Community acquired pressure injuries in a work-related spinal cord injury population: Problem characterization and assessment of a working solution.

BACKGROUND: To characterize the problem of community-acquired pressure injuries (CAPIs) in a work-related spinal cord injury (SCI) population in Canada and assess the benefits of a person-centered solution. Characterization of the problem and a solution, albeit in an insured Worker's Compensation Board of British Columbia (WorkSafeBC) cohort, may inform the supply of solutions in the larger SCI population with disparate access to healthcare. METHODS: For this observational study, data on 244 WorkSafeBC clients, who received an intervention featuring pressure injury (PI) assessment between 2011 and 2015, were used to characterize the problem. Data on observed injuries, risk, referrals, and outcomes were linked to healthcare service claims. Employing an activity-based costing methodology, total expenditures on attributed services were calculated for clients with 1 or more PIs. Intervention cost and benefits from the insurer's perspective are considered. RESULTS: 84 of 244 clients had 1 or more PIs at assessment, with attributed mean cost of $56,092 in 2015 Canadian dollars (CAD). Mean cost by PI severity range from $9580 to $238,736. At an intervention cost of $820,618, detection of less severe injuries provided an opportunity to prevent progression and achieve $3 million in cost avoidance. Follow-up data suggest reasonable returns. Reductions in the incidence, number, and risk of pressure injuries were also observed. CONCLUSIONS: The analysis establishes the cost of CAPIs in a Canadian-based work-related SCI population and suggests preventative and early intervention is not only feasible but also practical. Results are relevant to decisions regarding the use of proactive prevention-based treatment models as opposed to reactive, solutions in the larger SCI population.

Burnout in the emergency department: Randomized controlled trial of an attention-based training program.

BACKGROUND: Burnout (encompassing emotional exhaustion, depersonalization and personal accomplishment) in healthcare professionals is a major issue worldwide. Emergency medicine physicians are particularly affected, potentially impacting on quality of care and attrition from the specialty. OBJECTIVE: The aim of this study was to apply an attention-based training (ABT) program to reduce burnout among emergency multidisciplinary team (MDT) members from a large urban hospital. DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS: Emergency MDT members were randomized to either a no-treatment control or an intervention group. Intervention group participants engaged in a four session (4 h/session) ABT program over 7 weeks with a practice target of 20 min twice-daily. Practice adherence was measured using a smart phone application together with a wearable Charge 2 device. MAIN OUTCOME MEASURES: The primary outcome was a change in burnout, comprising emotional exhaustion, depersonalization and personal achievement. The secondary outcomes were changes in other psychological and biometric parameters. RESULTS: The ABT program resulted in a significant reduction (P < 0.05; T1 [one week before intervention] vs T3 [follow-up at two months after intervention]) in burnout, specifically, emotional exhaustion, with an effect size (probability of superiority) of 59%. Similar reductions were observed for stress (P < 0.05) and anxiety (P < 0.05). Furthermore, ABT group participants demonstrated significant improvements in heart rate variability, resting heart rate, sleep as well as an increase in pro-inflammatory cytokine expression. CONCLUSION: This study describes a positive impact of ABT on emergency department staff burnout compared to a no-treatment control group. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02887300.

Mantra meditation programme for emergency department staff: a qualitative study.

OBJECTIVES: Rates of burnout and stress in healthcare practitioners are steadily increasing. Emergency department (ED) staff are particularly susceptible to such poor outcomes. Mantra meditation (MM) may contribute to increased well-being. The primary aim of this study was to obtain indepth qualitative feedback on ED staff's experience of a MM programme. A secondary objective was to harness staff's perception of the ED working environment. DESIGN: Qualitative study. SETTING: ED in St James' Hospital, Dublin, Ireland. PARTICIPANTS: Doctors, nurses, allied health professionals and administrative staff (n=10, eight women, mean age 35.6 years) working in the ED who attended a MM programme. METHODS: Semistructured interviews were conducted by a trained independent researcher. Interviews were transcribed and thematically analysed. RESULTS: Five main themes and six subthemes were identified: work pressure and perceived stress; perceived benefits of meditation (with subthemes of increased attention/awareness, improved emotion regulation and new coping mechanisms, relaxation and sleep quality); conflicting attitudes to practice; barriers to meditation practice (with subthemes of schedule, length of practice and individual differences); and facilitators to practice. CONCLUSION: ED staff in this study described the demands of their work and voiced a need for a workplace well-being programme. Our findings suggest that MM might represent a viable tool to develop attention and awareness, improve emotion regulation and improve their capacity to cope with stress, which may impact their workplace well-being, wider health service, patient safety and quality of care. Support from the organisation is considered to be integral to embedding of a workplace well-being programme, such as the practice of meditation into their daily lives.

Relating Bryophyte Assemblages to a Remotely Sensed Depth-to-Water Index in Boreal Forests.

Given the habitat moisture (air humidity or soil moisture) preferences of many forest bryophytes, we explored whether the depth-to-water (DTW) index, derived from remotely sensed Light Detection and Ranging (LiDAR) data, was related to fine-scale patterns of spatial variation in bryophyte abundance, diversity, and composition. The goal was to assess the utility of the topographic DTW index as a tool to decipher trends in bryophyte assemblages along a site wetness gradient in the boreal mixedwood forest. Discrete Airborne Laser Scanning (ALS) data were acquired over the entire Ecosystem Management Emulating Natural Disturbance (EMEND) experimental site located in northwestern Alberta, Canada (56° 46' 13″ N, 118° 22' 28″ W), based on which we calculated a mathematical index of approximate depth to water at or below the soil surface at 1 m resolution using the Wet-Areas Mapping model. Bryophytes (mosses and liverworts) were sampled in permanent sample plots in unmanaged forest stands of varying dominant canopy tree composition. The relationships between DTW and bryophyte cover, richness, diversity, and composition in broadleaf (deciduous)-, mixed, and conifer-dominated boreal forest stands were analyzed using linear mixed-effect models and multivariate analyses. Bryophyte cover was highest in conifer-dominated forest, which occupied the wetter end of the DTW gradient, followed by mixed forest, whereas broadleaf forest, which occupied the drier end of the DTW gradient, had the lowest cover but highest bryophyte diversity. Bryophyte cover in conifer-dominated forests was positively related to site moisture (negatively related to the DTW index). In contrast, bryophyte species richness and diversity were negatively related to site moisture (increased at higher DTW values) in all forest types. DTW explained significant variation in bryophyte species composition in mixed forests, while indicator species analysis identified species with preferences for wet, moist, and dry site conditions in each forest type. Our results corroborate the importance of site moisture as a driver of bryophyte assemblages but, interestingly, there were important differences among forest types, which themselves are distributed across a gradient of site moisture. Our study demonstrates the utility of the topographic DTW index for understanding fine-scale (plot-level) variation in bryophyte assemblages in forested landscapes.

Significant gynecological bleeding in women with low von Willebrand factor levels.

Gynecological bleeding is frequently reported in women with von Willebrand disease (VWD). Low von Willebrand factor (VWF) may be associated with significant bleeding phenotype despite only mild plasma VWF reductions. The contribution of gynecological bleeding to this phenotype has yet to be described. The optimal clinical bleeding assessment tool (BAT) to evaluate bleeding remains unclear. Using a standardized approach to phenotypic assessment, we evaluated gynecological bleeding and directly compared the Condensed Molecular and Clinical Markers for the Diagnosis and Management of type 1 VWD (Condensed MCMDM-1 VWD) and International Society on Thrombosis and Haemostasis (ISTH) BAT scores in 120 women enrolled in the Low von Willebrand in Ireland Cohort study. Heavy menstrual bleeding (HMB) was reported in 89% of female participants; 45.8% developed iron deficiency. Using identical data, Condensed MCMDM-1 VWD menorrhagia domain scores were significantly lower than ISTH BAT scores (2 vs 3; P < .0001), the discrepant results related to 40% of women not seeking medical consultation for HMB, reducing the sensitivity of the Condensed score. For those who reported HMB to physicians, the low VWF diagnosis was not expedited (age at diagnosis 34.2 vs 33.4 years in women failing to present; P = .7). Postpartum hemorrhage (PPH) was self-reported in 63.5% of parous women (n = 74); 21.6% required transfusion, critical care, radiological, or surgical intervention. Our data demonstrate that gynecological bleeding is frequently reported in women with low VWF; despite pregnancy-related increases in plasma VWF levels, these women may experience PPH. Defining the optimal management approach for these patients requires further research. This trial was registered at www.clinicaltrials.gov as #NCT03167320.

Self-management interventions for skin care in people with a spinal cord injury: part 1-a systematic review of intervention content and effectiveness.

STUDY DESIGN: Systematic review. OBJECTIVES: To review the content and effectiveness of skin care self-management interventions for people with SCI. SETTING: International. METHODS: We searched electronic bibliographic databases, trial registers, and relevant reference lists. Eligibility criteria for the reviews of intervention content and effectiveness were identical with the exception of study design. The review of intervention content included non-randomized and randomized controlled trials (RCTs). The review of effectiveness included RCTs. A Behavior Change Technique (BCT) taxonomy of 93 BCTs was used to code intervention content. Intervention effects on outcomes of interest are summarized descriptively. Effect sizes were calculated, and the Cochrane risk of bias tool applied. RESULTS: In all, 15 studies testing 17 interventions were included in the review of intervention content. Interventions in these studies included 28 BCTs. The most common were "instructions on how to perform behavior" (16 interventions), "credible source" (12 interventions), and "social support (unspecified)" (9 interventions). Ten RCTs were included in the review of intervention effectiveness and they measured knowledge, self-efficacy, and skills relating to skin care/pressure ulcer (PU) prevention, skin care behaviors, skin status (PU prevalence, severity, and time to PU), and health-care utilization for skin problems. Evidence to support intervention effects on these outcomes was limited, particularly for clinical outcomes. Risk of bias assessments was often inconclusive due to poor reporting. CONCLUSIONS: There is potential to design SCI skin care interventions that include currently untested BCTs. Further research and better consistency in outcome measurements and reporting are required to synthesize evidence on effectiveness.

Quality of Life and Health Utility Scores Among Canadians Living With Traumatic Spinal Cord Injury - A National Cross-Sectional Study.

STUDY DESIGN: National, multicenter, cross-sectional study. OBJECTIVE: The goal of this study was to provide overall quality of life (QOL) and health utility (HU) values for patients with traumatic spinal cord injury (SCI) stratified by injury level and neurological status. SUMMARY OF BACKGROUND DATA: Traumatic SCI is a leading cause of disability. Varying injury level and severity generate a spectrum of neurological dysfunction and reduction in long-term QOL. METHODS: The Canadian SCI Community Survey was sent to Canadians living in the community after SCI. The impact of demographics, complications, and SCI classification on QOL was assessed using Analysis of variance, multiple linear regressions and ordinal logistic regression analyses. RESULTS: There were 1109 respondents with traumatic SCI. american spinal injury association impairment scale (AIS) grade was reported to be cervical motor complete in 20%, cervical motor incomplete in 28%, thoracolumbar motor complete in 32%, thoracolumbar motor incomplete in 16%, and normal (any level) in 1%. Injury level or AIS grade had no impact on either HU or QOL. The physical component of health-related quality of life (HRQOL) was significantly affected by the neurological level, but not the social or mental components. With a mean health utility score of 0.64 ±â€Š0.12, SCI patients living in the community reported having HRQOL similar to patients after total knee arthroplasty or lumbar spinal stenosis decompression. CONCLUSION: QOL or HU measured by generic HRQOL outcome tools should not be used as outcomes to assess the effectiveness of interventions targeting neurological function in traumatic SCI. A disease-specific instrument that captures the nuances specific to spinal cord injury patients is required. LEVEL OF EVIDENCE: 1.

Novel insights into the clinical phenotype and pathophysiology underlying low VWF levels.

Critical clinical questions remain unanswered regarding diagnosis and management of patients with low von Willebrand factor (VWF) levels (30-50 IU/dL). To address these questions, the Low VWF Ireland Cohort (LoVIC) study investigated 126 patients registered with low VWF levels. Despite marginally reduced plasma VWF levels, International Society of Thrombosis and Haemostasis Bleeding Assessment Tool (ISTH BAT) confirmed significant bleeding phenotypes in the majority of LoVIC patients. Importantly, bleeding tendency did not correlate with plasma VWF levels within the 30 to 50 IU/dL range. Furthermore, bleeding phenotypes could not be explained by concurrent hemostatic defects. Plasma factor VIII to VWF antigen (VWF:Ag) ratios were significantly increased in LoVIC patients compared with controls (P < .0001). In contrast, VWF propeptide to VWF:Ag ratios >3 were observed in only 6% of the LoVIC cohort. Furthermore, platelet-VWF collagen binding activity levels were both significantly reduced compared with controls (P < .05). In response to 1-desamino-8-D-arginine vasopressin (DDAVP), peak VWF:Ag levels exceeded 100 IU/dL in 88% of patients and was sustained >100 IU/dL after 4 hours in 72% of subjects. In conclusion, our novel data suggest that low VWF levels can be associated with significant bleeding and are predominantly due to reductions in VWF synthesis and/or constitutive secretion. Although enhanced VWF clearance may contribute to the pathophysiology in some individuals, the absolute reduction in VWF plasma half-life is usually mild and not sufficient to significantly impact upon the duration of DDAVP-induced VWF response. This trial was registered at www.clinicaltrials.gov as #NCT03167320.

The Economic Burden of Urinary Tract Infection and Pressure Ulceration in Acute Traumatic Spinal Cord Injury Admissions: Evidence for Comparative Economics and Decision Analytics from a Matched Case-Control Study.

Secondary complications of spinal cord injury (SCI) are a burden to affected individuals and the rest of society. There is limited evidence of the economic burden or cost of complications in SCI populations in Canada, however, which is necessary for comparative economic analyses and decision analytic modeling of possible solutions to these common health problems. Comparative economic analyses can inform resource allocation decisions, but the outputs are only as good as the inputs. In this article, new evidence of the excess or incremental costs of urinary tract infection (UTI) and pressure ulceration (PU) in acute traumatic SCI from an exploratory case series analysis of admissions to a Level I specialized Canadian spine facility (2008-2013) is presented. Participants in a national SCI registry were case-control matched (1:1) on the predicted probability of experiencing UTI or PU during initial acute SCI admission. The excess costs of UTI and PU are estimated as the mean of the differences in total direct acute SCI admission costs (length of stay, accommodation, nursing, pharmacy) from the perspective of the admitting facility between participants matched or paired on demographic and SCI characteristics. Even relatively minor UTI and PU, respectively, added an average of $7,790 (standard deviation [SD] $6,267) and $18,758 (SD $27,574) to the direct cost of acute SCI admission in 2013 Canadian dollars (CAD). This case series analysis established evidence of the excess costs of UTI and PU in acute SCI admissions, which will support decision-informing analyses in SCI.

Spinal Cord Injury Clinical Registries: Improving Care across the SCI Care Continuum by Identifying Knowledge Gaps.

Timely access and ongoing delivery of care and therapeutic interventions is needed to maximize recovery and function after traumatic spinal cord injury (tSCI). To ensure these decisions are evidence-based, access to consistent, reliable, and valid sources of clinical data is required. The Access to Care and Timing Model used data from the Rick Hansen SCI Registry (RHSCIR) to generate a simulation of healthcare delivery for persons after tSCI and to test scenarios aimed at improving outcomes and reducing the economic burden of SCI. Through model development, we identified knowledge gaps and challenges in the literature and current health outcomes data collection throughout the continuum of SCI care. The objectives of this article were to describe these gaps and to provide recommendations for bridging them. Accurate information on injury severity after tSCI was hindered by difficulties in conducting neurological assessments and classifications of SCI (e.g., timing), variations in reporting, and the lack of a validated SCI-specific measure of associated injuries. There was also limited availability of reliable data on patient factors such as multi-morbidity and patient-reported measures. Knowledge gaps related to structures (e.g., protocols) and processes (e.g., costs) at each phase of care have prevented comprehensive evaluation of system performance. Addressing these knowledge gaps will enhance comparative and cost-effectiveness evaluations to inform decision-making and standards of care. Recommendations to do so were: standardize data element collection and facilitate database linkages, validate and adopt more outcome measures for SCI, and increase opportunities for collaborations with stakeholders from diverse backgrounds.

Advancing research and clinical care in the management of neuropathic pain after spinal cord injury: Key findings from a Canadian summit.

Background: Optimal management of neuropathic pain (NP) is essential to enhancing health-related quality of life for individuals living with spinal cord injury (SCI). A key strategic priority for the Ontario Neurotrauma Foundation (ONF) and Rick Hansen Institute (RHI) is optimizing NP management after SCI. Aims: A National Canadian Summit, sponsored by ONF and RHI, was held to develop a strategic plan to improve NP management after SCI. Methods: In a one-day meeting held in Toronto, Ontario, a multidisciplinary panel of 18 Canadian stakeholders utilized a consensus workshop methodology to (1) describe the current state of the field, (2) create a long-term vision, and (3) identify steps for moving into action. Results: A review of the current state of the field identified strengths including rigourously developed evidence syntheses and practice landscape documentation. Identified gaps included limited evidence on NP hindering recommendation development in evidence syntheses, absence of a national strategy, care silos with limited cross-continuum connections, limited consumer involvement, and limited practice standard implementation. The panel identified key themes for a long-term vision to improve the management of SCI NP in Canada, including establishing an integrated collaborative network; standardized care and outcome evaluation; education; advocacy; and directing resources to innovative solutions. The panel identified the next step as prioritization of areas that will have the greatest impact in a 5-year time frame. Conclusion: A strategic plan outlining a long-term vision to improve management of NP after SCI in Canada was developed and will inform future activities of the sponsors.

Contexte: La gestion optimale de la douleur neuropathique est essentielle à l'amélioration de la qualité de vie liée à la santé des personnes vivant avec une lésion de la moelle épinière. L'une des priorités stratégiques de la Fondation ontarienne de neurotraumatologie et de l'Institut Rick Hansen est l'optimisation de la prise en charge de la douleur neuropathique après une lésion de la moelle épinière.Buts: Un sommet national canadien parrainé par la Fondation ontarienne de neurotraumatologie et l'Institut Rick Hansen a été tenu afin d'élaborer un plan stratégique pour l'amélioration de la gestion de la douleur neuropathique après une lésion de la moelle épinière.Méthodes: Dans le cadre d'une rencontre d'une journée tenue à Toronto, Ontario, un panel multidisciplinaire composé de 18 parties prenantes canadiennes a eu recours à la méthodologie de l'atelier consensuel pour (1) décrire la situation actuelle dans le domaine, (2) définir une vision à long terme et (3) déterminer les étapes à suivre pour passer à l'action.Résultats: Une revue de la situation actuelle dans le domaine a permis d'en répertorier les forces, parmi lesquelles on compte des synthèses de données probantes élaborées avec rigueur et la documentation des pratiques. Les lacunes suivantes ont été répertoriées: des données probantes limitées en ce qui concerne la formulation de recommandations pour empêcher la douleur neuropathique dans les synthèses de données probantes; l'absence de stratégie nationale; un mode de prestation des soins en silos, où les liens entre les continuums sont limités; une participation du consommateur limitée et une mise en œuvre limitée des normes de pratique. Le panel a répertorié les grands thèmes pour élaborer une vision à long terme afin d'améliorer la prise en charge de la douleur neuropathique occasionnée par une lésion de la moelle épinière au Canada, parmi lesquels on compte: l'établissement d'un réseau de collaboration intégré; la normalisation des soins et l'évaluation des résultats; l'éducation; le plaidoyer; et l'attribution de ressources aux solutions novatrices. Le panel a déterminé que la prochaine étape consisterait à prioriser les domaines qui auront le plus de répercussions au cours des cinq prochaines années.Conclusion: Un plan stratégique définissant une vision à long terme pour améliorer la prise en charge de la douleur neuropathique après une lésion de la moelle épinière a été élaboré. Ce plan servira de base aux prochaines activités des promoteurs.

Self-management interventions to improve skin care for pressure ulcer prevention in people with spinal cord injuries: a systematic review protocol.

BACKGROUND: Pressure ulcers are a serious, common, lifelong, and costly secondary complication of spinal cord injury (SCI). Community-dwelling people with a SCI can prevent them with appropriate skin care (i.e. pressure relieving activities, skin checks). Adherence to skin care remains suboptimal however, and self-management interventions that focus on improving this have been designed. Little is known on their content, effectiveness, or theoretical basis. The aim of the proposed systematic review is to synthesize the literature on self-management interventions to improve skin care in people with a SCI. Specific objectives are to describe these interventions in relation to their content, effectiveness, theory base, and adherence to reporting guidelines for intervention description. METHODS: The search strategy will combine an electronic search of nine bibliographic databases (MEDLINE, Embase, PsycInfo, CENTRAL, CINAHL, Rehabdata, CIRRIE, PEDro, ERIC) and two trial registers with a manual search of relevant reference lists. Predefined eligibility criteria will be applied in a two-phase selection process involving title and abstract screening, followed by full-text screening. A data extraction spreadsheet will be applied to included papers. Intervention content will be coded using two taxonomies (behaviour change taxonomy; PRISMS self-management support taxonomy). A validated tool (Theory Coding Scheme) and the Template for Intervention Description and Replication (TIDieR) will be used to examine theoretical basis and assess adherence to reporting guidelines for intervention description. A small number of heterogeneous studies are likely to be included in this review therefore a narrative synthesis is planned. DISCUSSION: This systematic review will help identify the gaps and priorities to guide future research activities in this area. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016033191.

Out of Sight, out of Mind? An Audit Which Proposes a Follow-Up and Management Pathway for Inferior Vena Cava Filters.

Insertion of an IVC filter can be a safe and effective way to avoid PE in thrombosis patients who cannot be anticoagulated. If temporary filters are not promptly removed they can become difficult to remove, causing avoidable complications and often requiring lifelong warfarin. In this study, two sequential audits of retrieval of temporary IVC filters were conducted before and after the implementation of a coordinated management strategy for IVC filter follow-up. 33 filter placements were examined over a 15-month period (Group A). Following implementation of the strategy a comparable 15-month period in which 33 IVC filters were placed was audited (Group B). Following implementation, failed retrievals dropped from 15% to 9%. The number successfully retrieved did not change at 45%. The number made permanent from the outset following expert discussion increased from 12% to 39%. The number of filters with no attempted retrieval and no consultation about retrieval decreased from 27% to 9% (these patients were lost to follow-up with multiple contact attempts made). In Group B 100% of placed IVC filters were followed up appropriately. The proposed model is an easily implemented plan to avoid patient morbidity caused by temporary IVC filters made unintentionally permanent by loss to follow-up.

The Economic Burden of Autonomic Dysreflexia during Hospitalization for Individuals with Spinal Cord Injury.

We sought to determine the economic burden of autonomic dysreflexia (AD) from the perspective of the Canadian healthcare system in a case series of individuals with spinal cord injury (SCI) presenting to emergency care. In doing so, we sought to illustrate the potential return on investments in the translation of evidence-informed practices and developments in the prevention, diagnosis, and management of AD. Activity-based costing methodology was employed to estimate the direct healthcare or hospitalization costs of AD following presentation to the emergency department. Differences in trends were noted between patients who were promptly diagnosed, managed, and discharged, and patients whose experience followed a less direct or ideal path to discharge. We recorded 29 emergency room visits for conditions ultimately diagnosed as AD. Overall, median length of stay was 3 days (interquartile range [IQR] = 1.25-5.75), but extended up to 103 consecutive days. Cost analysis revealed median healthcare costs of $5029 (IQR = $2397-9522) for hospital admissions for AD, with the highest estimated hospital cost for a single admission > $190,000. Emergency room admissions resulting from AD can result in dramatic healthcare costs. Delayed diagnosis and inefficient management of AD may lead to further complications, adding to the strain on already limited healthcare resources. Prompt recognition of AD; broader translation of evidence-informed practices; and novel diagnosis, self-management, and/or therapeutic/pharmaceutical applications may prove to mitigate the burden of AD and improve patient well-being.

School-based early childhood education and age-28 well-being: effects by timing, dosage, and subgroups.

Advances in understanding the effects of early education have benefited public policy and developmental science. Although preschool has demonstrated positive effects on life-course outcomes, limitations in knowledge on program scale, subgroup differences, and dosage levels have hindered understanding. We report the effects of the Child-Parent Center Education Program on indicators of well-being up to 25 years later for more than 1400 participants. This established, publicly funded intervention begins in preschool and provides up to 6 years of service in inner-city Chicago schools. Relative to the comparison group receiving the usual services, program participation was independently linked to higher educational attainment, income, socioeconomic status (SES), and health insurance coverage, as well as lower rates of justice-system involvement and substance abuse. Evidence of enduring effects was strongest for preschool, especially for males and children of high school dropouts. The positive influence of four or more years of service was limited primarily to education and SES. Dosage within program components was mostly unrelated to outcomes. Findings demonstrate support for the enduring effects of sustained school-based early education to the end of the third decade of life.

Age 26 cost-benefit analysis of the child-parent center early education program.

Using data collected up to age 26 in the Chicago Longitudinal Study, this cost-benefit analysis of the Child-Parent Centers (CPC) is the first for a sustained publicly funded early intervention. The program provides services for low-income families beginning at age 3 in 20 school sites. Kindergarten and school-age services are provided up to age 9 (third grade). Findings from a complete cohort of over 1,400 program and comparison group participants indicated that the CPCs had economic benefits in 2007 dollars that exceeded costs. The preschool program provided a total return to society of $10.83 per dollar invested (18% annual return). The primary sources of benefits were increased earnings and tax revenues and averted criminal justice system costs. The school-age program had a societal return of $3.97 per dollar invested (10% annual return). The extended intervention program (4-6 years) had a societal return of $8.24 (18% annual return). Estimates were robust across a wide range of analyses including Monte Carlo simulations. Males, 1-year preschool participants, and children from higher risk families derived greater benefits. Findings provide strong evidence that sustained programs can contribute to well-being for individuals and society.

Carbon isotope discrimination in western hemlock and its relationship to mineral nutrition and growth.

Western hemlock (Tsuga heterophylla [Raf.] Sarg.) is a major component of temperate rainforests in coastal British Columbia. Forest fertilization can enhance the growth of forest trees, but results are inconsistent for western hemlock. We investigated the relationship between delta13C (foliage and stemwood), growth response and tree nutritional status in this species. To establish a sampling protocol for stemwood, we first assessed spot-to-spot variation around and along the bole, which exceeded 1 per thousand. We utilized the reaction wood (high lignin content) and adjacent normal wood in two curved western hemlock stems to evaluate whether this variation was related to wood composition. There was a consistent 3.43 per thousand difference between lignin and holocellulose, but the isotopic mass balance of whole wood was conserved and, therefore, did not vary with lignin content. Therefore, extraction of cellulose or holocellulose prior to analysis can introduce (not remove) bias. In a detailed study of a third stem, circumferential and longitudinal variation in delta13C was associated with spiral grain indicating limited physiological mixing of isotopic signatures originating from the crown. Wood was subsequently pooled from four cardinal positions around each stem. Eight even-aged western hemlock stands were selected and fertilized with different combinations of nitrogen (N), phosphorous (P) and a blend of S, K, Mg, Zn and Cu. Fertilization was effective in increasing foliar N, P, K and S depending on treatment. At the end of the first growing season after fertilization, the effect of treatments on foliar delta13C was nearly significant (P = 0.054), but did not persist into a second year. Effects on tree-ring delta13C were more obvious and persisted for about 3 years, averaging approximately 0.2-0.4 per thousand over this period, depending on treatment. Combinations of N, P and blend had the greatest effect, consistent with relative increases in basal area increment. Effects of fertilizer additions on delta13C, though clear, were superimposed on larger site and annual weather-related patterns in delta13C. Large tree-to-tree variation in delta13C was positively correlated with basal area increment, both before and after treatment imposition, suggesting that high water-use efficiencies are associated with greater growth.

Predicting Adult Criminal Behavior from Juvenile Delinquency: Ex-Ante vs. Ex-Post Benefits of Early Intervention.

Recent analyses of the long-term societal benefits from early intervention (prenatal care, home visitation, and high quality preschool) for at-risk children commonly include significant savings to society in the form of reduced juvenile delinquency and adult criminal behavior. However, a nontrivial proportion of the reported benefits of several early intervention programs are based on forecasts of criminal behavior throughout adulthood conditional on intervention effects on delinquency in adolescence. Data from the Chicago Longitudinal Study (CLS), an investigation of the life course of 1,539 children from low-income families born in 1979-1980, are used to investigate the bias resulting from predicting the effect of early intervention on adult criminal behavior from the effect on delinquency in adolescence. The investigation concludes that the general method used to predict adult criminal behavior results in a conservative estimate of the reduction in the cost of adult criminal behavior attributed to early intervention.

Protamine sulfate down-regulates thrombin generation by inhibiting factor V activation.

Protamine sulfate is a positively charged polypeptide widely used to reverse heparin-induced anticoagulation. Paradoxically, prospective randomized trials have shown that protamine administration for heparin neutralization is associated with increased bleeding, particularly after cardiothoracic surgery with cardiopulmonary bypass. The molecular mechanism(s) through which protamine mediates this anticoagulant effect has not been defined. In vivo administration of pharmacologic doses of protamine to BALB/c mice significantly reduced plasma thrombin generation and prolonged tail-bleeding time (from 120 to 199 seconds). Similarly, in pooled normal human plasma, protamine caused significant dose-dependent prolongations of both prothrombin time and activated partial thromboplastin time. Protamine also markedly attenuated tissue factor-initiated thrombin generation in human plasma, causing a significant decrease in endogenous thrombin potential (41% +/- 7%). As expected, low-dose protamine effectively reversed the anticoagulant activity of unfractionated heparin in plasma. However, elevated protamine concentrations were associated with progressive dose-dependent reduction in thrombin generation. To assess the mechanism by which protamine mediates down-regulation of thrombin generation, the effect of protamine on factor V activation was assessed. Protamine was found to significantly reduce the rate of factor V activation by both thrombin and factor Xa. Protamine mediates its anticoagulant activity in plasma by down-regulation of thrombin generation via a novel mechanism, specifically inhibition of factor V activation.