Characterizing Waiting Room Time, Treatment Time, and Boarding Time in the Emergency Department Using Quantile Regression

ACADEMIC EMERGENCY MEDICINE 2010; 17:813–823 © 2010 by the Society for Academic Emergency MedicineThe objective was to characterize service completion times by patient, clinical, temporal, and crowding factors for different phases of emergency care using quantile regression (QR).A retrospective cohort study was conducted on 1-year visit data from four academic emergency departments (EDs; N  = 48,896–58,316). From each ED’s clinical information system, the authors extracted electronic service information (date and time of registration; bed placement, initial contact with physician, disposition decision, ED discharge, and disposition status; inpatient medicine bed occupancy rate); patient demographics (age, sex, insurance status, and mode of arrival); and clinical characteristics (acuity level and chief complaint) and then used the service information to calculate patients’ waiting room time, treatment time, and boarding time, as well as the ED occupancy rate. The 10th, 50th, and 90th percentiles of each phase of care were estimated as a function of patient, clinical, temporal, and crowding factors using multivariate QR. Accuracy of models was assessed by comparing observed and predicted service completion times and the proportion of observations that fell below the predicted 10th, 50th, and 90th percentiles.At the 90th percentile, patients experienced long waiting room times (105–222 minutes), treatment times (393–616 minutes), and boarding times (381–1,228 minutes) across the EDs. We observed a strong interaction effect between acuity level and temporal factors (i.e., time of day and day of week) on waiting room time at all four sites. Acuity level 3 patients waited the longest across the four sites, and their waiting room times were most influenced by temporal factors compared to other acuity level patients. Acuity level and chief complaint were important predictors of all phases of care, and there was a significant interaction effect between acuity and chief complaint. Patients with a psychiatric problem experienced the longest treatment times, regardless of acuity level. Patients who presented with an injury did not wait as long for an ED or inpatient bed. Temporal factors were strong predictors of service completion time, particularly waiting room time. Mode of arrival was the only patient characteristic that substantially affected waiting room time and treatment time. Patients who arrived by ambulance had shorter wait times but longer treatment times compared to those who did not arrive by ambulance. There was close agreement between observed and predicted service completion times at the 10th, 50th, and 90th percentile distributions across the four EDs.Service completion times varied significantly across the four academic EDs. QR proved to be a useful method for estimating the service completion experience of not only typical ED patients, but also the experience of those who waited much shorter or longer. Building accurate models of ED service completion times is a critical first step needed to identify barriers to patient flow, begin the process of reengineering the system to reduce variability, and improve the timeliness of care provided.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79320/1/j.1553-2712.2010.00812.x.pd

Real-time cine and myocardial perfusion with treadmill exercise stress cardiovascular magnetic resonance in patients referred for stress SPECT

Background: To date, stress cardiovascular magnetic resonance (CMR) has relied on pharmacologic agents, and therefore lacked the physiologic information available only with exercise stress. Methods: 43 patients age 25 to 81 years underwent a treadmill stress test incorporating both Tc99m SPECT and CMR. After rest Tc99m SPECT imaging, patients underwent resting cine CMR. Patients then underwent in-room exercise stress using a partially modified treadmill. 12-lead ECG monitoring was performed throughout. At peak stress, Tc99m was injected and patients rapidly returned to their prior position in the magnet for post-exercise cine and perfusion imaging. The patient table was pulled out of the magnet for recovery monitoring. The patient was sent back into the magnet for recovery cine and resting perfusion followed by delayed post-gadolinium imaging. Post-CMR, patients went to the adjacent SPECT lab to complete stress nuclear imaging. Each modality's images were reviewed blinded to the other's results. Results: Patients completed on average 9.3 ± 2.4 min of the Bruce protocol. Stress cine CMR was completed in 68 ± 14 sec following termination of exercise, and stress perfusion CMR was completed in 88 ± 8 sec. Agreement between SPECT and CMR was moderate (κ = 0.58). Accuracy in eight patients who underwent coronary angiography was 7/8 for CMR and 5/8 for SPECT (p = 0.625). Follow-up at 6 months indicated freedom from cardiovascular events in 29/29 CMRnegative and 33/34 SPECT-negative patients. Conclusions: Exercise stress CMR including wall motion and perfusion is feasible in patients with suspected ischemic heart disease. Larger clinical trials are warranted based on the promising results of this pilot study to allow comparative effectiveness studies of this stress imaging system vs. other stress imaging modalities

Mouse models of preterm birth: Suggested assessment and reporting guidelines

Preterm birth affects approximately 1 out of every 10 births in the United States, leading to high rates of mortality and long-term negative health consequences. To investigate the mechanisms leading to preterm birth so as to develop prevention strategies, researchers have developed numerous mouse models of preterm birth. However, the lack of standard definitions for preterm birth in mice limits our field\u27s ability to compare models and make inferences about preterm birth in humans. In this review, we discuss numerous mouse preterm birth models, propose guidelines for experiments and reporting, and suggest markers that can be used to assess whether pups are premature or mature. We argue that adoption of these recommendations will enhance the utility of mice as models for preterm birth

Bone marrow-derived mesenchymal stem cells become anti-angiogenic when chondrogenically or osteogenically differentiated:implications for bone and cartilage tissue engineering

Osteochondral tissue repair requires formation of vascularized bone and avascular cartilage. Mesenchymal stem cells stimulate angiogenesis both in vitro and in vivo but it is not known if these proangiogenic properties change as a result of chondrogenic or osteogenic differentiation. We investigated the angiogenic/antiangiogenic properties of equine bone marrow-derived mesenchymal stem cells (eBMSCs) before and after differentiation in vitro. Conditioned media from chondrogenic and osteogenic cell pellets and undifferentiated cells was applied to endothelial tube formation assays using Matrigel™. Additionally, the cell secretome was analysed using LC-MS/MS mass spectrometry and screened for angiogenesis and neurogenesis-related factors using protein arrays. Endothelial tube-like formation was supported by conditioned media from undifferentiated eBMSCs. Conversely, chondrogenic and osteogenic conditioned media was antiangiogenic as shown by significantly decreased length of endothelial tube-like structures and degree of branching compared to controls. Undifferentiated cells produced higher levels of angiogenesis-related proteins compared to chondrogenic and osteogenic pellets. In summary, eBMSCs produce an array of angiogenesis-related proteins and support angiogenesis in vitro via a paracrine mechanism. However, when these cells are differentiated chondrogenically or osteogenically, they produce a soluble factor(s) that inhibits angiogenesis. With respect to osteochondral tissue engineering, this may be beneficial for avascular articular cartilage formation but unfavourable for bone formation where a vascularized tissue is desired

Naturally occurring diacetyl and 2,3-pentanedione concentrations associated with roasting and grinding unflavored coffee beans in a commercial setting

AbstractOver the last decade, concerns have been raised about potential respiratory health effects associated with occupational exposure to the flavoring additives diacetyl and 2,3-pentanedione. Both of these diketones are also natural components of many foods and beverages, including roasted coffee. To date, there are no published studies characterizing workplace exposures to these diketones during commercial roasting and grinding of unflavored coffee beans. In this study, we measured naturally occurring diacetyl, 2,3-pentanedione, and respirable dust at a facility that roasts and grinds coffee beans with no added flavoring agents. Sampling was conducted over the course of three roasting batches and three grinding batches at varying distances from a commercial roaster and grinder. The three batches consisted of lightly roasted soft beans, lightly roasted hard beans, and dark roasted hard beans. Roasting occurred for 37 to 41min, and the grinding process took between 8 and 11min. Diacetyl, 2,3-pentanedione, and respirable dust concentrations measured during roasting ranged from less than the limit of detection (<LOD) to 0.0039ppm, <LOD to 0.018ppm, and <LOD to 0.31mg/m3, respectively. During grinding, diacetyl, 2,3-pentanedione, and respirable dust concentrations ranged from 0.018 to 0.39ppm, 0.0089 to 0.21ppm, and <LOD to 1.7mg/m3, respectively. For any given bean/roast combination and sample location, diketone concentrations during grinding were higher than those measured during roasting. During grinding, concentrations decreased with increased distance from the source. Measured concentrations of both diketones were higher during grinding of soft beans than hard beans. The results indicate that airborne concentrations of naturally occurring diacetyl and 2,3-pentanedione associated with unflavored coffee processing: (1) are similar to the concentrations that have been measured in food flavoring facilities; (2) are likely to exceed some recommended short-term occupational exposure limits, but; (3) based on previous analyses of exposure response relationships in animal studies, are far below the concentrations that are expected to cause even minimal responses in the human respiratory tract

Application of the Carolina Framework for Cervical Cancer Prevention

The Carolina Framework for Cervical Cancer Prevention describes 4 main causes of cervical cancer incidence: human papillomavirus (HPV) infection, lack of screening, screening errors, and not receiving follow-up care. We present 2 applications of the Carolina Framework in which we identify high-need counties in North Carolina and generate recommendations for improving prevention efforts

The SEGUE Stellar Parameter Pipeline. V. Estimation of Alpha-Element Abundance Ratios From Low-Resolution SDSS/SEGUE Stellar Spectra

We present a method for the determination of [alpha/Fe] ratios from low-resolution (R = 2000) SDSS/SEGUE stellar spectra. By means of a star-by-star comparison with degraded spectra from the ELODIE spectral library and with a set of moderately high-resolution (R = 15,000) and medium-resolution (R = 6000) spectra of SDSS/SEGUE stars, we demonstrate that we are able to measure [alpha/Fe] from SDSS/SEGUE spectra (with S/N > 20/1) to a precision of better than 0.1 dex, for stars with atmospheric parameters in the range Teff = [4500, 7000] K, log g = [1.5, 5.0], and [Fe/H] = [-1.4, +0.3], over the range [alpha/Fe] = [-0.1, +0.6]. For stars with [Fe/H] < -1.4, our method requires spectra with slightly higher signal-to-noise to achieve this precision (S/N > 25/1). Over the full temperature range considered, the lowest metallicity star for which a confident estimate of [alpha/Fe] can be obtained from our approach is [Fe/H] ~ -2.5; preliminary tests indicate that a metallicity limit as low as [Fe/H] ~ -3.0 may apply to cooler stars. As a further validation of this approach, weighted averages of [alpha/Fe] obtained for SEGUE spectra of likely member stars of Galactic globular clusters (M15, M13, and M71) and open clusters (NGC 2420, M67, and NGC 6791) exhibit good agreement with the values of [alpha/Fe] from previous studies. The results of the comparison with NGC 6791 imply that the metallicity range for the method may extend to ~ +0.5.Comment: 47 pages, 11 figures, 5 tables, to appear in A

The SEGUE Stellar Parameter Pipeline. II. Validation with Galactic Globular and Open Clusters

We validate the performance and accuracy of the current SEGUE (Sloan Extension for Galactic Understanding and Exploration) Stellar Parameter Pipeline (SSPP), which determines stellar atmospheric parameters (effective temperature, surface gravity, and metallicity) by comparing derived overall metallicities and radial velocities from selected likely members of three globular clusters (M 13, M 15, and M 2) and two open clusters (NGC 2420 and M 67) to the literature values. Spectroscopic and photometric data obtained during the course of the original Sloan Digital Sky Survey (SDSS-I) and its first extension (SDSS-II/SEGUE) are used to determine stellar radial velocities and atmospheric parameter estimates for stars in these clusters. Based on the scatter in the metallicities derived for the members of each cluster, we quantify the typical uncertainty of the SSPP values, sigma([Fe/H]) = 0.13 dex for stars in the range of 4500 K < Teff < 7500 K and 2.0 < log g < 5.0, at least over the metallicity interval spanned by the clusters studied (-2.3 < [Fe/H] < 0). The surface gravities and effective temperatures derived by the SSPP are also compared with those estimated from the comparison of the color-magnitude diagrams with stellar evolution models; we find satisfactory agreement. At present, the SSPP underestimates [Fe/H] for near-solar-metallicity stars, represented by members of M 67 in this study, by about 0.3 dex.Comment: 56 pages, 8 Tables, 15 figures, submitted to the Astronomical Journa

Surfactant protein D increases fusion of Mycobacterium tuberculosis- containing phagosomes with lysosomes in human macrophages

Lung surfactant protein D (SP-D) binds to Mycobacterium tuberculosis surface lipoarabinomannan and results in bacterial agglutination, reduced uptake, and inhibition of growth in human macrophages. Here we show that SP-D limits the intracellular growth of bacilli in macrophages by increasing phagosome-lysosome fusion but not by generating a respiratory burst

Factors associated with the performance and cost-effectiveness of using lymphatic filariasis transmission assessment surveys for monitoring soil-transmitted helminths: a case study in Kenya.

Transmission assessment surveys (TAS) for lymphatic filariasis have been proposed as a platform to assess the impact of mass drug administration (MDA) on soil-transmitted helminths (STHs). This study used computer simulation and field data from pre- and post-MDA settings across Kenya to evaluate the performance and cost-effectiveness of the TAS design for STH assessment compared with alternative survey designs. Variations in the TAS design and different sample sizes and diagnostic methods were also evaluated. The district-level TAS design correctly classified more districts compared with standard STH designs in pre-MDA settings. Aggregating districts into larger evaluation units in a TAS design decreased performance, whereas age group sampled and sample size had minimal impact. The low diagnostic sensitivity of Kato-Katz and mini-FLOTAC methods was found to increase misclassification. We recommend using a district-level TAS among children 8-10 years of age to assess STH but suggest that key consideration is given to evaluation unit size