The Effect of Patient Weight and Provider Training and Experience on Dosing of Rocuronium

Introduction. Maintenance dosing of neuromuscular blocking agents is complex and varies with patient, procedure, and clinical situation. With this in mind, we sought to identify factors impacting the maintenance dosing of neuromuscular blockers as a step toward identifying best practice with respect to minimizing residual neuromuscular blockade. Methods. Cases utilizing rocuronium from July 1, 2010, to June 30, 2014, at the sponsoring institution were analyzed. Using a mixed model to account for repeated measures, patients were analyzed by dose and weight category as defined by the World Health Organization (eight categories ranging from very severely underweight to very severely obese) as well as by the administering provider’s level of experience. Results. The study included 12,671 patients with a mean age of 49.7 (SD 16.7). Increasing weight category and higher levels of provider experience were associated with higher doses for rocuronium. There were no differences in initial dose or in frequency of maintenance dosing by weight category after controlling for case length. Discussion. The two dosing patterns identified, higher doses for overweight patients and higher doses administered by experienced providers, are modifiable factors that could enhance patient safety

The use of specialty training to retain doctors in Malawi: A discrete choice experiment

Emigration has contributed to a shortage of doctors in many sub-Saharan African countries. Specialty training is highly valued by doctors and a potential tool for retention. Yet not all types of training may be valued equally. In the first study to examine preferences for postgraduate training in depth, we carried out a discrete choice experiment as part of a cross-sectional survey of all Malawian doctors within seven years of graduation and not yet in specialty training. Over August 2012 to March 2013, 148 doctors took part out of 153 eligible in Malawi. Despite evidence that specialty training is highly sought after, Malawian junior doctors would not accept all types of training. Doctors preferred timely training outside of Malawi in core specialties (internal medicine, general surgery, paediatrics, obstetrics & gynaecology). Specialty preferences are particularly strong, with most junior doctors requiring nearly double their monthly salary to accept training all in Malawi and over six-fold to accept training in ophthalmology (representing a bundle of unpopular but priority specialties). In contrast, the location of work before training did not significantly influence most doctors' choices when guaranteed specialty training. Using a latent class model, we identified four subgroups of junior doctors with distinct preferences. Policy simulations showed that these preferences could be leveraged by policymakers to improve retention in exchange for guaranteed specialty training, however incentivising the uptake of training in priority specialties will only be effective in those with more flexible preferences. These results indicate that indiscriminate expansion of postgraduate training to slow emigration of doctors from sub-Saharan African countries may not be effective unless doctors' preferences are taken into account

Dissecting the luminosity function of the Coma cluster of galaxies using CFHT wide field images

[Abridged] We determined the luminosity function (LF) of the Coma cluster galaxies selected by luminosity, and the LF bi-variate in central brightness. The Coma cluster and control fields were imaged using the CFH12K (42x28 arcmin) and UH8K (28x28 arcmin) wide-field cameras at the CFHT. Selected HST images were used for testing. Quantities were derived from measurements in at least two colors, which have the following features: (1) Galaxies as faint as three times the luminosity of the brightest globular clusters are in the completeness region of our data. (2) We have a complete census (in the explored region) of low surface brightness galaxies with central surface brightness galaxies almost as low as the faintest so far cataloged ones. (3) The explored area is among the largest ever sampled with CCDs at comparable depth for any cluster of galaxies. (4) The error budget includes all sources of errors known to date. Using HST images we also discovered that blends of globular clusters, not resolved in individual components due to seeing, look like dwarf galaxies when observed from the ground and are numerous and bright. The derived Coma LF is relatively steep (alpha=-1.4) over the 11 magnitudes sampled, but the slope and shape depend on color. A large population of faint low surface brightness galaxies was discovered, representing the largest contributor (in number) to the LF at faint magnitudes. We found a clear progression for a faintening of the LF from high surface brightness galaxies (mu~20 mag/arcsec2) to galaxies of very faint central brightnesses (mu~24.5 mag/arcsec2), and some evidence for a steepening. Compact galaxies, usually classified as stars and therefore not included in the LF, are found to be a minor population in Coma.Comment: ApJ, in pres

Specialty training for the retention of Malawian doctors: A cost-effectiveness analysis

Few medical schools and sustained emigration have led to low numbers of doctors in many sub-Saharan African countries. The opportunity to undertake specialty training has been shown to be particularly important in retaining doctors. Yet limited training capacity means that doctors are often sent to other countries to specialise, increasing the risk that they may not return. Expanding domestic training, however, may be constrained by the reluctance of doctors to accept training in their home country. We modelled different policy options in an example country, Malawi, to examine the cost-effectiveness of expanding specialty training to retain doctors in sub-Saharan Africa. We designed a Markov model of the physician labour market in Malawi, incorporating data from graduate tracing studies in 2006 and 2012, a 2013 discrete choice experiment on 148 Malawian doctors and 2015 cost data. A government perspective was taken with a time horizon of 40 years. Expanded specialty training in Malawi or South Africa with increasing mandatory service before training was compared against baseline conditions. The outcome measures were cost per doctor-year and cost per specialist-year spent working in the Malawian public sector. Expanding specialty training in Malawi is more cost-effective than training outside Malawi. At least two years of mandatory service would be more cost-effective, with five years adding the most value in terms of doctor-years. After 40 years of expanded specialty training in Malawi, the medical workforce would be over fifty percent larger with over six times the number of specialists compared to current trends. However, the government would need to be willing to pay at least 3.5 times more per doctor-year for a 5% increase and a third more per specialist-year for a four-fold increase. Greater returns are possible from doctors with more flexible training preferences. Sustained funding of specialty training may improve retention in sub-Saharan Africa

Characterisation of organomineral fertilisers derived from nutrient-enriched biosolids granules

Organomineral fertilisers (OMFs) were produced by coating biosolids granules with urea and potash. Two OMF formulations with N : P2O5 : K2O compositions: 10 : 4 : 4 (OMF10) and 15 : 4 : 4 (OMF15) were developed for application in grassland and arable crops. Routine fertiliser analyses were conducted on four batches of OMF and biosolids granules and compared with a sample of urea to determine key physical and chemical properties of the materials which affect handling and spreading, soil behaviour, and fertiliser value. Bulk and particle densities were in the range of 608 to 618 kg m−3, and 1297 to 1357 kg m−3, respectively. Compression tests showed that OMF particles undergo deformation followed by multiple failures without disintegration of the granules when vertical load was applied. Static particle strength was between 1.18 and 4.33 N mm−2 depending on the particle diameter. The use of a model for fertiliser particle distribution studies showed that OMF granules should be between 1.10 and 5.50 mm in diameter with about 80% of the particles in the range of 2.25 to 4.40 mm to enable application at 18 m tramline spacing. This research utilises novel technology to improve the fertiliser value of biosolids, reduce disposal costs, and deliver a range of environmental benefits associated with recycling

Combining cosmological datasets: hyperparameters and Bayesian evidence

A method is presented for performing joint analyses of cosmological datasets, in which the weight assigned to each dataset is determined directly by it own statistical properties. The weights are considered in a Bayesian context as a set of hyperparameters, which are then marginalised over in order to recover the posterior distribution as a function only of the cosmological parameters of interest. In the case of a Gaussian likelihood function, this marginalisation may be performed analytically. Calculation of the Bayesian evidence for the data, with and without the introduction of hyperparameters, enables a direct determination of whether the data warrant the introduction of weights into the analysis; this generalises the standard likelihood ratio approach to model comparison. The method is illustrated by application to the classic toy problem of fitting a straight line to a set of data. A cosmological illustration of the technique is also presented, in which the latest measurements of the cosmic microwave background power spectrum are used to infer constraints on cosmological parameters.Comment: 12 pages, 6 figures, submitted to MNRA

Emission Line Galaxies in the STIS Parallel Survey I: Observations and Data Analysis

In the first three years of operation STIS obtained slitless spectra of approximately 2500 fields in parallel to prime HST observations as part of the STIS Parallel Survey (SPS). The archive contains almost 300 fields at high galactic latitude (|b|>30) with spectroscopic exposure times greater than 3000 seconds. This sample contains 220 fields (excluding special regions and requiring a consistent grating angle) observed between 6 June 1997 and 21 September 2000, with a total survey area of about 160 square arcminutes. At this depth, the SPS detects an average of one emission line galaxy per three fields. We present the analysis of these data, and the identification of 131 low to intermediate redshift galaxies detected by optical emission lines. The sample contains 78 objects with emission lines that we infer to be redshifted [OII]3727 emission at 0.43<z<1.7. The comoving number density of these objects is comparable to that of H-alpha emitting galaxies in the NICMOS parallel observations. One quasar and three probable Seyfert galaxies are detected. Many of the emission-line objects show morphologies suggestive of mergers or interactions. The reduced data are available upon request from the authors.Comment: 58 preprint pages, including 26 figures; accepted for publication in ApJ