Modeling Hourly Productivity of Advanced Practice Clinicians in the Emergency Department

Introduction: Advance practice clinicians (APC) play significant roles in academic and community emergency departments (ED). In attendings and residents, prior research demonstrated that productivity is dynamic and changes throughout a shift in a predictable way. However, this has not been studied in APCs. The primary outcome of this study was to model productivity for APCs in community EDs to determine whether it changes during a shift similar to the way it does for attendings and residents. Methods: This was a retrospective, observational analysis of 10-hour APC shifts at two suburban hospitals, worked by 14 total individuals. We examined the number of patients seen per hour of the shift by experienced APCs who see all acuity and staff all patients with an attending. We used a generalized estimating equation to construct the model of hour-by-hour productivity change. Results: We analyzed 862 shifts over one year across two sites, with three shift start times. Site 1 10 AM–8 PM saw an average of 13.31 (95% confidence interval [CI] 13.02–13.63) patients per shift; Site 2 8 AM–6 PM saw an average of 12.64 (95% CI 12.32–13.06) patients per shift; Site 2 4 PM–2 AM saw an average of 12.53 (95% CI 12.04–12.82) patients per shift. Across all sites and shifts, hour 1 saw the highest number of patients. Each subsequent hour was associated with a small, statistically significant decrease over the previous hours. This was most pronounced in the shift’s last two hours. Conclusion: The productivity of APCs demonstrates a similar pattern of hourly declines observed in both resident and attending physicians. This corroborates prior findings that patients per hour is a dynamic variable, decreasing throughout a shift. This provides further external validity to prior research to include both APCs and community EDs. These departments must take this phenomenon into account, as it has scheduling and operational consequences

Kelvin-Helmholtz instability in the presence of variable viscosity for mudflow resuspension in estuaries

The temporal stability of a parallel shear flow of miscible fluid layers of dif- ferent density and viscosity is investigated through a linear stability analysis and direct numerical simulations. The geometry and rheology of this Newto- nian fluid mixing can be viewed as a simplified model of the behavior of mud- flow at the bottom of estuaries for suspension studies. In this study, focus is on the stability and transition to turbulence of an initially laminar configuration. A parametric analysis is performed by varying the values of three control pa- rameters, namely the viscosity ratio, the Richardson and Reynolds numbers, in the case of initially identical thickness of the velocity, density and viscosity profiles. The range of parameters has been chosen so as to mimic a wide variety of real configurations. This study shows that the Kelvin-Helmholtz instability is controlled by the local Reynolds and Richardson numbers of the inflection point. In addition, at moderate Reynolds number, viscosity strat- ification has a strong influence on the onset of instability, the latter being enhanced at high viscosity ratio, while at high Reynolds number, the influ- ence is less pronounced. In all cases, we show that the thickness of the mixing layer (and thus resuspension) is increased by high viscosity stratification, in particular during the non-linear development of the instability and especially pairing processes. This study suggests that mud viscosity has to be taken into account for resuspension parameterizations because of its impact on the inflec- tion point Reynolds number and the viscosity ratio, which are key parameters for shear instabilities

Large bubble rupture sparks fast liquid jet

This Letter presents the novel experimental observation of long and narrow jets shooting out in disconnecting large elongated bubbles. We investigate this phenomenon by carrying out experiments with various viscosities, surface tensions, densities and nozzle radii. We propose a universal scaling law for the jet velocity, which unexpectedly involves the bubble height to the power 3/2. This anomalous exponent suggests an energy focusing phenomenon. We demonstrate experimentally that this focusing is purely gravity-driven and independent of the pinch-off singularity

Drop splashing after impact onto immiscible pools of different viscosities

Droplet impact onto liquid pools is a canonical scenario relevant to numerous natural phenomena and industrial processes. However, despite their ubiquity, multi-fluid systems with the drop and pool consisting of different liquids are far less well understood. Our hypothesis is that the post-impact dynamics greatly depends on the pool-to-droplet viscosity ratio , which we explore over a range of six orders of magnitude using a combination of experiments and theoretical approaches (mathematical modelling and direct numerical simulation). Our findings indicate that in this scenario the splashing threshold and the composition of the ejecta sheet are controlled by the viscosity ratio. We uncover that increasing the pool viscosity decreases the splashing threshold for high viscosity pools () when the splash comes from the droplet. By contrast, for low viscosity pools, the splash sheet comes from the pool and increasing the pool viscosity increases the splashing threshold. Surprisingly, there are conditions for which no splashing is observed under the conditions attainable in our laboratory. Furthermore, considering the interface velocity together with asymptotic arguments underlying the generation of the ejecta has allowed us to understand meaningful variations in the pressure during impact and rationalise the observed changes in the splashing threshold

Study Design and Methods: U.S. Study To Protect Brain Health Through Lifestyle Intervention To Reduce Risk (U.S. Pointer)

INTRODUCTION: The U.S. study to protect brain health through lifestyle intervention to reduce risk (U.S. POINTER) is conducted to confirm and expand the results of the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) in Americans. METHODS: U.S. POINTER was planned as a 2-year randomized controlled trial of two lifestyle interventions in 2000 older adults at risk for dementia due to well-established factors. The primary outcome is a global cognition composite that permits harmonization with FINGER. RESULTS: U.S. POINTER is centrally coordinated and conducted at five clinical sites (ClinicalTrials.gov: NCT03688126). Outcomes assessments are completed at baseline and every 6 months. Both interventions focus on exercise, diet, cognitive/social stimulation, and cardiovascular health, but differ in intensity and accountability. The study partners with a worldwide network of similar trials for harmonization of methods and data sharing. DISCUSSION: U.S. POINTER is testing a potentially sustainable intervention to support brain health and Alzheimer\u27s prevention for Americans. Impact is strengthened by the targeted participant diversity and expanded scientific scope through ancillary studies

At clinically relevant concentrations the anaesthetic/amnesic thiopental but not the anticonvulsant phenobarbital interferes with hippocampal sharp wave-ripple complexes

<p>Abstract</p> <p>Background</p> <p>Many sedative agents, including anesthetics, produce explicit memory impairment by largely unknown mechanisms. Sharp-wave ripple (SPW-R) complexes are network activity thought to represent the neuronal substrate for information transfer from the hippocampal to neocortical circuits, contributing to the explicit memory consolidation. In this study we examined and compared the actions of two barbiturates with distinct amnesic actions, the general anesthetic thiopental and the anticonvulsant phenobarbital, on in vitro SPW-R activity.</p> <p>Results</p> <p>Using an in vitro model of SPW-R activity we found that thiopental (50–200 μM) significantly and concentration-dependently reduced the incidence of SPW-R events (it increased the inter-event period by 70–430 %). At the concentration of 25 μM, which clinically produces mild sedation and explicit memory impairment, thiopental significantly reduced the quantity of ripple oscillation (it reduced the number of ripples and the duration of ripple episodes by 20 ± 5%, n = 12, <it>P </it>< 0.01), and suppressed the rhythmicity of SPWs by 43 ± 15% (n = 6, <it>P </it>< 0.05). The drug disrupted the synchrony of SPWs within the CA1 region at 50 μM (by 19 ± 12%; n = 5, <it>P </it>< 0.05). Similar effects of thiopental were observed at higher concentrations. Thiopental did not affect the frequency of ripple oscillation at any of the concentrations tested (10–200 μM). Furthermore, the drug significantly prolonged single SPWs at concentrations ≥50 μM (it increased the half-width and the duration of SPWs by 35–90 %). Thiopental did not affect evoked excitatory synaptic potentials and its results on SPW-R complexes were also observed under blockade of NMDA receptors. Phenobarbital significantly accelerated SPWs at 50 and 100 μM whereas it reduced their rate at 200 and 400 μM. Furthermore, it significantly prolonged SPWs, reduced their synchrony and reduced the quantity of ripples only at the clinically very high concentration of 400 μM, reported to affect memory.</p> <p>Conclusion</p> <p>We hypothesize that thiopental, by interfering with SPW-R activity, through enhancement of the GABA_Areceptor-mediated transmission, affects memory processes which involve hippocampal circuit activation. The quantity but not the frequency of ripple oscillation was affected by the drug.</p

A neural population model of the bi-phasic EEG-power spectrum during general anaesthesia

International audienceThe neuronal mechanisms of general anaesthesia are still poorly understood, though the induction of analgesia, amnesia, immobility and loss of consciousness by anaesthetic agents is well-established in hospital practice. To shed some light onto these mysterious effects, the chapter analyzes mathematically a neural field model describing the neural population dynamics by an integro-differential equation. The power spectrum is derived and compared to experimental results

Obstacles on the way to the clinical visualisation of beta cells: looking for the Aeneas of molecular imaging to navigate between Scylla and Charybdis

For more than a decade, researchers have been trying to develop non-invasive imaging techniques for the in vivo measurement of viable pancreatic beta cells. However, in spite of intense research efforts, only one tracer for positron emission tomography (PET) imaging is currently under clinical evaluation. To many diabetologists it may remain unclear why the imaging world struggles to develop an effective method for non-invasive beta cell imaging (BCI), which could be useful for both research and clinical purposes. Here, we provide a concise overview of the obstacles and challenges encountered on the way to such BCI, in both native and transplanted islets. We discuss the major difficulties posed by the anatomical and cell biological features of pancreatic islets, as well as the chemical and physical limits of the main imaging modalities, with special focus on PET, SPECT and MRI. We conclude by indicating new avenues for future research in the field, based on several remarkable recent results