Utilization and Workforce Integration of Physician Assistants

Background: The healthcare field is experiencing rapid growth in the number of advanced practice providers (APPs) with projections that demonstrate that this trend will only continue. Even though the number of APPs is growing, the development of facility-specific APP management infrastructure often grows at a slower pace. Specific policies and procedures on APP utilization and clinical efficiency metrics are lacking. This can lead to deficiencies in the understanding of the education and practice boundaries of APPs. Objective: Our study aimed to analyze the growth and utilization of physician assistants (PAs) in several hospitals located within Texas Medical Center (TMC) in Houston, Texas. We investigated potential factors influencing PA utilization and professional growth and information on the workflow structure, perceived barriers to the efficient utilization of PAs, and the integration of PAs into clinical teams and practice. Methods: We used a mixed methods design to investigate the trends of PAs in hospitals within a large urban medical center. Eight clinical managers at eight different TMC institutions were invited to participate in an email survey and qualitative phone interview. Results: The survey response rate was 62.5% (n=5). Analysis of interviews and survey responses identified five major themes regarding the utilization of the PA within the organizations: 1) the majority of locations employ PAs in team-based workflow structures with the main goal of creating increased access to care, 2) PAs provide an important degree of continuity and consistency for healthcare services, 3) most locations attempted to measure PA clinical efficiency, but struggled in regards to the best methods to do so, 4) hospitals have a favorable trend in retention rates of PAs and offer research opportunities and professional growth resources to their advanced practice providers, and 5) institutions encountered difficulty when it came to optimal billing practices for PAs. Conclusions: The primary focus of a PA’s job responsibility has shifted from providing physician satisfaction to an increased focus on providing quality patient care and increased patient access. PAs help facilitate coordination of care and create a solid foundation for continuity of care. There is a need for an updated method to measure PA clinical efficiency and a need for standardized PA billing practices

Funeral Programs-Book 1 (I-L)

https://digitalcommons.buffalostate.edu/aafp/1002/thumbnail.jp

Evaluation of microflow configurations for scale inhibition and serial X-ray diffraction analysis of crystallization processes

The clean and reproducible conditions provided by microfluidic devices are ideal sample environments for in situ analyses of chemical and biochemical reactions and assembly processes. However, the small size of microchannels makes investigating the crystallization of poorly soluble materials on-chip challenging due to crystal nucleation and growth that result in channel fouling and blockage. Here, we demonstrate a reusable insert-based microfluidic platform for serial X-ray diffraction analysis and examine scale formation in response to continuous and segmented flow configurations across a range of temperatures. Under continuous flow, scale formation on the reactor walls begins almost immediately on mixing of the crystallizing species, which over time results in occlusion of the channel. Depletion of ions at the start of the channel results in reduced crystallization towards the end of the channel. Conversely, segmented flow can control crystallization, so it occurs entirely within the droplet. Consequently, the spatial location within the channel represents a temporal point in the crystallization process. Whilst each method can provide useful crystallographic information, time-resolved information is lost when reactor fouling occurs and changes the solution conditions with time. The flow within a single device can be manipulated to give a broad range of information addressing surface interaction or solution crystallization

Vision and Foraging in Cormorants: More like Herons than Hawks?

Background Great cormorants (Phalacrocorax carbo L.) show the highest known foraging yield for a marine predator and they are often perceived to be in conflict with human economic interests. They are generally regarded as visually-guided, pursuit-dive foragers, so it would be expected that cormorants have excellent vision much like aerial predators, such as hawks which detect and pursue prey from a distance. Indeed cormorant eyes appear to show some specific adaptations to the amphibious life style. They are reported to have a highly pliable lens and powerful intraocular muscles which are thought to accommodate for the loss of corneal refractive power that accompanies immersion and ensures a well focussed image on the retina. However, nothing is known of the visual performance of these birds and how this might influence their prey capture technique. Methodology/Principal Findings We measured the aquatic visual acuity of great cormorants under a range of viewing conditions (illuminance, target contrast, viewing distance) and found it to be unexpectedly poor. Cormorant visual acuity under a range of viewing conditions is in fact comparable to unaided humans under water, and very inferior to that of aerial predators. We present a prey detectability model based upon the known acuity of cormorants at different illuminances, target contrasts and viewing distances. This shows that cormorants are able to detect individual prey only at close range (less than 1 m). Conclusions/Significance We conclude that cormorants are not the aquatic equivalent of hawks. Their efficient hunting involves the use of specialised foraging techniques which employ brief short-distance pursuit and/or rapid neck extension to capture prey that is visually detected or flushed only at short range. This technique appears to be driven proximately by the cormorant's limited visual capacities, and is analogous to the foraging techniques employed by herons

Polyfunctional T cell responses in children in early stages of chronic Trypanosoma cruzi infection contrast with monofunctional responses of long-term infected adults

Background: Adults with chronic Trypanosoma cruzi exhibit a poorly functional T cell compartment, characterized by monofunctional (IFN-γ-only secreting) parasite-specific T cells and increased levels of terminally differentiated T cells. It is possible that persistent infection and/or sustained exposure to parasites antigens may lead to a progressive loss of function of the immune T cells. Methodology/Principal Findings: To test this hypothesis, the quality and magnitude of T. cruzi-specific T cell responses were evaluated in T. cruzi-infected children and compared with long-term T. cruzi-infected adults with no evidence of heart failure. The phenotype of CD4+ T cells was also assessed in T. cruzi-infected children and uninfected controls. Simultaneous secretion of IFN-γ and IL-2 measured by ELISPOT assays in response to T. cruzi antigens was prevalent among T. cruzi-infected children. Flow cytometric analysis of co-expression profiles of CD4+ T cells with the ability to produce IFN-γ, TNF-α, or to express the co-stimulatory molecule CD154 in response to T. cruzi showed polyfunctional T cell responses in most T. cruzi-infected children. Monofunctional T cell responses and an absence of CD4+TNF-α+-secreting T cells were observed in T. cruzi-infected adults. A relatively high degree of activation and differentiation of CD4+ T cells was evident in T. cruzi-infected children. Conclusions/Significance: Our observations are compatible with our initial hypothesis that persistent T. cruzi infection promotes eventual exhaustion of immune system, which might contribute to disease progression in long-term infected subjects.Fil: Albareda, María Cecilia. Dirección Nacional de Instituto de Investigación. Administración Nacional de Laboratorio e Instituto de Salud. Instituto Nacional de Parasitología; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Provincia de Buenos Aires. Ministerio de Salud. Hospital Interzonal de Agudos "Eva Perón"; ArgentinaFil: de Rissio, Ana María. Dirección Nacional de Instituto de Investigación. Administración Nacional de Laboratorio e Instituto de Salud. Instituto Nacional de Parasitología; ArgentinaFil: Tomas, Gonzalo. Dirección Nacional de Instituto de Investigación. Administración Nacional de Laboratorio e Instituto de Salud. Instituto Nacional de Parasitología; ArgentinaFil: Serjan, Alicia. Gobierno de la Ciudad de Buenos Aires. Hospital General de Agudos "Juan A. Fernández"; ArgentinaFil: Alvarez, María Gabriela. Provincia de Buenos Aires. Ministerio de Salud. Hospital Interzonal de Agudos "Eva Perón"; ArgentinaFil: Viotti, Rodolfo Jorge. Provincia de Buenos Aires. Ministerio de Salud. Hospital Interzonal de Agudos "Eva Perón"; ArgentinaFil: Fichera, Laura Edith. Dirección Nacional de Instituto de Investigación. Administración Nacional de Laboratorio e Instituto de Salud. Instituto Nacional de Parasitología; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Esteva, Mónica Inés. Dirección Nacional de Instituto de Investigación. Administración Nacional de Laboratorio e Instituto de Salud. Instituto Nacional de Parasitología; ArgentinaFil: Potente, Daniel Fernando. Provincia de Buenos Aires. Ministerio de Salud. Hospital Interzonal de Agudos "Eva Perón"; ArgentinaFil: Armenti, Alejandro. Provincia de Buenos Aires. Ministerio de Salud. Hospital Interzonal de Agudos "Eva Perón"; ArgentinaFil: Tarleton, Rick L.. University of Georgia; Estados UnidosFil: Laucella, Susana Adriana. Dirección Nacional de Instituto de Investigación. Administración Nacional de Laboratorio e Instituto de Salud. Instituto Nacional de Parasitología; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentin

Understanding and examining teacher resilience from multiple perspectives

In this chapter, I argue that differing conceptualisations of the construct of resilience shape and enrich the research questions and methodology used to examine it. In addition, the conceptual focus has implications for questions such as whose responsibility it is for the development of resilience. Research conducted within two Australian projects, Keeping Cool and BRiTE (Building Resilience in Teacher Education) is used as an illustration of the impact of a changing conceptual focus. For example, beginning with a psychological perspective led to an examination of risk and protective factors for individuals. More contextual approaches involved a comparison of countries. Recent systemic views support a model that encompasses both personal and contextual characteristics, as well as strategies used and outcomes achieved. It is argued that taking multiple perspectives in this programme of work has enabled the incorporation of a broad range of research methods and findings, and contributed to a deeper understanding of the construct of teacher resilience

A machine learning system to optimise triage in an adult ophthalmic emergency department: a model development and validation study

BACKGROUND: A substantial proportion of attendances to ophthalmic emergency departments are for non-urgent presentations. We developed and evaluated a machine learning system (DemDx Ophthalmology Triage System: DOTS) to optimise triage, with the aim of reducing inappropriate emergency attendances and streamlining case referral when necessary. METHODS: DOTS was built using retrospective tabular data from 11,315 attendances between July 1st, 2021, to June 15th, 2022 at Moorfields Eye Hospital Emergency Department (MEH) in London, UK. Demographic and clinical features were used as inputs and a triage recommendation was given (“see immediately”, “see within a week”, or “see electively”). DOTS was validated temporally and compared with triage nurses’ performance (1269 attendances at MEH) and validated externally (761 attendances at the Federal University of Minas Gerais - UFMG, Brazil). It was also tested for biases and robustness to variations in disease incidences. All attendances from patients aged at least 18 years with at least one confirmed diagnosis were included in the study. FINDINGS: For identifying ophthalmic emergency attendances, on temporal validation, DOTS had a sensitivity of 94.5% [95% CI 92.3–96.1] and a specificity of 42.4% [38.8–46.1]. For comparison within the same dataset, triage nurses had a sensitivity of 96.4% [94.5–97.7] and a specificity of 25.1% [22.0–28.5]. On external validation at UFMG, DOTS had a sensitivity of 95.2% [92.5–97.0] and a specificity of 32.2% [27.4–37.0]. In simulated scenarios with varying disease incidences, the sensitivity was ≥92.2% and the specificity was ≥36.8%. No differences in sensitivity were found in subgroups of index of multiple deprivation, but the specificity was higher for Q2 when compared to Q4 (Q4 is less deprived than Q2). INTERPRETATION: At MEH, DOTS had similar sensitivity to triage nurses in determining attendance priority; however, with a specificity of 17.3% higher, DOTS resulted in lower rates of patients triaged to be seen immediately at emergency. DOTS showed consistent performance in temporal and external validation, in social-demographic subgroups and was robust to varying relative disease incidences. Further trials are necessary to validate these findings. This system will be prospectively evaluated, considering human-computer interaction, in a clinical trial. FUNDING: The Artificial Intelligence in Health and Care Award (AI_AWARD01671) of the NHS AI Lab under National Institute for Health and Care Research (NIHR) and the Accelerated Access Collaborative (AAC)

A Retrospective Analysis of the Haemodynamic and Metabolic Effects of Fluid Resuscitation in Vietnamese Adults with Severe Falciparum Malaria

BACKGROUND: Optimising the fluid resuscitation of patients with severe malaria is a simple and potentially cost-effective intervention. Current WHO guidelines recommend central venous pressure (CVP) guided, crystalloid based, resuscitation in adults. METHODS: Prospectively collected haemodynamic data from intervention trials in Vietnamese adults with severe malaria were analysed retrospectively to assess the responses to fluid resuscitation. RESULTS: 43 patients were studied of whom 24 received a fluid load. The fluid load resulted in an increase in cardiac index (mean increase: 0.75 L/min/m(2) (95% Confidence interval (CI): 0.41 to 1.1)), but no significant change in acid-base status post resuscitation (mean increase base deficit 0.6 mmol/L (95% CI: -0.1 to 1.3). The CVP and PAoP (pulmonary artery occlusion pressure) were highly inter-correlated (r(s) = 0.7, p<0.0001), but neither were correlated with acid-base status (arterial pH, serum bicarbonate, base deficit) or respiratory status (PaO(2)/FiO(2) ratio). There was no correlation between the oxygen delivery (DO(2)) and base deficit at the 63 time-points where they were assessed simultaneously (r(s) = -0.09, p = 0.46). CONCLUSIONS: In adults with severe falciparum malaria there was no observed improvement in patient outcomes or acid-base status with fluid loading. Neither CVP nor PAoP correlated with markers of end-organ perfusion or respiratory status, suggesting these measures are poor predictors of their fluid resuscitation needs

Complementary classifications of aeolian dunes based on morphology, dynamics, and fluid mechanics

Dunes form where winds blow over a bed of mobile sediment grains – conditions that are common in our solar system. On Earth, dunes abound in arid continental interiors and along sandy coastlines. Dune fields have also been recognized on Venus, Mars, Saturn's moon Titan, and Pluto. In response to the different boundary conditions and other environmental forcings, dunes adopt a rich diversity of shapes, sizes, and behaviors. Thus, people around the globe and over centuries have developed a rich vocabulary to describe dunes and their complexity. As a result, existing dune nomenclature often includes redundant terms with differing definitions across scientific communities. Previous studies have endeavored to link dune shape to environmental forcing, usually by means of correlation. Although instructive, correlation-based classifications can be misleading if not based on an underlying mechanics and if dune morphogenetic classes are not uniquely defined. Here, we synthesize existing dune terminology and use the last two decades of research on dune morphodynamics to propose three complementary dune classification schemes based on: (1) descriptive dune gemorphology, (2) morphodynamic processes, and (3) fluid mechanics and physics of sediment transport. The first classification relates dune types to geomorphic setting, presence or absence of vegetation or obstacles, and dune shape (including planform shape, and cross-sectional symmetry or asymmetry). Dune classes can be further subdivided where the direction of sand transport is known independently. The second classification relates dune types and shapes to bed properties (sand-covered vs partially starved bed) and wind forcing (directional variability or the relative strengths and directions of wind modes) that together influence dune dynamics (growth, migration, elongation) and select the dominant processes by which dunes are shaped and oriented relative to the resultant transport direction. The third classification relates, for different planetary environments, the range of possible dune sizes, from minimum to maximum wavelength, to flow regime (rough or smooth) and response of sediment transport, which influence the coupling between sand bed topography, fluid flow, and sediment transport. These characteristic lengths are useful scales for comparative geomorphology. The three classification schemes provide complementary information. Together, they form a unified framework for geomorphologists, sedimentologists, geographers, physicists, and others to describe windblown sand dunes on Earth and beyond through their shape, dynamics, and size as a response to winds and boundary conditions