Assessing the Influence of Banana Leaf Ash as Pozzolanic Material for the Production of Green Concrete: A Mechanical and Microstructural Evaluation.

This paper reports an investigation of the mechanical and microscopic properties of partially replaced banana leaf ash (BLA) concrete. In this research, the cement was partially replaced by BLA in two phases: Phase A (0%, 5%, 10%, 15%, 20%, 25% and 30%) and Phase B (0%, 10%, 20% and 30%). The consequence of partially replacing cement with BLA in concrete was investigated by the application of a range of tests, namely X-ray fluorescence (XRF), compressive strength, splitting tensile strength, flexure strength, ultrasonic pulse velocity and scanning electron microscopy (SEM) analysis. The properties were then correlated with the properties of a standard 100% Portland cement concrete of similar strength. The XRF result of the BLA identified a composition with 48.93% SiO2 and 3.48% Al2O3, which indicates that the material potentially possesses pozzolanic properties. The mechanical properties of the partially replaced BLA concrete noted minor strength loss, approximately 5% with 20% partial replacement. The nondestructive testing data showed enhanced performance up to 20% partial replacement, with ultrasonic pulse values above 3500 m/s. The scanning electron microscopy analysis illustrated that the morphology of BLA specimens contained increased microcracks compared with the control. The decrease in strength observed is attributed to the fibrous composition of the BLA. The mechanical, nondestructive testing and microscopic results highlight the potential to utilize BLA as a partial replacement for cement as a pozzolanic material in concrete at up to 20% by weight of cement.

Sociodemographic and clinical factors influencing serum potassium concentration: A retrospective cohort study.

Background: Self-care is crucial for maintaining the health and quality of life of individuals undergoing physical examinations, especially those with abnormal test results because they are at a higher risk of experiencing worse outcomes. However, there is currently a lack of comprehensive literature on the impact of sociodemographic and clinical factors on self-care practices related to serum potassium concentration among individuals undergoing physical examinations. Therefore, this study aimed to explore the sociodemographic and clinical factors influencing serum potassium concentration. Methods: Data from 43,151 individuals who underwent physical examinations were retrospectively collected in January, April, July, and October of 2019-2021. The serum potassium concentrations of these individuals were compared based on sex, age, and residential area. Additionally, the whole cohort and a subset of 6698 individuals with available occupational information were included to analyze the sociodemographic factors associated with serum potassium concentration using logistic regression analysis. Furthermore, a propensity score matching approach was employed to match 642 individuals with abnormal serum potassium concentrations to 642 with normal serum potassium concentrations. Pearson's correlation analysis was subsequently used to investigate the clinical factors contributing to abnormalities in serum potassium concentration. Results: High temperatures; older age; male sex; living in the southern part of the city; and chemical, communication system, and transportation occupations were associated with a higher likelihood of experiencing abnormal serum potassium concentrations. Individuals with abnormal serum potassium concentrations had a higher prevalence of underlying diseases. Compared with the hypokalemia group, the hyperkalemia group exhibited a higher incidence of diabetes and cardiovascular disease. In the hyperkalemia group, serum potassium concentration positively correlated with serum creatinine concentration and negatively correlated with the estimated glomerular filtration rate (eGFR). In contrast, in the hypokalemia group, serum potassium concentration negatively correlated with creatinine concentrations, blood glucose concentration, and systolic and diastolic blood pressure, and positively correlated with eGFR. Conclusions: Sociodemographic and clinical factors can affect blood potassium concentration. During daily self-care, it is essential for individuals with abnormal potassium concentrations to avoid exposure to relevant sociodemographic risk factors and seek medical attention as soon as possible to screen for diseases, such as hypertension, cardiovascular disease, and diabetes.

Creatine and Resistance Training: A Combined Approach to Attenuate Doxorubicin-Induced Cardiotoxicity.

Doxorubicin (DOX), a potent chemotherapy agent, useful in the treatment of solid tumors, lymphomas, and leukemias, is limited by its potentially lethal cardiotoxicity. However, exercise has been consistently shown to mitigate the side effects of DOX, including cardiotoxicity. To date, most studies examining the relationship between exercise and DOX-induced cardiotoxicity have focused on aerobic exercise, with very few examining the role of anerobic activity. Therefore, this investigation explored the potential of creatine (CR) and resistance training (RT) in preserving cardiac health during DOX therapy. Male Sprague-Dawley rats were grouped into RT, RT + CR, sedentary (SED), and SED + CR, with each division further branching into saline (SAL) or DOX-treated subsets post-10 weeks of RT or SED activity. RT comprised progressive training utilizing specialized cages for bipedal stance feeding. CR-treated groups ingested water mixed with 1% CR monohydrate and 5% dextrose, while control animals received 5% dextrose. At week 10, DOX was administered (2 mg/kg/week) over 4-weeks to an 8 mg/kg cumulative dose. Cardiac function post-DOX treatment was assessed via transthoracic echocardiography. Left ventricular diameter during diastole was lower in DOX + CR, RT + DOX, and RT + CR + DOX compared to SED + DOX (p < 0.05). Additionally, cardiac mass was significantly greater in RT + CR + DOX SED + DOX animals (p < 0.05). These results suggest RT and CR supplementation, separately and in combination, could attenuate some measures of DOX-induced cardiotoxicity and may offer a cost-effective way to complement cancer treatments and enhance patient outcomes. More investigations are essential to better understand CR's prolonged effects during DOX therapy and its clinical implications.

Performance of biochar mixed cement paste for removal of Cu, Pb and Zn from stormwater.

Using biochar as a partial replacement of Portland cement in cementitious materials is a promising solution to mitigate negative environmental impacts. However, current studies in available literature primarily focus on the mechanical properties of composites made with cementitious materials and biochar. Therefore, this paper reports the effects of the type of biochar, the percentage of biochar addition, and the particle size of the biochar on the removal efficiency of Cu, Pb, and Zn, as well as the effect of contact time on the removal efficiency of Cu, Pb, and Zn, along with the compressive strength. The peak intensities of OH-, CO32- and Calcium Silicate Hydrate (Ca-Si-H) peaks increase with increasing biochar addition levels, reflecting increased hydration product formation. The reduction of particle size of biochar causes the polymerization of the Ca-Si-H gel. However, no significant changes were observed in heavy metal removal, irrespective of the percentage of biochar addition, the particle size of biochar, or the type of biochar added to the cement paste. Adsorption capacities above 19 mg/g, 11 mg/g and 19 mg/g for Cu, Pb and Zn were recorded in all composites at an initial pH of 6.0. The Pseudo second order model best described the kinetics of the Cu, Pb, and Zn removal. The rate of adsorptive removal increases with the decrease in the density of the adsorbents. Over 40% of Cu and Zn were removed as carbonates and hydroxides through precipitation, whereas over 80% of Pb removal was via adsorption. Heavy metals bonded with OH-, CO32- and Ca-Si-H functional groups. The results demonstrate that biochar can be used as a cement replacement without negatively impacting heavy metal removal. However, neutralization of the high pH is needed before safe discharge.

Spatial variations in aromatic hydrocarbon emission in a dust-rich galaxy.

Dust grains absorb half of the radiation emitted by stars throughout the history of the universe, re-emitting this energy at infrared wavelengths1-3. Polycyclic aromatic hydrocarbons (PAHs) are large organic molecules that trace millimetre-size dust grains and regulate the cooling of interstellar gas within galaxies4,5. Observations of PAH features in very distant galaxies have been difficult owing to the limited sensitivity and wavelength coverage of previous infrared telescopes6,7. Here we present James Webb Space Telescope observations that detect the 3.3 µm PAH feature in a galaxy observed less than 1.5 billion years after the Big Bang. The high equivalent width of the PAH feature indicates that star formation, rather than black hole accretion, dominates infrared emission throughout the galaxy. The light from PAH molecules, hot dust and large dust grains and stars are spatially distinct from one another, leading to order-of-magnitude variations in PAH equivalent width and ratio of PAH to total infrared luminosity across the galaxy. The spatial variations we observe suggest either a physical offset between PAHs and large dust grains or wide variations in the local ultraviolet radiation field. Our observations demonstrate that differences in emission from PAH molecules and large dust grains are a complex result of localized processes within early galaxies.

Dialysis therapy and mortality in older adults with heart failure and advanced chronic kidney disease: A high-dimensional propensity-matched cohort study.

BACKGROUND: Heart failure (HF) and chronic kidney disease (CKD) frequently coexist, and the combination is linked to poor outcomes, but limited data exist to guide optimal management. We evaluated the outcome of dialysis therapy in older patients with HF and advanced CKD. METHODS: We examined adults aged ≥70 years with HF and eGFR ≤20 ml/min/1.73 m2 between 2008-2012 and no prior renal replacement therapy, cancer, cirrhosis or organ transplant. We identified patients who initiated chronic dialysis through 2013 and matched patients who did not initiate dialysis on age, gender, diabetes status, being alive on dialysis initiation date, and a high-dimensional propensity score for starting dialysis. Deaths were identified through 2013. We used Cox regression to evaluate the association of chronic dialysis and all-cause death. RESULTS: Among 348 adults with HF and advanced CKD who initiated dialysis and 947 matched patients who did not start dialysis, mean age was 80±5 years, 51% were women and 33% were Black. The crude rate of death was high overall but lower in those initiating vs. not initiating chronic dialysis (26.1 vs. 32.1 per 100 person-years, respectively, P = 0.02). In multivariable analysis, dialysis was associated with a 33% (95% Confidence Interval:17-46%) lower adjusted rate of death compared with not initiating dialysis. CONCLUSIONS: Among older adults with HF and advanced CKD, dialysis initiation was associated with lower mortality, but absolute rates of death were very high in both groups. Randomized trials should evaluate net outcomes of dialysis vs. conservative management on length and quality of life in this high-risk population.

Improvement of heavy metal removal from urban runoff using modified pervious concrete.

Heavy metals are one of the major chemical pollutant groups in urban runoff. The application of porous concrete is a potential alternative to conventional runoff management systems with the ability to remove heavy metals. Hence, a thorough understanding of the heavy metal removal mechanisms and constraints of conventional porous concrete opens a path for the development of effective modifications. This review critically discusses the major contributors in ordinary porous concrete which supports heavy metal removal. The effects of initial concentration, contact time and competing ions on heavy metal removal using porous concrete are also discussed. Additionally, the effect of decalcification, atmospheric carbonation, acid influent on heavy metal removal is reviewed. The major drawback of porous concrete is the high pH (>8.5) of the effluent water, decalcification of the porous concrete and leaching of adsorbed pollutants. Overall, the addition of adsorbent materials to the porous concrete increases removal efficiencies (7% - 65% increase) without neutralizing the effluent pH. Meanwhile, the addition of Reduced Graphene Oxide is successful in reducing the leachability of the removed heavy metals. The addition of pozzolanic materials can lower the effluent pH while maintaining similar removal efficiencies to unmodified porous concrete. Therefore, developing a novel method of neutralizing the effluent pH must be prioritized in future studies. Additionally, the toxicity that can occur due to the abrasion of modified porous concrete requires study in future research. Further, advanced characterization methods should be used in future studies to understand the mechanisms of removal via the modified porous concrete materials.

Performance of Reinforced Foam and Geopolymer Concretes against Prolonged Exposures to Chloride in a Normal Environment.

The utilization of sustainable cement replacement materials in concrete can control the emission of carbon dioxide and greenhouse gases in the construction industry, thus contributing significantly to the environment, society, and the global economy. Various types of sustainable concrete including geopolymer concrete are tested for their efficacy for construction in laboratories. However, the performance and longevity of sustainable concrete for civil engineering applications in corrosive environments are still debatable. This paper aims to investigate the performance of the reinforced geopolymer (GPC) and foam concretes (FC) against corrosive chloride exposure. Two long term key parameters, i.e., corrosion rate and mechanical performance of reinforcing steel in geopolymer and foam concrete were assessed to evaluate their performance against chloride attack. For experiments, reinforced GPC and FC specimens, each admixed with 3 and 5% chlorides, were kept at varying temperatures and humidity levels in the environmental chambers. The corrosion rates of the reinforced geopolymer and foam concrete specimens were also compared with control specimens after 803 days and the tensile strength of the corroded reinforcing steel was also determined. Moreover, the long term efficacy of repaired patches (810 days), in a chloride-rich surrounding environment utilizing FC and GPC, was investigated. The results suggested greater performance of FC compared to GPC under standard environmental conditions. However, the simulated patch repair with GPC showed better resistance against chloride attack compared to FC. The research also undertook the fractographical examination of the surfaces of the reinforcement exposed to 5% admixed chloride and develops models for the corrosion rates of foam concrete as a function of the corrosion rates of geopolymer concrete and chloride content. A correlation model for the corrosion rates of FC and GPC was also developed. The findings of the current research and the model developed are novel and contribute to the knowledge of long term degradation science of geopolymers and form concrete materials. Furthermore, the findings and methodology of the current research have practical significance in the construction and repair industry for determining the remaining service life for any reinforced and steel infrastructure.

Population-based identification and temporal trend of children with primary nephrotic syndrome: The Kaiser Permanente nephrotic syndrome study.

INTRODUCTION: Limited population-based data exist about children with primary nephrotic syndrome (NS). METHODS: We identified a cohort of children with primary NS receiving care in Kaiser Permanente Northern California, an integrated healthcare delivery system caring for >750,000 children. We identified all children <18 years between 1996 and 2012 who had nephrotic range proteinuria (urine ACR>3500 mg/g, urine PCR>3.5 mg/mg, 24-hour urine protein>3500 mg or urine dipstick>300 mg/dL) in laboratory databases or a diagnosis of NS in electronic health records. Nephrologists reviewed health records for clinical presentation and laboratory and biopsy results to confirm primary NS. RESULTS: Among 365 cases of confirmed NS, 179 had confirmed primary NS attributed to presumed minimal change disease (MCD) (72%), focal segmental glomerulosclerosis (FSGS) (23%) or membranous nephropathy (MN) (5%). The overall incidence of primary NS was 1.47 (95% Confidence Interval:1.27-1.70) per 100,000 person-years. Biopsy data were available in 40% of cases. Median age for patients with primary NS was 6.9 (interquartile range:3.7 to 12.9) years, 43% were female and 26% were white, 13% black, 17% Asian/Pacific Islander, and 32% Hispanic. CONCLUSION: This population-based identification of children with primary NS leveraging electronic health records can provide a unique approach and platform for describing the natural history of NS and identifying determinants of outcomes in children with primary NS.

The development of a comprehensive toolbox based on multi-level, high-throughput screening of MOFs for CO/N2 separations.

The separation of CO/N2 mixtures is a challenging problem in the petrochemical sector due to the very similar physical properties of these two molecules, such as size, molecular weight and boiling point. To solve this and other challenging gas separations, one requires a holistic approach. The complexity of a screening exercise for adsorption-based separations arises from the multitude of existing porous materials, including metal-organic frameworks. Besides, the multivariate nature of the performance criteria that needs to be considered when designing an optimal adsorbent and a separation process - i.e. an optimal material requires fulfillment of several criteria simultaneously - makes the screening challenging. To address this, we have developed a multi-scale approach combining high-throughput molecular simulation screening, data mining and advanced visualization, as well as process system modelling, backed up by experimental validation. We have applied our recent advances in the engineering of porous materials' morphology to develop advanced monolithic structures. These conformed, shaped monoliths can be used readily in industrial applications, bringing a valuable strategy for the development of advanced materials. This toolbox is flexible enough to be applied to multiple adsorption-based gas separation applications.

Primary Nephrotic Syndrome and Risks of ESKD, Cardiovascular Events, and Death: The Kaiser Permanente Nephrotic Syndrome Study.

BACKGROUND: Little population-based data exist about adults with primary nephrotic syndrome. METHODS: To evaluate kidney, cardiovascular, and mortality outcomes in adults with primary nephrotic syndrome, we identified adults within an integrated health care delivery system (Kaiser Permanente Northern California) with nephrotic-range proteinuria or diagnosed nephrotic syndrome between 1996 and 2012. Nephrologists reviewed medical records for clinical presentation, laboratory findings, and biopsy results to confirm primary nephrotic syndrome and assigned etiology. We identified a 1:100 time-matched cohort of adults without diabetes, diagnosed nephrotic syndrome, or proteinuria as controls to compare rates of ESKD, cardiovascular outcomes, and death through 2014, using multivariable Cox regression. RESULTS: We confirmed 907 patients with primary nephrotic syndrome (655 definite and 252 presumed patients with FSGS [40%], membranous nephropathy [40%], and minimal change disease [20%]). Mean age was 49 years; 43% were women. Adults with primary nephrotic syndrome had higher adjusted rates of ESKD (adjusted hazard ratio [aHR], 19.63; 95% confidence interval [95% CI], 12.76 to 30.20), acute coronary syndrome (aHR, 2.58; 95% CI, 1.89 to 3.52), heart failure (aHR, 3.01; 95% CI, 2.16 to 4.19), ischemic stroke (aHR, 1.80; 95% CI, 1.06 to 3.05), venous thromboembolism (aHR, 2.56; 95% CI, 1.35 to 4.85), and death (aHR, 1.34; 95% CI, 1.09 to 1.64) versus controls. Excess ESKD risk was significantly higher for FSGS and membranous nephropathy than for presumed minimal change disease. The three etiologies of primary nephrotic syndrome did not differ significantly in terms of cardiovascular outcomes and death. CONCLUSIONS: Adults with primary nephrotic syndrome experience higher adjusted rates of ESKD, cardiovascular outcomes, and death, with significant variation by underlying etiology in the risk for developing ESKD.

Life cycle assessment and cost analysis of fly ash-rice husk ash blended alkali-activated concrete.

The utilization of industrial and agricultural by-products for the production of alkali activated concrete (AAC) has the potential to yield significant benefits towards sustainability goals. To be a viable material, the construction industry requires a construction material that achieves the requisite strength and the other property requirements as specified in codes and standards while demonstrating improved sustainability criteria. Fly ash and Rice Husk Ash (RHA) are abundantly available waste products, principally located in Asian countries. Currently, a significant proportion of these materials are disposed of in landfills, lagoons and rivers but offer potential to utilize in AAC. Hence, the identification of variables associated with fly ash and fly ah-RHA blended AAC by utilizing fly ash and RHA is vital. This study quantifies the environmental and economic factors by assessing the Greenhouse gas (GHG) emission, environmental impacts and benefits, and cost analysis of utilizing fly ash and RHA in AAC compared to Portland Cement (PC) concrete. Alkaline activator is a key component responsible for the highest GHG emission, cost and environmental impact amounts obtained for fly ash geopolymer and blended alkali-activated concrete compared with PC concrete. Alkali activators contribute to 74% of the total GHG emission, while heat curing contributed only 9% to the total GHG emission. The addition of 10% RHA to alkali-activated concrete showed a slight benefit for the analysis. Utilization of waste fly ash and RHA is responsible for providing significant benefits in terms of fresh and marine water ecotoxicity by avoiding waste disposal at the dumpsites, rivers, and storage lagoons.

Novel Analytical Method for Mix Design and Performance Prediction of High Calcium Fly Ash Geopolymer Concrete.

Despite extensive in-depth research into high calcium fly ash geopolymer concretes and a number of proposed methods to calculate the mix proportions, no universally applicable method to determine the mix proportions has been developed. This paper uses an artificial neural network (ANN) machine learning toolbox in a MATLAB programming environment together with a Bayesian regularization algorithm, the Levenberg-Marquardt algorithm and a scaled conjugate gradient algorithm to attain a specified target compressive strength at 28 days. The relationship between the four key parameters, namely water/solid ratio, alkaline activator/binder ratio, Na2SiO3/NaOH ratio and NaOH molarity, and the compressive strength of geopolymer concrete is determined. The geopolymer concrete mix proportions based on the ANN algorithm model and contour plots developed were experimentally validated. Thus, the proposed method can be used to determine mix designs for high calcium fly ash geopolymer concrete in the range 25-45 MPa at 28 days. In addition, the design equations developed using the statistical regression model provide an insight to predict tensile strength and elastic modulus for a given compressive strength.

A diver's dilemma - a case report on bronchopulmonary sequestration.

BACKGROUND: An asymptomatic SCUBA (Self-contained underwater breathing apparatus) diver was discovered to have an intralobar bronchopulmonary sequestration during routine pre-course screening. This is the first reported case of a diver who, having previously completed several recreational and military diving courses, was subsequently diagnosed with a congenital lung condition, possibly contraindicating diving. Presently, there is no available literature providing guidance on the diving fitness of patients with such a condition. CASE PRESENTATION: An asymptomatic 26-year-old male diver was nominated to attend an overseas naval diving course. Prior to this, he had been medically certified to participate in, and had successfully completed other military and recreational diving courses. He had also completed several hyperbaric dives up to a depth of 50 m and 45 recreational dives up to a depth of 30 m. He did not have a history of diving-related injuries or complications. He had never smoked and did not have any medical or congenital conditions, specifically recurrent respiratory infections. As part of pre-course screening requirements, a lateral Chest X-ray was performed, which revealed a left lower lobe pulmonary nodule. This was subsequently diagnosed as a cavitatory left lower lobe intralobar bronchopulmonary sequestration on Computed Tomography Thorax. The diver remains asymptomatic and well at the time of writing and has been accepted to participate in another overseas course involving only dry diving in a hyperbaric chamber, with no prerequisites for him to undergo surgery. CONCLUSION: Although bronchopulmonary sequestrations lack communication with the tracheobronchial tree, they may still contain pockets of air, even if not radiologically visible. This can be attributed to anomalous connections which link them to other bronchi, lung parenchyma and/or pores of Kohn. As such, there is a higher theoretical risk of pulmonary barotrauma during diving, leading to pneumothorax, pneumomediastinum, or cerebral arterial gas embolism. Taking these into consideration, the current clinical consensus is that bronchopulmonary sequestrations and all other air-containing lung parenchymal lesions should be regarded as contraindications to diving. Patients who have undergone definitive and uncomplicated surgical resection may be considered fit to dive.

Optimisation of Cu+ impregnation of MOF-74 to improve CO/N2 and CO/CO2 separations.

Carbon monoxide (CO) purification from syngas impurities is a highly energy and cost intensive process. Adsorption separation using metal-organic frameworks (MOFs) is being explored as an alternative technology for CO/nitrogen (N2) and CO/carbon dioxide (CO2) separation. Currently, MOFs' uptake and selectivity levels do not justify displacement of the current commercially available technologies. Herein, we have impregnated a leading MOF candidate for CO purification, i.e. M-MOF-74 (M = Co or Ni), with Cu+ sites. Cu+ allows strong π-complexation from the 3d electrons with CO, potentially enhancing the separation performance. We have optimised the Cu loading procedure and confirmed the presence of the Cu+ sites using X-ray absorption fine structure analysis (XAFS). In situ XAFS and diffuse reflectance infrared Fourier Transform spectroscopy analyses have demonstrated Cu+-CO binding. The dynamic breakthrough measurements showed an improvement in CO/N2 and CO/CO2 separations upon Cu impregnation. This is because Cu sites do not block the MOF metal sites but rather increase the number of sites available for interactions with CO, and decrease the surface area/porosity available for adsorption of the lighter component.

Facile, Room-Temperature 17O Enrichment of Zeolite Frameworks Revealed by Solid-State NMR Spectroscopy.

A new approach for room-temperature 17O enrichment of zeolites reveals a surprisingly dynamic and labile framework, where rapid and reversible bond breaking takes place. 17O NMR spectroscopy shows that although O sites in both framework Si-O-Al and Si-O-Si linkages are enriched simply on exposure to H217O(l), the enrichment of Si-O-Al species is more rapid, with a more uniform framework enrichment observed at longer durations. We demonstrate that this unexpected enrichment can be observed for two different framework topologies and for Na-exchanged (i.e., nonacidic) zeolites, as well as their protonic forms, confirming that the Brønsted acid proton is not necessary for isotopic exchange into the framework. This work not only offers new opportunities for structural characterization of these chemically and industrially important materials using NMR spectroscopy but suggests that further investigation of the rate and position of enrichment in zeolite frameworks could provide new insight into their chemical reactivity and their stability in aqueous-based applications such as ion exchange and catalysis.

Study protocol for a Community Health Worker (CHW)-led comprehensive neighborhood-focused program for medicaid enrollees in detroit.

Residents of low income neighborhoods disproportionately experience poor health, and many have unmet social needs. Clinical trials have shown the efficacy of Community Health Worker (CHW) programs in improving outcomes for a variety of health conditions. An important next step is developing and evaluating financially sustainable CHW program models in real-life settings. This program evaluation examines health care utilization among participants in a geographically targeted program led by salaried CHWs from three Medicaid health plans. Beneficiaries who reside in the Cody Rouge neighborhood of Detroit and had more than 3 Emergency Department (ED) visits or at least 1 ambulatory care-sensitive hospitalization in the prior 12 months are eligible for the program. Health plan CHWs assigned to the program reach out to eligible beneficiaries to provide an assessment; link them to resources; and provide follow-up. At 12-month follow up, claims data on ED visits, ambulatory care-sensitive hospitalizations, primary care visits, and related costs will be compared between beneficiaries who participated and eligible beneficiaries randomized to receive usual outreach. We hypothesize that patients enrolled in the CHW intervention will experience a reduction in acute care usage resulting in cost savings compared to those receiving usual health plan outreach. This study is among the first to evaluate the impact on health care utilization of augmented services delivered by health plan CHWs for high-utilizing health plan members as part of a health plan-community-academic partnership. This study will provide important information on CHW program sustainability and provide insights into effective implementation of such programs. TRIAL REGISTRATION: NCT03924713.

Caring for adults with congenital heart disease in a regional setting.

OBJECTIVE: The number of adults with congenital heart disease has increased with improvements in surgical and medical management, posing a challenge for regional and rural settings, which might have difficulties accessing specialised professionals with congenital heart disease services. This study aims to ascertain the demographics and management of adults with congenital heart disease seen by a cardiology practice in regional Australia to better understand the needs of regional adults with congenital heart disease. DESIGN: A descriptive study using data from clinical notes collected between April 2013 and April 2016. SETTING: A private cardiology practice in Coffs Harbour, New South Wales. The practice has a treating cardiologist, senior sonographer, visiting cardiothoracic surgeon and visiting paediatric cardiologist. PARTICIPANTS: One-hundred-and-one adults with congenital heart disease (age: 16-88 years; 55 women). MAIN OUTCOME MEASURES: Congenital heart disease defect, lesion severity, referral reason, past surgery, pulmonary hypertension, cardiac surgery during the study, mortality, adherence with follow-up plans and specialist referral. RESULTS: Sixty-six patients had simple congenital heart disease, 24 had congenital heart disease of moderate complexity and 11 had congenital heart disease of great complexity. Most were referred for surveillance, seven were referred due to pregnancy and eight were new diagnoses. Six patients died, nine had cardiac operations and five were treated for pulmonary arterial hypertension. Overall adherence to the treating cardiologist's follow-up plans was 84%. All patients with congenital heart disease of great complexity were referred to congenital heart disease specialists. CONCLUSION: A substantial number of patients had complex pathology, new diagnoses or required surgery, highlighting the importance of developing integrated services with the close support of outside specialists in managing adults with congenital heart disease in regional settings.