Update on Inpatient Glycemic Control in Hospitals in the United States

ObjectiveTo provide data on glucose control in hospitals in the United States, analyzing measurements from the largest number of facilities to date.MethodsPoint-of-care bedside glucose (POC-BG) test results were extracted from 575 hospitals from January 2009 to December 2009 by using a laboratory information management system. Glycemic control for patients in the intensive care unit (ICU) and non-ICU areas was assessed by calculating patient-day-weighted mean POC-BG values and rates of hypoglycemia and hyperglycemia. The relationship between POC-BG levels and hospital characteristics was determined.ResultsA total of 49,191,313 POC-BG measurements (12,176,299 ICU and 37,015,014 non-ICU values) were obtained from 3,484,795 inpatients (653,359 in the ICU and 2,831,436 in non-ICU areas). The mean POC-BG was 167 mg/dL for ICU patients and 166 mg/dL for nonICU patients. The prevalence of hyperglycemia (> 180 mg/ dL) was 32.2% of patient-days for ICU patients and 32.0% of patient-days for non-ICU patients. The prevalence of hypoglycemia (< 70 mg/dL) was 6.3% of patient-days for ICU patients and 5.7% of patient-days for non-ICU patients. Patient-day-weighted mean POC-BG levels varied on the basis of hospital size (P < .01), type (P < .01), and geographic location (P < .01) for ICU and non-ICU patients, with larger hospitals (≥ 400 beds), academic hospitals, and US hospitals in the West having the lowest mean POC-BG values. The percentage of patient-days in the ICU characterized by hypoglycemia was highest among larger and academic hospitals (P < .05) and least among hospitals in the Northeast (P < .001).ConclusionHyperglycemia is common in hospitals in the United States, and glycemic control may vary on the basis of hospital characteristics. Increased hospital participation in data collection may support a national benchmarking process for the development of optimal practices to manage inpatient hyperglycemia. (Endocr Pract. 2011;17:853-861)     

Stream Restoration Practices in the Southeastern United States

We collected information on 860 stream restoration projects in four states in the southeastern United States—Georgia, Kentucky, North Carolina, and South Carolina—to gain a better understanding of the practice of stream restoration in this area of high aquatic biodiversity and rapid metropolitan expansion. This was completed as a part of the National River Restoration Science Synthesis, with the larger goal of understanding the state of the science of stream restoration. Stream restoration project density, goals, and monitoring rates varied by state, although southeastern monitoring rates were higher than in other parts of the country. North Carolina had the most projects in the Southeast, of which 36% were monitored. In‐depth phone interviews with project managers from a random subsample of projects provided insights into the process of stream restoration. Land availability was the most common basis for site prioritization, and 49% of projects involved mitigation. Although 51% of projects were associated with a watershed assessment, only 30% of projects were done as part of a larger plan for the watershed. Projects were monitored using physical (77% of monitored projects), chemical (36%), and biological (86%) variables, although many projects were planned and ultimately evaluated based on public opinion. Our results suggest that stream restoration in the southeastern United States is at an exciting point where better incorporation of a watershed perspective into planning and establishment and evaluation of stated, measurable success criteria for every project could lead to more effective projects.     

Best Management Practices for Trapping Furbearers in the United States

Humans have used wild furbearers for various purposes for thousands of years. Today, furbearers are sustainably used by the public for their pelts, leather, bones, glands, meat, or other purposes. In North America, contemporary harvest of furbearers has evolved along with trap technologies and societal concerns, and is now highly regulated and more closely coupled with harvest analysis and population monitoring. Traps and regulated trapping programs provide personal or cultural rewards that can also support conservation, and can assist with advancing ecological knowledge through research, protecting endangered species, restoring populations or habitats, protecting personal property, and enhancing public health and safety. However, animal welfare and trap selectivity remain important topics for furbearer management in North America, as they have for more than a century. A related international challenge to modern furbearer management came with the Wild Fur Regulation by the European Union, which passed in 1991. This regulation prohibited use of foothold traps in many European countries and the importation of furs and manufactured fur products to Europe from countries that allowed use of foothold traps or trapping methods that did not meet internationally agreed-upon humane trapping standards. To address existing national concerns and requirements of the Wild Fur Regulation, the United States and European Union signed a non-binding bilateral understanding that included a commitment by the United States to evaluate trap performance and advance the use of improved traps through development of best management practices (BMPs) for trapping. Our testing followed internationally accepted restraining-trap standards for quantifying injuries and capture efficiency, and we established BMP pass-fail thresholds for these metrics. We also quantified furbearer selectivity, and qualitatively assessed practicality and user safety for each trap, yielding overall species-specific performance profiles for individual trap models. We present performance data for 84 models of restraining traps (6 cage traps, 68 foothold traps, 9 foot-encapsulating traps, and 1 power-activated footsnare) on 19 furbearing species, or 231 trap-species combinations. We conducted post-mortem examinations on 8,566 furbearers captured by trappers. Of the 231 trap model-species combinations tested, we had sufficient data to evaluate 173 combinations, of which about 59% met all BMP criteria. Pooling species, cage traps produced the lowest average injury score (common injuries included tooth breakage), with minimal differences across other trap types; species-specific patterns were generally similar, with the exception of raccoons (Procyon lotor) for which foot-encapsulating traps performed better than other foot-restraining trap types. Padded-jaw foothold traps performed better than standard-jaw models for many species, though often similar to and occasionally worse than offset- or laminated-jaw models. Most traps we tested had high capture efficiency; only 5 (3%) failed BMP standards strictly because of poor efficiency. Average furbearer selectivity was high across all trap types we evaluated and was lowest for footsnares (88%) and highest for foot-encapsulating traps (99%). Mortality from trap-related injury in restraining traps we tested was very rare for furbearers (0.5% of animals). In over 230,000 trap-nights across a 21-year period, no individuals of a threatened or endangered species were captured. Of 9,589 total captures, 11% were non-furbearers, of which 83% were alive upon trap inspection; nearly all non-furbearer mortalities were birds, rabbits, or squirrels. Approximately 2% of total captures were feral or free-ranging dogs (Canis familiaris), of which none died or were deemed in need of veterinary care by either our technicians or the owners (if located). Similarly, 3% of total captures were feral or free-ranging cats (Felis catus); 2 were dead, and although locating potential owners was often impossible, none of the remaining cats were deemed in need of veterinary care by technicians or owners. Our results show that furbearer selectivity was high for all trap types evaluated, mortality or significant injury was very rare for domestic (or feral) animals, and the most potential for mortality or injury of non-furbearers was with smaller animals, a majority of which were squirrels and rabbits. Our results suggest that injury scores for a given trap-species combination are unlikely to vary significantly across states or regions of the United States, provided similar methods are employed. Our data also suggest that taxonomic affiliation and body-size groupings are correlated with injury scores, presumably through morphological, physiological, or behavioral adaptations or responses that influence injury potential during restraint; higher injury scores in foot-restraining trap types were more likely in smaller or more dexterous species, whereas injury scores were typically lowest for the felids we evaluated. For some species (e.g., American badger [Taxidea taxus], bobcat [Lynx rufus]), most restraining traps we tested met BMP standards, whereas few restraining traps we tested met standards for other species (e.g., muskrat [Ondatra zibethicus], striped skunk [Mephitis mephitis]). Comparison of our results with survey information collected during 2015 on trap use in the United States indicates that approximately 75% of all target furbearers harvested were taken in BMP-compliant traps, with another 10% taken in traps yet to be tested on that species. Future trap testing and development should focus on commonly used traps not yet tested on a species, species for which few passing traps currently pass BMP criteria, and trap models and modifications most likely to minimize trap injuries given a species morphology, physiology, and behavior. Outreach efforts should focus on general BMP awareness, discouraging use of traps that fail BMP standards for a given species, and public outreach on trapping. Restraining (and other) traps have evolved substantially in recent decades and offer numerous benefits to individuals, conservation, and society. However, continuing to address societal concerns remains a critical component of modern regulated trapping and furbearer management. Published trapping BMPs are regularly updated online and may include additional approved restraining and killing traps that were evaluated as part of testing by Canada. We will periodically update the trap performance tables and figures we presented and make them available online at the Association of Fish and Wildlife Agencies website. Published 2020. This article is a U.S. Government work and is in the public domain in the USA. Wildlife Monographs published by Wiley Periodicals LLC on behalf of The Wildlife Society.     

The Psychologizing of Chinese Healing Practices in the United States

This paper explores ways in which Chinese healing practices have undergone acculturation in the United States since the early 1970s. Reacting to what is perceived as biomedicine's focus on the physiological, those who describe themselves as favoring a holistic orientation often use the language of 'energy blockage' to explain illness, whether thought of as 'physical,' 'emotional,' or 'spiritual'. Acupuncture in particular has been appropriated as one modality with which to 'unblock' such conditions, leading to its being used by some practitioners in conjunction with more psychotherapeutic approaches which include valuing the verbalizing of feelings. Some non-Chinese practitioners in the United States, returning to older Chinese texts to develop 'an American acupuncture,' are reinserting diagnoses eliminated from Traditional Chinese Medicine (TCM) by the People's Republic of China as 'superstition'. The assumption has been that many such diagnostic categories refer to psychological or spiritual conditions, and therefore may be useful in those American contexts which favor this orientation. Among these categories are those drawn from traditions of demonology in Chinese medicine. What was once a religious category in China turns psychological in the American setting. At the same time, many who use these terms have, since the late 1960s, increasingly conflated the psychological and the religious, the latter being reframed as 'spiritual'. Thus, this indigenization of Chinese practices is a complex synthesis which can be described as simultaneously medical, psychotherapeutic, and religious.     

Encephalitis Hospitalization Rates and Inpatient Mortality in the United States, 2000-2010

Background

Encephalitis rates by etiology and acute-phase outcomes for encephalitis in the 21^st century are largely unknown. We sought to evaluate cause-specific rates of encephalitis hospitalizations and predictors of inpatient mortality in the United States.

Methods

Using the Nationwide Inpatient Sample (NIS) from 2000 to 2010, a retrospective observational study of 238,567 patients (mean [SD] age, 44.8 [24.0] years) hospitalized within non-federal, acute care hospitals in the U.S. with a diagnosis of encephalitis was conducted. Hospitalization rates were calculated using population-level estimates of disease from the NIS and population estimates from the United States Census Bureau. Adjusted odds of mortality were calculated for patients included in the study.

Results

In the U.S. from 2000–2010, there were 7.3±0.2 encephalitis hospitalizations per 100,000 population (95% CI: 7.1–7.6). Encephalitis hospitalization rates were highest among females (7.6±0.2 per 100,000) and those <1 year and >65 years of age with rates of 13.5±0.9 and 14.1±0.4 per 100,000, respectively. Etiology was unknown for approximately 50% of cases. Among patients with identified etiology, viral causes were most common (48.2%), followed by Other Specified causes (32.5%), which included predominantly autoimmune conditions. The most common infectious agents were herpes simplex virus, toxoplasma, and West Nile virus. Comorbid HIV infection was present in 7.7% of hospitalizations. Average length of stay was 11.2 days with mortality of 5.6%. In regression analysis, patients with comorbid HIV/AIDS or cancer had increased odds of mortality (odds ratio [OR]  = 1.70; 95% CI: 1.30–2.22 and OR = 2.26; 95% CI: 1.88–2.71, respectively). Enteroviral, postinfectious, toxic, and Other Specified causes were associated with lower odds vs. herpes simplex encephalitis.

Conclusions

While encephalitis and encephalitis-related mortality impose a considerable burden in the U.S. in the 21^st Century, the reported demographics of hospitalized encephalitis patients may be changing.     

美国孤儿药开发的政策、策略与实践

简述了罕见病及孤儿药的定义和研发意义,重点介绍了美国针对孤儿药开发的现有制度法规、激励政策及管理经验,并以实例 分析从研发、注册和上市等角度探讨了美国孤儿药开发的策略,旨在为从事孤儿药开发工作的人士提供参考。     

Breastfeeding in the United States

The breastfeeding of US infants born in 1974-76 is analyzed using data form the 1976 National Survey of Family Growth. Life table estimates of the proportion of children breastfed by duration since birth and mean breastfeeding durations are presented. The life tables reported are constructed by standard cohort table methods. To compare life tables for children of mothers in various attribute categories, generalised Wilcoxon tests are used, together with multiple classification analysis for continuation at select durations. Variables considered include mother's age at the birth, ethnicity, educational level, education by ethnicity, region of residence and the child's birth order. Findings are restricted to infants remaining with their mothers for at least 2 months following delivery and surviving as of the survey date in January-September 1976. It is found that the proportion of infants breastfed was increasing rapidly, with the highest rates found among white (39%), college-educated (56%), western (56%) mothers and lowest rates among black mothers (17%) mothers with less than a high school education (19%) and mothers living in the south (24%). By age, the highest proportions are mothers at ages 25-29 (44%), followed closely by the mothers under 25 (29%). The proportions breastfeeding were also found to be higher in urban than in rural areas (38% vs. 28%) and higher at parities 1-2 (29%). A multiple classification analysis of the factors most strongly influencing breastfeeding in 1975 shows educational level to be the strongest single predictor of breastfeeding, followed by western residence and white ethnicity. Age effects were found to correlate strongly with education. Reviewing 1971-1981 changes, the proportion of mothers with less than a college education who breastfed their children increased from 19% to 51% over the decade, while the proportion among college-educated mothers rose from 42% to 74%. For children who were breastfed, the median duration was about 4.5 months. The mean was 5.5 months, with a range from about 3.0 months among black mothers with less than a high school education, to 6.0 months among college-educated white women. The nationwide changes in breastfeeding patterns and duration may confer modest health benefits on current generations of youngsters, although not benefits that are easily measured, since human milk substitutes are routinely subjected to rigourous testing for nutritional adequacy.     

Breastfeeding in the United States

Abstract

The breastfeeding of U.S. infants born in 1974–76 is analyzed using data from the 1976 National Survey of Family Growth. It is found that the proportion of infants breastfed was increasing rapidly, with the highest rates found among white, college‐educated, western mothers and lowest rates among black mothers and mothers with less than a high‐school education. For children who were breastfed, the median duration was about 4.5 months and the mean 5.5 months, also with marked differences by ethnicity, education, and region. Data from other sources confirm these differences and quantify subsequent increases in breastfeeding.     

Necropsy rates in the United Birmingham Hospitals.

The necropsy rate in the United Birmingham Hospital has fallen from 74-4% in 1958 to 46-0% in 1972. In the Birmingham region as a whole the rate is 27-3%, approximately equal to the national rate. Most clinicians in the group who replied to a standard questionary considered that the necropsy still has an important part to play in their own practice and in undergraduate training, and they viewed the declining rate as a matter for concern. Some measure of disagreement was found between the ante-mortem and post-mortem diagnoses of patients in the two largest hospitals in the group. This suggests that the necropsy has a role to play in medical audit and that attempts to reverse the declining trend should be encouraged.