A quality improvement project was implemented across a large primary care network to decrease antibiotic use and improve guideline-concordant therapy for acute sinusitis. The multifaceted intervention included education, EHR decision support, and individual prescriber feedback with peer comparison. The program was associated with improvements in guideline-concordant prescribing.

Objectives/Goals: This study evaluated whether the Geriatric Acute and Post-acute Fall Prevention (GAPcare) intervention reduced fall-related emergency department (ED) visits and hospitalizations within 12 months of the index visit at three EDs and described adherence to pharmacy and physical therapy (PT) recommendations. Methods/Study Population: We enrolled ED patients aged ≥65 years presenting within 7 days of an accidental fall (excluding syncope, assault, or vehicle strike), who were community-dwelling, expected to be discharged, and without fractures preventing PT. We used the six-item screener for cognitive screening. Patients scoring ≤4 assented with proxy consent. Participants were randomized 1:1 to usual care or GAPcare intervention (ED-initiated pharmacy and PT consults). The primary outcome was fall-related ED visits within 12 months. Outcome assessors were blinded. Analyses followed intention-to-treat and adjusted for age, sex, prior falls, comorbidity index, activities of daily living, injury status, site, index ED visit, hospitalization, and assistive device use using negative binomial regression. Results/Anticipated Results: Among 196 patients, 100 received usual care and 96 received the GAPcare intervention. Median age was 78 (IQR 72–84), 68.4% were female, and 83.1% were white. Fall-related ED visits occurred in 30% of both groups (adjusted IRR 0.90, 95% CI 0.53–1.53). Fall-related hospitalizations were significantly lower in the intervention group (11% vs 21%; adjusted IRR 0.45, 95% CI 0.20–0.96), Adherence to pharmacy recommendations was 81%, and PT recommendations was 65%, with frequent medication optimization and assistive device use. Discussion/Significance of Impact: While GAPcare did not reduce fall-related ED visits, it significantly lowered fall-related hospitalizations and showed high adherence to fall prevention recommendations. These findings highlight GAPcare’s feasibility and potential to address fall risk during a critical window.

Plasma levels of procollagen type 1 N-propeptide (P1NP) and C-terminal telopeptide of type 1 collagen (CTX) are bone turnover markers (BTM) used to predict risk of fracture. We compared the effects of vitamin D supplements on plasma levels of P1NP and CTX in the Biochemical Efficacy and Safety Trial of vitamin D (BEST-D) trial (305 participants) after treatment with 2000 IU/d or 4000 IU/d vitamin D3 or placebo. The results of BEST-D were combined in a meta-analysis of all trials of vitamin D v. placebo on levels of P1NP (12 trials, 2654 participants) or CTX (16 trials, 2695 participants). In BEST-D, allocation to vitamin D3 resulted in a dose-dependent increase in 25-hydroxy-vitamin D (25(OH)D) levels but had no effects on P1NP or CTX. Geometric mean (se) levels at 12 months were similar for P1NP (41·7 (0·7) v. 42·9 (1·0) ng/ml; P = 0·29: either dose v. placebo) and likewise for CTX (0·23 (0·01) v. 0·23 (0·01) ng/ml; P = 0·98). In a meta-analysis of eighteen trials, the average difference between the within-trial change in P1NP for allocated vitamin D and control was −3·3 % (95 % CI −5·6, −1·0, P < 0·005). For CTX, this difference was slightly greater (−3·8 % (−6·8, −0·8); P = 0·01). There was no significant heterogeneity between these trials after stratifying trials with or without Ca, higher or lower doses of vitamin D, or lower v. higher pre-treatment levels of 25(OH)D. Overall, vitamin D supplementation was associated with modest reductions in both P1NP and CTX, and results provide support for further trials of vitamin D for prevention of fracture in older people.

A handful of planetary systems hosting a Hot Jupiter have been subsequently found to also host long-period giant planets. These ‘Cold Jupiters,’ giant planets residing beyond the snow line ($\sim$3 au), play an important role in the dynamical evolution of the system as a whole. In this work, we investigate the detectability of Cold Jupiters around a sample of 28 well-studied Hot Jupiter host stars to estimate the occurrence rate of this distinctive system architecture. We perform extensive simulations using the combination of all publicly available radial velocity (RV) data for those stars with synthetic RV data. The synthetic data test observing strategies along three axes: cadence, duration, and measurement precision. For each scenario, we determine detection limits based on the semi-major axis at which a 1 Jupiter mass planet would be recovered 50% of the time. We find the following: (1) the existing RV data are remarkably insensitive to these Hot Jupiter–Cold Jupiter pairs; (2) the total baseline over which an observational campaign is carried out is the dominant factor in our ability to detect Cold Jupiters; and (3) the results are relatively insensitive to the individual RV measurement precision. We conclude that metre-class telescopes with lower RV precision are ideally suited to surveying Hot Jupiter–Cold Jupiter systems.

Ethical consumerism describes market transactions where consumers’ preferences stretch beyond immediate self-interest to prosocial objectives. How such activities relate to more traditional forms of civic engagement (such as giving or activism) remains unclear; as a market-situated activity, ethical consumerism is often omitted from accounts of civic engagement or predicted to erode commitment to civic action. This paper reports findings from an empirical study of the civic identity of the ethical consumer. Using an online survey instrument, the study explores statistical relationships between individuals’ actual participation in ethical consumerism at three sites (Fairtrade, TOMS Shoes and (RED)) and the extent of individuals’ wider civic engagement—both philanthropic (giving, volunteering) and activist (campaigning). It finds evidence of a consistent civic identity that stretches across traditional civic engagement activities and ethical consumerism: the greater an individual’s civic engagement, the more likely they are to engage in ethical consumerism. The current analytic separation of ethical consumerism and civic engagement, therefore, does not capture the experience of individuals who are expanding their prosocial repertoire from the civic sphere to the market sphere; civic engagement cuts across sectors.

Antarctic ice-free coastal environments, like the Vestfold Hills (East Antarctica), are shaped by a complex interplay of physical processes. This study synthesizes new data and existing research from the Vestfold Hills across marine, terrestrial and cryosphere science, meteorology, geomorphology, coastal oceanography and hydrology to explore interconnected processes ranging from icescape morphology and sediment transport to ocean-floor scouring and ocean-atmosphere interactions. Coastal landforms and habitats result from the interaction of marine dynamics with the aeolian and fluvial transport of glacially derived sediments and geomorphic features. Rocky shorelines dominate the region, and extensive fjords are prominent coastal features, whereas intertidal sediments and beaches are scarce. The marine environment is characterized by slow currents, low-energy waves, annually variable land-fast ice, irregular sedimentation rates and a geomorphologically complex shoreline. Aeolian and fluvial sediment deposition into coastal waters and onto sea ice can significantly impact local ecological and physical processes. Human activity further modifies these dynamics. Ice-free coastal areas such as the Vestfold Hills are predicted to experience substantial environmental shifts due to climate change. Wind speeds, temperature and precipitation are increasing in the Vestfold Hills. Retreating grounded ice sheets are likely to expand this coastal area and increase meltwater and sediment inputs into nearshore marine systems. Concurrently, changes in sea-ice extent, thickness and/or duration may profoundly alter the structure and function of this coastal environment.

Over 15 million children in the United States have been infected with COVID-19; nearly 2,000 have died. Approval of COVID-19 vaccines for children enabled reductions in disease severity and mortality. Disparities in vaccine adoption exist along racial, ethnic, and rural–urban lines, with lower uptake among medically underserved populations (e.g. Black, non-Hispanic White rural populations) compared to urban White populations. This study examined efforts to recruit and engage a diverse cohort as part of a vaccine communication randomized trial conducted across 15 states and compared demographic characteristics of the enrolled cohort to the broader US population. To enhance recruitment of diverse populations, eligible clinics had to serve a significant proportion of medically underserved individuals based on race, ethnicity, or geographic location. Coordinators used both traditional (in-person daily clinic schedule review) and retrospective (EHR and billing data review) recruitment methods adapted to enrich engagement with focus populations. Demographic characteristics were compared to national statistics obtained from the CDC’s Household Pulse Survey. In total, 2999 parents/caregivers were screened; 725 were randomized (24.1%). Comparing enrolled subjects to the demographics of participating states, 17.3% vs 9.8% self-identified as Hispanic, 39.6% vs 13.0% as Black. Additionally, 34.3% self-described as living in a rural area. Of the 725 randomized, 512 (70.6%) completed the baseline survey. Of these 512, 422 (82.4%) also completed the final survey of the 24-week study. This analysis demonstrates the Institutional Development Award States Pediatric Clinical Trials Network can successfully recruit and engage populations from diverse and underrepresented populations in research.

Introduction: Although most rhinosinusitis cases are viral, misdiagnosis of an underlying bacterial cause is common, leading to excessive antibiotic utilization. Interventions to improve diagnosis and prescribing for sinusitis may reduce antimicrobial resistance and improve patient outcomes. Methods: Antibiotic prescriptions by 237 URMC Primary Care Network(PCN) clinicians between 9/1–11/31/2022 (baseline n=23,048) and 12/1/2023–2/29/2024 (post-intervention n=18,885) were extracted as part of a network-wide education and prescription feedback intervention focusing on antibiotic utilization rates, and guideline-concordant prescribing for sinusitis defined from local antibiograms and national guidelines. Random subsets of pre- and post-intervention prescriptions (250 each period for 90% power, Type I alpha=0.05) were systematically reviewed by two medical student or resident reviewers, with adjudication of discrepancies by infectious diseases-trained clinicians for 1) appropriate diagnosis of bacterial infection, 2) antibiotic selection, and 3) treatment duration. Charts were also reviewed for treatment failure requiring course extension, urgent care or emergency department utilization, hospital admission, and antibiotic-related toxicity during therapy or within 30 days of conclusion. Statistical analysis was performed in GraphPad and Excel ver. 2408. Results: Correct use of diagnostic criteria increased from 52.8% to 63.6% (p<0.01) post-intervention, a 10.8% absolute and 20.4% relative increase in appropriate diagnosis of bacterial sinusitis. Although rates of guideline-concordant treatment duration remained similar (74% vs. 74.4%, p=0.92), appropriate antibiotic selection increased from 71.6% to 85.6% (p< 0.01) (Fig. 1), and complete concordance of both spectrum and duration increased from 49.6% to 60.8% (p=0.012). Rates of antibiotic-associated adverse events requiring treatment discontinuation were similar pre- and post-intervention (Table 1). There were no Clostridium difficile infections. Health care contact beyond the prescribing office increased post-intervention (p < 0.01) (Table 1) but this was unrelated to sinusitis or antibiotic treatment complications (Fig. 2). Conclusions: A large-scale network intervention significantly improved use of diagnostic criteria and appropriate treatment of acute bacterial sinusitis without negatively impacting the incidence of treatment- or infection-related complications.

This paper examines the impact of complexity on New Product Development (NPD) within the context of an Engineer-to-Order (ETO) organisation. A descriptive literature review identified three categories of complexity: organisational, process and product complexity. The influence on NPD performance due to the dimensions contained in these categories are investigated in terms of the Law of Requisite Variety. A case study of NPD at Héroux-Devtek Inc., a landing gear supplier, evaluates these dimensions in practice. The findings reveal that increased organisational complexity often improves NPD performance, while increased process complexity reduces NPD performance. Product complexity evolves from being ‘complex’ initially to ‘complicated’ or ‘simple’ at delivery. Insights into managing these complexities contribute to understanding their role in achieving project success in the ETO context.

We present the serendipitous radio-continuum discovery of a likely Galactic supernova remnant (SNR) G305.4–2.2. This object displays a remarkable circular symmetry in shape, making it one of the most circular Galactic SNRs known. Nicknamed Teleios due to its symmetry, it was detected in the new Australian Square Kilometre Array Pathfinder (ASKAP) Evolutionary Map of the Universe (EMU) radio–continuum images with an angular size of 1 320$^{\prime\prime}$$\times$1 260$^{\prime\prime}$ and PA = 0$^\circ$. While there is a hint of possible H$\alpha$ and gamma-ray emission, Teleios is exclusively seen at radio–continuum frequencies. Interestingly, Teleios is not only almost perfectly symmetric, but it also has one of the lowest surface brightnesses discovered among Galactic SNRs and a steep spectral index of $\alpha$=–0.6$\pm$0.3. Our best estimates from Hi studies and the $\Sigma$–D relation place Teleios as a type Ia SNR at a distance of either $\sim$2.2 kpc (near-side) or $\sim$7.7 kpc (far-side). This indicates two possible scenarios, either a young (under 1 000 yr) or a somewhat older SNR (over 10 000 yr). With a corresponding diameter of 14/48 pc, our evolutionary studies place Teleios at the either early or late Sedov phase, depending on the distance/diameter estimate. However, our modelling also predicts X-ray emission, which we do not see in the present generation of eROSITA images. We also explored a type Iax explosion scenario that would point to a much closer distance of $\lt$1 kpc and Teleios size of only $\sim$3.3 pc, which would be similar to the only known type Iax remnant SN1181. Unfortunately, all examined scenarios have their challenges, and no definitive Supernova (SN) origin type can be established at this stage. Remarkably, Teleios has retained its symmetrical shape as it aged even to such a diameter, suggesting expansion into a rarefied and isotropic ambient medium. The low radio surface brightness and the lack of pronounced polarisation can be explained by a high level of ambient rotation measure (RM), with the largest RM being observed at Teleios’s centre.

In April 2023, eighteen scholars from nine different subjects representing the humanities, natural and social sciences came together for a one-day workshop at St John’s College, Durham. Despite our differences, all had one aim: the study of past environmental change and its effects on human societies. Talking across disciplinary divides, we discussed what environmental history is, how it may or may not contribute to tackling the climate crisis, and the problems of sources, scale and temporality. This article collects select conversations into a roundtable format split into four areas: scale, time and space, interdisciplinarity, and the future of environmental history. We argue that environmental history is more usefully understood not as a distinct sub-field of history, but as an interdisciplinary meeting place for innovative collaboration. This also presents a model for future research aimed at tackling the climate crisis at higher education institutions.