Paramedic-Initiated Home Care Referrals and Use of Home Care and Emergency Medical Services

Objective: We examined the association between paramedic-initiated home care referrals and utilization of home care, 9-1-1, and Emergency Department (ED) services. Methods: This was a retrospective cohort study of individuals who received a paramedic-initiated home care referral after a 9-1-1 call between January 1, 2011 and December 31, 2012 in Toronto, Ontario, Canada. Home care, 9-1-1, and ED utilization were compared in the 6 months before and after home care referral. Nonparametric longitudinal regression was performed to assess changes in hours of home care service use and zero-inflated Poisson regression was performed to assess changes in the number of 9-1-1 calls and ambulance transports to ED. Results: During the 24-month study period, 2,382 individuals received a paramedic-initiated home care referral. After excluding individuals who died, were hospitalized, or were admitted to a nursing home, the final study cohort was 1,851. The proportion of the study population receiving home care services increased from 18.2% to 42.5% after referral, representing 450 additional people receiving services. In longitudinal regression analysis, there was an increase of 17.4 hours in total services per person in the six months after referral (95% CI: 1.7–33.1, p = 0.03). The mean number of 9-1-1 calls per person was 1.44 (SD 9.58) before home care referral and 1.20 (SD 7.04) after home care referral in the overall study cohort. This represented a 10% reduction in 9-1-1 calls (95% CI: 7–13%, p < 0.001) in Poisson regression analysis. The mean number of ambulance transports to ED per person was 0.91 (SD 8.90) before home care referral and 0.79 (SD 6.27) after home care referral, representing a 7% reduction (95% CI: 3–11%, p < 0.001) in Poisson regression analysis. When only the participants with complete paramedic and home care records were included in the analysis, the reductions in 9-1-1 calls and ambulance transports to ED were attenuated but remained statistically significant. Conclusions: Paramedic-initiated home care referrals in Toronto were associated with improved access to and use of home care services and may have been associated with reduced 9-1-1 calls and ambulance transports to ED.     

Risk Factors and Hospitalization Costs of Dementia Patients: Examining Race and Gender Variations

Aims:

To examine the variation in risk factors and hospitalization costs among four elderly dementia cohorts by race and gender.

Materials and Methods:

The 2008 Tennessee Hospital Discharged database was examined. The prevalence, risk factors and cost of inpatient care of dementia were examined for individuals aged 65 years and above, across the four race gender cohorts - white males (WM), black males (BM), white females (WF), and black females (BF).

Results:

3.6% of patients hospitalized in 2008 had dementia. Dementia was higher among females than males, and higher among blacks than whites. Further, BF had higher prevalence of dementia than WF; similarly, BM had a higher prevalence of dementia than WM. Overall, six risk factors were associated with dementia for the entire sample including HTN, DM, CKD, CHF, COPD, and stroke. These risk factors varied slightly in predicting dementia by race and gender. Hospital costs were 14% higher among dementia patients compared to non-dementia patients.

Conclusions:

There exist significant race and gender disparities in prevalence of dementia. A greater degree of co-morbidity, increased duration of hospital stay, and more frequent hospitalizations, may result in a higher cost of inpatient dementia care. Aggressive management of risk factors may subsequently reduce stroke and cost of dementia care, especially in the black population. Race and gender dependent milestones for management of these risk factors should be considered.     

Monitoring respiration in wheezy preschool children by pulse oximetry plethysmogram analysis

The aim of this study was to investigate whether respiratory information can be derived from pulse oximetry plethysmogram (pleth) recordings in acutely wheezy preschool children. A digital pulse oximeter was connected via ‘Bluetooth’ to a notebook computer in order to acquire pleth data. Low pass filtering and frequency analysis were used to derive respiratory rate from the pleth trace; the ratio of heart rate to respiratory rate (HR/RR) was also calculated. Recordings were obtained during acute wheezy episodes in 18 children of median age 31 months and follow-up recordings from 16 of the children were obtained when they were wheeze-free. For the acutely wheezy children, frequency analysis of the pleth waveform was within 10 breaths/min of clinical assessment in 25 of 29 recordings in 15 children. For the follow-up measurements, frequency analysis of the pleth waveform showed similarly good agreement in recordings on 15 of the 16 children. Respiratory rate was higher (p < 0.001), and HR/RR ratio was lower (p = 0.03) during acute wheeze than at follow-up. This study suggests that respiratory rate can be derived from pleth traces in wheezy preschool children.     

Molecular characterization of human factor XSan Antonio

Enzymatic amplification technique was used to isolate all eight exons and sequences around the splice junctions, putative promoter, and polyadenylation sites of human factor X DNA from a patient with factor X deficiency. Two genetic changes in factor X have been observed in this patient. The patient is most likely a compound heterozygote since there is only 14% activity associated with factor X. A point mutation that resulted in the substitution of cysteine (TGC) for arginine (CGC) at amino acid 366 was found in exon VIII of one allele of the factor X gene. This mutation, which occurs in the catalytic domain, can affect the formation of a disulfide bridge and thus could result in a reduction in factor X activity. Sequencing all the regions revealed a second mutation: a deletion of one nucleotide (TCCT to TCT) in exon VII that would cause a frame shift at amino acid 272 followed by termination. We have also shown that the point mutation in exon VIII creates an ApaL1 restriction site and destroys the HinP1 site. Enzymatic DNA amplification followed by restriction digestion provides a quick, reliable, and sensitive method for carrier detection and antenatal diagnosis in affected kindreds. This is the first characterization of factor X deficiency at the molecular level. We propose to name this mutation Factor XSan Antonio.     

A radioreceptor assay for quantitating plasma factor VIII/von Willebrand's protein

A sensitive and precise radioreceptor assay for determining plasma levels of human factor VIII/von Willebrand's factor (FVIII/vWF) has been developed by taking advantage of the FVIII/vWF receptor sites on human platelets. Paraformaldehyde-fixed platelets, which were processed and then stored, retained FVIII/vWF binding activity and therefore could be used as a convenient source of receptors. The human plasma samples to be tested were initially filtered on 4% agarose columns to concentrate the FVIII/vWF protein in the void volume and to remove the factor(s) that interferes with the assay. The percent recovery of FVIII/vWF in the pooled eluent was measured by the recovery of added trace 125I-FVIII/vWF. The coefficients of intra- and interassay variation were 6% and 10%, respectively. The plasma FVIII/vWF concentrations determined by the assay for pooled normal plasma, hemophilia A plasma, and plasmas from two patients with von Willebrand's disease were 16.3 +/- 0.5, 52.6 +/- 1.5, 6.8 +/- 0.8, and 3.2 +/- 0.2 microgram/ml, respectively. The range of plasma FVIII/vWF concentrations varied between 8.3 microgram/ml and 24.9 microgram/ml for 10 normal adults. The plasma FVIII/vWF concentrations determined by the radioreceptor assay correlated well with levels measured by the ristocetin-induced platelet aggregation method, thus demonstrating the functional relevancy of the radioreceptor assay for plasma FVIII/vWF.     

From the Cover: Species interactions and the structure of complex communication networks

A universal challenge faced by animal species is the need to communicate effectively against a backdrop of heterospecific signals. It is often assumed that this need results in signal divergence to minimize interference among community members, yet previous support for this idea is mixed, and few studies have tested the opposing hypothesis that interactions among competing species promote widespread convergence in signaling regimes. Using a null model approach to analyze acoustic signaling in 307 species of Amazonian birds, we show that closely related lineages signal together in time and space and that acoustic signals given in temporal or spatial proximity are more similar in design than expected by chance. These results challenge the view that multispecies choruses are structured by temporal, spatial, or acoustic partitioning and instead suggest that social communication between competing species can fundamentally organize signaling assemblages, leading to the opposite pattern of clustering in signals and signaling behavior.One of the core principles of animal communication is that signals should be detectable and convey an accurate message against a noisy background (1–3). This background can involve direct overlap of sounds, as in the case of masking by simultaneous signals (4, 5), or simply the co-occurrence of different species using confusingly similar signals at the same location (6–8). As most animals communicate within assemblages of related species, the problem of signal interference is widespread and may have far-reaching implications for the evolution of signals and signaling behavior. This concept—variously termed the “noisy neighbors” hypothesis (9) or “cocktail party problem” (10)—has attracted much attention over recent years. However, the extent to which it provides a general explanation for patterns of signaling in animal communities remains contentious (6, 8).The traditional view is that the signaling strategies of animals are shaped by limiting similarity among competitors, much as competition for ecological resources is thought to promote partitioning of niche space (11–13). Partitioning of signal space may occur if species compete for position near overcrowded transmission optima, and, concurrently, if overlap in signal design impairs the detection or discrimination of signals mediating mate choice and resource competition (14). Under these conditions, mechanisms of selection against misdirected aggression (e.g., character displacement) or the production of unfit hybrids (e.g., reinforcement) are predicted to drive phenotypic divergence (9), whereas similar mechanisms may lead to related species signaling at different times or in different locations (13). These pathways theoretically lead to structural, temporal, and spatial partitioning of signals and signalers in animal assemblages, but tests of these patterns have produced mixed results (6, 11, 15).A contrasting possibility is that selection for signal divergence is weak and that co-occurring species instead show the opposite pattern of signal clustering (16). One potential driver of this pattern is that shared habitats can exert convergent selection on signals (17). Another is that signals often have dual function in mate attraction and resource defense (18), potentially mediating competition among closely related species for ecological resources (19). Thus, multispecies choruses may operate to some degree as extended communication networks, not only within species (20) but between species. The effect of such a network would be to increase the likelihood of interspecific communication involving closely related species with similar signals. A pattern of signal clustering caused by communication among similar congeners may be further exaggerated when competitive interactions among species promote signal similarity (16). This process may occur when individuals with convergent agonistic signals have higher fitness because they are better at defending resources against both conspecific and heterospecific competitors, driving convergent evolution (21, 22). Taken together, these alternative views suggest that the most pervasive effect of species interactions on animal communication systems may not be partitioning, as generally proposed, but synchrony and stereotypy among competing species.Progress in resolving these opposing viewpoints has been limited because most studies of signaling assemblages have compiled lists of species co-occurring at particular localities and then compared multiple assemblages across regional scales (6, 15). This approach may be misleading because of spatial biases in phylogenetic relationships and habitat. On the one hand, sympatric species tend to be significantly older than allopatric species, at least within radiations (23, 24), and thus the signals of co-occurring lineages may be more divergent than expected by chance simply because they have had more time to diverge, exaggerating the evidence for partitioning. Conversely, species co-occurring at local scales may be less divergent because they are segregated by habitat across a study site and therefore are unlikely to signal together. Although some studies (7, 11) partially overcome these issues by sampling assemblages from single points in space, none has considered the effects of habitat and the potential role of competitive interactions among related species (16). Moreover, previous studies have generally assessed partitioning in relatively small assemblages (<30 species), reducing both the likelihood of competition over transmission optima and the power of statistical tests.Here, we sample >90 signaling assemblages (Fig. S1) containing a combined total of >300 species (Dataset S1) to assess the role of species interactions in structuring and organizing the dawn chorus of Amazonian rainforest birds. Each assemblage comprised species producing acoustic signals, identified from standardized 120-min sound recordings taken at points distributed across a single study locality. We also restricted analyses to 10-min time blocks and assumed that assemblages of species signaling in these blocks were forced to discriminate among each other (i.e., they were each other’s background noise) and also that they had an increased likelihood of signaling simultaneously (i.e., directly masking each other’s signals). We use the term cosignaling to describe pairs of species signaling during the same 10- or 120-min time block and thus not necessarily signaling simultaneously. We coded all assemblages for habitat and time of day, calculated the acoustic similarity of cosignaling species using spectrographic analyses of voice recordings, and estimated the evolutionary relatedness of cosignaling species using a hierarchical taxonomic framework.Our null hypothesis states that species interactions have no effect on chorus structure and thus that species with similar signals are randomly distributed in space and time (Fig. 1A). The distance between signals in observed choruses should not differ significantly from that expected by chance, accounting for habitat and evolutionary relationships. We envisage two scenarios that may falsify the null. The partitioning hypothesis predicts that signal design is evenly spaced across communities, with a larger distance between co-occurring signals than predicted by chance (Fig. 1B). The network hypothesis predicts that competing species interact using phylogenetically conserved signals and thus that signals are clustered in distribution, with a smaller distance between co-occurring signals than predicted by chance (Fig. 1C). The partitioning and network hypotheses involve different forms of species interaction with opposing effects on chorus structure. Although we do not measure species interactions directly, we follow standard approaches in assuming that such interactions predict patterns in the trait structure of assemblages (25).Open in a separate windowFig. 1.Predictions of three hypotheses proposed to structure multispecies choruses, illustrated using hypothetical seven-species choruses with signal design plotted in multivariate signaling space. The null hypothesis that species interactions have no effect predicts that signal structure is random (A), generating an intermediate mean nearest-neighbor distance d. The partitioning hypothesis predicts an evenly spaced signal structure (B) reflected in larger values for d. The network hypothesis predicts that related species will signal together, causing signals to be clustered around optima (C), and generating small values for d. We test these predictions by assessing whether d, viewed across a sample of communities, is higher or lower than expected by chance. We calculated d in two ways: d₁ (Upper) is the mean nearest neighbor distance [nnd] across all community members; and d₂ (Lower) is the mean nnd across the three pairs of species with most similar signals.Our aims were to (i) quantify acoustic properties of signals transmitted in the dawn chorus; (ii) estimate the degree of signal similarity among cosignaling species; and (iii) compare the observed distribution of signal properties with that expected by chance. We also consider spatial explanations for chorus structure, including the reduced cosignaling of species with similar signals through spatial partitioning. This form of segregation may occur because ecological competition is elevated in tropical bird communities (26), causing parapatric (27) or “checkerboard” distributions (28) among closely related species, thus potentially leading to apparent signal partitioning by competitive exclusion. The network hypothesis predicts the opposite pattern as closely related species should synchronize their signaling activity using shared territorial signals. We test these predictions by comparing 120-min (spatially segregated) and 10-min (nonsegregated) choruses and using taxonomic relatedness to estimate the degree of cosignaling between close relatives.The Amazonian dawn chorus provides one of the world’s most diverse multispecies signaling assemblages and an ideal system for exploring the effects of competition on signaling strategies for three reasons. First, visibility is hampered by dense vegetation, and thus long-distance signaling is forced into one modality (acoustic communication). Second, background noise levels are extremely high as a result of other organisms, including insects, amphibians, and primates, suggesting that selection for partitioning of acoustic signals should be maximized (12). Finally, many tropical species are permanently resident and apparently interspecifically territorial, using acoustic signals to mediate competitive interactions with heterospecifics (18, 26, 29). In combination, these factors imply that large numbers of species compete both for ecological resources and a narrow window of optimal signaling space (7, 30), providing a context in which to test the relative importance of acoustic partitioning and interspecific communication networks.     

Age-related macular degeneration

Age-related macular degeneration is a major cause of blindness worldwide. With ageing populations in many countries, more than 20% might have the disorder. Advanced age-related macular degeneration, including neovascular age-related macular degeneration (wet) and geographic atrophy (late dry), is associated with substantial, progressive visual impairment. Major risk factors include cigarette smoking, nutritional factors, cardiovascular diseases, and genetic markers, including genes regulating complement, lipid, angiogenic, and extracellular matrix pathways. Some studies have suggested a declining prevalence of age-related macular degeneration, perhaps due to reduced exposure to modifiable risk factors. Accurate diagnosis combines clinical examination and investigations, including retinal photography, angiography, and optical coherence tomography. Dietary anti-oxidant supplementation slows progression of the disease. Treatment for neovascular age-related macular degeneration incorporates intraocular injections of anti-VEGF agents, occasionally combined with other modalities. Evidence suggests that two commonly used anti-VEGF therapies, ranibizumab and bevacizumab, have similar efficacy, but possible differences in systemic safety are difficult to assess. Future treatments include inhibition of other angiogenic factors, and regenerative and topical therapies.     

蜂胶对成纤维细胞、单核巨噬细胞系基质金属蛋白酶MMP-9表达的抑制作用

目的探讨蜂胶对糖尿病伤口愈合的作用及其机制。方法采用荧光电泳法,检测不同葡萄糖浓度（5、25mmol／L）和不同蜂胶浓度（10、50、100、200μg／ml）处理的体外培养的人成纤维细胞及单核巨噬细胞系的基质金属蛋白酶MMP-9蛋白的表达。结果高浓度葡萄糖（25mmol／L）状态下,MMP-9表达增加,但与低浓度（5mmol／L）比较,差异无统计学意义。蜂胶可显著降低MMP-9的表达,并呈剂量依赖性（P〈．05）。结论高糖能增加单核巨噬细胞系及成纤维细胞MMP-9的表达,可能会影响糖尿病患者伤口的愈合。蜂胶可抑制这些细胞MMP-9的表达,有益于细胞基质的积聚,从而有益于糖尿病患者伤口的愈合。