Patient satisfaction in emergency medicine

A systematic review was undertaken to identify published evidence relating to patient satisfaction in emergency medicine. Reviewed papers were divided into those that identified the factors influencing overall satisfaction in emergency department patients, and those in which a specific intervention was evaluated. Patient age and race influenced satisfaction in some, but not all, studies. Triage category was strongly correlated with satisfaction, but this also relates to waiting time. The three most frequently identified service factors were: interpersonal skills/staff attitudes; provision of information/explanation; perceived waiting times. Seven controlled intervention studies were found. These suggested that increased information on ED arrival, and training courses designed to improve staff attitudes and communication, are capable of improving patient satisfaction. None of the intervention studies looked specifically at the effect of reducing the perceived waiting time. Key interventions to improve patient satisfaction will be those that develop the interpersonal and attitudinal skills of staff, increase the information provided, and reduce the perceived waiting time. Future research should use a mixture of quantitative and qualitative methods to evaluate specific interventions

Ureteral calculi: What should you consider before intervening?

The size of the calculi, their location, and complicating factors such as infection should all be considered. Most ureteral calculi smaller than 5 mm pass spontaneously, as do approximately half of calculi between 5 and 10 mm. Calculi larger than 10 mm are unlikely to pass without intervention. Distal calculi are more likely to pass spontaneously than calculi in mid- or proximal ureteral locations; most spontaneous passage occurs within 4 to 6 weeks (strength of recommendation [SOR]: A, prospective cohort studies). All patients with calculi complicated by such factors as obstruction, infection, renal injury, or a single kidney require surgical consultation (SOR: C, expert opinion). Medical expulsion therapy with alpha-blockers (usually tamsulosin) and nifedipine improves passage rates, including for some calculi larger than 10 mm (SOR: A, metaanalysis of prospective cohort studies)

Tools for educational innovation

How does an instructor keep abreast of educational technology changes and developments? What tools, apps and add-ins are available and how can they be used innovatively? This session will cover a variety of resources and tools that answer these two questions plus address how to pick the best tools for your instructional environment

Shadow process tomography of quantum channels

Quantum process tomography is a critical capability for building quantum computers, enabling quantum networks, and understanding quantum sensors. Like quantum state tomography, the process tomography of an arbitrary quantum channel requires a number of measurements that scale exponentially in the number of quantum bits affected. However, the recent field of shadow tomography, applied to quantum states, has demonstrated the ability to extract key information about a state with only polynomially many measurements. In this work, we apply the concepts of shadow state tomography to the challenge of characterizing quantum processes. We make use of the Choi isomorphism to directly apply rigorous bounds from shadow state tomography to shadow process tomography, and we find additional bounds on the number of measurements that are unique to process tomography. Our results, which include algorithms for implementing shadow process tomography enable new techniques including evaluation of channel concatenation and the application of channels to shadows of quantum states. This provides a dramatic improvement for understanding large-scale quantum systems.Comment: 12 pages, 5 figures; Added citation to similar work; Errors corrected. Previous statements of main result first missed and then miscalculated an exponential cost in system size; Version accepted for publicatio

Ethical duties of nephrologists:when patients are nonadherent to treatment

When providing care, nephrologists are subject to various ethical duties. Beyond the Hippocratic notion of doing no harm, nephrologists also have duties to respect their patients' autonomy and dignity, to meet their patients' care goals in the least invasive way, to act impartially, and, ultimately, to do what is (clinically) beneficial for their patients. Juggling these often-conflicting duties can be challenging at the best of times, but can prove especially difficult when patients are not fully adherent to treatment. When a patient's nonadherence begins to cause harm to themselves and/or others, it may be questioned whether discontinuation of care is appropriate. We discuss how nephrologists can meet their ethical duties when faced with nonadherence in patients undergoing hemodialysis, including episodic extreme agitation, poor renal diet, missed hemodialysis sessions, and emergency presentations brought on by nonadherence. Furthermore, we consider the impact of cognitive impairment and provider-family conflict when making care decisions in a nonadherence context, as well as how the coronavirus disease 2019 pandemic might affect responses to nonadherence. Suggestions are provided for ethically informed responses, prioritizing a patient-narrative approach that is attentive to patients' values and preferences, multidisciplinarity, and the use of behavioral contracts and/or technology where appropriate

Perforated Small Intestine: A Case of a Delayed Presentation of an Intra-Abdominal Injury in a Pediatric Patient With a Seatbelt Sign

With the use of seatbelts comes a unique injury profile that has been called "the seatbelt syndrome." The classically described "seatbelt sign" has become a pattern of injury, describing potential underlying damage. As a clinician, clues to the underlying damage follow a thorough physical examination including the removal of all clothing to locate abrasions and bruises to the skin that potentially follow a seatbelt pattern. Delayed presentation of an intra-abdominal injury in the setting of a seatbelt sign has been well documented; however, the question is how long to observe these patients. We present the case of a 17-year-old woman involved in a motor vehicle collision who presented to the emergency department (ED) hemodynamically stable with a lower abdominal wall seatbelt sign. Her initial imaging revealed only an abdominal wall contusion. She was admitted for observation. Approximately 12 h later she started developing abdominal pain, and by 14 h abdominal distention, with repeat imaging showing free fluid and free air. She was taken to the operating room for an exploratory laparotomy and was ultimately discharged back home on day 7

Altering SARS Coronavirus Frameshift Efficiency Affects Genomic and Subgenomic RNA Production

In previous studies, differences in the amount of genomic and subgenomic RNA produced by coronaviruses with mutations in the programmed ribosomal frameshift signal of ORF1a/b were observed. It was not clear if these differences were due to changes in genomic sequence, the protein sequence or the frequency of frameshifting. Here, viruses with synonymous codon changes are shown to produce different ratios of genomic and subgenomic RNA. These findings demonstrate that the protein sequence is not the primary cause of altered genomic and subgenomic RNA production. The synonymous codon changes affect both the structure of the frameshift signal and frameshifting efficiency. Small differences in frameshifting efficiency result in dramatic differences in genomic RNA production and TCID50 suggesting that the frameshifting frequency must stay above a certain threshold for optimal virus production. The data suggest that either the RNA sequence or the ratio of viral proteins resulting from different levels of frameshifting affects viral replication

Multi-messenger astronomy of gravitational-wave sources with flexible wide-area radio transient surveys

We explore opportunities for multi-messenger astronomy using gravitational waves (GWs) and prompt, transient low-frequency radio emission to study highly energetic astrophysical events. We review the literature on possible sources of correlated emission of gravitational waves and radio transients, highlighting proposed mechanisms that lead to a short-duration, high-flux radio pulse originating from the merger of two neutron stars or from a superconducting cosmic string cusp. We discuss the detection prospects for each of these mechanisms by low-frequency dipole array instruments such as LWA1, LOFAR and MWA. We find that a broad range of models may be tested by searching for radio pulses that, when de-dispersed, are temporally and spatially coincident with a LIGO/Virgo GW trigger within a \usim 30 second time window and \usim 200 \mendash 500 \punits{deg}^{2} sky region. We consider various possible observing strategies and discuss their advantages and disadvantages. Uniquely, for low-frequency radio arrays, dispersion can delay the radio pulse until after low-latency GW data analysis has identified and reported an event candidate, enabling a \emph{prompt} radio signal to be captured by a deliberately targeted beam. If neutron star mergers do have detectable prompt radio emissions, a coincident search with the GW detector network and low-frequency radio arrays could increase the LIGO/Virgo effective search volume by up to a factor of \usim 2. For some models, we also map the parameter space that may be constrained by non-detections.Comment: 31 pages, 4 figure

Crystal structure of Mycobacterium tuberculosis FadB2 implicated in mycobacterial β-oxidation

The intracellular pathogen Mycobacterium tuberculosis is the causative agent of tuberculosis, which is a leading cause of mortality worldwide. The survival of M. tuberculosis in host macrophages through long-lasting periods of persistence depends, in part, on breaking down host cell lipids as a carbon source. The critical role of fatty-acid catabolism in this organism is underscored by the extensive redundancy of the genes implicated in β-oxidation (∼100 genes). In a previous study, the enzymology of the M. tuberculosisl-3-hydroxyacyl-CoA dehydrogenase FadB2 was characterized. Here, the crystal structure of this enzyme in a ligand-free form is reported at 2.1 Å resolution. FadB2 crystallized as a dimer with three unique dimer copies per asymmetric unit. The structure of the monomer reveals a dual Rossmann-fold motif in the N-terminal domain, while the helical C-terminal domain mediates dimer formation. Comparison with the CoA- and NAD + -bound human orthologue mitochondrial hydroxyacyl-CoA dehydrogenase shows extensive conservation of the residues that mediate substrate and cofactor binding. Superposition with the multi-catalytic homologue M. tuberculosis FadB, which forms a trifunctional complex with the thiolase FadA, indicates that FadB has developed structural features that prevent its self-association as a dimer. Conversely, FadB2 is unable to substitute for FadB in the tetrameric FadA–FadB complex as it lacks the N-terminal hydratase domain of FadB. Instead, FadB2 may functionally (or physically) associate with the enoyl-CoA hydratase EchA8 and the thiolases FadA2, FadA3, FadA4 or FadA6 as suggested by interrogation of the STRING protein-network database

A tubo-ovarian abscess mimicking an appendiceal abscess: a rare presentation of Streptococcus agalactiae.

A tubo-ovarian abscess (TOA) is a relatively rare medical complication that results from an untreated/unrecognized ascending pelvic infection of the female genital tract. In a right-sided TOA, this clinical entity may mimic appendicitis on computed tomography (CT). In addition, both disease processes can present with pelvic pain, leukocytosis and fever. We present the case of a 47-year-old female with mid right-sided abdominal pain that was diagnosed on CT scan with an appendiceal abscess. She underwent CT-guided percutaneous drainage with interventional radiology. On Day 8, a CT limited study involving a contrast injection was performed to evaluate for abscess resolution. The contrast within the drain filled the fallopian tube, endometrial cavity and contralateral fallopian tube. These findings demonstrated that the initial diagnosis actually represented a TOA. To the authors\u27 knowledge, this is the only reported case involving a TOA secondary to Streptococcus agalactiae (GBS) mimicking an appendicitis with abscess formation