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

The “Ebb and Flow” of Documentation: Does the Transition Between Two Electronic Medical Records Systems Affect Emergency Department Efficiency?

Background: Electronic Medical Record (EMR) systems are electronic databases for compiling patient records. As healthcare networks expand, it is critical for providers to have access to patient data more broadly. As a result individual healthcare facilities must adjust to enterprise wide EMRs. Objective: This study examined the operational effects of transitioning from an Emergency Department (ED) specific EMR to an enterprise wide EMR by evaluating throughput metrics in a community ED. Methods: During a 6-month transition period (July-December 2017) in a community-based, academic ED located in North Central West Virginia, length of stay (LOS) and the following operational metrics were analyzed: door-to-provider times, door to disposition time, average LOS, left without treatment (LWOT) rates, and total ED volumes. These metrics were compared with the prior year’s same 6-month period to account for seasonal variability in patient pathology or ED volumes. Results: Overall, there was a statistically significant increase in the LOS measures, including door-to-provider time (p=0.0003), door to disposition time (p Conclusion: An ED-specific EMR to enterprise wide EMR transition in a community ED had a negative effect on the overall efficiency of the emergency department

Lower-Third Standardized Letters of Evaluation in Emergency Medicine: Does Gender Make a Difference in Match Outcome?

Objective The purpose of this study was to determine whether gender influences the likelihood of receiving a lowerthird global assessment (GA) on the standardized letter of evaluation (SLOE) submitted as part of the emergency medicine (EM) application process as well as the impact of gender on ultimate match outcomes for applicants receiving a lower-third GA ranking. Our hypothesis was that female applicants with a lowerthird GA ranking have a higher risk of not matching. Methods We conducted a retrospective cohort study evaluating U.S.-based allopathic applicants to a single EM residency program in the Mid-Atlantic region during the 2017-2018 and 2018-2019 match cycles. GA SLOE rankings and gender for all applicants were extracted and compared to the National Resident Matching Program (NRMP) data for each applicant on match outcome. Comparative analyses were conducted between gender and SLOE GA rankings in order to obtain an odds ratio (OR) of gender and match outcomes. Results A total of 2,017 SLOEs were reviewed from 798 applicants in the 2018 and 2019 EM match cycles. Overall, 716 (90%) applicants successfully matched in EM, with 82 (10%) applicants failing to match into EM; 277 students had at least one lower-third GA ranking. For all applicants, having at least one lower-third GA ranking was associated with a significant risk of not matching (OR: 0.20; 95% CI: 0.12-0.34). Of the 277 students with at least one lower-third GA ranking, 85 (31%) were female and 192 (69%) were male. Of the female applicants with a lower-third GA ranking, 15 (18%) failed to match in EM, and 39 (20%) of the males failed to match in EM. For applicants with a lower-third GA ranking, female gender alone was not associated with a significantly increased risk of not matching (OR: 1.18; 95% CI: 0.61-2.21). Conclusions Female applicants receive a lower-third GA ranking less frequently than their male counterparts. One or more lower-third rankings on the GA significantly reduced an applicant’s chances of matching into an EM program. For those with a lower-third GA ranking, female gender alone does not significantly increase the risk of not matching into EM

Gravity Recovery and Interior Laboratory (GRAIL): Extended Mission and End-Game Status

The Gravity Recovery and Interior Laboratory (GRAIL) [1], NASA s eleventh Discovery mission, successfully executed its Primary Mission (PM) in lunar orbit between March 1, 2012 and May 29, 2012. GRAIL s Extended Mission (XM) initiated on August 30, 2012 and was successfully completed on December 14, 2012. The XM provided an additional three months of gravity mapping at half the altitude (23 km) of the PM (55 km), and is providing higherresolution gravity models that are being used to map the upper crust of the Moon in unprecedented detail

Validation of MIPAS ClONO2 measurements

Altitude profiles of ClONO2 retrieved with the IMK (Institut fur Meteorologie und Klimaforschung) science-oriented data processor from MIPAS/Envisat (Michelson Interferometer for Passive Atmospheric Sounding on Envisat) mid-infrared limb emission measurements between July 2002 and March 2004 have been validated by comparison with balloon-borne (Mark IV, FIRS2, MIPAS-B), airborne (MIPAS-STR), ground-based (Spitsbergen, Thule, Kiruna, Harestua, Jungfraujoch, Izana, Wollongong, Lauder), and spaceborne (ACE-FTS) observations. With few exceptions we found very good agreement between these instruments and MIPAS with no evidence for any bias in most cases and altitude regions. For balloon-borne measurements typical absolute mean differences are below 0.05 ppbv over the whole altitude range from 10 to 39 km. In case of ACE-FTS observations mean differences are below 0.03 ppbv for observations below 26 km. Above this altitude the comparison with ACE-FTS is affected by the photochemically induced diurnal variation of ClONO2. Correction for this by use of a chemical transport model led to an overcompensation of the photochemical effect by up to 0.1 ppbv at altitudes of 30-35 km in case of MIPAS-ACE-FTS comparisons while for the balloon-borne observations no such inconsistency has been detected. The comparison of MIPAS derived total column amounts with ground-based observations revealed no significant bias in the MIPAS data. Mean differences between MIPAS and FTIR column abundances are 0.11 +/- 0.12 x 10(14) cm(-2) (1.0 +/- 1.1%) and -0.09 +/- 0.19 x 10(14) cm(-2) (-0.8 +/- 1.7%), depending on the coincidence criterion applied. chi(2) tests have been performed to assess the combined precision estimates of MIPAS and the related instruments. When no exact coincidences were available as in case of MIPAS-FTIR or MIPAS-ACE-FTS comparisons it has been necessary to take into consideration a coincidence error term to account for chi(2) deviations. From the resulting chi(2) profiles there is no evidence for a systematic over/underestimation of the MIPAS random error analysis.Peer reviewe

A review of nitrogen isotopic alteration in marine sediments

Key Points: Use of sedimentary nitrogen isotopes is examined; On average, sediment 15N/14N increases approx. 2 per mil during early burial; Isotopic alteration scales with water depth Abstract: Nitrogen isotopes are an important tool for evaluating past biogeochemical cycling from the paleoceanographic record. However, bulk sedimentary nitrogen isotope ratios, which can be determined routinely and at minimal cost, may be altered during burial and early sedimentary diagenesis, particularly outside of continental margin settings. The causes and detailed mechanisms of isotopic alteration are still under investigation. Case studies of the Mediterranean and South China Seas underscore the complexities of investigating isotopic alteration. In an effort to evaluate the evidence for alteration of the sedimentary N isotopic signal and try to quantify the net effect, we have compiled and compared data demonstrating alteration from the published literature. A >100 point comparison of sediment trap and surface sedimentary nitrogen isotope values demonstrates that, at sites located off of the continental margins, an increase in sediment 15N/14N occurs during early burial, likely at the seafloor. The extent of isotopic alteration appears to be a function of water depth. Depth-related differences in oxygen exposure time at the seafloor are likely the dominant control on the extent of N isotopic alteration. Moreover, the compiled data suggest that the degree of alteration is likely to be uniform through time at most sites so that bulk sedimentary isotope records likely provide a good means for evaluating relative changes in the global N cycle

Fast Growth Increases the Selective Advantage of a Mutation Arising Recurrently during Evolution under Metal Limitation

Understanding the evolution of biological systems requires untangling the molecular mechanisms that connect genetic and environmental variations to their physiological consequences. Metal limitation across many environments, ranging from pathogens in the human body to phytoplankton in the oceans, imposes strong selection for improved metal acquisition systems. In this study, we uncovered the genetic and physiological basis of adaptation to metal limitation using experimental populations of Methylobacterium extorquens AM1 evolved in metal-deficient growth media. We identified a transposition mutation arising recurrently in 30 of 32 independent populations that utilized methanol as a carbon source, but not in any of the 8 that utilized only succinate. These parallel insertion events increased expression of a novel transporter system that enhanced cobalt uptake. Such ability ensured the production of vitamin B12, a cobalt-containing cofactor, to sustain two vitamin B12–dependent enzymatic reactions essential to methanol, but not succinate, metabolism. Interestingly, this mutation provided higher selective advantages under genetic backgrounds or incubation temperatures that permit faster growth, indicating growth-rate–dependent epistatic and genotype-by-environment interactions. Our results link beneficial mutations emerging in a metal-limiting environment to their physiological basis in carbon metabolism, suggest that certain molecular features may promote the emergence of parallel mutations, and indicate that the selective advantages of some mutations depend generically upon changes in growth rate that can stem from either genetic or environmental influences

Methylobacterium Genome Sequences: A Reference Blueprint to Investigate Microbial Metabolism of C1 Compounds from Natural and Industrial Sources

Methylotrophy describes the ability of organisms to grow on reduced organic compounds without carbon-carbon bonds. The genomes of two pink-pigmented facultative methylotrophic bacteria of the Alpha-proteobacterial genus Methylobacterium, the reference species Methylobacterium extorquens strain AM1 and the dichloromethane-degrading strain DM4, were compared. Methodology/Principal Findings The 6.88 Mb genome of strain AM1 comprises a 5.51 Mb chromosome, a 1.26 Mb megaplasmid and three plasmids, while the 6.12 Mb genome of strain DM4 features a 5.94 Mb chromosome and two plasmids. The chromosomes are highly syntenic and share a large majority of genes, while plasmids are mostly strain-specific, with the exception of a 130 kb region of the strain AM1 megaplasmid which is syntenic to a chromosomal region of strain DM4. Both genomes contain large sets of insertion elements, many of them strain-specific, suggesting an important potential for genomic plasticity. Most of the genomic determinants associated with methylotrophy are nearly identical, with two exceptions that illustrate the metabolic and genomic versatility of Methylobacterium. A 126 kb dichloromethane utilization (dcm) gene cluster is essential for the ability of strain DM4 to use DCM as the sole carbon and energy source for growth and is unique to strain DM4. The methylamine utilization (mau) gene cluster is only found in strain AM1, indicating that strain DM4 employs an alternative system for growth with methylamine. The dcm and mau clusters represent two of the chromosomal genomic islands (AM1: 28; DM4: 17) that were defined. The mau cluster is flanked by mobile elements, but the dcm cluster disrupts a gene annotated as chelatase and for which we propose the name “island integration determinant” (iid).Conclusion/Significance These two genome sequences provide a platform for intra- and interspecies genomic comparisons in the genus Methylobacterium, and for investigations of the adaptive mechanisms which allow bacterial lineages to acquire methylotrophic lifestyles.Organismic and Evolutionary Biolog

Analysis of the Effect of Race, Socioeconomic Status, and Center Size on Unrelated National Marrow Donor Program Donor Outcomes: Donor Toxicities Are More Common at Low-Volume Bone Marrow Collection Centers

Previous studies have shown that risks of collection-related pain and symptoms are associated with sex, body mass index (BMI), and age in unrelated donors undergoing collection at National Marrow Donor Program (NMDP) centers. We hypothesized that other important factors (race, socioeconomic status (SES), and number of procedures at the collection center) might affect symptoms in donors. We assessed outcomes in 2,726 bone marrow (BM) and 6,768 peripheral blood stem cell (PBSC) donors collected between 2004 and 2009. Pain/symptoms are reported as maximum levels over mobilization and collection (PBSC) or within 2 days of collection (BM) and at 1 week after collection. For PBSC donors, race and center volumes were not associated with differences in pain/symptoms at any time. PBSC donors with high SES levels reported higher maximum symptom levels 1 week post donation (p=0.017). For BM donors, black males reported significantly higher levels of pain (OR=1.90, CI=1.14-3.19, p=0.015). No differences were noted by SES groups. BM donors from low volume centers reported more toxicity (OR=2.09, CI=1.26-3.46, p=0.006). In conclusion, race and SES have a minimal effect on donation associated symptoms. However, donors from centers performing ≤1 BM collection every 2 months have more symptoms following BM donation. Approaches should be developed by registries and low volume centers to address this issue