Visit complexity, diagnostic uncertainty, and antibiotic prescribing for acute cough in primary care: a retrospective study

Background: Guidelines and performance measures recommend avoiding antibiotics for acute cough/acute bronchitis and presume visits are straightforward with simple diagnostic decision-making. We evaluated clinician-assigned diagnoses, diagnostic uncertainty, and antibiotic prescribing for acute cough visits in primary care. Methods: We conducted a retrospective analysis of acute cough visits – cough lasting ≤21 days in adults 18–64 years old without chronic lung disease – in a primary care practice from March 2011 through June 2012. Results: Of 56,301 visits, 962 (2%) were for acute cough. Clinicians diagnosed patients with 1, 2, or ≥ 3 cough-related diagnoses in 54%, 35%, and 11% of visits, respectively. The most common principal diagnoses were upper respiratory infection (46%), sinusitis (10%), acute bronchitis (9%), and pneumonia (8%). Clinicians prescribed antibiotics in 22% of all visits: 65% of visits with antibiotic-appropriate diagnoses and 4% of visits with non-antibiotic-appropriate diagnoses. Clinicians expressed diagnostic uncertainty in 16% of all visits: 43% of visits with antibiotic-appropriate diagnoses and 5% of visits with non-antibiotic-appropriate diagnoses. Clinicians expressed uncertainty more often when prescribing antibiotics than when not prescribing antibiotics (30% vs. 12%; p < 0.001). As the number of visit diagnoses increased from 1 to 2 to ≥ 3, clinicians were more likely to express diagnostic uncertainty (5%, 25%, 40%, respectively; p < 0.001) and prescribe antibiotics (16%, 25%, 41%, respectively; p < 0.001). Conclusions: Acute cough may be more complex and have more diagnostic uncertainty than guidelines and performance measures presume. Efforts to reduce antibiotic prescribing for acute cough should address diagnostic complexity and uncertainty that clinicians face

Primary care clinicians’ perceptions about antibiotic prescribing for acute bronchitis: a qualitative study

Background: Clinicians prescribe antibiotics to over 65% of adults with acute bronchitis despite guidelines stating that antibiotics are not indicated. Methods: To identify and understand primary care clinician perceptions about antibiotic prescribing for acute bronchitis, we conducted semi-structured interviews with 13 primary care clinicians in Boston, Massachusetts and used thematic content analysis. Results: All the participants agreed with guidelines that antibiotics are not indicated for acute bronchitis and felt that clinicians other than themselves were responsible for overprescribing. Barriers to guideline adherence included 6 themes: (1) perceived patient demand, which was the main barrier, although some clinicians perceived a recent decrease; (2) lack of accountability for antibiotic prescribing; (3) saving time and money; (4) other clinicians’ misconceptions about acute bronchitis; (5) diagnostic uncertainty; and (6) clinician dissatisfaction in failing to meet patient expectations. Strategies to decrease inappropriate antibiotic prescribing included 5 themes: (1) patient educational materials; (2) quality reporting; (3) clinical decision support; (4) use of an over-the-counter prescription pad; and (5) pre-visit triage and education by nurses to prevent visits. Conclusions: Clinicians continued to cite patient demand as the main reason for antibiotic prescribing for acute bronchitis, though some clinicians perceived a recent decrease. Clinicians felt that other clinicians were responsible for inappropriate antibiotic prescribing and that better pre-visit triage by nurses could prevent visits and change patients’ expectations. Electronic supplementary material The online version of this article (doi:10.1186/s12875-014-0194-5) contains supplementary material, which is available to authorized users

The workday of hospital surgeons: what they do, what makes them satisfied, and the role of core tasks and administrative tasks; a diary study.

BACKGROUND Many surgeons report passion for their work, but not all tasks are likely to be satisfying. Little is known about how hospital surgeons spend their days, how they like specific tasks, and the role of core tasks (i.e. surgery-related tasks) versus tasks that may keep them from core tasks (e.g., administrative work). This study aimed at a more detailed picture of hospital surgeons' daily work - how much time they spend with different tasks, how they like them, and associations with satisfaction. METHODS Hospital surgeons (N = 105) responded to a general survey, and 81 of these provided up to five daily questionnaires concerning daily activities and their attractiveness, as well as their job satisfaction. The data were analyzed using t-tests, analysis of variance, as well as analysis of covariance and repeated measures analysis of variance for comparing means across tasks. RESULTS Among 14 tasks, surgery-related tasks took 21.2%, patient-related tasks 21.7% of the surgeons' time; 10.4% entailed meetings and communicating about patients, and 18.6% documentation and administration. The remaining time was spent with teaching, research, leadership and management, and not task-related activities (e.g. walking between rooms). Surgery was rated as most (4.25; SD = .66), administration as least attractive (2.63; SD = .78). A higher percentage of administration predicted lower perceived legitimacy; perceived legitimacy of administrative work predicted job satisfaction (r = .47). Residents were least satisfied; there were few gender differences. CONCLUSIONS Surgeons seem to thrive on their core tasks, most notably surgery. By contrast, administrative duties are likely perceived as keeping them from their core medical tasks. Increasing the percentage of medical tasks proper, notably surgery, and reducing administrative duties may contribute to hospital surgeons' job satisfaction

Temporal factors in violence related injuries—An 11year trend analysis of violence-related injuries from a Swiss Emergency Department

Summary: Background: Injury from interpersonal violence is a major social and medical problem in the industrialized world. Little is known about the trends in prevalence and injury pattern or about the demographic characteristics of the patients involved. Methods: In this retrospective analysis, we screened the database of the Emergency Department of a large university hospital for all patients who were admitted for injuries due to interpersonal violence over an 11year period. For all patients identified, we gathered data on age, country of origin, quality of injury, and hospitalization or outpatient management. A trend analysis was performed using Kendall's tau-b correlation coefficients for regression analysis. Results: The overall number of patients admitted to our Emergency Department remained stable over the study period. Non-Swiss nationals were overrepresented in comparison to the demographics of the region where the study was conducted. There was a trend toward a more severe pattern of injury, such as an increase in the number of severe head injuries. Conclusions: Although the overall number of patients remained stable over the study period, there was an alarming trend toward a more severe pattern of injury, expressed by an increase in severe head trauma

Activated integrins identify functional antigen-specific CD8 T cells within minutes after antigen stimulation

Skin affections after sulfur mustard (SM) exposure include erythema, blister formation and severe inflammation. An antidote or specific therapy does not exist. Anti-inflammatory compounds as well as substances counteracting SM-induced cell death are under investigation. In this study, we investigated the benzylisoquinoline alkaloide berberine (BER), a metabolite in plants like berberis vulgaris, which is used as herbal pharmaceutical in Asian countries, against SM toxicity using a well-established in vitro approach. Keratinocyte (HaCaT) mono-cultures (MoC) or HaCaT/THP-1 co-cultures (CoC) were challenged with 100, 200 or 300 mM SM for 1 h. Post-exposure, both MoC and CoC were treated with 10, 30 or 50 mu M BER for 24 h. At that time, supernatants were collected and analyzed both for interleukine (IL) 6 and 8 levels and for content of adenylate-kinase (AK) as surrogate marker for cell necrosis. Cells were lysed and nucleosome formation as marker for late apoptosis was assessed. In parallel, AK in cells was determined for normalization purposes. BER treatment did not influence necrosis, but significantly decreased apoptosis. Anti-inflammatory effects were moderate, but also significant, primarily in CoC. Overall, BER has protective effects against SM toxicity in vitro. Whether this holds true should be evaluated in future in vivo studies

Relationship between ecosystem productivity and photosynthetically-active radiation for northern peatlands

We analyzed the relationship between net ecosystem exchange of carbon dioxide (NEE) and irradiance (as photosynthetic photon flux density or PPFD), using published and unpublished data that have been collected during midgrowing season for carbon balance studies at seven peatlands in North America and Europe. NEE measurements included both eddy-correlation tower and clear, static chamber methods, which gave very similar results. Data were analyzed by site, as aggregated data sets by peatland type (bog, poor fen, rich fen, and all fens) and as a single aggregated data set for all peatlands. In all cases, a fit with a rectangular hyperbola (NEE = α PPFD Pmax/(α PPFD + Pmax) + R) better described the NEE-PPFD relationship than did a linear fit (NEE = β PPFD + R). Poor and rich fens generally had similar NEE-PPFD relationships, while bogs had lower respiration rates (R = −2.0μmol m−2s−1 for bogs and −2.7 μmol m−2s−1 for fens) and lower NEE at moderate and high light levels (Pmax = 5.2 μmol m−2s−1 for bogs and 10.8 μmol m−2s−1 for fens). As a single class, northern peatlands had much smaller ecosystem respiration (R = −2.4 μmol m−2s−1) and NEE rates (α = 0.020 and Pmax = 9.2μmol m−2s−1) than the upland ecosystems (closed canopy forest, grassland, and cropland) summarized by Ruimy et al. [1995]. Despite this low productivity, northern peatland soil carbon pools are generally 5–50 times larger than upland ecosystems because of slow rates of decomposition caused by litter quality and anaerobic, cold soils

Pollutant dispersion in a developing valley cold-air pool

Pollutants are trapped and accumulate within cold-air pools, thereby affecting air quality. A numerical model is used to quantify the role of cold-air-pooling processes in the dispersion of air pollution in a developing cold-air pool within an alpine valley under decoupled stable conditions. Results indicate that the negatively buoyant downslope flows transport and mix pollutants into the valley to depths that depend on the temperature deficit of the flow and the ambient temperature structure inside the valley. Along the slopes, pollutants are generally entrained above the cold-air pool and detrained within the cold-air pool, largely above the ground-based inversion layer. The ability of the cold-air pool to dilute pollutants is quantified. The analysis shows that the downslope flows fill the valley with air from above, which is then largely trapped within the cold-air pool, and that dilution depends on where the pollutants are emitted with respect to the positions of the top of the ground-based inversion layer and cold-air pool, and on the slope wind speeds. Over the lower part of the slopes, the cold-air-pool-averaged concentrations are proportional to the slope wind speeds where the pollutants are emitted, and diminish as the cold-air pool deepens. Pollutants emitted within the ground-based inversion layer are largely trapped there. Pollutants emitted farther up the slopes detrain within the cold-air pool above the ground-based inversion layer, although some fraction, increasing with distance from the top of the slopes, penetrates into the ground-based inversion layer.Peer reviewe

Falsification Of The Atmospheric CO2 Greenhouse Effects Within The Frame Of Physics

The atmospheric greenhouse effect, an idea that many authors trace back to the traditional works of Fourier (1824), Tyndall (1861), and Arrhenius (1896), and which is still supported in global climatology, essentially describes a fictitious mechanism, in which a planetary atmosphere acts as a heat pump driven by an environment that is radiatively interacting with but radiatively equilibrated to the atmospheric system. According to the second law of thermodynamics such a planetary machine can never exist. Nevertheless, in almost all texts of global climatology and in a widespread secondary literature it is taken for granted that such mechanism is real and stands on a firm scientific foundation. In this paper the popular conjecture is analyzed and the underlying physical principles are clarified. By showing that (a) there are no common physical laws between the warming phenomenon in glass houses and the fictitious atmospheric greenhouse effects, (b) there are no calculations to determine an average surface temperature of a planet, (c) the frequently mentioned difference of 33 degrees Celsius is a meaningless number calculated wrongly, (d) the formulas of cavity radiation are used inappropriately, (e) the assumption of a radiative balance is unphysical, (f) thermal conductivity and friction must not be set to zero, the atmospheric greenhouse conjecture is falsified.Comment: 115 pages, 32 figures, 13 tables (some typos corrected

Turbulence generation by mountain wave breaking in flows with directional wind shear

Mountain wave breaking, and the resulting potential for the generation of turbulence in the atmosphere, is investigated using numerical simulations of idealized, nearly hydrostatic atmospheric flows with directional wind shear over an axisymmetric isolated mountain. These simulations, which use the WRF-ARWmodel, differ in degree of flow non-linearity and shear intensity, quantified through the dimensionless mountain height and the Richardson number of the incoming flow, respectively. The aim is to diagnose wave breaking based on large-scale flow variables. The simulation results have been used to produce a regime diagram giving a description of the wave breaking behaviour in Richardson number–dimensionless mountain height parameter space. By selecting flow overturning occurrence as a discriminating factor, it was possible to split the regime diagram into sub-regions with and without wave breaking. When mountain waves break, the associated convective instability leads to turbulence generation (which is one of the known forms of Clear Air Turbulence, also known as CAT). Thus, regions within the simulation domain where wave breaking and the development of CAT are expected have been identified. The extent of these regions increases with terrain elevation and background wind shear intensity. Analysis of the model output, supported by theoretical arguments, suggest the existence of a link between wave breaking and the relative orientations of the incoming wind vector and the horizontal velocity perturbation vector. More specifically, in a wave breaking event, due to the effect of critical levels, the background wind vector and the wave-number vector of the dominant mountain waves are perpendicular. It is shown that, at least for the wind profile employed in the present study, this corresponds to a situation where the background wind vector and the velocity perturbation vector are also approximately perpendicular