A Controlled Investigation of Optimal Internal Medicine Ward Team Structure at a Teaching Hospital

BACKGROUND: The optimal structure of an internal medicine ward team at a teaching hospital is unknown. We hypothesized that increasing the ratio of attendings to housestaff would result in an enhanced perceived educational experience for residents. METHODS: Harbor-UCLA Medical Center (HUMC) is a tertiary care, public hospital in Los Angeles County. Standard ward teams at HUMC, with a housestaff∶attending ratio of 5:1, were split by adding one attending and then dividing the teams into two experimental teams containing ratios of 3:1 and 2:1. Web-based Likert satisfaction surveys were completed by housestaff and attending physicians on the experimental and control teams at the end of their rotations, and objective healthcare outcomes (e.g., length of stay, hospital readmission, mortality) were compared. RESULTS: Nine hundred and ninety patients were admitted to the standard control teams and 184 were admitted to the experimental teams (81 to the one-intern team and 103 to the two-intern team). Patients admitted to the experimental and control teams had similar age and disease severity. Residents and attending physicians consistently indicated that the quality of the educational experience, time spent teaching, time devoted to patient care, and quality of life were superior on the experimental teams. Objective healthcare outcomes did not differ between experimental and control teams. CONCLUSIONS: Altering internal medicine ward team structure to reduce the ratio of housestaff to attending physicians improved the perceived educational experience without altering objective healthcare outcomes

Characteristics and provision of care of patients with the acute respiratory distress syndrome: descriptive findings from the DACAPO cohort baseline and comparison with international findings: a cross-sectional study

Background: Little is known about the characteristics and real world life circumstances of ARDS (acute respiratory distress syndrome) patient populations. This knowledge is essential for transferring evidence-based therapy into routine healthcare. The aim of this study was to report socio-demographic and clinical characteristics in an unselected population of ARDS patients and to compare these results to findings from other large ARDS cohorts. Methods: A German based cross-sectional observational study was carried out. A total of 700 ARDS patients were recruited in 59 study sites between September 2014 and January 2016. Socio-demographic, disease and care related variables were recorded. Additionally, characteristics of other large ARDS cohorts identified by a systematic literature search were extracted into evidence tables. Results: Median age of ARDS patients was 58 years, 69% were male. Sixty percent had no employment, predominantly due to retirement. Seventy-one percent lived with a partner. The main cause of ARDS was a pulmonary 'direct' origin (79%). The distribution of severity was as follows: mild (14%), moderate (48%), severe (38%). Overall ICU mortality was calculated to be 34%. The observed prevalence of critical events (hypoxemia, hypoglycemia, re-intubation) was 47%. Supportive measures during ICU-treatment were applied to 60% of the patients. Other ARDS cohorts revealed a high heterogeneity in reported concomitant diseases, but sepsis and pneumonia were most frequently reported. Mean age ranged from 54 to 71 years and most patients were male. Other socio-demographic factors have been almost neglected. Conclusions: The proportion of patients suffering of mild ARDS was lower compared to the only study identified, which also applied the Berlin definition. The frequency of critical events during ICU treatment was high and the implementation of evidence-based therapy (prone positioning, neuro-muscular blockers) was limited. More evidence on socio-demographic characteristics and further studies applying the current diagnostic criteria are desirable

Competition between highway operators: Can we expect toll differentiation?

Where there are alternative roads to the same destination, competition between profit maximising road operators is possible. Tolls on such roads could perform two welfare-enhancing functions: they discourage excessive driving and allocate drivers between roads. The second of these functions operates when some roads are more expensive to drive on, and less congested, than others. The Bertrand equilibrium will not always perform this second function; it may fail to allocate the most impatient drivers to less congested roads, as it does not always deliver toll differentiation. The performance of this second function is dependent on the first. That is, whether or not competing roads will be differentiated by tolls, and congestion will depend in part on the importance of discouraging marginal drivers. The equilibrium will not generally be fully efficient, but will often provide efficiency gains over other decentralised options. Copyright RSAI 2005.

4D printing of shape memory polymers: from Macro to Micro

A novel and versatile shape memory ink system allowing 4D printing with light at the macroscale as well as the microscale is presented. Digital light processing (DLP) and direct laser writing (DLW) are selected as suitable 3D printing technologies to cover both regimes. First, a system based on monofunctional isobornyl acrylate and two crosslinkers consisting of a soft and a hard diacrylate is identified and proven to be compatible with both printing techniques. Employing DLP, a large variety of structures exhibiting distinct complexity is printed. These structures range from simple frames to more demanding 3D geometries such as double platform structures, infinity rings, or cubic grids. The shape memory effect is demonstrated for all the 3D geometries. Excellent shape fixity as well as recovery and repeatability is shown. Furthermore, the formulation is adapted for fast 4D printing at the microscale using DLW. Importantly, the 4D printed microstructures display remarkable shape memory properties. The possibility of trapping and releasing microobjects, such as microspheres, is ultimately demonstrated by designing, smart box-like 4D microstructures that can be thermally actuated—evidencing the versatility and potential of the reported system

Canine scent detection for the diagnosis of lung cancer in a screening-like situation

The prognosis in lung cancer depends largely on early stage detection, and thus new screening methods are attracting increasing attention. Canine scent detection has shown promising results in lung cancer detection, but there has only been one previous study that reproduces a screening-like situation. Here breath samples were collected from 122 patients at risk for lung cancer (smokers and ex-smokers); 29 of the subjects had confirmed diagnosis of lung cancer but had not yet been treated and 93 subjects had no signs or symptoms of lung cancer at the time of inclusion. The breath samples were presented to a trained sniffer dog squadron in a double-blind manner. A rigid scientific protocol was used with respect to earlier canine scent detection studies, with one difference: instead of offering one in five positive samples to the dogs, we offered a random number of positive samples (zero to five). The final positive and negative predictive values of 30.9% and 84.0%, respec tively, were rather low compared to other studies. The results differed from those of previous studies, indicating that canine scent detection might not be as powerful as is looked for in real screening situations. One main reason for the rather poor performance in our setting might be the higher stress from the lack of positive responses for dogs and handlers

Determinants of quality of life and return to work following acute respiratory distress syndrome — a systematic review

Background: Acute respiratory distress syndrome (ARDS) in adults is a consequence of lung damage caused by either pulmonary or extrapulmonary disease. Survivors often suffer from an impaired health-related quality of life (HRQoL), mental and physical impairments, and persistent inability to work. Methods: In this systematic review of the literature, we consider the determinants of HRQoL and return to work (RtW). 24 observational studies showing a statistical association between one or more determinants and HRQoL or RtW were included. Because of the heterogeneity of these studies, no statistical aggregation of the individual effect estimates was carried out; instead, the results are summarized descriptively. Results: Psychopathological manifestations, in particular, are associated with impaired quality of life. In contrast, many care- and disease-related determinants had only small, non-significant effects on HRQoL and RtW. The one-second capacity was found in all studies to be positively associated with the HRQoL. ARDS induced by sepsis seems to be a risk factor for a lower HRQoL in comparison to ARDS of other causes. A synthesis of the evidence is impeded both by the high level of heterogeneity of studies and by the high risk of selection bias in all studies. Conclusion: The identification of determinants of impaired quality of life after ARDS is essential for the assessment of clinically relevant interventions. In multiple studies, major significant effects were only observed when determinants the content of which was closely related to the scales of the HRQoL instruments were measured at the same time as the HRQoL

Simultaneous Resistive and Ionization Readout of Single Metal Oxide Nanowires

AbstractGas detection experiments were performed with individual tin dioxide (SnO2) nanowires specifically configured to observe surface ion (SI) emission response towards representative analyte species. These devices were found to work at much lower temperatures (T≈280°C) and bias voltages (V≈2V) than their micro-counterparts, thereby demonstrating the inherent potential of individual nanostructures in building functional nanodevices. The high selectivity of our miniaturized sensors emerges from the dissimilar sensing mechanisms of SI as compared to standard resistive (RES) type gas sensors. By employing this innovative detection principle (SI) together with conventional RES measurements, significantly improved selectivity can be attained with a single gas sensor device. Self-heating of the SnO2 nanowires moreover opens up a road towards ultra-low power consumption gas sensors