Understanding variation in ambulance service non-conveyance rates: a mixed methods study

Background In England in 2015/16, ambulance services responded to nearly 11 million calls. Ambulance Quality Indicators show that half of the patients receiving a response by telephone or face to face were not conveyed to an emergency department. A total of 11% of patients received telephone advice only. A total of 38% of patients were sent an ambulance but were not conveyed to an emergency department. For the 10 large ambulance services in England, rates of calls ending in telephone advice varied between 5% and 17%. Rates of patients who were sent an ambulance but not conveyed to an emergency department varied between 23% and 51%. Overall non-conveyance rates varied between 40% and 68%. Objective To explain variation in non-conveyance rates between ambulance services. Design A sequential mixed methods study with five work packages. Setting Ten of the 11 ambulance services serving > 99% of the population of England. Methods (1) A qualitative interview study of managers and paramedics from each ambulance service, as well as ambulance commissioners (totalling 49 interviews undertaken in 2015). (2) An analysis of 1 month of routine data from each ambulance service (November 2014). (3) A qualitative study in three ambulance services with different published rates of calls ending in telephone advice (120 hours of observation and 20 interviews undertaken in 2016). (4) An analysis of routine data from one ambulance service linked to emergency department attendance, hospital admission and mortality data (6 months of 2013). (5) A substudy of non-conveyance for people calling 999 with breathing problems. Results Interviewees in the qualitative study identified factors that they perceived to affect non-conveyance rates. Where possible, these perceptions were tested using routine data. Some variation in non-conveyance rates between ambulance services was likely to be due to differences in the way rates were calculated by individual services, particularly in relation to telephone advice. Rates for the number of patients sent an ambulance but not conveyed to an emergency department were associated with patient-level factors: age, sex, deprivation, time of call, reason for call, urgency level and skill level of attending crew. However, variation between ambulance services remained after adjustment for patient-level factors. Variation was explained by ambulance service-level factors after adjustment for patient-level factors: the percentage of calls attended by advanced paramedics [odds ratio 1.05, 95% confidence interval (CI) 1.04 to 1.07], the perception of ambulance service staff and commissioners that advanced paramedics were established and valued within the workforce of an ambulance service (odds ratio 1.84, 95% CI 1.45 to 2.33), and the perception of ambulance service staff and commissioners that senior management was risk averse regarding non-conveyance within an ambulance service (odds ratio 0.78, 95% CI 0.63 to 0.98). Limitations Routine data from ambulance services are complex and not consistently collected or analysed by ambulance services, thus limiting the utility of comparative analyses. Conclusions Variation in non-conveyance rates between ambulance services in England could be reduced by addressing variation in the types of paramedics attending calls, variation in how advanced paramedics are used and variation in perceptions of the risk associated with non-conveyance within ambulance service management. Linking routine ambulance data with emergency department attendance, hospital admission and mortality data for all ambulance services in the UK would allow comparison of the safety and appropriateness of their different non-conveyance rates. Funding The National Institute for Health Research Health Services and Delivery Research programme

A coproduced patient and public event: An approach to developing and prioritizing ambulance performance measures

Background Patient and Public Involvement (PPI) is recognised as an important component of high quality health services research. PPI is integral within the Pre-hospital Outcomes for Evidence Based Evaluation (PhOEBE) programme. The PPI event described in detail in this paper focusses on the process of involving patients and public representatives in identifying, prioritising and refining a set of outcome measures that can be used to support ambulance service performance measurement. Objective To obtain public feedback on little known, complex aspects of ambulance service performance measurement. Design The event was co-designed and co-produced with the PhOEBE PPI reference group and PhOEBE research team. The event consisted of: brief researcher-led presentations, group discussions facilitated by the PPI reference group members and electronic voting. Setting and participants Data were collected from eighteen patient and public representatives who attended an event venue in Yorkshire. Results The results of the PPI event showed that this interactive format and mode of delivery was an effective method to obtain public feedback and produced a clear indication of which ambulance performance measures were most highly favoured by event participants. Discussion and Conclusions The event highlighted valuable contributions the PPI reference group made to the design process, supporting participant recruitment and facilitation of group discussions. In addition, the positive team working experience of the event proved a catalyst for further improvements in patient and public involvement within the PhOEBE project

Photon mixing in universes with large extra-dimensions

In presence of a magnetic field, photons can mix with any particle having a two-photon vertex. In theories with large compact extra-dimensions, there exists a hierachy of massive Kaluza-Klein gravitons that couple to any photon entering a magnetic field. We study this mixing and show that, in comparison with the four dimensional situation where the photon couples only to the massless graviton, the oscillation effect may be enhanced due to the existence of a large number of Kaluza-Klein modes. We give the conditions for such an enhancement and then investigate the cosmological and astrophysical consequences of this phenomenon; we also discuss some laboratory experiments. Axions also couple to photons in the same way; we discuss the effect of the existence of bulk axions in universes with large extra-dimensions. The results can also be applied to neutrino physics with extra-dimensions.Comment: 41 pages, LaTex, 6 figure

A Behavioural Foundation for Natural Computing and a Programmability Test

What does it mean to claim that a physical or natural system computes? One answer, endorsed here, is that computing is about programming a system to behave in different ways. This paper offers an account of what it means for a physical system to compute based on this notion. It proposes a behavioural characterisation of computing in terms of a measure of programmability, which reflects a system's ability to react to external stimuli. The proposed measure of programmability is useful for classifying computers in terms of the apparent algorithmic complexity of their evolution in time. I make some specific proposals in this connection and discuss this approach in the context of other behavioural approaches, notably Turing's test of machine intelligence. I also anticipate possible objections and consider the applicability of these proposals to the task of relating abstract computation to nature-like computation.Comment: 37 pages, 4 figures. Based on an invited Talk at the Symposium on Natural/Unconventional Computing and its Philosophical Significance, Alan Turing World Congress 2012, Birmingham, UK. http://link.springer.com/article/10.1007/s13347-012-0095-2 Ref. glitch fixed in 2nd. version; Philosophy & Technology (special issue on History and Philosophy of Computing), Springer, 201

Gravitomagnetic Effects in the Propagation of Electromagnetic Waves in Variable Gravitational Fields of Arbitrary-Moving and Spinning Bodies

Propagation of light in the gravitational field of self-gravitating spinning bodies moving with arbitrary velocities is discussed. The gravitational field is assumed to be "weak" everywhere. Equations of motion of a light ray are solved in the first post-Minkowskian approximation that is linear with respect to the universal gravitational constant $G$. We do not restrict ourselves with the approximation of gravitational lens so that the solution of light geodesics is applicable for arbitrary locations of source of light and observer. This formalism is applied for studying corrections to the Shapiro time delay in binary pulsars caused by the rotation of pulsar and its companion. We also derive the correction to the light deflection angle caused by rotation of gravitating bodies in the solar system (Sun, planets) or a gravitational lens. The gravitational shift of frequency due to the combined translational and rotational motions of light-ray-deflecting bodies is analyzed as well. We give a general derivation of the formula describing the relativistic rotation of the plane of polarization of electromagnetic waves (Skrotskii effect). This formula is valid for arbitrary translational and rotational motion of gravitating bodies and greatly extends the results of previous researchers. Finally, we discuss the Skrotskii effect for gravitational waves emitted by localized sources such as a binary system. The theoretical results of this paper can be applied for studying various relativistic effects in microarcsecond space astrometry and developing corresponding algorithms for data processing in space astrometric missions such as FAME, SIM, and GAIA.Comment: 36 pages, 1 figure, submitted to Phys. Rev.

Crystal structure of dichlorido(4,11-dimethyl-1,4,8,11-tetraazabicyclo[6.6.2]hexadecane)iron(III) hexafluoridophosphate

The title compound, [FeCl₂(C₁₄H₃₀N₄)]PF₆, contains Fe³⁺ coordinated by the four nitro­gen atoms of an ethyl­ene cross-bridged cyclam macrocycle and two cis chloride ligands in a distorted octa­hedral environment. In contrast to other similar compounds this is a monomer. Inter­molecular C-H...Cl inter­actions exist in the structure between the complex ions. Comparison with the mononuclear Fe²⁺ complex of the same ligand shows that the smaller Fe³⁺ ion is more fully engulfed by the cavity of the bicyclic ligand. Comparison with the μ-oxido dinuclear complex of an unsubstituted ligand of the same size demonstrates that the methyl groups of 4,11-dimethyl-1,4,8,11-tetra­aza­bicyclo­[6.6.2]hexa­decane prevent dimerization upon oxidation

Predictors of Virologic Failure in HIV/AIDS Patients Treated with Highly Active Antiretroviral Therapy in Brasília, Brazil During 2002–2008

Little data exists concerning the efficacy of the antiretroviral therapy in the Federal District in Brazil, therefore in order to improve HIV/AIDS patients’ therapy and to pinpoint hot spots in the treatment, this research work was conducted. Of 139 HIV/AIDS patients submitted to the highly active antiretroviral therapy, 12.2% failed virologically. The significant associated factors related to unresponsiveness to the lentiviral treatment were: patients’ place of origin (OR = 3.28; IC95% = 1.0–9.73; P = 0.032) and Mycobacterium tuberculosis infection (RR = 2.90; IC95% = 1.19–7.02; P = 0.019). In the logistic regression analysis, the remaining variables in the model were: patients’ birthplace (OR = 3.28; IC95% = 1.10–9.73; P = 0.032) and tuberculosis comorbidity (OR = 3.82; IC95% = 1.19–12.22; P = 0.024). The patients enrolled in this survey had an 88.0% therapeutic success rate for the maximum period of one year of treatment, predicting that T CD4+ low values and elevated viral loads at pretreatment should be particularly considered in tuberculosis coinfection, besides the availability of new antiretroviral drugs displaying optimal activity both in viral suppression and immunological reconstitution

The composition of the protosolar disk and the formation conditions for comets

Conditions in the protosolar nebula have left their mark in the composition of cometary volatiles, thought to be some of the most pristine material in the solar system. Cometary compositions represent the end point of processing that began in the parent molecular cloud core and continued through the collapse of that core to form the protosun and the solar nebula, and finally during the evolution of the solar nebula itself as the cometary bodies were accreting. Disentangling the effects of the various epochs on the final composition of a comet is complicated. But comets are not the only source of information about the solar nebula. Protostellar disks around young stars similar to the protosun provide a way of investigating the evolution of disks similar to the solar nebula while they are in the process of evolving to form their own solar systems. In this way we can learn about the physical and chemical conditions under which comets formed, and about the types of dynamical processing that shaped the solar system we see today. This paper summarizes some recent contributions to our understanding of both cometary volatiles and the composition, structure and evolution of protostellar disks.Comment: To appear in Space Science Reviews. The final publication is available at Springer via http://dx.doi.org/10.1007/s11214-015-0167-

Parity Violation Constraints Using Cosmic Microwave Background Polarization Spectra from 2006 and 2007 Observations by the QUaD Polarimeter

We constrain parity-violating interactions to the surface of last scattering using spectra from the QUaD experiment’s second and third seasons of observations by searching for a possible systematic rotation of the polarization directions of cosmic microwave background photons. We measure the rotation angle due to such a possible ‘‘cosmological birefringence’’ to be $0.55^{\circ} \pm 0.82^{\circ}$ (random) $\pm 0.5^{\circ}$ (systematic) using QUaD’s 100 and 150 GHz temperature-curl and gradient-curl spectra over the spectra over the multipole range 200 <$\ell$< 2000, consistent with null, and constrain Lorentz-violating interactions to <2 $\times$ 10$^ {-43}$ GeV (68% confidence limit). This is the best constraint to date on electrodynamic parity violation on cosmological scales.Astronom

The Response of Earth's Electron Radiation Belts to Geomagnetic Storms: Statistics From the Van Allen Probes Era Including Effects From Different Storm Drivers

A statistical study was conducted of Earth's radiation belt electron response to geomagnetic storms using NASA's Van Allen Probes mission. Data for electrons with energies ranging from 30 keV to 6.3 MeV were included and examined as a function of L-shell, energy, and epoch time during 110 storms with SYM-H 1 MeV also revealed a marked increase in likelihood of a depletion at all L-shells through the outer belt (3.5 1-MeV electrons throughout the outer belt, while storms driven by full CMEs and stream interaction regions are most likely to produce an enhancement of MeV electrons at lower (L similar to 4.5) L-shells, respectively. CME sheaths intriguingly result in a distinct enhancement of similar to 1-MeV electrons around L similar to 5.5, and on average, CME sheaths and stream interaction regions result in double outer belt structures