A Playroom Internal Waiting Area Improves Productivity in the Pediatric Emergency Department

Introduction: Pediatric emergency department (PED) volume is often constrained by the number of available treatment rooms. In many PEDs patients occupy treatment rooms while awaiting test results or imaging, thereby delaying care for patients who arrive after them.Methods: We opened a PED where selected patients were moved to a playroom when they did not actively require a treatment room. The treatment room was then available for the next patient. We measured the effect of using the playroom on time from arrival to rooming and length of stay (LOS) using proportional hazards regression and the odds of being roomed within 30 minutes of arrival using logistic regression. We adjusted for the number  of the previous eight patients who were “playroom eligible”; age; triage category; provider; the number of patients who arrived within the preceding hour; prior census; and testing ordered in the preceding eight patients.Results: We analyzed 43,634 patient encounters, of which 10,134 (23%) were playroom eligible. The adjusted hazards ratio for the next patient being roomed was 1.14 (95% confidence interval [CI], 1.10-1.18) per prior playroom eligible patient. The adjusted odds ratio of the next patient being roomed within 30 minutes was 1.46 (95% CI, 1.33-1.56) per prior playroom eligible patient. The playroom typically decreased median rooming time by four to 42 minutes and LOS by two to 40 minutes depending on patient volumes and acuity. The benefit of the playroom was maximal at busier times.Conclusion: Implementing a playroom in the PED for selected patients generally decreased time to rooming of the next patient and LOS

Psychological Adjustment and Caregive Attributes in Children Referred to Contact House

Child abuse and neglect (CAN) encompasses a heterogenous group of adverse practices with devastating personal, social, educational, health, legal and welfare consequences. The term child abuse and neglect covers four types maltreatment: physical abuse, emotional abuse, sexual abuse, and neglect, with many children experiencing a combination of these types. Australian child protection notifications have more than doubled in the 5-year period to 2004. Of most concern is that, of all the Australian States and Territories, Queensland has the highest rate of substantiated cases with 14.1 per 1,000 children (AIHW, 2006). Childhood abuse and neglect can have profound short- and long-term effects. Children with a history of abuse and neglect have been shown to experience insecure attachment, developmental delays, diminished social skills, violent behaviour and learning problems. Previous studies have also found that abused and neglected children frequently experience a higher incidence of a diverse range of adverse mental health outcomes including helplessness and sadness, lowered self-esteem and post traumatic stress disorder. However, relatively few studies have examined the psychological adjustment of children in more immediate terms especially within an Australian context. Furthermore, adults experiencing CAN during childhood frequently exhibit diverse psychopathologies. The variability in adverse consequences suggests the existence of mediating and moderating factors influencing the level of distress experienced by children. While associations have been made between factors surrounding the type of abuse, the child’s age and gender and negative outcomes, little is known about the role of the child’s non-offending caregiver and the relationship between caregiver attributes and the level of distress experienced by the child. A primary aim of this study was to investigate caregiver attributes and the psychological adjustment of children referred to a non-government treatment centre. This specific aims were: (i) to describe the psychological adjustment of children who have experienced abuse and/or neglect (ii) to compare the psychological functioning of children presenting for treatment with a community sample of children (iii) to describe the level of psychosocial functioning of the caregivers in the clinical group across a range of psychosocial and parenting practice variables and (iv) to explore the relationship between demographic variables, factors relating to the abuse and neglect, and caregiver variables, which may predict, mediate, or moderate the child’s psychological adjustment. In addition the study aimed to establish a database for future research into treatment outcomes. Through the inclusion of a comparison community sample, this study provided evidence to complement existing research and develop a more complete picture of families living with and without CAN. The findings also offer preliminary evidence regarding the effectiveness of treatment and underscore the need for ongoing evaluation of service outcomes to optimise the quality of life for children and families affected by CAN

Hybrid Zone Dynamics Between Saltmarsh (Ammodramus caudacutus) and Nelson\u27s (Ammodramus nelsoni) Sparrows

Hybrid zones in nature have long been equated to “windows on the evolutionary process” providing unique environments to understand patterns of gene flow and introgression and the role of these mechanisms in maintaining biodiversity. Ongoing hybridization and introgression can lead to a number of conservation and evolutionary outcomes; as such, identifying the role of introgression in natural populations can provide new insights into species interactions while contributing to our understanding of evolutionary theory. The research presented below characterizes hybrid zone dynamics between two tidal marsh endemics – the Saltmarsh (Ammodramus caudacutus) and Nelson’s (Ammodramus nelsoni) sparrow. Both species co-inhabit salt marshes from southern Maine to northern Massachusetts and hybridization has been documented in the overlap zone for over a century. While there is previous evidence for asymmetrical introgression and southward expansion, information regarding the rates and consequences of hybridization in this system is lacking. To address this objective, I evaluated five components that define a hybrid zone: 1) phenotypic and morphological variation; 2) strength of selection and patterns of introgression; 3) influence of habitat; 4) hybrid fitness; and 5) temporal stability. I combined genetic and ecological methods to evaluate the above components and to assess hybrid zone dynamics. I collected morphometric and plumage data from individuals sampled extensively across the hybrid zone and evaluated both phenotypic and genetic variation in pure and admixed populations. I found that morphological and genetic variation increased in sympatric populations and that a majority of the individuals sampled were backcrossed with a lack of both intermediate phenotypes and genotypes. I also found that plumage traits related to the darkness and definition of streaking on the breast, flanks, and back of the birds correlated more strongly with genotype than traits related to the amount of streaking on an individual or the color of the plumage. I also investigated patterns of genetic structure, selection, and differential introgression across the hybrid zone. I found that a high proportion (50%) of the sampled individuals were admixed to some degree, but that only 3% of individuals were recent generation hybrids. Genetic analyses revealed that pure and hybrid individuals were patchily distributed across the hybrid zone. I also found that introgression was highly variable among marker types and that, for a majority of the markers examined, selection was weak and introgression was asymmetrical toward Saltmarsh Sparrows. I did document abrupt patterns of selection for sex-linked markers, mitochondrial markers, and two gene-associated markers. Selection for sex-linked and mitochondrial markers supports findings of Haldane’s rule in this system. These results suggest a role for selection in maintaining pure species boundaries in the face of ongoing geneflow and introgression. I also investigated patterns of genetic structure, selection, and differential introgression across the hybrid zone. I found that a high proportion (50%) of the sampled individuals were admixed to some degree, but that only 3% of individuals were recent generation hybrids. Genetic analyses revealed that pure and hybrid individuals were patchily distributed across the hybrid zone. I also found that introgression was highly variable among marker types and that, for a majority of the markers examined, selection was weak and introgression was asymmetrical toward Saltmarsh Sparrows. I did document abrupt patterns of selection for sex-linked markers, mitochondrial markers, and two gene-associated markers. Selection for sex-linked and mitochondrial markers supports findings of Haldane’s rule in this system. These results suggest a role for selection in maintaining pure species boundaries in the face of ongoing geneflow and introgression. To identify patterns of differential fitness across the hybrid zone, I compared numerous reproductive parameters among pure, backcrossed, and recent generation hybrid females. I also compared the proportion of first generation hybrids among age and gender classes to test for differences in survival in hybrids. I found that pure and backcrossed Nelson’s Sparrows have reduced hatching and fledgling success compared to hybrids and pure and backcrossed Saltmarsh Sparrows. The reduced fitness in Nelson’s Sparrows is likely due to differential adaptation to coastal marshes and may be influential in shaping hybrid zone dynamics and asymmetries in this system. Also, hybrid females had lower survival than hybrid males. Lastly, I evaluated temporal stability in the hybrid zone by comparing genetic and morphological data between two temporal replicates. I compared plumage data, morphometric measurements, and data from neutral and mitochondrial markers between five marshes sampled in 1998 and then again 15 years later in 2012/2013. I detected a southward expansion of Nelson’s Sparrow alleles, supported by a shift in the center of the hybrid zone and an increase in introgression over the 15-year time period. Despite signs of hybrid zone expansion, some markers are under stronger selection now than they were in 1998 indicating that some genetic regions may be maintained despite introgression. These regions may be critical in maintaining species boundaries. Following the assumptions of existing theoretical frameworks, the above components were systematically evaluated to assess hybrid zone stability. The data have been used to evaluate impacts of hybridization and introgression in a naturally occurring avian hybrid zone. The work presented here identifies the mechanisms responsible for maintaining pure species boundaries in the face of ongoing introgression and gene flow. Further, this work has elucidated how hybridization shapes population dynamics while providing insight into the conservation management of hybridizing species. Although hybridization is ongoing between the two species, selective mechanisms likely play a role in reproductive isolation. Based on these findings, the management of both species, even within the hybrid zone, is warranted. This insight is particularly relevant to the management of Saltmarsh Sparrows, as this species is imminently threatened by habitat loss through sea level rise and the management and conservation of genetically “pure” populations is a high priority in the northeast

Patterns of population structure and productivity in Saltmarsh Sparrows

The Saltmarsh Sparrow (Ammodramus caudacutus) is one of the few species globally that is exclusively restricted to coastal wetlands. Despite the high vagility characteristic of avian species, the highly patchy distribution of tidal marshes can often lead to fine scale genetic structure in salt marsh obligates. To elucidate patterns of population structure, we investigated the degree of genetic differentiation among nine Saltmarsh Sparrow populations along the northeastern coastline of the United States. Although overall FST values were small (0.008), population substructuring was detected along with a positive correlation between geographic distance and genetic differentiation, suggesting that Ammodramus caudacutus follow an isolation by distance model. However, Chapman\u27s Landing was a distinct outlier despite its close proximity to other sampled marshes, indicating that additional factors other then geography play a role in genetic structuring. To identify patterns of source/sink dynamics, we implemented assignment tests from the software program GENECLASS2 using an exclusion method. Results from the assignment tests indicate that Parker River, in Newburyport, MA, is a source population. Findings from the genetic analyses were combined with field data collected on nesting success and density of breeding adults to correlate overall productivity of the sites sampled with results from assignment tests. Furthermore, results from point count surveys indicate a positive correlation between marsh size and the density of breeding adults (P=0.0148, R 2=0.8954), with the most birds observed at points located in Parker River. Results from our nesting study indicate that nesting success is variable among sites, and that the cause of chick mortality also varies. Despite this the percent of failed nests is comparably similar among four of the five sites surveyed. Our results offer new insight for conservation strategies, including information on population clusters, data on population trends, and the identification of source/sink dynamics

Patterns of Conflict in the Great Lakes Region

The African Great Lakes Region (GLR) has witnessed some of the most intense violence and protracted conflict of the last half-century. There has been spiralling and sometimes over-lapping conflict in Burundi, Rwanda, Uganda and the Democratic Republic of Congo (DRC) (hereinafter Zone 1 conflict states). Yet their neighbours—Kenya, Malawi, Tanzania and Zambia (hereinafter Zone 2 peaceful states)—have remained generally peaceful. This article asks what makes the difference in conflict outcomes between these neighbouring states? It has one goal: to identify a set of structural and historical factors (if any), that differentiate the zone 1 from the zone 2 states and which can explain the incidence of conflicts across time and countries. We set out to document and estimate the impact of a common set of structural factors that underpin the outbreak of wars in this region over the past fifty years, while controlling for time and country specific effects.

Teaching Artists in the High School: A Creative Approach to Student Self-Esteem

This thesis addresses the effect of teaching artists\u27 (TAs) classroom instruction in the arts on student self-esteem at Downtown College Preparatory (DCP) High School, an at-risk high school in San Jose, California, over the course of two semesters. The data collected and used to analyze these effects were student observations, student art work, student journal entries, student surveys, and data provided by a third party consulting company. The purpose of this study was to determine if having teaching artists working in an at-risk high school classroom environment could positively affect their students\u27 self-esteem through their arts programming. The results showed that there were some significant effects on student self-esteem as a result of the teaching artist work at DCP

Patient acceptability, safety and access : A balancing act for selecting age-appropriate oral dosage forms for paediatric and geriatric populations

© 2017 Elsevier B.V. All rights reserved.The selection and design of age-appropriate formulations intended for use in paediatric and geriatric patients are dependent on multiple factors affecting patient acceptability, safety and access. The development of an economic and effective product relies on a balanced consideration of the risks and benefits of these factors. This review provides a comprehensive and up-to-date analysis of oral dosage forms considering key aspects of formulation design including dosage considerations, ease of use, tolerability and safety, manufacturing complexity, stability, supply and cost. Patient acceptability has been examined utilising an evidence-based approach to evaluate regulatory guidance and literature. Safety considerations including excipients and potential risk of administration errors of the different dosage forms are also discussed, together with possible manufacturing and supply challenges. Age appropriate drug product design should consider and compare i) acceptability ii) safety and iii) access, although it is important to recognise that these factors must be balanced against each other, and in some situations a compromise may need to be reached when selecting an age-appropriate formulation.Peer reviewedFinal Accepted Versio

Differential introgression and the maintenance of species boundaries in an advanced generation avian hybrid zone

Background: Evolutionary processes, including selection and differential fitness, shape the introgression of genetic material across a hybrid zone, resulting in the exchange of some genes but not others. Differential introgression of molecular or phenotypic markers can thus provide insight into factors contributing to reproductive isolation. We characterized patterns of genetic variation across a hybrid zone between two tidal marsh birds, Saltmarsh (Ammodramus caudacutus) and Nelson’s (A. nelsoni) sparrows (n = 286), and compared patterns of introgression among multiple genetic markers and phenotypic traits. Results: Geographic and genomic cline analyses revealed variable patterns of introgression among marker types. Most markers exhibited gradual clines and indicated that introgression exceeds the spatial extent of the previously documented hybrid zone. We found steeper clines, indicating strong selection for loci associated with traits related to tidal marsh adaptations, including for a marker linked to a gene region associated with metabolic functions, including an osmotic regulatory pathway, as well as for a marker related to melanin-based pigmentation, supporting an adaptive role of darker plumage (salt marsh melanism) in tidal marshes. Narrow clines at mitochondrial and sex-linked markers also offer support for Haldane’s rule. We detected patterns of asymmetrical introgression toward A. caudacutus, which may be driven by differences in mating strategy or differences in population density between the two species. Conclusions: Our findings offer insight into the dynamics of a hybrid zone traversing a unique environmental gradient and provide evidence for a role of ecological divergence in the maintenance of pure species boundaries despite ongoing gene flow

Differential introgression and the maintenance of species boundaries in an advanced generation avian hybrid zone

Background: Evolutionary processes, including selection and differential fitness, shape the introgression of genetic material across a hybrid zone, resulting in the exchange of some genes but not others. Differential introgression of molecular or phenotypic markers can thus provide insight into factors contributing to reproductive isolation. We characterized patterns of genetic variation across a hybrid zone between two tidal marsh birds, Saltmarsh (Ammodramus caudacutus) and Nelson’s (A. nelsoni) sparrows (n = 286), and compared patterns of introgression among multiple genetic markers and phenotypic traits. Results: Geographic and genomic cline analyses revealed variable patterns of introgression among marker types. Most markers exhibited gradual clines and indicated that introgression exceeds the spatial extent of the previously documented hybrid zone. We found steeper clines, indicating strong selection for loci associated with traits related to tidal marsh adaptations, including for a marker linked to a gene region associated with metabolic functions, including an osmotic regulatory pathway, as well as for a marker related to melanin-based pigmentation, supporting an adaptive role of darker plumage (salt marsh melanism) in tidal marshes. Narrow clines at mitochondrial and sex-linked markers also offer support for Haldane’s rule. We detected patterns of asymmetrical introgression toward A. caudacutus, which may be driven by differences in mating strategy or differences in population density between the two species. Conclusions: Our findings offer insight into the dynamics of a hybrid zone traversing a unique environmental gradient and provide evidence for a role of ecological divergence in the maintenance of pure species boundaries despite ongoing gene flow