Operating room first case start times: a metric to assess systems-based practice milestones?

BACKGROUND: Resident competence in peri-operative care is a reflection on education and cost-efficiency. Inspecting pre-existing operating room metrics for performance outliers may be a potential solution for assessing competence. Statistical correlation of problematic benchmarks may reveal future opportunities for educational intervention. METHODS: Case-log database review yielded 3071 surgical cases involving residents over the course of 5 years. Surgery anticipated and actual start times were evaluated for delays and residents were assessed using the days of resident training performed at the time of each corresponding case. Other variables recorded included day of week, attending anesthesiologist name, attending surgeon name, patient age, sex, American Society of Anesthesiologists physical status classification (ASA PS), and in-patient versus day surgery status. Mixed-effect, multi-variable, linear regression determined independent determinants of delay time. RESULTS: The analysis identified day of the week (F = 25.65, P \u3c 0.0001), days of training (F = 8.39, P = 0.0038), attending surgeon (F = 2.67, P \u3c 0.0001), and anesthesiology resident (F = 1.67, P = 0.0012) as independent predictors of delay time for first-start cases, with an overall regression model F = 3.09, r2 = 0.186, and P \u3c 0.0001. CONCLUSIONS: The day of the week and attending surgeon demonstrated significant impact of case delay compared to resident days trained. If a learning curve for first-case start punctuality exists for anesthesiology residents, it is subtle and irrelevant to operating room efficiency. The regression model accounted for only 19% of the variability in the outcome of delay time, indicating a multitude of additional unidentified factors contributing to operating room efficiency

The Study of TeV Variability and Duty Cycle of Mrk 421 from 3 Years of Observations with the Milagro Observatory

TeV flaring activity with time scales as short as tens of minutes and an orphan TeV flare have been observed from the blazar Markarian 421 (Mrk 421). The TeV emission from Mrk 421 is believed to be produced by leptonic synchrotron self-Compton (SSC) emission. In this scenario, correlations between the X-ray and the TeV fluxes are expected, TeV orphan flares are hardly explained and the activity (measured as duty cycle) of the source at TeV energies is expected to be equal or less than that observed in X-rays if only SSC is considered. To estimate the TeV duty cycle of Mrk 421 and to establish limits on its variability at different time scales, we continuously observed Mrk 421 with the Milagro observatory. Mrk 421 was detected by Milagro with a statistical significance of 7.1 standard deviations between 2005 September 21 and 2008 March 15. The observed spectrum is consistent with previous observations by VERITAS. We estimate the duty cycle of Mrk 421 for energies above 1 TeV for different hypothesis of the baseline flux and for different flare selections and we compare our results with the X-ray duty cycle estimated by Resconi et al. 2009. The robustness of the results is discussed.Comment: 27 pages, 6 figures, ApJ accepte

Spectrum and Morphology of the Two Brightest Milagro Sources in the Cygnus Region: MGRO J2019+37 and MGRO J2031+41

The Cygnus region is a very bright and complex portion of the TeV sky, host to unidentified sources and a diffuse excess with respect to conventional cosmic-ray propagation models. Two of the brightest TeV sources, MGRO J2019+37 and MGRO J2031+41, are analyzed using Milagro data with a new technique, and their emission is tested under two different spectral assumptions: a power law and a power law with an exponential cutoff. The new analysis technique is based on an energy estimator that uses the fraction of photomultiplier tubes in the observatory that detect the extensive air shower. The photon spectrum is measured in the range 1 to 200 TeV using the last 3 years of Milagro data (2005-2008), with the detector in its final configuration. MGRO J2019+37 is detected with a significance of 12.3 standard deviations ($\sigma$), and is better fit by a power law with an exponential cutoff than by a simple power law, with a probability $>98$% (F-test). The best-fitting parameters for the power law with exponential cutoff model are a normalization at 10 TeV of $7^{+5}_{-2}\times10^{-10}$ $\mathrm{s^{-1}\: m^{-2}\: TeV^{-1}}$, a spectral index of $2.0^{+0.5}_{-1.0}$ and a cutoff energy of $29^{+50}_{-16}$ TeV. MGRO J2031+41 is detected with a significance of 7.3$\sigma$, with no evidence of a cutoff. The best-fitting parameters for a power law are a normalization of $2.4^{+0.6}_{-0.5}\times10^{-10}$ $\mathrm{s^{-1}\: m^{-2}\: TeV^{-1}}$ and a spectral index of $3.08^{+0.19}_{-0.17}$. The overall flux is subject to an $\sim$30% systematic uncertainty. The systematic uncertainty on the power law indices is $\sim$0.1. A comparison with previous results from TeV J2032+4130, MGRO J2031+41 and MGRO J2019+37 is also presented.Comment: 11 pages, 10 figure

Restoring Cystic Fibrosis Transmembrane Conductance Regulator Function Reduces Airway Bacteria and Inflammation in People with Cystic Fibrosis and Chronic Lung Infections

Rationale: Previous work indicates that ivacaftor improves cystic fibrosis transmembrane conductance regulator (CFTR) activity and lung function in people with cystic fibrosis and G551D-CFTR mutations but does not reduce density of bacteria or markers of inflammation in the airway. These findings raise the possibility that infection and inflammation may progress independently of CFTR activity once cystic fibrosis lung disease is established. Objectives: To better understand the relationship between CFTR activity, airway microbiology and inflammation, and lung function in subjects with cystic fibrosis and chronic airway infections. Methods: We studied 12 subjects with G551D-CFTR mutations and chronic airway infections before and after ivacaftor. We measured lung function, sputum bacterial content, and inflammation, and obtained chest computed tomography scans. Measurements and Main Results: Ivacaftor produced rapid decreases in sputum Pseudomonas aeruginosa density that began within 48 hours and continued in the first year of treatment. However, no subject eradicated their infecting P. aeruginosa strain, and after the first year P. aeruginosa densities rebounded. Sputum total bacterial concentrations also decreased, but less than P. aeruginosa. Sputum inflammatory measures decreased significantly in the first week of treatment and continued to decline over 2 years. Computed tomography scans obtained before and 1 year after ivacaftor treatment revealed that ivacaftor decreased airway mucous plugging. Conclusions: Ivacaftor caused marked reductions in sputum P. aeruginosa density and airway inflammation and produced modest improvements in radiographic lung disease in subjects with G551D-CFTR mutations. However, P. aeruginosa airway infection persisted. Thus, measures that control infection may be required to realize the full benefits of CFTR-targeting treatments

Observation and Spectral Measurements of the Crab Nebula with Milagro

The Crab Nebula was detected with the Milagro experiment at a statistical significance of 17 standard deviations over the lifetime of the experiment. The experiment was sensitive to approximately 100 GeV - 100 TeV gamma ray air showers by observing the particle footprint reaching the ground. The fraction of detectors recording signals from photons at the ground is a suitable proxy for the energy of the primary particle and has been used to measure the photon energy spectrum of the Crab Nebula between ~1 and ~100 TeV. The TeV emission is believed to be caused by inverse-Compton up-scattering scattering of ambient photons by an energetic electron population. The location of a TeV steepening or cutoff in the energy spectrum reveals important details about the underlying electron population. We describe the experiment and the technique for distinguishing gamma-ray events from the much more-abundant hadronic events. We describe the calculation of the significance of the excess from the Crab and how the energy spectrum is fit. The fit is consistent with values measured by IACTs between 1 and 20 TeV. Fixing the spectral index to values that have been measured below 1 TeV by IACT experiments (2.4 to 2.6), the fit to the Milagro data suggests that Crab exhibits a spectral steepening or cutoff between about 20 to 40 TeV.Comment: Submitted to Astrophysical Journa

Milagro Observations of Potential TeV Emitters

This paper reports the results from three targeted searches of Milagro TeV sky maps: two extragalactic point source lists and one pulsar source list. The first extragalactic candidate list consists of 709 candidates selected from the Fermi-LAT 2FGL catalog. The second extragalactic candidate list contains 31 candidates selected from the TeVCat source catalog that have been detected by imaging atmospheric Cherenkov telescopes (IACTs). In both extragalactic candidate lists Mkn 421 was the only source detected by Milagro. This paper presents the Milagro TeV flux for Mkn 421 and flux limits for the brighter Fermi- LAT extragalactic sources and for all TeVCat candidates. The pulsar list extends a previously published Milagro targeted search for Galactic sources. With the 32 new gamma-ray pulsars identified in 2FGL, the number of pulsars that are studied by both Fermi-LAT and Milagro is increased to 52. In this sample, we find that the probability of Milagro detecting a TeV emission coincident with a pulsar increases with the GeV flux observed by the Fermi-LAT in the energy range from 0.1 GeV to 100 GeV

Milagro Observations of Multi-TeV Emission from Galactic Sources in the Fermi Bright Source List

We present the result of a search of the Milagro sky map for spatial correlations with sources from a subset of the recent Fermi Bright Source List (BSL). The BSL consists of the 205 most significant sources detected above 100 MeV by the Fermi Large Area Telescope. We select sources based on their categorization in the BSL, taking all confirmed or possible Galactic sources in the field of view of Milagro. Of the 34 Fermi sources selected, 14 are observed by Milagro at a significance of 3 standard deviations or more. We conduct this search with a new analysis which employs newly-optimized gamma-hadron separation and utilizes the full 8-year Milagro dataset. Milagro is sensitive to gamma rays with energy from 1 to 100 TeV with a peak sensitivity from 10-50 TeV depending on the source spectrum and declination. These results extend the observation of these sources far above the Fermi energy band. With the new analysis and additional data, multi-TeV emission is definitively observed associated with the Fermi pulsar, J2229.0+6114, in the Boomerang Pulsar Wind Nebula (PWN). Furthermore, an extended region of multi-TeV emission is associated with the Fermi pulsar, J0634.0+1745, the Geminga pulsar.Comment: Accepted for publication in Astrophysical Journal Letters June 30, 200

Beliefs About Medication and Uptake of Preventive Therapy in Women at Increased Risk of Breast Cancer: Results From a Multicenter Prospective Study

Introduction Uptake of preventive therapies for breast cancer is low. We examined whether women at increased risk of breast cancer can be categorized into groups with similar medication beliefs, and whether belief group membership was prospectively associated with uptake of preventive therapy. Patients and Methods Women (n = 732) attending an appointment to discuss breast cancer risk were approached; 408 (55.7%) completed the Beliefs About Medicines and the Perceived Sensitivity to Medicines questionnaires. Uptake of tamoxifen at 3 months was reported in 258 (63.2%). The optimal number of belief groups were identified using latent profile analysis. Results Uptake of tamoxifen was 14.7% (38/258). One in 5 women (19.4%; 78/402) reported a strong need for tamoxifen. The model fit statistics supported a 2-group model. Both groups held weak beliefs about their need for tamoxifen for current and future health. Group 2 (38%; 154/406 of the sample) reported stronger concerns about tamoxifen and medicines in general, and stronger perceived sensitivity to the negative effects of medicines compared with group 1 (62%; 252/406). Women with low necessity and lower concerns (group 1) were more likely to initiate tamoxifen (18.3%; 33/180) than those with low necessity and higher concerns (group 2) (6.4%; 5/78). After adjusting for demographic and clinical factors, the odds ratio was 3.37 (95% confidence interval, 1.08-10.51; P = .036). Conclusion Uptake of breast cancer preventive therapy was low. A subgroup of women reported low need for preventive therapy and strong medication concerns. These women were less likely to initiate tamoxifen. Medication beliefs are targets for supporting informed decision-making