Association of Clinical Characteristics With Variation in Emergency Physician Preferences for Patients.

Importance:Much of the wide variation in health care has been associated with practice variation among physicians. Physicians choosing to see patients with more (or fewer) care needs could also produce variations in care observed across physicians. Objective:To quantify emergency physician preferences by measuring nonrandom variations in patients they choose to see. Design, Setting, and Participants:This cross-sectional study used a large, detailed clinical data set from an electronic health record system of a single academic hospital. The data set included all emergency department (ED) encounters of adult patients from January 1, 2010, to May 31, 2015, as well as ED visits information. Data were analyzed from September 1, 2018, to March 31, 2019. Exposure:Patient assignment to a particular emergency physician. Main Outcomes and Measures:Variation in patient characteristics (age, sex, acuity [Emergency Severity Index score], and comorbidities) seen by emergency physicians before patient selection, adjusted for temporal factors (seasonal, weekly, and hourly variation in patient mix). Results:This study analyzed 294 915 visits to the ED seen by 62 attending physicians. Of the 294 915 patients seen, the mean (SD) age was 48.6 (19.8) years and 176 690 patients (59.9%) were women. Many patient characteristics, such as age (F = 2.2; P < .001), comorbidities (F = 1.7; P < .001), and acuity (F = 4.7; P < .001), varied statistically significantly. Compared with the lowest-quintile physicians for each respective characteristic, the highest-quintile physicians saw patients who were older (mean age, 47.9 [95% CI, 47.8-48.1] vs 49.7 [95% CI, 49.5-49.9] years, respectively; difference, +1.8 years; 95% CI, 1.5-2.0 years) and sicker (mean comorbidity score: 0.4 [95% CI, 0.3-0.5] vs 1.8 [95% CI, 1.7-1.8], respectively; difference, +1.3; 95% CI, 1.2-1.4). These differences were absent or highly attenuated during overnight shifts, when only 1 physician was on duty and there was limited room for patient selection. Compared with earlier in the shift, the same physician later in the shift saw patients who were younger (mean age, 49.7 [95% CI, 49.4-49.7] vs 44.6 [95 % CI, 44.3-44.9] years, respectively; difference, -5.1 years; 95% CI, 4.8-5.5) and less sick (mean comorbidity score: 0.7 [95% CI, 0.7-0.8] vs 1.1 [95% CI, 1.1-1.1], respectively; difference, -0.4; 95% CI, 0.4-0.4). Accounting for preference variation resulted in substantial reordering of physician ranking by care intensity, as measured by ED charges, with 48 of 62 physicians (77%) being reclassified into a different quintile and 9 of 12 physicians (75%) in the highest care intensity quintile moving into a lower quintile. A regression model demonstrated that 22% of reported ED charges were associated with physician preference. Conclusions and Relevance:This study found preference variation across physicians and within physicians during the course of a shift. These findings suggest that current efforts to reduce practice variation may not affect the variation associated with physician preferences, which reflect underlying differences in patient needs and not physician practice

In-situ and laboratory investigation of modified drilling waste materials applied on base-course construction

Abstract This study focuses on in-situ and laboratory evaluation of modified drilling waste materials (MDWMs) applied on base course construction. Cement treated drilling waste materials have been used on a limited basis for full-depth base repair on Texas Department of Transportation (TxDOT) low volume roads. A road inspection was made of full-scale county roads that were constructed with the MDWMs. Field test results measured by the falling weight deflectomer (FWD) showed reasonable in-situ strengths. The MDWM section had stiffness values similar to those typically observed for newly constructed flexible bases. The old, in-service flexible base adjacent to the MDWM section exhibited values half those of the MDWMs. Cores removed from the field also had significantly higher strength values than the lab-molded samples. Moreover, the other non-TxDOT low volume county roads using MDWMs exhibited good field performance. From this observation, it is concluded that this material clearly has some unique engineering properties which has the ability to gain strength with time though weak initially and there is the potential applicability used in the low volume roadway

Organizational readiness for wellness promotion - a survey of 100 African American church leaders in South Los Angeles.

BackgroundChurches are an important asset and a trusted resource in the African American community. We needed a better understanding of their readiness to engage in health promotion before launching a large-scale health promotion effort in partnership with South Los Angeles churches.MethodsIn 2017, we conducted surveys with leaders of 100 churches. Surveys were conducted face-to-face (32%) or by telephone (68%) with senior pastors (one per church) and lasted on average 48 min. We compared small (less than 50 active members), medium (50-99 active members) and large churches (at least 100 active members), and assessed which church characteristics were associated with the implementation of wellness activities.ResultsMedium and large churches conducted significantly more wellness activities than small churches and were more likely to have wellness champions and health policies. Regardless of church size, insufficient budget was the most commonly cited barrier to implement wellness activities (85%). A substantial proportion of churches was not sure how to implement wellness activities (61%) and lacked volunteers (58%). Forty-five percent of the variation in the number of wellness activities in the last 12 months was explained by church characteristics, such as size of congregation, number of paid staff, leadership engagement, having a wellness ministry and barriers.ConclusionsMany churches in South Los Angeles are actively engaged in health promotion activities, despite a general lack of resources. We recommend a comprehensive assessment of church characteristics in intervention studies to enable the use of strategies (e.g., stratification by size) that reduce imbalances that could mask or magnify study outcomes. Our data provide empirical support for the inner settings construct of the Consolidated Framework for Implementation Research in the context of health promotion in African American churches

Population mixing due to dipole-dipole interactions in a 1D array of multilevel atoms

We examine theoretically how dipole-dipole interactions arising from multiple photon scattering lead to a modified distribution of ground state populations in a driven, ordered 1D array of multilevel atoms. Specifically, we devise a level configuration in which a ground-state population accumulated due solely to dipole-dipole interactions can be up to 20\% in regimes accessible to current experiments with neutral atom arrays. For much larger systems, the steady state can consist of an equal distribution of population across the ground state manifold. Our results illustrate how dipole-dipole interactions can be accentuated through interference, and regulated by the geometry of ordered atom arrays. More generally, control techniques for multilevel atoms that can be degraded by multiple scattering, such as optical pumping, will benefit from an improved understanding and control of dipole-dipole interactions available in ordered arrays.Comment: paper is now identical to published versio

Role of the ArcAB two-component system in the resistance of Escherichia coli to reactive oxygen stress

<p>Abstract</p> <p>Background</p> <p>The global regulatory system ArcAB controls the anaerobic growth of <it>E. coli</it>, however, its role in aerobic conditions is not well characterized. We have previously reported that ArcA was necessary for <it>Salmonella </it>to resist reactive oxygen species (ROS) in aerobic conditions.</p> <p>Results</p> <p>To investigate the mechanism of ROS resistance mediated by ArcAB, we generated deletion mutants of ArcA and ArcB in <it>E. coli</it>. Our results demonstrated that both ArcA and ArcB were necessary for resistance to hydrogen peroxide (H₂O₂), a type of ROS, and their function in this resistance was independent from H₂O₂scavenge. Mutagenesis analysis of ArcA indicated that ROS resistance was mediated through a distinct signaling pathway from that used in anaerobic conditions. An abundant protein flagellin was elevated at both the protein and mRNA levels in the <it>ΔarcA </it>mutant as compared to the wild type <it>E. coli</it>, and deletion of flagellin restored the resistance of the <it>ΔarcA </it>mutant to H₂O₂. The resistance of the <it>ΔarcA </it>mutant <it>E. coli </it>to H₂O₂can also be restored by amino acid supplementation, suggesting that a deficiency in amino acid and/or protein synthesis in the mutant contributed to its susceptibility to H₂O₂, which is consistent with the notion that protein synthesis is necessary for ROS resistance.</p> <p>Conclusion</p> <p>Our results suggest that in addition to its role as a global regulator for anaerobic growth of bacteria, ArcAB system is also important for bacterial resistance to ROS in aerobic conditions, possibly through its influence on bacterial metabolism, especially amino acid and/or protein assimilation and synthesis.</p

Fluorescence in situ hybridization (FISH) and risk factors for non-Hodgkin lymphoma (NHL) subtypes defined by t(14;18) translocations and bcl-2 expression

In hopes of increasing etiologic specificity of non-Hodgkin lymphoma (NHL), we defined NHL tumors by acquired chromosomal translocations involving the immunoglobulin heavy chain (any IGH), t(14;18), t(8;14) and BCL6 translocations using fluorescence in situ hybridization (FISH) assays of archival paraffin-embedded tumor blocks. Translocations were identified in samples from over 200 unselected NHL cases originally enrolled in the National Cancer Institute's Factors Affecting Rural Men (FARM) study (1981-1984). We re-evaluated reported associations between tobacco exposures and t(14;18)-NHL case-subtypes that were previously defined based on polymerase chain reaction (PCR) assays. We also evaluated bcl-2 protein expression based on immunohistochemistry. t(14;18)-FISH case-subtypes were compared with t(14;18)-PCR case-subtypes by frequency according to histologic subtype and bcl-2 status. Case:control associations were estimated using multivariate polytomous logistic regression for t(14;18)-NHL and factors including tobacco use, family history of hemolymphatic cancer, and hair dye use. The expectation-maximization (EM) algorithm was applied to case:control models to reduce bias due to missing case-subtype data. BCL6 translocations, t(8;14), and other IGH translocations were uncommon in the study population. t(14;18) was identified in 53% of cases, including 39% of diffuse large cell lymphomas (26 of 66 cases) and 81% of follicular lymphomas (35 of 43 cases). FISH assays detected almost twice as many t(14;18)-positive follicular lymphomas as PCR assays (44%) run on the same samples. The majority of cases expressed bcl-2, including 87% of t(14;18)-positive cases and 58% of t(14;18)-negative cases. Adjusting for age, state, and proxy status, t(14;18)-negative NHL was associated with any tobacco use (OR=1.98, 95% CI=1.09-3.59) and cigarette smoking, without evidence of a linear dose-response with increasing pack-years or intensity of smoking. In contrast, tobacco and cigarette use were not clearly associated with t(14;18)-positive NHL or with bcl-2 case-subtypes. Our results support the use of FISH assays of archival samples to identify t(14;18)-NHL case-subtypes. The association between t(14;18)-negative NHL and cigarette smoking was unexpected given previous evidence of associations between smoking and follicular lymphoma (which is largely t(14;18)-positive). Additional molecular characterization of t(14;18)-negative cases may clarify whether the association between tobacco use and t(14;18)-negative NHL was causal versus an artifact of chance or bias

Evaluating feasibility of modified drilling waste materials in flexible base course construction

The study focuses on the evaluation of the engineering properties of modified drilling waste materials (MDWMs) as base course materials in roadway construction. This goal was accomplished by two main laboratory test evaluations of the MDWMs which are the basic material characterization and the performance evaluation of base course material

ComPASS: a tool for distributed parallel finite volume discretizations on general unstructured polyhedral meshes

International audienceThe objective of the ComPASS project is to develop a parallel multiphase Darcy flow simulator adapted to general unstructured polyhedral meshes (in a general sense with possibly non planar faces) and to the parallelization of advanced finite volume discretizations with various choices of the degrees of freedom such as cell centres, vertices, or face centres. The main targeted applications are the simulation of CO2 geological storage, nuclear waste repository and reservoir simulations. The CEMRACS 2012 summer school devoted to high performance computing has been an ideal framework to start this collaborative project. This paper describes what has been achieved during the four weeks of the CEMRACS project which has been focusing on the implementation of basic features of the code such as the distributed unstructured polyhedral mesh, the synchronization of the degrees of freedom, and the connection to scientific libraries including the partitioner METIS, the visualization tool PARAVIEW, and the parallel linear solver library PETSc. The parallel efficiency of this first version of the ComPASS code has been validated on a toy parabolic problem using the Vertex Approximate Gradient finite volume spacial discretization with both cell and vertex degrees of freedom, combined with an Euler implicit time integration

Applying Anti Oppressive, Empowerment, and Strengths Based Approaches to Social Work Practice with Hmong Clients

This conceptual article discusses social work practice with Hmong Americans using a framework that embraces anti-oppressive practice, empowerment and strengths-based approaches. Specifically, the Hmong kinship social construct of kwv tij neej tsa&nbsp;(pronounced: ku tee ning ja) is used to elaborate on the importance of upholding family relationships that transcends the worker-client relationship. Social workers are encouraged to empower Hmong to seek and ask for resources that support their collective value of connection to family and group identity, which is a strength that contributes to resilience and buffers against historically oppressive practices and systems