a large number of subscales and items. However, for the daily use in research and practice, short measures are crucial. In this study we compare different short forms of the Pathological Narcissism Questionnaire, a 54 item measure with seven subscales. In different samples (total N>2000) we applied different theoretical models to construct short forms of approximately 20 items. In particular, we compared IRT, item-total correlation, and factor loading based short forms and versions based on content validity and random selection. In all versions the original subscale structure was preserved. Results show that the short forms all have high correlations with the original version. Furthermore, correlations with criterion validation measures were comparable. We conclude that the item number can be reduced substantially without loosing information. Pros and cons of the different reduction methods are discussed.

Ocean dynamics, not dust, have controlled equatorial Pacific productivity over the past 500,000 years

Biological productivity in the equatorial Pacific is relatively high compared with other low-latitude regimes, especially east of the dateline, where divergence driven by the trade winds brings nutrient rich waters of the Equatorial Undercurrent to the surface. The equatorial Pacific is one of the three principal high-nutrient low chlorophyll ocean regimes where biological utilization of nitrate and phosphate is limited, in part, by the availability of iron. Throughout most of the equatorial Pacific, upwelling of water from the Equatorial Undercurrent supplies far more dissolved iron than is delivered by dust, by as much as two orders of magnitude. Nevertheless, recent studies have inferred that the greater supply of dust during ice ages stimulated greater utilization of nutrients within the region of upwelling on the equator, thereby contributing to the sequestration of carbon in the ocean interior. Here we present proxy records for dust and for biological productivity over the past 500 ky at three sites spanning the breadth of the equatorial Pacific Ocean to test the dust fertilization hypothesis. Dust supply peaked under glacial conditions, consistent with previous studies, whereas proxies of export production exhibit maxima during ice age terminations. Temporal decoupling between dust supply and biological productivity indicates that other factors, likely involving ocean dynamics, played a greater role than dust in regulating equatorial Pacific productivity.

Field-Based Evaluations of Horizontal Flat-Plate Fish Screens

Diversions from streams are often screened to prevent the loss of or injury to fish. Hydraulic criteria meant to protect fish that encounter screens have been developed, but primarily for screens that are vertical to the water flow rather than horizontal. For this reason, we measured selected hydraulic variables and released wild rainbow trout Oncorhynchus mykiss over two types of horizontal flat-plate fish screens in the field. Our goal was to assess the efficacy of these screens under a variety of conditions in the field and provide information that could be used to develop criteria for safe fish passage. We evaluated three different inverted-weir screens over a range of strewn (0.24-1.77 m(3)/s) and diversion flows (0.10-0.31 m(3)/s). Approach velocities (AVs) ranged from 3 to 8 cm/s and sweeping velocities (SVs) from 69 to 143 cm/s. We also evaluated a simple backwatered screen over stream flows of 0.23-0.79 m(3)/s and diversion flows of 0.08-0.32 m(3)/s. The mean SVs for this screen ranged from 15 to 66 cm/s and the mean AVs from 1 to 5 cm/s. The survival rates of fish held for 24 h after passage over these screens exceeded 98%. Overall, the number of fish-screen contacts was low and the injuries related to passage were infrequent and consisted primarily of minor fin injuries. Our results indicate that screens of this type have great potential as safe and effective fish screens for small diversions. Care must be taken, however, to avoid operating conditions that produce shallow or no water over the screen surface, situations of high AVs and low SVs at backwatered screens, and situations producing a localized high AV with spiraling flow.