Solving the worldwide emergency department crowding problem - what can we learn from an Israeli ED?

ED crowding is a prevalent and important issue facing hospitals in Israel and around the world, including North and South America, Europe, Australia, Asia and Africa. ED crowding is associated with poorer quality of care and poorer health outcomes, along with extended waits for care. Crowding is caused by a periodic mismatch between the supply of ED and hospital resources and the demand for patient care. In a recent article in the Israel Journal of Health Policy Research, Bashkin et al. present an Ishikawa diagram describing several factors related to longer length of stay (LOS), and higher levels of ED crowding, including management, process, environmental, human factors, and resource issues. Several solutions exist to reduce ED crowding, which involve addressing several of the issues identified by Bashkin et al. This includes reducing the demand for and variation in care, and better matching the supply of resources to demands in care in real time. However, what is needed to reduce crowding is an institutional imperative from senior leadership, implemented by engaged ED and hospital leadership with multi-disciplinary cross-unit collaboration, sufficient resources to implement effective interventions, access to data, and a sustained commitment over time. This may move the culture of a hospital to facilitate improved flow within and across units and ultimately improve quality and safety over the long-term

Quality of life of chronic stable angina patients 4 years after coronary angioplasty or coronary artery bypass surgery

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72244/1/j.1365-2796.2001.00782.x.pd

Biogenesis of a Bacterial Organelle: The Carboxysome Assembly Pathway

SummaryThe carboxysome is a protein-based organelle for carbon fixation in cyanobacteria, keystone organisms in the global carbon cycle. It is composed of thousands of subunits including hexameric and pentameric proteins that form a shell to encapsulate the enzymes ribulose 1,5-bisphosphate carboxylase/oxygenase and carbonic anhydrase. Here, we describe the stages of carboxysome assembly and the requisite gene products necessary for progression through each. Our results demonstrate that, unlike membrane-bound organelles of eukaryotes, in carboxysomes the interior of the compartment forms first, at a distinct site within the cell. Subsequently, shell proteins encapsulate this procarboxysome, inducing budding and distribution of functional organelles within the cell. We propose that the principles of carboxysome assembly that we have uncovered extend to diverse bacterial microcompartments

The Evolution of Distorted Rotating Black Holes II: Dynamics and Analysis

We have developed a numerical code to study the evolution of distorted, rotating black holes. This code is used to evolve a new family of black hole initial data sets corresponding to distorted ``Kerr'' holes with a wide range of rotation parameters, and distorted Schwarzschild black holes with odd-parity radiation. Rotating black holes with rotation parameters as high as $a/m=0.87$ are evolved and analyzed in this paper. The evolutions are generally carried out to about $t=100M$, where $M$ is the ADM mass. We have extracted both the even- and odd-parity gravitational waveforms, and find the quasinormal modes of the holes to be excited in all cases. We also track the apparent horizons of the black holes, and find them to be a useful tool for interpreting the numerical results. We are able to compute the masses of the black holes from the measurements of their apparent horizons, as well as the total energy radiated and find their sum to be in excellent agreement with the ADM mass.Comment: 26 pages, LaTeX with RevTeX 3.0 macros. 27 uuencoded gz-compressed postscript figures. Also available at http://jean-luc.ncsa.uiuc.edu/Papers/ Submitted to Physical Review

Alcohol, Tobacco, and Other Drugs: Future Directions for Screening and Intervention in the Emergency Department

This article is a product of a breakout session on injury prevention from the 2009 Academic Emergency Medicine consensus conference on “Public Health in the ED: Screening, Surveillance, and Intervention.” The emergency department (ED) is an important entry portal into the medical care system. Given the epidemiology of substance use among ED patients, the delivery of effective brief interventions (BIs) for alcohol, drug, and tobacco use in the ED has the potential to have a large public health impact. To date, the results of randomized controlled trials of interventional studies in the ED setting for substance use have been mixed in regard to alcohol and understudied in the area of tobacco and other drugs. As a result, there are more questions remaining than answered. The work group developed the following research recommendations that are essential for the field of screening and BI for alcohol, tobacco, and other drugs in the ED. 1) Screening—develop and validate brief and practical screening instruments for ED patients and determine the optimal method for the administration of screening instruments. 2) Key components and delivery methods for intervention—conduct research on the effectiveness of screening, brief intervention, and referral to treatment (SBIRT) in the ED on outcomes (e.g., consumption, associated risk behaviors, and medical psychosocial consequences) including minimum dose needed, key components, optimal delivery method, interventions focused on multiple risk behaviors and tailored based on assessment, and strategies for addressing polysubstance use. 3) Effectiveness among patient subgroups—conduct research to determine which patients are most likely to benefit from a BI for substance use, including research on moderators and mediators of intervention effectiveness, and examine special populations using culturally and developmentally appropriate interventions. 4) Referral strategies—a) promote prospective effectiveness trials to test best strategies to facilitate referrals and access from the ED to preventive services, community resources, and substance abuse and mental health treatment; b) examine impact of available community services; c) examine the role of stigma of referral and follow-up; and d) examine alternatives to specialized treatment referral. 5) Translation—conduct translational and cost-effectiveness research of proven efficacious interventions, with attention to fidelity, to move ED SBIRT from research to practice.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78664/1/j.1553-2712.2009.00552.x.pd

The Evolution of Distorted Rotating Black Holes III: Initial Data

In this paper we study a new family of black hole initial data sets corresponding to distorted ``Kerr'' black holes with moderate rotation parameters, and distorted Schwarzschild black holes with even- and odd-parity radiation. These data sets build on the earlier rotating black holes of Bowen and York and the distorted Brill wave plus black hole data sets. We describe the construction of this large family of rotating black holes. We present a systematic study of important properties of these data sets, such as the size and shape of their apparent horizons, and the maximum amount of radiation that can leave the system during evolution. These data sets should be a very useful starting point for studying the evolution of highly dynamical black holes and can easily be extended to 3D.Comment: 16 page

Motivation rulers for smoking cessation: a prospective observational examination of construct and predictive validity

BACKGROUND: Although popular clinically, the psychometric properties of motivation rulers for tobacco cessation are unknown. This study examined the psychometric properties of rulers assessing importance, readiness, and confidence in tobacco cessation. METHODS: This observational study of current smokers was conducted at 10 US emergency departments (EDs). Subjects were assessed during their ED visit (baseline) and reassessed two weeks later. We examined intercorrelations between the rulers as well as their construct and predictive validity. Hierarchical multinomial logistic regressions were used to examine the rulers\u27 predictive ability after controlling for covariables. RESULTS: We enrolled 375 subjects. The correlations between the three rulers ranged from 0.50 (between Important and Confidence) to 0.70 (between Readiness and Confidence); all were significant (p \u3c 0.001). Individuals in the preparation stage displayed the highest motivation-ruler ratings (all rulers F 2, 363 \u3e/= 43; p \u3c 0.001). After adjusting for covariables, each of the rulers significantly improved prediction of smoking behavior change. The strength of their predictive ability was on par with that of stage of change. CONCLUSION: Our results provide preliminary support for the psychometric soundness of the importance, readiness, and confidence rulers