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\"This concise, accessible introduction to understanding agricultural chemicals and public health combines a broad synthesis on a global scale with rich ethnographic narratives on a human scale. Drawing on epidemiology, policy analysis, and social science research on the global commodity chain, the authors describe the system of global agrochemical dependence that constitutes a major threat to human health. Then they draw readers into the lush mountainsides of highland Guatemala, telling personal stories of farmers, their experiences with public health programs, their struggles against agrichemical dependence, and their innovations in sustainable agriculture. Finally, they show how this kind of qualitative, multi-level analysis holds practical lessons for public health. This engaging, brief text is an ideal supplement for courses in global health, introducing students to key concepts with broad coverage and engrossing ethnographic detail\"-- Provided by publisher.

The current research considers the capacity of a local organic food system for producer and consumer empowerment and sustainable development outcomes in western Guatemala. Many have argued that the forging of local agricultural networks linking farmers, consumers, and supporting institutions is an effective tool for challenging the negative economic, environmental, and sociopolitical impacts associated with industrial models of global food production. But does this work in the context of agrarian development in the developing world? Despite the fact that there is extensive literature concerning local food system formation in the global north, there remains a paucity of research covering how the principles of local food systems are being integrated into agricultural development projects in developing countries. My work critically examines claims to agricultural sustainability and actor empowerment in a local organic food system built around non-traditional agricultural crops in western Guatemala. Employing a mixed methods research design involving twenty months of participant observation, in-depth interviewing, surveying, and a self-administered questionnaire, the project evaluates the sustainability of this NGO-led development initiative and local food movement along several dimensions. Focusing on the unique economic and social networks of actors and institutions at each stage of the commodity chain, this research shows how the growth of an alternative food system continues to be shaped by context specific processes, politics, and structures of conventional food systems. Further, it shows how the specifics of context also produce new relationships of cooperation and power in the development process. Results indicate that structures surrounding agrarian development in the Guatemalan context give rise to a hybrid form of development that at the same time contests and reinforces conventional models of food production and consumption. Therefore, participation entails a host of compromises and tradeoffs that result in mixed successes and setbacks, as actors attempt to refashion conventional commodity chains through local food system formation.

Background Patients with cancer frequently visit the emergency department (ED) and are at high risk for hospitalization due to severe illness from cancer progression or treatment side effects. With an aging population and rising cancer incidence rates worldwide, it is crucial to understand how EDs and other acute care venues manage oncologic emergencies. Insights from other nations and health systems may inform resources necessary for optimal ED management and novel care delivery pathways. We described clinical management of oncologic emergencies and their contribution to ED visits and hospitalizations worldwide. Methods We performed a systematic review of peer-reviewed original research studies published in the English language between January 1st, 2003, to December 31st, 2022, garnered from PubMed, Web of Science, and EMBASE. We included all studies investigating adult (≥ 18 years) cancer patients with emergency visits. We examined chief complaints or predictors of ED use that explicitly defined oncologic emergencies. Results The search strategy yielded 49 articles addressing cancer-related emergency visits. Most publications reported single-site studies ( n  = 34/49), with approximately even distribution across clinical settings- ED ( n  = 22/49) and acute care hospital/ICU ( n  = 27/49). The number of patient observations varied widely among the published studies (range: 9 – 87,555 patients), with most studies not specifying the cancer type ( n  = 33/49), stage ( n  = 41/49), or treatment type ( n  = 36/49). Most studies ( n  = 31/49) examined patients aged ≥ 60 years. Infection was the most common oncologic emergency documented ( n  = 22/49), followed by pain ( n  = 20/49), dyspnea ( n  = 19/49), and gastrointestinal (GI) symptoms ( n  = 17/49). Interventions within the ED or hospital ranged from pharmacological management with opioids ( n  = 11/49), antibiotics ( n  = 9/49), corticosteroids ( n  = 5/49), and invasive procedures (e.g., palliative stenting; n  = 13/49) or surgical interventions ( n  = 2/49). Conclusion Limited research specifically addresses oncologic emergencies despite the international prevalence of ED presentations among cancer patients. Patients with cancer presenting to the ED appear to have a variety of complaints which could result from their cancers and thus may require tailored diagnostic and intervention pathways to provide optimal acute care. Further acute geriatric oncology research may clarify the optimal management strategies to improve the outcomes for this vulnerable patient population.

PurposeMany patients with cancer seek care for pain in the emergency department (ED). Prospective research on cancer pain in this setting has historically been insufficient. We conducted this study to describe the reported pain among cancer patients presenting to the ED, how pain is managed, and how pain may be associated with clinical outcomes.MethodsWe conducted a multicenter cohort study on adult patients with active cancer presenting to 18 EDs in the USA. We reported pain scores, response to medication, and analgesic utilization. We estimated the associations between pain severity, medication utilization, and the following outcomes: 30-day mortality, 30-day hospital readmission, and ED disposition.ResultsThe study population included 1075 participants. Those who received an opioid in the ED were more likely to be admitted to the hospital and were more likely to be readmitted within 30 days (OR 1.4 (95% CI: 1.11, 1.88) and OR 1.56 (95% CI: 1.17, 2.07)), respectively. Severe pain at ED presentation was associated with increased 30-day mortality (OR 2.30, 95% CI: 1.05, 5.02), though this risk was attenuated when adjusting for clinical factors (most notably functional status).ConclusionsPatients with severe pain had a higher risk of mortality, which was attenuated when correcting for clinical characteristics. Those patients who required opioid analgesics in the ED were more likely to require admission and were more at risk of 30-day hospital readmission. Future efforts should focus on these at-risk groups, who may benefit from additional services including palliative care, hospice, or home-health services.

Better understanding of the emergency care needs of patients with cancer will inform outpatient and emergency department (ED) management. To provide a benchmark description of patients who present to the ED with active cancer. This multicenter prospective cohort study included 18 EDs affiliated with the Comprehensive Oncologic Emergencies Research Network (CONCERN). Of 1564 eligible patients, 1075 adults with active cancer were included from February 1, 2016, through January 30, 2017. Data were analyzed from February 1 through August 1, 2018. The proportion of patients reporting symptoms (eg, pain, nausea) before and during the ED visit, ED and outpatient medications, most common diagnoses, and suspected infection as indicated by ED antibiotic administration. The proportions observed, admitted, and with a hospital length of stay (LOS) of no more than 2 days were identified. Of 1075 participants, mean (SD) age was 62 (14) years, and 51.8% were female. Seven hundred ninety-four participants (73.9%; 95% CI, 71.1%-76.5%) had undergone cancer treatment in the preceding 30 days; 674 (62.7%; 95% CI, 59.7%-65.6%) had advanced or metastatic cancer; and 505 (47.0%; 95% CI, 43.9%-50.0%) were 65 years or older. The 5 most common ED diagnoses were symptom related. Of all participants, 82 (7.6%; 95% CI, 6.1%-9.4%) were placed in observation and 615 (57.2%; 95% CI, 54.2%-60.2%) were admitted; 154 of 615 admissions (25.0%; 95% CI, 21.7%-28.7%) had an LOS of 2 days or less (median, 3 days; interquartile range, 2-6 days). Pain during the ED visit was present in 668 patients (62.1%; 95% CI, 59.2%-65.0%; mean [SD] pain score, 6.4 [2.6] of 10.0) and in 776 (72.2%) during the prior week. Opioids were administered in the ED to 228 of 386 patients (59.1%; 95% CI, 18.8%-23.8%) with moderate to severe ED pain. Outpatient opioids were prescribed to 368 patients (47.4%; 95% CI, 3.14%-37.2%) of those with pre-ED pain, including 244 of 428 (57.0%; 95% CI, 52.2%-61.8%) who reported quite a bit or very much pain. Nausea in the ED was present in 336 (31.3%; 95% CI, 28.5%-34.1%); of these, 160 (47.6%; 95% CI, 12.8%-17.1%) received antiemetics in the ED. Antibiotics were administered in the ED to 285 patients (26.5%; 95% CI, 23.9%-29.2%). Of these, 209 patients (73.3%; 95% CI, 17.1%-21.9%) were admitted compared with 427 of 790 (54.1%; 95% CI, 50.5%-57.6%) not receiving antibiotics. This initial prospective, multicenter study profiling patients with cancer who were treated in the ED identifies common characteristics in this patient population and suggests opportunities to optimize care before, during, and after the ED visit. Improvement requires collaboration between specialists and emergency physicians optimizing ED use, improving symptom control, avoiding unnecessary hospitalizations, and appropriately stratifying risk to ensure safe ED treatment and disposition of patients with cancer.

Objective:Urine cultures have poor specificity for catheter-associated urinary tract infections (CAUTIs). We evaluated the effect of a urine-culture stewardship program on urine culture utilization and CAUTI in adult intensive care units (ICUs).Design:A quasi-interventional study was performed from 2015 to 2017.Setting and patients:The study cohort comprised 21,367 patients admitted to the ICU at a teaching hospital.Intervention:The urine culture stewardship program included monthly 1-hour discussions with ICU house staff emphasizing avoidance of “pan-culture” for sepsis workup and obtaining urine culture only if a urinary source of sepsis is suspected. The urine culture utilization rate metric (UCUR; ie, no. urine cultueres/catheter days ×100) was utilized to measure the effect. Monthly UCUR, catheter utilization ratio (CUR), and CAUTI rate were reported on an interactive quality dashboard. To ensure safety, catheterized ICU patients (2015–2016) were evaluated for 30-day readmission for UTI. Time-series data and relationships were analyzed using Spearman correlation coefficients and regression analysis.Results:Urine culture utilization decreased from 3,081 in 2015 to 2,158 in 2016 to 1,218 in 2017. CAUTIs decreased from 78 in 2015 to 60 in 2016 and 28 in 2017. Regression analysis over time showed significant decreases in UCUR (r, 0.917; P < .0001) and CAUTI rate (r, 0.657; P < .0001). The co-correlation between UCUR and CAUTI rate was (r, 0.625; P < .0001) compared to CUR and CAUTI rate (r, 0.523; P = .004). None of these patients was readmitted with a CAUTI.Conclusions:Urine culture stewardship program was effective and safe in reducing UC overutilization and was correlated with a decrease in CAUTIs. Addition of urine-culture stewardship to standard best practices could reduce CAUTI in ICUs.

Background Patients with cancer visit the emergency department often and have a high rate of admission compared to other patients. Admission rates by institution may vary widely, even after accounting for patient and hospital-specific characteristics. Objectives To review the variables that affect admission rates among patients with cancer in the emergency department. Methods We performed a secondary analysis of a prospective cohort study of patients with cancer at 18 emergency departments between March 1, 2016, and January 30, 2017, to examine differences in patient populations between hospitals with varying admission rates. We calculated the percentage admitted by hospital and used it to categorize hospitals into quartiles. We compared outcomes, patient demographics, and disease characteristics between the admission quartiles using linear or logistic regression. Results A total of 1075 patients were included. The median age of our sample was 64, and 51% of patients were female, 84% were white, and 13% were Black. Of the 1075 patients, 615 (57.2%) were admitted as inpatients with a range from 21.2 to 81.7% by hospital. Differences between admission quartiles were found for education, mode of arrival, and recent chemotherapy ( p  < 0.05). There were no significant differences among quartiles in age, gender, race, or ECOG score. We found significant difference between admission quartiles in 30-day emergency department revisits. Differences in readmission rates and mortality did not appear to be significant between the various quartiles. Conclusions In our study, we observed several differences among patients with cancer receiving care at hospitals with different admission rates. These included patients’ education level, mode of arrival, and whether they had received recent chemotherapy. Emergency Severity Index (ESI) score may have also contributed to admission rate variability. Further study into unmeasured factors influencing hospital admissions, such as local culture, resources, and pathways, could identify generalizable findings to reduce avoidable admissions and reduce variation among similar patients in different hospitals.

A class of continuous controllers termed Robust Integral of the Signum of the Error (RISE) have been published over the last decade as a means to yield asymptotic convergence of the tracking error for classes of nonlinear systems that are subject to exogenous disturbances and/or modeling uncertainties. The development of this class of controllers relies on a property related to the integral of the signum of an error signal. A proof for this property is not available in previous literature. The stability of some RISE controllers is analyzed using differential inclusions. Such results rely on the hypothesis that a set of points is Lebesgue negligible. This paper states and proves two lemmas related to the properties.