Management of the temperate, grazed grasslands in New Zealand for more than a century has led to swards dominated by ryegrass/clover, which, with inputs of inorganic fertilizers, are highly ...productive for grazing animals. In the last 20 years the widespread introduction of irrigation to dryland areas on flat land has increased productivity further. However, these intensive practices decrease soil carbon stocks. In contrast, there is limited evidence that improved management of dryland, grazed, hill country grasslands can lead to increases in soil carbon stocks. To address global needs for food security and climate change mitigation, priority actions to increase soil carbon stocks need to focus on improved management practices to increase carbon inputs and retention in soils identified as having high potential for increasing carbon storage. While there are limited data from New Zealand studies, international observations suggest that soil carbon stocks can be increased by enhancing below-ground carbon inputs from plants with deep roots, using swards with diverse species, and moderate grazing rather than harvesting biomass. However, there is less certainty about the processes regulating the formation and decomposition of soil organic matter and their dependence on soil physical properties and microbial access. Scaling findings from plot studies to forecast long-term changes in soil carbon stocks at the landscape scale can be done using models but new approaches are required to integrate the impacts of multiple concurrent practices associated with grazing management.
An essential feature of the classical Greek city-state was the presence of a large body of 'metics', more or less permanent immigrants, most of them from other Greek cities, who played a large part ...in the economic, social and political life of the community but were excluded from citizenship in all but the most exceptional cases. Despite the importance of the subject, there has previously been no extended account in English. Dr Whitehead's monograph, based on an exhaustive register of the ancient sources, centres on the 'ideology' of the metic in Athens. How much ambiguity was there in his position vis-à-vis the exclusive in-group of citizens? Did the metic think of himself as in some respects an outsider? What were his rights and disabilities? After answering such questions in the analytical first part of the monograph, Dr Whitehead examines the history of the institution over two centuries and offers several new hypotheses about crucial stages in its history.
Remote patient monitoring (RPM) has shown promise in aiding safe and efficient remote care for chronic conditions; however, its use remains more limited within the hospital at home (HaH) model of ...care despite a significant opportunity to increase patient eligibility, improve safety, and decrease costs. HaH could achieve these goals by further adopting the 3 primary modalities of RPM (ie, vital sign, continuous single-lead electrocardiogram, and fall monitoring). With only 2 in-person vital sign checks required per day, HaH patient eligibility is currently often limited to lower-acuity cases. The use of vital sign RPM within HaH could better match the standard clinical practice of vital sign checks every 4-8 hours and enable safe care for appropriate moderate-acuity medical and surgical floor-level patients not traditionally enrolled in HaH. Robust, efficient collection of more frequent vital signs via RPM could expand patient eligibility for HaH and create a digital health safety net that enables high quality care. Similarly, our experience at Massachusetts General Hospital has demonstrated that appropriate use of continuous single-lead electrocardiogram RPM can also expand HaH enrollment, particularly for patients with acute decompensated heart failure. Through increasing enrollment of patients in HaH, RPM stands to enable more patients to reap the potential safety benefits of home hospitalization, including decreased rates of delirium and hospital-acquired infections, and better avoid aspects of posthospital syndrome. Furthermore, instituting fall detection RPM allows care teams to further HaH patient safety during their episode of acute care and develop enhanced mitigation strategies to avoid falls post home hospitalization. RPM also has the potential to assist HaH in achieving greater economies of scale and decreasing direct variable costs. By expanding HaH eligibility, RPM could enable HaH programs, which have traditionally operated under capacity, to care for a larger census and decrease allocated fixed costs per hospitalization. Additionally, RPM for HaH could further optimize hybrid in-home and remote nurse or physician evaluations, decreasing costs on a per-episode basis by up to an estimated 3.5%. Overall, RPM holds great promise to increase patient eligibility and patient safety while decreasing costs. However, it is in its infancy in achieving its potential to advance the HaH model of care; further research and experience that inform operational and technical as well as policy considerations are needed.
Emergency clinician–staffed telehealth programs seek to provide equitable, safe, efficient, effective, and patient-centered care. However, early studies show conflicting evidence on whether this aim ...is accomplished. Furthermore, how programs track the efficacy and safety of their programs remains largely unexplored. We sought to characterize ongoing quality monitoring among emergency clinician–staffed telehealth programs.
We identified representatives at emergency clinician–staffed telehealth programs through professional networks and published literature. Qualitative interviews were conducted, assessing quality metrics captured as well as motivations for and barriers to quality measurement. We classified quality metric measurement using the National Quality Forum Telehealth Measurement Framework Domains and Subdomains. We developed a codebook from interview transcripts for qualitative analysis to classify motivations for and barriers to quality measurement.
We held 8 qualitative interviews with physician representatives at primarily academic (7/8) and urban institutions (5/8). Most widely used quality metrics were related to patient and care team experience (7/8) as well as to access to care (6/8) and effectiveness (6/8). Few programs (2/8) measured finance-related quality metrics. Motivations for quality measurement varied considerably. Common barriers to implementation included technology challenges, data availability, and the lack of quality metric standardization.
We identified variation in the use and content of quality metrics across emergency clinician–staffed telehealth programs. Most commonly, programs used metrics related to clinical experience; financial metrics were rarely captured. Technology barriers to quality measurement were often cited across programs. Further work is needed to support the standardization and implementation of future quality measurement initiatives.
Climate change adaptation, mitigation and food security may be addressed at the same time by enhancing soil organic carbon (SOC) sequestration through environmentally sound land management practices. ...This is promoted by the “4 per 1000” Initiative, a multi-stakeholder platform aiming at increasing SOC storage through sustainable practices. The scientific and technical committee of the Initiative is working to identify indicators, research priorities and region-specific practices needed for their implementation. The Initiative received its name due to the global importance of soils for climate change, which can be illustrated by a thought experiment showing that an annual growth rate of only 0.4% of the standing global SOC stocks would have the potential to counterbalance the current increase in atmospheric CO₂. However, there are numerous barriers to the rise in SOC stocks and while SOC sequestration can contribute to partly offsetting greenhouse gas emissions, its main benefits are related to increased soil quality and climate change adaptation. The Initiative provides a collaborative platform for policy makers, practitioners, scientists and stakeholders to engage in finding solutions. Criticism of the Initiative has been related to the poor definition of its numerical target, which was not understood as an aspirational goal. The objective of this paper is to present the aims of the initiative, to discuss critical issues and to present challenges for its implementation. We identify barriers, risks and trade-offs and advocate for collaboration between multiple parties in order to stimulate innovation and to initiate the transition of agricultural systems toward sustainability.
In recent years, much of the discussion involving "smart grids" has implicitly involved only the distribution side, notably advanced metering. However, today's electric systems have many challenges ...that also involve the rest of the system. An enabling technology for improving the power system, which has emerged in recent years, is the ability to measure coherent, real-time data. In this paper, we describe major challenges facing electrical generation and transmission today that availability of these measurements can help address. We overview applications using coherent, real-time measurements that are in use today or proposed by researchers. Specifically, we describe, normalize, and then quantitatively compare key factors for these power applications that influence how the delivery system should be planned, implemented, and managed. These factors include whether a person or computer is in the loop and (for both inputs and outputs) latency, rate, criticality, quantity, and geographic scope. From this, we abstract the baseline communications requirements of a data delivery system supporting these applications and suggest implementation guidelines to achieve them. Finally, we overview the state of the art in the supporting computer science areas of overlay networking and distributed computing (including middleware) and analyze gaps in commercial middleware products, utility standards, and issues that limit low-level network protocols from meeting these requirements when used in isolation.
•We review evidence of the impacts of gibberellins on grazed grassland.•Gibberellins promote herbage production when reduces nitrous oxide emissions.•Substituting nitrogen fertiliser with ...gibberellins reduces nitrous oxide emissions.•We model the potential for gibberellins to mitigate farm nitrous oxide emissions.
Emissions of nitrous oxide from grassland systems are attributable largely to the use of nitrogen fertilisers and the excreta deposited by grazing animals. There is increasing interest in using gibberellins as a naturally-occurring growth promotant of herbage that could be used to reduce the use of nitrogen fertilisers while leading to similar or greater increases in dry matter. This may provide practical opportunities to reduce nitrogen intake by ruminants and extend the seasonality of herbage growth in spring and autumn while reducing nitrogen losses, resulting in lower rates of nitrogen excretion by grazing animals and reduced nitrous oxide emissions. Our findings from a review of previous studies confirm that gibberellins promote dry matter production, especially when applied in early spring or late summer/early autumn. When gibberellins are applied alone without nitrogen fertiliser, the nitrogen concentration of herbage is reduced and the impacts on forage quality are small and often not significantly different from those for untreated controls. We calculated the consequences of enhanced herbage production on nitrogen excreta returned to the soil as urine by a grazing dairy cow and estimated that one application of gibberellins will result in a relative reduction in nitrous oxide emission per urination event of 18% when compared with emissions from using nitrogen fertiliser. We used the OVERSEER® model and nitrous oxide emissions factors to estimate the impacts of changing herbage dry matter production, foliage nitrogen concentration and timing of one application of gibberellins on annual nitrous oxide emissions for a dairy farm. For one application of gibberellins in late summer and early spring, we estimate reductions in nitrous oxide emissions of 1.6% and 1.3%, respectively, relative to the response for an untreated control. Incorporating the effects of reduced use of nitrogen fertiliser by substituting one split application of fertiliser in late summer or autumn with gibberellins, we estimate reductions on nitrous oxide emissions of between 5 and 6% relative to the response for the untreated control. We conclude that the use of gibberellins with reduced addition of nitrogen fertiliser has the potential to reduce nitrous emissions from grazed grassland. However, acceptance of widespread use of gibberellins will be dependent on cost benefit analysis for farmers.
Background
Experts estimate virtual urgent care programs could replace approximately 20% of current emergency department visits. In the absence of widespread quality guidance to programs or quality ...reporting from these programs, little is known about the state of virtual urgent care quality monitoring initiatives.
Objective
We sought to characterize ongoing quality monitoring initiatives among virtual urgent care programs.
Approach
Semi-structured interviews of virtual health and health system leaders were conducted using a pilot-tested interview guide to assess quality metrics captured related to care effectiveness and equity as well as programs’ motivations for and barriers to quality measurement. We classified quality metrics according to the National Quality Forum Telehealth Measurement Framework. We developed a codebook from interview transcripts for qualitative analysis to classify motivations for and barriers to quality measurement.
Key Results
We contacted 13 individuals, and ultimately interviewed eight (response rate, 61.5%), representing eight unique virtual urgent care programs at primarily academic (6/8) and urban institutions (5/8). Most programs used quality metrics related to clinical and operational effectiveness (7/8). Only one program reported measuring a metric related to equity. Limited resources were most commonly cited by participants (6/8) as a barrier to quality monitoring.
Conclusions
We identified variation in quality measurement use and content by virtual urgent care programs. With the rapid growth in this approach to care delivery, more work is needed to identify optimal quality metrics. A standardized approach to quality measurement will be key to identifying variation in care and help focus quality improvement by virtual urgent care programs.
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