Potential health-care service utilization substitution effects induced by case management for emergency department frequent users

BACKGROUND: In most of the emergency departments (ED) in developed countries, a subset of patients visits the ED frequently. Despite their small numbers, these patients are the source of a disproportionally high number of all ED visits, and use a significant proportion of healthcare resources. They place a heavy economic burden on hospital and healthcare systems budgets overall. Several interventions have been carried out to improve the management of these ED frequent users. Case management has been shown in some North American studies to reduce ED utilization and costs. In these studies, cost analyses have been carried out from the hospital perspective without examining the costs induced by healthcare consumed in the community. However, case management might reduce ED visits and costs from the hospital's perspective, but induce substitution effects, and increase health service utilization outside the hospital. This study examined if an interdisciplinary case-management intervention-compared to standard ED care -reduced costs generated by frequent ED users not only from the hospital perspective, but also from the healthcare system perspective-that is, from a broader perspective taking into account the costs of healthcare services used outside the hospital. METHODS: In this randomized controlled trial, 250 adult frequent emergency department users (5 or more visits during the previous 12 months) who visited the ED of the University Hospital of Lausanne, Switzerland, between May 2012 and July 2013 were allocated to one of two groups: case management intervention (CM) or standard ED care (SC), and followed up for 12 months. Depending on the perspective of the analysis, costs were evaluated differently. For the analysis from the hospital's perspective, the true value of resources used to provide services was used as a cost estimate. These data were obtained from the hospital's analytical accounting system. For the analysis from the health-care system perspective, all health-care services consumed by users and charged were used as an estimate of costs. These data were obtained from health insurance providers for a subsample of participants. To allow comparisons in a same time period, individual monthly average costs were calculated. Multivariate linear models including a fixed effect "group" were run using socio-demographic characteristics and health-related variables as controlling variables (age, gender, educational level, citizenship, marital status, somatic and mental health problems, and risk behaviors).

pH:n stabiilisuus ditioniittivalkaistulla neutraalilla LWC-prosessilla

Tässä työssä Oy Keskuslaboratoriossa sijaitsevalla kiertovesisimulaattorilla on tutkittiu ditioniittivalkaisun ja hylyn määrän vaikutusta pH:n stabiilisuuteen ja häiriöaineiden määrään neutraalissa LWC-prosessissa. Lisäksi on tutkittu ditioniitin määrän seisokkien ja valkaisuviiveiden vaikutusta. Kirjallisuusosassa tutustutaan ditioniittivalkaisuun ja valkaisun kemiaan sekä kalsiumkarbonaatin liukenemiseen. Lyhyesti selvitetään myös paperikoneen vesikiertoja sekä prosessissa olevia häiriöaineita. Karbonaatin liukenemisen osalta tarkastellaan myös mahdollisuutta mallintaa prosessia. Diplomityön aikana ajettiin yhdeksän simulaattoriajoa, jotka ajettiin kahden tai kolmen ajon sarjoissa. Ajoja ajettiin kolmella eri hylkymäärällä. Ditioniittivalkaisun lisäksi suoritettiin referenssiajoja ilman valkaisua. Lyhyen kierron pH pyrittiin pääosin säätämään seitsemään. Valkaisuviiveiden ja yli-yön kestävien seisokkien vaikutusta tutkittiin myös. Kokeissa todettiin ditioniitin alentavan pH tasoa. Tämä pH:n aleneminen johtaa kalsiumkarbonaatin liukenemiseen kalsiumkarbonaatin pyrkiessä puskuroimaan pH:n laskua. Valkaisureaktiossa syntyy negatiivisesti varauruneita yhdisteitä, jotka lisäävät prosessin anionisuutta. Ditioniitin valkaisuvaikutus näkyi lopputuotteen vaaleuden kasvuna sekä kieroveden värillisten yhdisteiden vähenemisenä. Ditioniittivalkaisu näytti poistavan myös noin 30% ligniinistä. Lipofiilisiin uuteaineisiin ditioniitilla ei ollut vaikutusta. Riittävä ditioniittiannos kokeiden perusteella on korkeintaan 1% ditioniittiä käytetyn mekaanisen massan määrästä. Korkeammalla annostuksella ei ollut vaikutusta vaaleuteen. Valkaisuaikana 30 minuuttia on riittävä. Pidempien valkaisuviiveiden ja seisokkien aikana valkaisussa syntyvän sulfiitin todettiin muuttuvan sulfaatiksi. Hylyn määrän lisääminen nosti pH:ta, varausta, johtokykyä ja liuenneen kalsiumin määrään. Hylyn määrän lisäminen paransi myös optisia ominaisuuksia, mikä johtui osin hylyn sisältämästä kalsiumkarbonaatista ja osin hylyn sisältämästä mekaanisesta massasta, joka oli valkaistua.

Corruption scandals, press reporting, and accountability. Evidence from Spanish mayors.

[spa] En este trabajo se analiza con datos de España los efectos de la corrupción local sobre los resultados electorales. En base a las noticias publicadas entre 1996 y 2009, se construye una nueva base de datos que recoge los casos de corrupción y noticias relativas a cambios en los planes urbanísticos que no han seguido el procedimiento legal. La base de datos muestra que los primeros escándalos de corrupción urbanística surgieron durante el mandato electoral de 1999-2003, pero que éstos alcanzaron sus niveles máximos justo antes de las elecciones de 2007. Se estima una ecuación del porcentaje de voto obtenido por el partido en el poder en estas elecciones locales y se encuentra que la pérdida media de voto después de un caso de corrupción se sitúa alrededor del 4%. Este efecto es más elevado (del 9%) si el caso de corrupción ha recibido una amplia cobertura por los diarios. Los efectos estimados para las elecciones de 2003 son significativamente inferiores. Cuando se consideran los casos en que los políticos han tenido cargas judiciales por corrupción y amplia cobertura por los diarios, la pérdida de voto asciende hasta el 12%. No obstante, la cobertura por los diarios genera un efecto negativo en el voto incluso cuando no hay cargas judiciales.

Corruption scandals, press reporting, and accountability. Evidence from Spanish mayors.

[spa] En este trabajo se analiza con datos de España los efectos de la corrupción local sobre los resultados electorales. En base a las noticias publicadas entre 1996 y 2009, se construye una nueva base de datos que recoge los casos de corrupción y noticias relativas a cambios en los planes urbanísticos que no han seguido el procedimiento legal. La base de datos muestra que los primeros escándalos de corrupción urbanística surgieron durante el mandato electoral de 1999-2003, pero que éstos alcanzaron sus niveles máximos justo antes de las elecciones de 2007. Se estima una ecuación del porcentaje de voto obtenido por el partido en el poder en estas elecciones locales y se encuentra que la pérdida media de voto después de un caso de corrupción se sitúa alrededor del 4%. Este efecto es más elevado (del 9%) si el caso de corrupción ha recibido una amplia cobertura por los diarios. Los efectos estimados para las elecciones de 2003 son significativamente inferiores. Cuando se consideran los casos en que los políticos han tenido cargas judiciales por corrupción y amplia cobertura por los diarios, la pérdida de voto asciende hasta el 12%. No obstante, la cobertura por los diarios genera un efecto negativo en el voto incluso cuando no hay cargas judiciales.

Radio Imaging of the Very-High-Energy γ-Ray Emission Region in the Central Engine of a Radio Galaxy

The accretion of matter onto a massive black hole is believed to feed the relativistic plasma jets found in many active galactic nuclei (AGN). Although some AGN accelerate particles to energies exceeding 1012 electron volts and are bright sources of very-high-energy (VHE) γ-ray emission, it is not yet known where the VHE emission originates. Here we report on radio and VHE observations of the radio galaxy Messier 87, revealing a period of extremely strong VHE γ-ray flares accompanied by a strong increase of the radio flux from its nucleus. These results imply that charged particles are accelerated to very high energies in the immediate vicinity of the black hole.

Innate Immune Sensing of Fusarium culmorum by Mouse Dendritic Cells.

Chronic inhalation of grain dust is associated with asthma and chronic bronchitis in grain worker populations. Exposure to fungal particles was postulated to be an important etiologic agent of these pathologies. Fusarium species frequently colonize grain and straw and produce a wide array of mycotoxins that impact human health, necessitating an evaluation of risk exposure by inhalation of Fusarium and its consequences on immune responses. Data showed that Fusarium culmorum is a frequent constituent of aerosols sampled during wheat harvesting in the Vaud region of Switzerland. The aim of this study was to examine cytokine/chemokine responses and innate immune sensing of F. culmorum in bone-marrow-derived dendritic cells and macrophages. Overall, dendritic cells and macrophages responded to F. culmorum spores but not to its secreted components (i.e., mycotoxins) by releasing large amounts of macrophage inflammatory protein (MIP)-1α, MIP-1β, MIP-2, monocyte chemoattractant protein (MCP)-1, RANTES, and interleukin (IL)-12p40, intermediate amounts of tumor necrosis factor (TNF), IL-6, IL-12p70, IL-33, granulocyte colony-stimulating factor (G-CSF), and interferon gamma-induced protein (IP-10), but no detectable amounts of IL-4 and IL-10, a pattern of mediators compatible with generation of Th1 or Th17 antifungal protective immune responses rather than with Th2-dependent allergic responses. The sensing of F. culmorum spores by dendritic cells required dectin-1, the main pattern recognition receptor involved in β-glucans detection, but likely not MyD88 and TRIF-dependent Toll-like receptors. Taken together, our results indicate that F. culmorum stimulates potently innate immune cells in a dectin-1-dependent manner, suggesting that inhalation of F. culmorum from grain dust may promote immune-related airway diseases in exposed worker populations.

Capturing diagnosis-timing in ICD-coded hospital data: recommendations from the WHO ICD-11 topic advisory group on quality and safety.

PURPOSE: To develop a consensus opinion regarding capturing diagnosis-timing in coded hospital data. METHODS: As part of the World Health Organization International Classification of Diseases-11th Revision initiative, the Quality and Safety Topic Advisory Group is charged with enhancing the capture of quality and patient safety information in morbidity data sets. One such feature is a diagnosis-timing flag. The Group has undertaken a narrative literature review, scanned national experiences focusing on countries currently using timing flags, and held a series of meetings to derive formal recommendations regarding diagnosis-timing reporting. RESULTS: The completeness of diagnosis-timing reporting continues to improve with experience and use; studies indicate that it enhances risk-adjustment and may have a substantial impact on hospital performance estimates, especially for conditions/procedures that involve acutely ill patients. However, studies suggest that its reliability varies, is better for surgical than medical patients (kappa in hip fracture patients of 0.7-1.0 versus kappa in pneumonia of 0.2-0.6) and is dependent on coder training and setting. It may allow simpler and more precise specification of quality indicators. CONCLUSIONS: As the evidence indicates that a diagnosis-timing flag improves the ability of routinely collected, coded hospital data to support outcomes research and the development of quality and safety indicators, the Group recommends that a classification of 'arising after admission' (yes/no), with permitted designations of 'unknown or clinically undetermined', will facilitate coding while providing flexibility when there is uncertainty. Clear coding standards and guidelines with ongoing coder education will be necessary to ensure reliability of the diagnosis-timing flag.

Availability, Cost or Culture ? : Obstacles to Childcare Services for Low-Income Families

Recent research has highlighted the existence of a social bias in the extent to which children have access to childcare. In general, children living in higher income households are more likely to be cared for in childcare centres. While the existence of a social bias in access to childcare services has been clearly demonstrated, we currently lack a clear explanation as to why this is the case. This paper uses a unique dataset based on survey data collected specifically to study patterns of childcare use in the Swiss canton of Vaud (N = 875). The paper exploits the variation in the way childcare is organised within the canton. Childcare is a municipal policy, as a result of which there are twenty-nine different systems in operation. Fees are progressive everywhere, but variation is substantial. Availability is also very different. This peculiar institutional setup provides an ideal situation to examine the determinants of childcare use by different income groups. Our findings suggest that differences in the fees charged to low-income households, as well as the degree of progressivity of the fee structure, are significant predictors of use, while availability seems to matter less.

A definition and classification of status epilepticus - Report of the ILAE Task Force on Classification of Status Epilepticus.

The Commission on Classification and Terminology and the Commission on Epidemiology of the International League Against Epilepsy (ILAE) have charged a Task Force to revise concepts, definition, and classification of status epilepticus (SE). The proposed new definition of SE is as follows: Status epilepticus is a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms, which lead to abnormally, prolonged seizures (after time point t1 ). It is a condition, which can have long-term consequences (after time point t2 ), including neuronal death, neuronal injury, and alteration of neuronal networks, depending on the type and duration of seizures. This definition is conceptual, with two operational dimensions: the first is the length of the seizure and the time point (t1 ) beyond which the seizure should be regarded as "continuous seizure activity." The second time point (t2 ) is the time of ongoing seizure activity after which there is a risk of long-term consequences. In the case of convulsive (tonic-clonic) SE, both time points (t1 at 5 min and t2 at 30 min) are based on animal experiments and clinical research. This evidence is incomplete, and there is furthermore considerable variation, so these time points should be considered as the best estimates currently available. Data are not yet available for other forms of SE, but as knowledge and understanding increase, time points can be defined for specific forms of SE based on scientific evidence and incorporated into the definition, without changing the underlying concepts. A new diagnostic classification system of SE is proposed, which will provide a framework for clinical diagnosis, investigation, and therapeutic approaches for each patient. There are four axes: (1) semiology; (2) etiology; (3) electroencephalography (EEG) correlates; and (4) age. Axis 1 (semiology) lists different forms of SE divided into those with prominent motor systems, those without prominent motor systems, and currently indeterminate conditions (such as acute confusional states with epileptiform EEG patterns). Axis 2 (etiology) is divided into subcategories of known and unknown causes. Axis 3 (EEG correlates) adopts the latest recommendations by consensus panels to use the following descriptors for the EEG: name of pattern, morphology, location, time-related features, modulation, and effect of intervention. Finally, axis 4 divides age groups into neonatal, infancy, childhood, adolescent and adulthood, and elderly.

Molecular dynamics simulation of the spherical electrical double layer of a soft nanoparticle. Effect of the surface and counterion valence

Molecular dynamics simulations were performed to study the ion and water distribution around a spherical charged nanoparticle. A soft nanoparticle model was designed using a set of hydrophobic interaction sites distributed in six concentric spherical layers. In order to simulate the effect of charged functionalyzed groups on the nanoparticle surface, a set of charged sites were distributed in the outer layer. Four charged nanoparticle models, from a surface charge value of −0.035 Cm−2 to − 0.28 Cm−2, were studied in NaCl and CaCl2 salt solutions at 1 M and 0.1 M concentrations to evaluate the effect of the surface charge, counterion valence, and concentration of added salt. We obtain that Na + and Ca2 + ions enter inside the soft nanoparticle. Monovalent ions are more accumulated inside the nanoparticle surface, whereas divalent ions are more accumulated just in the plane of the nanoparticle surface sites. The increasing of the the salt concentration has little effect on the internalization of counterions, but significantly reduces the number of water molecules that enter inside the nanoparticle. The manner of distributing the surface charge in the nanoparticle (uniformly over all surface sites or discretely over a limited set of randomly selected sites) considerably affects the distribution of counterions in the proximities of the nanoparticle surface.

Effect of the surface charge discretization on electric double layers. A Monte Carlo simulation study

The structure of the electric double layer in contact with discrete and continuously charged planar surfaces is studied within the framework of the primitive model through Monte Carlo simulations. Three different discretization models are considered together with the case of uniform distribution. The effect of discreteness is analyzed in terms of charge density profiles. For point surface groups,a complete equivalence with the situation of uniformly distributed charge is found if profiles are exclusively analyzed as a function of the distance to the charged surface. However, some differences are observed moving parallel to the surface. Significant discrepancies with approaches that do not account for discreteness are reported if charge sites of finite size placed on the surface are considered.

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Occupational exposures to fungi are very frequent and are known to cause chronic or acute symptoms. To better assess health risks related to fungal exposure, it is crucial to characterize precisely the airborne fungal community in terms of quantity and composition. The objective of this chapter is to synthesize existing knowledge of airborne fungal contamination in various occupational settings. We analyzed 134 papers published between 2000 and 2014 focusing on five different work sectors considered as highly contaminated (i.e., more than 1000 fungal particles/m3): animal confinement buildings, sawmills, waste handling, the food industry, and grain/plant handling. Results show that harvesting grain, washing cheese, and handling salami seem to be the occupational situations with the worst potential for exposure. Moreover, a lack of standardized sampling and analysis methods among countries and even within the same country is highlighted. Occupational exposure limit values do not exist. Recommendations and guidelines based on culture-dependent methods, which are now recognized to underestimate true concentrations, are proposed. Those recommendations are frequently exceeded and protective measures are not always easy to implement.