A mixed methods study of the impact of consultant overnight working in an English Emergency Department

This is the final version. Available on open access from BMJ Publishing Group via the DOI in this recordBackground There is a growing expectation that consultant-level doctors should be present within an ED overnight. However, there is a lack of robust evidence substantiating the impact on patient waiting times, safety or the workforce. Objectives To evaluate the impact of consultant-level doctors overnight working in ED in a large university hospital. Methods We conducted a controlled interrupted time series analysis to study ED waiting times before and after the introduction of consultant night working. Adverse event reports (AER) were used as a surrogate for patient safety. We conducted interviews with medical and nursing staff to explore attitudes to night work. Results The reduction seen in average time in department relative to the day, following the introduction of consultant was non-significant ('12 min; 95% CI '28 to 4, p=0.148). Analysis of hourly arrivals and departures indicated that overnight work was inherited from the day. There were three (0.9%) moderate and 0 severe AERs in 1 year. The workforce reported that night working had a negative impact on sleep patterns, performance and well-being and there were mixed views about the benefits of consultant night presence. Additional time off during the day acted as compensation for night work but resulted in reduced contact with ED teams. Conclusions Our single-site study was unable to demonstrate a clinically important impact of consultant night working on total time patients spend in the department. Our analysis suggests there may be more potential to reduce total time in department during the day, at our study site. Negative impacts on well-being, and likely resistance to consultant night working should not be ignored. Further studies of night working are recommended to substantiate our results.National Institute for Health Research (NIHR)University Hospital Southampto

Serving GODAE Data and Products to the Ocean Community

The Global Ocean Data Assimilation Experiment (GODAE [http:// www.godae.org]) has spanned a decade of rapid technological development. The ever-increasing volume and diversity of oceanographic data produced by in situ instruments, remote-sensing platforms, and computer simulations have driven the development of a number of innovative technologies that are essential for connecting scientists with the data that they need. This paper gives an overview of the technologies that have been developed and applied in the course of GODAE, which now provide users of oceanographic data with the capability to discover, evaluate, visualize, download, and analyze data from all over the world. The key to this capability is the ability to reduce the inherent complexity of oceanographic data by providing a consistent, harmonized view of the various data products. The challenges of data serving have been addressed over the last 10 years through the cooperative skills and energies of many individuals

Trace Gas Assimilation in Preparation for Future Satellite Missions

This work aims to set up a framework for assimilation of trace gas species into a Martian Global Circulation Model (MGCM). The launch of the ISRO Mars Orbiter and NASA Mars Atmosphere and Volatile EvolutioN mission will add to our knowledge of trace gases and atmospheric chemistry. In addition, the Exomars Trace Gas Orbiter (TGO) launches in 2016 and will obtain observations of trace gas species using the Nadir and Occultation for MArs Discovery (NOMAD) instrument amongst others. These missions will lead to a wealth of trace gas observations to compare to an MGCM. To make optimal use of information, observations and an MGCM are combined by the process of data assimilation. The outcome of this process is a dynamical global reconstruction of the observations (See Figure 1). Using this methodology, observations of short-lived (and long-lived) species can be supplemented by knowledge of the transport and atmospheric chemistry from an MGCM. The satellites currently orbiting Mars (Mars Reconnaissance Orbiter, MRO, and Mars Express), combined with the future planned satellite missions, create a great opportunity for the development of a data assimilation technique for trace gases on Mars

Trends in aerosol abundances and distributions

The properties of aerosols that reside in the upper atmosphere are described. Special emphasis is given to the influence these aerosols have on ozone observation systems, mainly through radiative effects, and on ambient ozone concentrations, mainly through chemical effects. It has long been appreciated that stratospheric particles can interfere with the remote sensing of ozone distribution. The mechanism and magnitude of this interference are evaluated. Separate sections deal with the optical properties of upper atmospheric aerosols, long-term trends in stratospheric aerosols, perturbations of the stratospheric aerosol layer by volcanic eruptions, and estimates of the impacts that such particles have on remotely measured ozone concentrations. Another section is devoted to a discussion of the polar stratospheric clouds (PSC's). These unique clouds, recently discovered by satellite observation, are now thought to be intimately connected with the Antarctic ozone hole. Accordingly, interest in PSC's has grown considerably in recent years. This chapter describes what we know about the morphology, physical chemistry, and microphysics of PSC's

Shedding of endothelial protein C receptor contributes to vasculopathy and renal injury in lupus: In vivo and in vitro evidence1

Shedding of endothelial protein C receptor contributes to vasculopathy and renal injury in lupus: In vivo and in vitro evidence.BackgroundCandidate biomarkers for vasculopathy in systemic lupus erythematosus (SLE) include circulating endothelial cells and the recently identified endothelial protein C receptor (EPCR) which, when shed, promotes a thrombotic diathesis. This study sought correlation between plasma levels of soluble EPCR and disease manifestation/severity, with a focus on lupus nephritis.MethodsIn 81 SLE patients (evaluated cross-sectionally and longitudinally) and 59 healthy controls, levels of soluble EPCR and soluble E-selectin were assessed by sandwich enzyme-linked immunosorbent assay (ELISA), circulating endothelial cells isolated by immunomagnetic separation, and EPCR gene polymorphisms determined. Mechanisms of vascular injury were addressed in vitro in human aortic endothelial cells (HAEC) cultured in the presence and absence of interferon-γ (IFN-γ).ResultsThe mean level of soluble EPCR was significantly higher in SLE patients (263 ± 13ng/mL) than controls (174 ± 11ng/mL) (P < 0.0001). Patients with active or past renal involvement had significantly higher mean soluble EPCR levels (306 ± 21ng/mL) (N = 40) than patients without nephritis (228 ± 14ng/mL) (N = 41) (P = 0.0033). Mean soluble EPCR correlated positively with serum creatinine (R = 0.3429, P < 0.0001). The prevalence of the enhanced-shedding EPCR polymorphism A6936G was higher in SLE (41%) (N = 27) than controls (7%) (N = 29) (P = 0.0039). Patient and control plasma were also interrogated for soluble E-selectin, a comparator plasma marker. The results suggest that soluble E-selectin and soluble EPCR are not equivalent end points of vasculopathy and endothelial perturbation in SLE. Although in SLE patients the absence or diminished expression of membrane EPCR on circulating endothelial cells varied, the rare circulating endothelial cells detected in controls invariably expressed membrane-bound EPCR. IFN-γ-treated HAEC expressed less membrane-bound EPCR [133 relative fluorescence units (rfu)] than untreated HAEC (275 rfu); more soluble EPCR was detected in IFN-γ-treated (1.1ng/106 cells) than untreated HAEC (0.65ng/106 cells) (P = 0.027).ConclusionThe results obtained from this cross-sectional/longitudinal study support the hypothesis that the vascular dysfunction characteristic of SLE may be related to a dramatically altered distribution of EPCR, both soluble and membrane-bound forms

Initial Conditions in String Cosmology

We take a critical look at a recent conjecture concerning the past attractor in the pre-big-bang scenario. We argue that the Milne universe is unlikely to be a general past attractor for such models and support this with a number of examples.Comment: 10 pages standard Latex format, no figures. Submitted to Phys. Rev.

Asymptotic Behaviour of Inhomogeneous String Cosmologies

The asymptotic behaviour at late times of inhomogeneous axion-dilaton cosmologies is investigated. The space-times considered here admit two abelian space-like Killing vectors. These space-times evolve towards an anisotropic universe containing gravitational radiation. Furthermore, a peeling-off behaviour of the Weyl tensor and the antisymmetric tensor field strength is found. The relation to the pre-big-bang scenario is briefly discussed.Comment: 15 pages, Late