An Examination of Frequent Emergency Department Use and Emergency Department Reliance among OIF/OEF Veterans

Frequent emergency department (ED) use has been studied for decades but frequent ED user subgroups have not been adequately studied, classified, and validated by the research community so designing clear, focused policies have remained problematic. This study used a cross-sectional design, using secondary data obtained from national Veteran Health Administration’s (VHA) administrative databases for fiscal years 2010- 2011 in order to inform and enhance the VHA’s understanding about frequent ED users among the Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veteran group through the classification of distinct subgroups within the frequent ED user group including examining factors that explain variation in ED utilization among OIF/OEF veterans, address whether using Department of Veterans Affairs (VA) secondary data sources can classify distinct subgroups within a frequent ED user population, and determine if prior fiscal year ED utilization and associated factors can be used to predict future ED utilization. Using counts of ED visits as the dependent variable, results indicated that 5.2% of all ED OEF/OIF veteran users could be considered frequent ED users which is in alignment with previous studies. The adapted model of Andersen’s Behavioral Model of Health Services Use was adept at selecting predisposing, enabling, and need variables for our predictive models with a Zero-inflated Negative Binomial (ZINB) regression model. Results showed that veterans over 30 years of age within the OEF/OIF cohort had significant decreased odds of having another ED visit compared to the younger under 30 group. Compared to Whites, Blacks or African Americans were the only race group found to be significantly more likely to have increased numbers of ED visits. However, the final ZINB predictive regression model was unable to accurately predict future year utilization using only one prior year’s utilization and associated factors. Three distinct subgroups within ED users were identified, classified and characterized in this study: The Low ED-use/Low EDR subgroup constituted the majority of the sample, Based on primary care use, this subgroup has a primary care physician but never use the ED except in rare circumstances when they find themselves in the ED due to a traumatic event such as a broken bone, car accident or other type of true emergency; The Low EDuse/High EDR subgroup, which consisted of veterans who based on primary care use also have a primary care physician who helps them manage a chronic illness such as Asthma or Diabetes but had an incident where their chronic illness gets out of control after business hours and requires a trip to the ED for care. The High ED-use/High EDR subgroup consisted of those veterans who based on primary care use may or may not have a primary care physician and appear to use the ED as a source of usual care or as a method to access the VA system in order to obtain pain medications, care for their physical needs, or counseling for mental health needs since all of these services are in high demand within the VA system and often difficult to gain access to these services in a timely manner

Resolving the inner jet structure of 1924-292 with the EVENT HORIZON TELESCOPE

We present the first 1.3 mm (230 GHz) very long baseline interferometry model image of an AGN jet using closure phase techniques with a four-element array. The model image of the quasar 1924-292 was obtained with four telescopes at three observatories: the James Clerk Maxwell Telescope (JCMT) on Mauna Kea in Hawaii, the Arizona Radio Observatory's Submillimeter Telescope (SMT) in Arizona, and two telescopes of the Combined Array for Research in Millimeterwave Astronomy (CARMA) in California in April 2009. With the greatly improved resolution compared with previous observations and robust closure phase measurement, the inner jet structure of 1924-292 was spatially resolved. The inner jet extends to the northwest along a position angle of $-53^\circ$ at a distance of 0.38\,mas from the tentatively identified core, in agreement with the inner jet structure inferred from lower frequencies, and making a position angle difference of $\sim 80^{\circ}$ with respect to the cm-jet. The size of the compact core is 0.15\,pc with a brightness temperature of $1.2\times10^{11}$\,K. Compared with those measured at lower frequencies, the low brightness temperature may argue in favor of the decelerating jet model or particle-cascade models. The successful measurement of closure phase paves the way for imaging and time resolving Sgr A* and nearby AGN with the Event Horizon Telescope.Comment: 6 pages, 4 figures, accepted for publication in ApJ

Draft Guidance: Response, Restoration, and Recovery Checklist for Biologically Contaminated Facilities

The Checklist for Facility Response, Restoration, and Recovery presented in this document is principally focused on the Consequence Management Phase of a biothreat agent (i.e., Bacillus anthracis) release at a large facility, such as an airport or subway. Information in this document conforms to the National Response Plan (NRP) (DHS 2004) and the National Incident Management System (NIMS 2004). Under these two guidance documents, the personnel responsible for managing biological response and recovery efforts--that is, the decision-makers--are members of an Incident Command (IC), which is likely to transition to a Unified Command (UC) in the event of a biological warfare agent attack. A UC is used when more than one agency has incident jurisdiction or when incidents cross political jurisdictions. The location for primary, tactical-level command and management is referred to as the Incident Command Post (ICP), as described in the NRP. Thus, regardless of whether an IC or an UC is used, the responsible entities are located at an ICP. Agencies work together through designated members of the UC to establish their designated Incident Commanders at a single ICP and to establish a common set of objectives and strategies and a single Incident Action Plan. Initially during the Crisis Management Phase, the Incident Commander is likely to be the Chief of the fire department that serves the affected facility. As life-safety issues are resolved and the Crisis Management Phase shifts to the Consequence Management Phase, the work of characterization, decontamination, and facility clearance begins. There will likely be a coincident transition in organizational structure as well, and new restoration-focused groups, units, and personnel will be added as restoration needs are anticipated. Depending on the specific facility and type of incident, the responsible individual (Incident Commander or Unified Commander) within the UC during the Consequence Management Phase could be the Facility Manager, the Facility Emergency Operations Manager, or their designee. In an incident involving large-scale biological contamination, the Governor of the state would typically request, and the President of the United States would likely declare, an emergency under the Stafford Act (1974; amended 2002). The Secretary of Homeland Security would likely determine that the event is an Incident of National Significance on the basis of criteria established in Homeland Security Presidential Directive 5 (HSPD-5), ''Management of Domestic Incidents''. Incidents of National Significance are those high-impact events that require a coordinated and effective response by an appropriate combination of Federal, state, local, tribal, private-sector, and nongovernmental entities to save lives, minimize damage, and provide the basis for long-term community recovery and mitigation activities. If facility authorities request outside assistance, or if an emergency is declared under the Stafford Act, then other members of the UC could include local and state agencies as well as Federal agencies, such as the Federal Emergency Management Agency (FEMA) and the U.S. Environmental Protection Agency (USEPA). If an Incident of National Significance is declared, a Principal Federal Official will be appointed by the Department of Homeland Security (DHS) to facilitate Federal support to the UC structure. The following Checklist for Facility Response, Restoration, and Recovery presents the critical steps that would be taken by organizations involved in responding to a biological incident. It is intended for use by key decision-makers in the event that an incident occurs and steps must be taken immediately and systematically. The organizations would follow the Incident Command System (ICS). See Appendix A for more information on the ICS and how the responsible personnel identified in the checklist map into the consequence management organizational structure. The Notification and First-Response Phases are cursorily addressed in the checklist, whereas the main focus is on consequence management actions. The order of actions is generally sequential. However, depending on the specifics of an event and how the response is implemented, actions may be reordered. For example, preparing a Remediation Action Plan (RAP) is identified in the checklist as a critical step of the Remediation Phase. However, it is likely that preparation of the RAP would begin before completing all actions identified in the Characterization Phase. In addition to the actions recommended in the checklist, any emergency response conducted at a major metropolitan facility should comply with notification and response procedures established by the facility, as well as applicable procedures established by the jurisdictional responding agencies

Detection of intrinsic source structure at ~3 Schwarzschild radii with Millimeter-VLBI observations of SAGITTARIUS A*

We report results from very long baseline interferometric (VLBI) observations of the supermassive black hole in the Galactic center, Sgr A*, at 1.3 mm (230 GHz). The observations were performed in 2013 March using six VLBI stations in Hawaii, California, Arizona, and Chile. Compared to earlier observations, the addition of the APEX telescope in Chile almost doubles the longest baseline length in the array, provides additional {\it uv} coverage in the N-S direction, and leads to a spatial resolution of $\sim$30 $\mu$as ($\sim$3 Schwarzschild radii) for Sgr A*. The source is detected even at the longest baselines with visibility amplitudes of $\sim$4-13% of the total flux density. We argue that such flux densities cannot result from interstellar refractive scattering alone, but indicate the presence of compact intrinsic source structure on scales of $\sim$3 Schwarzschild radii. The measured nonzero closure phases rule out point-symmetric emission. We discuss our results in the context of simple geometric models that capture the basic characteristics and brightness distributions of disk- and jet-dominated models and show that both can reproduce the observed data. Common to these models are the brightness asymmetry, the orientation, and characteristic sizes, which are comparable to the expected size of the black hole shadow. Future 1.3 mm VLBI observations with an expanded array and better sensitivity will allow a more detailed imaging of the horizon-scale structure and bear the potential for a deep insight into the physical processes at the black hole boundary.Comment: 11 pages, 5 figures, accepted to Ap

Reinventing grounded theory: some questions about theory, ground and discovery

Grounded theory’s popularity persists after three decades of broad-ranging critique. In this article three problematic notions are discussed—‘theory,’ ‘ground’ and ‘discovery’—which linger in the continuing use and development of grounded theory procedures. It is argued that far from providing the epistemic security promised by grounded theory, these notions—embodied in continuing reinventions of grounded theory—constrain and distort qualitative inquiry, and that what is contrived is not in fact theory in any meaningful sense, that ‘ground’ is a misnomer when talking about interpretation and that what ultimately materializes following grounded theory procedures is less like discovery and more akin to invention. The procedures admittedly provide signposts for qualitative inquirers, but educational researchers should be wary, for the significance of interpretation, narrative and reflection can be undermined in the procedures of grounded theory