In March 2020, shelter-in-place orders were enacted to attenuate the spread of coronavirus 2019 (COVID-19). Emergency departments (EDs) experienced unexpected and dramatic decreases in patient ...volume, raising concerns about exacerbating health disparities.
We queried our electronic health record to describe the overall change in visits to a two-ED healthcare system in Northern California from March-June 2020 compared to 2019. We compared weekly absolute numbers and proportional change in visits focusing on race/ethnicity, insurance, household income, and acuity. We calculated the z-score to identify whether there was a statistically significant difference in proportions between 2020 and 2019.
Overall ED volume declined 28% during the study period. The nadir of volume was 52% of 2019 levels and occurred five weeks after a shelter-in-place order was enacted. Patient demographics also shifted. By week 4 (April 5), the proportion of Hispanic patients decreased by 3.3 percentage points (pp) (P = 0.0053) compared to a 6.2 pp increase in White patients (P = 0.000005). The proportion of patients with commercial insurance increased by 11.6 pp, while Medicaid visits decreased by 9.5 pp (P < 0.00001) at the initiation of shelter-in-place orders. For patients from neighborhoods <300% federal poverty levels (FPL), visits were -3.8 pp (P = 0.000046) of baseline compared to +2.9 pp (P = 0.0044) for patients from ZIP codes at >400% FPL the week of the shelter-in-place order. Overall, 2020 evidenced a consistently elevated proportion of high-acuity Emergency Severity Index (ESI) level 1 patients compared to 2019. Increased acuity was also demonstrated by an increase in the admission rate, with a 10.8 pp increase from 2019. Although there was an increased proportion of high-acuity patients, the overall census was decreased.
Our results demonstrate changing ED utilization patterns circa the shelter-in-place orders. Those from historically vulnerable populations such as Hispanics, those from lower socioeconomic areas, and Medicaid users presented at disproportionately lower rates and numbers than other groups. As the pandemic continues, hospitals should use operations data to monitor utilization patterns by demographic, in addition to clinical indicators. Messaging about availability of emergency care and other services should include vulnerable populations to avoid exacerbating healthcare disparities.
Coffee beverage is a source of dietary fiber composed by arabinogalactans, which can also be associated to proteins and phenolic compounds, originating melanoidins. Human colonic in vitro ...fermentations of coffee fractions, one rich in melanoidins (Mel) and the other in its parental polysaccharide arabinogalactans (AG), were performed in order to evaluate the metabolites produced by microbiota, namely short-chain fatty acids (SCFA), phenolic compounds, and bile acids. After 48 h of fermentation, a higher fermentability of the carbohydrate fraction of AG (62 %) than that of Mel (27 %) was observed, resulting in a SCFA content of 63 mM and 22 mM, respectively. Supplementation with AG and Mel fractions decreased the acetate:propionate ratio from 4.7 (in the absence of coffee fractions) to 2.5 and 3.5, respectively, suggesting a potential inhibition of HMG-CoA reductase, a rate-limiting enzyme for cholesterol synthesis. The fermentation of coffee fractions yielded dihydroferulic and dihydrocaffeic acids, known to have antioxidant properties. In the presence of Mel, it was observed a decrease (from 0.25 to 0.16 mg/mL) in the production of secondary bile acids, whose high content is associated to the development of several diseases, such as colorectal cancer, neurodegenerative and cardiovascular.
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•Arabinogalactan and melanoidin-rich fractions are fermented by human faecal microbiota.•Arabinogalactan-rich fractions enhances the production of propionate.•Hypercholesterolemic secondary bile acids decrease upon fermentation of coffee melanoidins.•Coffee fractions maintained high antioxidant activity after metabolization by gut microbiota.•Dihydro phenolic acids were produced in the presence of coffee macromolecular fractions.
This work intends to evaluate the use of epoxy composite materials reinforced with basalt fibers as replacement to metallic mechanical parts of a highly efficient electrical prototype. The analysis ...of the behavior of the original metallic bracket was made and an optimization process was carried out in order to achieve the most suitable geometry and stacking sequence if produced in composite material. Finite element analysis using Siemens NX12 and experimental tests to the produced composite part were performed in order to access it. It was verified that the total weight of the composite part shows a 45% reduction. The composite part shows a higher deformation than the metallic one due to basalt fiber’s higher flexibility. However, the advantages added by the new component largely compensate for the disadvantages that may have been added without compromising its performance. Obtained results show that the use of basalt fiber reinforced composites as the material of mechanical parts of a highly efficient electrical prototype that is a good alternative.
Artificial intelligence (AI), more specifically large language models (LLMs), holds significant potential in revolutionizing emergency care delivery by optimizing clinical workflows and enhancing the ...quality of decision-making. Although enthusiasm for integrating LLMs into emergency medicine (EM) is growing, the existing literature is characterized by a disparate collection of individual studies, conceptual analyses, and preliminary implementations. Given these complexities and gaps in understanding, a cohesive framework is needed to comprehend the existing body of knowledge on the application of LLMs in EM.
Given the absence of a comprehensive framework for exploring the roles of LLMs in EM, this scoping review aims to systematically map the existing literature on LLMs' potential applications within EM and identify directions for future research. Addressing this gap will allow for informed advancements in the field.
Using PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) criteria, we searched Ovid MEDLINE, Embase, Web of Science, and Google Scholar for papers published between January 2018 and August 2023 that discussed LLMs' use in EM. We excluded other forms of AI. A total of 1994 unique titles and abstracts were screened, and each full-text paper was independently reviewed by 2 authors. Data were abstracted independently, and 5 authors performed a collaborative quantitative and qualitative synthesis of the data.
A total of 43 papers were included. Studies were predominantly from 2022 to 2023 and conducted in the United States and China. We uncovered four major themes: (1) clinical decision-making and support was highlighted as a pivotal area, with LLMs playing a substantial role in enhancing patient care, notably through their application in real-time triage, allowing early recognition of patient urgency; (2) efficiency, workflow, and information management demonstrated the capacity of LLMs to significantly boost operational efficiency, particularly through the automation of patient record synthesis, which could reduce administrative burden and enhance patient-centric care; (3) risks, ethics, and transparency were identified as areas of concern, especially regarding the reliability of LLMs' outputs, and specific studies highlighted the challenges of ensuring unbiased decision-making amidst potentially flawed training data sets, stressing the importance of thorough validation and ethical oversight; and (4) education and communication possibilities included LLMs' capacity to enrich medical training, such as through using simulated patient interactions that enhance communication skills.
LLMs have the potential to fundamentally transform EM, enhancing clinical decision-making, optimizing workflows, and improving patient outcomes. This review sets the stage for future advancements by identifying key research areas: prospective validation of LLM applications, establishing standards for responsible use, understanding provider and patient perceptions, and improving physicians' AI literacy. Effective integration of LLMs into EM will require collaborative efforts and thorough evaluation to ensure these technologies can be safely and effectively applied.
EXPOsOMICS is a European Union funded project that aims to develop a novel approach to the assessment of exposure to high priority environmental pollutants, by characterizing the external and the ...internal components of the exposome. It focuses on air and water contaminants during critical periods of life. To this end, the project centres on 1) exposure assessment at the personal and population levels within existing European short and long-term population studies, exploiting available tools and methods which have been developed for personal exposure monitoring (PEM); and 2) multiple “omic” technologies for the analysis of biological samples (internal markers of external exposures). The search for the relationships between external exposures and global profiles of molecular features in the same individuals constitutes a novel advancement towards the development of “next generation exposure assessment” for environmental chemicals and their mixtures. The linkage with disease risks opens the way to what are defined here as ‘exposome-wide association studies’ (EWAS).
Resumo Desde os anos 1980, os sistemas de saúde europeus vêm passando por várias reformas, com ênfase à tendência de sua mercantilização. O objetivo deste artigo é evidenciar formas de implementação ...de mecanismos de mercado no funcionamento desses sistemas, alemão, britânico e francês – a partir da década de 1980. As reformas “mercantis” eram justificadas a partir da premissa de que a inserção da lógica de mercado poderia tanto diminuir a necessidade de gastos públicos como aumentar a eficiência dos existentes. O trabalho apresenta diferentes formas de mercantilização implementadas nas reformas, com a distinção entre os processos de mercantilização explícita, em que há efetivo aumento da presença privada, e implícita, em que ocorre a incorporação de princípios advindos do setor privado no sistema público, tanto no financiamento como na prestação de serviços de saúde. Além do detalhamento das diferentes maneiras em que este fenômeno se expressa, o artigo apresenta brevemente os potenciais efeitos negativos desse processo para os sistemas de saúde, principalmente em termos de acesso e equidade, explicitando que as premissas iniciais em torno da mercantilização (redução de gastos e melhora na eficiência) parecem ser falsas.
Abstract Since the 1980s, European health systems have undergone several reforms, with emphasis on the tendency of their commodification. The objective of this article is to demonstrate how market mechanisms were implemented in the functioning of these systems, german, british and french – from the 1980s. The “mercantile” reforms were justified on the premise that the insertion of market logic could both reduce the need for public spending and increase the efficiency of existing expenditure. The work presents different forms of commodification implemented in the reforms, with the distinction between processes of explicit commodification, in which there is an effective increase in private, and implicit presence, in which there is incorporation of principles from the private sector in the public system, both in financing and in the provision of health services. In addition to detailing the different ways in which this phenomenon is expressed, the article briefly presents the potential negative effects of this process for health systems, especially in terms of access and equity, stating that the initial assumptions surrounding commodification (cost reduction and efficiency improvement) appear to be false.
Histone variants establish structural and functional diversity of chromatin by affecting nucleosome stability and histone-protein interactions. H3.3 is an H3 histone variant that is incorporated into ...chromatin outside of S-phase in various eukaryotes. In animals, H3.3 is associated with active transcription and possibly maintenance of transcriptional memory. Plant H3 variants, which evolved independently of their animal counterparts, are much less well understood.
We profile the H3.3 distribution in Arabidopsis at mono-nucleosomal resolution using native chromatin immunoprecipitation. This results in the precise mapping of H3.3-containing nucleosomes, which are not only enriched in gene bodies as previously reported, but also at a subset of promoter regions and downstream of the 3' ends of active genes. While H3.3 presence within transcribed regions is strongly associated with transcriptional activity, H3.3 at promoters is often independent of transcription. In particular, promoters with GA motifs carry H3.3 regardless of the gene expression levels. H3.3 on promoters of inactive genes is associated with H3K27me3 at gene bodies. In addition, H3.3-enriched plant promoters often contain RNA Pol II considerably upstream of the transcriptional start site. H3.3 and RNA Pol II are found on active as well as on inactive promoters and are enriched at strongly regulated genes.
In animals and plants, H3.3 organizes chromatin in transcribed regions and in promoters. The results suggest a function of H3.3 in transcriptional regulation and support a model that a single ancestral H3 evolved into H3 variants with similar sub-functionalization patterns in plants and animals.
Precision emergency medicine Strehlow, Matthew; Alvarez, Al'ai; Blomkalns, Andra L. ...
Academic emergency medicine,
06/2024
Journal Article
Recenzirano
Odprti dostop
Abstract Background Precision health is a burgeoning scientific discipline that aims to incorporate individual variability in biological, behavioral, and social factors to develop personalized health ...solutions. To date, emergency medicine has not deeply engaged in the precision health movement. However, rapid advances in health technology, data science, and medical informatics offer new opportunities for emergency medicine to realize the promises of precision health. Methods In this article, we conceptualize precision emergency medicine as an emerging paradigm and identify key drivers of its implementation into current and future clinical practice. We acknowledge important obstacles to the specialty‐wide adoption of precision emergency medicine and offer solutions that conceive a successful path forward. Results Precision emergency medicine is defined as the use of information and technology to deliver acute care effectively, efficiently, and authentically to individual patients and their communities. Key drivers and opportunities include leveraging human data, capitalizing on technology and digital tools, providing deliberate access to care, advancing population health, and reimagining provider education and roles. Overcoming challenges in equity, privacy, and cost is essential for success. We close with a call to action to proactively incorporate precision health into the clinical practice of emergency medicine, the training of future emergency physicians, and the research agenda of the specialty. Conclusions Precision emergency medicine leverages new technology and data‐driven artificial intelligence to advance diagnostic testing, individualize patient care plans and therapeutics, and strategically refine the convergence of the health system and the community.
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