Academic literature on the topic 'Forms and Records Control – methods – United States'

Abstract Background: There are limited real-world data (RWD) available on the unmet needs of people with mild or moderate hemophilia A (PwHA). This population accounts for 40-52% of all PwHA, including nearly all women with hemophilia A (HA), and is under-represented in scientific literature (Michele, et al. Haemophilia 2014; Benson, et al. Blood Transfus 2018; Peyvandi, et al. Haemophilia 2019). Available claims data from payer databases are confined to billing codes, and lack key information on outcomes and disease characterization (e.g. severity, treatment response.) (Tyree, et al. Am J Med Qual 2006). Registry datasets can require resource-intensive data entry and potentially miss key information about care received at outside facilities, at home, or after patients switch providers (Gliklich, et al. Registries for Evaluating Patient Outcomes: A User's Guide. 2014). To address these data gaps, we developed a novel, patient-centered approach to create a longitudinal healthcare database from individuals with mild and moderate HA in the United States. This study assessed the feasibility of this approach, which integrates medical record data collected during routine clinical care along with patient-reported outcomes (PROs) to provide needed insights into this under-represented population. Methods: Recruitment began in June 2020 via a broad strategy of social media outreach, healthcare provider partnerships, and patient advocacy groups. Eligibility was confined to mild or moderate PwHA, confirmed via physician report within provider notes in combination with baseline factor VIII levels (>5-50% mild, 1-5% moderate.) This study received research ethics board approval and abides by the guiding principles of the Declaration of Helsinki. PwHA enrolled via an online record management platform, PicnicHealth. After signing authorization forms for collection of their electronic health records (EHR) and informed consent to share their de-identified data for research, participants were prompted to enter information on their care providers. Records were gathered from all providers, across any facility, retrospectively as records were available. (Figure 1) All records obtained were made available to the participants via a medical timeline. Records were translated to text via optical character recognition with human review. Data elements from structured text as well as disease-specific elements from narrative text were captured using natural language processing and supervised machine learning. All elements, including visit metadata, conditions, measurements, drugs, and procedures were mapped to standardized medical ontologies and reviewed by a team of nurses. (Table 1) Quality control was assessed via inter-abstractor agreement on outputs with physician review. Patient-reported bleed, treatment, and pain data were collected via online questionnaire for a subset of PwHA, with participants prompted to enter data every 2 weeks. Abstracted EHR data was linked to PRO responses in a de-identified dataset. Cohort and abstraction characteristics were summarized descriptively. Results: From June 1, 2020 to June 30, 2021, 104 PwHA met eligibility criteria for enrollment (65 [62.5%] mild; 39 [37.5%] moderate). Participants saw providers across 34 states in the US, 22.1% (23/104) were female, and 20.6% (14/68) of those with known race/ethnicity status were from minority groups. Records were gathered from a median of six care sites and 16 providers per participant. A median of 50 (IQR [21-93]) clinical documents from 11 years were processed for each PwHA. (Table 2) Inter-abstractor agreement to assess abstraction quality averaged 95.9% for condition, 99.5% for drug name, and 95.4% for drug start date. As of June 2021, the average PRO response rate was 90.3% (150/166 of all requests) and continues prospectively. Conclusions: The patient-centric data collection methods implemented in this study provide a novel approach to build longitudinal real-world data sets. Technology-enabled data abstraction showed consistent high quality when processing the heterogeneous clinical records across disparate providers and care sites, and direct engagement with patients complements potential gaps in the clinical record. Additionally, this approach provides needed data on groups under-represented in RWD and traditional PwHA cohorts, including those with mild and moderate disease and women with HA. Figure 1 Figure 1. Disclosures Skinner: ICER: Membership on an entity's Board of Directors or advisory committees; Spark (DMC): Honoraria; Sanofi: Honoraria; F. Hoffmann-La Roche Ltd/Genentech, Inc.: Honoraria; Pfizer (DMC): Honoraria; Bayer: Honoraria, Membership on an entity's Board of Directors or advisory committees; uniQure: Research Funding; Takeda: Honoraria, Research Funding; F. Hoffmann-La Roche Ltd: Research Funding; Freeline: Research Funding; BioMarin: Honoraria, Research Funding; IPA Ltd.: Current holder of individual stocks in a privately-held company; National Hemophilia Foundation: Consultancy; Institute for Policy Advancement Ltd: Current Employment; WFH USA: Membership on an entity's Board of Directors or advisory committees; BCBS MAP: Membership on an entity's Board of Directors or advisory committees. Hanson: PicnicHealth: Current Employment, Current holder of stock options in a privately-held company. Xu: F. Hoffmann-La Roche AG: Current Employment. Ofori-Asenso: F. Hoffmann-La Roche Ltd: Current Employment. Ko: Genentech, Inc.: Current Employment; Genentech, Inc.-Roche: Current equity holder in publicly-traded company, Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company. Cibelli: PicnicHealth: Current Employment. Nissen: Novartis: Consultancy; Actelion: Consultancy; F. Hoffmann-La Roche Ltd: Current Employment, Current holder of stock options in a privately-held company. Witkop: Roche Advisory Panel: Consultancy; National Hemophilia Foundation: Current Employment. Sanabria: F. Hoffmann-La Roche Ltd: Current Employment, Current holder of individual stocks in a privately-held company. Shapiro: Novartis: Research Funding; Novo Nordisk: Other: Advisory board fees, Research Funding, Speakers Bureau; Octapharma: Research Funding; Pfizer: Research Funding; OPKO: Research Funding; Prometric BioTherapeutics: Research Funding; Sangamo: Other: Advisory board fees, Research Funding; Sigilon Therapeutics: Other: Advisory board fees, Research Funding; Takeda: Research Funding; Kedrion Biopharma: Research Funding; Glover Blood Therapeutics: Research Funding; Genentech: Other: Advisory board fees, Research Funding, Speakers Bureau; Daiichi Sankyo: Research Funding; Bioverativ (a Sanofi company): Other: Advisory board fees, Research Funding; BioMarin: Research Funding; Agios: Research Funding.

Abstract Background About a third of patients with mod-sev UC receiving advanced therapy (AT, i.e. biologics and tofacitinib) do not respond initially and another third lose response. We examined reasons for treatment choice and outcomes in ATN and ATE mod-sev UC patients. Methods A point-in-time survey of US gastroenterologists and their respective consulting UC patients was conducted from Jan 2020–Feb 2021 (ongoing) using the Adelphi Disease Specific Programme™ for Inflammatory Bowel Disease. Physicians completed patient record forms for UC patients with a history of mod-sev disease covering treatment history and clinical status. Patients were classified as ATN and ATE based on treatment. Response to treatment status was identified by factor and cluster analyses using flare, remission and change in symptoms. Descriptive and comparative statistics were calculated for reasons for initiating/switching therapy and patient-reported outcomes (satisfaction, pain/fatigue, and quality of life via the EuroQol-5 dimension questionnaire [EQ-5D]). Results Based on the interim sample, 66 physicians and 394 mod-sev UC patients were analysed. Of patients who were ATN (n=82) and ATE (n=312), 29% and 32% were classified as non-responders respectively. Comparing ATN vs ATE patients, mean age was directionally lower (38.4 vs 40.7 years), proportion of males was directionally higher (65% vs 55%), and mean time since diagnosis was similar (3.9 vs 3.8 years). In general, non-responders experienced gastrointestinal-related (90% vs 41%), anorectal (38% vs 6%), and fatigue-related symptoms (66% vs 23%) more frequently than responders. ATN patients eligible to receive AT (n=26) reported dislike of injections/infusions (46%) or unwillingness to go to infusion centres (31%) as reasons for not receiving AT. Most common reasons for switching therapy in ATN patients were disease progression (40%) and lack of tolerability (27%), and in ATE patients were loss of response over time (43%) and disease progression (35%). In the ATE group, patient and physician satisfaction rates were higher in responders vs non-responders (>93% vs <79%), pain and fatigue scores were lower (0.8 vs 2.3 and 1.1 vs 2.3, p<0.0001), and EQ-5D scores higher (0.93 vs 0.81, p=0.005). In the ATN group, comparisons were not conducted due to small sample sizes. Conclusion In this point-in-time survey study with data collected during the COVID-19 pandemic period, about a third of mod-sev UC patients did not respond to current therapy. These results suggest an opportunity for new therapies that increase response rates, provide long-term disease control, provide alternatives to parenteral routes of administration, and enhance patient satisfaction.

Abstract Background Chagas disease (CD) is a neglected parasitic disease that affects >6 million people in the Americas, including >200,000 people in the United States (US). Medical provider knowledge of CD is key to decreasing morbidity and transmission; however, few studies have assessed diagnostic practices in US health systems serving at-risk patients. Our study aimed to describe existing provider approaches to diagnosing CD in California and Texas. Methods Site-based research teams at four hospital systems (the University of California [UC] San Francisco [UCSF], San Diego [UCSD], Irvine [UCI], and the Harris Health System [HHS] in Houston, TX) retrospectively identified patients ≥18 years old tested for CD between 2016-2019 and systematically extracted electronic medical record data using complementary electronic data entry forms. Specifically, eligible patients were identified using laboratory orders at UCSF and UCI, while the remaining sites employed SlicerDicer (Epic Systems). This study was approved by institutional review boards at each site. Results We identified 333 patients tested for CD, including 109 from UCSF, 88 from UCSD, 25 from UCI, and 111 from HHS. These patients had 125, 99, 31, and 181 tests sent to commercial laboratories, respectively. Test reactivity varied by system with the greatest percent reactivity among tests ordered at UCI (23%) followed by UCSD (16%), HHS (15%), and UCSF (10%). Among patients who screened positive for CD by commercial assays, confirmatory testing through the Centers for Disease Control and Prevention was sought for 100% at UCI; 59% at HHS, 55% at UCSF, and 40% at UCSD. The medical specialty that most often ordered CD testing was Cardiology at all UC sites (UCSF, 50%; UCSF, 55%; UCI, 35%) and Internal Medicine at HHS (46%; Cardiology ordered 13%). Only one recorded CD test was ordered by an Obstetrics/Gynecology service at any site. Conclusion These early results report positivity rates between our healthcare systems and demonstrate inconsistency in attaining recommended confirmatory testing, as well as a paucity of CD testing ordered through Obstetrics/Gynecology despite risk of congenital transmission. These findings suggest areas of opportunity to improve provider awareness and lay a foundation for standardizing CD diagnostic practices in the US. Disclosures Caryn Bern, MD, MPH, UpToDate (Wolters Kluwer) (Other Financial or Material Support, Author Royalties)

Per capita consumption of avocado in the United States has nearly doubled between 2000 and 2010. The California avocado industry supplies almost 40% of U.S. demand and the remaining 60% is supplied by imports from Latin America and New Zealand. The Tea Shot Hole Borer (TSHB) is an ambrosia beetle from Asia that forms a symbiosis with a new, yet undescribed Fusarium sp. and is a serious problem for the Israeli avocado industry (3). The beetle also causes severe damage on the branches of tea (Camelia sinensis) in Sri Lanka and India (1). In California, TSHB was first reported on black locust (Robinia pseudoacacia) in 2003, but there are no records of fungal damage (4). In 2012, nine backyard avocado trees (cvs. Hass, Bacon, Fuerte, and Nabal) exhibiting branch dieback were observed throughout the residential neighborhoods of South Gate, Downey, and Pico Rivera in Los Angeles County. Upon inspection, symptoms of white powdery exudate, either dry or surrounded by wet discoloration of the outer bark in association with a single beetle exit hole, were found on the trunk and main branches of the tree. Examination of the cortex and wood under the exit hole revealed brown discolored necrosis. The TSHB was also found within galleries that were 1 to 4 cm long going against the grain. Symptomatic cortex and sapwood tissues were plated onto potato dextrose agar amended with 0.01% tetracycline (PDA-tet). The TSHB was dissected and plated onto PDA-tet after surface disinfestation following methods described by Kajimura and Hijii (2). After 5 days of incubation at room temperature, regular fungal colonies with aerial mycelia and reddish brown margins were produced. Single spore isolations were used to establish pure culture of the fungus. Fifty conidia were hyaline, clavate with a rounded apex, and initially aseptate (4.1 to 12.0 × 2.4 to 4.1 μm) becoming one- to three-septate (7.6 to 15.1 × 2.8 to 4.5 μm, 9.2 to 17.2 × 3.4 to 4.8 μm, and 13.5 to 17.6 × 4.3 to 4.7 μm, respectively). Identity of the fungal isolates was determined by amplification of the rDNA genes with primers ITS4/5 and EF1/2, respectively. Sequences were deposited into GenBank under Accession Nos. JQ723753, JQ723760, JQ723756, and JQ723763. A BLASTn search revealed 100% similarity to Fusarium sp. (Accession Nos. JQ038020 and JQ038013). Detached green shoots of healthy 1-year-old avocado were wounded to a depth of 1 to 2 mm and 5-mm mycelial plugs from 5-day-old cultures (UCR 1781 and UCR 1837) were placed mycelial side down onto the freshly wounded surfaces and then wrapped with Parafilm. Control shoots were inoculated with sterile agar plugs and five replicates per treatment were used. Shoots were incubated at 25 ± 1°C in moist chambers for 3 weeks. Lesions were observed on all inoculated shoots except for the control. Mean lesion lengths were 10.7 and 12.8 cm for UCR1781 and UCR1837, respectively, and were significantly different (P ≤ 0.05) from the control. Both isolates were reisolated from 100% of symptomatic tissues of inoculated shoots to complete Koch's postulates. This experiment was conducted twice and similar results were obtained. To our knowledge, this is the first report of Fusarium sp. and its vector E. fornicatus causing Fusarium dieback on Avocado in California. References: (1) W. Danthanarayana. Tea Quarterly 39:61, 1968. (2) H. Kajimura and N. Hijii. Ecol. Res. 7:107, 1992; (3) Mendel et al., Phytoparasitica, DOI 10.1007/s12600-012-0223-7, 2012. (4) R. J. Rabaglia. Annals Entomol. Soc. Amer. 99:1034, 2006.

A Review of: Mulvaney, Shelagh A., Leonard Bickman, Nunzia B. Giuse, Warren E. Lambert, Nila A. Sathe, and Rebecca N. Jerome." A Randomized Effectiveness Trial of a Clinical Informatics Consult Service: Impact on Evidence-based Decision-making and Knowledge Implementation." Journal of the American Medical Informatics Association 15.2 (2008): 203-11. Objective – To determine whether the provision of synthesized research evidence provided by the Clinical Informatics Consult Service (CICS) affects the clinical decision-making of clinicians working in intensive care units (ICUs). Design – Non-blinded randomized control effectiveness trial. Setting – ICUs in United States-based 658 bed university hospital providing tertiary care for adults and children. Subjects – Clinical staff working within one of four ICUs who submitted a request for clinical information during the study period. Methods – Valid requests submitted by clinical staff from the four clinical ICUs (medical, paediatric, trauma, or neonatal) were randomly allocated to receive information from the CICS (CICS provided) or no information (no CICS provided). Pre-consult forms, completed at the time of the request, examined reasons for the request and the clinical actions clinicians thought might be influenced by the search results. Requestors could opt out of the no CICS provided group either before or after the randomization of their request. Responses to requests, supplied within 0.5 to 7 days as agreed with the requestor, included a search strategy and bibliographic references, a targeted list of full-text articles, and a written synthesis and critique of the relevant research. Clinicians within both groups were free to conduct their own searches and reviews. An online evaluation form, emailed to recipients, was used to assess the impact of the information supplied. The evaluation form asked clinicians to record the time spent on their own searches, sources of information consulted including colleagues, the immediate and future impact of the information provided (either from the CICS or their own searches), what influence the information had on their clinical actions, whether there were any barriers to using the information, and quality and overall satisfaction with the results provided by the CICS. Data was analyzed according to the randomized group assignment using standard intention-to-treat analysis for the main outcomes between the two groups. Statistical adjustments were made to control for possible clustering of responses or multiple ratings from individual clinicians. The data was also analyzed on an efficacy basis depending on who provided the search results. The groups were Clinician only, CICS librarian-only, or Both Clinician and CICS librarian. Results from the Clinician only search group were used as a comparison to the remaining groups. This assessment did not take account of the randomization and therefore constitutes a cohort analysis. Results were analysed by one of two methods using statistical software SAS Proc Mixed (v9) for multi-level quantitative data analysis, e.g., analysis of variance, and SPSS (v14) for all other quantitative data analysis, including descriptive statistics. Main Results – The study period was conducted over 19 months: August 2004 to March 2006. During this time, 299 valid requests were received and 226 post consult evaluation forms were returned giving a response rate of 76%. Post consult forms were returned for 108/146 of the CICS provided group and 118/153 of the no CICS provided group. The 24% of requests that had no post consult evaluation were excluded from further analysis. Statistical tests, conducted to check for potential bias relating to missing data, suggested that the missing data had little impact on the findings. Medical and neonatal ICUs accounted for the majority of completed forms (40.3% and 38.1% respectively). The majority of opt-outs (10.2% overall) were from the medical ICU. No significant difference in outcome variables was found between opt-out and other requests when tested using analysis of variance (ANOVA). Evaluation forms were completed by 89 unique clinicians and over half (49) submitted more than one request. The average requests per clinician was 2.96, SD 3.17, range 1-15, and the average number of requests per clinician who submitted more than one request was 4.57, SD 3.55, range 2-15. Total number of responses, mean, standard deviation, and Cohen’s d effect size were reported for the outcome variables based on intention to treat analysis. Results showed no significant difference between the groups on the immediate impact of the information provided, the number of articles read or the frequency with which clinicians consulted colleagues, either formally or informally. The potential future impact of the information was rated higher in the CICS group (p=

Abstract Introduction: Recombinant factor IX Fc fusion protein (rFIXFc) was the first extended half-life FIX product approved in the United States to treat children and adults with hemophilia B. Long-term data from clinical trials have demonstrated the safety and efficacy of rFIXFc as well as an extended dosing interval (once weekly or every 10‒14 days based on individual needs); however, real-world data are limited (Wang et al. Haemophilia, 2018; Buckley et al. AMCP NEXUS, 2015). We therefore performed a retrospective chart review to further understand the clinical experience and outcomes associated with real-world treatment of hemophilia B with rFIXFc. Methods: This retrospective chart review is being conducted at 6 sites across different regions of the United States and aims to include 70 patient charts. Data entry for 43 patient charts has been completed to date (cutoff: June 29, 2018). Data collection is ongoing. Inclusion criteria were diagnosis of hemophilia B and receipt of rFIXFc for ≥6 months. Subjects with other coagulation disorders or any record of positive FIX inhibitor titers were excluded. De-identified subject-level data were transcribed onto anonymous electronic case report forms. Endpoints included changes in FIX therapy dosing interval, factor consumption, bleed control, and patient adherence before and after rFIXFc initiation. Descriptive statistics were used to summarize the results. Results: For the 43 charts available for analysis, the duration of follow-up receiving rFIXFc ranged from 0.5 to 3.7 years. Of these, 58% of subjects (25/43) were >18 years of age, 77% (33/43) were of white race, and 51% (22/43) had severe hemophilia B (Table 1). The most common genotype was missense, occurring in 63% of subjects (27/43). Among subjects with comorbidity, 37% reported hemophilic arthropathy (16/43) and 28% had hepatitis C (12/43). All 22 subjects with severe hemophilia B were treated with rFIXFc prophylactically compared with 9/15 moderate and 3/6 mild cases. From the data collected thus far, 94% of prophylaxis subjects were on a dosing interval of weekly or longer (every 7 days, n=20; every 10 days, n=3; and every 14 days, n=9). The total weekly dose before and after switching to rFIXFc prophylaxis were available for 20 subjects. Of the 12 adults (9 severe, 2 moderate, and 1 mild), the median weekly factor consumption decreased from 111 IU/kg to 52.5 IU/kg. A similar pattern was observed for subjects who were 12-18 years of age (n=4). For subjects <12 years of age (n=4), 2 had reduced weekly consumption after switching to rFIXFc, whereas 2 (on plasma-derived product pre-rFIXFc) had an increase in weekly consumption. The annualized bleeding rates (ABRs), annualized spontaneous bleeding rates (AsBRs), and annualized joint bleeding rates (AjBRs) were available for 17 subjects treated with prophylaxis regimens pre- and post-rFIXFc (Table 2). Of these subjects, 11 had severe, 5 had moderate, and 1 had mild hemophilia B. Among 11 subjects with severe hemophilia B, median (interquartile range) ABRs decreased from 8.2 (4.4‒11.5) to 2.3 (0.6‒10.2), AsBR from 1.2 (0‒9.7) to 0.3 (0‒8.7), and AjBR from 2.3 (1.4‒8.2) to 0.7 (0‒6.9) before and after rFIXFc treatment. Subjects with moderate disease had a similar pattern (Table 2). The most common reason for switching to rFIXFc was to reduce the burden associated with therapy (21/43, 49%). No rationale for switching was documented in 40% (17/43) of subjects, and 7% (3/43) switched due to lack of efficacy with previous treatment. The other reasons, including difficult venous access, lack of adherence, and failure to reach desired trough were mentioned by <5% of subjects. No subject reported adherence issues while on rFIXFc. Conclusions: This real-world study of rFIXFc demonstrates improved bleed control, reduced overall consumption, and reduced frequency of injection for subjects with moderate and severe hemophilia B. The data also show that rFIXFc provides an opportunity to tailor dosing and improve adherence. These results echo the findings of the pivotal trials and add to the pool of evidence supporting rFIXFc in the treatment of hemophilia B. These data also reflect the use of rFIXFc for mild hemophilia patients in the real-world setting. Disclosures Shapiro: Kedrion Biopharma: Consultancy, Research Funding; Novo Nordisk: Membership on an entity's Board of Directors or advisory committees, Research Funding; Bioverativ, a Sanofi Company: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Prometic Life Sciences: Consultancy, Research Funding; Shire: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Genetech: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Bayer Healthcare: Other: International Network of Pediatric Hemophilia; BioMarin: Research Funding; Bio Products Laboratory: Consultancy; Octapharma: Research Funding; OPKO: Research Funding; Sangamo Biosciences: Consultancy; Daiichi Sankyo: Research Funding. Chaudhury:Bioverativ, a Sanofi Company: Consultancy, Research Funding; Bayer: Membership on an entity's Board of Directors or advisory committees. Jain:Bioverativ: Employment. Tsao:Bioverativ: Employment. Barnowski:Bioverativ, a Sanofi Company: Employment. Feng:Bioverativ: Employment. Quon:Shire: Speakers Bureau; Genetech: Consultancy, Speakers Bureau; NovoNordisk: Consultancy, Speakers Bureau; Bayer: Consultancy; Octapharma: Consultancy; Bioverativ, a Sanofi Company: Speakers Bureau.

corrosion refers to a chemical (dry corrosion) or electrochemical (wet corrosion) reaction of and the surrounding environment due to erosion of steel and its alloys or atmospheric gases causing substances used to break down or lose component atoms. Section Corrosion is also defined as an electrochemical process in which oxidation and reduction of metal occur simultaneously in the presence of an oxidizing agent such as oxygen. Section Dry corrosion and wet corrosion are two types. Oxidation of waste to form metal oxides; It is a good example of electrochemical dry corrosion, commonly known as rust. The loss of corrosion products often produces oxides or salts of the old metal. Corrosion cannot be prevented, but losses from corrosion can be minimized. Almost all materials, such as ceramics (concrete rusts) or polymers, corrode in one way or another, but in this case the word "degrades" is often used with . Section Corrosion is also defined as the loss of valuable properties. materials due to the attack of atmospheric gases. Surface corrosion of metals and their alloys due to atmospheric gases (wind and moisture), chemical or electrochemical reactions that cause corrosion (loss) of metals Atmospheric gases affect different metal alloys. Many processes alloys, moisture content, nature of disease, flow rate, etc. will corrode heavily, while others will corrode slightly. Corrosion rates can be greatly affected by exposure of to certain elements in the atmosphere. Corrosion occurs in many forms. Section Corrosion Similar to the diffusion control process as corrosion occurs in most materials and alloy . Main battery design is another cause of corrosion. The formation of primary cells in the body should be avoided as much as possible. Galvanic cells are created because when two dissimilar metals come into contact with each other, the formation of Section galvanic cells occurs, which causes galvanic corrosion. In galvanic cells, more reactive metals with hydrogen greater than in the EMF series will corrode at a high rate (anode), while noble metals with hydrogen less than in the EMF series will corrode at a slower rate (cathode). However, when they are separated, no galvanic cells are formed and each metal corrodes independently. The choice of metals and alloys used in industry prevents the Galvanic cell design from occurring, which can be done with the help of many galvanic cells. For example, zinc is often used as a sacrificial anode to protect steel and its alloys, to provide protection to steel structures. Galvanic Cell Corrosion Different factors affect the corrosion rate, such as the relative position of the anode, the type of metal , and physical conditions such as temperature, humidity, and salinity. The area between the anode and the cathode is also an important factor affecting the corrosion rate. Corrosion rate of records. Section Among the different factors affecting the corrosion rate, water in the air is the most important Section. Any metal electrode immersed in a standard ventilated environment such as steam Hot sea water in the house will be faster than the next Inert. . Chapter or more Chapter is being bullied as much as its position in the EMF series is different from When two dissimilar metals are in electrical contact with each other placed in the same electrolyte, and sharing the same electrons, there is competition between the two free electrons of the two materials. Item Electrolyte acts as a host for ions to flow in the same direction and eventually gains noble metal and takes electrons from active ions. The current generation can be scaled to increase or decrease data in the center of interest. There is a basic requirement that the metal be clean to reduce corrosion. Generally, corrosion products can be removed by chemical/physical means to obtain a clean surface , but one or another type of corrosion such as pitting corrosion may still occur. To reduce the corrosion of , different anti-corrosion agents should be used in the body; For example, phosphoric acid, usually in the form of dark blue glue, is used to surface ferrous equipment to remove rust. Different materials have different corrosion properties. For example, EMF and Galvanic series. Different types and alloys of series or reactive series metals can be prepared in different environments. Section will certainly help you understand the nature and type of rust. Among the different corrosion protection methods, the various methods for protecting carbon steel from corrosion include painting, hot dip galvanizing, anodic protection, altruistic protection, and a combination of methods.. More procedures can be used if more sensitive data is used. It is used to protect and components from damage during manufacture, transportation and storage. Section The most corrosion resistant materials are those that are thermodynamically unsuitable for corrosion. Any corrosion of gold or platinum will spontaneously convert to pure metal; therefore these elements can be found in the world in metallic form and are part of their true value. Article The more "base" metal can be preserved with longer use. Chapter Normal metals have slow reaction kinetics, but their corrosion is thermodynamically favored. These include metals such as zinc, magnesium and cadmium. The corrosion of these metals continues, but occurs at a lower rate. Section A 2002 study by the Federal Highway Administration entitled "Costs and Prevention in the United States" Section shows the direct costs associated with metal corrosion in virtually every industry in the United States. It showed that the estimated annual direct cost of corrosion in the United States in 1998 was .The United States is approximately $276 billion, of which is approximately 3.2% of US GDP. However, the cost directly related to the corrosion of steel is heavier. Failure is due to the loss of mechanical strength of the concrete structure due to corrosion. Corrosion limits the life of the concrete structure. As corrosion cannot be avoided, engineers will determine the service life of the model. Rust is one of the most common causes of bridge accidents. Article Harassment Corrosion was the main cause of the Milans River Bridge collapse in 1983 when internal corrosion at the bearings caused the angle of the road plate to come off its support. Meanwhile, three people driving on the road died when the stone slabs fell into the river below. NTSB research revealed that engineers blocked the drain in the road while renovating, but forgot to unclog it later, allowing water to seep into the hangers. Article It is also difficult for mechanics to find bearings by inspection. Section When rust builds up and the support is removed, it eventually causes serious damage to Section .There are many instances where rust was responsible for the tragic events of . Rust was a factor in the 1967 Silver Bridge disaster in West Virginia at ,when the steel suspension bridge collapsed in less than a minute, killing 46 drivers and passengers. Carbon and Mild Steel are the most common steels used in many industries as well as everyday life for the design and manufacture of in a variety of applications. Carbon steel and low carbon will corrode severely when exposed to corrosive medium, ie corrosive medium. is an acid, but their use is still mostly due to their low cost and good quality. Corrosion can cause loss of metals and their strength which can lead to serious accidents and loss of work, work and people. Scientists have always wanted to understand the corrosion process and ways to control it. Chapter A number of corrosion inhibitors have been reported to control the corrosion of steel and its alloys in different corrosion systems. Every step towards finding a new Corrosion Inhibitor for a corrosion remediation project will not only result in significant savings, but will also help engineers keep plants and machinery running smoothly as Corrosion occurs. Carbon Steel, Stainless Steel, and Mild Steel are the most common materials used in the design and manufacture of the Chloride ions can corrode steel, stainless steel, and mild steel and are found in plumbing, electrical equipment, boilers, condensing units, etc. can cause problems. The sea is also abundant in chloride , which is used for injection into water in oil for cooling, such as in desalination plants. Chemical corrosion inhibitors are generally used in manufacturing and processing. The challenge, however, is to develop a new corrosion inhibitor that will protect material and make it a good friend in many situations. Surfactants are environmentally acceptable as corrosion inhibitors and is very economical and readily available. The purpose of this article is to determine the ability of surfactants to prevent corrosion of on carbon, stainless and mild steel surfaces. Chapter The various uses and properties of various surfactants are also discussed. The effect of surfactant concentration, temperature and corrosion inhibition mechanisms, and type of adsorption are also discussed in this book. In this study, we try to study in detail surfactants as corrosion inhibitors to control corrosion of carbon steel, stainless steel and small iron in acidic environment. Chapter Experiments were performed using both gravitational and electrochemical polarization methods, and the results of all studied surfactants used in this study are discussed in detail.

The history of Internet activism and Internet control in China is one of mutual adaptation between citizen activists and party authorities. The party-state initially reacted to Internet activism with alarm, but has since built a comprehensive approach combining repressive policing with gentler methods of social management. This approach has evolved in response to the diverse forms of and participants in Internet activism. But the adaptability of the Chinese Internet control regime does not mean that it will root out Internet activism. On the contrary, Internet activism will continue to grow and will itself adapt to the changing forms of control. Comparisons with Russia and the United States highlight how political economy, history, and everyday practice shape the forms of Internet activism and control.

Objectives. To report on the expansion of syringe service programs (SSPs) in the United States from 2015 to 2018. Methods. We obtained data from records of the Buyers’ Club of the Dave Purchase Project/North American Syringe Exchange Network (NASEN), including the number of US SSPs and the numbers of sterile syringes purchased by programs. We conducted a subset analysis of states with high numbers of counties defined as “vulnerable” by the Centers for Disease Control and Prevention. Results. SSP participation in the Buyers’ Club increased from 141 in 2015 to 292 in 2018, with an increase in syringes purchased from 42 million to 88 million. In addition to these large increases in numbers of programs and in syringes purchased, there were also indications of instability among new programs in vulnerable states. Conclusions. There have been substantial increases in the number of programs established and the number of syringes distributed in response to the opioid epidemic. Ensuring high-quality services in these new programs will be critical to successfully addressing the current epidemic.

Abstract Background Elizabethkingia (EK) are non-motile gram-negative rods found in soil and water and are an emerging cause of healthcare-associated infections (HAIs). We describe Centers for Disease Control and Prevention (CDC) consultations for healthcare-associated EK infections and outbreaks. Methods CDC maintains records of consultations with state or local health departments related to HAI outbreaks and infection control breaches. We reviewed consultations involving EK species as the primary pathogen of concern January 1, 2013 to December 31, 2019 and summarized data on healthcare settings, infection types, laboratory analysis, and control measures. Results We identified 9 consultations among 8 states involving 73 patient infections. Long-term acute-care hospitals (LTACHs) accounted for 4 consultations and 32 (43%) infections, and skilled nursing facilities with ventilated patients (VSNFs) accounted for 2 consultations and 31 (42%) infections. Other settings included an acute care hospital, an assisted living facility, and an outpatient ear, nose, and throat clinic. Culture sites included the respiratory tract (n=7 consultations), blood (n=4), and sinus tract (n=1), and E. anophelis was the most commonly identified species. Six consultations utilized whole genome sequencing (WGS); 4 identified closely related isolates from different patients and 2 also identified closely related environmental and patient isolates. Mitigation measures included efforts to reduce EK in facility water systems, such as the development of water management plans, consulting water management specialists, flushing water outlets, and monitoring water quality, as well as efforts to minimize patient exposure such as cleaning of shower facilities and equipment, storage of respiratory therapy supplies away from water sources, and use of splash guards on sinks. Conclusion EK is an important emerging pathogen that causes HAI outbreaks, particularly among chronically ventilated patients. LTACHs and VSNFs accounted for the majority of EK consultations and patient infections. Robust water management plans and infection control practices to minimize patient exposure to contaminated water in these settings are important measures to reduce infection risk among vulnerable patients. Disclosures All Authors: No reported disclosures

Political, economic, and safety concerns have militated for the adoption of Electronic Health Records by physicians in the United States, but current rates of adoption have failed to penetrate the 50% level. A qualitative phenomenological study of practicing physicians reveals stumbling blocks to adoption. Maintaining a physician’s perceived sense of control of the process is key. Electronic Health Records (EHRs) are critical to the support of research, quality control, cost reduction, and implementation of new technologies and methods in healthcare. Progress in the USA towards adoption of standardized EHRs has been halting. The authors discuss the results of a phenomenological study of physicians and draw conclusions that will assist all stakeholders in building a more consistent, comprehensive, and cost-effective healthcare system. When attempting to persuade physicians to migrate to an EMR-based solution, a strong focus on the control that physicians will have should be emphasized. The transition to an EHR system is eased by clearly articulating early in the process the potential benefits and the degree of control physicians can have in the use of the applications.

<em>Abstract.</em>—The Red River of the North basin (RRNB) has an area of about 287,000 square kilometers of the upper Midwestern United States and south-central Canada. The river forms the North Dakota–Minnesota boundary and flows into Lake Winnipeg, Manitoba, and then, via the Nelson River, into Hudson Bay. While the Red River main stem remains a sinuous stream similar to early descriptions, the river’s watershed has been altered dramatically by intensive agriculture, wetland drainage, channelization of tributary streams, and dam construction. Early land surveys described a landscape largely covered by prairie and wetlands. However, thousands of kilometers of ditches have been excavated to drain wetlands for agriculture in the United States in the late 1800s to the 1920s, and continuing, in Canada, to the present. Over 500 dams have blocked access to critical spawning habitat in the basin starting in the late 1800s. Also, during the mid-1900s, many of the tributaries were channelized, causing the loss of several thousand stream kilometers. While much of RRNB’s fish assemblage remains similar to earliest historical records, the loss of the lake sturgeon <em>Acipenser fulvescens </em>is a notable change resulting from habitat loss and fragmentation, and overfishing. Additional localized extirpations of channel catfish <em>Ictalurus punctatus</em>, several redhorse <em>Moxostoma </em>species, sauger <em>Sander canadensis</em>, and other migratory fishes have occurred upstream of dams on several tributaries. Presently, efforts are underway to restore migratory pathways through dam removal, conversion of dams to rapids, and construction of nature-like fishways. Concurrently, lake sturgeon is being reintroduced in the hope that restored access to historic spawning areas will allow reestablishment of the species. Proposed construction of new flood control dams may undermine these efforts.

<em>Abstract.</em>—The Red River of the North basin (RRNB) has an area of about 287,000 square kilometers of the upper Midwestern United States and south-central Canada. The river forms the North Dakota–Minnesota boundary and flows into Lake Winnipeg, Manitoba, and then, via the Nelson River, into Hudson Bay. While the Red River main stem remains a sinuous stream similar to early descriptions, the river’s watershed has been altered dramatically by intensive agriculture, wetland drainage, channelization of tributary streams, and dam construction. Early land surveys described a landscape largely covered by prairie and wetlands. However, thousands of kilometers of ditches have been excavated to drain wetlands for agriculture in the United States in the late 1800s to the 1920s, and continuing, in Canada, to the present. Over 500 dams have blocked access to critical spawning habitat in the basin starting in the late 1800s. Also, during the mid-1900s, many of the tributaries were channelized, causing the loss of several thousand stream kilometers. While much of RRNB’s fish assemblage remains similar to earliest historical records, the loss of the lake sturgeon <em>Acipenser fulvescens </em>is a notable change resulting from habitat loss and fragmentation, and overfishing. Additional localized extirpations of channel catfish <em>Ictalurus punctatus</em>, several redhorse <em>Moxostoma </em>species, sauger <em>Sander canadensis</em>, and other migratory fishes have occurred upstream of dams on several tributaries. Presently, efforts are underway to restore migratory pathways through dam removal, conversion of dams to rapids, and construction of nature-like fishways. Concurrently, lake sturgeon is being reintroduced in the hope that restored access to historic spawning areas will allow reestablishment of the species. Proposed construction of new flood control dams may undermine these efforts.

The southern pine beetle, Dendroctonus frontalis Zimmermann (Coleoptera: Scolytidae), is an economically important pest of pine forests in the southern United States (Price et al. 1992). This native bark beetle is able to attack and kill living trees, typically loblolly (Pinus taeda L.) or shortleaf (Pinus echinata Mill.) pine, through a process of mass attack coordinated by pheromones emitted by the beetle (Payne 1980). During the attack process, thousands of beetles bore through the outer bark of the tree and begin constructing galleries in the phloem layer. Trees can respond to beetle attack by exuding resin from a network of ducts, but the large number of simultaneous attacks usually overcomes this defense, literally draining the resin from the tree. Oviposition and brood development then occur in the girdled (and ultimately dead) tree. Once a tree is fully colonized the attack process shifts to adjacent trees, often resulting in a cluster of freshly attacked trees, trees containing developing brood, and dead and vacated trees (Coulson 1980). These infestations can range in size from a single tree to tens of thousands, although the latter only occur in areas where no control methods are applied. Approximately six generations can be completed in a year in the southern United States (Ungerer et al. 1999). Like many other forest insect pests, D. frontalis populations are characterized by a considerable degree of fluctuation. The longest time series available are Texas Forest Service records of infestations in southeast Texas since 1958 (figure 5.la). These data suggest that the fluctuations have at least some periodic component, with major outbreaks occurring at intervals of 7-9 years (1968, 1976, 1985, and 1992). A variety of different analyses, including standard time series analysis and response surface methodology (Turchin 1990, Turchin and Taylor 1992), suggest that D.frontalis dynamics are indeed cyclic and appear governed by some kind of delayed negative feedback acting on population growth (see chapter 1). This effect can be seen by plotting the realized per-capita rate of growth (R-values) over a year against population density in the previous year (figure 5.1b).

Background: The association of Type 2 Diabetes (T2D) and Alzheimer’s Disease (AD), that is 6th cause of death in United States, have been long noted. The history of T2D increases the risk for AD by 50-200% and the 10 years risk in 10-30%, which is 25-35 times the general. Objective: To investigate findings of the last 5 years that directly correlate T2D with AD. Methods: Use of the PICO strategy, conducted on September 17, on PubMed using “Alzheimer disease” and “diabetes mellitus” as descriptors, identifying 14 articles, selecting 4 after screening. Inclusion criteria: clinical and randomized controlled trials with diabetic and Alzheimer patients, published on the last 5 years. Exclusion criteria: articles focused on medications. Results: Mexican Americans are more likely to evolve T2D, to have an earlier onset and severer forms of AD. Furthermore, cell-free mitochondrial DNA, common in diabetics, is related to cognitive impairment. Besides, metformin improves learning, memory and attention skills, and BG control is linked to longer survival time and an apparent delay of the dementia. Moreover, lower levels of plasma amyloid-β (Aβ) 40 and 42 were found when T2D and higher levels of Aβ42 have been found in people treated with insulin, but the Aβ levels meaning needs to be clarified. Conclusion: T2D is often related to lifestyle and AD to a genetic component. Anyhow, more studies are needed to clarify the meaning of these findings. Study limitations: few trials performed.

The Big Thicket National Preserve (BITH) vegetation inventory project classified and mapped vegetation within the administrative boundary and estimated thematic map accuracy quantitatively. National Park Service (NPS) Vegetation Mapping Inventory Program provided technical guidance. The overall process included initial planning and scoping, imagery procurement, vegetation classification field data collection, data analysis, imagery interpretation/classification, accuracy assessment (AA), and report writing and database development. Initial planning and scoping meetings took place during May, 2016 in Kountze, Texas where representatives gathered from BITH, the NPS Gulf Coast Inventory and Monitoring Network, and Colorado State University. The project acquired new 2014 orthoimagery (30-cm, 4-band (RGB and CIR)) from the Hexagon Imagery Program. Supplemental imagery for the interpretation phase included Texas Natural Resources Information System (TNRIS) 2015 50 cm leaf-off 4-band imagery from the Texas Orthoimagery Program (TOP), Farm Service Agency (FSA) 100-cm (2016) and 60 cm (2018) National Aerial Imagery Program (NAIP) imagery, and current and historical true-color Google Earth and Bing Maps imagery. In addition to aerial and satellite imagery, 2017 Neches River Basin Light Detection and Ranging (LiDAR) data was obtained from the United States Geological Survey (USGS) and TNRIS to analyze vegetation structure at BITH. The preliminary vegetation classification included 110 United States National Vegetation Classification (USNVC) associations. Existing vegetation and mapping data combined with vegetation plot data contributed to the final vegetation classification. Quantitative classification using hierarchical clustering and professional expertise was supported by vegetation data collected from 304 plots surveyed between 2016 and 2019 and 110 additional observation plots. The final vegetation classification includes 75 USNVC associations and 27 park special types including 80 forest and woodland, 7 shrubland, 12 herbaceous, and 3 sparse vegetation types. The final BITH map consists of 51 map classes. Land cover classes include five types: pasture / hay ground agricultural vegetation; non ? vegetated / barren land, borrow pit, cut bank; developed, open space; developed, low ? high intensity; and water. The 46 vegetation classes represent 102 associations or park specials. Of these, 75 represent natural vegetation associations within the USNVC, and 27 types represent unpublished park specials. Of the 46 vegetation map classes, 26 represent a single USNVC association/park special, 7 map classes contain two USNVC associations/park specials, 4 map classes contain three USNVC associations/park specials, and 9 map classes contain four or more USNVC associations/park specials. Forest and woodland types had an abundance of Pinus taeda, Liquidambar styraciflua, Ilex opaca, Ilex vomitoria, Quercus nigra, and Vitis rotundifolia. Shrubland types were dominated by Pinus taeda, Ilex vomitoria, Triadica sebifera, Liquidambar styraciflua, and/or Callicarpa americana. Herbaceous types had an abundance of Zizaniopsis miliacea, Juncus effusus, Panicum virgatum, and/or Saccharum giganteum. The final BITH vegetation map consists of 7,271 polygons totaling 45,771.8 ha (113,104.6 ac). Mean polygon size is 6.3 ha (15.6 ac). Of the total area, 43,314.4 ha (107,032.2 ac) or 94.6% represent natural or ruderal vegetation. Developed areas such as roads, parking lots, and campgrounds comprise 421.9 ha (1,042.5 ac) or 0.9% of the total. Open water accounts for approximately 2,034.9 ha (5,028.3 ac) or 4.4% of the total mapped area. Within the natural or ruderal vegetation types, forest and woodland types were the most extensive at 43,022.19 ha (106,310.1 ac) or 94.0%, followed by herbaceous vegetation types at 129.7 ha (320.5 ac) or 0.3%, sparse vegetation types at 119.2 ha (294.5 ac) or 0.3%, and shrubland types at 43.4 ha (107.2 ac) or 0.1%. A total of 784 AA samples were collected to evaluate the map?s thematic accuracy. When each AA sample was evaluated for a variety of potential errors, a number of the disagreements were overturned. It was determined that 182 plot records disagreed due to either an erroneous field call or a change in the vegetation since the imagery date, and 79 disagreed due to a true map classification error. Those records identified as incorrect due to an erroneous field call or changes in vegetation were considered correct for the purpose of the AA. As a simple plot count proportion, the reconciled overall accuracy was 89.9% (705/784). The spatially-weighted overall accuracy was 92.1% with a Kappa statistic of 89.6%. This method provides more weight to larger map classes in the park. Five map classes had accuracies below 80%. After discussing preliminary results with the parl, we retained those map classes because the community was rare, the map classes provided desired detail for management or the accuracy was reasonably close to the 80% target. When the 90% AA confidence intervals were included, an additional eight classes had thematic accruacies that extend below 80%. In addition to the vegetation polygon database and map, several products to support park resource management include the vegetation classification, field key to the associations, local association descriptions, photographic database, project geodatabase, ArcGIS .mxd files for map posters, and aerial imagery acquired for the project. The project geodatabase links the spatial vegetation data layer to vegetation classification, plot photos, project boundary extent, AA points, and PLOTS database sampling data. The geodatabase includes USNVC hierarchy tables allowing for spatial queries of data associated with a vegetation polygon or sample point. All geospatial products are projected using North American Datum 1983 (NAD83) in Universal Transverse Mercator (UTM) Zone 15 N. The final report includes methods and results, contingency tables showing AA results, field forms, species list, and a guide to imagery interpretation. These products provide useful information to assist with management of park resources and inform future management decisions. Use of standard national vegetation classification and mapping protocols facilitates effective resource stewardship by ensuring the compatibility and widespread use throughout NPS as well as other federal and state agencies. Products support a wide variety of resource assessments, park management and planning needs. Associated information provides a structure for framing and answering critical scientific questions about vegetation communities and their relationship to environmental processes across the landscape.