Comparison of Direct Staffing Costs of Advanced Practice Providers and Residents in a High Acuity Area of a Community Emergency Department

Background: Resident physicians and advanced practice providers (APPs) both have roles in providing care within emergency departments (ED). While both bring unique skill sets and capabilities to the health care team, little is known about the comparative financial impact of APPs and residents in a community ED. The objective of this study was to compare direct staffing costs per relative value unit (RVU) generated of emergency medicine (EM) residents and APPs in a community ED setting. Methods: This was a retrospective, observational analysis of RVU productivity of resident physicians and APPs in the high acuity area of a community ED. Billing data was acquired to determine RVUs generated by both APPs and residents when supervised by an attending physician. Direct costs and hours worked were used to calculate RVUs/hour and direct costs/hour. Direct cost/RVU generated were calculated for the four specific groups of providers (PGY1, PGY2, PGY3, and APP). Results: During the study period, APPs generated 2.88 RVUs/hour. Residents generated 2.01, 3.00, and 3.49 RVUs/hour respectively from PGY1 to PGY3. When the RVU data was combined with scheduled hours and direct costs for both groups, APPs were found to cost $22.46 per RVU generated. The average cost of a resident throughout three years of residency training is approximately$12.38 per RVU generated. Conclusion: In a high acuity area of a community ED, EM residents generate more RVUs/hour than APPs after completion of their PGY1 year. Given the lower direct hourly cost of a resident compared with an APP, the direct cost of a resident to assist an attending to generate RVUs is less than that of their APP counterparts during all three years of training. This suggests that community hospitals should consider sponsoring EM residency positions over hiring APPs for use in the high acuity setting

Real-time NMR monitoring of biological activities in complex physiological environments

Biological reactions occur in a highly organized spatiotemporal context and with kinetics that are modulated by multiple environmental factors. To integrate these variables in our experimental investigations of 'native' biological activities, we require quantitative tools for time-resolved in situ analyses in physiologically relevant settings. Here, we outline the use of high-resolution NMR spectroscopy to directly observe biological reactions in complex environments and in real-time. Specifically, we discuss how real-time NMR (RT-NMR) methods have delineated insights into metabolic processes, post-translational protein modifications, activities of cellular GTPases and their regulators, as well as of protein folding events.Fil: Smith, Matthew J.. Ontario Cancer Institute; CanadáFil: Marshall, Christopher B.. Ontario Cancer Institute; CanadáFil: Theillet, Francois Xavier. Leibniz Institute of Molecular Pharmacology; AlemaniaFil: Binolfi, Andrés. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Leibniz Institute of Molecular Pharmacology; AlemaniaFil: Selenko, Philipp. Leibniz Institute of Molecular Pharmacology; AlemaniaFil: Ikura, Mitsuhiko. Ontario Cancer Institute; Canadá. University of Toronto; Canad

Can we predict ectotherm responses to climate change using thermal performance curves and body temperatures?

Thermal performance curves (TPCs), which quantify how an ectotherm\u27s body temperature (Tb ) affects its performance or fitness, are often used in an attempt to predict organismal responses to climate change. Here, we examine the key - but often biologically unreasonable - assumptions underlying this approach; for example, that physiology and thermal regimes are invariant over ontogeny, space and time, and also that TPCs are independent of previously experienced Tb. We show how a critical consideration of these assumptions can lead to biologically useful hypotheses and experimental designs. For example, rather than assuming that TPCs are fixed during ontogeny, one can measure TPCs for each major life stage and incorporate these into stage-specific ecological models to reveal the life stage most likely to be vulnerable to climate change. Our overall goal is to explicitly examine the assumptions underlying the integration of TPCs with Tb , to develop a framework within which empiricists can place their work within these limitations, and to facilitate the application of thermal physiology to understanding the biological implications of climate change

A Search for Exozodiacal Clouds with Kepler

Planets embedded within dust disks may drive the formation of large scale clumpy dust structures by trapping dust into resonant orbits. Detection and subsequent modeling of the dust structures would help constrain the mass and orbit of the planet and the disk architecture, give clues to the history of the planetary system, and provide a statistical estimate of disk asymmetry for future exoEarth-imaging missions. Here we present the first search for these resonant structures in the inner regions of planetary systems by analyzing the light curves of hot Jupiter planetary candidates identified by the Kepler mission. We detect only one candidate disk structure associated with KOI 838.01 at the 3-sigma confidence level, but subsequent radial velocity measurements reveal that KOI 838.01 is a grazing eclipsing binary and the candidate disk structure is a false positive. Using our null result, we place an upper limit on the frequency of dense exozodi structures created by hot Jupiters. We find that at the 90% confidence level, less than 21% of Kepler hot Jupiters create resonant dust clumps that lead and trail the planet by ~90 degrees with optical depths >~5*10^-6, which corresponds to the resonant structure expected for a lone hot Jupiter perturbing a dynamically cold dust disk 50 times as dense as the zodiacal cloud.Comment: 22 pages, 6 figures, Accepted for publication in Ap

Polarimetry and the High-Energy Emission Mechanisms in Quasar Jets. The Case of PKS 1136-135

Since the discovery of kiloparsec-scale X-ray emission from quasar jets, the physical processes responsible for their high-energy emission have been poorly defined. A number of mechanisms are under active debate, including synchrotron radiation, inverse-Comptonized CMB (IC/CMB) emission, and other Comptonization processes. In a number of cases, the optical and X-ray emission of jet regions are inked by a single spectral component, and in those, high- resolution multi-band imaging and polarimetry can be combined to yield a powerful diagnostic of jet emission processes. Here we report on deep imaging photometry of the jet of PKS 1136$-$135 obtained with the {\it Hubble Space Telescope.} We find that several knots are highly polarized in the optical, with fractional polarization $\Pi>30$. When combined with the broadband spectral shape observed in these regions, this is very difficult to explain via IC/CMB models, unless the scattering particles are at the lowest-energy tip of the electron energy distribution, with Lorentz factor $\gamma \sim 1$, and the jet is also very highly beamed ($\delta \geq 20$) and viewed within a few degrees of the line of sight. We discuss both the IC/CMB and synchrotron interpretation of the X-ray emission in the light of this new evidence, presenting new models of the spectral energy distribution and also the matter content of this jet. The high polarizations do not completely rule out the possibility of IC/CMB optical-to-X-ray emission in this jet, but they do strongly disfavor the model. We discuss the implications of this finding, and also the prospects for future work.Comment: 14 pages, 8 figures, ApJ in pres

Evolved Resistance to a Novel Cationic Peptide Antibiotic Requires High Mutation Supply

Background and Objectives A key strategy for resolving the antibiotic resistance crisis is the development of new drugs with antimicrobial properties. The engineered cationic antimicrobial peptide WLBU2 (also known as PLG0206) is a promising broad-spectrum antimicrobial compound that has completed Phase I clinical studies. It has activity against Gram-negative and Gram-positive bacteria including infections associated with biofilm. No definitive mechanisms of resistance to WLBU2 have been identified. Methodology Here, we used experimental evolution under different levels of mutation supply and whole genome sequencing (WGS) to detect the genetic pathways and probable mechanisms of resistance to this peptide. We propagated populations of wild-type and hypermutator Pseudomonas aeruginosa in the presence of WLBU2 and performed WGS of evolved populations and clones. Results Populations that survived WLBU2 treatment acquired a minimum of two mutations, making the acquisition of resistance more difficult than for most antibiotics, which can be tolerated by mutation of a single target. Major targets of resistance to WLBU2 included the orfN and pmrB genes, previously described to confer resistance to other cationic peptides. More surprisingly, mutations that increase aggregation such as the wsp pathway were also selected despite the ability of WLBU2 to kill cells growing in a biofilm. Conclusions and implications The results show how experimental evolution and WGS can identify genetic targets and actions of new antimicrobial compounds and predict pathways to resistance of new antibiotics in clinical practice

Extending Human Perception of Electromagnetic Radiation to the UV Region through Biologically Inspired Photochromic Fuzzy Logic (BIPFUL) Systems.

Photochromic Fuzzy Logic Systems have been designed that extend human visual perception into the UV region. The systems are founded on a detailed knowledge of the activation wavelengths and quantum yields of a series of thermally reversible photochromic compounds. By appropriate matching of the photochromic behaviour unique colour signatures are generated in response differing UV activation frequencies

A Year of Gastrointestinal Bleeding: An Epidemiologic Study

Background: For decades the diagnosis and management of gastrointestinal bleeding (GIB) has been based largely on endoscopy. Studying a large cohort of patients presenting to the ED we may find cost-effective alternatives in the management of GIB. We analyzed the epidemiology and initial disposition of all patients who presented to our ED from the perspective of hematemesis versus non-hematemesis, to identify patterns among each cohort’s presentations to aid in this. Methods: Retrospective analysis of medical records for 338 patients presenting to the UMass ED. Two cohorts were identified: those with hematemesis (G1) or non-hematemesis (G2). Results: 105 patients presented to the ED with hematemesis (G1), 233 patients presented with non-hematemesis GIB (G2). G1 was younger than G2 (54.4 years vs. 65.6 years, p\u3c0.001). There were more males in G1 vs. G2 (61% vs. 53%, p=0.154). Comorbities in G1 were liver disease (21%), alcohol abuse (20%), and diabetes (11%). Comorbities in G2 were coronary artery disease (22%), atrial fibrillation (13.7%), and diverticulosis (8%). More patients in G2 than G1 used Coumadin (23% vs. 7%, p\u3c0.001), anti-platelet agents (12% and 3%, p\u3c0.004), and NSAIDs (40% and 32%y, p=0.203). Admission hematocrit was greater in G1 compared to G2 (34.1 vs. 30.0, p\u3c0.001). INR was greater in G2 compared to G1 (1.7 vs. 1.3, p=0.03). BUN was greater in G2 compared to G1 (30.2 vs. 23.6, p=0.021). More patients in G2 were admitted compared to G1 (89.6% vs. 78.1%, p=0.019). More were admitted to the ICU in G1 compared to G2 (46% vs. 38%, p=0.237).Discussion: This study uses a novel approach that elicits different patterns than the traditional delineation of upper versus lower GIB. These results may lead to new decision-making in patients presenting with GIB, allowing for new diagnostic and management paradigms, resulting in cost-effective care