Obtaining outpatient appointments with psychiatrists in three cities was difficult, irrespective of payer. RESULTS suggest that expanding insurance coverage alone may do little to improve access to psychiatrists-or worse, expansion might further overwhelm the capacity of available services.

Objective Dying in the intensive care unit (ICU) has changed over the last twenty years due to increased utilization of palliative care. We sought to examine how palliative medicine (PM) integration into critical care medicine has changed outcomes in end of life including the utilization of do not resuscitate (no cardiopulmonary resuscitation but continue treatment) and comfort care orders (No resuscitation, only comfort medication). Design: Retrospective observational review of critical care patients who died during admission between two decades, 2008 to 09 and 2018 to 19. Setting: Single urban tertiary care academic medical center in Washington, D.C. Patients: Adult patients who were treated in any ICU during the admission which they died. Interventions and Measurements We sought to measure PM involvement across the two decades and its association with end of life care including do not resuscitate (DNR) and comfort care (CC) orders. Main Results: 571 cases were analyzed. Mean age was 65 ± 15, 46% were female. In univariate analysis significantly more patients received PM in 2018 to 19 (40% vs. 27%, p = .002). DNR status increased significantly over time (74% to 84%, p = .002) and was significantly more common in patients who were receiving PM (96% vs. 72%, p < 0.001). CC also increased over time (56% to 70%, p = <0.001), and was more common in PM patients (87% vs. 53%, p < 0.001). Death in the ICU decreased significantly over time (94% to 86%, p = .002) and was significantly lower in PM patients (76% vs. 96%, p < 0.001). The adjusted odds of getting CC for those receiving versus those not receiving PM were 14.51 (5.49-38.36, p < 0.001) in 2008 to 09 versus 3.89 (2.27-6.68, p < 0.001) in 2018 to 19. Conclusion: PM involvement increased significantly across a decade in our ICU and was significantly associated with incidence of DNR and CC orders as well as the decreased incidence of dying in the ICU. The increase in DNR and CC orders independent of PM over the past decade reflect intensivists delivering PM services.

Information Security is a topic of growing concern within the space community. In particular ground control systems and space-link communications are required to ensure a minimum level of security and robustness. Security requirements are usually established using information risk assessment which evaluates the target systems' vulnerabilities and establishes the identification of potential threats. From this point, the risk assessment evaluates the likelihood of a threat against the severity of identified vulnerabilities and determines a quantifiable risk for each of these combinations. Many risk assessment methodologies such as ISO27005, NIST SP 800-30, or EBIOS exist, but they all face similar problems in practice. The risk assessment process looks easy on paper -but experience within ESA has shown that it can turn into a complex nightmare with unusable results if it is not done right especially when applied to complex systems. In our paper, we address the main pitfalls of risk assessment and how to avoid them. Our contribution is the result of the analysis of a number of ESA risk assessment exercises lessons learned. Some of these risk assessments were very successful while others were not. We elaborate on the following central buzzwords of successful risk assessment: Know your system, Know what is important for your system, Keep it simple, Don't believe you are done after the first round.

Aims To collect and analyse representative data of structural and process quality in the management of diabetic emergencies in Germany in 2020. Methods A standardised questionnaire comprising detailed items concerning clinically relevant parameters on the structural and process quality of out-of-hospital management of diabetic emergencies was sent nationwide to medical directors of emergency medical service districts (EMSDs). Results were compared with those from a similar study conducted in 2001. Results The return rate of the questionnaires represented 126 EMSDs, serving a total population of > 40.1 million. Only 4% of ambulances carried glucagon (6% in 2001). In 2020, blood glucose determination increased significantly to 71% of all emergency interventions and to 29% of suspected cardiac emergencies (24% and 15%, respectively, in 2001). In 100% of EMSDs severe hypoglycaemia (SH) was treated by paramedics by administering intravenous dextrose before the arrival of a doctor compared to 63% in 2001. The potential value of nasal glucagon was acknowledged by 43% of responders. In selected patients, treatment of SH was conducted without hospital admission in 78% of EMDs (60% in 2001). Fifty-three percent of medical directors acknowledged the need for further training in diabetic emergencies (47% in 2001). Cooperation for medical education between emergency teams and a diabetes centre was reported by 14% (41% in 2001). Conclusion Structural and process quality of the management of diabetic emergencies in Germany has improved considerably since 2001. Persisting deficiencies could be improved by providing better medical equipment in ambulances and ongoing education to the entire emergency teams.

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