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Background: Advanced parkinsonian syndromes represent a growing challenge for healthcare systems as their care needs are complex and costly. Current care models often lack integration of specialized neurology and palliative care, leading to suboptimal outcomes. The Advanced Care Team for Parkinson’s program (ACT-PD) addresses this gap by enhancing care quality and reducing costs. This study evaluates the cost-effectiveness of ACT-PD interventions compared to standard care (SC). Methods: A retrospective analysis compared 27 deceased ACT-PD patients (2022–2024) with 1,439 deceased SC patients (2011–2017). It assessed healthcare utilization, place of death, and patient Quality-Adjusted Life Years (QALYs). Healthcare utilization measures included hospitalizations, Intensive Care Unit (ICU) admissions, emergency department (ED) visits, and palliative care consultations. The analysis incorporated the incremental cost-effectiveness ratio (ICER) using Calgary Zone cost data from 2021–2022. Results: ACT-PD patients experienced fewer hospital deaths (33.33% vs. 45.90%) and more deaths at home (22.22% vs. 7.90%). They also had greater neurology (48.00% vs. 37.20%) and palliative care engagement (36.00% vs. 17.40%). ACT-PD avoided ICU admissions, saving $2.56 million annually, with total cost savings of $2.66 million. The ICER was $1,459 per QALY gained. Conclusions: Multidisciplinary palliative care interventions provided by ACT-PD are highly cost-effective, improving care quality while reducing healthcare costs.
Adverse Childhood Experiences (ACEs) are known to increase the risk of mental health challenges, and sleep is known to decrease risk. We investigated whether adequate sleep duration and sleep regularity would moderate the impact of ACE exposure on mental health risk.
Methods:
We conducted secondary cross-sectional analyses on the 2020–2021 waves of the National Survey of Children’s Health (NSCH; N = 92,669). Logistic and ordinal regressions explored the impact of ACEs (total, household, community and single) and sleep (duration and irregularity) and related interactions on mental health diagnosis and symptom severity.
Results:
Known main effects of ACEs and sleep on mental health were replicated. Interactions between ACE exposure and sleep factors were not clinically significant, although some were statistically significant due to the large sample, such that adequate duration was associated with marginally increased risk of mental health diagnosis (Omnibus B = 0.048, p < 0.0001) and greater bedtime irregularity was associated with marginally decreased risk (Omnibus B = –0.030, p < 0.001).
Discussion:
Dichotomous and categorical assessments of sleep health may not be sensitive to interaction effects, compared with continuous data. Examining mental health symptoms (rather than diagnosis status) may also allow for a nuanced understanding of potential interactions.
The record of mammal declines and extinctions in Australia raises concerns regarding geographically restricted and poorly known taxa. For many taxa, the existing data are insufficient to assess their conservation status and inform appropriate management. Concerns regarding the persistence of the subspecies of yellow-footed rock-wallaby Petrogale xanthopus celeris, which is endemic to Queensland, have been expressed since the 1970s because of red fox Vulpes vulpes predation, competition with feral goats Capra hircus and land clearing. This rock-wallaby is rarely observed, occupies rugged mountain ranges and, prior to our surveys, had not been surveyed for 25 years. We surveyed 138 sites across the range of this rock-wallaby during 2010–2023, including revisiting sites surveyed in the 1970s–1980s and locations of historical records. We examined occurrence in relation to habitat variables and threats. Occupancy and abundance remained similar over time at most sites. However, by 2023 the subspecies had recolonized areas in the north-east of its range where it had disappeared between surveys in the 1980s and 2010s, and three south-western subpopulations that were considered extinct in the 1980s were rediscovered. Recolonization and increases in abundance at numerous sites between the 2010s and 2020s are associated with declines in feral goat abundance, indicating dietary and habitat competition are major threats. Exclusion fences erected since 2010 could limit genetic exchange between rock-wallaby subpopulations whilst allowing domestic goats to be commercially grazed. Petrogale xanthopus celeris should remain categorized as Vulnerable based on these ongoing threats. Repeated monitoring approximately every decade should underpin management of this endemic taxon.
After a short discussion of the actual typescripts and manuscripts of Lowell’s letters, this chapter centers on the published books of letters, which have become a central, rewarding part of Lowell’s oeuvre. On the level of style, Lowell’s letters can help us hear the poems better: above all, they make audible the comic tones under-recognized in his poetry. On the level of content, the letters shed light on Lowell’s literary contexts, his interests, and his thinking in specific poems: When Lowell writes to other poets about their work, he frequently reveals quite a bit about his own. And finally, the letters create an autobiography that encompasses gossip, complaint, apology, argument, critique, and confession.
Background: People with parkinsonian syndromes (PPS) in advanced stages deal with a wide range of highly impactful motor and non-motor problems, including dementia, hallucinations, falls, and dysautonomia. Care planning becomes difficult and unpredictable. In addition, while healthcare providers focus on reducing symptom burden, PPS and carepartners deal with difficult emotions such as demoralization and grief. At those stages, multidisciplinary care becomes imperative. In October 2022 we launched Advanced Care Team for Parkinson’s (ACT-PD), a clinical research program whose goals include advanced care planning, symptoms management and emotional support. Methods: Our primary outcomes are changes in quality of life (QoL-AD), carepartner burden (ZBI-12) and patient satisfaction. The team involves neurology, palliative nursing, social-work, psychology, and spiritual care. Every three months, participants meet the team in person or virtually. In two hours, they address tailored concerns, complemented with phone calls as required. Accordingly, participants complete assessments. Results: In its first 4 months, ACT-PD included 40 PPS and 40 carepartners. Preliminary results show that the first visit with ACT-PD resulted in a 30% reduction in carepartner burden and 28% of improvement in patients’ QoL. Conclusions: Even in early phases, this novel patient and carepartner-centered approach improves QoL and reduces carepartner burden in PPS in advanced disease stages.
OBJECTIVES/GOALS: The rates of computational phenotyping algorithm reuse across health systems are low, leading to a proliferation of algorithms for the same trait. We propose a framework for reusing computational phenotyping algorithms and describe the real-world deployment of this framework for the development of the Colorado Diabetes EHR Research Repository. METHODS/STUDY POPULATION: The novel phenotype reuse framework consists of 4 steps: select algorithms that are appropriate for reuse by assessing whether they are fit for purpose; extend the algorithm to account for changes in data and care practice standards; localize the algorithm to use local database standards and terminologies; optimize the algorithm by applying a data driven approach to achieve the desired local performance. To identify individuals with type 1 diabetes (T1D) or type 2 diabetes (T2D), we selected and implemented T2D algorithms in a cohort of adults with any diabetes or pre-diabetes related diagnosis code, medication, or abnormal glucose-related laboratory test in the clinical data warehouse for UCHealth and the University of Colorado. RESULTS/ANTICIPATED RESULTS: We included a total of 926,290 patients who were identified by initial filters. Patients were more likely to be female (53%), identify as non-Hispanic white (69%) and had a median age of 58 years (IQR: 41, 70). Implementation, extension, localization, & optimization through iterative chart review prioritized high sensitivity for all-cause diabetes and high specificity for T1D and T2D. Of the original cohort, 252,946 (27%) were identified by the all-cause diabetes algorithm. Of these 11,688 were identified as T1D and 135,588 as T2D. After optimization the all-cause diabetes algorithm had 88% sensitivity, 90% specificity, 74% positive predictive value (PPV), and 96% negative predictive value (NPV). Our algorithms for T1D and T2D had high specificity (100% and 99%, respectively) and PPV (100 and 96% respectively). DISCUSSION/SIGNIFICANCE: Developing computational phenotyping algorithms is expensive and time consuming, yet algorithm reuse is low due to a lack of practical approaches for reusing algorithms. We demonstrate application of a novel framework for algorithm reuse, yielding good alignment of algorithm performance with study goals for identifying individuals with diabetes.
The Geographies of David Foster Wallace's Novels takes a fresh look at David Foster Wallace's novels through the lens of historical geography. It explores the connections between Wallace's literary practice and the reshaping of American geographical space that resulted from the transition between Fordist and post-Fordist forms of capitalism, presenting critical readings of the novels together with analysis of manuscripts and notebooks from Wallace's archive. Deploying an innovative methodology that combines aspects of cultural geography and literary criticism, each novel is historically situated through a spatial keyword, expanding our understanding of the connections between social context and formal innovation in Wallace's work.
Introduction: Infinite Jest, Boston and the ‘city novel’
If the Midwest, and notions of regional identity, had structured the geographies of Broom, Wallace’s move to Boston in 1989 entailed a shift in focus: having been concerned with the construction of a regional ‘heartland’ city in his first novel, he would now set Infinite Jest in and around one of America’s oldest and largest cities. But the depth of Wallace’s engagement with Cleveland and its topographical history in the earlier novel indicates that Boston might well have presented Wallace with more than simply a setting for this next project. How did this city shape Wallace’s approach to his novel? Can Jest be placed in a particular moment in the history of Boston – and of the American metropolis, and the literary and cultural attitudes associated with it? And what might a reading attentive to this geography tell us about Wallace’s relationship to the context of social and economic change in late twentieth-century America?
At first glance, these might seem counterintuitive questions to ask of Jest. Description of the cityscape is sparse: there is no direct glimpse of the exterior geography of the city until page 85, when Tiny Ewell makes a brief journey through Watertown by taxi (Jest pp. 85–7). Narrative action which takes place in the exterior spaces of the city is also limited to a relatively small number of scenes: of the 981 pages of the novel’s main text (excluding endnotes), only around 139 are set in Boston’s streets and public spaces. It is not often in this sprawling text that we find ourselves, like Randy Lenz, ‘abroad in the urban night’ (p. 539). By contrast, the Enfield Tennis Academy (‘E.T.A.’) and Ennet House – the novel’s two dominant institutions – take up a combined total of approximately 507 pages. The novel’s long final chapter, meanwhile, is organised around situations of interiority and stasis, with Hal Incandenza and Don Gately in parallel states of horizontal motionlessness within the confines of E.T.A. and St Elizabeth’s Hospital; the city almost entirely absent, apart from the occasional glimpse. (I refer, here and in the following chapter, to the parts of the text separated by circular figures as ‘chapters’. There are twenty-eight of these, though they are not numbered in the text).
In his 1992 essay on the landscapes of the Midwest, ‘Derivative Sport in Tornado Alley’, David Foster Wallace wrote: ‘the only part of Proust that really moved me in college was the early description of the kid’s geometric relation to the distant church spire at Combray’ (Supposedly p. 11). Space and place, this line suggests, were central to Wallace’s literary imagination. But at the same time, the uneasy juxtaposition of geometry and affect, mathematical abstraction and emotional engagement, is an indication that geography, for this writer, was not a simple matter. Interviewing Wallace for a Rolling Stone feature (that would never in fact appear in the magazine), David Lipsky recalls being given a tour of Wallace’s home: among the assorted furnishings, he notes ‘globes from [an] old cartography thing’. This is a tantalising hint at an explicit engagement with practices of geographical representation; no such ‘cartography thing’ has appeared in print. A clue to its nature, though, might be found in the ‘Eschaton’ scene in Infinite Jest, in which the map of cold war geopolitics and the space of the tennis court are brought into collision, with chaotic results – and to the dismay of the game’s overseer Michael Pemulis, who exclaims: ‘“it’s snowing on the goddamn map, not the territory, you dick!”’ (Jest p. 333). Space and its mediations were not easy to separate in Wallace’s imagination, it seems: ‘I like to mess with maps a little bit’, he admitted in a 1996 interview. He set all three of his novels in recognisable American places – Cleveland, Boston, Peoria – but this geographical familiarity is counterposed with wildly speculative elements. He embellished the landscape of Ohio with an artificial desert of black sand; redrew the diplomatic map of the North American Free Trade Agreement as the ‘Organization of North American Nations’ and placed a vast ecological disaster zone in the middle for good measure; and populated an ordinary Peoria office building with ‘actual, non-hallucinatory’ ghosts (Pale King p. 317). Wallace’s imagination was a deeply spatial one; but one in which space was always a problem, not a solution. This book explores the richly generative problems – aesthetic, social and political – that geography poses in his novels.
Over the first decade of Wallace’s work on The Pale King, the question ‘what is Peoria for?’ had opened the project onto searching questions about the efficacy of literary practice in the face of the geographical upheavals that characterised postindustrial life. Around 2005, though, the shape and status of the project itself began to come more fundamentally into question. In a note to himself dated 7 June 2005, Wallace reflected on the difficulty of incorporating his already drafted material into a coherent structure: he had been working to the assumption that ‘the book were a puzzle and all these pieces fit into it’, but ‘[t]his is not so’ (HRC 39.1). And this pragmatic structural issue was also joined by more fundamental doubts about the purpose of the work Wallace had done and was doing on the project: ‘The despair is that so much time and work has apparently gone into these nuggets, and so many of them just stop, as if the spirit just gave out’ – ‘I do not feel inspired’ (HRC 39.1). Across the ‘electric girl’ drafts, §1 and the Claude Sylvanshine section, the question of place had provided a focal point for Wallace’s renewed worry about the relationship between literary practice and the conditions of work and life in contemporary America. His 2005 note suggests that this conceptual concern had morphed into a compositional crisis.
David Hering places this note at the beginning of Wallace’s third and last phase of work on the novel, running from 2005 to 2007. As Hering points out, the note ‘clearly represents a crisis point in the life of The Pale King’ – necessitating ‘a new narrative strategy that [Wallace] clearly hoped would bring the disparate drafts together’. In Hering’s account, this strategy was the introduction of the character and narrative voice of ‘David Wallace’, who serves as the narrator of §9, §24 and §38 of the published text. At the same time, though – and in §24 in particular – this character’s appearance also coincides with a significantly more developed image of the Peoria Regional Examination Center and its surrounding landscape of ‘Lake James’, which began to form the geographical centre of the developing novel from this point.
‘They are also Midwesterners’, Mr. Bloemker notes of the residents at his nursing home in The Broom of the System. To Bloemker, this Midwestern-ness is troubled and ambiguous: ‘this area of the country, what are we to say of this area of the country, Ms. Beadsman?’ (Broom p. 142). The issue is geographical, economic and cultural – the experience of a people who stand in an ambiguous productive relationship with the rest of the nation: ‘we feed and stoke and supply a nation much of which doesn’t know we exist. A nation we tend to be decades behind, culturally and intellectually’ (p. 142). And this geographical experience has a psychological dimension; the locational and existential unease of life in an area of America ‘both in the middle and on the fringe’, both ‘the physical heart and the cultural extremity’ (p. 142). Bloemker’s residents, in his diagnosis, are troubled by a need to ‘come to terms with and recognize the implications of their consciousness of themselves as part of this strange, occluded place’ (p. 142). But there is also an ambivalence in the novel about how seriously we are to take Mr Bloemker’s interpretations: he rehashes the theme in very similar terms later in the novel (p. 369), so that by the time we hear of him ‘acting as if he were whispering to someone under his arm when there was clearly no-one there, and asking Judith and Candy how they perceived their own sense of the history of the Midwest’, we come to recognise a less-than-healthy obsession (p. 446). Midwestern-ness is doubly pathologised here: both the psychology associated with this geographical identity itself, and the interpretation and expression of that psychology, are problematic. In this ambiguous fashion, Bloemker’s orations signpost a dimension of Broom – with its primary setting in and around the Midwestern city of Cleveland, Ohio – that is concerned with the distinctive late twentieth-century experience of the Midwest as a particular American region, and with the ways in which this region can be spoken about.
The notion of the ‘regional’, and of the Midwestern-ness of Wallace’s writing, is the geographical category that has been most extensively brought to bear on Wallace’s work by his critics – though this has led to some disagreement.
Introduction: The Pale King and the Changing Geography of Work
What is Peoria for? The question does not appear in the published text of The Pale King, compiled by Michael Pietsch from the mass of draft material Wallace left on his death in 2008. But it does appear, with almost obsessive frequency, in the margins of notebooks and drafts from the earliest to the last stages of Wallace’s work on the project. The extensive ‘Evidence’ notebook, whose inside cover is dated ‘3/96’ (a month after the publication of Jest), is replete with instances (HRC 43.1). Nearly ten years later, Wallace labelled a zip disk containing draft material ‘WPF/PK 05’ (according to Pietsch’s index of materials, kept in the Harry Ransom Center archive), giving the question of (w)hat (P)eoria is (f)or equal weight alongside the eventual title of the published text (HRC 36.0). In between, numerous drafts and notebooks are headed or annotated with the question. In his extensive treatment of the archival material related to the novel, David Hering identifies a three-stage compositional history: an initial stage running from 1996 to 1999, a second phase from 1999 to 2005, and a third period from 2005 to 2007, with each bookended by a fundamental rethinking of direction. But the persistence of the question of what Peoria is for suggests that this guiding concern with the function of place – in America at the turn of the twenty-first century, and in the novel itself – remained at the centre of Wallace’s project throughout this troubled process.
This concern is also signalled in Wallace’s conversation with David Lipsky in 1996, where it takes on an explicitly economic inflection. Showing Lipsky around Bloomington-Normal, Illinois – where he settled in 1993 – Wallace took pains to outline features of the local economy: ‘there’s a Mitsubishi plant, and then there’s a lot of farm-support stuff. There’s a lot of firms called like Ro-tech and Anderson Seeds. And State Farm Insurance.’ That this material frame was important to Wallace’s work on the novel is indicated by his frequent compilation of detailed lists of imagined industries and services with which to populate his version of Peoria: the ‘Evidence’ notebook contains several notes for invented manufacturing and extractive concerns, like ‘Frigid Coal Inc.’ and ‘Midwest Foam’ – a ‘place that makes foam insulation, rubber foam’ (HRC 43.1).
Wallace’s move to Boston had, as the previous chapter has shown, entailed a reframing of the question of how his literary practice could align with the social conditions that had emerged from the socioeconomic upheavals at the end of the twentieth century: a question that was now intimately bound up with the deep formal and representational problems that the ‘postmetropolitan’ city posed for the novel. The city appears in the early stages of Infinite Jest as a space of fragmentation, loss and nostalgia; but Joelle van Dyne’s broadcast had also signalled the prospect of a connective artistic practice embedded in the metropolis. Is this possibility a dead end for Jest, one that dissipates along with the crowd whose elision from the text reflects the social atomisation of the city? Despite the dominant sense of dissolution, the tentative urban excursions of Joelle and Don Gately in the opening half of the text also contain latent suggestions that a renewed juncture between city and novel might yet revive the metropolis as a shared environment, a lived social space. How the novel builds on this suggestion despite the predominance of fragmentation, and how it locates possibilities of community in the very metropolis that seems so inimical to collective life, is the question I explore in this chapter. And as a starting point, I want to return to Wallace’s own encounter with the social scene of Boston.
In Chapter 2, I emphasised the excitement Wallace expressed on first moving to the city in the summer of 1989; but this excitement proved short-lived, as a serious mental health crisis saw him hospitalised in late 1989 and 1991, before gradually returning to city life through Boston’s addiction recovery network and halfway house facilities. This experience perhaps explains his later reflection that ‘I don’t do well in big cities’, a sentiment that might seem to justify the view that Wallace’s attitude to metropolitan environments was essentially a negative one. But even this crisis, on closer inspection, took on a generative role in Jest’s development.