Assessing Variability in End-of-Life Intensity of Care After Out-of-Hospital Cardiac Arrest

Out of hospital cardiac arrest (OHCA) affects over 300,000 Americans per year.1 Many factors affect the outcomes and overall OHCA survival in a community; some of these include an individual’s characteristics such as age, co-morbid conditions, availability of an AED on scene, time to CPR, and the characteristics of the hospital they are treated at.1,2 Directly following resuscitation from cardiac arrest, the individual is at risk of developing numerous problems caused by sequelae of ischemic injury sustained during the arrest. The national average rate of survival to discharge is only 10%.2,3 Many of these factors are modifiable and provide an opportunity to improve outcomes. In our project, we focus on lifesustaining procedures administered by hospitals upon receiving and admitting individuals experiencing OHCA. We used previously validated measures as defined by Barnato et al as “life sustaining end of life (EOL) measures”:4 • Intubation and mechanical ventilation • Tracheostomy • Gastrostomy tube insertion • Hemodialysis • Enteral/parenteral nutrition • CPRhttps://jdc.jefferson.edu/cwicposters/1035/thumbnail.jp

Alternative Routes from Fossil Resources to Chemical Feedstocks

The chemical industry depends very heavily on hydrocarbon feedstocks, which are presently derived almost exclusively from crude oil. Although only about seven percent of the hydrocarbons suitable for chemical processing are actually used in this way, it is already clear that there is a potential conflict between the needs of the energy sector and those of the chemical industry: they are competing for increasingly scarce liquid hydrocarbon resources. The authors suggest that the supply of hydrocarbon feedstocks to the chemical industry could be protected against the effects of changing patterns of energy use by modifying the underlying industrial structure. They have developed an approach which takes a variety of production processes (either in use or under development), compares their efficiency their consumption of different resources, etc., and finds the combination of technologies that best satisfies a particular demand while staying within the limits imposed by resource availability. This approach uses the techniques of interactive decision analysis to incorporate the unquantifiable social and political factors that must influence any development decision. By way of illustration, the method is applied to one very small part of the problem area: the different routes to the production of methanol. This report does not attempt to provide any final answer to the problem of feedstock supply, but rather to explain one possible approach to the problem and discuss some intermediate results. It is addressed not only to researchers, but also, and in particular, to all decision makers and industrial consultants facing problems of this type

Generating Efficient Alternatives for Development in the Chemical Industry

Industrial development can be seen as the process of changing the production structure by means of investment over the course of time. To control this development to the benefit of society while maintaining the profitability of the industry, decision makers must learn how socioeconomic changes and market conditions affect the static and dynamic properties of the production structure. This paper reports on the progress of collaborative research into the design of tools which could help decision makers to control development in the chemical industry. The basic approach is to formulate a model of the equilibrium state of the industry or, in the case considered here, of a particular subsector of the industry. The development process is initially described by a static multiobjective optimization problem, from which a dynamic multiobjective optimization problem is then derived. An example illustrating the use of this method for the pesticide-producing sector is given. The optimization problem and method for controlling industrial development put forward in this paper were worked out as part of the research program on Growth Strategy Optimization Systems (GSOS), sponsored by the Ministry of the Chemical Industry in Poland. This program is actually carried out at the Institute for Control and Systems Engineering (ICSE), part of the Academy of Mining and Metallurgy (AMM) in Cracow. The multiobjective optimization method for generating efficient alternatives and the related software were developed by the System and Decision Sciences Area at IIASA. This collaborative research was carried out within the framework of the agreement on scientific cooperation cosigned by IIASA and the AMM in June 1980

State-Level CPR Education Legislation Associated With Higher Survival After Out-Of-Hospital Cardiac Arrest in Older Adults

Introduction: State-level legislation requiring CPR education prior to high school graduation is associated with an increased likelihood of community-level CPR training. CPR Legislation has also been shown to be associated with increased bystander CPR. We hypothesized that states with CPR Legislation would be associated with higher survival following out-of-hospital cardiac arrest (OHCA). Methods: Utilizing 2014 Medicare Claims data for emergency department visits and inpatient stays, we identified OHCA via ICD-9-CM code. CPR Legislation data was collected through online statute review. Exposure to CPR Legislation was assessed using the patient state of residence. All disposition categories were considered survival to discharge except for death/hospice. Associations between categorical variables were assessed by chi-squared test. Multiple logistic regression was used to calculate the odds ratio associated with OHCA survival and CPR Legislation, controlling for patient age and sex. Results: States that passed CPR Legislation in 2013 had the highest survival compared to states with earlier passage or no CPR Legislation (22.2% vs 20.6% vs. 21.8%, respectively, p \u3c 0.001). Results of the multiple logistic regression showed CPR Legislation passed in 2013 was associated with a 12% increase in the odds of survival to discharge compared to states with CPR Legislation prior to 2013 (OR: 1.12, p \u3c0.001). Discussion: States with CPR Legislation passed in 2013 were associated with higher survival to discharge and discharge to home, compared to earlier adopters and states with no legislation. Further work is needed to assess the mechanisms underlying this relationship

Inpatient hospital performance is associated with post-discharge sepsis mortality.

BACKGROUND: Post-discharge deaths are common in patients hospitalized for sepsis, but the drivers of post-discharge deaths are unclear. The objective of this study was to test the hypothesis that hospitals with high risk-adjusted inpatient sepsis mortality also have high post-discharge mortality, readmissions, and discharge to nursing homes. METHODS: Retrospective cohort study of age-qualifying Medicare beneficiaries with sepsis hospitalization between January 2013 and December 2014. Hospital survivors were followed for 180-days post-discharge, and mortality, readmissions, and new admission to skilled nursing facility were measured. Inpatient hospital-specific sepsis risk-adjusted mortality ratio (observed: expected) was the primary exposure. RESULTS: A total of 830,721 patients in the cohort were hospitalized for sepsis, with inpatient mortality of 20% and 90-day mortality of 48%. Higher hospital-specific sepsis risk-adjusted mortality was associated with increased 90-day post-discharge mortality (aOR 1.03 per each 0.1 increase in hospital inpatient O:E ratio, 95% CI 1.03-1.04). Higher inpatient risk adjusted mortality was also associated with increased probability of being discharged to a nursing facility (aOR 1.03, 95% CI 1.02-1.03) and 90-day readmissions (aOR 1.03, 95% CI 1.02-1.03). CONCLUSIONS: Hospitals with the highest risk-adjusted sepsis inpatient mortality also have higher post-discharge mortality and increased readmissions, suggesting that post-discharge complications are a modifiable risk that may be affected during inpatient care. Future work will seek to elucidate inpatient and healthcare practices that can reduce sepsis post-discharge complications

Evaluation on the use of cerium in the NBL Titrimetric Method

An alternative to potassium dichromate as titrant in the New Brunswick Laboratory Titrimetric Method for uranium analysis was sought since chromium in the waste makes disposal difficult. Substitution of a ceric-based titrant was statistically evaluated. Analysis of the data indicated statistically equivalent precisions for the two methods, but a significant overall bias of +0.035% for the ceric titrant procedure. The cause of the bias was investigated, alterations to the procedure were made, and a second statistical study was performed. This second study revealed no statistically significant bias, nor any analyst-to-analyst variation in the ceric titration procedure. A statistically significant day-to-day variation was detected, but this was physically small (0.01 5%) and was only detected because of the within-day precision of the method. The added mean and standard deviation of the %RD for a single measurement was found to be 0.031%. A comparison with quality control blind dichromate titration data again indicated similar overall precision. Effects of ten elements on the ceric titration`s performance was determined. Co, Ti, Cu, Ni, Na, Mg, Gd, Zn, Cd, and Cr in previous work at NBL these impurities did not interfere with the potassium dichromate titrant. This study indicated similar results for the ceric titrant, with the exception of Ti. All the elements (excluding Ti and Cr), caused no statistically significant bias in uranium measurements at levels of 10 mg impurity per 20-40 mg uranium. The presence of Ti was found to cause a bias of {minus}0.05%; this is attributed to the presence of sulfate ions, resulting in precipitation of titanium sulfate and occlusion of uranium. A negative bias of 0.012% was also statistically observed in the samples containing chromium impurities

Capturing protest in urban environments:The ‘police kettle’ as a territorial strategy

‘Kettling’ has emerged in recent decades as an established, if controversial, tactic of public order policing. Departing from a historical emphasis on dispersal, kettling instead acts to contain protesters within a police cordon for sustained periods of time. This article elaborates upon the spatial and temporal logics of kettling by investigating the conditions of is historical emergence. We argue that kettling should be understood as a territorial strategy that co-evolved in relation to forms of disruptive protest. Whereas techniques of crowd dispersal serve to diffuse a unified collective, ‘kettling’ aims to capture the volatile intensities of public dissent and exhaust its political energies. Drawing on police manuals, media coverage, accounts from activists and expert interviews, we show how the ‘kettle’ re-territorializes protest by acting on its spatio-temporal and affective constitution. By fabricating an inner outside of the urban milieu, freezing the time of collective mobilization and inducing debilitating affects such as fear and boredom, kettling intervenes into the scene of political subjectification that each congregation of protesting bodies seeks to fashion