Failure of an Educational Intervention to Improve Consultation and Implications for Healthcare Consultation.

INTRODUCTION: Consultation of another physician for his or her specialized expertise regarding a patient's care is a common occurrence in most physicians' daily practice, especially in the emergency department (ED). Therefore, the ability to communicate effectively with another physician during a patient consultation is an essential skill. However, there has been limited research on a standardized method for a physician to physician consultation with little guidance on teaching consultations to physicians in training. The objective of our study was to measure the effect of a structured consultation intervention on both content standardization and quality of medical student consultations. METHODS: Senior medical students were assessed on a required emergency medicine rotation with a physician phone consultation during a standardized, simulated chest pain case. The intervention groups received a standard consult checklist as part of their orientation to the rotation, followed by a video recording of a good consult call and a bad consult call with commentary from an emergency physician. The intervention was given to students every other month, alternating with a control group who received no additional education. Recordings were reviewed by three second-year internal medicine residents pursuing a fellowship in cardiology. Each recording was evaluated by two of the three reviewers and scored using a standardized checklist. RESULTS: Providing a standardized consultation intervention did not improve students' ability to communicate with consultants. In addition, there was variability between evaluators in regards to how they received the same information and how they perceived the quality of the same recorded consultation calls. Evaluator inter-rater reliability (IRR) was poor on the questions of 1) would you have any other questions of the student calling the consult and 2) did the student calling the consult provide an accurate account of information and case detail. The IRR was also poor on objective data such as whether the student stated their name. CONCLUSIONS: A brief intervention may not be enough to change complex behavior such as a physician to physician consultant communication. Importantly, despite consultants listening to the same audio recordings, the information was processed differently. Future investigations should focus on both those delivering as well as those receiving a consultation

Editorial: Advances in the Dynamics of Granular Materials

Granular materials exhibit a complex array of phenomena which makes the prediction of their behavior extremely difficult. Granular materials are strongly dissipative and show collective (heap formation, jamming) and size segregation phenomena, and can propagate surface waves. They display fluidization and convective motion, and under certain vibration regimes, they tend to mix when they would otherwise segregate, and segregate when they might otherwise mix. The wide range of behaviors that granular materials can display has been one of the main factors for which the development of predictive models has continued to remain an open problem. The papers in this Special Issue on Advances in the Dynamics of Granular Materials show some recent theoretical, computational, and experimental results in various aspects of the mechanics of granular materials. A better understanding of the mechanics (and especially dynamics) of granular matter can lead to significant savings in energy and costs in various industries, such as pharmaceutical and chemical industries, food and agriculture, mining and oil extraction, construction, and transportation. The papers in this issue address fundamental and practical issues in the mechanics of granular matter

Bioresorbable Film for the Prevention of Adhesion to the Anterior Spine After Anterolateral Discectomy

Background context The development of scar tissue and adhesions postoperatively is a natural consequence of healing but can be associated with medical complications and render reoperation difficult. Many biocompatible products have been evaluated as barriers or deterrents to adhesions. Purpose To evaluate the efficacy of a bioresorbable polylactide film as a barrier to adhesion formation after anterolateral discectomy. Study design Experimental study. Methods Seven, skeletally mature female sheep underwent a retroperitoneal approach to the anterolateral lumbar spine. A discectomy was performed at two levels with an intervening unoperated disc site. One site was treated with a polylactide film barrier (Hydrosorb Shield; MacroPore Biosurgery, San Diego, CA) affixed with tacks manufactured from the same material. The second site was left untreated. Treatment and control sites were randomly assigned. Postmortem analysis included scar tenacity scoring on five spines and histological evaluation on two spines. Results The application of the Hydrosorb film barrier allowed a definite dissection plane during scar tenacity scoring and there was a significant difference in the development of adhesions to the disc between the control and treated sites. Histological evaluation revealed evidence of barrier formation to scar tissue and no significant adverse inflammatory reactions. Conclusions Hydrosorb Shield appears to be an effective postoperative barrier to scar tissue adhesion after anterolateral discectomy. The use of polylactide tacks was beneficial to affix the barrier film in place. Safety issues associated with delayed healing or adverse response to the film or tacks were not observed. Hydrosorb film may be useful as an antiadhesion barrier facilitating dissection during surgical revision in anterior approaches to the spine. Further studies are indicated to evaluate the performance of the bioresorbable material as an antiadhesion barrier in techniques of spinal fusion and disc replacement

Quantifying the radiation belt seed population in the 17 March 2013 electron acceleration event

Abstract We present phase space density (PSD) observations using data from the Magnetic Electron Ion Spectrometer instrument on the Van Allen Probes for the 17 March 2013 electron acceleration event. We confirm previous results and quantify how PSD gradients depend on the first adiabatic invariant. We find a systematic difference between the lower-energy electrons (1-MeV with a source region within the radiation belts. Our observations show that the source process begins with enhancements to the 10s-100s-keV energy seed population, followed by enhancements to the \u3e1-MeV population and eventually leading to enhancements in the multi-MeV electron population these observations provide the clearest evidence to date of the timing and nature of the radial transport of a 100s keV electron seed population into the heart of the outer belt and subsequent local acceleration of those electrons to higher radiation belt energies. Key Points Quantification of phase space density gradients inside geostationary orbit Clear differences between the source of low energy and relativistic electrons Clear observations of how the acceleration process evolves in energy

Seasonal changes in soil organic matter after a decade of nutrient addition in a lowland tropical forest

© 2015, US Government. Soil organic matter is an important pool of carbon and nutrients in tropical forests. The majority of this pool is assumed to be relatively stable and to turn over slowly over decades to centuries, although changes in nutrient status can influence soil organic matter on shorter timescales. We measured carbon, nitrogen, and phosphorus concentrations in soil organic matter and leaf litter over an annual cycle in a long-term nutrient addition experiment in lowland tropical rain forest in the Republic of Panama. Total soil carbon was not affected by a decade of factorial combinations of nitrogen, phosphorus, or potassium. Nitrogen addition increased leaf litter nitrogen concentration by 7 % but did not affect total soil nitrogen. Phosphorus addition doubled the leaf litter phosphorus concentration and increased soil organic phosphorus by 50 %. Surprisingly, concentrations of carbon, nitrogen, and phosphorus in soil organic matter declined markedly during the four-month dry season, and then recovered rapidly during the following wet season. Between the end of the wet season and the late dry season, total soil carbon declined by 16 %, total nitrogen by 9 %, and organic phosphorus by between 19 % in control plots and 25 % in phosphorus addition plots. The decline in carbon and nitrogen was too great to be explained by changes in litter fall, bulk density, or the soil microbial biomass. However, a major proportion of the dry-season decline in soil organic phosphorus was explained by a corresponding decline in the soil microbial biomass. These results have important implications for our understanding of the stability and turnover of organic matter in tropical forest soils, because they demonstrate that a considerable fraction of the soil organic matter is seasonally transient, despite the overall pool being relatively insensitive to long-term changes in nutrient status

The Effect of Electronic Cigarette User Modifications and E-liquid Adulteration on the Particle Size Profile of an Aerosolized Product

Electronic cigarettes (e-cigarettes) are an alternate nicotine delivery system that generate a condensation aerosol to be inhaled by the user. The size of the droplets formed in the aerosol can vary and contributes to drug deposition and ultimate bioavailability in the lung. The growing popularity of e-cigarette products has caused an increase in internet sources promoting the use of drugs other than nicotine (DOTNs) in e-cigarettes. The purpose of this study was to determine the effect of various e-cigarette and e-liquid modifications, such as coil resistance, battery voltage, and glycol and drug formulation, on the aerosol particle size. E-liquids containing 12 mg/mL nicotine prepared in glycol compositions of 100% propylene glycol (PG), 100% vegetable glycerin (VG), or 50:50 PG:VG were aerosolized at three voltages and three coil resistances. Methamphetamine and methadone e-liquids were prepared at 60 mg/mL in 50:50 PG:VG and all e-liquids were aerosolized onto a 10 stage Micro-Orifice Uniform Deposit Impactor. Glycol deposition correlated with drug deposition, and the majority of particles centered between 0.172–0.5 μm in diameter, representing pulmonary deposition. The 100% PG e-liquid produced the largest aerosol particles and the 100% VG and 50:50 PG:VG e-liquids produced ultra-fine particles \u3c0.3 μm. The presence of ultrafine particles indicates that drugs can be aerosolized and reach the pulmonary alveolar regions, highlighting a potential for abuse and risk of overdose with DOTNs aerosolized in an e-cigarette system

Electroelastic Effect of Thickness Mode Langasite Resonators

Langasite is a very promising material for resonators due to its good temperature behavior and high piezoelectric coupling, low acoustic loss, and high Q factor. The biasing effect for langasite resonators is crucial for resonator design. In this article, the resonant frequency shift of a thickness-mode langasite resonator is analyzed with respect to a direct current (DC) electric field applied in the thickness direction. The vibration modes of a thin langasite plate fully coated with an electrode are analyzed. The analysis is based on the theory for small fields superposed on a bias in electroelastic bodies and the first-order perturbation integral theory. The electroelastic effect of the resonator is analyzed by both analytical and finite-element methods. The complete set of nonlinear elastic, piezoelectric, dielectric permeability, and electrostrictive constants of langasite is used in the theoretical and numerical analysis. The sensitivity of electroelastic effect to nonlinear material constants is analyzed

Predicting performance of constant flow depth filtration using constant pressure filtration data

This paper describes a method of predicting constant flow filtration capacities using constant pressure datasets collected during the purification of several monoclonal antibodies through depth filtration. The method required characterisation of the fouling mechanism occurring in constant pressure filtration processes by evaluating the best fit of each of the classic and combined theoretical fouling models. The optimised coefficients of the various models were correlated with the corresponding capacities achieved during constant flow operation at the specific pressures performed during constant pressure operation for each centrate. Of the classic and combined fouling models investigated, the Cake-Adsorption fouling model was found to best describe the fouling mechanisms observed for each centrate at the various different pressures investigated. A linear regression model was generated with these coefficients and was shown to predict accurately the capacities at constant flow operation at each pressure. This model was subsequently validated using an additional centrate and accurately predicted the constant flow capacities at three different pressures (0.69, 1.03 and 1.38 bar). The model used the optimised Cake-Adsorption model coefficients that best described the flux decline during constant pressure operation. The proposed method of predicting depth filtration performance proved to be faster than the traditional approach whilst requiring significantly less material, making it particularly attractive for early process development activities

Introducing Medical Students into the Emergency Department: The Impact upon Patient Satisfaction

Introduction: Performance on patient satisfaction surveys is becoming increasingly important for practicing emergency physicians and the introduction of learners into a new clinical environment may impact such scores. This study aimed to quantify the impact of introducing fourth-year medical students on patient satisfaction in two university-affiliated community emergency departments (EDs). Methods: Two community-based EDs in the Indiana University Health (IUH) system began hosting medical students in March 2011 and October 2013, respectively. We analyzed responses from patient satisfaction surveys at each site for seven months before and after the introduction of students. Two components of the survey, “Would you recommend this ED to your friends and family?” and “How would you rate this facility overall?” were selected for analysis, as they represent the primary questions reviewed by the Center for Medicare Services (CMS) as part of value-based purchasing. We evaluated the percentage of positive responses for adult, pediatric, and all patients combined. Results: Analysis did not reveal a statistically significant difference in the percentage of positive response for the “would you recommend” question at both clinical sites with regards to the adult and pediatric subgroups, as well as the all-patient group. At one of the sites, there was significant improvement in the percentage of positive response to the “overall rating” question following the introduction of medical students when all patients were analyzed (60.3% to 68.2%, p=0.038). However, there was no statistically significant difference in the “overall rating” when the pediatric or adult subgroups were analyzed at this site and no significant difference was observed in any group at the second site. Conclusion: The introduction of medical students in two community-based EDs is not associated with a statistically significant difference in overall patient satisfaction, but was associated with a significant positive effect on the overall rating of the ED at one of the two clinical sites studied. Further study is needed to evaluate the effect of medical student learners upon patient satisfaction in settings outside of a single health system