Impact of Scribes with Flow Coordination Duties on Throughput in an Academic Emergency Department

Introduction: With the increasing influence of electronic health records in emergency medicine came concerns of decreasing operational efficiencies. Particularly worrisome was increasing patient length of stay (LOS). Medical scribes were identified to be in a good position to quickly address barriers to treatment delivery and patient flow. The objective of this study was to investigate patient LOS in the mid- and low-acuity zones of an academic emergency department (ED) with and without medical scribes.Methods: A retrospective cohort study compared patient volume and average LOS between a cohort without scribes and a cohort after the implementation of a scribe-flow coordinator program. Patients were triaged to the mid-acuity Vertical Zone (primarily Emergency Severity Index [ESI] 3) or low-acuity Fast Track (primarily ESI 4 and 5) at a tertiary academic ED. Patients were stratified by treatment zone, acuity level, and disposition.Results: The pre-intervention and post-intervention periods included 8900 patients and 9935 patients, respectively. LOS for patients discharged from the Vertical Zone decreased by 12 minutes from 235 to 223 minutes (p<0.0001, 95% confidence interval [CI], -17,-7) despite a 10% increase in patient volume. For patients admitted from the Vertical Zone, volume increased 13% and LOS remained almost the same, increasing from 225 to 228 minutes (p=0.532, 95% CI, -6,12). For patients discharged from the Fast Track, volume increased 14% and LOS increased six minutes, from 89 to 95 minutes (p<0.0001, 95% CI, 4,9). Predictably, only 1% of Fast Track patients were admitted.Conclusion: Despite substantially increased volume, the use of scribes as patient flow facilitators in the mid-acuity zone was associated with decreased LOS. In the low-acuity zone, scribes were not shown to be as effective, perhaps because rapid patient turnover required them to focus on documentation

Differential strengths of selection on S-RNases from Physalis and Solanum (Solanaceae)

<p>Abstract</p> <p>Background</p> <p>The S-RNases of the Solanaceae are highly polymorphic self-incompatibility (S-) alleles subject to strong balancing selection. Relatively recent diversification of S-alleles has occurred in the genus <it>Physalis </it>following a historical restriction of S-allele diversity. In contrast, the genus <it>Solanum </it>did not undergo a restriction of S-locus diversity and its S-alleles are generally much older. Because recovery from reduced S-locus diversity should involve increased selection, we employ a statistical framework to ask whether S-locus selection intensities are higher in <it>Physalis </it>than <it>Solanum</it>. Because different S-RNase lineages diversify in <it>Physalis </it>and <it>Solanum</it>, we also ask whether different sites are under selection in different lineages.</p> <p>Results</p> <p>Maximum-likelihood and Bayesian coalescent methods found higher intensities of selection and more sites under significant positive selection in the 48 <it>Physalis </it>S-RNase alleles than the 49 from <it>Solanum</it>. Highest posterior densities of dN/dS (ω) estimates show that the strength of selection is greater for <it>Physalis </it>at 36 codons. A nested maximum likelihood method was more conservative, but still found 16 sites with greater selection in <it>Physalis</it>. Neither method found any codons under significantly greater selection in <it>Solanum</it>. A random effects likelihood method that examines data from both taxa jointly confirmed higher selection intensities in <it>Physalis</it>, but did not find different proportions of sites under selection in the two datasets. The greatest differences in strengths of selection were found in the most variable regions of the S-RNases, as expected if these regions encode self-recognition specificities. Clade-specific likelihood models indicated some codons were under greater selection in background <it>Solanum </it>lineages than in specific lineages of <it>Physalis </it>implying that selection on sites may differ among lineages.</p> <p>Conclusions</p> <p>Likelihood and Bayesian methods provide a statistical approach to testing differential selection across populations or species. These tests appear robust to the levels of polymorphism found in diverse S-allele collections subject to strong balancing selection. As predicted, the intensity of selection at the S-locus was higher in the taxon with more recent S-locus diversification. This is the first confirmation by statistical test of differing selection intensities among self-incompatibility alleles from different populations or species.</p

You're the Camera! Mapping Physical Movements to Transitioning Between Environments in Virtual Reality

Virtual reality gives users the ability to experience amazing and unusual experiences in an immersive environment. As new media are developed, designers tend to remediate several design aspects from media that came before it. Video games remediated techniques from cinema, and cinema remediated techniques from plays and musicals. However, not everything that remediates from past digital media is appropriate for virtual reality. Consequently, there are several areas in virtual reality design that warrant scientific investigation in that regard. The research question asked in this thesis specifically addresses transitioning between environments: when transitioning in a virtual world, will camera movements made simultaneously with movements from the user produce a preferred scene transition experience than with virtual camera movement alone? Multiple research studies have shown that physical movement in a virtual environment supports a strong immersive and presence induced experience. This thesis uses a within-subject experimental design where participants were tasked with transitioning between two different environments; once using physical motion to trigger the transition and once with using physical movement to pass a predetermined threshold and allowing the game to finish the transition for them. Results showed an overwhelming preference for the Non-Direct Version of this thesis game in nearly every regard.M.S., Digital Media -- Drexel University, 201

Heme Dissociation from Myoglobin in the Presence of the Zwitterionic Detergent N,N-Dimethyl-N-Dodecylglycine Betaine: Effects of Ionic Liquids

We have investigated myoglobin protein denaturation using the zwitterionic detergent Empigen BB (EBB, N,N-Dimethyl-N-dodecylglycine betaine). A combination of absorbance, fluorescence, and circular dichroism spectroscopic measurements elucidated the protein denaturation and heme dissociation from myoglobin. The results indicated that Empigen BB was not able to fully denature the myoglobin structure, but apparently can induce the dissociation of the heme group from the protein. This provides a way to estimate the heme binding free energy, ΔGdissociation. As ionic liquids (ILs) have been shown to perturb the myoglobin protein, we have investigated the effects of the ILs 1-butyl-3-methylimidazolium chloride (BMICl), 1-ethyl-3-methylimidazolium acetate (EMIAc), and 1-butyl-3-methylimidazolium tetrafluoroborate (BMIBF4) in aqueous solution on the ΔGdissociation values. Absorbance experiments show the ILs had minimal effect on ΔGdissociation values when compared to controls. Fluorescence and circular dichroism data confirm the ILs have no effect on heme dissociation, demonstrating that low concentrations ILs do not impact the heme dissociation from the protein and do not significantly denature myoglobin on their own or in combination with EBB. These results provide important data for future studies of the mechanism of IL-mediated protein stabilization/destabilization and biocompatibility studies

Polarized Redundant-Baseline Calibration for 21 cm Cosmology Without Adding Spectral Structure

21 cm cosmology is a promising new probe of the evolution of visible matter in our universe, especially during the poorly-constrained Cosmic Dawn and Epoch of Reionization. However, in order to separate the 21 cm signal from bright astrophysical foregrounds, we need an exquisite understanding of our telescopes so as to avoid adding spectral structure to spectrally-smooth foregrounds. One powerful calibration method relies on repeated simultaneous measurements of the same interferometric baseline to solve for the sky signal and for instrumental parameters simultaneously. However, certain degrees of freedom are not constrained by asserting internal consistency between redundant measurements. In this paper, we review the origin of these "degeneracies" of redundant-baseline calibration and demonstrate how they can source unwanted spectral structure in our measurement and show how to eliminate that additional, artificial structure. We also generalize redundant calibration to dual-polarization instruments, derive the degeneracy structure, and explore the unique challenges to calibration and preserving spectral smoothness presented by a polarized measurement.Comment: 12 pages, 3 figures, updated to match the published MNRAS versio

Characterizing Signal Loss in the 21 cm Reionization Power Spectrum: A Revised Study of PAPER-64

The Epoch of Reionization (EoR) is an uncharted era in our Universe's history during which the birth of the first stars and galaxies led to the ionization of neutral hydrogen in the intergalactic medium. There are many experiments investigating the EoR by tracing the 21cm line of neutral hydrogen. Because this signal is very faint and difficult to isolate, it is crucial to develop analysis techniques that maximize sensitivity and suppress contaminants in data. It is also imperative to understand the trade-offs between different analysis methods and their effects on power spectrum estimates. Specifically, with a statistical power spectrum detection in HERA's foreseeable future, it has become increasingly important to understand how certain analysis choices can lead to the loss of the EoR signal. In this paper, we focus on signal loss associated with power spectrum estimation. We describe the origin of this loss using both toy models and data taken by the 64-element configuration of the Donald C. Backer Precision Array for Probing the Epoch of Reionization (PAPER). In particular, we highlight how detailed investigations of signal loss have led to a revised, higher 21cm power spectrum upper limit from PAPER-64. Additionally, we summarize errors associated with power spectrum error estimation that were previously unaccounted for. We focus on a subset of PAPER-64 data in this paper; revised power spectrum limits from the PAPER experiment are presented in a forthcoming paper by Kolopanis et al. (in prep.) and supersede results from previously published PAPER analyses.Comment: 25 pages, 18 figures, Accepted by Ap

The Hydrogen Epoch of Reionization Array Dish II: Characterization of Spectral Structure with Electromagnetic Simulations and its science Implications

We use time-domain electromagnetic simulations to determine the spectral characteristics of the Hydrogen Epoch of Reionization Arrays (HERA) antenna. These simulations are part of a multi-faceted campaign to determine the effectiveness of the dish's design for obtaining a detection of redshifted 21 cm emission from the epoch of reionization. Our simulations show the existence of reflections between HERA's suspended feed and its parabolic dish reflector that fall below -40 dB at 150 ns and, for reasonable impedance matches, have a negligible impact on HERA's ability to constrain EoR parameters. It follows that despite the reflections they introduce, dishes are effective for increasing the sensitivity of EoR experiments at relatively low cost. We find that electromagnetic resonances in the HERA feed's cylindrical skirt, which is intended to reduce cross coupling and beam ellipticity, introduces significant power at large delays ($-40$ dB at 200 ns) which can lead to some loss of measurable Fourier modes and a modest reduction in sensitivity. Even in the presence of this structure, we find that the spectral response of the antenna is sufficiently smooth for delay filtering to contain foreground emission at line-of-sight wave numbers below $k_\parallel \lesssim 0.2$ $h$Mpc$^{-1}$, in the region where the current PAPER experiment operates. Incorporating these results into a Fisher Matrix analysis, we find that the spectral structure observed in our simulations has only a small effect on the tight constraints HERA can achieve on parameters associated with the astrophysics of reionization.Comment: Accepted to ApJ, 18 pages, 17 Figures. Replacement matches accepted manuscrip

Effects of Ionic Liquid Alkyl Chain Length on Denaturation of Myoglobin by Anionic, Cationic, and Zwitterionic Detergents

The unique electrochemical properties of ionic liquids (ILs) have motivated their use as solvents for organic synthesis and green energy applications. More recently, their potential in pharmaceutical chemistry has prompted investigation into their effects on biomolecules. There is evidence that some ILs can destabilize proteins via a detergent-like manner; however, the mechanism still remains unknown. Our hypothesis is that if ILs are denaturing proteins via a detergent-like mechanism, detergent-mediated protein unfolding should be enhanced in the presence of ILs. The properties of myoglobin was examined in the presence of a zwitterionic (N,N-dimethyl-N-dodecylglycine betaine (Empigen BB®, EBB)), cationic (tetradecyltrimethylammonium bromide (TTAB)), and anionic (sodium dodecyl sulfate (SDS)) detergent as well as ILs based on alkylated imidazolium chlorides. Protein structure was measured through a combination of absorbance, fluorescence, and circular dichroism (CD) spectroscopy: absorbance and CD were used to monitor heme complexation to myoglobin, and tryptophan fluorescence quenching was used as an indicator for heme dissociation. Notably, the detergents tested did not fully denature the protein but instead resulted in loss of the heme group. At low IL concentrations, heme dissociation remained a traditional, cooperative process; at high concentrations, ILs with increased detergent-like character exhibited a more complex pattern, which is most likely attributable to micellization of the ionic liquids or direct denaturation or heme dissociation induced by the ILs. These trends were consistent across all species of detergents. 1,6-diphenyl-1,3,5-hexatriene (DPH) fluorescence was further used to characterize micelle formation in aqueous solutions containing detergent and ionic liquid. The dissociation thermodynamics show that EBB- and TTAB-induced dissociation of heme is not significantly impacted by room temperature ionic liquids (RTILs), whereas SDS-induced dissociation is more dramatically impacted by all RTILs examined. Together, these results indicate a complex interaction of detergents, likely based on headgroup charge, and the active component of RTILs to influence heme dissociation and potentially protein denaturation

The Hydrogen Epoch of Reionization Array Dish I: Beam Pattern Measurements and Science Implications

The Hydrogen Epoch of Reionization Array (HERA) is a radio interferometer aiming to detect the power spectrum of 21 cm fluctuations from neutral hydrogen from the Epoch of Reionization (EOR). Drawing on lessons from the Murchison Widefield Array (MWA) and the Precision Array for Probing the Epoch of Reionization (PAPER), HERA is a hexagonal array of large (14 m diameter) dishes with suspended dipole feeds. Not only does the dish determine overall sensitivity, it affects the observed frequency structure of foregrounds in the interferometer. This is the first of a series of four papers characterizing the frequency and angular response of the dish with simulations and measurements. We focus in this paper on the angular response (i.e., power pattern), which sets the relative weighting between sky regions of high and low delay, and thus, apparent source frequency structure. We measure the angular response at 137 MHz using the ORBCOMM beam mapping system of Neben et al. We measure a collecting area of 93 m^2 in the optimal dish/feed configuration, implying HERA-320 should detect the EOR power spectrum at z~9 with a signal-to-noise ratio of 12.7 using a foreground avoidance approach with a single season of observations, and 74.3 using a foreground subtraction approach. Lastly we study the impact of these beam measurements on the distribution of foregrounds in Fourier space.Comment: 13 pages, 9 figures. Replaced to match accepted ApJ versio