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BackgroundFrequent emergency department (ED) users account for a disproportionately high number of ED visits. Studies on case management (CM) interventions to reduce frequent ED use have shown mixed results, and few studies have been conducted within a universal health coverage system.ObjectiveTo determine whether a CM intervention—compared to standard emergency care—reduces ED attendance.DesignRandomized controlled trial.ParticipantsTwo hundred fifty frequent ED users (5 or more visits in the prior 12 months) who visited a public urban ED at the Lausanne University Hospital between May 2012 and July 2013 were allocated to either an intervention (n = 125) or control (n = 125) group, and monitored for 12 months.InterventionsAn individualized CM intervention consisting of concrete assistance in obtaining income entitlements, referral to primary or specialty medical care, access to mental health care or substance abuse treatment, and counseling on at-risk behaviors and health care utilization (in addition to standard care) at baseline and 1, 3, and 5 months.Main MeasuresWe used a generalized linear model for count data (negative binomial distribution) to compare the number of ED visits during the 12-month follow-up between CM and usual care, from an intention-to-treat perspective.Key ResultsAt 12 months, there were 2.71 (±0.23) ED visits in the intervention group versus 3.35 (±0.32) visits among controls (ratio = 0.81, 95 % CI = 0.63; 1.02). In the multivariate model, the effect of the CM intervention on the number of ED visits approached statistical significance (b = −0.219, p = 0.075). The presence of poor social determinants of health was a significant predictor of ED use in the multivariate model (b = 0.280, p = 0.048).ConclusionsCM may reduce ED use by frequent users through an improved orientation to the health care system. Poor social determinants of health significantly increase use of the ED by frequent users.

Background The poor outcome after a hip fracture is not fully understood. The aim of the study was to describe the prevalence of co-morbidities, complications and causes of death and to investigate factors that are able to predict mortality in old people with femoral neck fracture. Methods Data was obtained from a randomized, controlled trial with a 3-year follow-up at Umeå University Hospital, Sweden, which included 199 consecutive patients with femoral neck fracture, aged ≥70 years. The participants were assessed during hospitalization and in their homes 4, 12 and 36 months after surgery. Medical records and death certificates were analysed. Results Multivariate analysis revealed that cancer, dependence in P-ADL (Personal Activities of Daily Living), cardiovascular disease, dementia at baseline or pulmonary emboli or cardiac failure during hospitalization were all independent predictors of 3-year mortality. Seventy-nine out of 199 participants (40 %) died within 3 years. Cardiovascular events (24 %), dementia (23 %), hip-fracture (19 %) and cancer (13 %) were the most common primary causes of death. In total, 136 participants suffered at least one urinary tract infection; 114 suffered 542 falls and 37 sustained 56 new fractures, including 13 hip fractures, during follow-up. Conclusion Old people with femoral neck fracture have multiple co-morbidities and suffer numerous complications. Thus randomized intervention studies should focus on prevention of complications that might be avoidable such as infections, heart diseases, falls and fractures.

“If students are going to miss half of what usually constitutes the student experience, are they really receiving the same value for money?” Furthermore, online learning is no substitute for laboratory work. [...]recessions diminish the prospects for graduate employment. “Without any action, universities will be forced to make huge cuts, jobs will be lost, and vital research will be halted”, a spokesperson for Universities UK, an umbrella group representing 137 institutions, told The Lancet Oncology. “Pretty much every university in the country is looking at voluntary redundancies”, added Malcolm Reed (Dean of Brighton and Sussex Medical School, Brighton, UK, and Co-Chair of the Medical Schools Council, London, UK).

How virtual classrooms and dire finances could alter academia: part 1 in a series on science after the pandemic. How virtual classrooms and dire finances could alter academia: part 1 in a series on science after the pandemic.

Background Antibiotic-resistant bacteria are a major public health problem throughout the world. In 2006, in accordance with the national guidelines for antibiotic use, the CHRU of Nancy created an operational multidisciplinary antibiotic team at one of its sites. In 2011, a cluster-controlled trial showed that the operational multidisciplinary antibiotic team (the intervention) had a favourable short-term effect on antibiotic use and costs. Objective Our objective was to determine whether these effects continued over the medium to long term (that is, 2–7 years after creation of the operational multidisciplinary antibiotic team, 2009–2014). Setting The 1800-bed University Hospital of Nancy (France). Method The effect in the medium to long term is measured according to the same criteria and assessed by the same methods as the first study. A cluster controlled trial was performed on the period 2009–2014. The intervention group comprised 11 medical and surgical wards in settings where the operational multidisciplinary antibiotic team was implemented and the control group comprised 6 wards without this operational team. Main outcome measure Consumption of antibiotics overall and by therapeutic class (in defined daily doses per 1000 patient-days) and costs savings (in €). Results The reduction in antibiotic use and costs continued, but at a lower rate than in the short term (11% between 2009 and 2014 compared with 33% between 2007 and 2009) at the site of the intervention. The principal decreases concerned fluoroquinolones and glycopeptides. At the site without an operational multidisciplinary antibiotic team (the control group), total antibiotic use remained stable. Between 2009 and 2014, costs fell 10.5% in the intervention group and 5.7% in the control group. Conclusion This study shows that it is possible to maintain the effectiveness over time of such an intervention and demonstrates its role in defining a hospital’s antibiotic policy.

The term “repetitive head impacts” (RHI) refers to the cumulative exposure to concussive and subconcussive events. Although RHI are believed to increase risk for later-life neurological consequences (including chronic traumatic encephalopathy), quantitative analysis of this relationship has not yet been examined because of the lack of validated tools to quantify lifetime RHI exposure. The objectives of this study were: 1) to develop a metric to quantify cumulative RHI exposure from football, which we term the “cumulative head impact index” (CHII); 2) to use the CHII to examine the association between RHI exposure and long-term clinical outcomes; and 3) to evaluate its predictive properties relative to other exposure metrics (i.e., duration of play, age of first exposure, concussion history). Participants included 93 former high school and collegiate football players who completed objective cognitive and self-reported behavioral/mood tests as part of a larger ongoing longitudinal study. Using established cutoff scores, we transformed continuous outcomes into dichotomous variables (normal vs. impaired). The CHII was computed for each participant and derived from a combination of self-reported athletic history (i.e., number of seasons, position[s], levels played), and impact frequencies reported in helmet accelerometer studies. A bivariate probit, instrumental variable model revealed a threshold dose-response relationship between the CHII and risk for later-life cognitive impairment (p < 0.0001), self-reported executive dysfunction (p < 0.0001), depression (p < 0.0001), apathy (p = 0.0161), and behavioral dysregulation (p < 0.0001). Ultimately, the CHII demonstrated greater predictive validity than other individual exposure metrics.

Students with autism spectrum disorder (ASD) are at heightened risk of post-secondary educational failure and account for approximately 1% of students in post-secondary education. Findings from an on-line survey of students with ASD attending university in Australian are reported in this study. Respondents indicated high rates of academic and non-academic difficulties but low usage of supports. Ratings for supports were idiosyncratic, and some students indicated discomfort from using supports or disclosing their disability. Those students who delayed their disclosure accessed fewer supports and reported a poorer overall university experience. Recommendations were made including the need for better transition support and alternative strengths based approaches that use more flexible and individualised curriculum designs.

Online education has grown rapidly in recent years with many universities now offering fully online degree programs even in STEM disciplines. These programs have the potential to broaden access to STEM degrees for people with social identities currently underrepresented in STEM. Here, we ask to what extent is that potential realized in terms of student enrollment and grades for a fully online degree program. Our analysis of data from more than 10,000 course-enrollments compares student demographics and course grades in a fully online biology degree program to demographics and grades in an equivalent in-person biology degree program at the same university. We find that women, first-generation to college students and students eligible for federal Pell grants constitute a larger proportion of students in the online program compared to the in-person mode. However, the online mode of instruction is associated with lower course grades relative to the in-person mode. Moreover, African American/Black, Hispanic/Latinx, Native American, and Pacific Islander students as well as federal Pell grant eligible students earned lower grades than white students and non-Pell grant eligible students, respectively, but the grade disparities were similar among both in-person and online student groups. Finally, we find that grade disparities between men and women are larger online compared to in-person, but that for first-generation to college women, the online mode of instruction is associated with little to no grade gap compared to continuing generation women. Our findings indicate that although this online degree program broadens access for some student populations, inequities in the experience remain and need to be addressed in order for online education to achieve its inclusive mission.

Scholars and pundits alike argue that U.S. scientists could do more to reach out to the general public. Yet, to date, there have been few systematic studies that examine how scientists understand the barriers that impede such outreach. Through analysis of 97 semi-structured interviews with academic biologists and physicists at top research universities in the United States, we classify the type and target audiences of scientists' outreach activities. Finally, we explore the narratives academic scientists have about outreach and its reception in the academy, in particular what they perceive as impediments to these activities. We find that scientists' outreach activities are stratified by gender and that university and disciplinary rewards as well as scientists' perceptions of their own skills have an impact on science outreach. Research contributions and recommendations for university policy follow.