Calculating the proportion of avoidable attendances at UK emergency departments: analysis of the Royal College of Emergency Medicine’s Sentinel Site Survey data

Introduction Avoidable attendances (AAs; defined as non-urgent, self-referred patients who could be managed more effectively and efficiently by other services) have been identified as a contributor to ED crowding. Internationally, AAs have been estimated to constitute 10%–90% of ED attendances, with the UK 2013 Urgent and Emergency Care Review suggesting a figure of 40%. Methods This pilot study used data from the Royal College of Emergency Medicine’s Sentinel Site Survey to estimate the proportion of AAs in 12 EDs across England on a standard day (20 March 2014). AAs were defined by an expert panel using questions from the survey. All patients attending the EDs were recorded with details of investigations and treatments received, and the proportion of patients meeting criteria for AA was calculated. Results Visits for 3044 patients were included. Based on these criteria, a mean of 19.4% (95% CI 18.0% to 20.8%) of attendances could be deemed avoidable. The lowest proportion of AAs reported was 10.7%, while the highest was 44.3%. Younger age was a significant predictor of AA with mean age of 38.6 years for all patients attending compared with 24.6 years for patients attending avoidably (p≤0.001). Discussion The proportion of AAs in this study was lower than many estimates in the literature, including that reported by the 2013 Urgent and Emergency Care Review. This suggests the ED is the most appropriate healthcare setting for many patients due to comprehensive investigations, treatments and capability for urgent referrals. The proportion of AAs is dependent on the defining criteria used, highlighting the need for a standardised, universal definition of an appropriate/avoidable ED attendance. This is essential to understanding how AAs contribute to the overall issue of crowding

Sensitivity of nonlinear photoionization to resonance substructure in collective excitation

Collective behaviour is a characteristic feature in many-body systems, important for developments in fields such as magnetism, superconductivity, photonics and electronics. Recently, there has been increasing interest in the optically nonlinear response of collective excitations. Here we demonstrate how the nonlinear interaction of a many-body system with intense XUV radiation can be used as an effective probe for characterizing otherwise unresolved features of its collective response. Resonant photoionization of atomic xenon was chosen as a case study. The excellent agreement between experiment and theory strongly supports the prediction that two distinct poles underlie the giant dipole resonance. Our results pave the way towards a deeper understanding of collective behaviour in atoms, molecules and solid-state systems using nonlinear spectroscopic techniques enabled by modern short-wavelength light sources

“In Limbo”—use of, and alterations to, modified diets by nursing home staff in the absence of timely specialist support

BackgroundDysphagia is common in nursing home (NH) residents. Staff may not always be able to access speech and language therapist (SLT) assessments in a timely manner and there are some reports of nurses initiating or changing modified diets in these circumstances.MethodsA mixed quantitative and qualitative approach was used to analyse responses to an online anonymized survey of senior nurses working in Irish NHs. They were asked about their experience of delays accessing SLT services and whether they would ever initiate or change modified diets. Respondents were asked if they would give water to a thirsty resident, prescribed mildly thick liquids, who demanded it on a hot day because thickened fluid was not thirst quenching.ResultsOf 77 nurses surveyed, 63 (82%) responded. Three quarters reported delays accessing SLT services sometimes or often. Thirty-four (54.0%) would not give the thirsty resident water. About 70% reported that thickened fluids or modified texture diets were started without SLT sometimes or often. A third of respondents would thicken fluids or modify food to a greater extent than previously recommended but very few would make a diet less restrictive. The main themes that emerged from the comments provided were related to the uncertainty and dilemmas created for staff, what mitigating actions they might take in those circumstances and the need for better guidance and better access to SLT services.DiscussionDelays accessing SLT services are common for Irish NHs, and staff may initiate or change modified diets themselves in these circumstances. The responses suggest a widespread, and unjustified, belief that thicker or more modified is better for those with dysphagia. Clear and accurate guidance, and a better SLT service, is needed for NH staff

Electronic structure of periodic curved surfaces -- topological band structure

Electronic band structure for electrons bound on periodic minimal surfaces is differential-geometrically formulated and numerically calculated. We focus on minimal surfaces because they are not only mathematically elegant (with the surface characterized completely in terms of "navels") but represent the topology of real systems such as zeolites and negative-curvature fullerene. The band structure turns out to be primarily determined by the topology of the surface, i.e., how the wavefunction interferes on a multiply-connected surface, so that the bands are little affected by the way in which we confine the electrons on the surface (thin-slab limit or zero thickness from the outset). Another curiosity is that different minimal surfaces connected by the Bonnet transformation (such as Schwarz's P- and D-surfaces) possess one-to-one correspondence in their band energies at Brillouin zone boundaries.Comment: 6 pages, 8 figures, eps files will be sent on request to [email protected]

Transformation Pathways of Silica under High Pressure

Concurrent molecular dynamics simulations and ab initio calculations show that densification of silica under pressure follows a ubiquitous two-stage mechanism. First, anions form a close-packed sub-lattice, governed by the strong repulsion between them. Next, cations redistribute onto the interstices. In cristobalite silica, the first stage is manifest by the formation of a metastable phase, which was observed experimentally a decade ago, but never indexed due to ambiguous diffraction patterns. Our simulations conclusively reveal its structure and its role in the densification of silica.Comment: 14 pages, 4 figure

Photoelectron Angular Distributions for Two-photon Ionization of Helium by Ultrashort Extreme Ultraviolet Free Electron Laser Pulses

Phase-shift differences and amplitude ratios of the outgoing $s$ and $d$ continuum wave packets generated by two-photon ionization of helium atoms are determined from the photoelectron angular distributions obtained using velocity map imaging. Helium atoms are ionized with ultrashort extreme-ultraviolet free-electron laser pulses with a photon energy of 20.3, 21.3, 23.0, and 24.3 eV, produced by the SPring-8 Compact SASE Source test accelerator. The measured values of the phase-shift differences are distinct from scattering phase-shift differences when the photon energy is tuned to an excited level or Rydberg manifold. The difference stems from the competition between resonant and non-resonant paths in two-photon ionization by ultrashort pulses. Since the competition can be controlled in principle by the pulse shape, the present results illustrate a new way to tailor the continuum wave packet.Comment: 5 pages, 1 table, 3 figure

Spin Susceptibility and Superexchange Interaction in the Antiferromagnet CuO

Evidence for the quasi one-dimensional (1D) antiferromagnetism of CuO is presented in a framework of Heisenberg model. We have obtained an experimental absolute value of the paramagnetic spin susceptibility of CuO by subtracting the orbital susceptibility separately from the total susceptibility through the $^{63}$Cu NMR shift measurement, and compared directly with the theoretical predictions. The result is best described by a 1D $S=1/2$ antiferromagnetic Heisenberg (AFH) model, supporting the speculation invoked by earlier authors. We also present a semi-quantitative reason why CuO, seemingly of 3D structure, is unexpectedly a quasi 1D antiferromagnet.Comment: 7 pages including 4 tables and 9 figure

Financing methods for small-scale hardwood plantations in Queensland, Australia

Under Vision 2020, a target was set in 1997 for trebling the plantation area in Australia by the year 2020. Government subsidies and extension for plantation establishment have largely disappeared, hence forestry expansion is highly dependent on access to private finance. In the state of Queensland, plantation expansion has occurred predominantly through managed investment schemes and the joint venture scheme managed by Forestry Plantations Queensland, a government-owned corporation. Most of these plantings are relatively small-scale hardwood plantations, which are designed to replace the hardwood timber from the native forests that will be protected from further logging after 2024 under the South-East Queensland Regional Forestry Agreement. Views on financing methods for forestry expansion in Queensland were investigated through by an email survey of 12 forestry and finance professionals, followed by in-depth personal interviews of the same group of key informants. Some of the issues identified include lack of transparent information, inequitable taxation system between Managed Investment Scheme (MIS) companies and small-scale forest operators, the need for further R&D on all aspects of the industry, the potential impacts of carbon credit schemes on the industry, and the design of a strategic model for forestry investors. Participants took the view that adoption of a strategic alliance model would encourage further investment in small-scale forestry, arguing that this model could protect the interest of all the stakeholders through reducing investment risk and creating competitive advantage. The potential introduction of a carbon trading scheme also attracted interest from investors, who look for recognisable structures that may alleviate the risk of investing in an industry with which they are unfamiliar. The participants considered that further R&D should be the main focus for government participation in small-scale forestry