Disparities in Aesthetic Procedures Performed by Plastic Surgery Residents.

PubMed

Silvestre, Jason; Serletti, Joseph M; Chang, Benjamin

2017-05-01

Operative experience in aesthetic surgery is an important issue affecting plastic surgery residents. This study addresses the variability of aesthetic surgery experience during plastic surgery residency. National operative case logs of chief residents in independent/combined and integrated plastic surgery residency programs were analyzed (2011-2015). Fold differences between the bottom and top 10th percentiles of residents were calculated for each aesthetic procedure category and training model. The number of residents not achieving case minimums was also calculated. Case logs of 818 plastic surgery residents were analyzed. There was marked variability in craniofacial (range, 6.0-15.0), breast (range, 2.4-5.9), trunk/extremity (range, 3.0-16.0), and miscellaneous (range, 2.7-22.0) procedure categories. In 2015, the bottom 10th percentile of integrated and independent/combined residents did not achieve case minimums for botulinum toxin and dermal fillers. Case minimums were achieved for the other aesthetic procedure categories for all graduating years. Significant variability persists for many aesthetic procedure categories during plastic surgery residency training. Greater efforts may be needed to improve the aesthetic surgery experience of plastic surgery residents. © 2016 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com

40 CFR 63.443 - Standards for the pulping system at kraft, soda, and semi-chemical processes.

Code of Federal Regulations, 2014 CFR

2014-07-01

... operated at a minimum temperature of 871 °C (1600 °F) and a minimum residence time of 0.75 seconds; or (4... Paper Industry § 63.443 Standards for the pulping system at kraft, soda, and semi-chemical processes. (a...)(ii)(C) of this section. (A) Each knotter system with emissions of 0.05 kilograms or more of total HAP...

40 CFR 63.443 - Standards for the pulping system at kraft, soda, and semi-chemical processes.

Code of Federal Regulations, 2013 CFR

2013-07-01

... operated at a minimum temperature of 871 °C (1600 °F) and a minimum residence time of 0.75 seconds; or (4... Paper Industry § 63.443 Standards for the pulping system at kraft, soda, and semi-chemical processes. (a...)(ii)(C) of this section. (A) Each knotter system with emissions of 0.05 kilograms or more of total HAP...

40 CFR 63.443 - Standards for the pulping system at kraft, soda, and semi-chemical processes.

Code of Federal Regulations, 2012 CFR

2012-07-01

... operated at a minimum temperature of 871 °C (1600 °F) and a minimum residence time of 0.75 seconds; or (4... Paper Industry § 63.443 Standards for the pulping system at kraft, soda, and semi-chemical processes. (a...)(ii)(C) of this section. (A) Each knotter system with emissions of 0.05 kilograms or more of total HAP...

40 CFR 63.443 - Standards for the pulping system at kraft, soda, and semi-chemical processes.

Code of Federal Regulations, 2010 CFR

2010-07-01

... operated at a minimum temperature of 871 °C (1600 °F) and a minimum residence time of 0.75 seconds; or (4... Paper Industry § 63.443 Standards for the pulping system at kraft, soda, and semi-chemical processes. (a...)(ii)(C) of this section. (A) Each knotter system with emissions of 0.05 kilograms or more of total HAP...

Explaining Direct Care Resource Use of Nursing Home Residents: Findings from Time Studies in Four States

PubMed Central

Arling, Greg; Kane, Robert L; Mueller, Christine; Lewis, Teresa

2007-01-01

Objective To explain variation in direct care resource use (RU) of nursing home residents based on the Resource Utilization Groups III (RUG-III) classification system and other resident- and unit-level explanatory variables. Data Sources/Study Setting Primary data were collected on 5,314 nursing home residents in 156 nursing units in 105 facilities from four states (CO, IN, MN, MS) from 1998 to 2004. Study Design Nurses and other direct care staff recorded resident-specific and other time caring for all residents on sampled nursing units. Care time was linked to resident data from the Minimum Data Set assessment instrument. Major variables were: RUG-III group (34-group), other health and functional conditions, licensed and other professional minutes per day, unlicensed minutes per day, and direct care RU (wage-weighted minutes). Resident- and unit-level relationships were examined through hierarchical linear modeling. Data Collection/Extraction Methods Time study data were recorded with hand-held computers, verified for accuracy by project staff at the data collection sites and then merged into resident and unit-level data sets. Principal Findings Resident care time and RU varied between and within nursing units. RUG-III group was related to RU; variables such as length of stay and unit percentage of high acuity residents also were significantly related. Case-mix indices (CMIs) constructed from study data displayed much less variation across RUG-III groups than CMIs from earlier time studies. Conclusions Results from earlier time studies may not be representative of care patterns of Medicaid and private pay residents. New RUG-III CMIs should be developed to better reflect the relative costs of caring for these residents. PMID:17362220

Estimating Potential Reductions in Premature Mortality in New York City From Raising the Minimum Wage to $15

PubMed Central

Konty, Kevin J.; Van Wye, Gretchen; Barbot, Oxiris; Hadler, James L.; Linos, Natalia; Bassett, Mary T.

2016-01-01

Objectives. To assess potential reductions in premature mortality that could have been achieved in 2008 to 2012 if the minimum wage had been $15 per hour in New York City. Methods. Using the 2008 to 2012 American Community Survey, we performed simulations to assess how the proportion of low-income residents in each neighborhood might change with a hypothetical $15 minimum wage under alternative assumptions of labor market dynamics. We developed an ecological model of premature death to determine the differences between the levels of premature mortality as predicted by the actual proportions of low-income residents in 2008 to 2012 and the levels predicted by the proportions of low-income residents under a hypothetical $15 minimum wage. Results. A $15 minimum wage could have averted 2800 to 5500 premature deaths between 2008 and 2012 in New York City, representing 4% to 8% of total premature deaths in that period. Most of these avertable deaths would be realized in lower-income communities, in which residents are predominantly people of color. Conclusions. A higher minimum wage may have substantial positive effects on health and should be considered as an instrument to address health disparities. PMID:27077350

Estimating Potential Reductions in Premature Mortality in New York City From Raising the Minimum Wage to $15.

PubMed

Tsao, Tsu-Yu; Konty, Kevin J; Van Wye, Gretchen; Barbot, Oxiris; Hadler, James L; Linos, Natalia; Bassett, Mary T

2016-06-01

To assess potential reductions in premature mortality that could have been achieved in 2008 to 2012 if the minimum wage had been $15 per hour in New York City. Using the 2008 to 2012 American Community Survey, we performed simulations to assess how the proportion of low-income residents in each neighborhood might change with a hypothetical $15 minimum wage under alternative assumptions of labor market dynamics. We developed an ecological model of premature death to determine the differences between the levels of premature mortality as predicted by the actual proportions of low-income residents in 2008 to 2012 and the levels predicted by the proportions of low-income residents under a hypothetical $15 minimum wage. A $15 minimum wage could have averted 2800 to 5500 premature deaths between 2008 and 2012 in New York City, representing 4% to 8% of total premature deaths in that period. Most of these avertable deaths would be realized in lower-income communities, in which residents are predominantly people of color. A higher minimum wage may have substantial positive effects on health and should be considered as an instrument to address health disparities.

Determination of the Residence Time of Food Particles During Aseptic Sterilization

NASA Technical Reports Server (NTRS)

Carl, J. R.; Arndt, G. D.; Nguyen, T. X.

1994-01-01

The paper describes a non-invasive method to measure the time an individual particle takes to move through a length of stainless steel pipe. The food product is in two phase flow (liquids and solids) and passes through a pipe with pressures of approximately 60 psig and temperatures of 270-285 F. The proposed problem solution is based on the detection of transitory amplitude and/or phase changes in a microwave transmission path caused by the passage of the particles of interest. The particles are enhanced in some way, as will be discussed later, such that they will provide transitory changes that are distinctive enough not to be mistaken for normal variations in the received signal (caused by the non-homogeneous nature of the medium). Two detectors (transmission paths across the pipe) will be required and place at a known separation. A minimum transit time calculation is made from which the maximum velocity can be determined. This provides the minimum residence time. Also average velocity and statistical variations can be computed so that the amount of 'over-cooking' can be determined.

Atomistic modeling of dropwise condensation

DOE Office of Scientific and Technical Information (OSTI.GOV)

Sikarwar, B. S., E-mail: bssikarwar@amity.edu; Singh, P. L.; Muralidhar, K.

The basic aim of the atomistic modeling of condensation of water is to determine the size of the stable cluster and connect phenomena occurring at atomic scale to the macroscale. In this paper, a population balance model is described in terms of the rate equations to obtain the number density distribution of the resulting clusters. The residence time is taken to be large enough so that sufficient time is available for all the adatoms existing in vapor-phase to loose their latent heat and get condensed. The simulation assumes clusters of a given size to be formed from clusters of smallermore » sizes, but not by the disintegration of the larger clusters. The largest stable cluster size in the number density distribution is taken to be representative of the minimum drop radius formed in a dropwise condensation process. A numerical confirmation of this result against predictions based on a thermodynamic model has been obtained. Results show that the number density distribution is sensitive to the surface diffusion coefficient and the rate of vapor flux impinging on the substrate. The minimum drop radius increases with the diffusion coefficient and the impinging vapor flux; however, the dependence is weak. The minimum drop radius predicted from thermodynamic considerations matches the prediction of the cluster model, though the former does not take into account the effect of the surface properties on the nucleation phenomena. For a chemically passive surface, the diffusion coefficient and the residence time are dependent on the surface texture via the coefficient of friction. Thus, physical texturing provides a means of changing, within limits, the minimum drop radius. The study reveals that surface texturing at the scale of the minimum drop radius does not provide controllability of the macro-scale dropwise condensation at large timescales when a dynamic steady-state is reached.« less

An analytical study of nitrogen oxides and carbon monoxide emissions in hydrocarbon combustion with added nitrogen - Preliminary results

NASA Technical Reports Server (NTRS)

Bittker, D. A.

1980-01-01

The influence of ground-based gas turbine combustor operating conditions and fuel-bound nitrogen (FBN) found in coal-derived liquid fuels on the formation of nitrogen oxides and carbon monoxide is investigated. Analytical predictions of NOx and CO concentrations are obtained for a two-stage, adiabatic, perfectly-stirred reactor operating on a propane-air mixture, with primary equivalence ratios from 0.5 to 1.7, secondary equivalence ratios of 0.5 or 0.7, primary stage residence times from 12 to 20 msec, secondary stage residence times of 1, 2 and 3 msec and fuel nitrogen contents of 0.5, 1.0 and 2.0 wt %. Minimum nitrogen oxide but maximum carbon monoxide formation is obtained at primary zone equivalence ratios between 1.4 and 1.5, with percentage conversion of FBN to NOx decreasing with increased fuel nitrogen content. Additional secondary dilution is observed to reduce final pollutant concentrations, with NOx concentration independent of secondary residence time and CO decreasing with secondary residence time; primary zone residence time is not observed to affect final NOx and CO concentrations significantly. Finally, comparison of computed results with experimental values shows a good semiquantitative agreement.

Efficiency and large deviations in time-asymmetric stochastic heat engines

DOE PAGES

Gingrich, Todd R.; Rotskoff, Grant M.; Vaikuntanathan, Suriyanarayanan; ...

2014-10-24

In a stochastic heat engine driven by a cyclic non-equilibrium protocol, fluctuations in work and heat give rise to a fluctuating efficiency. Using computer simulations and tools from large deviation theory, we have examined these fluctuations in detail for a model two-state engine. We find in general that the form of efficiency probability distributions is similar to those described by Verley et al (2014 Nat. Commun. 5 4721), in particular featuring a local minimum in the long-time limit. In contrast to the time-symmetric engine protocols studied previously, however, this minimum need not occur at the value characteristic of a reversible Carnot engine. Furthermore, while the local minimum may reside at the global minimum of a large deviation rate function, it does not generally correspond to the least likely efficiency measured over finite time. Lastly, we introduce a general approximation for the finite-time efficiency distribution,more » $$P(\\eta )$$, based on large deviation statistics of work and heat, that remains very accurate even when $$P(\\eta )$$ deviates significantly from its large deviation form.« less

Effects of Hurricane Katrina on nursing facility resident mortality, hospitalization, and functional decline.

PubMed

Dosa, David; Feng, Zhanlian; Hyer, Kathy; Brown, Lisa M; Thomas, Kali; Mor, Vincent

2010-09-01

The study was designed to examine the 30- and 90-day mortality and hospitalization rates among nursing facility (NF) residents in the affected areas of Louisiana and Mississippi following Hurricane Katrina and to assess the rate of significant posthurricane functional decline. A secondary data analysis was conducted using Medicare claims merged with NF resident data from the Minimum Data Set. Thirty- and 90-day mortality and hospitalization rates for long-stay (>90 days) residents residing in 141 at-risk NFs during Hurricane Katrina were compared to rates for residents residing at the same facilities during the same time period in prior nonhurricane years (2003 and 2004). Functional decline was assessed as a 4+ drop in function using a 28-point Minimum Data Set Activities of Daily Living Scale. There were statistically significant differences (all P < .0001) in mortality, hospitalization, and functional decline among residents exposed to Hurricane Katrina. At 30 days, the mortality rate was 3.88% among the exposed cohort compared with 2.10% and 2.28% for residents in 2003 and 2004, respectively. The 90-day mortality rate was 9.27% compared with 6.71% and 6.31%, respectively. These mortality differences translated into an additional 148 deaths at 30 days and 230 deaths at 90 days. The 30-day hospitalization rate was 9.87% compared with 7.21% and 7.53%, respectively. The 90-day hospitalization rate was 20.39% compared with 18.61% and 17.82%, respectively. Finally, the rate of significant functional decline among survivors was 6.77% compared with 5.81% in 2003 and 5.10% in 2004. NF residents experienced a significant increase in mortality, hospitalization, and functional decline during Hurricane Katrina.

Resident away rotations allow adaptive neurosurgical training.

PubMed

Gephart, Melanie Hayden; Derstine, Pamela; Oyesiku, Nelson M; Grady, M Sean; Burchiel, Kim; Batjer, H Hunt; Popp, A John; Barbaro, Nicholas M

2015-04-01

Subspecialization of physicians and regional centers concentrate the volume of certain rare cases into fewer hospitals. Consequently, the primary institution of a neurological surgery training program may not have sufficient case volume to meet the current Residency Review Committee case minimum requirements in some areas. To ensure the competency of graduating residents through a comprehensive neurosurgical education, programs may need for residents to travel to outside institutions for exposure to cases that are either less common or more regionally focused. We sought to evaluate off-site rotations to better understand the changing demographics and needs of resident education. This would also allow prospective monitoring of modifications to the neurosurgery training landscape. We completed a survey of neurosurgery program directors and query of data from the Accreditation Council of Graduate Medical Education to characterize the current use of away rotations in neurosurgical education of residents. We found that 20% of programs have mandatory away rotations, most commonly for exposure to pediatric, functional, peripheral nerve, or trauma cases. Most of these rotations are done during postgraduate year 3 to 6, lasting 1 to 15 months. Twenty-six programs have 2 to 3 participating sites and 41 have 4 to 6 sites distinct from the host program. Programs frequently offset potential financial harm to residents rotating at a distant site by support of housing and transportation costs. As medical systems experience fluctuating treatment paradigms and demographics, over time, more residency programs may adapt to meet the Accreditation Council of Graduate Medical Education case minimum requirements through the implementation of away rotations.

7 CFR 3201.100 - Aircraft and boat cleaners.

Code of Federal Regulations, 2014 CFR

2014-01-01

... products designed to remove built-on grease, oil, dirt, pollution, insect reside, or impact soils on both..., dirt, pollution, insect reside, or impact soils on both interior and exterior of aircraft. (ii) Boat... impact soils on both interior and exterior of boats. (b) Minimum biobased content. The minimum biobased...

A multilevel analysis of aggressive behaviors among nursing home residents.

PubMed

Cassie, Kimberly M

2012-01-01

Individual and organizational characteristics associated with aggressive behavior among nursing home residents were examined among a sample of 5,494 residents from 23 facilities using the Minimum Data Set 2.0 and the Organizational Social Context scale. On admission, some individual level variables (age, sex, depression, activities of daily life [ADL] impairments, and cognitive impairments) and no organizational level variables were associated with aggressive behaviors. Over time, aggressive behaviors were linked with some individual characteristics (age, sex, and ADL impairments) and several organizational level variables (stressful climates, less rigid cultures, more resistant cultures, geographic location, facility size and staffing patterns). Findings suggest multi-faceted change strategies are needed.

Predictors of nursing home residents' time to hospitalization.

PubMed

O'Malley, A James; Caudry, Daryl J; Grabowski, David C

2011-02-01

To model the predictors of the time to first acute hospitalization for nursing home residents, and accounting for previous hospitalizations, model the predictors of time between subsequent hospitalizations. Merged file from New York State for the period 1998-2004 consisting of nursing home information from the minimum dataset and hospitalization information from the Statewide Planning and Research Cooperative System. Accelerated failure time models were used to estimate the model parameters and predict survival times. The models were fit to observations from 50 percent of the nursing homes and validated on the remaining observations. Pressure ulcers and facility-level deficiencies were associated with a decreased time to first hospitalization, while the presence of advance directives and facility staffing was associated with an increased time. These predictors of the time to first hospitalization model had effects of similar magnitude in predicting the time between subsequent hospitalizations. This study provides novel evidence suggesting modifiable patient and nursing home characteristics are associated with the time to first hospitalization and time to subsequent hospitalizations for nursing home residents. © Health Research and Educational Trust.

Species-specific patterns of diel migration into the Oxygen Minimum Zone by euphausiids in the Humboldt Current Ecosystem

NASA Astrophysics Data System (ADS)

Antezana, Tarsicio

2009-12-01

A series of stratified bongo net samples taken over a 2 day period at ca. 18°S, about 20 nm off the coast of Peru, South America, suggest species-specific patterns of diel vertical migration into the Oxygen Minimum Zone (OMZ) of the Humboldt Current Ecosystem (HCE). The OMZ was the most dramatic feature of the water column and seemed to determine the extent of migration: Stylocheiron affine migrated only to the shallow oxycline; whereas Euphausia mucronata, Euphausia eximia, Euphausia distinguenda and Euphausia tenera migrated to the core of the OMZ; and Nematoscelis gracilis to beneath the core of the OMZ. Some differences were also found in the timing and duration of the ascent and descent, and residence times in shallow and deep layers. E. mucronata, N. gracilis and E. distinguenda displayed a normal descent during sunrise, and ascent during sunset. E. eximia and E. tenera also descended during sunrise but seemed to begin their ascent earlier in the afternoon and consequently shortened their deep residence times. S. affine showed the most extended residence times at the shallow layer and the shortest vertical displacement. Day and night vertical stratification and differences in the timing of migration into and out of the OMZ of the HCE suggest a community structure based on habitat partitioning whereby species avoided co-occurrence in time and space. Species-specific patterns of vertical stratification and migratory chronology are examined with regard to body and gill sizes, feeding adaptations of euphausiids, and potential food resources at the OMZ.

40 CFR 61.356 - Recordkeeping requirements.

Code of Federal Regulations, 2011 CFR

2011-07-01

... also establish the design minimum and average temperature in the combustion zone and the combustion... temperatures, combustion zone residence time, and description of method and location where the vent stream is... control device are not operated as designed including all periods and the duration when: (i) Any valve car...

Oral/dental items in the resident assessment instrument - minimum Data Set 2.0 lack validity: results of a retrospective, longitudinal validation study.

PubMed

Hoben, Matthias; Poss, Jeffrey W; Norton, Peter G; Estabrooks, Carole A

2016-01-01

Oral health in nursing home residents is poor. Robust, mandated assessment tools such as the Resident Assessment Instrument - Minimum Data Set (RAI-MDS) 2.0 are key to monitoring and improving quality of oral health care in nursing homes. However, psychometric properties of RAI-MDS 2.0 oral/dental items have been challenged and criterion validity of these items has never been assessed. We used 73,829 RAI-MDS 2.0 records (13,118 residents), collected in a stratified random sample of 30 urban nursing homes in Western Canada (2007-2012). We derived a subsample of all residents ( n  = 2,711) with an admission and two or more subsequent annual assessments. Using Generalized Estimating Equations, adjusted for known covariates of nursing home residents' oral health, we assessed the association of oral/dental problems with time, dentate status, dementia, debris, and daily cleaning. Prevalence of oral/dental problems fluctuated (4.8 %-5.6 %) with no significant differences across time. This range of prevalence is substantially smaller than the ones reported by studies using clinical assessments by dental professionals. Denture wearers were less likely than dentate residents to have oral/dental problems (adjusted odds ratio [OR] = 0.458, 95 % confidence interval [CI]: 0.308, 0.680). Residents lacking teeth and not wearing dentures had higher odds than dentate residents of oral/dental problems (adjusted OR = 2.718, 95 % CI: 1.845, 4.003). Oral/dental problems were more prevalent in persons with debris (OR = 2.187, 95 % CI: 1.565, 3.057). Of the other variables assessed, only age at assessment was significantly associated with oral/dental problems. Robust, reliable RAI-MDS 2.0 oral health indicators are vital to monitoring and improving oral health related quality and safety in nursing homes. However, severe underdetection of oral/dental problems and lack of association of well-known oral health predictors with oral/dental problems suggest validity problems. Lacking teeth and not wearing dentures should be considered an indicator for urgent oral/dental treatment needs.

Challenges in assessing nursing home residents with advanced dementia for suspected urinary tract infections.

PubMed

D'Agata, Erika; Loeb, Mark B; Mitchell, Susan L

2013-01-01

To describe the presentation of suspected urinary tract infections (UTIs) in nursing home (NH) residents with advanced dementia and how they align with minimum criteria to justify antimicrobial initiation. Twelve-month prospective study. Twenty-five NHs. Two hundred sixty-six NH residents with advanced dementia. Charts were abstracted monthly for documentation of suspected UTI episodes to determine whether episodes met minimum criteria to initiate antimicrobial therapy according to consensus guidelines. Seventy-two residents experienced 131 suspected UTI episodes. Presenting symptoms and signs for these episodes are mental status change (44.3%), fever (20.6%), hematuria (6.9%), dysuria (3.8%), costovertebral tenderness (2.3%), urinary frequency (1.5%), rigor (1.5%), urgency (0%), and suprapubic pain (0%). Only 21 (16.0%) episodes met minimal criteria to initiate antimicrobial therapy based on signs and symptoms. Of the 110 episodes that lacked minimum criteria to justify antimicrobial initiation, 82 (74.5%) were treated with antimicrobial therapy. Urinalyses and urine culture results were available for 101 episodes, of which 80 (79.2%) had positive results on both tests. The proportion of episodes with a positive urinalysis and culture was similar for those that met (83.3%) and did not meet (78.3%) minimum criteria (P = .06). The symptoms and signs necessary to meet minimum criteria to support antimicrobial initiation for UTIs are frequently absent in NH residents with advanced dementia. Antimicrobial therapy is prescribed for the majority of suspected UTIs that do not meet these minimum criteria. Urine specimens are frequently positive regardless of symptoms. These observations underscore the need to reconsider the diagnosis and the initiation of treatment for suspected UTIs in advanced dementia. © 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.

Pediatric Program Director Minimum Milestone Expectations before Allowing Supervision of Others and Unsupervised Practice.

PubMed

Li, Su-Ting T; Tancredi, Daniel J; Schwartz, Alan; Guillot, Ann; Burke, Ann E; Trimm, R Franklin; Guralnick, Susan; Mahan, John D; Gifford, Kimberly

2018-04-25

The Accreditation Council for Graduate Medical Education requires semiannual Milestone reporting on all residents. Milestone expectations of performance are unknown. Determine pediatric program director (PD) minimum Milestone expectations for residents prior to being ready to supervise and prior to being ready to graduate. Mixed methods survey of pediatric PDs on their programs' Milestone expectations before residents are ready to supervise and before they are ready to graduate, and in what ways PDs use Milestones to make supervision and graduation decisions. If programs had no established Milestone expectations, PDs indicated expectations they considered for use in their program. Mean minimum Milestone level expectations adjusted for program size, region, and clustering of Milestone expectations by program were calculated for prior to supervise and prior to graduate. Free-text questions were analyzed using thematic analysis. The response rate was 56.8% (113/199). Most programs had no required minimum Milestone level before residents are ready to supervise (80%; 76/95) or ready to graduate (84%; 80/95). For readiness to supervise, minimum Milestone expectations PDs considered establishing for their program were highest for humanism (2.46, 95% CI: 2.21-2.71) and professionalization (2.37, 2.15-2.60). Minimum Milestone expectations for graduates were highest for help-seeking (3.14, 2.83-3.46). Main themes included the use of Milestones in combination with other information to assess learner performance and Milestones are not equally weighted when making advancement decisions. Most PDs have not established program minimum Milestones, but would vary such expectations by competency. Copyright © 2018. Published by Elsevier Inc.

40 CFR 60.692-5 - Standards: Closed vent systems and control devices.

Code of Federal Regulations, 2011 CFR

2011-07-01

... residence time of 0.75 seconds at a minimum temperature of 816 °C (1,500 °F). (b) Vapor recovery systems... comply with provisions of this subpart shall be operated at all times when emissions may be vented to... purged to direct vapor to the control device. (3) A flow indicator shall be installed on a vent stream to...

40 CFR 60.692-5 - Standards: Closed vent systems and control devices.

Code of Federal Regulations, 2013 CFR

2013-07-01

... residence time of 0.75 seconds at a minimum temperature of 816 °C (1,500 °F). (b) Vapor recovery systems... comply with provisions of this subpart shall be operated at all times when emissions may be vented to... purged to direct vapor to the control device. (3) A flow indicator shall be installed on a vent stream to...

40 CFR 60.692-5 - Standards: Closed vent systems and control devices.

Code of Federal Regulations, 2012 CFR

2012-07-01

... residence time of 0.75 seconds at a minimum temperature of 816 °C (1,500 °F). (b) Vapor recovery systems... comply with provisions of this subpart shall be operated at all times when emissions may be vented to... purged to direct vapor to the control device. (3) A flow indicator shall be installed on a vent stream to...

40 CFR 60.692-5 - Standards: Closed vent systems and control devices.

Code of Federal Regulations, 2014 CFR

2014-07-01

... residence time of 0.75 seconds at a minimum temperature of 816 °C (1,500 °F). (b) Vapor recovery systems... comply with provisions of this subpart shall be operated at all times when emissions may be vented to... purged to direct vapor to the control device. (3) A flow indicator shall be installed on a vent stream to...

Fast growing, healthy and resident green turtles (Chelonia mydas) at two neritic sites in the central and northern coast of Peru: implications for conservation.

PubMed

Velez-Zuazo, Ximena; Quiñones, Javier; Pacheco, Aldo S; Klinge, Luciana; Paredes, Evelyn; Quispe, Sixto; Kelez, Shaleyla

2014-01-01

In order to enhance protection and conservation strategies for endangered green turtles (Chelonia mydas), the identification of neritic habitats where this species aggregates is mandatory. Herein, we present new information about the population parameters and residence time of two neritic aggregations from 2010 to 2013; one in an upwelling dominated site (Paracas ∼14°S) and the other in an ecotone zone from upwelling to warm equatorial conditions (El Ñuro ∼4°S) in the Southeast Pacific. We predicted proportionally more adult individuals would occur in the ecotone site; whereas in the site dominated by an upwelling juvenile individuals would predominate. At El Ñuro, the population was composed by (15.3%) of juveniles, (74.9%) sub-adults, and (9.8%) adults, with an adult sex ratio of 1.16 males per female. Times of residence in the area ranged between a minimum of 121 and a maximum of 1015 days (mean 331.1 days). At Paracas the population was composed by (72%) of juveniles and (28%) sub-adults, no adults were recorded, thus supporting the development habitat hypothesis stating that throughout the neritic distribution there are sites exclusively occupied by juveniles. Residence time ranged between a minimum of 65 days and a maximum of 680 days (mean 236.1). High growth rates and body condition index values were estimated suggesting healthy individuals at both study sites. The population traits recorded at both sites suggested that conditions found in Peruvian neritic waters may contribute to the recovery of South Pacific green turtles. However, both aggregations are still at jeopardy due to pollution, bycatch and illegal catch and thus require immediate enforcing of conservation measurements.

Fast Growing, Healthy and Resident Green Turtles (Chelonia mydas) at Two Neritic Sites in the Central and Northern Coast of Peru: Implications for Conservation

PubMed Central

Velez-Zuazo, Ximena; Quiñones, Javier; Pacheco, Aldo S.; Klinge, Luciana; Paredes, Evelyn; Quispe, Sixto; Kelez, Shaleyla

2014-01-01

In order to enhance protection and conservation strategies for endangered green turtles (Chelonia mydas), the identification of neritic habitats where this species aggregates is mandatory. Herein, we present new information about the population parameters and residence time of two neritic aggregations from 2010 to 2013; one in an upwelling dominated site (Paracas ∼14°S) and the other in an ecotone zone from upwelling to warm equatorial conditions (El Ñuro ∼4°S) in the Southeast Pacific. We predicted proportionally more adult individuals would occur in the ecotone site; whereas in the site dominated by an upwelling juvenile individuals would predominate. At El Ñuro, the population was composed by (15.3%) of juveniles, (74.9%) sub-adults, and (9.8%) adults, with an adult sex ratio of 1.16 males per female. Times of residence in the area ranged between a minimum of 121 and a maximum of 1015 days (mean 331.1 days). At Paracas the population was composed by (72%) of juveniles and (28%) sub-adults, no adults were recorded, thus supporting the development habitat hypothesis stating that throughout the neritic distribution there are sites exclusively occupied by juveniles. Residence time ranged between a minimum of 65 days and a maximum of 680 days (mean 236.1). High growth rates and body condition index values were estimated suggesting healthy individuals at both study sites. The population traits recorded at both sites suggested that conditions found in Peruvian neritic waters may contribute to the recovery of South Pacific green turtles. However, both aggregations are still at jeopardy due to pollution, bycatch and illegal catch and thus require immediate enforcing of conservation measurements. PMID:25409240

Mental dysfunction and resource use in nursing homes.

PubMed

Fries, B E; Mehr, D R; Schneider, D; Foley, W J; Burke, R

1993-10-01

The role of dementia and other mental disorders in nursing home case-mix classification systems has been an area of controversy. The role of mental dysfunctions was considered in developing a new case-mix measurement system for facility payment in a national demonstration to understand staff time use in nursing homes. Nursing staff (nurses and aides) time and resident assessment data were collected for 6,663 nursing home residents in 6 states. Measures of signs and symptoms of cognitive impairment (dementia), depression, and delirium were created based on items from the new National Minimum Data Set. These measures then were used to determine whether mental dysfunctions were predictive of resource use (nursing staff times and costs) when controlling for other case-mix variables. Cognitive impairment was associated with slightly higher staff time only in less physically-impaired residents without serious medical conditions and not receiving heavy rehabilitation. Similarly, depression and delirium were associated with higher resource use only in selected types of residents. Based on these findings, the new Resource Utilization Groups Version III (RUG-III) contain a major category of residents who are cognitively impaired but not severely dependent in Activities of Daily Living. Depression is used to differentiate subgroups of residents with major medical conditions such as hemiplegia and aphasia. Delirium, when used together with other resident characteristics, was not found useful in explaining resource use. Case-mix groups defined by mental dysfunctions can foster improved care, but careful consideration must be given to appropriate incentives and documentation requirements for providers.

Estimation of residence time in a shallow lacustrine embayment

NASA Astrophysics Data System (ADS)

Razmi, A. M.; Barry, D. A.; Lemmin, U.; Bakhtyar, R.

2012-12-01

Near-shore water quality in lacustrine bays subjected to effluent or stream discharges is affected by, amongst other things, the residence time within a given bay. Vidy Bay, located on the northern shore of Lake Geneva, Switzerland, receives discharge from a wastewater treatment plant, the Chamberonne River and a storm-water drain. The residence time of water in the bay largely depends on water exchanges with the main basin (Grand Lac) of Lake Geneva. Field investigations and modeling of the hydrodynamics of Vidy Bay have shown that currents are variable, due mainly to wind variability over the lake. However, in broad terms there are two main current patterns in the bay, (i) currents are linked to large gyres in the Grand Lac, or (ii) currents are partially independent of the Grand Lac and are controlled by small-scale gyres within the bay. Residence times in Vidy Bay were computed using the hydrodynamic model Delft3D. Since the Vidy Bay shoreline follows a shallow arc, the definition of the off-shore extent of the bay is ambiguous. Here, the largest within-bay gyre is used. Particle tracking was conducted for each of the three discharges into the bay. Model results were computed using meteorological data for 2010, and thus include the natural variability in wind patterns and seasonal stratification. An analysis of the results shows that a water parcel from the waste water outfall has a residence time ranging from hours to days. The water residence time is minimum near to the surface and maximum at the near bottom layer. The results confirmed that wind force, thermal stratification, and water depth are the main factors influencing residence time.

40 CFR 63.1365 - Test methods and initial compliance procedures.

Code of Federal Regulations, 2012 CFR

2012-07-01

... temperature of 760 °C, the design evaluation must document that these conditions exist. (ii) For a combustion... autoignition temperature of the organic HAP, must consider the vent stream flow rate, and must establish the design minimum and average temperature in the combustion zone and the combustion zone residence time. (B...

40 CFR 63.1365 - Test methods and initial compliance procedures.

Code of Federal Regulations, 2010 CFR

2010-07-01

... temperature of 760 °C, the design evaluation must document that these conditions exist. (ii) For a combustion... autoignition temperature of the organic HAP, must consider the vent stream flow rate, and must establish the design minimum and average temperature in the combustion zone and the combustion zone residence time. (B...

40 CFR 63.1365 - Test methods and initial compliance procedures.

Code of Federal Regulations, 2011 CFR

2011-07-01

... temperature of 760 °C, the design evaluation must document that these conditions exist. (ii) For a combustion... autoignition temperature of the organic HAP, must consider the vent stream flow rate, and must establish the design minimum and average temperature in the combustion zone and the combustion zone residence time. (B...

40 CFR 63.1365 - Test methods and initial compliance procedures.

Code of Federal Regulations, 2014 CFR

2014-07-01

... temperature of 760 °C, the design evaluation must document that these conditions exist. (ii) For a combustion... autoignition temperature of the organic HAP, must consider the vent stream flow rate, and must establish the design minimum and average temperature in the combustion zone and the combustion zone residence time. (B...

The clinician-educator track: training internal medicine residents as clinician-educators.

PubMed

Smith, C Christopher; McCormick, Ian; Huang, Grace C

2014-06-01

Although resident-as-teacher programs bring postgraduate trainees' teaching skills to a minimum threshold, intensive, longitudinal training is lacking for residents who wish to pursue careers in medical education. The authors describe the development, implementation, and preliminary assessment of the novel track for future clinician-educators that they introduced in the internal medicine residency program at Beth Israel Deaconess Medical Center in 2010. Categorical medical interns with a career interest in medical education apply to participate in the clinician-educator track (CET) at the midpoint of their first postgraduate year. CET residents complete a 2.5-year curriculum in which they review foundations of medical education, design and assess new curricula, and evaluate learners and programs. They apply these skills in a variety of clinical settings and receive frequent feedback from faculty and peers. All CET residents design and implement at least one medical education research project. A comprehensive evaluation plan to assess the impact of the CET on resident teaching skills, scholarly productivity, career selection, and advancement is under way. A preliminary evaluation demonstrates high satisfaction with the track among the first cohort of CET residents, who graduated in 2012. Compared with residents in the traditional resident-as-teacher program, CET residents reported higher gains in their confidence in core medical education skills. Although these preliminary data are promising, data will be collected over the next several years to explore whether the additional curricular time, faculty time, and costs and potential expansion to other institutions are justified.

Flow convergence caused by a salinity minimum in a tidal channel

USGS Publications Warehouse

Warner, John C.; Schoellhamer, David H.; Burau, Jon R.; Schladow, S. Geoffrey

2006-01-01

Residence times of dissolved substances and sedimentation rates in tidal channels are affected by residual (tidally averaged) circulation patterns. One influence on these circulation patterns is the longitudinal density gradient. In most estuaries the longitudinal density gradient typically maintains a constant direction. However, a junction of tidal channels can create a local reversal (change in sign) of the density gradient. This can occur due to a difference in the phase of tidal currents in each channel. In San Francisco Bay, the phasing of the currents at the junction of Mare Island Strait and Carquinez Strait produces a local salinity minimum in Mare Island Strait. At the location of a local salinity minimum the longitudinal density gradient reverses direction. This paper presents four numerical models that were used to investigate the circulation caused by the salinity minimum: (1) A simple one-dimensional (1D) finite difference model demonstrates that a local salinity minimum is advected into Mare Island Strait from the junction with Carquinez Strait during flood tide. (2) A three-dimensional (3D) hydrodynamic finite element model is used to compute the tidally averaged circulation in a channel that contains a salinity minimum (a change in the sign of the longitudinal density gradient) and compares that to a channel that contains a longitudinal density gradient in a constant direction. The tidally averaged circulation produced by the salinity minimum is characterized by converging flow at the bed and diverging flow at the surface, whereas the circulation produced by the constant direction gradient is characterized by converging flow at the bed and downstream surface currents. These velocity fields are used to drive both a particle tracking and a sediment transport model. (3) A particle tracking model demonstrates a 30 percent increase in the residence time of neutrally buoyant particles transported through the salinity minimum, as compared to transport through a constant direction density gradient. (4) A sediment transport model demonstrates increased deposition at the near-bed null point of the salinity minimum, as compared to the constant direction gradient null point. These results are corroborated by historically noted large sedimentation rates and a local maximum of selenium accumulation in clams at the null point in Mare Island Strait.

Effects of gas residence time of CH4/H2 on sp2 fraction of amorphous carbon films and dissociated methyl density during radical-injection plasma-enhanced chemical vapor deposition

NASA Astrophysics Data System (ADS)

Sugiura, Hirotsugu; Jia, Lingyun; Kondo, Hiroki; Ishikawa, Kenji; Tsutsumi, Takayoshi; Hayashi, Toshio; Takeda, Keigo; Sekine, Makoto; Hori, Masaru

2018-06-01

Quadruple mass spectrometric measurements of CH3 density during radical-injection plasma-enhanced chemical vapor deposition to consider the sp2 fraction of amorphous carbon (a-C) films were performed. The sp2 fraction of the a-C films reached a minimum of 46%, where the CH3 density was maximum for a residence time of 6 ms. The sp2 fraction of the a-C films was tailored with the gaseous phase CH3 density during the deposition. This knowledge is useful for understanding the formation mechanism of bonding structures in the a-C films, which enables the precise control of their electronic properties.

Green House Adoption and Nursing Home Quality.

PubMed

Afendulis, Christopher C; Caudry, Daryl J; O'Malley, A James; Kemper, Peter; Grabowski, David C

2016-02-01

To evaluate the impact of the Green House (GH) model on nursing home resident-level quality of care measures. Resident-level minimum data set (MDS) assessments merged with Medicare inpatient claims for the period 2005 through 2010. Using a difference-in-differences framework, we compared changes in care quality and outcomes in 15 nursing homes that adopted the GH model relative to changes over the same time period in 223 matched nursing homes that had not adopted the GH model. For individuals residing in GH homes, adoption of the model lowered readmissions and several MDS measures of poor quality, including bedfast residents, catheter use, and pressure ulcers, but these results were not present across the entire GH organization, suggesting possible offsetting effects for residents of non-GH "legacy" units within the GH organization. GH adoption led to improvement in rehospitalizations and certain nursing home quality measures for individuals residing in a GH home. The absence of evidence of a decline in other clinical quality measures in GH nursing homes should reassure anyone concerned that GH might have sacrificed clinical quality for improved quality of life. © Health Research and Educational Trust.

Why are hospital-based nursing homes so costly? Relative importance of acuity and treatment setting.

PubMed

Pizer, Steven D; White, Alan J; White, Chapin

2002-05-01

To determine the extent to which higher costs in hospital-based skilled nursing facilities (HBSNF) can be explained by observable resident characteristics and unobservable selection effects, implying a design shortcoming of the skilled nursing facility prospective payment system (SNF PPS) implemented for Medicare-covered stays by the Balanced Budget Act of 1997 (BBA 1997). Data on resident characteristics from the Minimum Data Set (MDS) are combined with staff time costs from the Centers for Medicare and Medicaid Services' (CMS, formerly HCFA) 1995 and 1997 SNF Staff Time Measurement (STM) studies and nontherapy ancillary claim costs extracted from CMS SNF claim records. An endogenous switching model was estimated to measure the effect on costs of the relatively high acuity of HBSNF residents, net of differences purely attributable to the treatment setting. It was found that virtually the entire HBSNF differential is attributable to setting effects with resident characteristics and selection effects playing a negligible role. In addition, it was found that marginal costs associated with particular services and conditions are often lower in hospital-based than in freestanding facilities. HBSNFs incur high costs regardless of the characteristics of their residents. Their high fixed costs accompany relatively low marginal costs associated with admitting high-acuity residents. Consequently, a PPS casemix system that depends on resident characteristics and excludes consideration of facility characteristics (as mandated by BBA 1997) need not unfairly penalize HBSNFs, provided a powerful casemix system is used and HBSNFs specialize in the care of high-acuity residents.

A review of general cosmetic surgery training in fellowship programs offered by the American Academy of Cosmetic Surgery.

PubMed

Handler, Ethan; Tavassoli, Javad; Dhaliwal, Hardeep; Murray, Matthew; Haiavy, Jacob

2015-04-01

We sought, first, to evaluate the operative experience of surgeons who have completed postresidency fellowships offered by the American Academy of Cosmetic Surgery (AACS), and second, to compare this cosmetic surgery training to other surgical residency and fellowship programs in the United States. Finally, we suggest how new and existing oral and maxillofacial surgeons can use these programs. We reviewed the completed case logs from AACS-accredited fellowships. The logs were data mined for 7 of the most common cosmetic operations, including the median total number of operations. We then compared the cosmetic case requirements from the different residencies and fellowships. Thirty-nine case logs were reviewed from the 1-year general cosmetic surgery fellowships offered by the AACS from 2007 to 2012. The fellows completed a median of 687 total procedures. The median number of the most common cosmetic procedures performed was 14 rhinoplasties, 31 blepharoplasties, 21 facelifts, 24 abdominoplasties, 28 breast mastopexies, 103 breast augmentations, and 189 liposuctions. The data obtained were compared with the minimum cosmetic surgical requirements in residency and fellowship programs. The minimum residency requirements were as follows: no minimum listed for plastic surgery, 35 for otolaryngology, 20 for oral and maxillofacial surgery, 28 for ophthalmology, 0 for obstetrics and gynecology, and 20 for dermatology. The minimum fellowship requirements were as follows: 300 for the AACS cosmetic surgery fellowship, no minimum listed for facial plastic surgery and reconstruction, no minimum listed for aesthetic surgery, 133 for oculoplastic and reconstructive surgery, and 0 for Mohs dermatology. Dedicating one's practice exclusively to cosmetic surgery requires additional postresidency training owing to the breadth of the field. The AACS created comprehensive fellowship programs to fill an essential part in the continuum of cosmetic surgeons' education, training, and experience. This builds on the foundation of their primary board residency program. The AACS fellowships are a valuable option for additional training for qualified surgeons seeking proficiency and competency in cosmetic surgery. Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

10 CFR 35.490 - Training for use of manual brachytherapy sources.

Code of Federal Regulations, 2014 CFR

2014-01-01

... minimum of 3 years of residency training in a radiation oncology program approved by the Residency Review... supervised clinical experience in radiation oncology, under an authorized user who meets the requirements in... approved by the Residency Review Committee for Radiation Oncology of the Accreditation Council for Graduate...

10 CFR 35.490 - Training for use of manual brachytherapy sources.

Code of Federal Regulations, 2011 CFR

2011-01-01

... minimum of 3 years of residency training in a radiation oncology program approved by the Residency Review... supervised clinical experience in radiation oncology, under an authorized user who meets the requirements in... approved by the Residency Review Committee for Radiation Oncology of the Accreditation Council for Graduate...

10 CFR 35.490 - Training for use of manual brachytherapy sources.

Code of Federal Regulations, 2012 CFR

2012-01-01

... minimum of 3 years of residency training in a radiation oncology program approved by the Residency Review... supervised clinical experience in radiation oncology, under an authorized user who meets the requirements in... approved by the Residency Review Committee for Radiation Oncology of the Accreditation Council for Graduate...

10 CFR 35.490 - Training for use of manual brachytherapy sources.

Code of Federal Regulations, 2013 CFR

2013-01-01

... minimum of 3 years of residency training in a radiation oncology program approved by the Residency Review... supervised clinical experience in radiation oncology, under an authorized user who meets the requirements in... approved by the Residency Review Committee for Radiation Oncology of the Accreditation Council for Graduate...

10 CFR 35.490 - Training for use of manual brachytherapy sources.

Code of Federal Regulations, 2010 CFR

2010-01-01

... minimum of 3 years of residency training in a radiation oncology program approved by the Residency Review... supervised clinical experience in radiation oncology, under an authorized user who meets the requirements in... approved by the Residency Review Committee for Radiation Oncology of the Accreditation Council for Graduate...

Aerosol reactor production of uniform submicron powders

NASA Technical Reports Server (NTRS)

Flagan, Richard C. (Inventor); Wu, Jin J. (Inventor)

1991-01-01

A method of producing submicron nonagglomerated particles in a single stage reactor includes introducing a reactant or mixture of reactants at one end while varying the temperature along the reactor to initiate reactions at a low rate. As homogeneously small numbers of seed particles generated in the initial section of the reactor progress through the reactor, the reaction is gradually accelerated through programmed increases in temperature along the length of the reactor to promote particle growth by chemical vapor deposition while minimizing agglomerate formation by maintaining a sufficiently low number concentration of particles in the reactor such that coagulation is inhibited within the residence time of particles in the reactor. The maximum temperature and minimum residence time is defined by a combination of temperature and residence time that is necessary to bring the reaction to completion. In one embodiment, electronic grade silane and high purity nitrogen are introduced into the reactor and temperatures of approximately 770.degree. K. to 1550.degree. K. are employed. In another embodiment silane and ammonia are employed at temperatures from 750.degree. K. to 1800.degree. K.

Aerosol reactor production of uniform submicron powders

DOEpatents

Flagan, Richard C.; Wu, Jin J.

1991-02-19

A method of producing submicron nonagglomerated particles in a single stage reactor includes introducing a reactant or mixture of reactants at one end while varying the temperature along the reactor to initiate reactions at a low rate. As homogeneously small numbers of seed particles generated in the initial section of the reactor progress through the reactor, the reaction is gradually accelerated through programmed increases in temperature along the length of the reactor to promote particle growth by chemical vapor deposition while minimizing agglomerate formation by maintaining a sufficiently low number concentration of particles in the reactor such that coagulation is inhibited within the residence time of particles in the reactor. The maximum temperature and minimum residence time is defined by a combination of temperature and residence time that is necessary to bring the reaction to completion. In one embodiment, electronic grade silane and high purity nitrogen are introduced into the reactor and temperatures of approximately 770.degree. K. to 1550.degree. K. are employed. In another embodiment silane and ammonia are employed at temperatures from 750.degree. K. to 1800.degree. K.

Time spent on daytime direct care activities by personal carers in two Australian residential aged care facilities: a time-motion study.

PubMed

Qian, Siyu; Yu, Ping; Hailey, David M; Zhang, Zhenyu; Davy, Pamela J; Nelson, Mark I

2014-05-01

To examine the time, frequency and duration of each direct care activity conducted by personal carers in Australian residential aged care homes. A time-motion study was conducted to observe 46 personal carers at two high-care houses in two facilities (14 days at Site 1 and 16 days at Site 2). Twenty-three direct care activities were classified into eight categories for analysis. Overall, a personal carer spent approximately 45% of their time on direct care, corresponding to 3.5h in an 8-h daytime shift. The two sites had similar ratios of personal carers to residents, and each resident received 30 min of direct care. No significant differences between the two sites were found in the time spent on oral communication, personal hygiene and continence activities. Personal carers at Site 1 spent significantly less time on toileting and mobility activities than those at Site 2, but more time on lunch activity. Although oral communication took the longest time (2h), it occurred concurrently with other activities (e.g. dressing) for 1.5h. The findings provide information that may assist decision makers in managing the operation of high-care residential aged care facilities, such as planning for task allocation and staffing. What is known about the topic? Overall, 30%-45% of the care staff's time is spent on direct care in residential aged care facilities. What does this paper add? This paper adds knowledge about how much time is required to conduct each direct care activity and the frequency and duration of conducting these activities to meet residents' day-to-day care needs in two high-care houses in two aged care facilities. What are the implications for practitioners? On average, a resident with high-care needs requires 30 min direct care. There may exist a basic minimum desirable ratio of personal carers to residents in high-care facilities. Residents' toileting needs are high after meals. Communication with residents represents an essential role in providing care.

Medicaid Bed-Hold Policies and Hospitalization of Long-Stay Nursing Home Residents

PubMed Central

Unruh, Mark Aaron; Grabowski, David C; Trivedi, Amal N; Mor, Vincent

2013-01-01

Objective To evaluate the effect of Medicaid bed-hold policies on hospitalization of long-stay nursing home residents. Data Sources A nationwide random sample of long-stay nursing home residents with data elements from Medicare claims and enrollment files, the Minimum Data Set, the Online Survey Certification and Reporting System, and Area Resource File. The sample consisted of 22,200,089 person-quarters from 754,592 individuals who became long-stay residents in 17,149 nursing homes over the period beginning January 1, 2000 through December 31, 2005. Study Design Linear regression models using a pre/post design adjusted for resident, nursing home, market, and state characteristics. Nursing home and year-quarter fixed effects were included to control for time-invariant facility influences and temporal trends associated with hospitalization of long-stay residents. Principal Findings Adoption of a Medicaid bed-hold policy was associated with an absolute increase of 0.493 percentage points (95% CI: 0.039–0.946) in hospitalizations of long-stay nursing home residents, representing a 3.883 percent relative increase over the baseline mean. Conclusions Medicaid bed-hold policies may increase the likelihood of hospitalization of long-stay nursing home residents and increase costs for the federal Medicare program. PMID:23521571

Otolaryngology Residency Program Research Resources and Scholarly Productivity.

PubMed

Villwock, Jennifer A; Hamill, Chelsea S; Nicholas, Brian D; Ryan, Jesse T

2017-06-01

Objective To delineate research resources available to otolaryngology residents and their impact on scholarly productivity. Study Design Survey of current otolaryngology program directors. Setting Otolaryngology residency programs. Subjects and Methods An anonymous web-based survey was sent to 98 allopathic otolaryngology training program directors. Fisher exact tests and nonparametric correlations were used to determine statistically significant differences among various strata of programs. Results Thirty-nine percent (n = 38) of queried programs responded. Fourteen (37%) programs had 11 to 15 full-time, academic faculty associated with the residency program. Twenty (53%) programs have a dedicated research coordinator. Basic science lab space and financial resources for statistical work were present at 22 programs (58%). Funding is uniformly provided for presentation of research at conferences; a minority of programs (13%) only funded podium presentations. Twenty-four (63%) have resident research requirements beyond the Accreditation Council for Graduate Medical Education (ACGME) mandate of preparing a "manuscript suitable for publication" prior to graduation. Twenty-five (67%) programs have residents with 2 to 3 active research projects at any given time. None of the investigated resources were significantly associated with increased scholarly output. There was no uniformity to research curricula. Conclusions Otolaryngology residency programs value research, evidenced by financial support provided and requirements beyond the ACGME minimum. Additional resources were not statistically related to an increase in resident research productivity, although they may contribute positively to the overall research experience during training. Potential future areas to examine include research curricula best practices, how to develop meaningful mentorship and resource allocation that inspires continued research interest, and intellectual stimulation.

Resident outcomes in small-house nursing homes: a longitudinal evaluation of the initial green house program.

PubMed

Kane, Rosalie A; Lum, Terry Y; Cutler, Lois J; Degenholtz, Howard B; Yu, Tzy-Chyi

2007-06-01

To determine the effects of a small-house nursing home model, THE GREEN HOUSE (GH), on residents' reported outcomes and quality of care. Two-year longitudinal quasi-experimental study comparing GH residents with residents at two comparison sites using data collected at baseline and three follow-up intervals. Four 10-person GHs, the sponsoring nursing home for those GHs, and a traditional nursing home with the same owner. All residents in the GHs (40 at any time) at baseline and three 6-month follow-up intervals, and 40 randomly selected residents in each of the two comparison groups. The GH alters the physical scale environment (small-scale, private rooms and bathrooms, residential kitchen, dining room, and hearth), the staffing model for professional and certified nursing assistants, and the philosophy of care. Scales for 11 domains of resident quality of life, emotional well-being, satisfaction, self-reported health, and functional status were derived from interviews at four points in time. Quality of care was measured using indicators derived from Minimum Data Set assessments. Controlling for baseline characteristics (age, sex, activities of daily living, date of admission, and proxy interview status), statistically significant differences in self-reported dimensions of quality of life favored the GHs over one or both comparison groups. The quality of care in the GHs at least equaled, and for change in functional status exceeded, the comparison nursing homes. The GH is a promising model to improve quality of life for nursing home residents, with implications for staff development and medical director roles.

Refining a case-mix measure for nursing homes: Resource Utilization Groups (RUG-III).

PubMed

Fries, B E; Schneider, D P; Foley, W J; Gavazzi, M; Burke, R; Cornelius, E

1994-07-01

A case-mix classification system for nursing home residents is developed, based on a sample of 7,658 residents in seven states. Data included a broad assessment of resident characteristics, corresponding to items of the Minimum Data Set, and detailed measurement of nursing staff care time over a 24-hour period and therapy staff time over a 1-week period. The Resource Utilization Groups, Version III (RUG-III) system, with 44 distinct groups, achieves 55.5% variance explanation of total (nursing and therapy) per diem cost and meets goals of clinical validity and payment incentives. The mean resource use (case-mix index) of groups spans a nine-fold range. The RUG-III system improves on an earlier version not only by increasing the variance explanation (from 43%), but, more importantly, by identifying residents with "high tech" procedures (e.g., ventilators, respirators, and parenteral feeding) and those with cognitive impairments; by using better multiple activities of daily living; and by providing explicit qualifications for the Medicare nursing home benefit. RUG-III is being implemented for nursing home payment in 11 states (six as part of a federal multistate demonstration) and can be used in management, staffing level determination, and quality assurance.

Applying Resource Utilization Groups (RUG-III) in Hong Kong nursing homes.

PubMed

Chou, Kee-Lee; Chi, Iris; Leung, Joe C B

2008-01-01

Resource Utilization Groups III (RUG-III) is a case-mix system developed in the United States for categorization of nursing home residents and the financing of residential care services. In Hong Kong, RUG-III is based on several board groups of residents. The aim of this study was to examine the reliability and validity of the RUG-III in Hong Kong nursing homes. A cross-sectional survey was conducted in seven residential facilities operated by one agency. Residents ( N = 1,127) were assessed by the Minimum Data Set (MDS) and nursing as well as auxiliary staff care times were recorded within 2 weeks before or after the completion of MDS assessment. Forty-five out 1,127 residents were re-interviewed by an independent assessor to assess the inter-rater reliability. The inter-rater reliability of MDS assessment was excellent (kappa = 0.76) and the original RUG-III accounted for about 30 per cent of nursing staff time. Results provide preliminary evidence to support that RUG-III is a reliable and valid case-mix system for Hong Kong nursing homes, but future studies must be explored to reduce the variance of resource use explained by this case-mix system.

A Perspective on the Effect of the 80-Hour Work Week: Has It Changed the Graduating Orthopaedic Resident?

PubMed

Pellegrini, Vincent D

2017-06-01

Orthopaedic residency education has changed substantially in recent decades because of the imposition of the 80-hour work week, a decrease in quality and quantity of general surgical education, regulations mandating closer trainee supervision, and an expansion of orthopaedic subspecialty rotations. These factors pose a challenge in efforts to prepare competent, confident, cautious, caring, and communicative orthopaedic residents within the traditional 5-year program. Evidence suggests that contemporary graduates are more intelligent, better balanced in life and work, and more in touch with humanistic aspects of medicine than were earlier graduates. Yet insufficient competence and confidence in surgical skills after residency and a lack of "ownership" of patient care have become an increasing concern of educators and trainees. The concept of 10,000 hours of deliberate practice to achieve mastery of a technical skill applies to orthopaedic residency education. A different approach to graduate medical education must address the critical minimum training time required to achieve the necessary skills to support independent medical and surgical practice.

The effect of catalyst length and downstream reactor distance on catalytic combustor performance

NASA Technical Reports Server (NTRS)

Anderson, D.

1980-01-01

A study was made to determine the effects on catalytic combustor performance which resulted from independently varying the length of a catalytic reactor and the length available for gas-phase reactions downstream of the catalyst. Monolithic combustion catalysts from three manufacturers were tested in a combustion test rig with no. 2 diesel fuel. Catalytic reactor lengths of 2.5 and 5.4 cm, and downstream gas-phase reaction distances of 7.3, 12.4, 17.5, and 22.5 cm were evaluated. Measurements of carbon monoxide, unburned hydrocarbons, nitrogen oxides, and pressure drop were made. The catalytic-reactor pressure drop was less than 1 percent of the upstream total pressure for all test configurations and test conditions. Nitrogen oxides and unburned hydrocarbons emissions were less than 0.25 g NO2/kg fuel and 0.6 g HC/kg fuel, respectively. The minimum operating temperature (defined as the adiabatic combustion temperature required to obtain carbon monoxide emissions below a reference level of 13.6 g CO/kg fuel) ranged from 1230 K to 1500 K for the various conditions and configurations tested. The minimum operating temperature decreased with increasing total (catalytic-reactor-plus-downstream-gas-phase-reactor-zone) residence time but was independent of the relative times spent in each region when the catalytic-reactor residence time was greater than or equal to 1.4 ms.

Factors that affect the willingness of residents to pay for solid waste management in Hong Kong.

PubMed

Yeung, Iris M H; Chung, William

2018-03-01

In Hong Kong, problems involving solid waste management have become an urgent matter in recent years. To solve these problems, the Hong Kong government proposed three policies, namely, waste charging, landfill extension, and development of new incinerators. In this study, a large sample questionnaire survey was conducted to examine the knowledge and attitude of residents on the three policies, the amount of their daily waste disposal, and their willingness to pay (WTP). Results reveal that only 22.7% of respondents are aware of the earliest time that one of the landfills will be sated, and more than half of respondents support the three policies. However, more than one third of residents (36.1%) are unwilling to pay the minimum waste charge amount of HK$30 estimated by the Council for Sustainable Development in Hong Kong. Logit model results indicate that five key factors affect WTP, namely, knowledge of residents on the timing of landfill fullness, degree of support in waste charge policy, amount of daily waste disposal, age, and income. These results suggest that strong and rigorous promotional and educational programs are needed to improve the knowledge and positive attitude of residents towards recycling methods and the three policies. However, subsidy should be provided to low-income groups who cannot afford to pay the waste charge.

Anticipated Supply and Demand for Independent Interventional Radiology Residency Positions: A Survey of Department Chairs.

PubMed

Herwald, Sanna E; Spies, James B; Yucel, E Kent

2017-02-01

The first participants in the independent interventional radiology (IR) residency match will begin prerequisite diagnostic radiology (DR) residencies before the anticipated launch of the independent IR programs in 2020. The aim of this study was to estimate the competitiveness level of the first independent IR residency matches before these applicants have already committed to DR residencies and possibly early specialization in IR (ESIR) programs. The Society of Chairs of Academic Radiology Departments (SCARD) Task Force on the IR Residency distributed a survey to all active SCARD members using SurveyMonkey. The survey requested the number of planned IR residency and ESIR positions. The average, minimum, and maximum of the range of planned independent IR residency positions were compared with the average, maximum, and minimum, respectively, of the range of planned ESIR positions, to model matches of average, high, and low competitiveness. Seventy-four active SCARD members (56%) answered at least one survey question. The respondents' programs planned to fill, in total, 98 to 102 positions in integrated IR residency programs, 61 to 76 positions in independent IR residency programs, and 50 to 77 positions in ESIR DR residency programs each year. The ranges indicate the uncertainty of some programs regarding the number of positions. The survey suggests that participating programs will fill sufficient independent IR residency positions to accommodate all ESIR applicants in a match year of average or low competitiveness, but not in a match year of high competitiveness. This suggestion does not account for certain difficult-to-predict factors that may affect the independent IR residency match. Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Pain and Aggression in Nursing Home Residents With Dementia: Minimum Data Set 3.0 Analysis.

PubMed

Ahn, Hyochol; Garvan, Cynthia; Lyon, Debra

2015-01-01

Few studies have examined the potential relationship between pain and aggressive behavioral symptoms in nursing home (NH) residents with dementia as a function of resident communicative status (ability to self-report pain). The objective of this study was to examine the relationship between pain and aggression for residents who self-reported pain and for those whose pain was measured by staff evaluation of pain-related behaviors. This is a secondary analysis of the comprehensive data collected from January to March 2012 in the national Minimum Data Set (MDS) 3.0 of NH residents, aged 65 years or older, with dementia (N = 71,227). Pain was measured using the MDS Pain Assessment Interview for residents who could communicate or by staff evaluation using the MDS Pain Behavior Scale for residents who could not communicate. The relationship between pain and aggressive behavioral symptoms was estimated from logistic regression models after controlling for covariates (functional/cognitive impairments, pain medications, comorbidities, and sociodemographic variables). In residents who could not communicate, pain was associated with both verbal and physical aggression (verbal aggression: adjusted odds ratio [AOR] = 1.23, 95% CI [1.17, 1.29]; physical aggression: AOR = 1.20, 95% CI [1.14, 1.26]). In residents who could communicate, pain was associated with verbal aggression only (AOR = 1.12, 95% CI [1.04, 1.18]). The relationship between pain and aggressive behavioral symptoms varies according to the communicative status of NH residents and disproportionately affects those who cannot articulate their pain. Strategies for enhancing pain management in these residents are needed to adequately treat pain and reduce aggression.

Resident and Facility Factors Associated With the Incidence of Urinary Tract Infections Identified in the Nursing Home Minimum Data Set.

PubMed

Castle, Nicholas; Engberg, John B; Wagner, Laura M; Handler, Steven

2017-02-01

This research examined resident and facility-specific factors associated with a diagnosis of a urinary tract infection (UTI) in the nursing home setting. Minimum Data Set and Online Survey, Certification and Reporting system data were used to identify all nursing home residents in the United States on April 1, 2006, who did not have a UTI ( n = 1,138,418). Residents were followed until they contracted a UTI (9.5%), died (8.3%), left the nursing home (33.2%), or the year ended (49.0%). A Cox proportional hazards model was estimated, controlling for resident and facility characteristics and for the state of residence. The presence of an indwelling catheter was the primary predictor of whether a resident contracted a UTI (adjusted incidence ratio = 3.35, p < .001), but only 6.1% of the residents in the sample had such a catheter. Therefore, only one eighth of the UTIs were contracted by residents with a catheter. Thus, subsequent analysis examined the populations with and without catheters separately. Demographic characteristics (such as age) have a much greater association with incidence among residents without catheters. The association with facility factors such as percentage of Medicaid residents, for-profit, and chain status was less significant. Estimates regarding staffing levels indicate that increased contact hours with more highly educated nursing staff are associated with less catheter use. Several facility-specific risk factors are of significance. Of significance, UTIs may be reduced by modifying factors such as staffing levels.

Psychosocial assessment of nursing home residents via MDS 3.0: recommendations for social service training, staffing, and roles in interdisciplinary care.

PubMed

Simons, Kelsey; Connolly, Robert P; Bonifas, Robin; Allen, Priscilla D; Bailey, Kathleen; Downes, Deirdre; Galambos, Colleen

2012-02-01

The Minimum Data Set 3.0 has introduced a higher set of expectations for assessment of residents' psychosocial needs, including new interviewing requirements, new measures of depression and resident choice, and new discharge screening procedures. Social service staff are primary providers of psychosocial assessment and care in nursing homes; yet, research demonstrates that many do not possess the minimum qualifications, as specified in federal regulations, to effectively provide these services given the clinical complexity of this client population. Likewise, social service caseloads generally exceed manageable levels. This article addresses the need for enhanced training and support of social service and interdisciplinary staff in long term care facilities in light of the new Minimum Data Set 3.0 assessment procedures as well as new survey and certification guidelines emphasizing quality of life. A set of recommendations will be made with regard to training, appropriate role functions within the context of interdisciplinary care, and needs for more realistic staffing ratios. Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.

Importation, Antibiotics, and Clostridium difficile Infection in Veteran Long-Term Care: A Multilevel Case-Control Study.

PubMed

Brown, Kevin A; Jones, Makoto; Daneman, Nick; Adler, Frederick R; Stevens, Vanessa; Nechodom, Kevin E; Goetz, Matthew B; Samore, Matthew H; Mayer, Jeanmarie

2016-06-21

Although clinical factors affecting a person's susceptibility to Clostridium difficile infection are well-understood, little is known about what drives differences in incidence across long-term care settings. To obtain a comprehensive picture of individual and regional factors that affect C difficile incidence. Multilevel longitudinal nested case-control study. Veterans Health Administration health care regions, from 2006 through 2012. Long-term care residents. Individual-level risk factors included age, number of comorbid conditions, and antibiotic exposure. Regional risk factors included importation of cases of acute care C difficile infection per 10 000 resident-days and antibiotic use per 1000 resident-days. The outcome was defined as a positive result on a long-term care C difficile test without a positive result in the prior 8 weeks. 6012 cases (incidence, 3.7 cases per 10 000 resident-days) were identified in 86 regions. Long-term care C difficile incidence (minimum, 0.6 case per 10 000 resident-days; maximum, 31.0 cases per 10 000 resident-days), antibiotic use (minimum, 61.0 days with therapy per 1000 resident-days; maximum, 370.2 days with therapy per 1000 resident-days), and importation (minimum, 2.9 cases per 10 000 resident-days; maximum, 341.3 cases per 10 000 resident-days) varied substantially across regions. Together, antibiotic use and importation accounted for 75% of the regional variation in C difficile incidence (R2 = 0.75). Multilevel analyses showed that regional factors affected risk together with individual-level exposures (relative risk of regional antibiotic use, 1.36 per doubling [95% CI, 1.15 to 1.60]; relative risk of importation, 1.23 per doubling [CI, 1.14 to 1.33]). Case identification was based on laboratory criteria. Admission of residents with recent C difficile infection from non-Veterans Health Administration acute care sources was not considered. Only 25% of the variation in regional C difficile incidence in long-term care remained unexplained after importation from acute care facilities and antibiotic use were accounted for, which suggests that improved infection control and antimicrobial stewardship may help reduce the incidence of C difficile in long-term care settings. U.S. Department of Veterans Affairs and Centers for Disease Control and Prevention.

28 CFR 115.341 - Obtaining information from residents.

Code of Federal Regulations, 2012 CFR

2012-07-01

... ACT NATIONAL STANDARDS Standards for Juvenile Facilities Screening for Risk of Sexual Victimization... use information about each resident's personal history and behavior to reduce the risk of sexual abuse... instrument. (c) At a minimum, the agency shall attempt to ascertain information about: (1) Prior sexual...

28 CFR 115.341 - Obtaining information from residents.

Code of Federal Regulations, 2013 CFR

2013-07-01

... ACT NATIONAL STANDARDS Standards for Juvenile Facilities Screening for Risk of Sexual Victimization... use information about each resident's personal history and behavior to reduce the risk of sexual abuse... instrument. (c) At a minimum, the agency shall attempt to ascertain information about: (1) Prior sexual...

28 CFR 115.341 - Obtaining information from residents.

Code of Federal Regulations, 2014 CFR

2014-07-01

... ACT NATIONAL STANDARDS Standards for Juvenile Facilities Screening for Risk of Sexual Victimization... use information about each resident's personal history and behavior to reduce the risk of sexual abuse... instrument. (c) At a minimum, the agency shall attempt to ascertain information about: (1) Prior sexual...

Study of the motion and deposition of micro particles in a vertical tube containing uniform gas flow

NASA Astrophysics Data System (ADS)

Abolpour, Bahador; Afsahi, M. Mehdi; Soltani Goharrizi, Ataallah; Azizkarimi, Mehdi

2017-12-01

In this study, effects of a gaseous jet, formed in a vertical tube containing a uniform gas flow, on the injected micro particles have been investigated. A CFD model has been developed to simulate the particle motion in the tube. This simulation is very close to the experimental data. The results show that, increasing the flow rate of carrier gas or decreasing the flow rate of surrounding gas increases the effect of gaseous jet and also increases trapping rate of the particles by the tube wall. The minimum and maximum residence times of particles approach together with increasing the size of solid particles. Particles larger than 60 μm have a certain and fixed residence time at different flow rates of the carrier or surrounding gas. About 40 μm particle size has minimal trapping by the tube wall at various experimental conditions.

Thermal modelling and control of 130kw direct contact (salt/air) heat exchanger

NASA Astrophysics Data System (ADS)

Qureshi, Omer A.; Calvet, Nicolas; Armstrong, Peter R.

2017-06-01

This work investigates the transient response of a certain type of direct contact heat exchanger (DCHX) that consists of packing (Raschig Rings) to increase the surface area for effective heat transfer between molten salt and air. Molten salt from the hot tank enters the heat exchanger (HX) and exit after heating the air still in the molten form. Thermal capacitance of the HX, mainly due to packing and resident salt inside the HX, results in strong transient response. Pure delay from salt residence time may also impact transient response. Both phenomena have been modelled in this paper. A Proportional-Integral controller (PI control) performance has been evaluated to maintain the minimum salt temperature above avoid crystallization temperature of the salt.

Ground water stratification and delivery of nitrate to an incised stream under varying flow conditions.

PubMed

Böhlke, J K; O'Connell, Michael E; Prestegaard, Karen L

2007-01-01

Ground water processes affecting seasonal variations of surface water nitrate concentrations were investigated in an incised first-order stream in an agricultural watershed with a riparian forest in the coastal plain of Maryland. Aquifer characteristics including sediment stratigraphy, geochemistry, and hydraulic properties were examined in combination with chemical and isotopic analyses of ground water, macropore discharge, and stream water. The ground water flow system exhibits vertical stratification of hydraulic properties and redox conditions, with sub-horizontal boundaries that extend beneath the field and adjacent riparian forest. Below the minimum water table position, ground water age gradients indicate low recharge rates (2-5 cm yr(-1)) and long residence times (years to decades), whereas the transient ground water wedge between the maximum and minimum water table positions has a relatively short residence time (months to years), partly because of an upward increase in hydraulic conductivity. Oxygen reduction and denitrification in recharging ground waters are coupled with pyrite oxidation near the minimum water table elevation in a mottled weathering zone in Tertiary marine glauconitic sediments. The incised stream had high nitrate concentrations during high flow conditions when much of the ground water was transmitted rapidly across the riparian zone in a shallow oxic aquifer wedge with abundant outflow macropores, and low nitrate concentrations during low flow conditions when the oxic wedge was smaller and stream discharge was dominated by upwelling from the deeper denitrified parts of the aquifer. Results from this and similar studies illustrate the importance of near-stream geomorphology and subsurface geology as controls of riparian zone function and delivery of nitrate to streams in agricultural watersheds.

Ground water stratification and delivery of nitrate to an incised stream under varying flow conditions

USGS Publications Warehouse

Böhlke, J.K.; O'Connell, M. E.; Prestegaard, K.L.

2007-01-01

Ground water processes affecting seasonal variations of surface water nitrate concentrations were investigated in an incised first-order stream in an agricultural watershed with a riparian forest in the coastal plain of Maryland. Aquifer characteristics including sediment stratigraphy, geochemistry, and hydraulic properties were examined in combination with chemical and isotopic analyses of ground water, macropore discharge, and stream water. The ground water flow system exhibits vertical stratification of hydraulic properties and redox conditions, with sub-horizontal boundaries that extend beneath the field and adjacent riparian forest. Below the minimum water table position, ground water age gradients indicate low recharge rates (2-5 cm yr-1) and long residence times (years to decades), whereas the transient ground water wedge between the maximum and minimum water table positions has a relatively short residence time (months to years), partly because of an upward increase in hydraulic conductivity. Oxygen reduction and denitrification in recharging ground waters are coupled with pyrite oxidation near the minimum water table elevation in a mottled weathering zone in Tertiary marine glauconitic sediments. The incised stream had high nitrate concentrations during high flow conditions when much of the ground water was transmitted rapidly across the riparian zone in a shallow oxic aquifer wedge with abundant outflow macropores, and low nitrate concentrations during low flow conditions when the oxic wedge was smaller and stream discharge was dominated by upwelling from the deeper denitrified parts of the aquifer. Results from this and similar studies illustrate the importance of near-stream geomorphology and subsurface geology as controls of riparian zone function and delivery of nitrate to streams in agricultural watersheds. ?? ASA, CSSA, SSSA.

42 CFR 483.20 - Resident assessment.

Code of Federal Regulations, 2011 CFR

2011-10-01

... additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS.... (f) Automated data processing requirement—(1) Encoding data. Within 7 days after a facility completes...) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable...

42 CFR 483.20 - Resident assessment.

Code of Federal Regulations, 2012 CFR

2012-10-01

... additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS.... (f) Automated data processing requirement—(1) Encoding data. Within 7 days after a facility completes...) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable...

42 CFR 483.20 - Resident assessment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS.... (f) Automated data processing requirement—(1) Encoding data. Within 7 days after a facility completes...) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable...

42 CFR 483.20 - Resident assessment.

Code of Federal Regulations, 2013 CFR

2013-10-01

... additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS.... (f) Automated data processing requirement—(1) Encoding data. Within 7 days after a facility completes...) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable...

42 CFR 483.20 - Resident assessment.

Code of Federal Regulations, 2014 CFR

2014-10-01

... additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS.... (f) Automated data processing requirement—(1) Encoding data. Within 7 days after a facility completes...) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable...

How long is enough to detect terrestrial animals? Estimating the minimum trapping effort on camera traps

PubMed Central

Si, Xingfeng; Kays, Roland

2014-01-01

Camera traps is an important wildlife inventory tool for estimating species diversity at a site. Knowing what minimum trapping effort is needed to detect target species is also important to designing efficient studies, considering both the number of camera locations, and survey length. Here, we take advantage of a two-year camera trapping dataset from a small (24-ha) study plot in Gutianshan National Nature Reserve, eastern China to estimate the minimum trapping effort actually needed to sample the wildlife community. We also evaluated the relative value of adding new camera sites or running cameras for a longer period at one site. The full dataset includes 1727 independent photographs captured during 13,824 camera days, documenting 10 resident terrestrial species of birds and mammals. Our rarefaction analysis shows that a minimum of 931 camera days would be needed to detect the resident species sufficiently in the plot, and c. 8700 camera days to detect all 10 resident species. In terms of detecting a diversity of species, the optimal sampling period for one camera site was c. 40, or long enough to record about 20 independent photographs. Our analysis of evaluating the increasing number of additional camera sites shows that rotating cameras to new sites would be more efficient for measuring species richness than leaving cameras at fewer sites for a longer period. PMID:24868493

Minimum-Impact Camping in the Front Woods.

ERIC Educational Resources Information Center

Schatz, Curt

1994-01-01

Minimum-impact camping techniques that can be applied to resident camp programs include controlling group size and behavior, designing camp sites, moving groups frequently, proper use of fires, proper disposal of food and human wastes, use of biodegradable soaps, and encouraging staff and camper awareness of impacts on the environment. (LP)

24 CFR 570.431 - Citizen participation.

Code of Federal Regulations, 2014 CFR

2014-04-01

... residents in the case of public hearings where a significant number of non-English speaking residents can... follow a detailed citizen participation plan and must make the plan public. The plan must be completed... minimum of two public hearings, for the purpose of obtaining citizens' views and formulating or responding...

24 CFR 570.431 - Citizen participation.

Code of Federal Regulations, 2013 CFR

2013-04-01

... residents in the case of public hearings where a significant number of non-English speaking residents can... follow a detailed citizen participation plan and must make the plan public. The plan must be completed... minimum of two public hearings, for the purpose of obtaining citizens' views and formulating or responding...

24 CFR 570.431 - Citizen participation.

Code of Federal Regulations, 2012 CFR

2012-04-01

... residents in the case of public hearings where a significant number of non-English speaking residents can... follow a detailed citizen participation plan and must make the plan public. The plan must be completed... minimum of two public hearings, for the purpose of obtaining citizens' views and formulating or responding...

24 CFR 570.431 - Citizen participation.

Code of Federal Regulations, 2010 CFR

2010-04-01

... residents in the case of public hearings where a significant number of non-English speaking residents can... follow a detailed citizen participation plan and must make the plan public. The plan must be completed... minimum of two public hearings, for the purpose of obtaining citizens' views and formulating or responding...

24 CFR 570.431 - Citizen participation.

Code of Federal Regulations, 2011 CFR

2011-04-01

... residents in the case of public hearings where a significant number of non-English speaking residents can... follow a detailed citizen participation plan and must make the plan public. The plan must be completed... minimum of two public hearings, for the purpose of obtaining citizens' views and formulating or responding...

28 CFR 115.241 - Screening for risk of victimization and abusiveness.

Code of Federal Regulations, 2014 CFR

2014-07-01

... prior institutional violence or sexual abuse, as known to the agency, in assessing residents for risk of... ELIMINATION ACT NATIONAL STANDARDS Standards for Community Confinement Facilities Screening for Risk of Sexual... minimum, the following criteria to assess residents for risk of sexual victimization: (1) Whether the...

28 CFR 115.241 - Screening for risk of victimization and abusiveness.

Code of Federal Regulations, 2012 CFR

2012-07-01

... prior institutional violence or sexual abuse, as known to the agency, in assessing residents for risk of... ELIMINATION ACT NATIONAL STANDARDS Standards for Community Confinement Facilities Screening for Risk of Sexual... minimum, the following criteria to assess residents for risk of sexual victimization: (1) Whether the...

28 CFR 115.241 - Screening for risk of victimization and abusiveness.

Code of Federal Regulations, 2013 CFR

2013-07-01

... prior institutional violence or sexual abuse, as known to the agency, in assessing residents for risk of... ELIMINATION ACT NATIONAL STANDARDS Standards for Community Confinement Facilities Screening for Risk of Sexual... minimum, the following criteria to assess residents for risk of sexual victimization: (1) Whether the...

The size of the irregular migrant population in the European Union – counting the uncountable?

PubMed

Vogel, Dita; Kovacheva, Vesela; Prescott, Hannah

2011-01-01

It is difficult to estimate the size of the irregular migrant population in a specific city or country, and even more difficult to arrive at estimates at the European level. A review of past attempts at European-level estimates reveals that they rely on rough and outdated rules-of-thumb. In this paper, we present our own European level estimates for 2002, 2005, and 2008. We aggregate country-specific information, aiming at approximate comparability by consistent use of minimum and maximum estimates and by adjusting for obvious differences in definition and timescale. While the aggregated estimates are not considered highly reliable, they do -- for the first time -- provide transparency. The provision of more systematic medium quality estimates is shown to be the most promising way for improvement. The presented estimate indicates a minimum of 1.9 million and a maximum of 3.8 million irregular foreign residents in the 27 member states of the European Union (2008). Unlike rules-of-thumb, the aggregated EU estimates indicate a decline in the number of irregular foreign residents between 2002 and 2008. This decline has been influenced by the EU enlargement and legalisation programmes.

Assessment of radiation exposure from cesium-137 contaminated roads for epidemiological studies in Seoul, Korea.

PubMed

Lee, Yun-Keun; Ju, Young-Su; Lee, Won Jin; Hwang, Seung Sik; Yim, Sang-Hyuk; Yoo, Sang-Chul; Lee, Jieon; Choi, Kyung-Hwa; Burm, Eunae; Ha, Mina

2015-01-01

We aimed to assess the radiation exposure for epidemiologic investigation in residents exposed to radiation from roads that were accidentally found to be contaminated with radioactive cesium-137 ((137)Cs) in Seoul. Using information regarding the frequency and duration of passing via the (137)Cs contaminated roads or residing/working near the roads from the questionnaires that were obtained from 8875 residents and the measured radiation doses reported by the Nuclear Safety and Security Commission, we calculated the total cumulative dose of radiation exposure for each person. Sixty-three percent of the residents who responded to the questionnaire were considered as ever-exposed and 1% of them had a total cumulative dose of more than 10 mSv. The mean (minimum, maximum) duration of radiation exposure was 4.75 years (0.08, 11.98) and the geometric mean (minimum, maximum) of the total cumulative dose was 0.049 mSv (<0.001, 35.35) in the exposed. An individual exposure assessment was performed for an epidemiological study to estimate the health risk among residents living in the vicinity of (137)Cs contaminated roads. The average exposure dose in the exposed people was less than 5% of the current guideline.

Racial and socioeconomic differences in psychiatric symptoms in nursing home residents: a minimum data set-based pilot study.

PubMed

Zisselman, Marc H; Smith, Robert V; Smith, Stephanie A; Daskalakis, Constantine; Sanchez, Francisco

2006-01-01

Little research has explored racial and socioeconomic differences in the presence, detection, and treatment of neuropsychiatric symptoms in nursing home residents. To evaluate racial and socioeconomic differences on mood and behavior Minimum Data Set (MDS) recorded symptoms, MDS recorded psychiatric diagnoses, and MDS identified psychotropic medication use. Data were obtained through a cross-sectional review of MDS data of 290 African-American and white residents of 2 nursing homes. The association between age, gender, race, and pay status with mood and behavior patterns, psychiatric diagnoses, and use of psychotropic medication was evaluated. White residents were more likely than African American residents to have MDS recorded psychiatric diagnoses (odds ratio, OR = 3.24), but there were no significant racial differences in recorded mood or behavior symptomatology or in the pharmacologic treatment of mental illness. Medicaid recipients were more likely than nonrecipients to have behavior symptoms (OR = 2.09), have a psychiatric diagnosis (OR = 2.91), and receive psychotropic medications in the absence of a psychiatric diagnosis (OR = 3.62). Pay status was associated with recorded symptoms, diagnoses, and medications, but racial differences were found only for recorded diagnoses.

A meta-synthesis of factors influencing nursing home staff decisions to transfer residents to hospital.

PubMed

Laging, Bridget; Ford, Rosemary; Bauer, Michael; Nay, Rhonda

2015-10-01

To report a meta-synthesis of qualitative research studies exploring the role of nursing home staff in decisions to transfer residents to hospital. Nurses and nurse assistants provide the majority of care to residents living in nursing homes and may be the only health workers present when a resident deteriorates. To inform future strategies, it is vital to understand the role of nursing home staff in decisions to transfer to hospital. A systematic review identified 17 studies to be included. The process of meta-synthesis was undertaken using the Joanna Briggs Institute's guidelines. Qualitative research papers published between January 1989-October 2012 were identified in key databases including Cinahl, Embase, Medline and PsycInfo. Nursing home staff members play a key role in decision-making at the time of a resident's deterioration. Multiple factors influence decisions to transfer to hospital including an unclear expectation of the nursing home role; limited staffing capacity; fear of working outside their scope of practice; poor access to multidisciplinary support and difficulties communicating with other decision-makers. There is a lack of consensus regarding the role of the nursing home when a resident's health deteriorates. Nursing home staff would benefit from a clear prescription of their expected minimum clinical skill set; a staffing capacity that allows for the increased requirements to manage residents on-site, greater consistency in access to outside resources and further confidence and skills to optimize their role in resident advocacy. © 2015 John Wiley & Sons Ltd.

Thermomechanical milling of accessory lithics in volcanic conduits

NASA Astrophysics Data System (ADS)

Campbell, Michelle E.; Russell, James K.; Porritt, Lucy A.

2013-09-01

Accessory lithic clasts recovered from pyroclastic deposits commonly result from the failure of conduit wall rocks, and represent an underutilized resource for constraining conduit processes during explosive volcanic eruptions. The morphological features of lithic clasts provide distinctive 'textural fingerprints' of processes that have reshaped them during transport in the conduit. Here, we present the first study focused on accessory lithic clast morphology and show how the shapes and surfaces of these accessory pyroclasts can inform on conduit processes. We use two main types of accessory lithic clasts from pyroclastic fallout deposits of the 2360 B.P. subplinian eruption of Mount Meager, British Columbia, as a case study: (i) rough and subangular dacite clasts, and (ii) variably rounded and smoothed monzogranite clasts. The quantitative morphological data collected on these lithics include: mass, volume, density, 2-D image analysis of convexity (C), and 3-D laser scans for sphericity (Ψ) and smoothness (S). Shaping and comminution (i.e. milling) of clasts within the conduit are ascribed to three processes: (1) disruptive fragmentation due to high-energy impacts between clasts or between clasts and conduit walls, (2) ash-blasting of clasts suspended within the volcanic flux, and (3) thermal effects. We use a simplified conduit eruption model to predict ash-blasting velocities and lithic residence times as a function of clast size and source depth, thereby constraining the lithic milling processes. The extent of shape and surface modification (i.e. rounding and honing) is directly proportional to clast residence times within the conduit prior to evacuation. We postulate that the shallow-seated dacite clasts remain subangular and rough due to short (<2 min) residence times, whereas monzogranite clasts are much more rounded and smoothed due to deeper source depths and consequently longer residence times (up to ˜1 h). Larger monzogranite clasts are smoother than smaller clasts due to longer residence times and to greater differential velocities within the ash-laden jet. Lastly, our model residence times and mass loss estimates for rounded clasts are used to estimate minimum attrition rates due to volcanic ash-blasting within the conduit (e.g., 12 cm3 s-1 for 25 cm clasts, sourced at 2500 m depth).

Association between proportion of provider clinical effort in nursing homes and potentially avoidable hospitalizations and medical costs of nursing home residents.

PubMed

Kuo, Yong-Fang; Raji, Mukaila A; Goodwin, James S

2013-10-01

To assess potential avoidable hospitalizations of nursing home (NH) residents as a function of the percentage of clinical effort their primary care provider (PCP) devotes to NH practice. Retrospective cohort study. NHs in Texas. Residents newly admitted to long-term NHs in 2006 to 2008 were identified by linking the Minimum Data Set to 100% Texas Medicare claims data (N = 12,249). The care that residents received over successive 6-month periods was measured as a time-dependent covariate. Potentially avoidable hospitalizations and Medicare costs were assessed over 6 to 48 months. Seventy percent of NH residents had a physician as their major PCP, 25% had an advance practice nurse (APN), and 5% had a physician assistant (PA). Physician PCPs who derived less than 20% of their Medicare billings from NH residents cared for 36% of all NH residents. Most NH residents with APN or PA PCPs had providers with 85% or more of Medicare billings generated in NHs. Residents with PCPs who devoted less than 5% of their clinical effort to NH care were at 52% higher risk of potentially avoidable hospitalization than those whose PCPs devoted 85% or more of their clinical effort to NHs (hazard ratio = 1.52, 95% confidence interval = 1.25-1.83) and had $2,179 higher annual Medicare spending, controlling for PCP discipline. The percentage of clinical effort that providers devote to NHs is associated with risk of avoidable hospitalization. © 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.

Relationship Between Citation-Based Scholarly Activity of United States Radiation Oncology Residents and Subsequent Choice of Academic Versus Private-Practice Career.

PubMed

McClelland, Shearwood; Mitin, Timur; Wilson, Lynn D; Thomas, Charles R; Jaboin, Jerry J

2018-05-01

To assess h-index data and their association with radiation oncology resident choice of academic versus private-practice career, using a recent resident graduating class. A list of 2016 radiation oncology resident graduates (163 residents from 76 Accreditation Council for Graduate Medical Education-certified programs) and their postresidency career choice (academic vs private practice) was compiled. The Scopus bibliometric citation database was then searched to collect h-index data for each resident. Demographics included in analyses were gender and PhD degree status. Mean h-index score for all resident graduates was 4.15. Residents with a PhD had significantly higher h-index scores (6.75 vs 3.42; P < .01), whereas there was no statistically significant difference in h-index scores between male and female residents (4.38 vs 3.36; P = .06). With regard to career choice, residents choosing academic careers had higher h-index scores than those choosing private practice (5.41 vs 2.96; P < .01). There was no significant difference in mean h-index scores between male and female residents regardless of private-practice (3.15 vs 2.19; P = .25) or academic (5.80 vs 4.30; P = .13) career choice. The average radiation oncology resident graduate published a minimum of 4 manuscripts cited at least 4 times. Graduates with a PhD are significantly more likely to have higher h-index scores, as are residents who choose academic over private-practice careers. There is no significant difference in h-index score between male and female residents, regardless of career choice. These results offer up-to-date benchmarks for evaluating radiation oncology resident productivity and have potential utility in predicting postresidency career choices. Copyright © 2018 Elsevier Inc. All rights reserved.

Pain and pharmacologic pain management in long-stay nursing home residents.

PubMed

Hunnicutt, Jacob N; Ulbricht, Christine M; Tjia, Jennifer; Lapane, Kate L

2017-06-01

Previous studies estimate that >40% of long-stay nursing home (NH) residents experience persistent pain, with 20% of residents in pain receiving no analgesics. Strengthened NH surveyor guidance and improved pain measures on the Minimum Data Set 3.0 were introduced in March 2009 and October 2010, respectively. This study aimed to provide estimates after the important initiatives of (1) prevalence and correlates of persistent pain; and (2) prevalence and correlates of untreated or undertreated persistent pain. We identified 1,387,405 long-stay residents in U.S. NHs between 2011 and 2012 with 2 Minimum Data Set assessments 90 days apart. Pain was categorized as persistent (pain on both assessments), intermittent (pain on either assessment), or none. Pharmacologic pain management was classified as untreated pain (no scheduled or as needed medications received) or potentially undertreated (no scheduled received). Modified Poisson models adjusting for resident clustering within NHs provided adjusted prevalence ratios (APRs) estimates and 95% confidence intervals (CIs). The prevalence of persistent and intermittent pain was 19.5% and 19.2%, respectively, but varied substantially by age, sex, race and ethnicity, cognitive impairment, and cancer. Of residents in persistent pain, 6.4% and 32.0% were untreated and undertreated, respectively. Racial and ethnic minorities (non-Hispanic blacks vs whites, APR = 1.19, 95% CI: 1.13-1.25) and severely cognitively impaired residents (severe vs no/mild APR = 1.51, 95% CI: 1.44-1.57) had an increased prevalence of untreated and undertreated pain. One in 5 NH residents has persistent pain. Although this estimate is greatly improved, many residents may be undertreated. The disturbing disparities in untreated and undertreated pain need to be addressed.

Design, construction, and optimization of a novel, modular, and scalable incubation chamber for continuous viral inactivation.

PubMed

Orozco, Raquel; Godfrey, Scott; Coffman, Jon; Amarikwa, Linus; Parker, Stephanie; Hernandez, Lindsay; Wachuku, Chinenye; Mai, Ben; Song, Brian; Hoskatti, Shashidhar; Asong, Jinkeng; Shamlou, Parviz; Bardliving, Cameron; Fiadeiro, Marcus

2017-07-01

We designed, built or 3D printed, and screened tubular reactors that minimize axial dispersion to serve as incubation chambers for continuous virus inactivation of biological products. Empirical residence time distribution data were used to derive each tubular design's volume equivalent to a theoretical plate (VETP) values at a various process flow rates. One design, the Jig in a Box (JIB), yielded the lowest VETP, indicating optimal radial mixing and minimal axial dispersion. A minimum residence time (MRT) approach was employed, where the MRT is the minimum time the product spends in the tubular reactor. This incubation time is typically 60 minutes in a batch process. We provide recommendations for combinations of flow rates and device dimensions for operation of the JIB connected in series that will meet a 60-min MRT. The results show that under a wide range of flow rates and corresponding volumes, it takes 75 ± 3 min for 99% of the product to exit the reactor while meeting the 60-min MRT criterion and fulfilling the constraint of keeping a differential pressure drop under 5 psi. Under these conditions, the VETP increases slightly from 3 to 5 mL though the number of theoretical plates stays constant at about 1326 ± 88. We also demonstrated that the final design volume was only 6% ± 1% larger than the ideal plug flow volume. Using such a device would enable continuous viral inactivation in a truly continuous process or in the effluent of a batch chromatography column. Viral inactivation studies would be required to validate such a design. © 2017 American Institute of Chemical Engineers Biotechnol. Prog., 33:954-965, 2017. © 2017 American Institute of Chemical Engineers.

Assessment of radiation exposure from cesium-137 contaminated roads for epidemiological studies in Seoul, Korea

PubMed Central

Lee, Yun-Keun; Ju, Young-Su; Lee, Won Jin; Hwang, Seung Sik; Yim, Sang-Hyuk; Yoo, Sang-Chul; Lee, Jieon; Choi, Kyung-Hwa; Burm, Eunae; Ha, Mina

2015-01-01

Objectives We aimed to assess the radiation exposure for epidemiologic investigation in residents exposed to radiation from roads that were accidentally found to be contaminated with radioactive cesium-137 (137Cs) in Seoul. Methods Using information regarding the frequency and duration of passing via the 137Cs contaminated roads or residing/working near the roads from the questionnaires that were obtained from 8875 residents and the measured radiation doses reported by the Nuclear Safety and Security Commission, we calculated the total cumulative dose of radiation exposure for each person. Results Sixty-three percent of the residents who responded to the questionnaire were considered as ever-exposed and 1% of them had a total cumulative dose of more than 10 mSv. The mean (minimum, maximum) duration of radiation exposure was 4.75 years (0.08, 11.98) and the geometric mean (minimum, maximum) of the total cumulative dose was 0.049 mSv (<0.001, 35.35) in the exposed. Conclusions An individual exposure assessment was performed for an epidemiological study to estimate the health risk among residents living in the vicinity of 137Cs contaminated roads. The average exposure dose in the exposed people was less than 5% of the current guideline. PMID:26184047

The Minimum Data Set Depression Quality Indicator: Does It Reflect Differences in Care Processes?

ERIC Educational Resources Information Center

Simmons, S.F.; Cadogan, M.P.; Cabrera, G.R.; Al-Samarrai, N.R.; Jorge, J.S.; Levy-Storms, L.; Osterweil, D.; Schnelle, J.F.

2004-01-01

Purpose. The objective of this work was to determine if nursing homes that score differently on prevalence of depression, according to the Minimum Data Set (MDS) quality indicator, also provide different processes of care related to depression. Design and Methods. A cross-sectional study with 396 long-term residents in 14 skilled nursing…

42 CFR 483.315 - Specification of resident assessment instrument.

Code of Federal Regulations, 2010 CFR

2010-10-01

... updated periodically, and consists of the following: (1) The minimum data set (MDS) and common definitions... specified by CMS. (4) The requirements for use of the RAI that appear at § 483.20. (e) Minimum data set (MDS...) Specify to a facility the method of transmission of data, and instruct the facility on this method. (3...

42 CFR 483.315 - Specification of resident assessment instrument.

Code of Federal Regulations, 2014 CFR

2014-10-01

... updated periodically, and consists of the following: (1) The minimum data set (MDS) and common definitions... specified by CMS. (4) The requirements for use of the RAI that appear at § 483.20. (e) Minimum data set (MDS...) Specify to a facility the method of transmission of data, and instruct the facility on this method. (3...

42 CFR 483.315 - Specification of resident assessment instrument.

Code of Federal Regulations, 2012 CFR

2012-10-01

... updated periodically, and consists of the following: (1) The minimum data set (MDS) and common definitions... specified by CMS. (4) The requirements for use of the RAI that appear at § 483.20. (e) Minimum data set (MDS...) Specify to a facility the method of transmission of data, and instruct the facility on this method. (3...

42 CFR 483.315 - Specification of resident assessment instrument.

Code of Federal Regulations, 2013 CFR

2013-10-01

... updated periodically, and consists of the following: (1) The minimum data set (MDS) and common definitions... specified by CMS. (4) The requirements for use of the RAI that appear at § 483.20. (e) Minimum data set (MDS...) Specify to a facility the method of transmission of data, and instruct the facility on this method. (3...

42 CFR 483.315 - Specification of resident assessment instrument.

Code of Federal Regulations, 2011 CFR

2011-10-01

... updated periodically, and consists of the following: (1) The minimum data set (MDS) and common definitions... specified by CMS. (4) The requirements for use of the RAI that appear at § 483.20. (e) Minimum data set (MDS...) Specify to a facility the method of transmission of data, and instruct the facility on this method. (3...

Medicare payment changes and nursing home quality: effects on long-stay residents.

PubMed

Konetzka, R Tamara; Norton, Edward C; Stearns, Sally C

2006-09-01

The Balanced Budget Act of 1997 dramatically changed the way that Medicare pays skilled nursing facilities, providing a natural experiment in nursing home behavior. Medicare payment policy (directed at short-stay residents) may have affected outcomes for long-stay, chronic-care residents if services for these residents were subsidized through cost-shifting prior to implementation of Medicare prospective payment for nursing homes. We link changes in both the form and level of Medicare payment at the facility level with changes in resident-level quality, as represented by pressure sores and urinary tract infections in Minimum Data Set (MDS) assessments. Results show that long-stay residents experienced increased adverse outcomes with the elimination of Medicare cost reimbursement.

Family Support in Nursing Homes Serving Residents with a Mental Health History

ERIC Educational Resources Information Center

Frahm, Kathryn; Gammonley, Denise; Zhang, Ning Jackie; Paek, Seung Chun

2010-01-01

Using 2003 nursing home data from the Minimum Data Set (MDS) database, this study investigated the role of family support among nursing homes serving residents with a mental health history. Exploratory factor analysis was used to create and test a conceptual model of family support using indicators located within the MDS database. Families were…

Does Availability of Mental Health Resources Prevent Recurrent Suicidal Behavior? An Ecological Analysis

ERIC Educational Resources Information Center

Cooper, Sara L.; Lezotte, Dennis; Jacobellis, Jillian; DiGuiseppi, Carolyn

2006-01-01

This study examines whether availability of mental health resources in the county of residence is associated with subsequent suicidal behavior after a previous suicide attempt. Among 10,922 individuals who attempted suicide in Colorado between 1998 and 2002, residence in a county that offered a minimum safety-net of mental health services…

4-aminoquinolone piperidine amides: noncovalent inhibitors of DprE1 with long residence time and potent antimycobacterial activity.

PubMed

Naik, Maruti; Humnabadkar, Vaishali; Tantry, Subramanyam J; Panda, Manoranjan; Narayan, Ashwini; Guptha, Supreeth; Panduga, Vijender; Manjrekar, Praveena; Jena, Lalit Kumar; Koushik, Krishna; Shanbhag, Gajanan; Jatheendranath, Sandesh; Manjunatha, M R; Gorai, Gopinath; Bathula, Chandramohan; Rudrapatna, Suresh; Achar, Vijayashree; Sharma, Sreevalli; Ambady, Anisha; Hegde, Naina; Mahadevaswamy, Jyothi; Kaur, Parvinder; Sambandamurthy, Vasan K; Awasthy, Disha; Narayan, Chandan; Ravishankar, Sudha; Madhavapeddi, Prashanti; Reddy, Jitendar; Prabhakar, Kr; Saralaya, Ramanatha; Chatterji, Monalisa; Whiteaker, James; McLaughlin, Bob; Chiarelli, Laurent R; Riccardi, Giovanna; Pasca, Maria Rosalia; Binda, Claudia; Neres, João; Dhar, Neeraj; Signorino-Gelo, François; McKinney, John D; Ramachandran, Vasanthi; Shandil, Radha; Tommasi, Ruben; Iyer, Pravin S; Narayanan, Shridhar; Hosagrahara, Vinayak; Kavanagh, Stefan; Dinesh, Neela; Ghorpade, Sandeep R

2014-06-26

4-Aminoquinolone piperidine amides (AQs) were identified as a novel scaffold starting from a whole cell screen, with potent cidality on Mycobacterium tuberculosis (Mtb). Evaluation of the minimum inhibitory concentrations, followed by whole genome sequencing of mutants raised against AQs, identified decaprenylphosphoryl-β-d-ribose 2'-epimerase (DprE1) as the primary target responsible for the antitubercular activity. Mass spectrometry and enzyme kinetic studies indicated that AQs are noncovalent, reversible inhibitors of DprE1 with slow on rates and long residence times of ∼100 min on the enzyme. In general, AQs have excellent leadlike properties and good in vitro secondary pharmacology profile. Although the scaffold started off as a single active compound with moderate potency from the whole cell screen, structure-activity relationship optimization of the scaffold led to compounds with potent DprE1 inhibition (IC50 < 10 nM) along with potent cellular activity (MIC = 60 nM) against Mtb.

Recent Immigrants as Labor Market Arbitrageurs: Evidence from the Minimum Wage.

PubMed

Cadena, Brian C

2014-03-01

This paper investigates the local labor supply effects of changes to the minimum wage by examining the response of low-skilled immigrants' location decisions. Canonical models emphasize the importance of labor mobility when evaluating the employment effects of the minimum wage; yet few studies address this outcome directly. Low-skilled immigrant populations shift toward labor markets with stagnant minimum wages, and this result is robust to a number of alternative interpretations. This mobility provides behavior-based evidence in favor of a non-trivial negative employment effect of the minimum wage. Further, it reduces the estimated demand elasticity using teens; employment losses among native teens are substantially larger in states that have historically attracted few immigrant residents.

0 + 5 Vascular Surgery Residents' Operative Experience in General Surgery: An Analysis of Operative Logs from 12 Integrated Programs.

PubMed

Smith, Brigitte K; Kang, P Chulhi; McAninch, Chris; Leverson, Glen; Sullivan, Sarah; Mitchell, Erica L

2016-01-01

Integrated (0 + 5) vascular surgery (VS) residency programs must include 24 months of training in core general surgery. The Accreditation Council for Graduate Medical Education currently does not require specific case numbers in general surgery for 0 + 5 trainees; however, program directors have structured this time to optimize operative experience. The aim of this study is to determine the case volume and type of cases that VS residents are exposed to during their core surgery training. Accreditation council for graduate medical education operative logs for current 0 + 5 VS residents were obtained and retrospectively reviewed to determine general surgery case volume and distribution between open and laparoscopic cases performed. Standard statistical methods were applied. A total of 12 integrated VS residency programs provided operative case logs for current residents. A total of 41 integrated VS residents in clinical years 2 through 5. During the postgraduate year-1 training year, residents participated in significantly more open than laparoscopic general surgery cases (p < 0.0001). This difference was consistent over the first 3 years of training. The most frequently logged open general surgery cases are hernia repair (20%), skin and soft tissue (7.4%), and breast (6.3%). Residents in programs with core surgery over 3 years participated in significantly more general surgery operations compared with residents in programs with core surgery spread out over 4 years (p = 0.035). 0 + 5 VS residents perform significantly more open operations than laparoscopic operations during their core surgery training. The majority of these operations are minor, nonabdominal procedures. The 0 + 5 VS residency program general surgery operative training requirements should be reevaluated and case minimums defined. The general surgery training component of 0 + 5 VS residencies may need to be restructured to meet the needs of current and future trainees. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

A national curriculum for ophthalmology residency training

PubMed Central

Grover, Ashok Kumar; Honavar, Santosh G; Azad, Rajvardhan; Verma, Lalit

2018-01-01

We present a residency curriculum for Ophthalmology in India. The document derives from a workshop by the All India Ophthalmological Society (AlOS) which adapted the International Council of Ophthalmology residency curriculum and refined and customized it based on inputs by the residency program directors who participated in the work shop. The curriculum describes the course content, lays down the minimum requirements of infrastructure and mandates diagnostic and therapeutic procedures required for optimal training. It emphasises professionalism, management, research methodology, community ophthalmology as integral to the curriculum. The proposed national ophthalmology residency curriculum for India incorporates the required knowledge and skills for effective and safe practice of ophthalmology and takes into account the specific needs of the country. PMID:29785982

New Opportunities for Cancer Health Services Research: Linking the SEER-Medicare Data to the Nursing Home Minimum Data Set.

PubMed

Thomas, Kali S; Boyd, Eric; Mariotto, Angela B; Penn, Dolly C; Barrett, Michael J; Warren, Joan L

2018-02-02

The Surveillance, Epidemiology and End Results (SEER)-Medicare data combine clinical information from population-based cancer registries with Medicare claims. These data have been used in many studies to understand cancer screening, treatment, outcomes, and costs. However, until recently, these data included limited information related to the characteristics and outcomes of cancer patients residing in or admitted to nursing homes. To provide an overview of the new linkage between SEER-Medicare data and the Minimum Data Set (MDS), a nursing home resident assessment instrument detailing residents' physical, psychological, and psychosocial functioning as well as any therapies or treatments received. This is a descriptive, retrospective cohort study. Persons in SEER-Medicare diagnosed with cancer from 2004 to 2013 were linked to the 2011-2014 MDS, with 17% of SEER-Medicare patients linked to the MDS data. During 2011-2014, we identified 318,617 cancer patients receiving care in a nursing home and 256,947 cancer patients newly admitted to a total of 10,953 nursing homes. Of these patients, approximately two thirds were Medicare fee-for-service beneficiaries. The timing from cancer diagnoses to nursing home admission varied by cancer. In total, 93% of all patients were admitted directly to a nursing home from an acute care hospital. The majority of patients were cognitively intact, 21% reported some level of depression, and 9% had severe functional limitations. The new SEER-Medicare-MDS dataset provides a valuable resource for understanding the postacute and long-term care experiences of cancer patients receiving care in United States' nursing homes.

Risk Factors for Pressure Ulcers Including Suspected Deep Tissue Injury in Nursing Home Facility Residents: Analysis of National Minimum Data Set 3.0.

PubMed

Ahn, Hyochol; Cowan, Linda; Garvan, Cynthia; Lyon, Debra; Stechmiller, Joyce

2016-04-01

To provide information on risk factors associated with pressure ulcers (PrUs), including suspected deep tissue injury (sDTI), in nursing home residents in the United States. This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. After participating in this educational activity, the participant should be better able to:1. Examine the literature related to risk factors for the development of PrUs.2. Compare risk factors associated with the prevalence of PrUs and sDTI from the revised Minimum Data Set 3.0 2012 using a modified Defloor's conceptual model of PrUs as a theoretical framework. This study aims to characterize and compare risk factors associated with pressure ulcers (PrUs), including suspected deep tissue injury (sDTI), in nursing home (NH) residents in the United States. Secondary analysis of the 2012 Minimum Data Set (MDS 3.0). Medicare- or Medicaid-certified NHs in the United States. Nursing home residents (n = 2,936,146) 18 years or older with complete PrU data, who received comprehensive assessments from January to December 2012. Pressure ulcer by stage was the outcome variable. Explanatory variables (age, gender, race and ethnicity, body mass index, skin integrity, system failure, disease, infection, mobility, and cognition) from the MDS 3.0 were aligned with the 4 elements of Defloor's conceptual model: compressive forces, shearing forces, tissue tolerance for pressure, and tissue tolerance for oxygen. Of 2,936,146 NH residents who had complete data for PrU, 89.9% had no PrU; 8.4% had a Stage 2, 3, or 4 or unstagable PrU; and 1.7% had an sDTI. The MDS variables corresponding to the 4 elements of Defloor's model were significantly predictive of both PrU and sDTI. Black residents had the highest risk of any-stage PrU, and Hispanic residents had the highest risk of sDTI. Skin integrity, system failure, infection, and disease risk factors had larger effect sizes for sDTI than for other PrU stages. The MDS data support Defloor's model and inform clinicians, educators, researchers, and policymakers on risk factors associated with PrUs and sDTI in NH residents in the United States participating in Medicare and Medicaid.

Resident Cosmetic Clinic: Practice Patterns, Safety, and Outcomes at an Academic Plastic Surgery Institution.

PubMed

Qureshi, Ali A; Parikh, Rajiv P; Myckatyn, Terence M; Tenenbaum, Marissa M

2016-10-01

Comprehensive aesthetic surgery education is an integral part of plastic surgery residency training. Recently, the ACGME increased minimum requirements for aesthetic procedures in residency. To expand aesthetic education and prepare residents for independent practice, our institution has supported a resident cosmetic clinic for over 25 years. To evaluate the safety of procedures performed through a resident clinic by comparing outcomes to benchmarked national aesthetic surgery outcomes and to provide a model for resident clinics in academic plastic surgery institutions. We identified a consecutive cohort of patients who underwent procedures through our resident cosmetic clinic between 2010 and 2015. Major complications, as defined by CosmetAssure database, were recorded and compared to published aesthetic surgery complication rates from the CosmetAssure database for outcomes benchmarking. Fisher's exact test was used to compare sample proportions. Two hundred and seventy-one new patients were evaluated and 112 patients (41.3%) booked surgery for 175 different aesthetic procedures. There were 55 breast, 19 head and neck, and 101 trunk or extremity aesthetic procedures performed. The median number of preoperative and postoperative visits was 2 and 4 respectively with a mean follow-up time of 35 weeks. There were 3 major complications (2 hematomas and 1 infection requiring IV antibiotics) with an overall complication rate of 1.7% compared to 2.0% for patients in the CosmetAssure database (P = .45). Surgical outcomes for procedures performed through a resident cosmetic clinic are comparable to national outcomes for aesthetic surgery procedures, suggesting this experience can enhance comprehensive aesthetic surgery education without compromising patient safety or quality of care. 4 Risk. © 2016 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.

Pressure Ulcer Prevention Program Study: a randomized, controlled prospective comparative value evaluation of 2 pressure ulcer prevention strategies in nursing and rehabilitation centers.

PubMed

Shannon, Ronald J; Brown, Lynne; Chakravarthy, Debashish

2012-10-01

This article assesses the comparative prevention-effectiveness and economic implications of a Pressure Ulcer Prevention Program (PUPP) against standard practice of prevention using Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality [AHRQ]) guidelines and a mixture of commercial products. The study is a randomized, controlled, prospective cohort study with an accompanying economic evaluation. The economic evaluation is performed from the perspective of the nursing and rehabilitation centers. Two nursing and rehabilitation centers under the same quality and safety support organization. Both institutions are experiencing high nursing staff turnover and incidence of pressure ulcers (PrUs). 133 residents at risk of developing PrUs (EQUIP-for-Quality Risk Score Moderate to Very High [MVH]). All are Medicare-eligible residents with Minimum Data Set (MDS) 2.0 evaluations. The PUPP includes a strategic product bundle and decision algorithms driven by MDS 2.0 Resident Assessment Scores to assist in reducing or preventing PrUs and incontinence-associated skin conditions. The control group utilizes a different brand and assortment of commercial skin care products, briefs, pads, and mattresses, but without use of the decision algorithms driven by MDS 2.0 Resident Assessment Scores. Pressure ulcer prevention education was done for all nurses by a nurse certified in the PUPP program at the beginning and ad libitum by trained senior nursing staff at the end of the study. Comparative reduction in the incidence of nosocomial PrUs and average 6-month net cost savings per MVH-risk resident. Residents were assessed for PrU risk using EQUIP-for-Quality risk assessment algorithm based on data from their Minimum Data Set (MDS 2.0), then assigned to either the PUPP program or control group (standard practice following AHRQ guidelines). Residents were followed until discharge, death, development of PrU, or a maximum time period of 6 months. Direct medical costs of prevention and PrU treatment were recorded using a modified activity-based costing method. A decision model was used to estimate the net cost savings attributed to the PUPP program over a 6-month period. A 67% reduction in the incidence of nosocomial pressure ulcers is attributable to the PUPP strategy over a 6-month period for MVH residents. The average 6-month cost for a MVH Medicare resident is $1928 and $1130 for the control group and PUPP group respectively. Mean difference (net cost savings per resident at risk of pressure ulceration) is $798 per resident for PUPP. PUPP assisted in reducing the incidence of PrUs by 67% in a 6-month period in nursing home facilities. The estimated annual net cost savings attributed to PUPP for 300 MVH residents is estimated at approximately $240,000.

The Minimum Data Set 3.0 Cognitive Function Scale.

PubMed

Thomas, Kali S; Dosa, David; Wysocki, Andrea; Mor, Vincent

2017-09-01

The Minimum Data Set (MDS) 3.0 introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents. Not all residents are able to complete the BIMS and are consequently assessed by staff. We designed a Cognitive Function Scale (CFS) integrating self-report and staff-report data and present evidence of the scale's construct validity. A retrospective cohort study. The subjects consisted of 3 cohorts: (1) long-stay NH residents (N=941,077) and (2) new admissions (N=2,066,580) during 2011-2012, and (3) residents with the older MDS 2.0 assessment in 2010 and the newer MDS 3.0 assessment (n=688,511). MDS 3.0 items were used to create a single, integrated 4-category hierarchical CFS that was compared with residents' prior MDS 2.0 Cognitive Performance Scale scores and other concurrent MDS 3.0 measures of construct validity. The new CFS suggests that 28% of the long-stay cohort in 2011-2012 were cognitively intact, 22% were mildly impaired, 33% were moderately impaired, and 17% were severely impaired. For the admission cohort, the CFS noted 56% as cognitively intact, 23% as mildly impaired, 17% as moderately impaired, and 4% as severely impaired. The CFS corresponded closely with residents' prior MDS 2.0 Cognitive Performance Scale scores and with performance of Activities of Daily Living, and nurses' judgments of function and behavior in both the admission and long-stay cohorts. The new CFS is valuable to researchers as it provides a single, integrated measure of NH residents' cognitive function, regardless of the mode of assessment.

The Minimum Data Set Prevalence of Restraint Quality Indicator: Does It Reflect Differences in Care?

ERIC Educational Resources Information Center

Schnelle, John F.; Bates-Jensen, Barbara M.; Levy-Storms, Lene; Grbic, Valena; Yoshii, June; Cadogan, Mary; Simmons, Sandra F.

2004-01-01

Purpose: This study investigated whether the use of restraining devices and related measures of care quality are different in nursing homes that score in the upper and lower quartiles on the Minimum Data Set (MDS) "prevalence of restraint" quality indicator, which assesses daily use of restraining devices when residents are out of bed. Design and…

Do suburban residents want to pay for wide streets? a survey on consumer preference and ability to afford towards wide street and on-street parking in American suburbia.

DOT National Transportation Integrated Search

2016-08-01

All local governments in the U.S. set the street minimum width and cross-section design for local : neighborhood streets. Because local streets typically require no more than two traffic lanes (approx. 20 feet : wide), a minimum width of 26 feet or w...

The Effects of the Green House Nursing Home Model on ADL Function Trajectory: A Retrospective Longitudinal Study

PubMed Central

YOON, Ju Young; BROWN, Roger L.; BOWERS, Barbara J.; SHARKEY, Siobhan S.; HORN, Susan D.

2015-01-01

Background Growing attention in the past few decades has focused on improving care quality and quality of life for nursing home residents. Many traditional nursing homes have attempted to transform themselves to become more homelike emphasizing individualized care. This trend is referred to as nursing home culture change in the U.S. A promising culture change nursing home model, the Green House (GH) nursing home model, has shown positive psychological outcomes. However, little is known about whether the GH nursing home model has positive effects on physical function compared to traditional nursing homes. Objectives To examine the longitudinal effects of the GH nursing home model by comparing change patterns of ADL function over time between GH home residents and traditional nursing home residents. Design A retrospective longitudinal study. Settings Four GH organizations (nine GH units and four traditional units). Participants A total of 242 residents (93 GH residents and 149 traditional home residents) who had stayed in the nursing home at least six months from admission. Methods The outcome was ADL function, and the main independent variable was the facility type in which the resident stayed: a GH or traditional unit. Age, gender, comorbidity score, cognitive function, and depressive symptoms at baseline were controlled. All of these measures were from a minimum dataset. Growth curve modeling and growth mixture modeling were employed in this study for longitudinal analyses. Results The mean ADL function showed deterioration over time, and the rates of deterioration between GH and traditional home residents were not different over time. Four different ADL function trajectories were identified for 18 months, but there was no statistical difference in the likelihood of being in one of the four trajectory classes between the two groups. Conclusions Although GH nursing homes are considered to represent an innovative model changing the nursing home environment into more person-centered, this study did not demonstrate significant differences in ADL function changes for residents in the GH nursing homes compared to traditional nursing homes. Given that the GH model continues to evolve as it is being implemented and variations within and across GH homes are identified, large-scale longitudinal studies are needed to provide further relevant information on the effects of the GH model. PMID:26260709

Nurse staffing levels and Medicaid reimbursement rates in nursing facilities.

PubMed

Harrington, Charlene; Swan, James H; Carrillo, Helen

2007-06-01

To examine the relationship between nursing staffing levels in U.S. nursing homes and state Medicaid reimbursement rates. Facility staffing, characteristics, and case-mix data were from the federal On-Line Survey Certification and Reporting (OSCAR) system and other data were from public sources. Ordinary least squares and two-stage least squares regression analyses were used to separately examine the relationship between registered nurse (RN) and total nursing hours in all U.S. nursing homes in 2002, with two endogenous variables: Medicaid reimbursement rates and resident case mix. RN hours and total nursing hours were endogenous with Medicaid reimbursement rates and resident case mix. As expected, Medicaid nursing home reimbursement rates were positively related to both RN and total nursing hours. Resident case mix was a positive predictor of RN hours and a negative predictor of total nursing hours. Higher state minimum RN staffing standards was a positive predictor of RN and total nursing hours while for-profit facilities and the percent of Medicaid residents were negative predictors. To increase staffing levels, average Medicaid reimbursement rates would need to be substantially increased while higher state minimum RN staffing standards is a stronger positive predictor of RN and total nursing hours.

Nitrogen chemistry during burnout in fuel-staged combustion

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kristensen, P.G.; Glarborg, P.; Dam-Johansen, K.

A parametric study of the chemistry of the burnout zone in reburning has been performed in laboratory plug flow reactors in the temperature range 800--1,350 K. Inlet mole fractions of NO, NH{sub 3}, HCN, CO, and O{sub 2} were varied, together with different temperatures and residence times to simulate reaction conditions in practical systems. Under lean conditions, a minimum in NO emission exists as a function of temperature. Both HCN and NH{sub 3} can act as either NO reductants or as sources for NO by oxidation. Reactions and selectivities for HCN and NH{sub 3} are controlled by the radical poolmore » produced by fuel (CO) oxidation. As increasing amounts of CO were added, temperatures for both ignition and the minimum in NO became lower. At 2% CO, 4% O{sub 2}, and 100 ms residence time, the minimum in NO was found at approximately 1,000 K. At low temperatures, significant amounts of N{sub 2}O were measured in the reactor outlet. This is attributed to N{sub 2}O formation by HCN/NO reactions and to the slow decomposition of N{sub 2}O at these temperatures. Large reductions in NO were seen under fuel-rich conditions and at high temperatures. The observed NO reduction was very much dependent on the inlet mole fraction of O{sub 2}. Detailed chemical kinetic modeling of the experiments showed reasonable predictions for overall fuel-lean conditions, but the model failed to predict experimental results under fuel-rich conditions. The present results provide guidelines for optimizing the conditions for the burnout process of reburning, as well as other processes for NO{sub x} reduction by staged combustion. The results also provide a test basis for verifying kinetic models for nitrogen chemistry at low temperatures (800--1,350 K).« less

The Impact of Green House Adoption on Medicare Spending and Utilization.

PubMed

Grabowski, David C; Afendulis, Christopher C; Caudry, Daryl J; O'Malley, A James; Kemper, Peter

2016-02-01

To evaluate the impact of the Green House (GH) model of nursing home care on Medicare acute hospital, other hospital, skilled nursing facility, and hospice spending and utilization. Medicare claims and enrollment data from 2005 through 2010 merged with resident-level minimum data set (MDS) assessments. Using a difference-in-differences framework, we compared Medicare Part A and hospice expenditures and utilization in 15 nursing homes that adopted the GH model relative to changes over the same time period in 223 matched nonadopting nursing homes. We applied the same method for residents of GH homes and for residents of "legacy" homes, the original nursing homes that stay open alongside the GH home(s). The adoption of GH had no detectable impact on Medicare Part A (plus hospice) spending and utilization across all residents living in the nursing home. When we analyzed residents living in GH homes and legacy units separately, however, we found that the adoption of the GH model reduced overall annual Medicare Part A spending by $7,746 per resident, although this appeared to be partially offset by an increase in spending in legacy homes. To the extent that the GH model reduces Medicare spending, adopting nursing homes do not receive any of the related Medicare savings under traditional payment mechanisms. New approaches that are currently being developed and piloted, which better align financial incentives for providers and payers, could incentivize greater adoption of the GH model. © Health Research and Educational Trust.

Recent Immigrants as Labor Market Arbitrageurs: Evidence from the Minimum Wage*

PubMed Central

Cadena, Brian C.

2014-01-01

This paper investigates the local labor supply effects of changes to the minimum wage by examining the response of low-skilled immigrants’ location decisions. Canonical models emphasize the importance of labor mobility when evaluating the employment effects of the minimum wage; yet few studies address this outcome directly. Low-skilled immigrant populations shift toward labor markets with stagnant minimum wages, and this result is robust to a number of alternative interpretations. This mobility provides behavior-based evidence in favor of a non-trivial negative employment effect of the minimum wage. Further, it reduces the estimated demand elasticity using teens; employment losses among native teens are substantially larger in states that have historically attracted few immigrant residents. PMID:24999288

The consistency between treatments provided to nursing facility residents and orders on the physician orders for life-sustaining treatment form.

PubMed

Hickman, Susan E; Nelson, Christine A; Moss, Alvin H; Tolle, Susan W; Perrin, Nancy A; Hammes, Bernard J

2011-11-01

To evaluate the consistency between treatments provided and Physician Orders for Life-Sustaining Treatment (POLST) orders. Retrospective chart abstraction. Stratified, random sample of 90 nursing facilities in Oregon, Wisconsin, and West Virginia. Eight hundred seventy living and deceased nursing facility residents aged 65 and older with a minimum 60-day stay. Chart data about POLST form orders and related treatments over a 60-day period were abstracted. Decision rules were created to determine whether the rationale for each treatment was consistent with POLST orders. Most residents (85.2%) had the same POLST form in place during the review period. A majority of treatments provided to residents with orders for comfort measures only (74.3%) and limited antibiotics (83.3%) were consistent with POLST orders because they were primarily comfort focused rather than life-prolonging, but antibiotics were provided to 32.1% of residents with orders for no antibiotics. Overall consistency rates between treatments and POLST orders were high for resuscitation (98%), medical interventions (91.1%), and antibiotics (92.9%) and modest for feeding tubes (63.6%). In all, POLST orders were consistent with treatments provided 94.0% of the time. With the exception of feeding tubes and antibiotic use in residents with orders for no antibiotics, the use of medical treatments was nearly always consistent with POLST orders to provide or withhold life-sustaining interventions. The POLST program is a useful tool for ensuring that the treatment preferences of nursing facility residents are honored. © 2011, Copyright the Authors Journal compilation © 2011, The American Geriatrics Society.

Impact of Malnutrition on Physical, Cognitive Function and Mortality among Older Men Living in Veteran Homes by Minimum Data Set: A Prospective Cohort Study in Taiwan.

PubMed

Chen, L-Y; Liu, L-K; Hwang, A-C; Lin, M-H; Peng, L-N; Chen, L-K; Lan, C-F; Chang, P-L

2016-01-01

To evaluate the prevalence of malnutrition and its impact on mortality, functional decline and cognitive impairment among elder residents in long-term care settings. A prospective cohort study. Two veteran homes in Taiwan. A total of 1,248 male residents aged equal or more than 65 years. Charlson's comorbidity index (CCI), Minimum data set (MDS), resident assessment protocols (RAP), Activity of daily living-Hierarchy scale, Cognitive Performance Scale, MDS Social engagement scale. The mean age of participants is 83.1 ± 5.1 years, and the prevalence of malnutrition was 6.1%. Inadequate dietary content (57.9%) and unintentional weight loss (31.6%) account for the majority of malnutrition identified by MDS tool. Higher 18-month mortality rate (25% vs. 14.2%), higher baseline CCI (median 1 vs. 0), and higher baseline sum of RAP triggers (median 8.5 vs. 5) were noted among residents with malnutrition. Furthermore, malnutrition was shown predictive for functional decline (OR: 3.096, 95% CI: 1.715-5.587) and potential cognitive improvement (OR: 2.469, 95% CI: 1.188-5.128) among survivors after adjustment for age, body mass index and CCI. Malnutrition among elder men residing in veteran homes was associated with multimorbidities and higher care complexity, and was predictive for mortality and functional decline.

Using the RUG-III classification system for understanding the resource intensity of persons with intellectual disability residing in nursing homes.

PubMed

Martin, Lynn; Fries, Brant E; Hirdes, John P; James, Mary

2011-06-01

Since 1991, the Minimum Data Set 2.0 (MDS 2.0) has been the mandated assessment in US nursing homes. The Resource Utilization Groups III (RUG-III) case-mix system provides person-specific means of allocating resources based on the variable costs of caring for persons with different needs. Retrospective analyses of data collected on a sample of 9707 nursing home residents (2.4% had an intellectual disability) were used to examine the fit of the RUG-III case-mix system for determining the cost of supporting persons with intellectual disability (intellectual disability). The RUG-III system explained 33.3% of the variance in age-weighted nursing time among persons with intellectual disability compared to 29.6% among other residents, making it a good fit among persons with intellectual disability in nursing homes. The RUG-III may also serve as the basis for the development of a classification system that describes the resource intensity of persons with intellectual disability in other settings that provide similar types of support.

Non-Hispanic Black-White disparities in pain and pain management among newly admitted nursing home residents with cancer.

PubMed

Mack, Deborah S; Hunnicutt, Jacob N; Jesdale, Bill M; Lapane, Kate L

2018-01-01

Racial disparities in pain management persist across health care settings and likely extend into nursing homes. No recent studies have evaluated racial disparities in pain management among residents with cancer in nursing homes at time of admission. Using a cross-sectional study design, we compared reported pain and pain management between non-Hispanic White and non-Hispanic Black newly admitted nursing home residents with cancer (n=342,920) using the de-identified Minimum Data Set version 3.0. Pain management strategies included the use of scheduled analgesics, pro re nata analgesics, and non-pharmacological methods. Presence of pain was based on self-report when residents were able, and staff report when unable. Robust Poisson models provided estimates of adjusted prevalence ratios (aPR) and 95% CIs for reported pain and pain management strategies. Among nursing home residents with cancer, ~60% reported pain with non-Hispanic Blacks less likely to have both self-reported pain (aPR [Black versus White]: 0.98, 95% CI: 0.97-0.99) and staff-reported pain (aPR: 0.89, 95% CI: 0.86-0.93) documentation compared with Non-Hispanic Whites. While most residents received some pharmacologic pain management, Blacks were less likely to receive any compared with Whites (Blacks: 66.6%, Whites: 71.1%; aPR: 0.98, 95% CI: 0.97-0.99), consistent with differences in receipt of non-pharmacologic treatments (Blacks: 25.8%, Whites: 34.0%; aPR: 0.98, 95 CI%: 0.96-0.99). Less pain was reported for Black compared with White nursing home residents and White residents subsequently received more frequent pain management at admission. The extent to which unequal reporting and management of pain persists in nursing homes should be further explored.

The Nursing Home Minimum Data Set Assessment Instrument: Manifest Functions and Unintended Consequences--Past, Present, and Future

ERIC Educational Resources Information Center

Rahman, Anna N.; Applebaum, Robert A.

2009-01-01

The Minimum Data Set (MDS) is a uniform instrument used in nursing homes to assess residents. In January 2008, the Centers for Medicare and Medicaid Services published a draft of a new MDS--version 3.0. This article traces the instrument's development and the design decisions that shaped it, discusses the MDS's manifest functions--data collection…

Residence times and age distributions of spring waters at the Semmering catchment area, Eastern Austria, as inferred from tritium, CFCs and stable isotopes.

PubMed

Han, Liangfeng; Hacker, Peter; Gröning, Manfred

2007-03-01

The groundwater system in the mountainous area of Semmering, Austria, was studied by environmental tracers in several karst springs. The tracers used included stable isotopes ((18)O, (2)H), tritium ((3)H) and chlorofluorocarbons (CFCs). The tracers provided valuable information in regard to (1) the mean altitude of the spring catchment areas; (2) the residence time and age distribution of the spring waters; and (3) the interconnection of the springs to a sinkhole. The combination of the stable isotopic data and the topography/geology provided the estimates of the mean altitudes of the catchment areas. Based on the stable isotopic data the recharge temperature of the spring waters was estimated. The smoothing of precipitation's isotopic signal in spring discharge provided information on the minimum transit time of the spring waters. Due to short observation time, (3)H data alone cannot be used for describing the mean residence time of the karst waters. CFCs, though useful in recognizing the co-existence of young (post-1993) water with old (CFC-free) water, could not be used to resolve age distribution models. It is shown in this article, however, that the combined use of tritium and CFCs can provide a better assessment of models to account for different groundwater age distributions. In Appendix A, a simplified method for collecting groundwater samples for the analysis of CFCs is described. The method provides a real facilitation for fieldwork. Test data are given for this sampling method in regard to potential contamination by atmospheric CFCs.

Development of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial Protocol: A National Cluster-Randomized Trial of Resident Duty Hour Policies.

PubMed

Bilimoria, Karl Y; Chung, Jeanette W; Hedges, Larry V; Dahlke, Allison R; Love, Remi; Cohen, Mark E; Tarpley, John; Mellinger, John; Mahvi, David M; Kelz, Rachel R; Ko, Clifford Y; Hoyt, David B; Lewis, Frank H

2016-03-01

Debate continues regarding whether to further restrict resident duty hour policies, but little high-level evidence is available to guide policy changes. To inform decision making regarding duty hour policies, the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial is being conducted to evaluate whether changing resident duty hour policies to permit greater flexibility in work hours affects patient postoperative outcomes, resident education, and resident well-being. Pragmatic noninferiority cluster-randomized trial of general surgery residency programs with 2 study arms. Participating in the study are Accreditation Council for Graduate Medical Education (ACGME)-approved US general surgery residency programs (n = 118), their affiliated hospitals (n = 154), surgical residents and program directors, and general surgery patients from July 1, 2014, to June 30, 2015, with additional patient safety outcomes collected through June 30, 2016. The data collection platform for patient outcomes is the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), thus only hospitals participating in the ACS NSQIP were included. In the usual care arm, programs adhered to current ACGME resident duty hour standards. In the intervention arm, programs were allowed to deviate from current standards regarding maximum shift lengths and minimum time off between shifts through an ACGME waiver. Death or serious morbidity within 30 days of surgery measured through ACS NSQIP, as well as resident satisfaction and well-being measured through a survey delivered at the time of the 2015 American Board of Surgery in Training Examination (ABSITE). A total of 118 general surgery residency programs and 154 hospitals were enrolled in the FIRST Trial and randomized. Fifty-nine programs (73 hospitals) were randomized to the usual care arm and 59 programs (81 hospitals) were randomized to the intervention arm. Intent-to-treat analysis will be used to estimate the effectiveness of assignment to the intervention arm on patient outcomes, resident education, and resident well-being compared with the usual care arm. Several sensitivity analyses will be performed to determine whether there were differential effects when examining only inpatients, high-risk patients, and emergent/urgent cases. To our knowledge, the FIRST Trial is the first national randomized clinical trial of duty hour policies. Results of this study may be informative to policymakers and other stakeholders engaged in restructuring graduate medical training to enhance the quality of patient care and resident education. clinicaltrials.org Identifier: NCT02050789.

Development of Geriatric Competencies for Emergency Medicine Residents Using an Expert Consensus Process

PubMed Central

Hogan, Teresita M.; Losman, Eve D.; Carpenter, Christopher R.; Sauvigne, Karen; Irmiter, Cheryl; Emanuel, Linda; Leipzig, Rosanne M.

2011-01-01

Background The emergency department (ED) visit rate for older patients exceeds that of all age groups other than infants. The aging population will increase elder ED patient utilization to 35% to 60% of all visits. Older patients can have complex clinical presentations and be resource-intensive. Evidence indicates that emergency physicians fail to provide consistent high-quality care for elder ED patients, resulting in poor clinical outcomes. Objectives The objective was to develop a consensus document, “Geriatric Competencies for Emergency Medicine Residents,” by identified experts. This is a minimum set of behaviorally based performance standards that all residents should be able to demonstrate by completion of their residency training. Methods This consensus-based process utilized an inductive, qualitative, multiphase method to determine the minimum geriatric competencies needed by emergency medicine (EM) residents. Assessments of face validity and reliability were used throughout the project. Results In Phase I, participants (n = 363) identified 12 domains and 300 potential competencies. In Phase II, an expert panel (n = 24) clustered the Phase I responses, resulting in eight domains and 72 competencies. In Phase III, the expert panel reduced the competencies to 26. In Phase IV, analysis of face validity and reliability yielded a 100% consensus for eight domains and 26 competencies. The domains identified were atypical presentation of disease; trauma, including falls; cognitive and behavioral disorders; emergent intervention modifications; medication management; transitions of care; pain management and palliative care; and effect of comorbid conditions. Conclusions The Geriatric Competencies for EM Residents is a consensus document that can form the basis for EM residency curricula and assessment to meet the demands of our aging population. PMID:20370765

Development of geriatric competencies for emergency medicine residents using an expert consensus process.

PubMed

Hogan, Teresita M; Losman, Eve D; Carpenter, Christopher R; Sauvigne, Karen; Irmiter, Cheryl; Emanuel, Linda; Leipzig, Rosanne M

2010-03-01

The emergency department (ED) visit rate for older patients exceeds that of all age groups other than infants. The aging population will increase elder ED patient utilization to 35% to 60% of all visits. Older patients can have complex clinical presentations and be resource-intensive. Evidence indicates that emergency physicians fail to provide consistent high-quality care for elder ED patients, resulting in poor clinical outcomes. The objective was to develop a consensus document, "Geriatric Competencies for Emergency Medicine Residents," by identified experts. This is a minimum set of behaviorally based performance standards that all residents should be able to demonstrate by completion of their residency training. This consensus-based process utilized an inductive, qualitative, multiphase method to determine the minimum geriatric competencies needed by emergency medicine (EM) residents. Assessments of face validity and reliability were used throughout the project. In Phase I, participants (n=363) identified 12 domains and 300 potential competencies. In Phase II, an expert panel (n=24) clustered the Phase I responses, resulting in eight domains and 72 competencies. In Phase III, the expert panel reduced the competencies to 26. In Phase IV, analysis of face validity and reliability yielded a 100% consensus for eight domains and 26 competencies. The domains identified were atypical presentation of disease; trauma, including falls; cognitive and behavioral disorders; emergent intervention modifications; medication management; transitions of care; pain management and palliative care; and effect of comorbid conditions. The Geriatric Competencies for EM Residents is a consensus document that can form the basis for EM residency curricula and assessment to meet the demands of our aging population. Copyright (c) 2010 by the Society for Academic Emergency Medicine.

Attainable region analysis for continuous production of second generation bioethanol

PubMed Central

2013-01-01

Background Despite its semi-commercial status, ethanol production from lignocellulosics presents many complexities not yet fully solved. Since the pretreatment stage has been recognized as a complex and yield-determining step, it has been extensively studied. However, economic success of the production process also requires optimization of the biochemical conversion stage. This work addresses the search of bioreactor configurations with improved residence times for continuous enzymatic saccharification and fermentation operations. Instead of analyzing each possible configuration through simulation, we apply graphical methods to optimize the residence time of reactor networks composed of steady-state reactors. Although this can be easily made for processes described by a single kinetic expression, reactions under analysis do not exhibit this feature. Hence, the attainable region method, able to handle multiple species and its reactions, was applied for continuous reactors. Additionally, the effects of the sugars contained in the pretreatment liquor over the enzymatic hydrolysis and simultaneous saccharification and fermentation (SSF) were assessed. Results We obtained candidate attainable regions for separate enzymatic hydrolysis and fermentation (SHF) and SSF operations, both fed with pretreated corn stover. Results show that, despite the complexity of the reaction networks and underlying kinetics, the reactor networks that minimize the residence time can be constructed by using plug flow reactors and continuous stirred tank reactors. Regarding the effect of soluble solids in the feed stream to the reactor network, for SHF higher glucose concentration and yield are achieved for enzymatic hydrolysis with washed solids. Similarly, for SSF, higher yields and bioethanol titers are obtained using this substrate. Conclusions In this work, we demonstrated the capabilities of the attainable region analysis as a tool to assess the optimal reactor network with minimum residence time applied to the SHF and SSF operations for lignocellulosic ethanol production. The methodology can be readily modified to evaluate other kinetic models of different substrates, enzymes and microorganisms when available. From the obtained results, the most suitable reactor configuration considering residence time and rheological aspects is a continuous stirred tank reactor followed by a plug flow reactor (both in SSF mode) using washed solids as substrate. PMID:24286451

Attainable region analysis for continuous production of second generation bioethanol.

PubMed

Scott, Felipe; Conejeros, Raúl; Aroca, Germán

2013-11-29

Despite its semi-commercial status, ethanol production from lignocellulosics presents many complexities not yet fully solved. Since the pretreatment stage has been recognized as a complex and yield-determining step, it has been extensively studied. However, economic success of the production process also requires optimization of the biochemical conversion stage. This work addresses the search of bioreactor configurations with improved residence times for continuous enzymatic saccharification and fermentation operations. Instead of analyzing each possible configuration through simulation, we apply graphical methods to optimize the residence time of reactor networks composed of steady-state reactors. Although this can be easily made for processes described by a single kinetic expression, reactions under analysis do not exhibit this feature. Hence, the attainable region method, able to handle multiple species and its reactions, was applied for continuous reactors. Additionally, the effects of the sugars contained in the pretreatment liquor over the enzymatic hydrolysis and simultaneous saccharification and fermentation (SSF) were assessed. We obtained candidate attainable regions for separate enzymatic hydrolysis and fermentation (SHF) and SSF operations, both fed with pretreated corn stover. Results show that, despite the complexity of the reaction networks and underlying kinetics, the reactor networks that minimize the residence time can be constructed by using plug flow reactors and continuous stirred tank reactors. Regarding the effect of soluble solids in the feed stream to the reactor network, for SHF higher glucose concentration and yield are achieved for enzymatic hydrolysis with washed solids. Similarly, for SSF, higher yields and bioethanol titers are obtained using this substrate. In this work, we demonstrated the capabilities of the attainable region analysis as a tool to assess the optimal reactor network with minimum residence time applied to the SHF and SSF operations for lignocellulosic ethanol production. The methodology can be readily modified to evaluate other kinetic models of different substrates, enzymes and microorganisms when available. From the obtained results, the most suitable reactor configuration considering residence time and rheological aspects is a continuous stirred tank reactor followed by a plug flow reactor (both in SSF mode) using washed solids as substrate.

Optimising the performance of an outpatient setting.

PubMed

Sendi, Pedram; Al, Maiwenn J; Battegay, Manuel; Al Maiwenn, J

2004-01-24

An outpatient setting typically includes experienced and novice resident physicians who are supervised by senior staff physicians. The performance of this kind of outpatient setting, for a given mix of experienced and novice resident physicians, is determined by the number of senior staff physicians available for supervision. The optimum mix of human resources may be determined using discrete-event simulation. An outpatient setting represents a system where concurrency and resource sharing are important. These concepts can be modelled by means of timed Coloured Petri Nets (CPN), which is a discrete-event simulation formalism. We determined the optimum mix of resources (i.e. the number of senior staff physicians needed for a given number of experienced and novice resident physicians) to guarantee efficient overall system performance. In an outpatient setting with 10 resident physicians, two staff physicians are required to guarantee a minimum level of system performance (42-52 patients are seen per 5-hour period). However, with 3 senior staff physicians system performance can be improved substantially (49-56 patients per 5-hour period). An additional fourth staff physician does not substantially enhance system performance (50-57 patients per 5-hour period). Coloured Petri Nets provide a flexible environment in which to simulate an outpatient setting and assess the impact of any staffing changes on overall system performance, to promote informed resource allocation decisions.

Falls documentation in nursing homes: agreement between the minimum data set and chart abstractions of medical and nursing documentation.

PubMed

Hill-Westmoreland, Elizabeth E; Gruber-Baldini, Ann L

2005-02-01

To assess the agreement between falls as recorded in the Minimum Data Set (MDS) and fall events abstracted from chart documentation of elderly nursing home (NH) residents. Secondary analysis of data from a longitudinal panel study. Fifty-six randomly selected NHs in Maryland stratified by facility size and geographic region. Four hundred sixty-two NH residents, aged 65 and older, in NHs for 1 year. Falls were abstracted from resident charts and compared with MDS fall variables. Fall events data obtained from other sources of chart documentation were matched for the corresponding periods of 30 and 180 days before the 1-year MDS assessment date. For a 30-day period, concordance between the MDS and chart abstractions of falls occurred in 65% of cases, with a kappa coefficient of 0.29 (P<.001), indicating fair agreement. Concordance occurred between the sources for 75% of cases for a 180-day period, with a kappa of 0.50 (P<.001), indicating moderate agreement. During the 180-day period, chart abstractions showed that 49% of the sample fell, whereas the MDS revealed that only 28% fell. An analysis of residents whose falls the MDS missed indicated that these residents had significantly more activity of daily living impairment and significantly less unsteady gait and cane/walker use. The MDS underreported falls. Nurses completing MDS assessments must carefully review residents' medical records for falls documentation. Future studies should use caution when employing MDS data as the only indicator of falls.

The effect on nursing home resident outcomes of creating a household within a traditional structure.

PubMed

Chang, Yu-Ping; Li, Junxin; Porock, Davina

2013-04-01

Person-centered care (PCC) is a revolutionary approach to the culture change of elder care that is being adopted by nursing home providers across the nation. One aspect of PCC is the introduction of more self-contained units or households within long term care facilities. This study aimed to evaluate the effect of households on nursing home residents' physical and psychological outcomes using the Minimum Data Set (MDS) comprehensive assessment data. A retrospective, longitudinal study. Two care units in a large urban nursing home within the Western New York long term care system. Residents living in two units (household unit and traditional care unit) within one nursing home during January 2005 to April 2007. The MDS 2.0 is a standardized and comprehensive assessment tool that measures long term care facility residents' functional, medical, cognitive, and psycho-social status. The de-identified MDS 2.0 records of residents living in these units during this time period were retrieved from the New York Association of Homes and Services for the Aging. The residents' cognitive patterns, mood and behavior pattern, physical functioning, pain, fall, nutritional status, number of ulcers, medication use, and special treatment were compared. Descriptive and correlational statistics were used for data analysis. MDS records of 35 household-unit residents and 33 traditional-unit residents were analyzed. After adjusting for baseline differences, household-unit residents had better self- performed eating ability, daytime sleepiness, and restraint use; however, more fall incidents were reported for the household unit. Our findings indicate that households generated some better outcomes for residents and provide preliminary evidence to support households in nursing homes. Further research is needed to overcome design issues; however, the MDS may be useful for PCC outcomes measurement. Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.

Identifying nursing home residents at risk for falling.

PubMed

Kiely, D K; Kiel, D P; Burrows, A B; Lipsitz, L A

1998-05-01

To develop a fall risk model that can be used to identify prospectively nursing home residents at risk for falling. The secondary objective was to determine whether the nursing home environment independently influenced the development of falls. A prospective study involving 1 year of follow-up. Two hundred seventy-two nursing homes in the state of Washington. A total of 18,855 residents who had a baseline assessment in 1991 and a follow-up assessment within the subsequent year. Baseline Minimum Data Set items that could be potential risk factors for falling were considered as independent variables. The dependent variable was whether the resident fell as reported at the follow-up assessment. We estimated the extrinsic risk attributable to particular nursing home environments by calculating the annual fall rate in each nursing home and grouping them into tertiles of fall risk according to these rates. Factors associated independently with falling were fall history, wandering behavior, use of a cane or walker, deterioration of activities of daily living performance, age greater than 87 years, unsteady gait, transfer independence, wheelchair independence, and male gender. Nursing home residents with a fall history were more than three times as likely to fall during the follow-up period than residents without a fall history. Residents in homes with the highest tertile of fall rates were more than twice as likely to fall compared with residents of homes in the lowest tertile, independent of resident-specific risk factors. Fall history was identified as the strongest risk factor associated with subsequent falls and accounted for the vast majority of the predictive strength of the model. We recommend that fall history be used as an initial screener for determining eligibility for fall intervention efforts. Studies are needed to determine the facility characteristics that contribute to fall risk, independent of resident-specific risk factors.

Assessing quality of nursing home care: the foundation for improving resident outcomes.

PubMed

Rantz, M J; Mehr, D R; Conn, V S; Hicks, L L; Porter, R; Madsen, R W; Petrowski, G F; Maas, M

1996-07-01

Efforts to improve the quality of care and outcomes for nursing home residents are constantly of concern to state and federal regulators, nursing home providers, nursing home advocacy groups, and health policy researchers. The article describes a study that analyzed the quality indicators identified by the Health Care Financing Administration-sponsored Case Mix and Quality Demonstration Project using the Missouri nursing home Minimum Data Set database. The range of performance was considerable, and five of the indicators analyzed were risk adjusted to account for variation in resident acuity within facilities. Determining quality of care from assessment information that is routinely collected for nursing home residents has the potential to influence dramatically public policy decisions regarding reimbursement, recertification, and regulation and can play a vital role in improving resident outcomes.

Predicting Diagnosed Depression and Anti-depressant Treatment in Institutionalized Older Adults by Symptom Profiles: A Closer Look at Anhedonia and Dysphoria

ERIC Educational Resources Information Center

Stones, Michael J.; Clyburn, Leah D.; Gibson, Margaret C.; Woodbury, M. Gail

2006-01-01

The purpose of this study was to examine the relationships of diagnosis and treatment of depression with anhedonic and dysphoric symptom presentation, using the Minimum Data Set 2.0. Participants were from two sectors of longterm care: 70 nursing home residents and 92 residents in a Veterans' Care Service. The samples differed in their sex…

Development of the psychometric property of a Minimum Data-Set-Based Depression Rating Scale for use in long-term care facilities in Taiwan.

PubMed

Hsiao, C Y; Lan, C F; Chang, P L; Li, I C

2015-01-01

Our aim is to develop the psychometric property of the Minimum Data-Set-Based Depression Rating Scale (MDS-DRS) to ensure its use to assess service needs and guide care plans for institutionalized residents. 378 residents were recruited from the Haoran Senior Citizen Home in northern Taiwan. The MDS-DRS and GDS-SF were used to identify observable features of depression symptoms in the elderly residents. A total of 378 residents participated in this study. The receiver operating characteristic (ROC) curve indicated that the MDS-DRS has a 43.3% sensitivity and a 90.6% specificity when screening for depression symptoms. The total variance, explained by the two factors 'sadness' and 'distress,' was 58.1% based on the factor analysis. Reliable assessment tools for nurses are important because they allow the early detection of depression symptoms. The MDS-DRS items perform as well as the GDS-SF items in detecting depression symptoms. Furthermore, the MDS-DRS has the advantage of providing information to staff about care process implementation, which can facilitate the identification of areas that need improvement. Further research is needed to validate the use of the MDS-DRS in long-term care facilities.

Phase-Based Adaptive Estimation of Magnitude-Squared Coherence Between Turbofan Internal Sensors and Far-Field Microphone Signals

NASA Technical Reports Server (NTRS)

Miles, Jeffrey Hilton

2015-01-01

A cross-power spectrum phase based adaptive technique is discussed which iteratively determines the time delay between two digitized signals that are coherent. The adaptive delay algorithm belongs to a class of algorithms that identifies a minimum of a pattern matching function. The algorithm uses a gradient technique to find the value of the adaptive delay that minimizes a cost function based in part on the slope of a linear function that fits the measured cross power spectrum phase and in part on the standard error of the curve fit. This procedure is applied to data from a Honeywell TECH977 static-engine test. Data was obtained using a combustor probe, two turbine exit probes, and far-field microphones. Signals from this instrumentation are used estimate the post-combustion residence time in the combustor. Comparison with previous studies of the post-combustion residence time validates this approach. In addition, the procedure removes the bias due to misalignment of signals in the calculation of coherence which is a first step in applying array processing methods to the magnitude squared coherence data. The procedure also provides an estimate of the cross-spectrum phase-offset.

Synthetic Modeling of Autonomous Learning with a Chaotic Neural Network

NASA Astrophysics Data System (ADS)

Funabashi, Masatoshi

We investigate the possible role of intermittent chaotic dynamics called chaotic itinerancy, in interaction with nonsupervised learnings that reinforce and weaken the neural connection depending on the dynamics itself. We first performed hierarchical stability analysis of the Chaotic Neural Network model (CNN) according to the structure of invariant subspaces. Irregular transition between two attractor ruins with positive maximum Lyapunov exponent was triggered by the blowout bifurcation of the attractor spaces, and was associated with riddled basins structure. We secondly modeled two autonomous learnings, Hebbian learning and spike-timing-dependent plasticity (STDP) rule, and simulated the effect on the chaotic itinerancy state of CNN. Hebbian learning increased the residence time on attractor ruins, and produced novel attractors in the minimum higher-dimensional subspace. It also augmented the neuronal synchrony and established the uniform modularity in chaotic itinerancy. STDP rule reduced the residence time on attractor ruins, and brought a wide range of periodicity in emerged attractors, possibly including strange attractors. Both learning rules selectively destroyed and preserved the specific invariant subspaces, depending on the neuron synchrony of the subspace where the orbits are situated. Computational rationale of the autonomous learning is discussed in connectionist perspective.

Characteristic correlation study of UV disinfection performance for ballast water treatment

NASA Astrophysics Data System (ADS)

Ba, Te; Li, Hongying; Osman, Hafiiz; Kang, Chang-Wei

2016-11-01

Characteristic correlation between ultraviolet disinfection performance and operating parameters, including ultraviolet transmittance (UVT), lamp power and water flow rate, was studied by numerical and experimental methods. A three-stage model was developed to simulate the fluid flow, UV radiation and the trajectories of microorganisms. Navier-Stokes equation with k-epsilon turbulence was solved to model the fluid flow, while discrete ordinates (DO) radiation model and discrete phase model (DPM) were used to introduce UV radiation and microorganisms trajectories into the model, respectively. The UV dose statistical distribution for the microorganisms was found to move to higher value with the increase of UVT and lamp power, but moves to lower value when the water flow rate increases. Further investigation shows that the fluence rate increases exponentially with UVT but linearly with the lamp power. The average and minimum resident time decreases linearly with the water flow rate while the maximum resident time decrease rapidly in a certain range. The current study can be used as a digital design and performance evaluation tool of the UV reactor for ballast water treatment.

Electromagnetic Smart Valves for Cryogenic Applications

NASA Astrophysics Data System (ADS)

Traum, M. J.; Smith, J. L.; Brisson, J. G.; Gerstmann, J.; Hannon, C. L.

2004-06-01

Electromagnetic valves with smart control capability have been developed and demonstrated for use in the cold end of a Collins-style cryocooler. The toroidal geometry of the valves was developed utilizing a finite-element code and optimized for maximum opening force with minimum input current. Electromagnetic smart valves carry two primary benefits in cryogenic applications: 1) magnetic actuation eliminates the need for mechanical linkages and 2) valve timing can be modified during system cool down and in regular operation for cycle optimization. The smart feature of these electromagnetic valves resides in controlling the flow of current into the magnetic coil. Electronics have been designed to shape the valve actuation current, limiting the residence time of magnetic energy in the winding. This feature allows control of flow through the expander via an electrical signal while dissipating less than 0.0071 J/cycle as heat into the cold end. The electromagnetic smart valves have demonstrated reliable, controllable dynamic cycling. After 40 hours of operation, they suffered no perceptible mechanical degradation. These features enable the development of a miniaturized Collins-style cryocooler capable of removing 1 Watt of heat at 10 K.

Design and performance characterization strategy using modeling for biofiltration control of odorous hydrogen sulfide.

PubMed

Martin, Ronald W; Mihelcic, James R; Crittenden, John C

2004-07-01

Biofilter, dynamic modeling software characterizing contaminant removal via biofiltration, was used in the preliminary design of a biofilter to treat odorous hydrogen sulfide (H2S). Steady-state model simulations were run to generate performance plots for various influent concentrations, loadings, residence times, media sizes, and temperatures. Although elimination capacity and removal efficiency frequently are used to characterize biofilter performance, effluent concentration can be used to characterize performance when treating to a target effluent concentration. Model simulations illustrate that, at a given temperature, a biofilter cannot reduce H2S emissions below a minimum value, no matter how large the biofilter or how long the residence time. However, a higher biofilter temperature results in lower effluent H2S concentrations. Because dynamic model simulations show that shock loading can significantly increase the effluent concentration above values predicted by the steady-state model simulations, it is recommended that, to consistently meet treatment objectives, dynamic feed conditions should be considered. This study illustrates that modeling can serve as a valuable tool in the design and performance optimization of biofilters.

Anesthesiologists' perceptions of minimum acceptable work habits of nurse anesthetists.

PubMed

Logvinov, Ilana I; Dexter, Franklin; Hindman, Bradley J; Brull, Sorin J

2017-05-01

Work habits are non-technical skills that are an important part of job performance. Although non-technical skills are usually evaluated on a relative basis (i.e., "grading on a curve"), validity of evaluation on an absolute basis (i.e., "minimum passing score") needs to be determined. Survey and observational study. None. None. The theme of "work habits" was assessed using a modification of Dannefer et al.'s 6-item scale, with scores ranging from 1 (lowest performance) to 5 (highest performance). E-mail invitations were sent to all consultant and fellow anesthesiologists at Mayo Clinic in Florida, Arizona, and Minnesota. Because work habits expectations can be generational, the survey was designed for adjustment based on all invited (responding or non-responding) anesthesiologists' year of graduation from residency. The overall mean±standard deviation of the score for anesthesiologists' minimum expectations of nurse anesthetists' work habits was 3.64±0.66 (N=48). Minimum acceptable scores were correlated with the year of graduation from anesthesia residency (linear regression P=0.004). Adjusting for survey non-response using all N=207 anesthesiologists, the mean of the minimum acceptable work habits adjusted for year of graduation was 3.69 (standard error 0.02). The minimum expectations for nurse anesthetists' work habits were compared with observational data obtained from the University of Iowa. Among 8940 individual nurse anesthetist work habits scores, only 2.6% were <3.69. All N=65 of the Iowa nurse anesthetists' mean work habits scores were significantly greater than the Mayo estimate (3.69) for the minimum expectations; all P<0.00024. Our results suggest that routinely evaluated work habits of nurse anesthetists within departments should not be compared with an appropriate minimum score (i.e., of 3.69). Instead, work habits scores should be analyzed based on relative reporting among anesthetists. Copyright © 2017 Elsevier Inc. All rights reserved.

Developing an Internet-based Communication System for Residency Training Programs

PubMed Central

Fortin, Auguste H; Luzzi, Kristina; Galaty, Leslie; Wong, Jeffrey G; Huot, Stephen J

2002-01-01

Administrative communication is increasingly challenging for residency programs as the number of training sites expands. The Internet provides a cost-effective opportunity to address these needs. Using the World Wide Web, we developed a single, reliable, accurate, and accessible source of administrative information for residents, faculty, and staff in a multisite internal medicine residency at reduced costs. Evaluation of the effectiveness of the website was determined by tracking website use, materials and personnel costs, and resident, staff, and faculty satisfaction. Office supply and personnel costs were reduced by 89% and personnel effort by 85%. All users were highly satisfied with the web communication tool and all reported increased knowledge of program information and a greater sense of “connectedness.” We conclude that an internet-based communication system that provides a single, reliable, accurate, and accessible source of information for residents, faculty, and staff can be developed with minimum resources and reduced costs. PMID:11972724

[Strategy for educating senior dermatological residents in mycology].

PubMed

Mochizuki, Takashi; Tsuboi, Ryoji; Sei, Yoshihiro; Hiruma, Masataro; Watanabe, Shinichi; Makimura, Koichi

2012-01-01

To improve the ability of dermatologists to diagnose cutaneous mycoses, we have proposed a list of the minimum mycological knowledge and skills required by senior residents of dermatology. The list includes ability to select the most appropriate sampling method, knowledge of the basic method of potassium hydroxide (KOH) examination and skill in performing fungal cultures and identifying the most prevalent fungal species isolated from skin lesions. It is not possible for the Japanese Society of Medical Mycology to train every senior resident directly, and it is difficult for them to acquire sufficient expertise independently. Consequently, training and advice given by instructors in residents' home institutes is essential. A project of an advanced course for instructors, who are in charge of educating senior residents in their own institute, may be possible. Therefore, we have proposed here a list for instructors of the knowledge and skills required to educate senior residents. Employing this list should realize improved skill in dermatologists.

Common and gender specific factors associated with one-year mortality in nursing home residents.

PubMed

Kiely, Dan K; Flacker, Jonathan M

2002-01-01

To identify common and gender-specific factors associated with mortality in two distinct nursing home (NH) populations: newly admitted (NA), and long-stay (LS) residents. A retrospective cohort study. NH facilities in the state of New York. A total of 59,080 NA female and 28,080 NA male NH residents, and 24,260 LS female and 8,928 LS male NH residents evaluated between June 1994 and December 1997 who were at least 65 years of age. Minimum Data Set information including measures of health, functional, cognitive, psychological, and social status. Multivariate proportional hazards regression results indicate that in NA residents, use of feeding tubes, bowel incontinence, and refuses fluids were associated with mortality in women only, whereas fever was associated with mortality in men only. Cancer and congestive heart failure (CHF) were more strongly associated with mortality in women than men. In LS residents, deterioration in communication, refuses fluids, use of indwelling catheters, and deterioration in cognition were associated with mortality in women but not men. Bedfast most of the time, use of new medications, and a balance problem were associated with mortality in men but not women. Shortness-of-breath was more strongly associated with mortality in women than men. In both NA and LS residents, although men and women share many common factors associated with mortality, each gender has some unique factors associated with mortality. Furthermore, the strength of some common factors is significantly different across genders. These readily available data could be useful in making medical decisions and advance directive planning, and in the development of quality improvement initiatives and mortality prediction models.

The effects of the Green House nursing home model on ADL function trajectory: A retrospective longitudinal study.

PubMed

Yoon, Ju Young; Brown, Roger L; Bowers, Barbara J; Sharkey, Siobhan S; Horn, Susan D

2016-01-01

Growing attention in the past few decades has focused on improving care quality and quality of life for nursing home residents. Many traditional nursing homes have attempted to transform themselves to become more homelike emphasizing individualized care. This trend is referred to as nursing home culture change in the U.S. A promising culture change nursing home model, the Green House nursing home model, has shown positive psychological outcomes. However, little is known about whether the Green House nursing home model has positive effects on physical function compared to traditional nursing homes. To examine the longitudinal effects of the Green House nursing home model by comparing change patterns of activities of daily living function over time between Green House home residents and traditional nursing home residents. A retrospective longitudinal study. Four Green House organizations (nine Green House units and four traditional units). A total of 242 residents (93 Green House residents and 149 traditional home residents) who had stayed in the nursing home at least 6 months from admission. The outcome was activities of daily living function, and the main independent variable was the facility type in which the resident stayed: a Green House or traditional unit. Age, gender, comorbidity score, cognitive function, and depressive symptoms at baseline were controlled. All of these measures were from a minimum dataset. Growth curve modeling and growth mixture modeling were employed in this study for longitudinal analyses. The mean activities of daily living function showed deterioration over time, and the rates of deterioration between Green House and traditional home residents were not different over time. Four different activities of daily living function trajectories were identified for 18 months, but there was no statistical difference in the likelihood of being in one of the four trajectory classes between the two groups. Although Green House nursing homes are considered to represent an innovative model changing the nursing home environment into more person-centered, this study did not demonstrate significant differences in activities of daily living function changes for residents in the Green House nursing homes compared to traditional nursing homes. Given that the Green House model continues to evolve as it is being implemented and variations within and across Green House homes are identified, large-scale longitudinal studies are needed to provide further relevant information on the effects of the Green House model. Copyright © 2015 Elsevier Ltd. All rights reserved.

Landscape Analysis of Global Health Tracks in United States Pediatric Residencies: Moving Toward Standards.

PubMed

Watts, Jennifer; Russ, Christiana; St Clair, Nicole E; Uwemedimo, Omolara Thomas

2018-03-28

The number of pediatric Global Health (GH) tracks has more than doubled in less than 10 years. The goal of this study was to describe the characteristics of the pediatric GH tracks to identify commonalities and differences in track structure, funding, and education. In addition, we also identified demographic, institutional, and residency-related factors that were significantly associated with educational offerings and logistical challenges. A cross-sectional survey was electronically administered to pediatric residency programs with GH tracks. Statistical analyses included frequencies to describe GH track characteristics. Fisher's exact tests were used to identify bivariate associations between track structure and funding with educational offerings and logistical challenges. Leaders of 32 pediatric GH tracks (67%) completed the survey. The majority of GH tracks were completed within the 3 years of residency (94%) and identified a GH track director (100%); however, tracks varied in size, enrollment methods, domestic and international partnerships, funding, and evaluations. Dedicated faculty time and GH track budget amounts were associated with more robust infrastructure pertaining to resident international electives, including funding and mentorship. Many tracks did not meet American Academy of Pediatrics recommended standards for clinical international rotations. Despite the presence of multiple similarities among pediatric GH tracks, there are large variations in track structure, education, and funding. The results from this study support the proposal of a formal definition and minimum standards for a GH track, which may provide a framework for quality, consistency, and comparison of GH tracks. Copyright © 2018. Published by Elsevier Inc.

Toward Data-Driven Radiology Education-Early Experience Building Multi-Institutional Academic Trainee Interpretation Log Database (MATILDA).

PubMed

Chen, Po-Hao; Loehfelm, Thomas W; Kamer, Aaron P; Lemmon, Andrew B; Cook, Tessa S; Kohli, Marc D

2016-12-01

The residency review committee of the Accreditation Council of Graduate Medical Education (ACGME) collects data on resident exam volume and sets minimum requirements. However, this data is not made readily available, and the ACGME does not share their tools or methodology. It is therefore difficult to assess the integrity of the data and determine if it truly reflects relevant aspects of the resident experience. This manuscript describes our experience creating a multi-institutional case log, incorporating data from three American diagnostic radiology residency programs. Each of the three sites independently established automated query pipelines from the various radiology information systems in their respective hospital groups, thereby creating a resident-specific database. Then, the three institutional resident case log databases were aggregated into a single centralized database schema. Three hundred thirty residents and 2,905,923 radiologic examinations over a 4-year span were catalogued using 11 ACGME categories. Our experience highlights big data challenges including internal data heterogeneity and external data discrepancies faced by informatics researchers.

Medical residencies and increased admissions in rural hospitals with fewer than 200 beds.

PubMed

Connor, R A

2000-01-01

Medical education programs in general, and rural residency programs in particular, can be beneficial for rural hospitals. This study of 1,792 non-metropolitan statistical area, acute general hospitals with fewer than 200 beds from 1993 to 1996 was designed to help rural hospitals and communities to quantify the likely effects of rural residency programs on hospital admissions. Data came from the hospital Prospective Payment System minimum data set. The results show that additional residents at rural hospitals with fewer than 200 beds generally result in an increase of approximately 100 to 200 admissions per resident--more for smaller hospitals and fewer for larger hospitals. Because increased admissions generally improve the financial health and continued operation of rural hospitals, this study confirms the importance of education-based strategies in ensuring access to care in rural communities.

Relationship between internal medicine program board examination pass rates, accreditation standards, and program size.

PubMed

Falcone, John L; Gonzalo, Jed D

2014-01-19

To determine Internal Medicine residency program compliance with the Accreditation Council for Graduate Medical Education 80% pass-rate standard and the correlation between residency program size and performance on the American Board of Internal Medicine Certifying Examination. Using a cross-sectional study design from 2010-2012 American Board of Internal Medicine Certifying Examination data of all Internal Medicine residency pro-grams, comparisons were made between program pass rates to the Accreditation Council for Graduate Medical Education pass-rate standard. To assess the correlation between program size and performance, a Spearman's rho was calculated. To evaluate program size and its relationship to the pass-rate standard, receiver operative characteristic curves were calculated. Of 372 Internal Medicine residency programs, 276 programs (74%) achieved a pass rate of =80%, surpassing the Accreditation Council for Graduate Medical Education minimum standard. A weak correlation was found between residency program size and pass rate for the three-year period (p=0.19, p<0.001). The area underneath the receiver operative characteristic curve was 0.69 (95% Confidence Interval [0.63-0.75]), suggesting programs with less than 12 examinees/year are less likely to meet the minimum Accreditation Council for Graduate Medical Education pass-rate standard (sensitivity 63.8%, specificity 60.4%, positive predictive value 82.2%, p<0.001). Although a majority of Internal Medicine residency programs complied with Accreditation Council for Graduate Medical Education pass-rate standards, a quarter of the programs failed to meet this requirement. Program size is positively but weakly associated with American Board of Internal Medicine Certifying Examination performance, suggesting other unidentified variables significantly contribute to program performance.

Patterns of home and community care service delivery to culturally and linguistically diverse residents of rural Victoria.

PubMed

Ward, Bernadette M; Anderson, Karen S; Sheldon, Maria S

2005-12-01

To describe and compare patterns of Home and Community Care (HACC) utilisation among culturally and linguistically diverse (CALD) people and Australian-born residents of rural Victoria. The HACC Minimum Data Set provides information regarding levels of service provision and coverage in Victoria. Data from January to June 2002 were analysed to provide a profile of client characteristics and service usage in rural Victoria. Patterns of service utilisation were compared with the profile of the CALD population in the 2001 Census. The proportion of CALD residents who are HACC clients is consistent with demographic profiles. However, their extent of service usage is not consistent with patterns of use by Australian-born residents. HACC clients born in non-English-speaking countries, receive 35% less hours of HACC service than their Australian-born counterparts. HACC clients born overseas in English-speaking countries receive nine per cent less hours of HACC service than the Australian-born group (F = 8.9, P = 0.00). Both groups of overseas-born clients use a smaller range of HACC services (F = 1.9, P = 0.16). Planners and service providers need to monitor levels of HACC service delivery among population groups to ensure that CALD population groups receive equitable levels of HACC services. The HACC Minimum Data Set is one source of data that can assist in this process.

Facility versus unit level reporting of quality indicators in nursing homes when performance monitoring is the goal

PubMed Central

Norton, Peter G; Murray, Michael; Doupe, Malcolm B; Cummings, Greta G; Poss, Jeff W; Squires, Janet E; Teare, Gary F; Estabrooks, Carole A

2014-01-01

Objectives To demonstrate the benefit of defining operational management units in nursing homes and computing quality indicators on these units as well as on the whole facility. Design Calculation of adjusted Resident Assessment Instrument – Minimum Data Set 2.0 (RAI–MDS 2.0) quality indicators for: PRU05 (prevalence of residents with a stage 2–4 pressure ulcer), PAI0X (prevalence of residents with pain) and DRG01 (prevalence of residents receiving an antipsychotic with no diagnosis of psychosis), for quarterly assessments between 2007 and 2011 at unit and facility levels. Comparisons of these risk-adjusted quality indicators using statistical process control (control charts). Setting A representative sample of 30 urban nursing homes in the three Canadian Prairie Provinces. Measurements Explicit decision rules were developed and tested to determine whether the control charts demonstrated improving, worsening, unchanging or unclassifiable trends over the time period. Unit and facility performance were compared. Results In 48.9% of the units studied, unit control chart performance indicated different changes in quality over the reporting period than did the facility chart. Examples are provided to illustrate that these differences lead to quite different quality interventions. Conclusions Our results demonstrate the necessity of considering facility-level and unit-level measurement when calculating quality indicators derived from the RAI–MDS 2.0 data, and quite probably from any RAI measures. PMID:24523428

Pseudo paths towards minimum energy states in network dynamics

NASA Astrophysics Data System (ADS)

Hedayatifar, L.; Hassanibesheli, F.; Shirazi, A. H.; Vasheghani Farahani, S.; Jafari, G. R.

2017-10-01

The dynamics of networks forming on Heider balance theory moves towards lower tension states. The condition derived from this theory enforces agents to reevaluate and modify their interactions to achieve equilibrium. These possible changes in network's topology can be considered as various paths that guide systems to minimum energy states. Based on this theory the final destination of a system could reside on a local minimum energy, ;jammed state;, or the global minimum energy, balanced states. The question we would like to address is whether jammed states just appear by chance? Or there exist some pseudo paths that bound a system towards a jammed state. We introduce an indicator to suspect the location of a jammed state based on the Inverse Participation Ratio method (IPR). We provide a margin before a local minimum where the number of possible paths dramatically drastically decreases. This is a condition that proves adequate for ending up on a jammed states.

The health consequences of using physical restraints in nursing homes.

PubMed

Castle, Nicholas G; Engberg, John

2009-11-01

Using a national longitudinal sample of nursing homes residents (N = 264,068), we examine whether physical restraint use contributes to subsequent physical or psychological health decline. The minimum data set, the on-line survey certification and recording system, and the area resource file were the data sources used. This data represented the period of 2004 and 2005. To control for the difference in characteristics between residents who were subsequently physically restrained and who were not, we use a propensity score matching method. For all outcomes examined (except depression), that is, behavior issues, cognitive performance, falls, walking dependence, activities of daily living, pressure ulcers, and contractures, were all significantly worse for restrained residents compared with matched residents who were not restrained. Physical restraint use represents poor clinical practice, and the benefits to residents of further reducing physical restraint use in nursing homes are substantial.

Which organizational characteristics are associated with increased management of depression using antidepressants in US nursing homes?

PubMed

Lapane, Kate L; Hughes, Carmel M

2004-10-01

There is universal agreement that organizational characteristics of nursing facilities can and do influence the quality of care and resident outcomes. This study evaluated the relation between organizational characteristics and management of depression using antidepressants. This was a cross-sectional study of Medicare/Medicaid certified nursing homes in 6 states in 2000. We studied 87,907 residents with depression in 2,128 facilities. Minimum Data Set (MDS) provided information regarding use of antidepressants and resident factors. On-line Survey and Certification of Automated Records (OSCAR) provided facility characteristics information including structural, resource, and staffing levels. Adjusted estimates of organizational effects on antidepressant drug use were derived from generalized estimating equations. Increased treatment of depression with antidepressants was associated with facilities with a higher percentage of residents from payer sources other than Medicare/Medicaid (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02-1.06) and more professional nursing staff (OR, 1.15; 95% CI, 1.05-1.26). Decreased treatment tended to be related to larger homes (OR, 0.76; 95% CI, 0.68-0.84) or if the home employed full-time physicians (OR, 0.87; 95% CI, 0.78-0.96). Once the decision to treat was made, treatment with tricyclics tended to be inversely related to larger homes, for-profit facilities, and homes with more Medicare residents. Facilities that are required to be more fiscally conservative, be it larger facilities with fewer private pay patients or for profit facilities, have lower rates of pharmacologic treatment. Resource and structural characteristics influence the type of antidepressant being prescribed; resident characteristics may not be the over-riding factor in prescribing.

Kinetics of thermal decomposition of hydrated minerals associated with hematite ore in a fluidized bed reactor

NASA Astrophysics Data System (ADS)

Beuria, P. C.; Biswal, S. K.; Mishra, B. K.; Roy, G. G.

2017-03-01

The kinetics of removal of loss on ignition (LOI) by thermal decomposition of hydrated minerals present in natural iron ores (i.e., kaolinite, gibbsite, and goethite) was investigated in a laboratory-scale vertical fluidized bed reactor (FBR) using isothermal methods of kinetic analysis. Experiments in the FBR in batch processes were carried out at different temperatures (300 to 1200°C) and residence time (1 to 30 min) for four different iron ore samples with various LOIs (2.34wt% to 9.83wt%). The operating velocity was maintained in the range from 1.2 to 1.4 times the minimum fluidization velocity ( U mf). We observed that, below a certain critical temperature, the FBR did not effectively reduce the LOI to a desired level even with increased residence time. The results of this study indicate that the LOI level could be reduced by 90% within 1 min of residence time at 1100°C. The kinetics for low-LOI samples (<6wt%) indicates two different reaction mechanisms in two temperature regimes. At lower temperatures (300 to 700°C), the kinetics is characterized by a lower activation energy (diffusion-controlled physical moisture removal), followed by a higher activation energy (chemically controlled removal of LOI). In the case of high-LOI samples, three different kinetics mechanisms prevail at different temperature regimes. At temperature up to 450°C, diffusion kinetics prevails (removal of physical moisture); at temperature from 450 to 650°C, chemical kinetics dominates during removal of matrix moisture. At temperatures greater than 650°C, nucleation and growth begins to influence the rate of removal of LOI.

Effect of nursing home ownership on hospitalization of long-stay residents: an instrumental variables approach

PubMed Central

Grabowski, David C.; Feng, Zhanlian; Rahman, Momotazur; Mor, Vincent

2014-01-01

Hospitalizations among nursing home residents are frequent, expensive, and often associated with further deterioration of resident condition. The literature indicates that a substantial fraction of admissions is potentially preventable and that nonprofit nursing homes are less likely to hospitalize their residents. However, the correlation between ownership and hospitalization might reflect unobserved resident differences rather than a causal relationship. Using national minimum data set assessments linked with Medicare claims, we use a national cohort of long-stay residents who were newly admitted to nursing homes within an 18-month period spanning January 1, 2004 and June 30, 2005. After instrumenting for ownership status, we found that IV estimates of the effect of nonprofit ownership on hospitalization are at least as large as the non-instrumented effects, indicating that selection bias does not explain the observed relationship. We also found evidence suggesting the lower rate of hospitalizations among nonprofits was due to a different threshold for transfer. PMID:24234287

Effect of nursing home ownership on hospitalization of long-stay residents: an instrumental variables approach.

PubMed

Hirth, Richard A; Grabowski, David C; Feng, Zhanlian; Rahman, Momotazur; Mor, Vincent

2014-03-01

Hospitalizations among nursing home residents are frequent, expensive, and often associated with further deterioration of resident condition. The literature indicates that a substantial fraction of admissions is potentially preventable and that nonprofit nursing homes are less likely to hospitalize their residents. However, the correlation between ownership and hospitalization might reflect unobserved resident differences rather than a causal relationship. Using national minimum data set assessments linked with Medicare claims, we use a national cohort of long-stay residents who were newly admitted to nursing homes within an 18-month period spanning January 1, 2004 and June 30, 2005. After instrumenting for ownership status, we found that IV estimates of the effect of nonprofit ownership on hospitalization are at least as large as the non-instrumented effects, indicating that selection bias does not explain the observed relationship. We also found evidence suggesting the lower rate of hospitalizations among nonprofits was due to a different threshold for transfer.

Comment on "Scrutinizing the carbon cycle and CO2residence time in the atmosphere" by H. Harde

NASA Astrophysics Data System (ADS)

Köhler, Peter; Hauck, Judith; Völker, Christoph; Wolf-Gladrow, Dieter A.; Butzin, Martin; Halpern, Joshua B.; Rice, Ken; Zeebe, Richard E.

2018-05-01

Harde (2017) proposes an alternative accounting scheme for the modern carbon cycle and concludes that only 4.3% of today's atmospheric CO2 is a result of anthropogenic emissions. As we will show, this alternative scheme is too simple, is based on invalid assumptions, and does not address many of the key processes involved in the global carbon cycle that are important on the timescale of interest. Harde (2017) therefore reaches an incorrect conclusion about the role of anthropogenic CO2 emissions. Harde (2017) tries to explain changes in atmospheric CO2 concentration with a single equation, while the most simple model of the carbon cycle must at minimum contain equations of at least two reservoirs (the atmosphere and the surface ocean), which are solved simultaneously. A single equation is fundamentally at odds with basic theory and observations. In the following we will (i) clarify the difference between CO2 atmospheric residence time and adjustment time, (ii) present recently published information about anthropogenic carbon, (iii) present details about the processes that are missing in Harde (2017), (iv) briefly discuss shortcoming in Harde's generalization to paleo timescales, (v) and comment on deficiencies in some of the literature cited in Harde (2017).

Association of supermarket characteristics with the body mass index of their shoppers

PubMed Central

2013-01-01

Background Research on the built food environment and weight status has mostly focused on the presence/absence of food outlets while ignoring their internal features or where residents actually shop. We explored associations of distance travelled to supermarkets and supermarket characteristics with shoppers’ body mass index (BMI). Methods Shoppers (n=555) of five supermarkets situated in different income areas in the city were surveyed for food shopping habits, demographics, home postal code, height and weight. Associations of minimum distance to a supermarket (along road network, objectively measured using ArcGIS), its size, food variety and food basket price with shoppers’ BMI were investigated. The ‘food basket’ was defined as the mixture of several food items commonly consumed by residents and available in all supermarkets. Results Supermarkets ranged in total floor space (7500–135 000 square feet) and had similar varieties of fruits, vegetables and cereals. The majority of participants shopped at the surveyed supermarket more than once per week (mean range 1.2 ± 0.8 to 2.3 ± 2.1 times per week across the five supermarkets, p < 0.001), and identified it as their primary store for food (52% overall). Mean participant BMI of the five supermarkets ranged from 23.7 ± 4.3 kg/m2 to 27.1 ± 4.3 kg/m2 (p < 0.001). Median minimum distance from the shoppers’ residence to the supermarket they shopped at ranged from 0.96 (0.57, 2.31) km to 4.30 (2.83, 5.75) km (p < 0.001). A negative association was found between food basket price and BMI. There were no associations between BMI and minimum distance to the supermarket, or other supermarket characteristics. After adjusting for age, sex, dissemination area median individual income and car ownership, BMI of individuals who shopped at Store 1 and Store 2, the supermarkets with lowest price of the ‘food basket’, was 3.66 kg/m2 and 3.73 kg/m2 higher compared to their counterparts who shopped at the supermarket where the ‘food basket’ price was highest (p < 0.001). Conclusions The food basket price in supermarkets was inversely associated with BMI of their shoppers. Our results suggest that careful manipulation of food prices may be used as an intervention for decreasing BMI. PMID:23941309

Association of supermarket characteristics with the body mass index of their shoppers.

PubMed

Lear, Scott A; Gasevic, Danijela; Schuurman, Nadine

2013-08-13

Research on the built food environment and weight status has mostly focused on the presence/absence of food outlets while ignoring their internal features or where residents actually shop. We explored associations of distance travelled to supermarkets and supermarket characteristics with shoppers' body mass index (BMI). Shoppers (n=555) of five supermarkets situated in different income areas in the city were surveyed for food shopping habits, demographics, home postal code, height and weight. Associations of minimum distance to a supermarket (along road network, objectively measured using ArcGIS), its size, food variety and food basket price with shoppers' BMI were investigated. The 'food basket' was defined as the mixture of several food items commonly consumed by residents and available in all supermarkets. Supermarkets ranged in total floor space (7500-135,000 square feet) and had similar varieties of fruits, vegetables and cereals. The majority of participants shopped at the surveyed supermarket more than once per week (mean range 1.2 ± 0.8 to 2.3 ± 2.1 times per week across the five supermarkets, p < 0.001), and identified it as their primary store for food (52% overall). Mean participant BMI of the five supermarkets ranged from 23.7 ± 4.3 kg/m² to 27.1 ± 4.3 kg/m² (p < 0.001). Median minimum distance from the shoppers' residence to the supermarket they shopped at ranged from 0.96 (0.57, 2.31) km to 4.30 (2.83, 5.75) km (p < 0.001). A negative association was found between food basket price and BMI. There were no associations between BMI and minimum distance to the supermarket, or other supermarket characteristics. After adjusting for age, sex, dissemination area median individual income and car ownership, BMI of individuals who shopped at Store 1 and Store 2, the supermarkets with lowest price of the 'food basket', was 3.66 kg/m² and 3.73 kg/m² higher compared to their counterparts who shopped at the supermarket where the 'food basket' price was highest (p < 0.001). The food basket price in supermarkets was inversely associated with BMI of their shoppers. Our results suggest that careful manipulation of food prices may be used as an intervention for decreasing BMI.

Medicare program; prospective payment system and consolidated billing for skilled nursing facilities for FY 2010; minimum data set, version 3.0 for skilled nursing facilities and Medicaid nursing facilities. Final rule.

PubMed

2009-08-11

This final rule updates the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs), for fiscal year (FY) 2010. In addition, it recalibrates the case-mix indexes so that they more accurately reflect parity in expenditures related to the implementation of case-mix refinements in January 2006. It also discusses the results of our ongoing analysis of nursing home staff time measurement data collected in the Staff Time and Resource Intensity Verification project, as well as a new Resource Utilization Groups, version 4 case-mix classification model for FY 2011 that will use the updated Minimum Data Set 3.0 resident assessment for case-mix classification. In addition, this final rule discusses the public comments that we have received on these and other issues, including a possible requirement for the quarterly reporting of nursing home staffing data, as well as on applying the quality monitoring mechanism in place for all other SNF PPS facilities to rural swing-bed hospitals. Finally, this final rule revises the regulations to incorporate certain technical corrections.

Pharmacokinetic Study of Intravenous Acetaminophen Administered to Critically Ill Multiple-Trauma Patients at the Usual Dosage and a New Proposal for Administration.

PubMed

Fuster-Lluch, Oscar; Zapater-Hernández, Pedro; Gerónimo-Pardo, Manuel

2017-10-01

The pharmacokinetic profile of intravenous acetaminophen administered to critically ill multiple-trauma patients was studied after 4 consecutive doses of 1 g every 6 hours. Eleven blood samples were taken (predose and 15, 30, 45, 60, 90, 120, 180, 240, 300, and 360 minutes postdose), and urine was collected (during 6-hour intervals between doses) to determine serum and urine acetaminophen concentrations. These were used to calculate the following pharmacokinetic parameters: maximum and minimum concentrations, terminal half-life, area under serum concentration-time curve from 0 to 6 hours, mean residence time, volume of distribution, and serum and renal clearance of acetaminophen. Daily doses of acetaminophen required to obtain steady-state minimum (bolus dosing) and average plasma concentrations (continuous infusion) of 10 μg/mL were calculated (10 μg/mL is the presumed lower limit of the analgesic range). Data are expressed as median [interquartile range]. Twenty-two patients were studied, mostly young (age 44 [34-64] years) males (68%), not obese (weight 78 [70-84] kg). Acetaminophen concentrations and pharmacokinetic parameters were these: maximum concentration 33.6 [25.7-38.7] μg/mL and minimum concentration 0.5 [0.2-2.3] μg/mL, all values below 10 μg/mL and 8 below the detection limit; half-life 1.2 [1.0-1.9] hours; area under the curve for 6 hours 34.7 [29.7-52.7] μg·h/mL; mean residence time 1.8 [1.3-2.6] hours; steady-state volume of distribution 50.8 [42.5-66.5] L; and serum and renal clearance 28.8 [18.9-33.7] L/h and 15 [11-19] mL/min, respectively. Theoretically, daily doses for a steady-state minimum concentration of 10 μg/mL would be 12.2 [7.8-16.4] g/day (166 [112-202] mg/[kg·day]); for an average steady-state concentration of 10 μg/mL, they would be 6.9 [4.5-8.1] g/day (91 [59-111] mg/[kg·day]). In conclusion, administration of acetaminophen at the recommended dosage of 1 g per 6 hours to critically ill multiple-trauma patients yields serum concentrations below 10 μg/mL due to increased elimination. To reach the 10 μg/mL target, and from a strictly pharmacokinetic point of view, continuous infusion may be more feasible than bolus dosing. Such a change in dosing strategy requires appropriate, pharmacokinetic-pharmacodynamic and specific safety study. © 2017, The American College of Clinical Pharmacology.

Quantum resonant activation.

PubMed

Magazzù, Luca; Hänggi, Peter; Spagnolo, Bernardo; Valenti, Davide

2017-04-01

Quantum resonant activation is investigated for the archetype setup of an externally driven two-state (spin-boson) system subjected to strong dissipation by means of both analytical and extensive numerical calculations. The phenomenon of resonant activation emerges in the presence of either randomly fluctuating or deterministic periodically varying driving fields. Addressing the incoherent regime, a characteristic minimum emerges in the mean first passage time to reach an absorbing neighboring state whenever the intrinsic time scale of the modulation matches the characteristic time scale of the system dynamics. For the case of deterministic periodic driving, the first passage time probability density function (pdf) displays a complex, multipeaked behavior, which depends crucially on the details of initial phase, frequency, and strength of the driving. As an interesting feature we find that the mean first passage time enters the resonant activation regime at a critical frequency ν^{*} which depends very weakly on the strength of the driving. Moreover, we provide the relation between the first passage time pdf and the statistics of residence times.

Quantum resonant activation

NASA Astrophysics Data System (ADS)

Magazzó, Luca; Hänggi, Peter; Spagnolo, Bernardo; Valenti, Davide

2017-04-01

Quantum resonant activation is investigated for the archetype setup of an externally driven two-state (spin-boson) system subjected to strong dissipation by means of both analytical and extensive numerical calculations. The phenomenon of resonant activation emerges in the presence of either randomly fluctuating or deterministic periodically varying driving fields. Addressing the incoherent regime, a characteristic minimum emerges in the mean first passage time to reach an absorbing neighboring state whenever the intrinsic time scale of the modulation matches the characteristic time scale of the system dynamics. For the case of deterministic periodic driving, the first passage time probability density function (pdf) displays a complex, multipeaked behavior, which depends crucially on the details of initial phase, frequency, and strength of the driving. As an interesting feature we find that the mean first passage time enters the resonant activation regime at a critical frequency ν* which depends very weakly on the strength of the driving. Moreover, we provide the relation between the first passage time pdf and the statistics of residence times.

Nursing home quality and financial performance: does the racial composition of residents matter?

PubMed

Chisholm, Latarsha; Weech-Maldonado, Robert; Laberge, Alex; Lin, Feng-Chang; Hyer, Kathryn

2013-12-01

To examine the effects of the racial composition of residents on nursing homes' financial and quality performance. The study examined Medicare and Medicaid-certified nursing homes across the United States that submitted Medicare cost reports between the years 1999 and 2004 (11,472 average per year). Data were obtained from the Minimum Data Set, the On-Line Survey Certification and Reporting, Medicare Cost Reports, and the Area Resource File. Panel data regression with random intercepts and negative binomial regression were conducted with state and year fixed effects. Financial and quality performance differed between nursing homes with high proportions of black residents and nursing homes with no or medium proportions of black residents. Nursing homes with no black residents had higher revenues and higher operating margins and total profit margins and they exhibited better processes and outcomes than nursing homes with high proportions of black residents. Nursing homes' financial viability and quality of care are influenced by the racial composition of residents. Policy makers should consider initiatives to improve both the financial and quality performance of nursing homes serving predominantly black residents. © Health Research and Educational Trust.

Simulation-based education with mastery learning improves residents' lumbar puncture skills

PubMed Central

Cohen, Elaine R.; Caprio, Timothy; McGaghie, William C.; Simuni, Tanya; Wayne, Diane B.

2012-01-01

Objective: To evaluate the effect of simulation-based mastery learning (SBML) on internal medicine residents' lumbar puncture (LP) skills, assess neurology residents' acquired LP skills from traditional clinical education, and compare the results of SBML to traditional clinical education. Methods: This study was a pretest-posttest design with a comparison group. Fifty-eight postgraduate year (PGY) 1 internal medicine residents received an SBML intervention in LP. Residents completed a baseline skill assessment (pretest) using a 21-item LP checklist. After a 3-hour session featuring deliberate practice and feedback, residents completed a posttest and were expected to meet or exceed a minimum passing score (MPS) set by an expert panel. Simulator-trained residents' pretest and posttest scores were compared to assess the impact of the intervention. Thirty-six PGY2, 3, and 4 neurology residents from 3 medical centers completed the same simulated LP assessment without SBML. SBML posttest scores were compared to neurology residents' baseline scores. Results: PGY1 internal medicine residents improved from a mean of 46.3% to 95.7% after SBML (p < 0.001) and all met the MPS at final posttest. The performance of traditionally trained neurology residents was significantly lower than simulator-trained residents (mean 65.4%, p < 0.001) and only 6% met the MPS. Conclusions: Residents who completed SBML showed significant improvement in LP procedural skills. Few neurology residents were competent to perform a simulated LP despite clinical experience with the procedure. PMID:22675080

Prevalence and factors associated with underutilization of antenatal care services in Nigeria: A comparative study of rural and urban residences based on the 2013 Nigeria demographic and health survey

PubMed Central

Auta, Asa; Khanal, Vishnu; Bamidele, Olasunkanmi David; Akuoko, Cynthia Pomaa; Adefemi, Kazeem; Tapshak, Samson Joseph; Zhao, Yun

2018-01-01

Introduction Antenatal care (ANC) is a major public health intervention aimed at ensuring safe pregnancy outcomes. In Nigeria, the recommended minimum of four times ANC attendance is underutilized. This study investigates the prevalence and factors associated with underutilization of ANC services with a focus on the differences between rural and urban residences in Nigeria. Methods We analyzed the 2013 Nigeria Demographic and Health Survey dataset with adjustment for the sampling weight and the cluster design of the survey. The prevalence of underutilization of ANC was assessed using frequency tabulation while associated factors were examined using Chi-Square test and multivariable logistic regression analysis. Results The prevalence of underutilization of ANC was 46.5% in Nigeria, 61.1% in rural residence and 22.4% in urban residence. The North-West region had the highest prevalence of ANC underuse in Nigeria at 69.3%, 76.6% and 44.8% for the overall, rural and urban residences respectively. Factors associated with greater odds of ANC underuse in rural residence were maternal non-working status, birth interval < 24 months, single birth type, not listening to radio at all, lack of companionship to health facility and not getting money for health services. In urban residence, mothers professing Islam, those who did not read newspaper at all, and those who lacked health insurance, had greater odds of ANC underuse. In both rural and urban residence, maternal and husband’s education level, region of residence, wealth index, maternal age, frequency of watching television, distance to- and permission to visit health facility were significantly associated with ANC underuse. Conclusions Rural-urban differences exist in the use of ANC services, and to varying degrees, factors associated with underuse of ANC in Nigeria. Interventions aimed at addressing factors identified in this study may help to improve the utilization of ANC services both in rural and urban Nigeria. Such interventions need to focus more on reducing socioeconomic, geographic and regional disparities in access to ANC in Nigeria. PMID:29782511

Prevalence and factors associated with underutilization of antenatal care services in Nigeria: A comparative study of rural and urban residences based on the 2013 Nigeria demographic and health survey.

PubMed

Adewuyi, Emmanuel Olorunleke; Auta, Asa; Khanal, Vishnu; Bamidele, Olasunkanmi David; Akuoko, Cynthia Pomaa; Adefemi, Kazeem; Tapshak, Samson Joseph; Zhao, Yun

2018-01-01

Antenatal care (ANC) is a major public health intervention aimed at ensuring safe pregnancy outcomes. In Nigeria, the recommended minimum of four times ANC attendance is underutilized. This study investigates the prevalence and factors associated with underutilization of ANC services with a focus on the differences between rural and urban residences in Nigeria. We analyzed the 2013 Nigeria Demographic and Health Survey dataset with adjustment for the sampling weight and the cluster design of the survey. The prevalence of underutilization of ANC was assessed using frequency tabulation while associated factors were examined using Chi-Square test and multivariable logistic regression analysis. The prevalence of underutilization of ANC was 46.5% in Nigeria, 61.1% in rural residence and 22.4% in urban residence. The North-West region had the highest prevalence of ANC underuse in Nigeria at 69.3%, 76.6% and 44.8% for the overall, rural and urban residences respectively. Factors associated with greater odds of ANC underuse in rural residence were maternal non-working status, birth interval < 24 months, single birth type, not listening to radio at all, lack of companionship to health facility and not getting money for health services. In urban residence, mothers professing Islam, those who did not read newspaper at all, and those who lacked health insurance, had greater odds of ANC underuse. In both rural and urban residence, maternal and husband's education level, region of residence, wealth index, maternal age, frequency of watching television, distance to- and permission to visit health facility were significantly associated with ANC underuse. Rural-urban differences exist in the use of ANC services, and to varying degrees, factors associated with underuse of ANC in Nigeria. Interventions aimed at addressing factors identified in this study may help to improve the utilization of ANC services both in rural and urban Nigeria. Such interventions need to focus more on reducing socioeconomic, geographic and regional disparities in access to ANC in Nigeria.

Determining Nurse Aide Staffing Requirements to Provide Care Based on Resident Workload: A Discrete Event Simulation Model.

PubMed

Schnelle, John F; Schroyer, L Dale; Saraf, Avantika A; Simmons, Sandra F

2016-11-01

Nursing aides provide most of the labor-intensive activities of daily living (ADL) care to nursing home (NH) residents. Currently, most NHs do not determine nurse aide staffing requirements based on the time to provide ADL care for their unique resident population. The lack of an objective method to determine nurse aide staffing requirements suggests that many NHs could be understaffed in their capacity to provide consistent ADL care to all residents in need. Discrete event simulation (DES) mathematically models key work parameters (eg, time to provide an episode of care and available staff) to predict the ability of the work setting to provide care over time and offers an objective method to determine nurse aide staffing needs in NHs. This study had 2 primary objectives: (1) to describe the relationship between ADL workload and the level of nurse aide staffing reported by NHs; and, (2) to use a DES model to determine the relationship between ADL workload and nurse aide staffing necessary for consistent, timely ADL care. Minimum Data Set data related to the level of dependency on staff for ADL care for residents in over 13,500 NHs nationwide were converted into 7 workload categories that captured 98% of all residents. In addition, data related to the time to provide care for the ADLs within each workload category was used to calculate a workload score for each facility. The correlation between workload and reported nurse aide staffing levels was calculated to determine the association between staffing reported by NHs and workload. Simulations to project staffing requirements necessary to provide ADL care were then conducted for 65 different workload scenarios, which included 13 different nurse aide staffing levels (ranging from 1.6 to 4.0 total hours per resident day) and 5 different workload percentiles (ranging from the 5th to the 95th percentile). The purpose of the simulation model was to determine the staffing necessary to provide care within each workload percentile based on resident ADL care needs and compare the simulated staffing projections to the NH reported staffing levels. The percentage of scheduled care time that was omitted was estimated by the simulation model for each of the 65 workload scenarios using optimistic assumptions about staff productivity and efficiency. There was a low correlation between ADL workload and reported nurse aide staffing (Pearson = .11; P < .01), which suggests that most of the 13,500 NHs were not using ADL acuity to determine nurse aide staffing levels. Based on the DES model, the nurse aide staffing required for ADL care that would result in a rate of care omissions below 10% ranged from 2.8 hours/resident/day for NHs with a low workload (5th percentile) to 3.6 hours/resident/day for NHs with a high workload (95th percentile). In contrast, NHs reported staffing levels that ranged from an average of 2.3 to 2.5 hours/resident/day across all 5 workload percentiles. Higher workload NHs had the largest discrepancies between reported and predicted nurse aide staffing levels. The average nurse aide staffing levels reported by NHs falls below the level of staffing predicted as necessary to provide consistent ADL care to all residents in need. DES methodology can be used to determine nurse aide staffing requirements to provide ADL care and simulate management interventions to improve care efficiency and quality. Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Discourse on malaria elimination: where do forcibly displaced persons fit in these discussions?

PubMed Central

2013-01-01

Background Individuals forcibly displaced are some of the poorest people in the world, living in areas where infrastructure and services are at a bare minimum. Out of a total of 10,549,686 refugees protected and assisted by the United Nations High Commissioner for Refugees globally, 6,917,496 (65.6%) live in areas where malaria is transmitted. Historically, national malaria control programmes have excluded displaced populations. Results The current discourse on malaria elimination rarely includes discussion of forcibly displaced persons who reside within malaria-eliminating countries. Of the 100 malaria-endemic countries, 64 are controlling malaria and 36 are in some stage of elimination. Of these, 30 malaria-controlling countries and 13 countries in some phase of elimination host displaced populations of ≥50,000, even though 13 of the 36 (36.1%) malaria-elimination countries host displaced populations of ≥50,000 people. Discussion Now is the time for the malaria community to incorporate forcibly displaced populations residing within malarious areas into malaria control activities. Beneficiaries, whether they are internally displaced persons or refugees, should be viewed as partners in the delivery of malaria interventions and not simply as recipients. Conclusion Until equitable and sustainable malaria control includes everyone residing in an endemic area, the goal of malaria elimination will not be met. PMID:23575209

The Effects of Evacuation on Nursing Home Residents With Dementia

PubMed Central

Brown, Lisa M.; Dosa, David M.; Thomas, Kali; Hyer, Kathryn; Feng, Zhanlian; Mor, Vincent

2013-01-01

Background In response to the hurricane-related deaths of nursing home residents, there has been a steady increase in the number of facilities that evacuate under storm threat. This study examined the effects of evacuation during Hurricane Gustav on residents who were cognitively impaired. Methods Nursing homes in counties located in the path of Hurricane Gustav were identified. The Minimum Data Set resident assessment files were merged with the Centers for Medicare enrollment file to determine date of death for residents in identified facilities. Difference-in-differences analyses were conducted adjusting for residents’ demographic characteristics and acuity. Results The dataset included 21,255 residents living in 119 at risk nursing homes over three years of observation. Relative to the two years before the storm, there was a 2.8 percent increase in death at 30 days and a 3.9 percent increase in death at 90 days for residents with severe dementia who evacuated for Hurricane Gustav, controlling for resident demographics and acuity. Conclusions The findings of this research reveal the deleterious effects of evacuation on residents with severe dementia. Interventions need to be developed and tested to determine the best methods for protecting this at risk population when there are no other options than to evacuate the facility. PMID:22930698

A single-institution experience: the integrated vascular surgery residency's effect on fellowship and general surgery resident case volume and diversity.

PubMed

Carroll, Megan I; Downes, Kathryne; Miladinovic, Branko; Illig, Karl A; Armstrong, Paul A; Back, Martin R; Johnson, Brad L; Shames, Murray L

2014-01-01

To determine whether the formation of an integrated vascular surgery residency (0 + 5) has negatively impacted the case volume and diversity of the vascular surgery fellows (5 + 2) and chief general surgeons at the same institution. Operative data from the vascular integrated (0 + 5), independent (5 + 2), and general surgery residencies at a single institution were retrospectively reviewed and analyzed to determine vascular surgery case volumes from 2006-2012. National operative data (Residency Review Committee) were used for comparison of diversity and volume. Standard statistical methods were applied. During this period, the 5 + 2 fellows at our institution performed on average 741 (range, 554-1002) primary cases and 1091 (range, 844-1479) combined primary and secondary cases for the 2-year fellowship. Our integrated residency began in July 2007. Our fellows' primary case volumes remained relatively stable between 2006 and 2011, with a 4% increase in the number of cases, although their total (primary and secondary) case volumes fell 15%; by comparison, the equivalent national 50th percentile rates rose 16% during this time frame. Our institution's general surgery residents performed an average of 116 (range, 56-221) vascular cases individually during their 5-year residency from 2005-2011. From 2006-2011, the total case volume fell only 5%, while the national 50th percentile rate fell 24%. Across all years, however, resident and fellow volumes both continue to be above Accreditation Council for Graduate Medical Education minimum requirements, and the major vascular case volume at our institution in all groups studied remained statistically greater than or equal to the national 50th percentile of cases. Our first integrated resident to graduate finished in June 2012 with 931 total vascular cases and 249 general surgery cases for a total operative experience of 1180 cases during the 5-year residency. Finally, after an 8-year period (2003-2010) in which none of our general surgery residents pursued vascular training, 1 resident in each of the 2011, 2012, and 2013 graduating years has now done so. At our institution, the introduction of a 0 + 5 vascular residency has correlated with a modest drop (15%) in overall case volume for the 5 + 2 fellows, but the number of primary cases have actually increased slightly and they continue to meet or exceed Accreditation Council for Graduate Medical Education requirements and national 50th percentile rates. General surgery residents' vascular volumes, by contrast, have remained stable, and interest in vascular surgery by residents has increased. Our integrated vascular residents are projected to exceed the fellows' 50th percentile case volume and diversity targets during their residency experience. Copyright © 2014 Elsevier Inc. All rights reserved.

Residence Times in Central Valley Aquifers Recharged by Dammed Rivers

NASA Astrophysics Data System (ADS)

Loustale, M.; Paukert Vankeuren, A. N.; Visser, A.

2017-12-01

Groundwater is a vital resource for California, providing between 30-60% of the state's water supply. Recent emphasis on groundwater sustainability has induced a push to characterize recharge rates and residence times for high priority aquifers, including most aquifers in California's Central Valley. Flows in almost all rivers from the western Sierra to the Central Valley are controlled by dams, altering natural flow patterns and recharge to local aquifers. In eastern Sacramento, unconfined and confined shallow aquifers (depth <300 feet) are recharged by a losing reach of the Lower American River, despite the presence of levees with slurry cut-off walls.1 Flow in the Lower American River is controlled through the operation of the Folsom and Nimbus Dams, with a minimum flow of 500 cfs. Water table elevation in wells in close proximity to the river are compared to river stage to determine the effect of river stage on groundwater recharge rates. Additionally, Tritium-3Helium dates and stable isotopes (∂18O and ∂2H) have been measured in monitoring wells 200- 2400 ft lateral distance from the river, and depths of 25 -225 feet BGS. Variation in groundwater age in the vertical and horizontal directions are used to determine groundwater flow path and velocity. These data are then used to calculate residence time of groundwater in the unconfined and confined aquifer systems for the Central Valley in eastern Sacramento. Applying groundwater age tracers can benefit future compliance metrics of the California Sustainable Groundwater Resources Act (SGMA), by quantifying river seepage rates and impacts of groundwater management on surface water resources. 1Moran et al., UCRL-TR-203258, 2004.

Serious Mental Illness and Nursing Home Quality of Care

PubMed Central

Rahman, Momotazur; Grabowski, David C; Intrator, Orna; Cai, Shubing; Mor, Vincent

2013-01-01

Objective To estimate the effect of a nursing home's share of residents with a serious mental illness (SMI) on the quality of care. Data Sources Secondary nursing home level data over the period 2000 through 2008 obtained from the Minimum Data Set, OSCAR, and Medicare claims. Study Design We employ an instrumental variables approach to address the potential endogeneity of the share of SMI residents in nursing homes in a model including nursing home and year fixed effects. Principal Findings An increase in the share of SMI nursing home residents positively affected the hospitalization rate among non-SMI residents and negatively affected staffing skill mix and level. We did not observe a statistically significant effect on inspection-based health deficiencies or the hospitalization rate for SMI residents. Conclusions Across the majority of indicators, a greater SMI share resulted in lower nursing home quality. Given the increased prevalence of nursing home residents with SMI, policy makers and providers will need to adjust practices in the context of this new patient population. Reforms may include more stringent preadmission screening, new regulations, reimbursement changes, and increased reporting and oversight. PMID:23278400

Obesity and intensive staffing needs of nursing home residents.

PubMed

Harris, John Alexander; Engberg, John; Castle, Nicholas George

2018-06-05

The objective of this study is to examine how increasing body mass index (BMI) among nursing home residents affects the amount of staffing assistance needed for activities of daily living (ADL). We analyzed 1,627,141 US nursing home residents reported in the 2013 Minimum Data Set in seven BMI categories, from underweight (BMI < 18.5 kg/m 2 ) to obesity Class IIIB (≥50 kg/m 2 ). Logistic regression models estimated the odds of nursing home-reported need for extensive (≥2 staff member) assistance needed for ADLs. The adjusted odds increased from 1.07 (95% Confidence Interval (95%CI) 1.06-1.08) for Class I, 1.16 (95%CI 1.14-1.17) for Class II, 1.33 (95%CI 1.31-1.35) for Class IIIA, and 1.90 (95%CI 1.86-1.95) for Class IIIB obesity residents compared to residents of normal weight. As a nursing home resident's BMI increases, especially for BMI ≥40 kg/m 2 , the need for extensive staffing assistance with ADLs also increases substantially. Copyright © 2018 Elsevier Inc. All rights reserved.

The Oldest, Slowest Rainforests in the World? Massive Biomass and Slow Carbon Dynamics of Fitzroya cupressoides Temperate Forests in Southern Chile.

PubMed

Urrutia-Jalabert, Rocio; Malhi, Yadvinder; Lara, Antonio

2015-01-01

Old-growth temperate rainforests are, per unit area, the largest and most long-lived stores of carbon in the terrestrial biosphere, but their carbon dynamics have rarely been described. The endangered Fitzroya cupressoides forests of southern South America include stands that are probably the oldest dense forest stands in the world, with long-lived trees and high standing biomass. We assess and compare aboveground biomass, and provide the first estimates of net primary productivity (NPP), carbon allocation and mean wood residence time in medium-age stands in the Alerce Costero National Park (AC) in the Coastal Range and in old-growth forests in the Alerce Andino National Park (AA) in the Andean Cordillera. Aboveground live biomass was 113-114 Mg C ha(-1) and 448-517 Mg C ha(-1) in AC and AA, respectively. Aboveground productivity was 3.35-3.36 Mg C ha(-1) year(-1) in AC and 2.22-2.54 Mg C ha(-1) year(-1) in AA, values generally lower than others reported for temperate wet forests worldwide, mainly due to the low woody growth of Fitzroya. NPP was 4.21-4.24 and 3.78-4.10 Mg C ha(-1) year(-1) in AC and AA, respectively. Estimated mean wood residence time was a minimum of 539-640 years for the whole forest in the Andes and 1368-1393 years for only Fitzroya in this site. Our biomass estimates for the Andes place these ecosystems among the most massive forests in the world. Differences in biomass production between sites seem mostly apparent as differences in allocation rather than productivity. Residence time estimates for Fitzroya are the highest reported for any species and carbon dynamics in these forests are the slowest reported for wet forests worldwide. Although primary productivity is low in Fitzroya forests, they probably act as ongoing biomass carbon sinks on long-term timescales due to their low mortality rates and exceptionally long residence times that allow biomass to be accumulated for millennia.

The Oldest, Slowest Rainforests in the World? Massive Biomass and Slow Carbon Dynamics of Fitzroya cupressoides Temperate Forests in Southern Chile

PubMed Central

Urrutia-Jalabert, Rocio; Malhi, Yadvinder; Lara, Antonio

2015-01-01

Old-growth temperate rainforests are, per unit area, the largest and most long-lived stores of carbon in the terrestrial biosphere, but their carbon dynamics have rarely been described. The endangered Fitzroya cupressoides forests of southern South America include stands that are probably the oldest dense forest stands in the world, with long-lived trees and high standing biomass. We assess and compare aboveground biomass, and provide the first estimates of net primary productivity (NPP), carbon allocation and mean wood residence time in medium-age stands in the Alerce Costero National Park (AC) in the Coastal Range and in old-growth forests in the Alerce Andino National Park (AA) in the Andean Cordillera. Aboveground live biomass was 113–114 Mg C ha-1 and 448–517 Mg C ha-1 in AC and AA, respectively. Aboveground productivity was 3.35–3.36 Mg C ha-1 year-1 in AC and 2.22–2.54 Mg C ha-1 year-1 in AA, values generally lower than others reported for temperate wet forests worldwide, mainly due to the low woody growth of Fitzroya. NPP was 4.21–4.24 and 3.78–4.10 Mg C ha-1 year-1 in AC and AA, respectively. Estimated mean wood residence time was a minimum of 539–640 years for the whole forest in the Andes and 1368–1393 years for only Fitzroya in this site. Our biomass estimates for the Andes place these ecosystems among the most massive forests in the world. Differences in biomass production between sites seem mostly apparent as differences in allocation rather than productivity. Residence time estimates for Fitzroya are the highest reported for any species and carbon dynamics in these forests are the slowest reported for wet forests worldwide. Although primary productivity is low in Fitzroya forests, they probably act as ongoing biomass carbon sinks on long-term timescales due to their low mortality rates and exceptionally long residence times that allow biomass to be accumulated for millennia. PMID:26353111

Design and Analysis of Optimal Ascent Trajectories for Stratospheric Airships

NASA Astrophysics Data System (ADS)

Mueller, Joseph Bernard

Stratospheric airships are lighter-than-air vehicles that have the potential to provide a long-duration airborne presence at altitudes of 18-22 km. Designed to operate on solar power in the calm portion of the lower stratosphere and above all regulated air traffic and cloud cover, these vehicles represent an emerging platform that resides between conventional aircraft and satellites. A particular challenge for airship operation is the planning of ascent trajectories, as the slow moving vehicle must traverse the high wind region of the jet stream. Due to large changes in wind speed and direction across altitude and the susceptibility of airship motion to wind, the trajectory must be carefully planned, preferably optimized, in order to ensure that the desired station be reached within acceptable performance bounds of flight time and energy consumption. This thesis develops optimal ascent trajectories for stratospheric airships, examines the structure and sensitivity of these solutions, and presents a strategy for onboard guidance. Optimal ascent trajectories are developed that utilize wind energy to achieve minimum-time and minimum-energy flights. The airship is represented by a three-dimensional point mass model, and the equations of motion include aerodynamic lift and drag, vectored thrust, added mass effects, and accelerations due to mass flow rate, wind rates, and Earth rotation. A representative wind profile is developed based on historical meteorological data and measurements. Trajectory optimization is performed by first defining an optimal control problem with both terminal and path constraints, then using direct transcription to develop an approximate nonlinear parameter optimization problem of finite dimension. Optimal ascent trajectories are determined using SNOPT for a variety of upwind, downwind, and crosswind launch locations. Results of extensive optimization solutions illustrate definitive patterns in the ascent path for minimum time flights across varying launch locations, and show that significant energy savings can be realized with minimum-energy flights, compared to minimum-time time flights, given small increases in flight time. The performance of the optimal trajectories are then studied with respect to solar energy production during ascent, as well as sensitivity of the solutions to small changes in drag coefficient and wind model parameters. Results of solar power model simulations indicate that solar energy is sufficient to power ascent flights, but that significant energy loss can occur for certain types of trajectories. Sensitivity to the drag and wind model is approximated through numerical simulations, showing that optimal solutions change gradually with respect to changing wind and drag parameters and providing deeper insight into the characteristics of optimal airship flights. Finally, alternative methods are developed to generate near-optimal ascent trajectories in a manner suitable for onboard implementation. The structures and characteristics of previously developed minimum-time and minimum-energy ascent trajectories are used to construct simplified trajectory models, which are efficiently solved in a smaller numerical optimization problem. Comparison of these alternative solutions to the original SNOPT solutions show excellent agreement, suggesting the alternate formulations are an effective means to develop near-optimal solutions in an onboard setting.

Cosmetic Surgery Training in Plastic Surgery Residency Programs.

PubMed

McNichols, Colton H L; Diaconu, Silviu; Alfadil, Sara; Woodall, Jhade; Grant, Michael; Lifchez, Scott; Nam, Arthur; Rasko, Yvonne

2017-09-01

Over the past decade, plastic surgery programs have continued to evolve with the addition of 1 year of training, increase in the minimum number of required aesthetic cases, and the gradual replacement of independent positions with integrated ones. To evaluate the impact of these changes on aesthetic training, a survey was sent to residents and program directors. A 37 question survey was sent to plastic surgery residents at all Accreditation Council for Graduate Medical Education-approved plastic surgery training programs in the United States. A 13 question survey was sent to the program directors at the same institutions. Both surveys were analyzed to determine the duration of training and comfort level with cosmetic procedures. Eighty-three residents (10%) and 11 program directors (11%) completed the survey. Ninety-four percentage of residents had a dedicated cosmetic surgery rotation (an increase from 68% in 2015) in addition to a resident cosmetic clinic. Twenty percentage of senior residents felt they would need an aesthetic surgery fellowship to practice cosmetic surgery compared with 31% in 2015. Integrated chief residents were more comfortable performing cosmetic surgery cases compared with independent chief residents. Senior residents continue to have poor confidence with facial aesthetic and body contouring procedures. There is an increase in dedicated cosmetic surgery rotations and fewer residents believe they need a fellowship to practice cosmetic surgery. However, the comfort level of performing facial aesthetic and body contouring procedures remains low particularly among independent residents.

Cosmetic Surgery Training in Plastic Surgery Residency Programs

PubMed Central

McNichols, Colton H. L.; Diaconu, Silviu; Alfadil, Sara; Woodall, Jhade; Grant, Michael; Lifchez, Scott; Nam, Arthur

2017-01-01

Background: Over the past decade, plastic surgery programs have continued to evolve with the addition of 1 year of training, increase in the minimum number of required aesthetic cases, and the gradual replacement of independent positions with integrated ones. To evaluate the impact of these changes on aesthetic training, a survey was sent to residents and program directors. Methods: A 37 question survey was sent to plastic surgery residents at all Accreditation Council for Graduate Medical Education–approved plastic surgery training programs in the United States. A 13 question survey was sent to the program directors at the same institutions. Both surveys were analyzed to determine the duration of training and comfort level with cosmetic procedures. Results: Eighty-three residents (10%) and 11 program directors (11%) completed the survey. Ninety-four percentage of residents had a dedicated cosmetic surgery rotation (an increase from 68% in 2015) in addition to a resident cosmetic clinic. Twenty percentage of senior residents felt they would need an aesthetic surgery fellowship to practice cosmetic surgery compared with 31% in 2015. Integrated chief residents were more comfortable performing cosmetic surgery cases compared with independent chief residents. Senior residents continue to have poor confidence with facial aesthetic and body contouring procedures. Conclusions: There is an increase in dedicated cosmetic surgery rotations and fewer residents believe they need a fellowship to practice cosmetic surgery. However, the comfort level of performing facial aesthetic and body contouring procedures remains low particularly among independent residents. PMID:29062658

SU-E-E-01: ABR Diagnostic Radiology Core Exam: Was Our Redesigned Physics Course Successful in Teaching Physics to Radiology Residents?

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kanal, K; Hoff, M; Dickinson, R

Purpose: Our purpose is to evaluate the effectiveness of our two year physics course in preparing radiology residents for the American Board of Radiology (ABR) diagnostic radiology exam. Methods: We designed a new two-year physics course that integrates radiology clinical content and practice and is primarily based on the AAPM curriculum and RSNA/AAPM physics modules. Biweekly classes focus on relevant concepts from assigned reading and use audience response systems to encourage participation. Teaching efficiency is optimized through lecturer rotations of physicists, radiologists, and guest speakers. An emphasis is placed on clinical relevance by requiring lab work and providing equipment demonstrations.more » Periodic quiz were given during the course. The course website was also redesigned for usability, and physics review lectures were conducted two weeks before the board exam to refresh key concepts. At the completion of our first two-year course, we conducted a confidential evaluation of the faculty and course. The evaluation assessed metrics such as overall organization, clinical relevance of content, and level of difficulty, with a rating scale from poor to excellent. Results: Our evaluation indicated that the redesigned course provided effective board exam preparation, with most responses between good and excellent. There was some criticism on the course length and on chronological discontinuity, but the review lectures were appreciated by the residents. All of our residents passed the physics component of the ABR exam with scores exceeding the minimum passing score by a significant margin. Conclusion: The course evaluation and board exam results indicate that our new two-year course format provides valuable board exam preparation. This is possible thanks to the time and effort taken by the physics faculty on ensuring the residents get quality physics education.« less

Feeding tubes and health costs postinsertion in nursing home residents with advanced dementia.

PubMed

Hwang, Deborah; Teno, Joan M; Gozalo, Pedro; Mitchell, Susan

2014-06-01

The best evidence suggests that feeding tubes are ineffective in persons with advanced dementia. Little is known about their health care costs. To estimate Medicare costs attributable to inpatient care among nursing home (NH) residents with advanced dementia during the year following the placement of a percutaneous endoscopic gastrostomy (PEG) tube during an index hospitalization. Medicare claims (1999-2009) and Minimum Data Set data (1999-2009) were used to estimate Medicare costs attributable to inpatient care among NH residents with advanced dementia during the year following the placement of a PEG tube and compared with those who did not get a PEG tube. The study used a 3:1 propensity-matched cohort design. Matched residents with (n=1924, 68.9% female, 28.8% African American, average age 83.1 years) and without (weighted n=1924, unique n=4337) PEG insertion showed comparable sociodemographic characteristics, similar rates of feeding tube risk factors, and similar mortality (51.9% 180 day mortality among those with a feeding tube vs. 49.8% among those without a feeding tube, P=0.11). One year hospital costs were $2224 higher in NH residents with a feeding tube ($10,191 vs. $7967, 95% CI of difference=$1514, $2933), with those with a feeding tube likely to spend more time in an intensive care unit (1.92 vs. 1.29 days, 95% CI of difference=0.34, 0.92 days). In an analysis controlling for selection bias, PEG tube insertion is associated with a small but significant increase in annual inpatient health care costs, as well as in hospital and intensive care unit days, postinsertion. Copyright © 2014 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Design and Implementation of an Educational Program in Advanced Airway Management for Anesthesiology Residents

PubMed Central

Borovcanin, Zana; Shapiro, Janine R.

2012-01-01

Education and training in advanced airway management as part of an anesthesiology residency program is necessary to help residents attain the status of expert in difficult airway management. The Accreditation Council for Graduate Medical Education (ACGME) emphasizes that residents in anesthesiology must obtain significant experience with a broad spectrum of airway management techniques. However, there is no specific number required as a minimum clinical experience that should be obtained in order to ensure competency. We have developed a curriculum for a new Advanced Airway Techniques rotation. This rotation is supplemented with a hands-on Difficult Airway Workshop. We describe here this comprehensive advanced airway management educational program at our institution. Future studies will focus on determining if education in advanced airway management results in a decrease in airway related morbidity and mortality and overall better patients' outcome during difficult airway management. PMID:22505885

Determination of crystal residence timescales in magma reservoirs by diffusion modeling of dendritic phosphorus zoning patterns in olivine

NASA Astrophysics Data System (ADS)

Chakraborty, S.; Potrafke, A.

2016-12-01

Deciphering the early stages of crystallization and the chronological evolution of phenocrysts in magma reservoirs is one of the main goals in volcanology. Established approaches that model the concentration evolution of fast diffusing elements like Fe/Mg carry limited information on timescales once the concentration gradients are homogenized. Elements that diffuse more slowly, such as P and Al, become useful in these cases. We present a novel modeling tool that combines high-resolution EMP mapping of slow diffusing phosphorus in olivine with 2D kinetic modeling of the diffusive relaxation of initial chemical zoning pattern of P as well as Fe/Mg. The modeling approach offers a new possibility for determining crystal residence times in magma reservoirs. P diffusion coefficients from the experimental determination of [1] and Fe/Mg diffusion coefficients from [2] were used. The method yields a time-bracket between the minimum time required to homogenize the zoning of fast-diffusing Fe/Mg and the maximum time period for which details of chemical zoning of slow-diffusing P may be retained. To illustrate the approach we have studied the compositional zoning patterns of 7 olivine crystals from Piton de la Fournaise volcano, La Réunion. All crystals show a narrow range of forsterite contents (=Fo82-84) with fully homogenized Fe/Mg distribution, whereas P-mapping reveals oscillatory to dendritic zoning patterns [3]. P concentrations scatter in the range of 0.4 wt-% to below detection limit. Revealed phosphorus zoning patterns were considered to display the initial crystal architecture, whereas Fe and Mg zoning has been wiped out due to faster diffusion. For La Réunion magmas at 1453 K, timescales between few days to weeks were determined to be the time brackets for growth and residence of the olivine crystals in the magmas. These short residence times combined with knowledge of very fast developing dendritic crystals that have recently been revealed worldwide [e.g. 3] indicate that dendritic crystal growth in such rapidly evolving dynamic environments should be considered as a widespread feature of olivine growth and evolution of many basaltic volcanic systems. [1] Watson et al., 2015, Am Min, 100, pp. 2053-2065 [2] Dohmen et al., 2007, Phys Chem Miner, 34(6), pp. 389-407 [3] Welsch et al., 2014, Geology, 42, pp. 867-870

24 CFR 583.300 - General operation.

Code of Federal Regulations, 2010 CFR

2010-04-01

... residents from the elements. (2) Access. The housing must be accessible and capable of being utilized... recipient must provide a formal process that recognizes the rights of individuals receiving assistance to due process of law. This process, at a minimum, must consist of: (1) Written notice to the participant...

Correlates of post-hospital physical function at 1 year in skilled nursing facility residents.

PubMed

Lee, Jia; Rantz, Marilyn

2008-05-01

This paper is a report of a study to examine the relationship between health-related admission factors and post-hospital physical function at 3, 6, 9 and 12 months in older adult nursing facility residents. Physical functional decline is a significant health problem for older adults and has far-reaching effects. In particular, the immediate post-hospital period is a high-risk time, because shortened hospital stays make it likely that older patients are discharged in a state of incomplete recovery. Data spanning from July 2002 to June 2005 were extracted from a comprehensive assessment tool, the Minimum Data Set, for 38,591 beneficiaries of a federal health insurance programme covering older adults in the Midwestern region of the United States of America. We investigated relationships between admission factors and post-hospital physical function at 3, 6, 9 and 12 months. The admission factors were health-related variables assessed at the time of skilled nursing facility admission from an acute care hospital. The most important admission factors related to post-hospital physical function at 3, 6, 9 and 12 months were baseline physical function, urinary incontinence and pressure ulcer. Cognitive impairment at admission demonstrated a stronger relationship with poor physical function as resident length of stay increased. Nurses in skilled nursing facilities should screen post-hospital older adults for risk of physical functional decline at admission using identified admission factors. For continuous nursing care, older adults need to be assessed at least once a month during the first 3 months after hospital discharge.

78 FR 60453 - Application of the Fair Labor Standards Act to Domestic Service

Federal Register 2010, 2011, 2012, 2013, 2014

2013-10-01

...In 1974, Congress extended the protections of the Fair Labor Standards Act (FLSA or the Act) to ``domestic service'' employees, but it exempted from the Act's minimum wage and overtime provisions domestic service employees who provide ``companionship services'' to elderly people or people with illnesses, injuries, or disabilities who require assistance in caring for themselves, and it exempted from the Act's overtime provision domestic service employees who reside in the household in which they provide services. This Final Rule revises the Department's 1975 regulations implementing these amendments to the Act to better reflect Congressional intent given the changes to the home care industry and workforce since that time. Most significantly, the Department is revising the definition of ``companionship services'' to clarify and narrow the duties that fall within the term; in addition third party employers, such as home care agencies, will not be able to claim either of the exemptions. The major effect of this Final Rule is that more domestic service workers will be protected by the FLSA's minimum wage, overtime, and recordkeeping provisions.

Evaluation of the stability and antimicrobial activity of an ethanolic extract of Libidibia ferrea

PubMed Central

de Oliveira Marreiro, Raquel; Bandeira, Maria Fulgência Costa Lima; de Souza, Tatiane Pereira; de Almeida, Mailza Costa; Bendaham, Katiana; Venâncio, Gisely Naura; Rodrigues, Isis Costa; Coelho, Cristiane Nagai; Milério, Patrícia Sâmea Lêdo Lima; de Oliveira, Glauber Palma; de Oliveira Conde, Nikeila Chacon

2014-01-01

Biofilm is a dense, whitish, noncalcified aggregate of bacteria, with desquamated epithelial cells and food debris creating conditions for an imbalance of resident oral microflora and favoring the destruction of hard and soft tissues by development of caries and gingivitis. The aim of this study was to obtain and characterize an extract of Libidibia ferrea, ex Caesalpinia ferrea L. and to evaluate its feasibility for formulation as a mouthwash, according to current legislation. For this purpose, pH, sedimentation, density, and stability were evaluated, along with microbiological testing of the extract. The microbiological test was used to verify the presence of Staphylococcus aureus, Pseudomonas aeruginosa, fungi, yeasts, coliforms, and minimum inhibitory concentrations of Streptococcus mutans and Streptococcus oralis strains. Characterization, microbiological evaluation, and minimum inhibitory concentration results were tabulated and described using descriptive statistics. The L. ferrea extract showed stable characteristics, product quality, and antibacterial activity against the microorganisms tested irrespective of experimental time intervals. According to these results, it can be concluded that formulation of a mouthwash containing L. ferrea extract to control biofilm is feasible, but further studies are needed. PMID:24501546

Evaluation of musculoskeletal pain management practices in rural nursing homes compared with evidence-based criteria.

PubMed

Decker, Sheila A; Culp, Kennith R; Cacchione, Pamela Z

2009-06-01

Chronic pain, mainly associated with musculoskeletal diagnoses, is inadequately and often inappropriately treated in nursing home residents. The purpose of this descriptive study is to identify the musculoskeletal diagnoses associated with pain and to compare pain management of a sample of nursing home residents with the 1998 evidence-based guideline proposed by the American Geriatrics Society (AGS). The sample consists of 215 residents from 13 rural Iowa nursing home homes. The residents answered a series of face-to-face questions that addressed the presence/absence of pain and completed the Mini Mental State Examination (MMSE). Data on pain were abstracted from the Minimum Data Set (MDS). Analyses included descriptive statistics, cross tabulations, and one-way analysis of variance. Residents' responses to the face-to-face pain questions yielded higher rates of pain compared with the MDS pain data. Resident records showed that acetaminophen was the most frequently administered analgesic medication (30.9%). Propoxyphene, not an AGS-recommended opioid, was also prescribed for 23 residents (10.7%). Of the 70 residents (32.6%) expressing daily pain, 23 (32.9%) received no scheduled or pro re nata analgesics. There was no significant difference between MMSE scores and number of scheduled analgesics. Additionally, residents' self-reported use of topical agents was not documented in the charts. The findings suggest that the 1998 AGS evidence-based guideline for the management of chronic pain is inconsistently implemented.

Low NOx Heavy Fuel Combustor Concept Program

NASA Technical Reports Server (NTRS)

Novick, A. S.; Troth, D. L.

1981-01-01

The development of the technology required to operate an industrial gas turbine combustion system on minimally processed, heavy petroleum or residual fuels having high levels of fuel-bound nitrogen (FBN) while producing acceptable levels of exhaust emissions is discussed. Three combustor concepts were designed and fabricated. Three fuels were supplied for the combustor test demonstrations: a typical middle distillate fuel, a heavy residual fuel, and a synthetic coal-derived fuel. The primary concept was an air staged, variable-geometry combustor designed to produce low emissions from fuels having high levels of FBN. This combustor used a long residence time, fuel-rich primary combustion zone followed by a quick-quench air mixer to rapidly dilute the fuel rich products for the fuel-lean final burnout of the fuel. This combustor, called the rich quench lean (RQL) combustor, was extensively tested using each fuel over the entire power range of the model 570 K engine. Also, a series of parameteric tests was conducted to determine the combustor's sensitivity to rich-zone equivalence ratio, lean-zone equivalence ratio, rich-zone residence time, and overall system pressure drop. Minimum nitrogen oxide emissions were measured at 50 to 55 ppmv at maximum continuous power for all three fuels. Smoke was less than a 10 SAE smoke number.

Formation of polychlorinated dibenzofurans and dioxins during combustion, electrical equipment fires and PCB incineration.

PubMed Central

Hutzinger, O; Choudhry, G G; Chittim, B G; Johnston, L E

1985-01-01

Polychlorinated dibenzo-p-dioxins (PCDDs) and polychlorinated dibenzofurans (PCDFs) are likely formed by thermal synthesis of a variety of primary precursors. Highest levels of these compounds are expected, however, when the starting material requires only one or two reaction steps for their formation, as is the case with chlorophenols, chlorobenzenes and polychlorinated biphenyls (PCBs). Laboratory pyrolyses have indeed shown that PCBs give significant yields of PCDFs, and chlorobenzenes give both PCDFs and PCDDs. In addition, a variety of other chloroaromatic compounds are formed. From these experiments and from accidents involving PCB fires, it is known that PCDFs are the most important toxic compounds associated with PCBs. Most commercial PCBs contain PCDFs in the low ppm range. PCDF concentration does not increase during normal operation in electrical equipment. Accidents (fires and explosions) involving PCBs can give PCDF levels in soot of up to 1000 ppm and higher. Effective thermal destruction of PCB is possible in modern incineration units, provided high temperatures, excess air and sufficient residence times are used. Exact figures for minimum temperature and residence time cannot be given, since feedstock and incinerator construction greatly influence destruction efficiency. Effluents from EPA-licensed incinerators used for PCB destruction contain only very low levels of PCDDs and PCDFs. PMID:3928357

Depression recognition and capacity for self-report among ethnically diverse nursing homes residents: Evidence of disparities in screening.

PubMed

Chun, Audrey; Reinhardt, Joann P; Ramirez, Mildred; Ellis, Julie M; Silver, Stephanie; Burack, Orah; Eimicke, Joseph P; Cimarolli, Verena; Teresi, Jeanne A

2017-12-01

To examine agreement between Minimum Data Set clinician ratings and researcher assessments of depression among ethnically diverse nursing home residents using the 9-item Patient Health Questionnaire. Although depression is common among nursing homes residents, its recognition remains a challenge. Observational baseline data from a longitudinal intervention study. Sample of 155 residents from 12 long-term care units in one US facility; 50 were interviewed in Spanish. Convergence between clinician and researcher ratings was examined for (i) self-report capacity, (ii) suicidal ideation, (iii) at least moderate depression, (iv) Patient Health Questionnaire severity scores. Experiences by clinical raters using the depression assessment were analysed. The intraclass correlation coefficient was used to examine concordance and Cohen's kappa to examine agreement between clinicians and researchers. Moderate agreement (κ = 0.52) was observed in determination of capacity and poor to fair agreement in reporting suicidal ideation (κ = 0.10-0.37) across time intervals. Poor agreement was observed in classification of at least moderate depression (κ = -0.02 to 0.24), lower than the maximum kappa obtainable (0.58-0.85). Eight assessors indicated problems assessing Spanish-speaking residents. Among Spanish speakers, researchers identified 16% with Patient Health Questionnaire scores of 10 or greater, and 14% with thoughts of self-harm whilst clinicians identified 6% and 0%, respectively. This study advances the field of depression recognition in long-term care by identification of possible challenges in assessing Spanish speakers. Use of the Patient Health Questionnaire requires further investigation, particularly among non-English speakers. Depression screening for ethnically diverse nursing home residents is required, as underreporting of depression and suicidal ideation among Spanish speakers may result in lack of depression recognition and referral for evaluation and treatment. Training in depression recognition is imperative to improve the recognition, evaluation and treatment of depression in older people living in nursing homes. © 2017 John Wiley & Sons Ltd.

A comparison of weather variables linked to infectious disease patterns using laboratory addresses and patient residence addresses.

PubMed

Djennad, Abdelmajid; Lo Iacono, Giovanni; Sarran, Christophe; Fleming, Lora E; Kessel, Anthony; Haines, Andy; Nichols, Gordon L

2018-04-27

To understand the impact of weather on infectious diseases, information on weather parameters at patient locations is needed, but this is not always accessible due to confidentiality or data availability. Weather parameters at nearby locations are often used as a proxy, but the accuracy of this practice is not known. Daily Campylobacter and Cryptosporidium cases across England and Wales were linked to local temperature and rainfall at the residence postcodes of the patients and at the corresponding postcodes of the laboratory where the patient's specimen was tested. The paired values of daily rainfall and temperature for the laboratory versus residence postcodes were interpolated from weather station data, and the results were analysed for agreement using linear regression. We also assessed potential dependency of the findings on the relative geographic distance between the patient's residence and the laboratory. There was significant and strong agreement between the daily values of rainfall and temperature at diagnostic laboratories with the values at the patient residence postcodes for samples containing the pathogens Campylobacter or Cryptosporidium. For rainfall, the R-squared was 0.96 for the former and 0.97 for the latter, and for maximum daily temperature, the R-squared was 0.99 for both. The overall mean distance between the patient residence and the laboratory was 11.9 km; however, the distribution of these distances exhibited a heavy tail, with some rare situations where the distance between the patient residence and the laboratory was larger than 500 km. These large distances impact the distributions of the weather variable discrepancies (i.e. the differences between weather parameters estimated at patient residence postcodes and those at laboratory postcodes), with discrepancies up to ±10 °C for the minimum and maximum temperature and 20 mm for rainfall. Nevertheless, the distributions of discrepancies (estimated separately for minimum and maximum temperature and rainfall), based on the cases where the distance between the patient residence and the laboratory was within 20 km, still exhibited tails somewhat longer than the corresponding exponential fits suggesting modest small scale variations in temperature and rainfall. The findings confirm that, for the purposes of studying the relationships between meteorological variables and infectious diseases using data based on laboratory postcodes, the weather results are sufficiently similar to justify the use of laboratory postcode as a surrogate for domestic postcode. Exclusion of the small percentage of cases where there is a large distance between the residence and the laboratory could increase the precision of estimates, but there are generally strong associations between daily weather parameters at residence and laboratory.

Resource Manual for Alcohol and Other Drug Abuse Education in Internal Medicine.

ERIC Educational Resources Information Center

Bigby, JudyAnn, Ed.; England, Susan, Ed.

The resource manual provides guidelines and resources for individuals interested in integrating a substance abuse curriculum into existing programs for medical students and residents in internal medicine. Materials and resources appropriate for practicing physicians are also included. Three sections are: (1) a statement of minimum knowledge and…

28 CFR 115.313 - Supervision and monitoring.

Code of Federal Regulations, 2014 CFR

2014-07-01

... from internal or external oversight bodies; (5) All components of the facility's physical plant... juvenile facility shall maintain staff ratios of a minimum of 1:8 during resident waking hours and 1:16... fully documented. Only security staff shall be included in these ratios. Any facility that, as of the...

28 CFR 115.313 - Supervision and monitoring.

Code of Federal Regulations, 2012 CFR

2012-07-01

... from internal or external oversight bodies; (5) All components of the facility's physical plant... juvenile facility shall maintain staff ratios of a minimum of 1:8 during resident waking hours and 1:16... fully documented. Only security staff shall be included in these ratios. Any facility that, as of the...

28 CFR 115.313 - Supervision and monitoring.

Code of Federal Regulations, 2013 CFR

2013-07-01

... from internal or external oversight bodies; (5) All components of the facility's physical plant... juvenile facility shall maintain staff ratios of a minimum of 1:8 during resident waking hours and 1:16... fully documented. Only security staff shall be included in these ratios. Any facility that, as of the...

Charting the Road to Competence: Developmental Milestones for Internal Medicine Residency Training

PubMed Central

Green, Michael L.; Aagaard, Eva M.; Caverzagie, Kelly J.; Chick, Davoren A.; Holmboe, Eric; Kane, Gregory; Smith, Cynthia D.; Iobst, William

2009-01-01

Background The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project requires that residency program directors objectively document that their residents achieve competence in 6 general dimensions of practice. Intervention In November 2007, the American Board of Internal Medicine (ABIM) and the ACGME initiated the development of milestones for internal medicine residency training. ABIM and ACGME convened a 33-member milestones task force made up of program directors, experts in evaluation and quality, and representatives of internal medicine stakeholder organizations. This article reports on the development process and the resulting list of proposed milestones for each ACGME competency. Outcomes The task force adopted the Dreyfus model of skill acquisition as a framework the internal medicine milestones, and calibrated the milestones with the expectation that residents achieve, at a minimum, the “competency” level in the 5-step progression by the completion of residency. The task force also developed general recommendations for strategies to evaluate the milestones. Discussion The milestones resulting from this effort will promote competency-based resident education in internal medicine, and will allow program directors to track the progress of residents and inform decisions regarding promotion and readiness for independent practice. In addition, the milestones may guide curriculum development, suggest specific assessment strategies, provide benchmarks for resident self-directed assessment-seeking, and assist remediation by facilitating identification of specific deficits. Finally, by making explicit the profession's expectations for graduates and providing a degree of national standardization in evaluation, the milestones may improve public accountability for residency training. PMID:21975701

A Narrative Review and Novel Framework for Application of Team-Based Learning in Graduate Medical Education.

PubMed

Poeppelman, Rachel Stork; Liebert, Cara A; Vegas, Daniel Brandt; Germann, Carl A; Volerman, Anna

2016-10-01

Team-based learning (TBL) promotes problem solving and teamwork, and has been applied as an instructional method in undergraduate medical education with purported benefits. Although TBL curricula have been implemented for residents, no published systematic reviews or guidelines exist for the development and use of TBL in graduate medical education (GME). To review TBL curricula in GME, identify gaps in the literature, and synthesize a framework to guide the development of TBL curricula at the GME level. We searched PubMed, MEDLINE, and ERIC databases from 1990 to 2014 for relevant articles. References were reviewed to identify additional studies. The inclusion criteria were peer-reviewed publications in English that described TBL curriculum implementation in GME. Data were systematically abstracted and reviewed for consensus. Based on included publications, a 4-element framework-system, residents, significance, and scaffolding-was developed to serve as a step-wise guide to planning a TBL curriculum in GME. Nine publications describing 7 unique TBL curricula in residency met inclusion criteria. Outcomes included feasibility, satisfaction, clinical behavior, teamwork, and knowledge application. TBL appears feasible in the GME environment, with learner reactions ranging from positive to neutral. Gaps in the literature occur within each of the 4 elements of the suggested framework, including: system , faculty preparation time and minimum length of effective TBL sessions; residents , impact of team heterogeneity and inconsistent attendance; significance , comparison to other instructional methods and outcomes measuring knowledge retention, knowledge application, and skill development; and scaffolding , factors that influence the completion of preparatory work.

Quantifying hyporheic exchange dynamics in a highly regulated large river reach

NASA Astrophysics Data System (ADS)

Zhou, T.; Bao, J.; Huang, M.; Hou, Z.; Arntzen, E.; Mackley, R.; Harding, S.; Crump, A.; Xu, Y.; Song, X.; Chen, X.; Stegen, J.; Hammond, G. E.; Thorne, P. D.; Zachara, J. M.

2016-12-01

Hyporheic exchange is an important mechanism taking place in riverbanks and riverbed sediments, where the river water and shallow groundwater mix and interact with each other. The direction and magnitude of hyporheic flux that penetrates the river bed and residence time of river water in the hyporheic zone are critical for biogeochemical processes such as carbon and nitrogen cycling, and biodegradation of organic contaminants. Hyporheic flux can be quantified using many direct and indirect measurements as well as analytical and numerical modeling tools. However, in a relatively large river, these methods can be limited by the accessibility, spatial constraints, complexity of geomorphologic features and subsurface properties, and computational power. In rivers regulated by hydroelectric dams, quantifying hyporheic fluxes becomes more challenging due to frequent hydropeaking events created by dam operations. In this study, we developed and validated methods that combined field measurements and numerical modeling for estimating hyporheic fluxes across the river bed in a 7-km long reach of the highly regulated Columbia River. The reach has a minimum width of about 800 meters and variations in river stage within a day could be up to two meters due to the upstream dam operations. In shallow water along the shoreline, vertical thermal profiles measured by self-recording thermistors were combined with time series of hydraulic gradient derived from river stage and water level at in-land wells to estimate the hyporheic flux rate. For the deep section, a high resolution computational fluid dynamics (CFD) modeling framework was developed to characterize the spatial distribution of flux rates at the river bed and the residence time of hyporheic flow at different river flow conditions. Our modeling results show that the rates of hyporheic exchange and residence time are controlled by (1) hydrostatic pressure induced by river stage fluctuations, and (2) hydrodynamic drivers associated with flow velocity variations, which also to certain extent dependent on flow conditions.

Trait differences between naturalized and invasive plant species independent of residence time and phylogeny.

PubMed

Gallagher, R V; Randall, R P; Leishman, M R

2015-04-01

The ability to predict which alien plants will transition from naturalized to invasive prior to their introduction to novel regions is a key goal for conservation and has the potential to increase the efficacy of weed risk assessment (WRA). However, multiple factors contribute to plant invasion success (e.g., functional traits, range characteristics, residence time, phylogeny), and they all must be taken into account simultaneously in order to identify meaningful correlates of invasion success. We compiled 146 pairs of phylogenetically paired (congeneric) naturalized and invasive plant species in Australia with similar minimum residence times (i.e., time since introduction in years). These pairs were used to test for differences in 5 functional traits (flowering duration, leaf size, maximum height, specific leaf area [SLA], seed mass) and 3 characteristics of species' native ranges (biome occupancy, mean annual temperature, and rainfall breadth) between naturalized and invasive species. Invasive species, on average, had larger SLA, longer flowering periods, and were taller than their congeneric naturalized relatives. Invaders also exhibited greater tolerance for different environmental conditions in the native range, where they occupied more biomes and a wider breadth of rainfall and temperature conditions than naturalized congeners. However, neither seed mass nor leaf size differed between pairs of naturalized and invasive species. A key finding was the role of SLA in distinguishing between naturalized and invasive pairs. Species with high SLA values were typically associated with faster growth rates, more rapid turnover of leaf material, and shorter lifespans than those species with low SLA. This suite of characteristics may contribute to the ability of a species to transition from naturalized to invasive across a wide range of environmental contexts and disturbance regimes. Our findings will help in the refinement of WRA protocols, and we advocate the inclusion of quantitative traits, in particular SLA, into the WRA schemes. © 2014 The Authors. Conservation Biology published by Wiley Periodicals, Inc. on behalf of Society for Conservation Biology.

Modelling Ecosystem Dynamics of the Oxygen Minimum Zones in the Angola Gyre and the Northern Benguela Upwelling System.

NASA Astrophysics Data System (ADS)

Schmidt, M.; Eggert, A.

2016-02-01

The Angola Gyre and the Northern Benguela Upwelling System are two major oxygen minimum zones (OMZ) of different kind connected by the system of African Eastern Boundary Currents. We discuss results from a 3-dimensional coupled biogeochemical model covering both oxygen-deficient systems. The biogeochemical model component comprises trophic levels up to zooplankton. Physiological properties of organisms are parameterized from field data gained mainly in the course of the project "Geochemistry and Ecology of the Namibian Upwelling System" (GENUS). The challenge of the modelling effort is the different nature of both systems. The Angola Gyre, located in a "shadow zone" of the tropical Atlantic, has a low productivity and little ventilation, hence a long residence time of water masses. In the northern Benguela Upwelling System, trade winds drive an intermittent, but permanent nutrient supply into the euphotic zone which fuels a high coastal productivity, large particle export and high oxygen consumption from dissimilatory processes. In addition to the local processes, oxygen-deficient water formed in the Angola Gyre is one of the source water masses of the poleward undercurrent, which feeds oxygen depleted water into the Benguela system. In order to simulate the oxygen distribution in the Benguela system, both physical transport as well as local biological processes need to be carefully adjusted in the model. The focus of the analysis is on the time scale and the relative contribution of the different oxygen related processes to the oxygen budgets in both the oxygen minimum zones. Although these are very different in both the OMZ, the model is found as suitable to produce oxygen minimum zones comparable with observations in the Benguela and the Angola Gyre as well. Variability of the oxygen concentration in the Angola Gyre depends strongly on organismic oxygen consumption, whereas the variability of the oxygen concentration on the Namibian shelf is governed mostly by pole-ward advection of tropical water masses.

Differences in presenting advance directives in the chart, in the minimum data set, and through the staff's perceptions.

PubMed

Cohen-Mansfield, Jiska; Libin, Alexander; Lipson, Steven

2003-06-01

Decisions concerning end-of-life care depend on information contained in advance directives that are documented in residents' charts in the nursing home. The availability of that information depends on the quality of the chart and on the location of the information in the chart. No research was found that compared directives by the manner in which they are collected and summarized in the chart. The goal of the proposed study was to clarify how advance directives are summarized in the patient's record and to clarify how physicians perceive the same advance directives and formal orders. The study involved 122 elderly persons who reside in one large (587 beds) nursing home. The authors collected data regarding the advance directives from three sources-Minimum Data Set (MDS), the front cover of the resident's chart, and from inside the chart. The rates of documented advance directives found in this study are higher than those reported in the literature. Agreement rates between sources varied as a function of which sources were compared, as well as on the basis of which directive was examined. More specifically, the authors found higher rates of agreement between the information inside the chart and on the cover of the chart than between the MDS and the other two sources. The reasons for discrepancies may lie in the different functions and procedures pertaining to these source documents.

Feedforward interview technique in obstetrics and gynaecology residents: a fact or fallacy.

PubMed

Sami, Shehla; Ahmad, Amina

2015-01-01

To determine the role of Feedforward Interview (FFI) technique in motivating residents of Obstetrics and Gynaecology for better learning and performance. An explorative study with mixed method approach being employed. Department of Obstetrics and Gynaecology, Sandeman (Provincial) Hospital, Quetta, from November 2010 till May 2013. Feedforward interview technique was complimented by survey questionnaire employing similar philosophy of FFI to triangulate data through two methods. Survey questionnaire was filled-up by 21 residents and analysed by SPSS version 17. Fourteen of these participants were identified for in-depth Feedforward Interviews (FFI), based on nonprobability purposive sampling after informed consent, and content analysis was done. Feedforward interview technique enabled majority of residents in recalling minimum of 3 positive experiences, mainly related to surgical experiences, which enhanced their motivation to aspire for further improvement in this area. Hard work was the main personal contributing factor both in FFI and survey. In addition to identifying clinical experiences enhancing desire to learn, residents also reported need for more academic support as an important factor which could also boost motivation to attain better performance. Feedforward interview technique not only helps residents in recalling positive learning experiences during their training but it also has a significant influence on developing insight about one's performance and motivating residents to achieve higher academic goals.

Effect of Commuter Time on Emergency Medicine Residents.

PubMed

Sampson, Christopher; Borenstein, Marc

2018-01-12

Background The impact of resident work hours on resident well-being and patient safety has long been a controversial issue. Objectives What has not been considered in resident work hour limitations is whether resident commuting time has any impact on a resident's total work hours or well-being. Methods A self-administered electronic survey was distributed to emergency medicine residents in 2016. Results The survey response was 8% (569/6828). Commuter time was 30 minutes or less in 70%. Two residents reported a commuter time of 76 to 90 minutes and one resident had a commuter time of 91 to 105 minutes. None reported commuter times greater than 105 minutes. Of most concern was that 29.3% of the residents reported falling asleep while driving their car home from work. We found 12% of respondents reporting being involved in a car collision while commuting. For residents with commute times greater than one hour, 66% reported they had fallen asleep while driving. When asked their opinion on the effect of commute time, those with commute times greater than one hour (75% of residents) responded that it was detrimental. Conclusions While the majority of emergency medicine residents in this survey have commuter times of 30 minutes or less, there is a small population of residents with commuter times of 76 to 105 minutes. At times, residents whose commute is up to 105 minutes each way could be traveling a total of more than 3.5 hours for each round trip. Given that these residents often work 12-hour shifts, these extended commuter times may be having detrimental effects on their health and well-being.

Effect of Commuter Time on Emergency Medicine Residents

PubMed Central

Borenstein, Marc

2018-01-01

Background The impact of resident work hours on resident well-being and patient safety has long been a controversial issue. Objectives What has not been considered in resident work hour limitations is whether resident commuting time has any impact on a resident's total work hours or well-being. Methods A self-administered electronic survey was distributed to emergency medicine residents in 2016. Results The survey response was 8% (569/6828). Commuter time was 30 minutes or less in 70%. Two residents reported a commuter time of 76 to 90 minutes and one resident had a commuter time of 91 to 105 minutes. None reported commuter times greater than 105 minutes. Of most concern was that 29.3% of the residents reported falling asleep while driving their car home from work. We found 12% of respondents reporting being involved in a car collision while commuting. For residents with commute times greater than one hour, 66% reported they had fallen asleep while driving. When asked their opinion on the effect of commute time, those with commute times greater than one hour (75% of residents) responded that it was detrimental. Conclusions While the majority of emergency medicine residents in this survey have commuter times of 30 minutes or less, there is a small population of residents with commuter times of 76 to 105 minutes. At times, residents whose commute is up to 105 minutes each way could be traveling a total of more than 3.5 hours for each round trip. Given that these residents often work 12-hour shifts, these extended commuter times may be having detrimental effects on their health and well-being. PMID:29545979

Depression and cognitive impairment among newly admitted nursing home residents in the USA.

PubMed

Ulbricht, Christine M; Rothschild, Anthony J; Hunnicutt, Jacob N; Lapane, Kate L

2017-11-01

The objective of this study is to describe the prevalence of depression and cognitive impairment among newly admitted nursing home residents in the USA and to describe the treatment of depression by level of cognitive impairment. We identified 1,088,619 newly admitted older residents between 2011 and 2013 with an active diagnosis of depression documented on the Minimum Data Set 3.0. The prevalence of receiving psychiatric treatment was estimated by cognitive impairment status and depression symptoms. Binary logistic regression using generalized estimating equations provided adjusted odds ratios and 95% confidence intervals for the association between level of cognitive impairment and receipt of psychiatric treatment, adjusted for clustering of residents within nursing homes and resident characteristics. Twenty-six percent of newly admitted residents had depression; 47% of these residents also had cognitive impairment. Of those who had staff assessments of depression, anhedonia, impaired concentration, psychomotor disturbances, and irritability were more commonly experienced by residents with cognitive impairment than residents without cognitive impairment. Forty-eight percent of all residents with depression did not receive any psychiatric treatment. Approximately one-fifth of residents received a combination of treatment. Residents with severe cognitive impairment were less likely than those with intact cognition to receive psychiatric treatment (adjusted odds ratio = 0.95; 95% confidence interval: 0.93-0.98). Many newly admitted residents with an active diagnosis of depression are untreated, potentially missing an important window to improve symptoms. The extent of comorbid cognitive impairment and depression and lack of treatment suggest opportunities for improved quality of care in this increasingly important healthcare setting. Copyright © 2017 John Wiley & Sons, Ltd. Copyright © 2017 John Wiley & Sons, Ltd.

Pharmacologic management of non-cancer pain among nursing home residents.

PubMed

Lapane, Kate L; Quilliam, Brian J; Chow, Wing; Kim, Myoung S

2013-01-01

Pain is common in nursing home settings. To describe scheduled analgesic use among nursing home (NH) residents experiencing non-cancer pain and evaluate factors associated with scheduled analgesic use. We identified 2508 residents living in one of 185 NHs predominantly from one for-profit chain, with pain recorded on two consecutive Minimum Data Set assessments. Pharmacy transaction files provided detailed medication information. Logistic regression models adjusted for clustering of residents in NHs identified factors related to scheduled prescription analgesics. Twenty-three percent had no scheduled analgesics prescribed. Those with scheduled analgesics were more likely to have excruciating pain (5.5% vs. 1.2%) and moderate pain documented (64.7% vs. 47.5%) than residents without scheduled analgesics. Hydrocodone (41.7%), short-acting oxycodone (16.6%), and long-acting fentanyl (9.4%) were common, and 13.8% reported any nonsteroidal anti-inflammatory agent use. Factors associated with decreased odds of scheduled analgesics included severe cognitive impairment (adjusted odds ratio [AOR] 0.56; 95% confidence interval [CI] 0.36 to 0.88), age more than 85 years (AOR 0.57; 95% CI 0.41 to 0.80), and Parkinson's disease (AOR 0.55; 95% CI 0.30 to 0.99). Factors associated with increased odds of scheduled analgesic use included history of fracture (AOR 1.79; 95% CI 1.16 to 2.76), diabetes (AOR 1.30; 95% CI 1.02 to 1.66), and higher Minimum Data Set mood scores (AOR 1.11; 95% CI 1.04 to 1.19). Some improvements in pharmacologic management of pain in NHs have been realized. Yet, presence of pain without scheduled analgesics prescribed was still common. Evidence-based procedures to assure adherence to clinical practice guidelines for pain management in this setting are warranted. Copyright © 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

The impact of Medicaid payer status on hospitalizations in nursing homes

PubMed Central

Cai, Shubing; Miller, Susan C.; Nelson, Dallas L.; Mukamel, Dana B.

2015-01-01

Objectives To examine the association between payer status (Medicaid versus private-pay) and the risk of hospitalizations among long-term stay nursing home (NH) residents who reside in the same facility. Data and study population The 2007–2010 national Medicare Claims and the Minimum Data Set were linked. We identified newly admitted NH residents who became long-stayers and then followed them for 180 days. Analyses Three dichotomous outcomes – all-cause, discretionary and nondiscretionary hospitalizations during the follow-up period – were defined. Linear probability model with facility fixed-effects and robust standard errors were used to examine the within-facility difference in hospitalizations between Medicaid and private-pay residents. A set of sensitivity analyses were performed to examine the robustness of the findings. Results The prevalence of all-cause hospitalization during a 180-day follow-up period was 23.3% among Medicaid residents compared to 21.6% among private-pay residents. After accounting for individual characteristics and facility effects, the probability of any all-cause hospitalization was 1.8 percentage point (P<0.01) higher for Medicaid residents than for private-pay residents within the same facility. We also found Medicaid residents were more likely to be hospitalized for discretionary conditions (5% increase in the likelihood of discretionary hospitalizations), but not for non-discretionary conditions. The findings from the sensitivity analyses were consistent with the main analyses. Conclusion Observed higher hospitalization rates for Medicaid NH residents are at least in part driven by the financial incentive NHs have to hospitalize Medicaid residents. PMID:26067881

Racial and ethnic disparities in social engagement among US nursing home residents.

PubMed

Li, Yue; Cai, Xueya

2014-04-01

The numbers and proportions of racial and ethnic minorities have increased dramatically in US nursing homes in recent years. Concerns exist about whether nursing homes can serve appropriately the clinical and psychosocial needs of patients with increasingly diverse ethnic and cultural backgrounds. This study determined racial and ethnic disparities in social engagement among nursing home long-term residents. We analyzed the 2008 national Minimum Data Set supplemented with the Online Survey, Certification, and Reporting File and the Area Resource File. We estimated multivariable logistic regressions to determine disparities and how disparities were explained by individual, facility, and geographic factors. Stratified analyses further determined persistent disparities within patient and facility subgroups. Compared with white residents (n = 690,228), black (n = 123,116), Hispanic (n = 37,099), and other (n = 17,568) residents showed lower social engagement, with overall scores (mean ± SD) being 2.5 ± 1.7, 2.2 ± 1.6, 2.0 ± 1.6, and 2.1 ± 1.6, respectively. Disparities were partially explained by variations in individual, facility, and geographic covariates, but persisted after multivariable adjustments. Stratified analyses confirmed that disparities were similar in magnitude across patient and facility subgroups. Although nursing home residents showed overall low social engagement levels, racial/ethnic minority residents were even less socially engaged than white residents. Efforts to address disparities in psychosocial well-being and quality of life of nursing home residents are warranted.

A Time Study of Plastic Surgery Residents.

PubMed

Lau, Frank H; Sinha, Indranil; Jiang, Wei; Lipsitz, Stuart R; Eriksson, Elof

2016-05-01

Resident work hours are under scrutiny and have been subject to multiple restrictions. The studies supporting these changes have not included data on surgical residents. We studied the workday of a team of plastic surgery residents to establish prospective time-study data of plastic surgery (PRS) residents at a single tertiary-care academic medical center. Five trained research assistants observed all residents (n = 8) on a PRS service for 10 weeks and produced minute-by-minute activity logs. Data collection began when the team first met in the morning and continued until the resident being followed completed all non-call activities. We analyzed our data from 3 perspectives: 1) time spent in direct patient care (DPC), indirect patient care, and didactic activities; 2) time spent in high education-value activities (HEAs) versus low education-value activities; and 3) resident efficiency. We defined HEAs as activities that surgeons must master; other activities were LEAs. We quantified resident efficiency in terms of time fragmentation and time spent waiting. A total of 642.4 hours of data across 50 workdays were collected. Excluding call, residents worked an average of 64.2 hours per week. Approximately 50.7% of surgical resident time was allotted to DPC, with surgery accounting for the largest segment of this time (34.8%). Time spent on HEAs demonstrated trended upward with higher resident level (P = 0.086). Time in spent in surgery was significantly associated with higher resident levels (P < 0.0001); 57.7% of activities require 4 minutes or less, suggesting that resident work was highly fragmented. Residents spent 10.7% of their workdays waiting for other services. In this first-time study of PRS residents, we found that compared with medicine trainees, surgical residents spent 3.23 times more time on DPC. High education-value activities comprised most of our residents' workdays. Surgery was the leading component of both DPC and HEAs. Our residents were highly efficient and fragmented, with the majority of all activities requiring 4 minutes or less. Residents spent a large portion of their time waiting for other services. In light of these data, we suggest that future changes to residency programs be pilot tested, with preimplantation and postimplementation time studies performed to quantify the changes' impact.

Keeping granny safe on July 1: a consensus on minimum geriatrics competencies for graduating medical students.

PubMed

Leipzig, Rosanne M; Granville, Lisa; Simpson, Deborah; Anderson, M Brownell; Sauvigné, Karen; Soriano, Rainier P

2009-05-01

Competency-based education prepares trainees to perform tasks occurring within the context of practice. There are currently no geriatrics-specific, competency-based consensus performance standards for medical students.The authors present the results of a systematic, multimethod process to identify and define the minimum geriatrics-specific competencies needed by a new intern to adequately care for older adults. An alpha draft was crafted by geriatricians, identifying measurable performance subtasks associated with accepted standards of evidence-based geriatric care, patient safety, and "do no harm" within the first-year resident's expected scope of practice. The competencies were then assessed for content validity by key stakeholders and informants. Of the 315 respondents, 26% were geriatricians, 21% family physicians, 24% general internists, 6% neurology program directors, 14% surgery program directors, and 9% other. Twenty-four were decanal appointees. Faculty from almost half (44%) of U.S. medical schools and representatives of several major medical education organizations were present at the working conference.The final document consists of 26 competencies nested within eight content domains: Medication Management; Self-Care Capacity; Falls, Balance and Gait Disorders; Hospital Care for Elders; Cognitive and Behavioral Disorders; Atypical Presentation of Disease; Health Care Planning and Promotion; and Palliative Care.Setting minimum geriatric competency standards establishes the performance benchmarks for medical school graduates who as first-year residents will care for geriatric patients. Only half-facetiously, they are referred to as the "Don't Kill Granny" competencies. Achievement of these minimum competencies by medical students, grounded in evidence-based principles of quality care for older adults, will assure that, each year, older patients are in safer hands on July 1.

Developing a strategic plan for a neonatal nurse practitioner service.

PubMed

Lee, Laurie A; Jones, Luann R

2004-10-01

Neonatal nurse practitioners (NNPs) have been in practice for over 3 decades. More recently, NNPs have begun to take ownership for building their group practice models. The purpose of this article is to present a detailed case study demonstrating how one NNP group used a 4-phase strategic planning process to turn a crisis into an opportunity. The article describes data obtained during the strategic planning process from an informal national survey of NNP managers that focused on key benchmarks, such as role definition, responsibilities, protected nonclinical time, NNP salary and benefits, and educational and professional development support. Using the strategic planning process, the group defined mutually agreed upon minimum safe staffing levels for NNPs, interns, residents and neonatologists in their setting. Based on the data generated, the group successfully justified additional NNP positions and organizational support for 10% protected nonclinical time. A sample operational budget, comparison of 3 staffing scenarios, and a timeline are also provided.

42 CFR 136.406 - Under what circumstances will the minimum standards of character be considered to be met?

Code of Federal Regulations, 2010 CFR

2010-10-01

... background investigation shall include a review of: (a) The individual's trustworthiness, through inquiries... background check, which includes a fingerprint check through the Criminal Justice Information Services... to State and Tribal law enforcement agencies for the previous five years of residence listed on the...

49 CFR 192.917 - How does an operator identify potential threats to pipeline integrity and use the threat...

Code of Federal Regulations, 2012 CFR

2012-10-01

... BY PIPELINE: MINIMUM FEDERAL SAFETY STANDARDS Gas Transmission Pipeline Integrity Management § 192... internal corrosion, external corrosion, and stress corrosion cracking; (2) Static or resident threats, such... its integrity management program addressing actions it will take to respond to findings from this data...

49 CFR 192.917 - How does an operator identify potential threats to pipeline integrity and use the threat...

Code of Federal Regulations, 2011 CFR

2011-10-01

... BY PIPELINE: MINIMUM FEDERAL SAFETY STANDARDS Gas Transmission Pipeline Integrity Management § 192... internal corrosion, external corrosion, and stress corrosion cracking; (2) Static or resident threats, such... its integrity management program addressing actions it will take to respond to findings from this data...

49 CFR 192.917 - How does an operator identify potential threats to pipeline integrity and use the threat...

Code of Federal Regulations, 2013 CFR

2013-10-01

... BY PIPELINE: MINIMUM FEDERAL SAFETY STANDARDS Gas Transmission Pipeline Integrity Management § 192... internal corrosion, external corrosion, and stress corrosion cracking; (2) Static or resident threats, such... its integrity management program addressing actions it will take to respond to findings from this data...

49 CFR 192.917 - How does an operator identify potential threats to pipeline integrity and use the threat...

Code of Federal Regulations, 2014 CFR

2014-10-01

... BY PIPELINE: MINIMUM FEDERAL SAFETY STANDARDS Gas Transmission Pipeline Integrity Management § 192... internal corrosion, external corrosion, and stress corrosion cracking; (2) Static or resident threats, such... its integrity management program addressing actions it will take to respond to findings from this data...

24 CFR 570.441 - Citizen participation-insular areas.

Code of Federal Regulations, 2013 CFR

2013-04-01

... actual beneficiaries; (4) Meeting the needs of non-English speaking residents in the case of public... and must make the plan public. The plan must be completed and available before the statement for... not include the provision of funds to the groups; (3) Holding a minimum of two public hearings for the...

25 CFR 36.97 - What basic requirements must a program's health services meet?

Code of Federal Regulations, 2010 CFR

2010-04-01

... MINIMUM ACADEMIC STANDARDS FOR THE BASIC EDUCATION OF INDIAN CHILDREN AND NATIONAL CRITERIA FOR DORMITORY... necessary health services for all students residing in the homeliving program, subject to agreements between... dealing with emergency health care issues. (c) Parents or guardians may opt out of any non-emergency...

20 CFR 416.2060 - Mandatory minimum supplementary payments not applicable.

Code of Federal Regulations, 2010 CFR

2010-04-01

... applicable. 416.2060 Section 416.2060 Employees' Benefits SOCIAL SECURITY ADMINISTRATION SUPPLEMENTAL... supplemental income benefits under title XVI of the Social Security Act by reason of the provisions of section 1611(e) (1)(A), (2) or (3), 1611(f), or 1615(c) of such Act; or (d) Month of change in residence...

Graduating med-peds residents' interest in part-time employment.

PubMed

Fix, Amy L; Kaelber, David C; Melgar, Thomas A; Chamberlain, John; Cull, William; Robbins, Brett W

2011-01-01

As part-time work is becoming more popular among the primary care specialties, we examined the demographic descriptors of med-peds residents seeking and finding part-time employment upon completion of residency training. As part of the 2006 annual American Academy of Pediatrics (AAP) Graduating Med-Peds Residents Survey, we surveyed the graduating residents of all med-peds programs about their interest in and plans for part-time employment. A total of 199 (60%) of the residents responded. Of the resident respondents applying for nonfellowship jobs, 19% sought part-time positions and 10% actually accepted a part-time position. Female residents were significantly more likely than male residents to apply for part-time jobs (26% vs. 7%, P = .034). Sixty percent of female residents immediately seeking work and 58% of those going on to fellowship reported an interest in arranging a part-time or reduced-hours position at some point in the next 5 years. Part-time employment among med-peds residents applying for nonfellowship positions after graduation is similar to the current incidence of part-time employment in other fields of primary care. A much higher percentage of med-peds residents are interested in arranging part-time work within 5 years after graduation. This strong interest in part-time work has many implications for the primary care workforce. Copyright © 2011 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Long and short hospice stays among nursing home residents at the end of life.

PubMed

Huskamp, Haiden A; Stevenson, David G; Grabowski, David C; Brennan, Eric; Keating, Nancy L

2010-08-01

To identify characteristics of nursing homes and residents associated with particularly long or short hospice stays. Observational study using administrative data on resident characteristics and hospice utilization from a large regional hospice linked with publicly available data on nursing home characteristics. A total of 13,479 residents who enrolled in hospice during 2001-2008. Logistic regression models of the probability of a long (>180 days) or very short (

[Needs assessment of a core curriculum for residency training].

PubMed

Kwon, Hyo-Jin; Lee, Young-Mee; Chang, Hyung-Joo; Kim, Ae-Ri

2015-09-01

The core curriculum in graduate medical education (GME) is an educational program that covers the minimum body of knowledge and skills that is required of all residents, regardless of their specialty. This study examined the opinions of stakeholders in GME regarding the core curriculum. A questionnaire was administered at three tertiary hospitals that were affiliated with one university; 192 residents and 61 faculty members and attending physicians participated in the survey. The questionnaire comprised six items on physician competency and the needs for a core curriculum. Questions on subjects or topics and adequate training years for each topics were asked only to residents. Most residents (78.6%) and faculty members (86.9%) chose "medical expertise" as the "doctor's role in the 21st century." In contrast, communicator, manager, and collaborator were recognized by less than 30% of all participants. Most residents (74.1%) responded that a core curriculum is "necessary but not feasible," whereas 68.3% of faculty members answered that it is "absolutely needed." Regarding subjects that should be included in the core curriculum, residents and faculty members had disparate preferences- residents preferred more "management of a private clinic" and "financial management," whereas faculty members desired "medical ethics" and "communication skills." Residents and faculty members agree that residents should develop a wide range of competencies in their training. However, the perception of the feasibility and opinions on the contents of the core curriculum differed between groups. Further studies with larger samples should be conducted to define the roles and professional competencies of physicians and the needs for a core curriculum in GME.

Teaching the Basics: Development and Validation of a Distal Radius Reduction and Casting Model.

PubMed

Seeley, Mark A; Fabricant, Peter D; Lawrence, J Todd R

2017-09-01

Approximately one-third of reduced pediatric distal radius fractures redisplace, resulting in further treatment. Two major modifiable risk factors for loss of reduction are reduction adequacy and cast quality. Closed reduction and immobilization of distal radius fractures is an Accreditation Council for Graduate Medical Education residency milestone. Teaching and assessing competency could be improved with a life-like simulation training tool. Our goal was to develop and validate a realistic distal radius fracture reduction and casting simulator as determined by (1) a questionnaire regarding the "realism" of the model and (2) the quantitative assessments of reduction time, residual angulation, and displacement. A distal radius fracture model was created with radiopaque bony segments and articulating elbows and shoulders. Simulated periosteum and internal deforming forces required proper reduction and casting techniques to achieve and maintain reduction. The forces required were estimated through an iterative process through feedback from experienced clinicians. Embedded monofilaments allowed for quantitative assessment of residual displacement and angulation through the use of fluoroscopy. Subjects were asked to perform closed reduction and apply a long arm fiberglass cast. Primary performance variables assessed included reduction time, residual angulation, and displacement. Secondary performance variables consisted of number of fluoroscopic images, casting time, and cast index (defined as the ratio of the internal width of the forearm cast in the sagittal plane to the internal width in the coronal plane at the fracture site). Subject grading was performed by two blinded reviewers. Interrater reliability was nearly perfect across all measurements (intraclass correlation coefficient range, 0.94-0.99), thus disagreements in measurements were handled by averaging the assessed values. After completion the participants answered a Likert-based questionnaire regarding the realism of simulation. Eighteen participants consented to participate in the study (eight attending pediatric orthopaedic surgeons, six junior residents, four senior residents). The performances of junior residents (Postgraduate Year [PGY] 1-2), senior residents (PGY 3-5), and attending surgeons were compared using one-way ANOVA with Tukey's-adjusted pairwise comparisons. The majority of participants (15 of 18) felt that the model looked, felt, and moved like a human forearm. All participants strongly agreed that the model taught the basic steps of fracture reduction and should be implemented in orthopaedic training. Attending surgeons reduced fractures in less time than junior residents (60 ± 27 seconds versus 460 ± 62 seconds; mean difference, 400 seconds; 95% CI, 335-465 seconds; p < 0.001). Residual angulation was greater for junior residents when compared with attending surgeons on AP (7° ± 5° versus 0.7° ± 0.9°; mean difference, 6.3°; 95% CI, 3°-11°; p = 0.003) and lateral (27° ± 7° versus 7° ± 5°; mean difference, 20°; 95% CI, 13°-27°; p = 0.001) radiographs. Similarly, residual displacement was greater for junior residents than either senior residents (mean difference, 16 mm; 95% CI, 2-34 mm; p = 0.05) or attending surgeons (mean difference, 15 mm; 95% CI, 3-27 mm; p = 0.02) on lateral images. There were no differences identified in secondary performance variables (number of fluoroscopic images, casting time, and cast index) between groups. This is the first distal radius fracture reduction model to incorporate an elbow and shoulder and allow quantitative assessment of the fracture reduction. This simulator may be useful in an orthopaedic resident training program to help them reach a defined minimum level of competency. This simulator also could easily be integrated in other accreditation and training programs, including emergency medicine. Level II, therapeutic study.

[Part-time residency training in Israel].

PubMed

Fishbain, Dana; Levi, Baruch; Borow, Malke; Ashkenazi, Shai; Lindner, Arie

2012-08-01

Full-time work has long been perceived as a cornerstone of medical residency, the consensus being that a resident must apply the bulk of his time and attention to his professional training. Demographic and cultural changes that have taken place over the last several years, specifically the rise in the number of female doctors and the importance of leisure time to the younger generation, have intensified the need to find new and innovative ways to deal with the plight of the resident population. One idea, already in effect in many Western countries, is the institution of part-time residency programs. The possibility of fulfilling residency requirements on a part-time basis is intended to assist medical residents in integrating their professional development with their personal and family life, without compromising the quality of their training. A number of research studies conducted over the last several years in countries that allow part-time residency, among them the United States, England and Switzerland, aimed to examine the quality of part-time training. The various studies evinced a high level of satisfaction from the program both by the residents themselves and their supervisors, and in many aspects those doing residency part-time received higher appraisals than their full-time colleagues. Some of the residents polled noted that they would have totally foregone the practice of medicine had there not been an option to complete residency part-time. In light of the experience throughout the world and the changing landscape in Israel, the Scientific Council of the Israeli Medical Association decided to examine the issue and its various aspects, and weighed all the considerations in favor and against part-time residency. Recently, the Scientific Council approved the launch of a pilot program to allow part-time residency in several fields that were carefully selected according to specific criteria. Once the Ministry of Health completes the LegisLation process, part-time residency will officially begin in Israel.

Does availability of mental health resources prevent recurrent suicidal behavior? An ecological analysis.

PubMed

Cooper, Sara L; Lezotte, Dennis; Jacobellis, Jillian; Diguiseppi, Carolyn

2006-08-01

This study examines whether availability of mental health resources in the county of residence is associated with subsequent suicidal behavior after a previous suicide attempt. Among 10,922 individuals who attempted suicide in Colorado between 1998 and 2002, residence in a county that offered a minimum safety-net of mental health services significantly reduced the risk of suicidal behavior for at least 1 year after the index attempt. Safety-net services included mental health treatment, crisis treatment, and case management. These results suggest one strategy for prevention of suicidal behavior that could inform state-level health policy development and resource allocation.

Protected Time for Research During Orthopaedic Residency Correlates with an Increased Number of Resident Publications.

PubMed

Williams, Benjamin R; Agel, Julie A; Van Heest, Ann E

2017-07-05

The Accreditation Council for Graduate Medical Education (ACGME) requires orthopaedic residency programs to promote scholarship and research, which manifest differently among programs. We assess the impact of protected research time during orthopaedic residency on the number of resident publications. Rotation schedules and resident names were collected from 125 ACGME-accredited U.S. orthopaedic residency programs. Protected research time was classified as 1 of 3 types: (1) block time, (2) longitudinal time, or (3) no dedicated time. In April 2016, we searched residents in postgraduate year (PGY)-3 to PGY-5 on pubmed.gov to generate all orthopaedic publications with a PubMed identifier published during residency. Each publication's 2015 Thomson Reuters Journal Citation Reports 5-Year Journal Impact Factor and resident first authorship were noted. The number of PubMed identifiers for each program was summed and was divided by the number of residents in PGY-3 to PGY-5, giving a mean number of publications per resident. The relationship between output and program research time was compared using t tests and analysis of variance (ANOVA). A total of 1,690 residents were included, with an overall mean number (and standard deviation) of 1.2 ± 2.4 publications per resident. Eighty-seven programs reported block time, 14 programs reported longitudinal time, and 24 programs reported no time. There was a significant difference (p = 0.02) in the mean number of publications per resident when compared between programs with protected time (1.1 ± 1.2 publications) and programs with no protected time (0.6 ± 0.5 publication). One-way ANOVA demonstrated a significant mean difference across the 3 groups (p < 0.001), with longitudinal time correlating with significantly greater output at 1.9 ± 1.8 publications than block time at 1.0 ± 1.0 publication or no time at 0.6 ± 0.5 publication, a difference that persisted when adjusted to include only impact factors of >0 and exclude case reports (p = 0.0015). Both the presence of and the type of dedicated research time correlate with residents' research productivity; further consideration of protected research time during residency is warranted. This article provides objective data with regard to research strategies in training orthopaedic surgeons.

Residency times and patterns of movement of postbreeding dunlin on a subarctic staging area in Alaska

USGS Publications Warehouse

Warnock, Nils; Handel, Colleen M.; Gill, Robert E.; McCaffery, Brian J.

2013-01-01

Understanding how individuals use key resources is critical for effective conservation of a population. The Yukon-Kuskokwim Delta (YKD) in western Alaska is the most important postbreeding staging area for shorebirds in the subarctic North Pacific, yet little is known about movements of shorebirds there during the postbreeding period. To address this information gap, we studied residency times and patterns of movement of 17 adult and 17 juvenile radio-marked Dunlin (Calidris alpina) on the YKD between early August and early October 2005. Throughout this postbreeding period, during which Dunlin were molting, most birds were relocated within a 130 km radius of their capture site on the YKD, but three birds were relocated more than 600 km to the south at estuaries along the Alaska Peninsula. On average, juvenile Dunlin were relocated farther away from the banding site (median relocation distance = 36.3 km) than adult Dunlin (median relocation distance = 8.8 km). Post-capture, minimum lengths of stay by Dunlin on the YKD were not significantly different between juveniles (median = 19 days) and adults (median = 23 days), with some birds staging for more than 50 days. Body mass at time of capture was the best single variable explaining length of stay on the YKD, with average length of stay decreasing by 2.5 days per additional gram of body mass at time of capture. Conservation efforts for postbreeding shorebirds should consider patterns of resource use that may differ not only by age cohort but also by individual condition.

Formation and spreading of Red Sea Outflow Water in the Red Sea

NASA Astrophysics Data System (ADS)

Zhai, Ping; Bower, Amy S.; Smethie, William M.; Pratt, Larry J.

2015-09-01

Hydrographic data, chlorofluorocarbon-12 (CFC-12) and sulfur hexafluoride (SF6) measurements collected in March 2010 and September-October 2011 in the Red Sea, as well as an idealized numerical experiment are used to study the formation and spreading of Red Sea Outflow Water (RSOW) in the Red Sea. Analysis of inert tracers, potential vorticity distributions, and model results confirm that RSOW is formed through mixed-layer deepening caused by sea surface buoyancy loss in winter in the northern Red Sea and reveal more details on RSOW spreading rates, pathways, and vertical structure. The southward spreading of RSOW after its formation is identified as a layer with minimum potential vorticity and maximum CFC-12 and SF6. Ventilation ages of seawater within the RSOW layer, calculated from the partial pressure of SF6 (pSF6), range from 2 years in the northern Red Sea to 15 years at 17°N. The distribution of the tracer ages is in agreement with the model circulation field which shows a rapid transport of RSOW from its formation region to the southern Red Sea where there are longer circulation pathways and hence longer residence time due to basin wide eddies. The mean residence time of RSOW within the Red Sea estimated from the pSF6 age is 4.7 years. This time scale is very close to the mean transit time (4.8 years) for particles from the RSOW formation region to reach the exit at the Strait of Bab el Mandeb in the numerical experiment.

Scaling laws for oxygen transport across the space-filling system of respiratory membranes in the human lung

NASA Astrophysics Data System (ADS)

Hou, Chen

Space-filling fractal surfaces play a fundamental role in how organisms function at various levels and in how structure determines function at different levels. In this thesis, we develop a quantitative theory of oxygen transport to and across the surface of the highly branched, space-filling system of alveoli, the fundamental gas exchange unit (acinar airways), in the human lung. Oxygen transport in the acinar airways is by diffusion, and we treat the two steps---diffusion through the branched airways, and transfer across the alveolar membranes---as a stationary diffusion-reaction problem, taking into account that there may be steep concentration gradients between the entrance and remote alveoli (screening). We develop a renormalization treatment of this screening effect and derive an analytic formula for the oxygen current across the cumulative alveolar membrane surface, modeled as a fractal, space-filling surface. The formula predicts the current from a minimum of morphological data of the acinus and appropriate values of the transport parameters, through a number of power laws (scaling laws). We find that the lung at rest operates near the borderline between partial screening and no screening; that it switches to no screening under exercise; and that the computed currents agree with measured values within experimental uncertainties. From an analysis of the computed current as a function of membrane permeability, we find that the space-filling structure of the gas exchanger is simultaneously optimal with respect to five criteria. The exchanger (i) generates a maximum oxygen current at minimum permeability; (ii) 'wastes' a minimum of surface area; (iii) maintains a minimum residence time of oxygen in the acinar airways; (iv) has a maximum fault tolerance to loss of permeability; and (v) generates a maximum current increase when switching from rest to exercise.

Protected Resident Research Time Does Not Increase the Quantity or Quality of Residency Program Research Publications: A Comparison of 3 Orthopedic Residencies.

PubMed

Krueger, Chad A; Hoffman, Jeffery D; Balazs, George C; Johnson, Anthony E; Potter, Benjamin K; Belmont, Philip J

The effect of dedicated resident research time in terms of residency program research productivity remains largely unknown. We hypothesize that the quantity and quality of a residency program's peer-reviewed publications (PRPs) increase proportionately with the amount of dedicated research time given to residents. Three residency programs (P1, P2, and P3) were examined. P1 has a mandatory research year for all residents between postgraduate years 3 and 4. P2 has an elective research year for 1 resident between postgraduate years 2 and 3. P3 has no dedicated research time for residents. All publications produced by residents and staff at each program from January 2007 through December were recorded from PUBMED. SCImago Journal Rankings were used as a proxy to measure research quality. There was no significant difference in the number of publications produced between the institutions on a per-staff (p = 0.27) and per-resident (p = 0.80) basis. There were no residents at P3 who graduated without at least 1 PRP, whereas there were 7 residents from P1 and 8 residents from P2 who graduated without a PRP. There were no significant differences between programs in terms of the SCImago Journal Ranking for the journals containing their publications (p = 0.135). Residency programs with dedicated research time did not produce significantly (p > 0.05) more, or higher quality, PRPs than residencies without dedicated research time. It may be that the quantity and quality of PRPs is related more to faculty engagement, research interest, and mentorship at individual programs rather than the number of residents given dedicated time to complete research. Level 3. Published by Elsevier Inc.

Hospital Costs of Foreign Non-Resident Patients: A Comparative Analysis in Catalonia, Spain.

PubMed

Arroyo-Borrell, Elena; Renart-Vicens, Gemma; Saez, Marc; Carreras, Marc

2017-09-14

Although patient mobility has increased over the world, in Europe there is a lack of empirical studies. The aim of the study was to compare foreign non-resident patients versus domestic patients for the particular Catalan case, focusing on patient characteristics, hospitalisation costs and differences in costs depending on the typology of the hospital they are treated. We used data from the 2012 Minimum Basic Data Set-Acute Care hospitals (CMBD-HA) in Catalonia. We matched two case-control groups: first, foreign non-resident patients versus domestic patients and, second, foreign non-resident patients treated by Regional Public Hospitals versus other type of hospitals. Hospitalisation costs were modelled using a GLM Gamma with a log-link. Our results show that foreign non-resident patients were significantly less costly than domestic patients (12% cheaper). Our findings also suggested differences in the characteristics of foreign non-resident patients using Regional Public Hospitals or other kinds of hospitals although we did not observe significant differences in the healthcare costs. Nevertheless, women, 15-24 and 35-44 years old patients and the days of stay were less costly in Regional Public Hospitals. In general, acute hospitalizations of foreign non-resident patients while they are on holiday cost substantially less than domestic patients. The typology of hospital is not found to be a relevant factor influencing costs.

Hospital Costs of Foreign Non-Resident Patients: A Comparative Analysis in Catalonia, Spain

PubMed Central

Arroyo-Borrell, Elena; Renart-Vicens, Gemma; Saez, Marc

2017-01-01

Although patient mobility has increased over the world, in Europe there is a lack of empirical studies. The aim of the study was to compare foreign non-resident patients versus domestic patients for the particular Catalan case, focusing on patient characteristics, hospitalisation costs and differences in costs depending on the typology of the hospital they are treated. We used data from the 2012 Minimum Basic Data Set-Acute Care hospitals (CMBD-HA) in Catalonia. We matched two case-control groups: first, foreign non-resident patients versus domestic patients and, second, foreign non-resident patients treated by Regional Public Hospitals versus other type of hospitals. Hospitalisation costs were modelled using a GLM Gamma with a log-link. Our results show that foreign non-resident patients were significantly less costly than domestic patients (12% cheaper). Our findings also suggested differences in the characteristics of foreign non-resident patients using Regional Public Hospitals or other kinds of hospitals although we did not observe significant differences in the healthcare costs. Nevertheless, women, 15–24 and 35–44 years old patients and the days of stay were less costly in Regional Public Hospitals. In general, acute hospitalizations of foreign non-resident patients while they are on holiday cost substantially less than domestic patients. The typology of hospital is not found to be a relevant factor influencing costs. PMID:28906459

Screening for tinea unguium by Dermatophyte Test Strip.

PubMed

Tsunemi, Y; Takehara, K; Miura, Y; Nakagami, G; Sanada, H; Kawashima, M

2014-02-01

The direct microscopy, fungal culture and histopathology that are necessary for the definitive diagnosis of tinea unguium are disadvantageous in that detection sensitivity is affected by the level of skill of the person who performs the testing, and the procedures take a long time. The Dermatophyte Test Strip, which was developed recently, can simply and easily detect filamentous fungi in samples in a short time, and there are expectations for its use as a method for tinea unguium screening. With this in mind, we examined the detection capacity of the Dermatophyte Test Strip for tinea unguium. The presence or absence of fungal elements was judged by direct microscopy and Dermatophyte Test Strip in 165 nail samples obtained from residents in nursing homes for the elderly. Moreover, the minimum sample amount required for positive determination was estimated using 32 samples that showed positive results by Dermatophyte Test Strip. The Dermatophyte Test Strip showed 98% sensitivity, 78% specificity, 84·8% positive predictive value, 97% negative predictive value and a positive and negative concordance rate of 89·1%. The minimum sample amount required for positive determination was 0·002-0·722 mg. The Dermatophyte Test Strip showed very high sensitivity and negative predictive value, and was considered a potentially useful method for tinea unguium screening. Positive determination was considered to be possible with a sample amount of about 1 mg. © 2013 British Association of Dermatologists.

Greater Independence in Activities of Daily Living is Associated with Higher Health-Related Quality of Life Scores in Nursing Home Residents with Dementia

PubMed Central

Chan, Charice S.; Slaughter, Susan E.; Jones, C. Allyson; Wagg, Adrian S.

2015-01-01

Health-related quality of life (HRQL) for nursing home residents is important, however, the concept of quality of life is broad, encompasses many domains and is difficult to assess in people with dementia. Basic activities of daily living (ADL) are measured routinely in nursing homes using the Resident Assessment Instrument-Minimum Data Set Version 2.0 (RAI-MDS) and Functional Independence Measure (FIM) instrument. We examined the relationship between HRQL and ADL to assess the future possibility of ADL dependency level serving as a surrogate measure of HRQL in residents with dementia. To assess ADL, measures derived from the RAI-MDS and FIM data were gathered for 111 residents at the beginning of our study and at 6-month follow-up. Higher scores for independence in ADL were correlated with higher scores for a disease-specific HRQL measure, the Quality of Life—Alzheimer’s Disease Scale. Preliminary evidence suggests that FIM-assessed ADL is associated with HRQL for these residents. The associations of the dressing and toileting items with HRQL were particularly strong. This finding suggests the importance of ADL function in HRQL. The RAI-MDS ADL scales should be used with caution to evaluate HRQL. PMID:27417776

Did the introduction of a prospective payment system for nursing home stays reduce the likelihood of pharmacological management of secondary ischaemic stroke?

PubMed

Lapane, Kate L; Hughes, Carmel M

2006-01-01

Since 1998, a prospective payment system (PPS) for Medicare services provided by nursing homes in the US has been in operation. Concerns have been expressed that the PPS may affect the quality of care delivered to residents. This study evaluates the impact of the PPS on pharmacological secondary ischaemic stroke prevention in nursing homes. The nationally mandated Minimum Data Set and Online Survey Certification and Automated Record data system from 1997 and 2000 for four states were used. We conducted a quasi-experimental study comparing the pharmacological treatment rates for secondary stroke prevention in the pre-PPS period (1997) with those in the post-PPS period (2000) in residents who experienced an ischaemic stroke within 6 months (n1997 = 5008; n2000 = 5243) of living in nursing facilities (n1997 = 1226; n2000 = 1092) in Kansas, Maine, Mississippi or Ohio. The sample was stratified according to recommendations for use of warfarin. Logistic regression models adjusting for clustering effects of residents residing in homes using generalised estimating equations provided estimates of the PPS effect on use of antiplatelets and the use of warfarin. The unadjusted proportion of use of pharmacological agents for the secondary prevention of stroke was similar for warfarin in both time periods and increased for antiplatelets in 2000. Relative to the pre-PPS era, the likelihood of use of antiplatelets increased in the post-PPS era (adjusted odds ratio 1.26; 95% CI 1.15, 1.38); there was no effect on the use of warfarin. Although the lack of a PPS effect on pharmacological management of secondary ischaemic stroke is encouraging, there is still room for improvement in overall stroke management.

Population structure and residency patterns of whale sharks, Rhincodon typus, at a provisioning site in Cebu, Philippines.

PubMed

Araujo, Gonzalo; Lucey, Anna; Labaja, Jessica; So, Catherine Lee; Snow, Sally; Ponzo, Alessandro

2014-01-01

This study represents the first description of whale sharks, Rhincodon typus, occurring at a provisioning site in Oslob, Cebu, Philippines. Frequent observations of sharks are often difficult, even at tourism sites, giving rise to provisioning activities to attract them. The present study provides repeated longitudinal data at a site where daily provisioning activities took place, and whale sharks were present every day. A total of 158 individual whale sharks were photographically identified between Mar 2012 and Dec 2013, with 129 males (82%), 19 females (12%) and 10 (6%) of undetermined sex. Mean estimated total length was 5.5 m (±1.3 m S.D.). Twenty individuals were measured with laser photogrammetry to validate researchers' estimated sizes, yielding a good correlation (r (2) = 0.83). Fifty-four (34%) individuals were observed being hand-fed by local fishermen (provisioned), through in-water behavioural observations. Maximum likelihood methods were used to model mean residency time of 44.9 days (±20.6 days S.E.) for provisioned R. typus contrasting with 22.4 days (±8.9 days S.E.) for non-provisioned individuals. Propeller scars were observed in 47% of the animals. A mean of 12.7 (±4.3 S.D.) R. typus were present in the survey area daily, with a maximum of 26 individuals (Aug 10 2013) and a minimum of 2 (Dec 6 2012). Twelve (8%) individuals were seen on at least 50% of survey days (n = 621), with a maximum residency of 572 days for one individual (P-396). Twenty four individuals were photographically identified across regional hotsposts, highlighting the species' migratory nature and distribution. Extended residency and differences in lagged identification rates suggest behavioural modification on provisioned individuals, underlying the necessity for proper management of this tourism activity.

The Annual Glaciohydrology Cycle in the Ablation Zone of the Greenland Ice Sheet: Part 1. Hydrology Model

NASA Technical Reports Server (NTRS)

Colgan, William; Rajaram, Harihar; Anderson, Robert; Steffen. Konrad; Phillips, Thomas; Zwally, H. Jay; Abdalati, Waleed

2012-01-01

We apply a novel one-dimensional glacier hydrology model that calculates hydraulic head to the tidewater-terminating Sermeq Avannarleq flowline of the Greenland ice sheet. Within a plausible parameter space, the model achieves a quasi-steady-state annual cycle in which hydraulic head oscillates close to flotation throughout the ablation zone. Flotation is briefly achieved during the summer melt season along a approx.17 km stretch of the approx.50 km of flowline within the ablation zone. Beneath the majority of the flowline, subglacial conduit storage closes (i.e. obtains minimum radius) during the winter and opens (i.e. obtains maximum radius) during the summer. Along certain stretches of the flowline, the model predicts that subglacial conduit storage remains open throughout the year. A calculated mean glacier water residence time of approx.2.2 years implies that significant amounts of water are stored in the glacier throughout the year. We interpret this residence time as being indicative of the timescale over which the glacier hydrologic system is capable of adjusting to external surface meltwater forcings. Based on in situ ice velocity observations, we suggest that the summer speed-up event generally corresponds to conditions of increasing hydraulic head during inefficient subglacial drainage. Conversely, the slowdown during fall generally corresponds to conditions of decreasing hydraulic head during efficient subglacial drainage.

[Aluminium in the lower respiratory tract of people living in México City].

PubMed

Manquián-Tejos, Adelaida R I; Tovar-Gálvez, Luis R; Yáñez-Canal, Gabriel

2008-01-01

Investigating the presence of aluminium (Al) and respiratory pathologies in the lower respiratory tract of people who had lived in Mexico City for a minimum of two years. 250 respiratory tissue samples were obtained from pulmonary lobes, lymph nodes, bronchial and hilum regions during 36 individuals' autopsies. Inductively coupled plasma optical emission spectrometry (ICP-OES) was used for quantifying Al; the samples has been previously dried, ground and digested. 13 different pathologies were identified but only three of them (pulmonary emphysema, bronchitis and anthracosis) were correlated with the presence of Al, an element being distributed in very variable concentrations (range: 2.7 to 836.1 micrograms of Al per gram of dry tissue (ì g Al/g ts)). The amount of Al found in lobes, bronchial and hilum regions was much smaller than that found in lymph nodes; such difference was statistically significant. Multivariate analysis by conglomerates revealed that the sample consisted of three classes of individuals, grouped according to the amount and distribution of Al in the lower respiratory tract, age, time spent living in Mexico City and the presence of pathologies. The Al found in the lower respiratory tract of residents of Mexico City would thus seem to have come from the air. The amount of Al and its distribution pattern depended on the time and place of residence and can lead to respiratory illness.

42 CFR 422.514 - Minimum enrollment requirements.

Code of Federal Regulations, 2010 CFR

2010-10-01

... individuals if the organization is a PSO) are enrolled for the purpose of receiving health benefits from the organization; or (2) At least 1,500 individuals (or 500 individuals if the organization is a PSO) are enrolled... individuals residing outside of urbanized areas as defined in § 412.62(f) (or, in the case of a PSO, the PSO...

42 CFR 422.514 - Minimum enrollment requirements.

Code of Federal Regulations, 2011 CFR

2011-10-01

... individuals if the organization is a PSO) are enrolled for the purpose of receiving health benefits from the organization; or (2) At least 1,500 individuals (or 500 individuals if the organization is a PSO) are enrolled... individuals residing outside of urbanized areas as defined in § 412.62(f) (or, in the case of a PSO, the PSO...

Obtaining Your License: Careers in Real Estate.

ERIC Educational Resources Information Center

Lyon, Robert

Two steps are required to obtain a real estate salesperson's license in Texas: (1) selecting a broker to serve as an advisor, and (2) meeting personal requirements (at least 18 years old, a Texas resident, completion of a minimum of 12 semester hours of real estate and related courses, application, acceptable score on state exam, and payment of…

41 CFR 302-11.404 - What controls must we establish for paying allowances for expenses incurred in connection with...

Code of Federal Regulations, 2010 CFR

2010-07-01

... residence transactions expenses on the employee's travel authorization; (b) Determine who will review... beyond the 2-year limitation for completing sales and purchase or lease termination transactions, under... support his/her payment of the expenses claimed, which must include as a minimum; (1) The sales agreement...

Influence of forest and rangeland management on anadromous fish habitat in Western North America: habitat requirements of anadromous salmonids.

Treesearch

D.W. Reiser; T.C. Bjornn

1979-01-01

Habitat requirements of anadromous and some resident salmonid fishes have been described for various life stages, including upstream migration of adults, spawning, incubation, and juvenile rearing. Factors important in the migration of adults are water temperature, minimum water depth, maximum water velocity, turbidity, dissolved oxygen, and...

Preparedness for epidemic disease or bioterrorism: minimum cost planning for the location and staffing of urban point-of-dispensing centers.

PubMed

Bowen, William M; Chen, Jen-Yi; Tukel, Oya I

2014-01-01

Urban health authorities in the United States have been charged with developing plans for providing the infrastructure necessary to dispense prophylactic medications to their populations in the case of epidemic disease outbreak or bioterrorist attack. However, no specific method for such plans has been prescribed. This article formulates and demonstrates the use of an integer programming technique for helping to solve a part of the dispensing problem faced by cities, namely that of providing the federally required infrastructure at minimum cost, using their limited time and resources. Specifically, the technique minimizes the number of point-of-dispensing (POD) centers while covering every resident in all the census tracts within the city's jurisdiction. It also determines the optimal staffing requirement in terms of the number of nurses at each POD. This article includes a demonstration of the model using real data from Cleveland, OH, a mid-sized US city. Examples are provided of data and computational results for a variety of input parameter values such as population throughput rate, POD capacities, and distance limitations. The technique can be readily adapted to a wide range of urban areas.

A young surgeon's perspective on alternate surgical training pathways.

PubMed

Sutherland, Michael J

2007-02-01

Most residents in training today are in focused on their training, and the thoughts of changing the structure of residencies and fellowships is something that they are ambivalent about or have never heard anything about. The small minority who are vocal on these issues represent an activist group supporting change. This group is very vocal and raises many of the excellent questions we have examined. In discussion with residents, some feel that shortened training will help with the financial issues facing residents. However, many people today add additional years to their training with research years or "super" fellowships. The residents demonstrate that they want to get the skill sets that they desire despite the added length of training. This is unlikely to change even if the minimum number of years of training changes with the evolution of tracked training programs. Medical students, in the Resident and Associate Society of the American College of Surgeons survey, did not indicate that shortened training would have an affect on decision to pursue or not pursue a surgical career. If the focus of these changes is to encourage medical students to pursue a residency in surgical specialties, we may need to look at other options to increase medical student interest. Medical students indicated that lifestyle issues, types of clinical problems, stress-related concerns, and interactions with the surgical faculty were far more important in their decision to enter a surgical specialty than work hours or duration of training. If we are to make a difference in the quality and quantity of applicants for surgical residencies, then changes in the structure of residencies do not seem to be the most effective way to accomplish this. We should possibly focus more on faculty and medical student interaction and the development of positive role models for medical students to see surgeons with attractive practices that minimize some of the traditionally perceived negative stereotypes. Residents in general surgery training programs often do not make decisions on the type of fellowship that they will pursue until late in their residency. Many residents are apprehensive about these types of tracked training programs because it will accelerate the timeline for choosing a track. Changes in the structure of residency and fellowships would result in residents having to decide and "match" in their second or third postgraduate years of training instead of the fourth or fifth postgraduate year time frame. Many residents will not have been exposed to all of the types of tracks by their third postgraduate year and many voice concerns over being ready to make this decision that early in their training. Acceptance and enthusiasm about this concept among all residents will likely depend on the final version of any planned changes. A wholesale rewrite of surgical training in the United States would likely not be well received. However, the addition of alternate pathways, on a limited scale and under close scrutiny and supervision, could evaluate interest and ease into this type of program. Before embarking on massive changes in surgical training, scientific, statistically valid research determining the interest of residents in these types of programs will target changes to make these programs successful.

Suicide Mortality Following Nursing Home Discharge in the Department of Veterans Affairs Health System

PubMed Central

Szymanski, Benjamin R.; Karlin, Bradley E.; Katz, Ira R.

2013-01-01

Objectives. We assessed suicide rates up to 6 months following discharge from US Department of Veterans Affairs (VA) nursing homes. Methods. In VA Minimum Data Set (MDS) records, we identified 281 066 live discharges from the 137 VA nursing homes during fiscal years 2002 to 2008. We used MDS and administrative data to assess resident age, gender, behaviors, pain, and indications of psychoses, bipolar disorder, dementia, and depression. We identified vital status and suicide mortality within 6 months of discharge through National Death Index searches. Results. Suicide rates within 6 months of discharge were 88.0 per 100 000 person-years for men and 89.4 overall. Standardized mortality ratios relative to age- and gender-matched individuals in the VA patient population were 2.3 for men (95% confidence interval [CI] = 1.9, 2.8) and 2.4 overall (95% CI = 2.0, 2.9). In multivariable proportional hazards regression analyses, resident characteristics, diagnoses, behaviors, and pain were not significantly associated with suicide risk. Conclusions. Suicide risk was elevated following nursing home discharge. This underscores the importance of ongoing VA efforts to enhance discharge planning and timely postdischarge follow-up. PMID:24134359

Community Discharge of Nursing Home Residents: The Role of Facility Characteristics.

PubMed

Holup, Amanda A; Gassoumis, Zachary D; Wilber, Kathleen H; Hyer, Kathryn

2016-04-01

Using a socio-ecological model, this study examines the influence of facility characteristics on the transition of nursing home residents to the community after a short stay (within 90 days of admission) or long stay (365 days of admission) across states with different long-term services and supports systems. Data were drawn from the Minimum Data Set, the federal Online Survey, Certification, and Reporting (OSCAR) database, the Area Health Resource File, and the LTCFocUs.org database for all free-standing, certified nursing homes in California (n = 1,127) and Florida (n = 657) from July 2007 to June 2008. Hierarchical generalized linear models were used to examine the impact of facility characteristics on the probability of transitioning to the community. Facility characteristics, including size, occupancy, ownership, average length of stay, proportion of Medicare and Medicaid residents, and the proportion of residents admitted from acute care facilities are associated with discharge but differed by state and whether the discharge occurred after a short or long stay. Short- and long-stay nursing home discharge to the community is affected by resident, facility, and sometimes market characteristics, with Medicaid consistently influencing discharge in both states. © Health Research and Educational Trust.

Early learning effect of residents for laparoscopic sigmoid resection.

PubMed

Bosker, Robbert; Groen, Henk; Hoff, Christiaan; Totte, Eric; Ploeg, Rutger; Pierie, Jean-Pierre

2013-01-01

To evaluate the effect of learning the laparoscopic sigmoid resection procedure on resident surgeons; establish a minimum number of cases before a resident surgeon could be expected to achieve proficiency with the procedure; and examine if an analysis could be used to measure and support the clinical evaluation of the surgeon's competence with the procedure. Retrospective analysis of data which was prospective entered in the database. From 2003 to 2007 all patients who underwent a laparoscopic sigmoid resection carried out by senior residents, who completed the procedure as the primary surgeon proctored by an experienced surgeon, were included in the study. A cumulative sum control chart (CUSUM) analysis was used evaluate performance. The procedure was defined as a failure if major intra-operative complications occurred such as intra abdominal organ injury, bleeding, or anastomotic leakage; if an inadequate number of lymph nodes (<12 nodes) were removed; or if conversion to an open surgical procedure was required. Thirteen residents performed 169 laparoscopic sigmoid resections in the period evaluated. A significant majority of the resident surgeons were able to consistently perform the procedure without failure after 11 cases and determined to be competent. One resident was not determined to be competent and the CUSUM score supported these findings. We concluded that at least 11 cases are required for most residents to obtain necessary competence with the laparoscopic sigmoid resection procedure. Evaluation with the CUSUM analysis can be used to measure and support the clinical evaluation of the resident surgeon's competence with the procedure. Copyright © 2013 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Elective time during dermatology residency: A survey of residents and program directors.

PubMed

Uppal, Pushpinder; Shantharam, Rohini; Kaufmann, Tara Lynn

2017-12-15

Elective time during residency training provides residents with exposure to different subspecialties. This opportunity gives residents the chance tonurture growth in particular areas of interest and broaden their knowledge base in certain topics in dermatology by having the chance to work withexperts in the field. The purpose of this study was to assess the views of residency program directors and dermatology residents on the value of elective time through a cross sectional survey. An eight-questionIRB exempt survey was sent out to 113 residency program directors via email through the American Professors of Dermatology (APD) program director listserv. Program directors were asked to forward a separate set of 9 questions to their residents. The majority of programs that responded allowed for some elective time within their schedule, often duringthe PGY 4 (3rd year of dermatology training), but the amount of time allowed widely varied among many residency programs. Overall, residents and program directors agree that elective is important in residencytraining, but no standardization is established across programs.

Seasonal change of residence time in spring water and groundwater at a mountainous headwater catchment

NASA Astrophysics Data System (ADS)

Nagano, Kosuke; Tsujimura, Maki; Onda, Yuichi; Iwagami, Sho; Sakakibara, Koichi; Sato, Yutaro

2017-04-01

Determination of water age in headwater is important to consider water pathway, source and storage in the catchment. Previous studies showed that groundwater residence time changes seasonally. These studies reported that mean residence time of water in dry season tends to be longer than that in rainy season, and it becomes shorter as precipitation and discharge amount increases. However, there are few studies to clarify factors causing seasonal change in mean residence time in spring water and groundwater based on observed data. Therefore, this study aims to reveal the relationship between mean residence time and groundwater flow system using SFconcentration in spring and 10 minutes interval hydrological data such as discharge volume, groundwater level and precipitation amount in a headwater catchment in Fukushima, Japan. The SF6 concentration data in spring water observed from April 2015 to November 2016 shows the mean residence time of springs ranged from zero to 14 years. We also observed a clear negative correlation between discharge rate and residence time in the spring. The residence time in shallow groundwater in rainy season was younger as compared with that in low rainfall period. Therefore, the shallow groundwater with young residence time seems to contribute to the spring in rainy season, causing shorter residence time. Additionally, the residence time of groundwater ranged from 3 to 5 years even in low rainfall period. The residence time in high groundwater table level in ridge was older as compared with that in low groundwater table level. These suggest that the contribution of groundwater with older age in the ridge becomes dominant in the low discharge.

Indoor Residence Times of Semivolatile Organic Compounds: Model Estimation and Field Evaluation

EPA Science Inventory

Indoor residence times of semivolatile organic compounds (SVOCs) are a major and mostly unavailable input for residential exposure assessment. We calculated residence times for a suite of SVOCs using a fugacity model applied to residential environments. Residence times depend on...

Moon Park: A research and educational facility

NASA Technical Reports Server (NTRS)

Kuriki, Kyoichi; Saito, Takao; Ogawa, Yukimasa

1992-01-01

Moon Park has been proposed as an International Space Year (ISY) event for international cooperative efforts. Moon Park will serve as a terrestrial demonstration of a prototype lunar base and provide research and educational opportunities. The kind of data that can be obtained in the Moon Park facilities is examined taking the minimum number of lunar base residents as an example.

Roland: A Case for or Against NATO Standardization?

DTIC Science & Technology

1980-05-01

with often competing, even opposing, objectives in testing, financial auditing , cost estimating, reliability, value engineering, maintenance, training...supposedly mature system. Multilocation tests, early in the program when test beds and spare parts availability would be at a minimum, would require...Similar institutionalized conflicts resided in the audit community, which, under the Armed Services Procurement Regulation, was required to audit and

A multivariate fall risk assessment model for VHA nursing homes using the minimum data set.

PubMed

French, Dustin D; Werner, Dennis C; Campbell, Robert R; Powell-Cope, Gail M; Nelson, Audrey L; Rubenstein, Laurence Z; Bulat, Tatjana; Spehar, Andrea M

2007-02-01

The purpose of this study was to develop a multivariate fall risk assessment model beyond the current fall Resident Assessment Protocol (RAP) triggers for nursing home residents using the Minimum Data Set (MDS). Retrospective, clustered secondary data analysis. National Veterans Health Administration (VHA) long-term care nursing homes (N = 136). The study population consisted of 6577 national VHA nursing home residents who had an annual assessment during FY 2005, identified from the MDS, as well as an earlier annual or admission assessment within a 1-year look-back period. A dichotomous multivariate model of nursing home residents coded with a fall on selected fall risk characteristics from the MDS, estimated with general estimation equations (GEE). There were 17 170 assessments corresponding to 6577 long-term care nursing home residents. The increased odds ratio (OR) of being classified as a faller relative to the omitted "dependent" category of activities of daily living (ADL) ranged from OR = 1.35 for "limited" ADL category up to OR = 1.57 for "extensive-2" ADL (P < .0001). Unsteady gait more than doubles the odds of being a faller (OR = 2.63, P < .0001). The use of assistive devices such as canes, walkers, or crutches, or the use of wheelchairs increases the odds of being a faller (OR = 1.17, P < .0005) or (OR = 1.19, P < .0002), respectively. Foot problems may also increase the odds of being a faller (OR = 1.26, P < .0016). Alzheimer's or other dementias also increase the odds of being classified as a faller (OR = 1.18, P < .0219) or (OR=1.22, P < .0001), respectively. In addition, anger (OR = 1.19, P < .0065); wandering (OR = 1.53, P < .0001); or use of antipsychotic medications (OR = 1.15, P < .0039), antianxiety medications (OR = 1.13, P < .0323), or antidepressant medications (OR = 1.39, P < .0001) was also associated with the odds of being a faller. This national study in one of the largest managed healthcare systems in the United States has empirically confirmed the relative importance of certain risk factors for falls in long-term care settings. The model incorporated an ADL index and adjusted for case mix by including only long-term care nursing home residents. The study offers clinicians practical estimates by combining multiple univariate MDS elements in an empirically based, multivariate fall risk assessment model.

The effect of birthplace on heat tolerance and mortality in Milan, Italy, 1980 1989

NASA Astrophysics Data System (ADS)

Vigotti, Maria Angela; Muggeo, Vito M. R.; Cusimano, Rosanna

2006-07-01

The temperature mortality relationship follows a well-known J-V shaped pattern with mortality excesses recorded at cold and hot temperatures, and minimum at some optimal value, referred as Minimum Mortality Temperature (MMT). As the MMT, which is used to measure the population heat-tolerance, is higher for people living in warmer places, it has been argued that populations will adapt to temperature changes. We tested this notion by taking advantage of a huge migratory flow that occurred in Italy during the 1950s, when a large number of unemployed people moved from the southern to the industrializing north-western regions. We have analyzed mortality temperature relationships in Milan residents, split by groups identified by area of birth. In order to obtain estimates of the temperature-related risks, log-linear models have been used to fit daily death count data as a function of different explanatory variables. Results suggest that mortality risks differ by birthplace, regardless of the place of residence, namely heat tolerance in adult life could be modulated by outdoor temperature experienced early in life. This indicates that no complete adaptation might occur with rising external environmental temperatures.

Assessing patients' eligibility for fully funded nursing care.

PubMed

Anderson, William; Bungay, Hilary

The introduction of free nursing care in nursing homes requires that patients' needs for care from a registered nurse are determined as part of the assessment of health and social care needs. It is important that patients are assigned to the band of care that is appropriate for them so that they receive the correct contribution to their care. A minimum data set/resident assessment instrument was piloted on residents living in nursing homes as an assessment tool to see whether this agreed with decisions that had been made by the NHS-designated assessor for the registered nursing contribution to care. Comparison of findings showed that the assessment tool was a means of improving the quality of assessments.

The role of topography on catchment‐scale water residence time

USGS Publications Warehouse

McGuire, K.J.; McDonnell, Jeffery J.; Weiler, M.; Kendall, C.; McGlynn, B.L.; Welker, J.M.; Seibert, J.

2005-01-01

The age, or residence time, of water is a fundamental descriptor of catchment hydrology, revealing information about the storage, flow pathways, and source of water in a single integrated measure. While there has been tremendous recent interest in residence time estimation to characterize watersheds, there are relatively few studies that have quantified residence time at the watershed scale, and fewer still that have extended those results beyond single catchments to larger landscape scales. We examined topographic controls on residence time for seven catchments (0.085–62.4 km2) that represent diverse geologic and geomorphic conditions in the western Cascade Mountains of Oregon. Our primary objective was to determine the dominant physical controls on catchment‐scale water residence time and specifically test the hypothesis that residence time is related to the size of the basin. Residence times were estimated by simple convolution models that described the transfer of precipitation isotopic composition to the stream network. We found that base flow mean residence times for exponential distributions ranged from 0.8 to 3.3 years. Mean residence time showed no correlation to basin area (r2 < 0.01) but instead was correlated (r2 = 0.91) to catchment terrain indices representing the flow path distance and flow path gradient to the stream network. These results illustrate that landscape organization (i.e., topography) rather than basin area controls catchment‐scale transport. Results from this study may provide a framework for describing scale‐invariant transport across climatic and geologic conditions, whereby the internal form and structure of the basin defines the first‐order control on base flow residence time.

Orthopaedic Surgery Residents and Program Directors Agree on How Time Is Currently Spent in Training and Targets for Improvement.

PubMed

Camp, Christopher L; Martin, John R; Karam, Matthew D; Ryssman, Daniel B; Turner, Norman S

2016-04-01

Although much attention has been paid to the role of deliberate practice as a means of achieving expert levels of performance in other medical specialties, little has been published regarding its role in maximizing orthopaedic surgery resident potential. As an initial step in this process, this study seeks to determine how residents and program directors (PDs) feel current time spent in training is allocated compared with a theoretical ideal distribution of time. According to residents and PDs, (1) how do resident responsibilities change by level of training as perceived and idealized by residents and PDs? (2) How do resident and PD perceptions of current and ideal time distributions compare with one another? (3) Do the current training structures described by residents and PDs differ from what they feel represents an ideal time allocation construct that maximizes the educational value of residency training? A survey was sent to orthopaedic surgery resident and PD members of the Midwest Orthopedic Surgical Skills Consortium asking how they felt residents' time spent in training was distributed across 10 domains and four operating room (OR) roles and what they felt would be an ideal distribution of that time. Responses were compared between residents and PDs and between current schedules and ideal schedules. Both residents and PDs agreed that time currently spent in training differs by postgraduate year with senior-level residents spending more time in the OR (33.7% ± 8.3% versus 17.9% ± 6.2% [interns] and 27.4% ± 10.2% [juniors] according to residents, p < 0.001; and 38.6% ± 8.1% versus 11.8% ± 6.4% [interns] and 26.1% ± 5.7% [juniors] according to PD, p < 0.001). The same holds true for their theoretical ideals. Residents and PDs agree on current resident time allocation across the 10 domains; however, they disagree on multiple components of the ideal program with residents desiring more time spent in the OR than what PDs prefer (residents 40.3% ± 10.3% versus PD 32.6% ± 14.6% [mean difference {MD}, 7.7; 95% confidence interval {CI}, 4.4, 11.0], p < 0.001). Residents would also prefer to have more time spent deliberately practicing surgical skills outside of the OR (current 1.8% ± 2.1% versus ideal 3.7% ± 3.2% [MD, -1.9; 95% CI, -.2.4 to -1.4], p < 0.001). Both residents and PDs want residents to spend less time completing paperwork (current 4.4% ± 4.1% versus ideal 0.8% ± 1.6% [MD, 3.6; 95% CI, 3.0-4.2], p < 0.001 for residents; and current 3.6% ± 4.1% versus ideal 1.5% ± 1.9% [MD, 2.1; 95% CI, 0.9-3.3], p < 0.001 for PDs). Residents and PDs seem to agree on how time is currently spent in residency training. Some differences of opinions continue to exist regarding how an ideal program should be structured; however, this work identifies a few potential targets for improvement that are agreed on by both residents and PDs. These areas include increasing OR time, finding opportunities for deliberate practice of surgical skills outside of the OR, and decreased clerical burden. This study may serve as a template to allow programs to continue to refine their educational models in an effort to achieve curricula that meet the desired goals of both learners and educators. Additionally, it is an initial step toward more objective identification of the optimal educational structure of an orthopaedic residency program.

Inference from habitat-selection analysis depends on foraging strategies.

PubMed

Bastille-Rousseau, Guillaume; Fortin, Daniel; Dussault, Christian

2010-11-01

1. Several methods have been developed to assess habitat selection, most of which are based on a comparison between habitat attributes in used vs. unused or random locations, such as the popular resource selection functions (RSFs). Spatial evaluation of residency time has been recently proposed as a promising avenue for studying habitat selection. Residency-time analyses assume a positive relationship between residency time within habitat patches and selection. We demonstrate that RSF and residency-time analyses provide different information about the process of habitat selection. Further, we show how the consideration of switching rate between habitat patches (interpatch movements) together with residency-time analysis can reveal habitat-selection strategies. 2. Spatially explicit, individual-based modelling was used to simulate foragers displaying one of six foraging strategies in a heterogeneous environment. The strategies combined one of three patch-departure rules (fixed-quitting-harvest-rate, fixed-time and fixed-amount strategy), together with one of two interpatch-movement rules (random or biased). Habitat selection of simulated foragers was then assessed using RSF, residency-time and interpatch-movement analyses. 3. Our simulations showed that RSFs and residency times are not always equivalent. When foragers move in a non-random manner and do not increase residency time in richer patches, residency-time analysis can provide misleading assessments of habitat selection. This is because the overall time spent in the various patch types not only depends on residency times, but also on interpatch-movement decisions. 4. We suggest that RSFs provide the outcome of the entire selection process, whereas residency-time and interpatch-movement analyses can be used in combination to reveal the mechanisms behind the selection process. 5. We showed that there is a risk in using residency-time analysis alone to infer habitat selection. Residency-time analyses, however, may enlighten the mechanisms of habitat selection by revealing central components of resource-use strategies. Given that management decisions are often based on resource-selection analyses, the evaluation of resource-use strategies can be key information for the development of efficient habitat-management strategies. Combining RSF, residency-time and interpatch-movement analyses is a simple and efficient way to gain a more comprehensive understanding of habitat selection. © 2010 The Authors. Journal compilation © 2010 British Ecological Society.

Incidence of venous thromboembolism in nursing home residents.

PubMed

Reardon, Gregory; Pandya, Naushira; Nutescu, Edith A; Lamori, Joyce; Damaraju, C V; Schein, Jeff; Bookhart, Brahim

2013-08-01

Venous thromboembolism (VTE) is common in the elderly, but its epidemiology in nursing home residents remains unclear. This study estimated rates of VTE recorded on nursing home admission and incidence during residence. Retrospective analysis of AnalytiCare long term care (LTC) database for the period January 2007 to June 2009. 181 nursing homes in 19 US states. Eligible residents had 1 or more admission Minimum Data Set (MDS) 2.0 assessment(s) over the study period. All VTE cases were extracted if MDS indicated deep vein thrombosis or pulmonary embolism. The number of admissions and days at risk were estimated from a random sample (n = 1350) of all residents. The earliest admission was identified as the admission index date. VTE cases were classified as either "On Admission" (VTE coded on admission index date) or "During Residence" (coded afterward). Residents were followed from admission index date until censoring. A total of 2144 VTE admission cases (3.7% of all admissions) were identified. A further 757 cases of VTE occurring during residence were identified, yielding an incidence of 3.68 cases of VTE per 100 person-years of postadmission residence. VTE admission rates were highest for residents younger than 50 years (4.8%, confidence interval [CI]: 3.9%-5.9%) and 50 to 64 years (5.1%, CI: 4.6%-5.7%) but similar for those aged 65 to 74 (3.6%, CI: 3.3%-4.0%), 75 to 84 (3.6%, CI: 3.3%-3.9%), and 85 years or older (3.1%, CI: 2.9%-3.4%). The incidence of VTE during residence was similar among these age strata. Approximately 1 in 25 nursing home admissions had a VTE diagnosis. VTE incidence during residence was higher than reported in earlier nursing home studies. These incidence rates merit further investigation because diagnostic improvements may be driving greater recognition of VTE in LTC. Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.

Percolation flux and Transport velocity in the unsaturated zone, Yucca Mountain, Nevada

USGS Publications Warehouse

Yang, I.C.

2002-01-01

The percolation flux for borehole USW UZ-14 was calculated from 14C residence times of pore water and water content of cores measured in the laboratory. Transport velocity is calculated from the depth interval between two points divided by the difference in 14C residence times. Two methods were used to calculate the flux and velocity. The first method uses the 14C data and cumulative water content data directly in the incremental intervals in the Paintbrush nonwelded unit and the Topopah Spring welded unit. The second method uses the regression relation for 14C data and cumulative water content data for the entire Paintbrush nonwelded unit and the Topopah Spring Tuff/Topopah Spring welded unit. Using the first method, for the Paintbrush nonwelded unit in boreholeUSW UZ-14 percolation flux ranges from 2.3 to 41.0 mm/a. Transport velocity ranges from 1.2 to 40.6 cm/a. For the Topopah Spring welded unit percolation flux ranges from 0.9 to 5.8 mm/a in the 8 incremental intervals calculated. Transport velocity ranges from 1.4 to 7.3 cm/a in the 8 incremental intervals. Using the second method, average percolation flux in the Paintbrush nonwelded unit for 6 boreholes ranges from 0.9 to 4.0 mm/a at the 95% confidence level. Average transport velocity ranges from 0.6 to 2.6 cm/a. For the Topopah Spring welded unit and Topopah Spring Tuff, average percolation flux in 5 boreholes ranges from 1.3 to 3.2 mm/a. Average transport velocity ranges from 1.6 to 4.0 cm/a. Both the average percolation flux and average transport velocity in the PTn are smaller than in the TS/TSw. However, the average minimum and average maximum values for the percolation flux in the TS/TSw are within the PTn average range. Therefore, differences in the percolation flux in the two units are not significant. On the other hand, average, average minimum, and average maximum transport velocities in the TS/TSw unit are all larger than the PTn values, implying a larger transport velocity for the TS/TSw although there is a small overlap.

Impact of extended duty hours on medical trainees

PubMed Central

Weiss, Pnina; Kryger, Meir; Knauert, Melissa

2018-01-01

Many studies on resident physicians have demonstrated that extended work hours are associated with a negative impact on well-being, education, and patient care. However, the relationship between the work schedule and the degree of impairment remains unclear. In recent years, because of concerns for patient safety, national minimum standards for duty hours have been instituted (2003) and revised (2011). These changes were based on studies of the effects of sleep deprivation on human performance and specifically on the effect of extended shifts on resident performance. These requirements necessitated significant restructuring of resident schedules. Concerns were raised that these changes have impaired continuity of care, resident education and supervision, and patient safety. We review the studies on the effect of extended work hours on resident well-being, education, and patient care as well as those assessing the effect of work hour restrictions. Although many studies support the adverse effects of extended shifts, there are some conflicting results due to factors such as heterogeneity of protocols, schedules, subjects, and environments. Assessment of the effect of work hour restrictions has been even more difficult. Recent data demonstrating that work hour limitations have not been associated with improvement in patient outcomes or resident education and well-being have been interpreted as support for lifting restrictions in some specialties. However, these studies have significant limitations and should be interpreted with caution. Until future research clarifies duty hours that optimize patient outcomes, resident education, and well-being, it is recommended that current regulations be followed. PMID:29073389

The effect of state medicaid case-mix payment on nursing home resident acuity.

PubMed

Feng, Zhanlian; Grabowski, David C; Intrator, Orna; Mor, Vincent

2006-08-01

To examine the relationship between Medicaid case-mix payment and nursing home resident acuity. Longitudinal Minimum Data Set (MDS) resident assessments from 1999 to 2002 and Online Survey Certification and Reporting (OSCAR) data from 1996 to 2002, for all freestanding nursing homes in the 48 contiguous U.S. states. We used a facility fixed-effects model to examine the effect of introducing state case-mix payment on changes in nursing home case-mix acuity. Facility acuity was measured by aggregating the nursing case-mix index (NCMI) from the MDS using the Resource Utilization Group (Version III) resident classification system, separately for new admits and long-stay residents, and by an OSCAR-derived index combining a range of activity of daily living dependencies and special treatment measures. We followed facilities over the study period to create a longitudinal data file based on the MDS and OSCAR, respectively, and linked facilities with longitudinal data on state case-mix payment policies for the same period. Across three acuity measures and two data sources, we found that states shifting to case-mix payment increased nursing home acuity levels over the study period. Specifically, we observed a 2.5 percent increase in the average acuity of new admits and a 1.3 to 1.4 percent increase in the acuity of long-stay residents, following the introduction of case-mix payment. The adoption of case-mix payment increased access to care for higher acuity Medicaid residents.

Meteorologic, oceanographic, and geomorphic controls on circulation and residence time in a coral reef-lined embayment: Faga'alu Bay, American Samoa

NASA Astrophysics Data System (ADS)

Storlazzi, C. D.; Cheriton, O. M.; Messina, A. M.; Biggs, T. W.

2018-06-01

Water circulation over coral reefs can determine the degree to which reef organisms are exposed to the overlying waters, so understanding circulation is necessary to interpret spatial patterns in coral health. Because coral reefs often have high geomorphic complexity, circulation patterns and the duration of exposure, or "local residence time" of a water parcel, can vary substantially over small distances. Different meteorologic and oceanographic forcings can further alter residence time patterns over reefs. Here, spatially dense Lagrangian surface current drifters and Eulerian current meters were used to characterize circulation patterns and resulting residence times over different regions of the reefs in Faga'alu Bay, American Samoa, during three distinct forcing periods: calm, strong winds, and large waves. Residence times varied among different geomorphic zones of the reef and were reflected in the spatially varying health of the corals across the embayment. The relatively healthy, seaward fringing reef consistently had the shortest residence times, as it was continually flushed by wave breaking at the reef crest, whereas the degraded, sheltered, leeward fringing reef consistently had the longest residence times, suggesting this area is more exposed to land-based sources of pollution. Strong wind forcing resulted in the longest residence times by pinning the water in the bay, whereas large wave forcing flushed the bay and resulted in the shortest residence times. The effect of these different forcings on residence times was fairly consistent across all reef geomorphic zones, with the shift from wind to wave forcing shortening mean residence times by approximately 50%. Although ecologically significant to the coral organisms in the nearshore reef zones, these shortened residence times were still 2-3 times longer than those associated with the seaward fringing reef across all forcing conditions, demonstrating how the geomorphology of a reef environment sets a first-order control on reef health.

Flow Through Cement Fracture Under Geological Carbon Sequestration Conditions: Critical Residence Time as a Unifying Parameter for Fracture Opening or Self-Sealing Behavior

NASA Astrophysics Data System (ADS)

Li, L.; Brunet, J. P. L.; Karpyn, Z.; Huerta, N. J.

2016-12-01

During geological carbon sequestration (GCS) large quantities of CO2 are injected in underground formations. Cement fractures represent preferential leakage pathways in abandoned wells upon exposure to CO2-rich fluid. Contrasting self- healing and fracture opening behavior have been observed while a unifying framework is still missing. The modelling of this process is challenging as it involves complex chemical, mechanical and transport interactions. We developed a process-based reactive transport model that explicitly simulates flow and multi-component reactive transport in fractured cement by reproducing experimental observations of sharp flow rate reduction during exposure to carbonated water. Mechanical interactions have not been included. The simulation shows a similar reaction network as in diffusion-controlled systems without flow. That is, CO2-rich water induced portlandite dissolution, releasing calcium that further reacted with carbonate to form calcite. This created localized changes in porosity and permeability inducing large differences in the long term response of the system through a complex positive feedback loop (e.g., a decrease in local permeability induces a decrease in flow that in turn amplifies the precipitation of calcite through a reduced acidic brine flow). The calibrated model was used to generate 250 numerical experiments of CO2-flooding in cement fractures with varying initial hydraulic apertures (b) and residence times (τ) defined as the ratio of fracture volume over flow rate. A long τ leads to slow replenishment of carbonated water, calcite precipitation, and self-sealing. The opposite occurs when τ is small with short fractures and fast flow rates. Simulation results indicate that a critical residence time τc - the minimum τ required for self-sealing -divides the conditions that trigger the diverging opening and self-sealing behavior. The τc value depends on the initial aperture size (see figure). Among the 250 simulated fracture cases, significant changes in effective permeability - self-healing or opening - typically occurs within hours to a day, thus providing a supporting argument for the extrapolation of short-term laboratory observations (hours to months) to long-term predictions at relevant GCS time scales (years to hundreds of years).

Prolonged and tunable residence time using reversible covalent kinase inhibitors

PubMed Central

Bradshaw, J. Michael; McFarland, Jesse M.; Paavilainen, Ville O.; Bisconte, Angelina; Tam, Danny; Phan, Vernon T.; Romanov, Sergei; Finkle, David; Shu, Jin; Patel, Vaishali; Ton, Tony; Li, Xiaoyan; Loughhead, David G.; Nunn, Philip A.; Karr, Dane E.; Gerritsen, Mary E.; Funk, Jens Oliver; Owens, Timothy D.; Verner, Erik; Brameld, Ken A.; Hill, Ronald J.; Goldstein, David M.; Taunton, Jack

2015-01-01

Drugs with prolonged, on-target residence time often show superior efficacy, yet general strategies for optimizing drug-target residence time are lacking. Here, we demonstrate progress toward this elusive goal by targeting a noncatalytic cysteine in Bruton's tyrosine kinase (BTK) with reversible covalent inhibitors. Utilizing an inverted orientation of the cysteine-reactive cyanoacrylamide electrophile, we identified potent and selective BTK inhibitors that demonstrate biochemical residence times spanning from minutes to 7 days. An inverted cyanoacrylamide with prolonged residence time in vivo remained bound to BTK more than 18 hours after clearance from the circulation. The inverted cyanoacrylamide strategy was further utilized to discover fibroblast growth factor receptor (FGFR) kinase inhibitors with residence times of several days, demonstrating generalizability of the approach. Targeting noncatalytic cysteines with inverted cyanoacrylamides may serve as a broadly applicable platform that facilitates “residence time by design”, the ability to modulate and improve the duration of target engagement in vivo. PMID:26006010

Assessment of procedural skills in residents working in a research and training institute: An effort to ensure patient safety and quality control.

PubMed

Kumari, Kamlesh; Samra, Tanvir; Naik, B Naveen; Saini, Vikas

2018-01-01

To ensure patient safety, it is important to regularly assess the knowledge and practical skills of anesthesia trainees. This study was conducted to evaluate the competency of the residents and the impact of various corrective measures in the form of didactic lectures and clinical skill demonstrations on the conduct of various procedural skills by the residents. Ninety-five junior residents were enrolled in this study. Assessment of competency of 1 st , 2 nd , and 3 rd year residents in performing various procedure skills of anesthesia was done in two stages using procedure specific checklist (PSC) and Global Rating Scales (GRSs). Preliminary results of the first assessment (Score 1) were discussed with the residents; deficiencies were identified and corrective measures suggested by didactic lectures and clinical skill demonstrations which were followed by a subsequent assessment after 3 months (Score 2). There was a statistically significant improvement in the PSC and GRS scores after corrective measures for all the procedural interventions studied. Percentage increase in scores was maximum in 1 st year (42.98 ± 6.62) followed by 2 nd year (34.62 ± 5.49) and minimum in 3 rd year residents (18.06 ± 3.69). The percentage increase of scores was almost similar for all subset of procedural skills; low, intermediate, and high skill anesthetic procedures. For assessment of procedural skills of residents, use of PSC and GRS scores should be incorporated and the same should be used to monitor the impact of various corrective measures (didactic lectures and clinical skill demonstrations) on the conduct of various procedural skills by the resident.

Prevalence of pseudobulbar affect symptoms and clinical correlates in nursing home residents.

PubMed

Foley, Kevin; Konetzka, R Tamara; Bunin, Anthony; Yonan, Charles

2016-07-01

Pseudobulbar affect (PBA) is a neurological disorder of emotional expression, characterized by uncontrollable episodes of crying or laughing in patients with certain neurological disorders affecting the brain. The purposes of this study were to estimate the prevalence of PBA in US nursing home residents and examine the relationship between PBA symptoms and other clinical correlates, including the use of psychopharmacological medications. A retrospective study was conducted between 2013 and 2014 with a convenience sample of residents from nine Michigan nursing homes. Chronic-care residents were included in the "predisposed population" if they had a neurological disorder affecting the brain and no evidence of psychosis, delirium, or disruptive behavior (per chart review). Residents were screened for PBA symptoms by a geropsychologist using the Center for Neurologic Study-Lability Scale (CNS-LS). Additional clinical information was collected using a diagnostic evaluation checklist and the most recent Minimum Data Set 3.0 assessment. Of 811 residents screened, complete data were available for 804, and 412 (51%) met the criteria for the "predisposed population." PBA symptom prevalence, based on having a CNS-LS score ≥13, was 17.5% in the predisposed population and 9.0% among all nursing home residents. Those with PBA symptoms were more likely to have a documented mood disorder and be using a psychopharmacological medication, including antipsychotics, than those without PBA symptoms. Pseudobulbar affect symptoms were present in 17.5% of nursing home residents with neurological conditions, and 9.0% of residents overall. Increasing awareness and improving diagnostic accuracy of PBA may help optimize treatment. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

Prevalence of pseudobulbar affect symptoms and clinical correlates in nursing home residents

PubMed Central

Konetzka, R. Tamara; Bunin, Anthony; Yonan, Charles

2015-01-01

Objective Pseudobulbar affect (PBA) is a neurological disorder of emotional expression, characterized by uncontrollable episodes of crying or laughing in patients with certain neurological disorders affecting the brain. The purposes of this study were to estimate the prevalence of PBA in US nursing home residents and examine the relationship between PBA symptoms and other clinical correlates, including the use of psychopharmacological medications. Methods A retrospective study was conducted between 2013 and 2014 with a convenience sample of residents from nine Michigan nursing homes. Chronic‐care residents were included in the “predisposed population” if they had a neurological disorder affecting the brain and no evidence of psychosis, delirium, or disruptive behavior (per chart review). Residents were screened for PBA symptoms by a geropsychologist using the Center for Neurologic Study‐Lability Scale (CNS‐LS). Additional clinical information was collected using a diagnostic evaluation checklist and the most recent Minimum Data Set 3.0 assessment. Results Of 811 residents screened, complete data were available for 804, and 412 (51%) met the criteria for the “predisposed population.” PBA symptom prevalence, based on having a CNS‐LS score ≥13, was 17.5% in the predisposed population and 9.0% among all nursing home residents. Those with PBA symptoms were more likely to have a documented mood disorder and be using a psychopharmacological medication, including antipsychotics, than those without PBA symptoms. Conclusions Pseudobulbar affect symptoms were present in 17.5% of nursing home residents with neurological conditions, and 9.0% of residents overall. Increasing awareness and improving diagnostic accuracy of PBA may help optimize treatment. © 2015 The Authors. International Journal of Geriatric Psychiatry Published by John Wiley & Sons Ltd. PMID:26526856

Data for improvement and clinical excellence: report of an interrupted time series trial of feedback in long-term care.

PubMed

Sales, Anne E; Schalm, Corinne; Baylon, Melba Andrea B; Fraser, Kimberly D

2014-11-11

There is considerable evidence about the effectiveness of audit coupled with feedback for provider behavior change, although few feedback interventions have been conducted in long-term care settings. The primary purpose of the Data for Improvement and Clinical Excellence-Long-Term Care (DICE-LTC) project was to assess the effects of a feedback intervention delivered to all direct care providers on resident outcomes. Our objective in this report is to assess the effect of feedback reporting on rates of pain assessment, depression screening, and falls over time. The intervention consisted of monthly feedback reports delivered to all direct care providers, facility and unit administrators, and support staff, delivered over 13 months in nine LTC units across four facilities. Data for feedback reports came from the Resident Assessment Instrument Minimum Data Set (RAI) version 2.0, a standardized instrument mandated in LTC facilities throughout Alberta. The primary evaluation used an interrupted time series design with a comparison group (units not included in the feedback intervention) and a comparison condition (pressure ulcers). We used segmented regression analysis to assess the effect of the feedback intervention. The primary outcome of the study, falls, showed little change over the period of the intervention, except for a small increase in the rate of falls during the intervention period. The only outcome that improved during the intervention period was the proportion of residents with high pain scores, which decreased at the beginning of the intervention. The proportion of residents with high depression scores appeared to worsen during the intervention. Maintaining all nine units in the study for its 13-month duration was a positive outcome. The feedback reports, without any other intervention included, did not achieve the desired reduction in proportion of falls and elevated depression scores. The survey on intention to change pain assessment practice which was conducted shortly after most of the feedback distribution cycles may have acted as a co-intervention supporting a reduction in pain scores. The processing and delivery of feedback reports could be accomplished at relatively low cost because the data are mandated and could be added to other intervention approaches to support implementation of evidence-based practices.

Impact of Dean Vortices on the Integrity Testing of a Continuous Viral Inactivation Reactor.

PubMed

Amarikwa, Linus; Orozco, Raquel; Brown, Matthew; Coffman, Jon

2018-05-26

We propose a standard protocol for integrity testing the residence-time distribution (RTD) in a "Jig in a Box" design (JIB)-a previously described tortuous-path, tubular, low-pH, continuous viral inactivation reactor, ensuring that biopharmaceutical products will be incubated for the required minimum residence time, t min . t min is the time by which just 0.001% of the total product containing virus has exited the incubation chamber (i.e., t 0.00001 ). This t 0.00001 is selected to ensure a >4-log reduction in viral load. As current tracers and in-line analytical technologies may not be able to detect tracers at the 0.001% level, an alternative approach is required. The authors describe a method for deriving t min from t 0.005 (i.e., the time at which 0.5% of the product has emerged from the reactor outlet) and an experimentally confirmed offset value, t offset  = t 0.005 -t 0.00001 . The authors also evaluate tracer candidates-including 100-nm-diameter gold nanoparticles, dextrose, monoclonal antibody, and riboflavin-for pre-process acceptability and the effects of viscosity, molecular diffusion coefficient, and particle size. The authors show that a JIB will yield t min and RTDs that are nearly identical for multiple tracers due to Dean vortex induced mixing. Results indicate that almost any small-molecule tracer that is generally recognized as safe can be used in pre-use integrity testing of a continuous viral inactivation reactor under the Deans values (De) of 119-595. © 2018 Boehringer Ingelheim Fremont Inc. Biotechnology Journal published by Wiley-VCH Verlag GmbH & Co. KGaA, Weinheim.

An Analysis of Research Quality and Productivity at Six Academic Orthopaedic Residencies.

PubMed

Osborn, Patrick M; Ames, S Elizabeth; Turner, Norman S; Caird, Michelle S; Karam, Matthew D; Mormino, Matthew A; Krueger, Chad A

2018-06-06

It remains largely unknown what factors impact the research productivity of residency programs. We hypothesized that dedicated resident research time would not affect the quantity and quality of a program's peer-reviewed publication within orthopedic residencies. These findings may help programs improve structure their residency programs to maximize core competencies. Three hundred fifty-nine residents and 240 staff from six different US orthopedic residency programs were analyzed. All publications published by residents and faculty at each program from January 2007 to December 2015 were recorded. SCImago Journal Rankings (SJR) were found for each journal. There were no significant differences in publications by residents at each program (p > 0.05). Faculty with 10+ years of on staff, had significantly more publications than those with less than 10years (p < 0.01). Programs with increased resident research time did not consistently produce publications with higher SJR than those without dedicated research time. Increased dedicated resident research time did not increase resident publication rates or lead to publications with higher SJR. Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

[The specialty program as a training tool: an individual training plan for each resident].

PubMed

Rodríguez González, R; Capilla Cabezuelo, E

2010-01-01

The official training program for the specialty "Diagnostic Imaging" establishes minimum learning objectives that must be fulfilled. Each accredited teaching unit is responsible for designing and carrying out a curriculum to ensure that these objectives are met, and this approach permits a degree of flexibility. Various aspects must be considered in the individual training plans for each resident: the rotation scheme according to the way the department is organized, plans for recovering missed material or reinforcing weak points, optional rotations, increasing degrees of responsibility as skills are acquired during training, and accommodating special needs of handicapped persons. Nevertheless, the individual plan must be fitted to the established curriculum and guarantee that the content of the official program is covered and that the objectives stipulated therein are met. Furthermore, the methods of teaching must be adapted to the individual characteristics of the residents, and this is the most important aspect of the individualization of training. To this end, it is fundamental for residents to take on an active role in their training, guided by their tutor and with the participation of all the radiologists in the department including the other residents, all of whom should act as teachers. Copyright © 2010 SERAM. Published by Elsevier Espana. All rights reserved.

Nurse Workforce Characteristics and Infection Risk in VA Community Living Centers: A Longitudinal Analysis

PubMed Central

Uchida-Nakakoji, Mayuko; Stone, Patricia W.; Schmitt, Susan K.; Phibbs, Ciaran S.

2015-01-01

Objective To examine effects of workforce characteristics on resident infections in Veterans Affairs (VA) Community Living Centers (CLCs). Data Sources A six-year panel of monthly, unit-specific data included workforce characteristics (from the VA Decision Support System and Payroll data) and characteristics of residents and outcome measures (from the Minimum Data Set). Study Design A resident infection composite was the dependent variable. Workforce characteristics of registered nurses (RN), licensed practical nurses (LPN), nurse aides (NA), and contract nurses included: staffing levels, skill mix and tenure. Descriptive statistics and unit-level fixed effects regressions were conducted. Robustness checks varying workforce and outcome parameters were examined. Principal Findings Average nursing hours per resident day was 4.59 hours (sd = 1.21). RN tenure averaged 4.7 years (sd = 1.64) and 4.2 years for both LPN (sd= 1.84) and NA (sd= 1.72). In multivariate analyses RN and LPN tenure were associated with decreased infections by 3.8% (IRR= 0.962 p<0.01) and 2% (IRR=0.98 p<0.01) respectively. Robustness checks consistently found RN and LPN tenure to be associated with decreased infections. Conclusions Increasing RN and LPN tenure are likely to reduce CLC resident infections. Administrators and policymakers need to focus on recruiting and retaining a skilled nursing workforce. PMID:25634087

Nurse workforce characteristics and infection risk in VA Community Living Centers: a longitudinal analysis.

PubMed

Uchida-Nakakoji, Mayuko; Stone, Patricia W; Schmitt, Susan K; Phibbs, Ciaran S

2015-03-01

To examine effects of workforce characteristics on resident infections in Veterans Affairs (VA) Community Living Centers (CLCs). A 6-year panel of monthly, unit-specific data included workforce characteristics (from the VA Decision Support System and Payroll data) and characteristics of residents and outcome measures (from the Minimum Data Set). A resident infection composite was the dependent variable. Workforce characteristics of registered nurses (RN), licensed practical nurses (LPN), nurse aides (NA), and contract nurses included: staffing levels, skill mix, and tenure. Descriptive statistics and unit-level fixed effects regressions were conducted. Robustness checks varying workforce and outcome parameters were examined. Average nursing hours per resident day was 4.59 hours (SD=1.21). RN tenure averaged 4.7 years (SD=1.64) and 4.2 years for both LPN (SD=1.84) and NA (SD=1.72). In multivariate analyses RN and LPN tenure were associated with decreased infections by 3.8% (incident rate ratio [IRR]=0.962, P<0.01) and 2% (IRR=0.98, P<0.01) respectively. Robustness checks consistently found RN and LPN tenure to be associated with decreased infections. Increasing RN and LPN tenure are likely to reduce CLC resident infections. Administrators and policymakers need to focus on recruiting and retaining a skilled nursing workforce.

The Relationship between Costs and Quality in Veterans Health Administration Community Living Centers: An Analysis Using Longitudinal Data.

PubMed

Burgess, James F; Shwartz, Michael; Stolzmann, Kelly; Sullivan, Jennifer L

2018-05-18

To examine the relationship between cost and quality in Veterans Health Administration (VA) nursing homes (called Community Living Centers, CLCs) using longitudinal data. One hundred and thirty CLCs over 13 quarters (from FY2009 to FY2012) were studied. Costs, resident days, and resident severity (RUGs score) were obtained from the VA Managerial Cost Accounting System. Clinical quality measures were obtained from the Minimum Data Set, and resident-centered care (RCC) was measured using the Artifacts of Culture Change Tool. We used a generalized estimating equation model with facilities included as fixed effects to examine the relationship between total cost and quality after controlling for resident days and severity. The model included linear and squared terms for all independent variables and interactions with resident days. With the exception of RCC, all other variables had a statistically significant relationship with total costs. For most poorer performing smaller facilities (lower size quartile), improvements in quality were associated with higher costs. For most larger facilities, improvements in quality were associated with lower costs. The relationship between cost and quality depends on facility size and current level of performance. © Published 2018. This article is a U.S. Government work and is in the public domain in the USA.

Hospice Use and Pain Management in Elderly Nursing Home Residents With Cancer.

PubMed

Hunnicutt, Jacob N; Tjia, Jennifer; Lapane, Kate L

2017-03-01

Pain management is suboptimal in nursing homes. To estimate the extent to which receipt of hospice in nursing homes (NHs) increases the receipt of pain management for residents with cancer at the end of life. Study participants included Medicare beneficiaries with cancer who were NH residents in the last 90 days of life in 2011-2012 (n = 78,160). Residents in pain on hospice were matched to like residents without hospice by facility, type of pain assessment (self-report/staff assessment), and weeks until death (9064 matched strata, 16,968 unique residents). Minimum Data Set 3.0 provided information on residents' pain prevalence and receipt of pain management (scheduled analgesics, as needed [pro re nata {PRN}] medication, nonpharmacologic interventions). We developed conditional logistic models to estimate the association between hospice use and pain management, stratified by self-reported and staff-assessed pain. We found that pain prevalence was higher in residents using hospice versus those without hospice (e.g., residents who self-reported pain: hospice: 59.9%, 95% CIs = 59.3%-60.5%; nonhospice: 50.0%, 95% CI = 49.4%-50.6%). In matched analyses, untreated pain was uncommon (self-reported pain: 2.9% and 5.6% in hospice users and nonusers, respectively). Hospice use was associated with receipt of scheduled analgesics (self-reported: adjusted odds ratio = 1.85, 95% CI = 1.73-1.971) and PRN medication (self-reported: adjusted odds ratio = 1.31, 95% CI = 1.20-1.43). Pain prevalence and the association between hospice and pain management were similar in residents with staff-assessed pain. Untreated pain at the end of life among residents with cancer in NHs is unusual. Hospice is associated with increased pain management among those with documented pain. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Differences in Presenting Advance Directives in the Chart, in the Minimum Data Set, and through the Staffs Perceptions

ERIC Educational Resources Information Center

Cohen-Mansfield, Jiska; Libin, Alexander; Lipson, Steven

2003-01-01

Purpose: Decisions concerning end-of-life care depend on information contained in advance directives that are documented in residents' charts in the nursing home. The availability of that information depends on the quality of the chart and on the location of the information in the chart. No research was found that compared directives by the manner…

Neglecting the Importance of the Decision Making and Care Regimes of Personal Support Workers: A Critique of Standardization of Care Planning through the RAI/MDS

ERIC Educational Resources Information Center

Kontos, Pia C.; Miller, Karen-Lee; Mitchell, Gail J.

2010-01-01

Purpose: The Resident Assessment Instrument-Minimum Data Set (RAI/MDS) is an interdisciplinary standardized process that informs care plan development in nursing homes. This standardized process has failed to consistently result in individualized care planning, which may suggest problems with content and planning integrity. We examined the…

Career Choice in Academic Medicine: Systematic Review

PubMed Central

Straus, Sharon E; Straus, Christine; Tzanetos, Katina

2006-01-01

OBJECTIVES To review systematically the evidence about what factors influence the decision to choose or not choose a career in academic medicine. DESIGN A systematic review of relevant literature from 1990 to May 2005. DATA SOURCES Searches of The Cochrane Library, Medline (using Ovid and PubMed) from 1990 to May 2005, and EMBASE from 1990 to May 2005 were completed to identify relevant studies that explored the influential factors. Additional articles were identified from searching the bibliographies of retrieved articles. SELECTION OF STUDIES We attempted to identify studies that included residents, fellows, or staff physicians. No restrictions were placed on the study methodologies identified and all articles presenting empirical evidence were retrieved. For cohort, case-control, and cross-sectional studies, minimum inclusion criteria were the presence of defined groups, and the ability to extract relevant data. For surveys that involved case series, minimum inclusion criteria were a description of the population, and the availability of extractable data. Minimum inclusion criteria for qualitative studies were descriptions of the sampling strategy and methods. RESULTS The search identified 251 abstracts; 25 articles were included in this review. Completion of an MD with a graduate degree or fellowship program is associated with a career in academic medicine. Of the articles identified in this review, this finding is supported by the highest quality of evidence. Similarly, the completion of research and publication of this research in medical school and residency are associated with a career in academic medicine. The desire to teach, conduct research, and the intellectual stimulation and challenge provided in academia may also persuade people to choose this career path. The influence of a role model or a mentor was reported by physicians to impact their decision making. Trainees' interest in academic medicine wanes as they progress through their residency. CONCLUSIONS In order to revitalize academic medicine, we must engage trainees and retain their interest throughout their training. Research opportunities for medical students, and fellowships or graduate training can meet this challenge and influence career choice. Initiatives to stimulate and maintain interest in academic medicine should be evaluated in prospective studies across multiple sites. PMID:17105520

Career choice in academic medicine: systematic review.

PubMed

Straus, Sharon E; Straus, Christine; Tzanetos, Katina

2006-12-01

To review systematically the evidence about what factors influence the decision to choose or not choose a career in academic medicine. A systematic review of relevant literature from 1990 to May 2005. Searches of The Cochrane Library, Medline (using Ovid and PubMed) from 1990 to May 2005, and EMBASE from 1990 to May 2005 were completed to identify relevant studies that explored the influential factors. Additional articles were identified from searching the bibliographies of retrieved articles. We attempted to identify studies that included residents, fellows, or staff physicians. No restrictions were placed on the study methodologies identified and all articles presenting empirical evidence were retrieved. For cohort, case-control, and cross-sectional studies, minimum inclusion criteria were the presence of defined groups, and the ability to extract relevant data. For surveys that involved case series, minimum inclusion criteria were a description of the population, and the availability of extractable data. Minimum inclusion criteria for qualitative studies were descriptions of the sampling strategy and methods. The search identified 251 abstracts; 25 articles were included in this review. Completion of an MD with a graduate degree or fellowship program is associated with a career in academic medicine. Of the articles identified in this review, this finding is supported by the highest quality of evidence. Similarly, the completion of research and publication of this research in medical school and residency are associated with a career in academic medicine. The desire to teach, conduct research, and the intellectual stimulation and challenge provided in academia may also persuade people to choose this career path. The influence of a role model or a mentor was reported by physicians to impact their decision making. Trainees' interest in academic medicine wanes as they progress through their residency. In order to revitalize academic medicine, we must engage trainees and retain their interest throughout their training. Research opportunities for medical students, and fellowships or graduate training can meet this challenge and influence career choice. Initiatives to stimulate and maintain interest in academic medicine should be evaluated in prospective studies across multiple sites.

Protected health information on social networking sites: ethical and legal considerations.

PubMed

Thompson, Lindsay A; Black, Erik; Duff, W Patrick; Paradise Black, Nicole; Saliba, Heidi; Dawson, Kara

2011-01-19

Social networking site use is increasingly common among emerging medical professionals, with medical schools even reporting disciplinary student expulsion. Medical professionals who use social networking sites have unique responsibilities since their postings could violate patient privacy. However, it is unknown whether students and residents portray protected health information and under what circumstances or contexts. The objective of our study was to document and describe online portrayals of potential patient privacy violations in the Facebook profiles of medical students and residents. A multidisciplinary team performed two cross-sectional analyses at the University of Florida in 2007 and 2009 of all medical students and residents to see who had Facebook profiles. For each identified profile, we manually scanned the entire profile for any textual or photographic representations of protected health information, such as portrayals of people, names, dates, or descriptions of procedures. Almost half of all eligible students and residents had Facebook profiles (49.8%, or n=1023 out of 2053). There were 12 instances of potential patient violations, in which students and residents posted photographs of care they provided to individuals. No resident or student posted any identifiable patient information or likeness in text form. Each instance occurred in developing countries on apparent medical mission trips. These portrayals increased over time (1 in the 2007 cohort; 11 in 2009; P = .03). Medical students were more likely to have these potential violations on their profiles than residents (11 vs 1, P = .04), and there was no difference by gender. Photographs included trainees interacting with identifiable patients, all children, or performing medical examinations or procedures such as vaccinations of children. While students and residents in this study are posting photographs that are potentially violations of patient privacy, they only seem to make this lapse in the setting of medical mission trips. Trainees need to learn to equate standards of patient privacy in all medical contexts using both legal and ethical arguments to maintain the highest professional principles. We propose three practical guidelines. First, there should be a legal resource for physicians traveling on medical mission trips such as an online list of local laws, or a telephone legal contact. Second, institutions that organize medical mission trips should plan an ethics seminar prior the departure on any trip since the legal and ethical implications may not be intuitive. Finally, at minimum, traveling physicians should apply the strictest legal precedent to any situation.

Protected Health Information on Social Networking Sites: Ethical and Legal Considerations

PubMed Central

2011-01-01

Background Social networking site use is increasingly common among emerging medical professionals, with medical schools even reporting disciplinary student expulsion. Medical professionals who use social networking sites have unique responsibilities since their postings could violate patient privacy. However, it is unknown whether students and residents portray protected health information and under what circumstances or contexts. Objective The objective of our study was to document and describe online portrayals of potential patient privacy violations in the Facebook profiles of medical students and residents. Methods A multidisciplinary team performed two cross-sectional analyses at the University of Florida in 2007 and 2009 of all medical students and residents to see who had Facebook profiles. For each identified profile, we manually scanned the entire profile for any textual or photographic representations of protected health information, such as portrayals of people, names, dates, or descriptions of procedures. Results Almost half of all eligible students and residents had Facebook profiles (49.8%, or n=1023 out of 2053). There were 12 instances of potential patient violations, in which students and residents posted photographs of care they provided to individuals. No resident or student posted any identifiable patient information or likeness in text form. Each instance occurred in developing countries on apparent medical mission trips. These portrayals increased over time (1 in the 2007 cohort; 11 in 2009; P = .03). Medical students were more likely to have these potential violations on their profiles than residents (11 vs 1, P = .04), and there was no difference by gender. Photographs included trainees interacting with identifiable patients, all children, or performing medical examinations or procedures such as vaccinations of children. Conclusions While students and residents in this study are posting photographs that are potentially violations of patient privacy, they only seem to make this lapse in the setting of medical mission trips. Trainees need to learn to equate standards of patient privacy in all medical contexts using both legal and ethical arguments to maintain the highest professional principles. We propose three practical guidelines. First, there should be a legal resource for physicians traveling on medical mission trips such as an online list of local laws, or a telephone legal contact. Second, institutions that organize medical mission trips should plan an ethics seminar prior the departure on any trip since the legal and ethical implications may not be intuitive. Finally, at minimum, traveling physicians should apply the strictest legal precedent to any situation. PMID:21247862

Minimum time and fuel flight profiles for an F-15 airplane with a Highly Integrated Digital Electronic Control (HIDEC) system

NASA Technical Reports Server (NTRS)

Haering, E. A., Jr.; Burcham, F. W., Jr.

1984-01-01

A simulation study was conducted to optimize minimum time and fuel consumption paths for an F-15 airplane powered by two F100 Engine Model Derivative (EMD) engines. The benefits of using variable stall margin (uptrim) to increase performance were also determined. This study supports the NASA Highly Integrated Digital Electronic Control (HIDEC) program. The basis for this comparison was minimum time and fuel used to reach Mach 2 at 13,716 m (45,000 ft) from the initial conditions of Mach 0.15 at 1524 m (5000 ft). Results were also compared to a pilot's estimated minimum time and fuel trajectory determined from the F-15 flight manual and previous experience. The minimum time trajectory took 15 percent less time than the pilot's estimate for the standard EMD engines, while the minimum fuel trajectory used 1 percent less fuel than the pilot's estimate for the minimum fuel trajectory. The F-15 airplane with EMD engines and uptrim, was 23 percent faster than the pilot's estimate. The minimum fuel used was 5 percent less than the estimate.

Bond-selective imaging of deep tissue through the optical window between 1600 and 1850 nm.

PubMed

Wang, Pu; Wang, Han-Wei; Sturek, Michael; Cheng, Ji-Xin

2012-01-01

We report the employment of an optical window between 1600 nm and 1850 nm for bond-selective deep tissue imaging through harmonic vibrational excitation and acoustic detection of resultant pressure waves. In this window where a local minimum of water absorption resides, we found a 5 times enhancement of photoacoustic signal by first overtone excitation of the methylene group CH(2) at 1730 nm, compared to the second overtone excitation at 1210 nm. The enhancement allows 3D mapping of intramuscular fat with improved contrast and of lipid deposition inside an atherosclerotic artery wall in the presence of blood. Moreover, lipid and protein are differentiated based on the first overtone absorption profiles of CH(2) and methyl group CH(3) in this window. Copyright © 2012 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.

Spatial patterns of ecosystem carbon residence time and NPP-driven carbon uptake in the conterminous United States

NASA Astrophysics Data System (ADS)

Zhou, Tao; Luo, Yiqi

2008-09-01

Ecosystem carbon (C) uptake is determined largely by C residence times and increases in net primary production (NPP). Therefore, evaluation of C uptake at a regional scale requires knowledge on spatial patterns of both residence times and NPP increases. In this study, we first applied an inverse modeling method to estimate spatial patterns of C residence times in the conterminous United States. Then we combined the spatial patterns of estimated residence times with a NPP change trend to assess the spatial patterns of regional C uptake in the United States. The inverse analysis was done by using the genetic algorithm and was based on 12 observed data sets of C pools and fluxes. Residence times were estimated by minimizing the total deviation between modeled and observed values. Our results showed that the estimated C residence times were highly heterogeneous over the conterminous United States, with most of the regions having values between 15 and 65 years; and the averaged C residence time was 46 years. The estimated C uptake for the whole conterminous United States was 0.15 P g C a-1. Large portions of the taken C were stored in soil for grassland and cropland (47-70%) but in plant pools for forests and woodlands (73-82%). The proportion of C uptake in soil was found to be determined primarily by C residence times and be independent of the magnitude of NPP increase. Therefore, accurate estimation of spatial patterns of C residence times is crucial for the evaluation of terrestrial ecosystem C uptake.

Production of aluminum--silicon alloy and ferrosilicon and commercial purity aluminum by the direct reduction process. First interim technical report, Phase B, September 1--November 30, 1978

DOE Office of Scientific and Technical Information (OSTI.GOV)

Bruno, M.J.

1978-12-01

The parameters of charge content, reaction temperatures and residence time were studied in a bench reactor concerning the production of Al--Si and Fe--Si alloys. Results confirmed that minimum final stage reaction temperature is 1950 to 2000/sup 0/C. Residence time varied with initial charge concentration. Fe/sub 2/O/sub 3/ additions to the charge produced a significant increase in metallic yield. A burden preparation procedure was developed for making acceptable agglomerates containing Fe/sub 2/O/sub 3/, bauxite, clay and coke. Particle size distribution of starting materials was correlated with agglomerate strength. A new bench scale reactor was designed and built to facilitate semi-continuous operation,more » using O/sub 2/ injection to burn coke supporting the burden, resulting in burden movement. In a number of runs bridging of the burden material occurred due to condensation of volatilized sub-oxides in the cooler zones of the reactor. The reactor operated smoothly as an iron blast furnace at 1500/sup 0/C, demonstrating the validity of the equipment and test procedures. Initial construction of pilot reactor VSR-1 was completed. Bench scale fractional crystallizer runs were continued to determine the impurity effects of Fe up to 6.9% and Ti up to 1.25% on alloy product concentration and yield. High levels of impurities formed intermetallic complexes with Al and reduced product yield.« less

RESIDENCE TIME DISTRIBUTION OF FLUIDS IN STIRRED ANNULAR PHOTOREACTORS

EPA Science Inventory

When gases flow through an annular photoreactor at constant rate, some of the gas spends more or less than the average residence time in the reactor. This spread of residence time can have an important effect on the performance of the reactor. this study tested how the residence...

Positive affect among nursing home residents with Alzheimer's dementia: the effect of recreational activity.

PubMed

Schreiner, A S; Yamamoto, E; Shiotani, H

2005-03-01

The experience of positive emotions is an integral component of quality of life. Research suggests that cognitive deficits in persons with dementia may impede their ability to generate pleasurable moments and hence decrease their positive affect. Therefore, structured recreation activities may have the potential to significantly improve resident affect. However, differences in affect between ordinary time and recreation time are not well known. The present study used previously published structured-observation instruments to measure affect and behaviour among 35 dementia residents at two nursing homes in Japan during ordinary time and during recreation time. A total of 3,854 one-minute observations were coded. Dementia residents expressed happiness over seven times more often during recreation time than during ordinary time. Over 60% of ordinary time was solitary, with 65.72% of all observed affect being 'Null Affect'. A total of 43.75% of residents expressed happiness only during recreation time. In addition 48.9% of all behaviour during 'Ordinary Time' was coded as 'Null Behaviour', which indicated that the resident was sitting and doing nothing. Findings indicate that recreation time is significantly higher in positive affect than ordinary time and that virtually all residents benefited from recreation.

Connections between residence time distributions and watershed characteristics across the continental US

NASA Astrophysics Data System (ADS)

Condon, L. E.; Maxwell, R. M.; Kollet, S. J.; Maher, K.; Haggerty, R.; Forrester, M. M.

2016-12-01

Although previous studies have demonstrated fractal residence time distributions in small watersheds, analyzing residence time scaling over large spatial areas is difficult with existing observational methods. For this study we use a fully integrated groundwater surface water simulation combined with Lagrangian particle tracking to evaluate connections between residence time distributions and watershed characteristics such as geology, topography and climate. Our simulation spans more than six million square kilometers of the continental US, encompassing a broad range of watershed sizes and physiographic settings. Simulated results demonstrate power law residence time distributions with peak age rages from 1.5 to 10.5 years. These ranges agree well with previous observational work and demonstrate the feasibility of using integrated models to simulate residence times. Comparing behavior between eight major watersheds, we show spatial variability in both the peak and the variance of the residence time distributions that can be related to model inputs. Peak age is well correlated with basin averaged hydraulic conductivity and the semi-variance corresponds to aridity. While power law age distributions have previously been attributed to fractal topography, these results illustrate the importance of subsurface characteristics and macro climate as additional controls on groundwater configuration and residence times.

Defining service and education: the first step to developing the correct balance.

PubMed

Reines, H David; Robinson, Linda; Nitzchke, Stephanie; Rizzo, Anne

2007-08-01

Service and education activities have not been well defined or studied. The purpose of this study is to describe how attendings and residents categorize common resident activities on a service-education continuum. A web-based survey was designed to categorize resident activities. A panel of residents and surgical educators reviewed the survey for content validity. Residents and attendings categorized 27 resident activities on a 5-point scale from 1 (pure service) to 5 (pure education). Data analysis was performed using SPSS ver.12. 125 residents and 71 attendings from eight residency programs participated. 66% of residents and 90% of attendings were male. On average, attendings had practiced 14.3 years. Residents' post-graduate year ranged from PGY-1 to PGY-6 (mean of 2.78). Attendings and residents agreed on the categorization of most activities. Residents felt more time should be devoted to pure education than did attendings. Forty percent of residents felt that more than half of their time was spent in pure service versus 10% of attendings. Twenty-five percent of residents and 23% of attendings were dissatisfied with the service-education balance. The Residency Review Committee mandates that education is the central purpose of the surgical residency without clearly defining the balance between education and service. Attendings and residents agree on the educational value of most activities and that the balance between education and service is acceptable. When compared with attendings, residents feel they need significantly more time in education. Adequate learning can be facilitated by the development of clear definitions of service and education and guidelines for the distribution of resident time.

Do mentors matter in graduating pediatrics residents' career choices?

PubMed

Umoren, Rachel A; Frintner, Mary Pat

2014-01-01

Little is known about the association between mentorship and career choice during residency in pediatrics. This study examines graduating residents with mentors who provide career advice and the relationship between having a mentor who is a subspecialist and having a subspecialty practice goal. National, random samples of 1000 graduating pediatrics residents were surveyed each year from 2006 to 2012; 4197 (61%) responded. Responses were pooled across years to examine mentor specialty and career goal at time of residency graduation. Multivariable logistic regression was used to examine relationships between mentor specialty and career goal at the time of graduation. Most (87%) residents reported having a mentor who provided career advice during residency; the proportion linearly increased from 83% in 2006 to 87% in 2012; P < .05. Forty-five percent of those with mentors had a mentor who was a subspecialist; 55% had a generalist as a mentor. Overall, 45% of residents had a subspecialty career goal at time of graduation. After controlling for career goal at the start of residency and resident characteristics, residents with a subspecialist mentor were more likely to have a subspecialty career goal at time of graduation (adjusted odds ratio = 5.25; 95% confidence interval, 4.41-6.25). Residents who were male, without children, without debt, not married, not minority, and from larger residency programs were also more likely to have a subspecialty career goal at the time of graduation from residency. Almost 9 in 10 pediatric residents have a mentor who provides career advice. Although multiple factors shape decisions about careers, mentor specialty is one factor that might encourage residents to pursue fellowship training. Copyright © 2014 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Establishing a community pharmacy residency at an independent pharmacy: Time allocation and valuation.

PubMed

Shugart, Katherine; Bryant, Jason; Kress, Dean; Ziegler, Bryan; Connelly, Lynn; Brittain, Kristy

2015-12-01

The value of a first-year community pharmacy residency program (CPRP) at an independent pharmacy was estimated based on time allocation for resident responsibilities. Predefined time allocation categories for the pharmacy resident were used to consistently classify and document time completing residency activities. Benefit-to-cost ratio was determined by tabulating total costs and total benefits of the residency program. A retrospective-prospective comparison of overall change in revenue, operating expense, and prescription volume was performed between the preresident time period (July 2012 to June 2013) and the postresident time period (July 2013 to June 2014). This comparison accounted for resident activities that did not directly generate revenue. Time allocations for the resident out of 2,221 total hours logged were dispensing (40%), clinical setup (16%), research (8%), professional meetings (7%), clinical activities (5%), resident education (5%), site precepting (4%), residency meetings (4%), didactic teaching (3%), miscellaneous (3%), marketing (2%), training (2%), and public health promotion (1%). Total costs were $77,422, and total benefits were $118,410. The benefit-to-cost ratio was 1.53. The postresident time interval had $172,451 more revenue and $6,622 more in operating expenses than the preresident time interval, and prescription volume decreased by 2,000 prescriptions compared to the previous year. The benefit-to-cost analysis indicated a $1.53 return for every $1.00 invested into a CPRP. An increase in revenue and operating expenses for the pharmacy was observed after implementation of the CPRP compared to the previous year. Copyright © 2015 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Pediatric dermatology training survey of United States dermatology residency programs.

PubMed

Nijhawan, Rajiv I; Mazza, Joni M; Silverberg, Nanette B

2014-01-01

Variability exists in pediatric dermatology education for dermatology residents. We sought to formally assess the pediatric dermatology curriculum and experience in a dermatology residency program. Three unique surveys were developed for dermatology residents, residency program directors, and pediatric dermatology fellowship program directors. The surveys consisted of questions pertaining to residency program characteristics. Sixty-three graduating third-year residents, 51 residency program directors, and 18 pediatric dermatology fellowship program directors responded. Residents in programs with one or more full-time pediatric dermatologist were more likely to feel very competent treating children and were more likely to be somewhat or extremely satisfied with their pediatric curriculums than residents in programs with no full-time pediatric dermatologist (50.0% vs 5.9%, p = 0.002, and 85.3% vs 52.9%, p < 0.001, respectively). Residents in programs with no full-time pediatric dermatologist were the only residents who were somewhat or extremely dissatisfied with their pediatric training. Residency program directors were more satisfied with their curriculums when there was one or more pediatric dermatologist on staff (p < 0.01). Residents in programs with pediatric dermatology fellowships were much more likely to report being extremely satisfied than residents in programs without a pediatric dermatology fellowship (83.3% vs 21.2%; p < 0.001). The results of this survey support the need for dermatology residency programs to continue to strengthen their pediatric dermatology curriculums, especially through the recruitment of full-time pediatric dermatologists. © 2013 Wiley Periodicals, Inc.

[Distribution characteristics of dissolved oxygen and its affecting factors in the Pearl River Estuary during the summer of the extremely drought hydrological year 2011].

PubMed

Ye, Feng; Huang, Xiao-ping; Shi, Zhen; Liu, Qing-xi

2013-05-01

More and more attention has focused on assessing impacts of extreme hydrologic events on estuarine ecosystem under the background of climate change. Based on a summer cruise conducted in the Pearl River Estuary in 2011 (extreme drought event), we have investigated the spatial distribution of dissolved oxygen (DO) and its relationships to water column stability, nutrient concentrations, and organic matter; besides, the major reason which caused the oxygen depletion was discussed. Under the influence of the extreme drought event, low bottom water dissolved oxygen was apparent in regions characterized by great depths, with an oxygen minimum value of 1.38 mg x L(-1). Statistical analysis shows significant correlations among deltaDO, deltaT, deltaS and deltaPOC. A comparison was conducted to show the mechanisms of oxygen depletion during the summers of 1999, 2009 and 2011, respectively. The result indicates that prolonged residence time of water due to the extremely low discharge and the subsequently decomposition of organic substance are major factors causing the formation of hypoxia during the summer drought in 2011. Despite the changing nutrient and organic matter regime in the Pearl River Estuary, there was no apparent trend in the minimum values of DO over the past 2 decades.

A retrospective comparison of clinical outcomes and Medicare expenditures in skilled nursing facility residents with chronic wounds.

PubMed

DaVanzo, Joan E; El-Gamil, Audrey M; Dobson, Allen; Sen, Namrata

2010-09-01

Medicare skilled nursing facility (SNF) residents with chronic wounds require more resources and have relatively high healthcare expenditures compared to Medicare patients without wounds. A retrospective cohort study was conducted using 2006 Medicare Chronic Condition Warehouse claims data for SNF, inpatient, outpatient hospital, and physician supplier settings along with 2006 Long-Term Care Minimum Data Set (MDS) information to compare Medicare expenditures between two groups of SNF residents with a diagnosis of pressure, venous, ischemic, or diabetic ulcers whose wounds healed during the 10-month study period. The study group (n = 372) was managed using a structured, comprehensive wound management protocol provided by an external wound management team. The matched comparison group consisted of 311 SNF residents who did not receive care from the wound management team. Regression analyses indicate that after controlling for resident comorbidities and wound severity, study group residents experienced lower rates of wound-related hospitalization per day (0.08% versus 0.21%, P < 0.01) and shorter wound episodes (94 days versus 115 days, P < 0.01) than comparison group patients. Total Medicare costs were $21,449.64 for the study group and $40,678.83 for the comparison group (P < 0.01) or $229.07 versus $354.26 (P < 0.01) per resident episode day. Additional studies including wounds that do not heal are warranted. Increasing the number of SNF residents receiving the care described in this study could lead to significant Medicare cost savings. Incorporating wound clinical outcomes into a pay-for-performance measures for SNFs could increase broader SNF adoption of comprehensive wound care programs to treat chronic wounds.

Advance Directives among Nursing Home Residents with Mild, Moderate, and Advanced Dementia.

PubMed

Tjia, Jennifer; Dharmawardene, Marisa; Givens, Jane L

2018-01-01

To describe prevalence and content of AD documentation among NH residents by dementia stage. The prevalence of advance directives (ADs) among nursing home (NH) residents with mild, moderate, and advanced dementia remains unclear. Population-based, cross-sectional study of all licensed NHs in five U.S. states. Subjects included all long-stay (>90 day) NH residents with dementia, aged ≥65 years, and a Cognitive Performance Scale (CPS) score ≥1 from the 2007 to 2008 Minimum Data Set 2.0 (n = 180,621). Dementia severity was classified as follows: mild (CPS 1-2), moderate (CPS 3-4), and advanced (CPS 5-6). ADs were defined as the presence of a living will, do-not-resuscitate order, do-not-hospitalize order, medication restriction, or feeding restriction). Overall, 59% of residents had any AD and 17% had a living will. Prevalence of any AD increased by dementia severity: mild (51.2%), moderate (58.2%), and advanced (61.5%) (p < 0.001). In adjusted analysis, resident characteristics associated with any AD documentation included older age, female gender, being white, and having more severe dementia. Having a living will was associated with higher education (≥high school graduate vs. some high school or less) and being married. While dementia severity was associated with greater likelihood of having documented any AD, almost 4 in 10 residents with dementia lacked any AD. Effective outreach may focus efforts on subgroups with lower odds of any AD or living wills, including non-white, less educated, and unmarried NH residents. A greater understanding of how such factors impact care planning will help to address barriers to patient-centered care for this population.

Constructing a Measure of Private-pay Nursing Home Days.

PubMed

Thomas, Kali S; Silver, Benjamin; Gozalo, Pedro L; Dosa, David; Grabowski, David C; Makineni, Rajesh; Mor, Vincent

2018-05-01

Nursing home (NH) care is financed through multiple sources. Although Medicaid is the predominant payer for NH care, over 20% of residents pay out-of-pocket for their care. Despite this large percentage, an accepted measure of private-pay NH occupancy has not been established and little is known about the types of facilities and the long-term care markets that cater to this population. To describe 2 novel measures of private-pay utilization in the NH setting, including the proportion of privately financed residents and resident days, and examine their construct validity. Retrospective descriptive analysis of US NHs in 2007-2009. We used Medicare claims, Medicare Enrollment records, and the Minimum Data Set to create measures of private-pay resident prevalence and proportion of privately financed NH days. We compared our estimates of private-pay utilization to payer data collected in the NH annual certification survey and evaluated the relationships of our measures with facility characteristics. Our measures of private-pay resident prevalence and private-pay days are highly correlated (r=0.83, P<0.001 and r=0.83, P<0.001, respectively) with the rate of "other payer" reported in the annual certification survey. We also observed a significantly higher proportion of private-pay residents and days in higher quality facilities. This new methodology provides estimates of private-pay resident prevalence and resident days. These measures were correlated with estimates using other data sources and validated against measures of facility quality. These data set the stage for additional work to examine questions related to NH payment, quality of care, and responses to changes in the long-term care market.

41 CFR 302-11.5 - To be reimbursed for expenses incurred in my residence transactions, must I occupy the residence...

Code of Federal Regulations, 2010 CFR

2010-07-01

... residence transactions, must I occupy the residence at the time I am notified of my transfer? Yes, to be... expenses incurred in my residence transactions, must I occupy the residence at the time I am notified of my transfer? 302-11.5 Section 302-11.5 Public Contracts and Property Management Federal Travel Regulation...

41 CFR 302-11.5 - To be reimbursed for expenses incurred in my residence transactions, must I occupy the residence...

Code of Federal Regulations, 2013 CFR

2013-07-01

... residence transactions, must I occupy the residence at the time I am notified of my transfer? Yes, to be... expenses incurred in my residence transactions, must I occupy the residence at the time I am notified of my transfer? 302-11.5 Section 302-11.5 Public Contracts and Property Management Federal Travel Regulation...

41 CFR 302-11.5 - To be reimbursed for expenses incurred in my residence transactions, must I occupy the residence...

Code of Federal Regulations, 2014 CFR

2014-07-01

... residence transactions, must I occupy the residence at the time I am notified of my transfer? Yes, to be... expenses incurred in my residence transactions, must I occupy the residence at the time I am notified of my transfer? 302-11.5 Section 302-11.5 Public Contracts and Property Management Federal Travel Regulation...

41 CFR 302-11.5 - To be reimbursed for expenses incurred in my residence transactions, must I occupy the residence...

Code of Federal Regulations, 2012 CFR

2012-07-01

... residence transactions, must I occupy the residence at the time I am notified of my transfer? Yes, to be... expenses incurred in my residence transactions, must I occupy the residence at the time I am notified of my transfer? 302-11.5 Section 302-11.5 Public Contracts and Property Management Federal Travel Regulation...

41 CFR 302-11.5 - To be reimbursed for expenses incurred in my residence transactions, must I occupy the residence...

Code of Federal Regulations, 2011 CFR

2011-07-01

... residence transactions, must I occupy the residence at the time I am notified of my transfer? Yes, to be... expenses incurred in my residence transactions, must I occupy the residence at the time I am notified of my transfer? 302-11.5 Section 302-11.5 Public Contracts and Property Management Federal Travel Regulation...

The Effect of State Medicaid Case-Mix Payment on Nursing Home Resident Acuity

PubMed Central

Feng, Zhanlian; Grabowski, David C; Intrator, Orna; Mor, Vincent

2006-01-01

Objective To examine the relationship between Medicaid case-mix payment and nursing home resident acuity. Data Sources Longitudinal Minimum Data Set (MDS) resident assessments from 1999 to 2002 and Online Survey Certification and Reporting (OSCAR) data from 1996 to 2002, for all freestanding nursing homes in the 48 contiguous U.S. states. Study Design We used a facility fixed-effects model to examine the effect of introducing state case-mix payment on changes in nursing home case-mix acuity. Facility acuity was measured by aggregating the nursing case-mix index (NCMI) from the MDS using the Resource Utilization Group (Version III) resident classification system, separately for new admits and long-stay residents, and by an OSCAR-derived index combining a range of activity of daily living dependencies and special treatment measures. Data Collection/Extraction Methods We followed facilities over the study period to create a longitudinal data file based on the MDS and OSCAR, respectively, and linked facilities with longitudinal data on state case-mix payment policies for the same period. Principal Findings Across three acuity measures and two data sources, we found that states shifting to case-mix payment increased nursing home acuity levels over the study period. Specifically, we observed a 2.5 percent increase in the average acuity of new admits and a 1.3 to 1.4 percent increase in the acuity of long-stay residents, following the introduction of case-mix payment. Conclusions The adoption of case-mix payment increased access to care for higher acuity Medicaid residents. PMID:16899009

Application of behavior-based ergonomics therapies to improve quality of life and reduce medication usage for Alzheimer's/dementia residents.

PubMed

Mowrey, Corinne; Parikh, Pratik J; Bharwani, Govind; Bharwani, Meena

2013-02-01

Behavior-based ergonomics therapy (BBET) has been proposed in the past as a viable individualized non-pharmacological intervention to manage challenging behaviors and promote engagement among long-term care residents diagnosed with Alzheimer's/dementia. We evaluate the effect of BBET on quality of life and behavioral medication usage in an 18-bed dementia care unit at a not-for-profit continuing care retirement community in West Central Ohio. Comparing a target cohort during the 6-month pre-implementation period with the 6-month post-implementation period, our study indicates that BBET appears to have a positive impact on the resident's quality of life and also appears to correlate with behavioral medical reduction. For instance, the number of days with behavioral episodes decreased by 53%, the total Minimum Data Set (MDS) mood counts decreased by 70%, and the total MDS behavior counts decreased by 65%. From a medication usage standpoint, the number of pro re nata (PRN) Ativan doses decreased by 57%.

Residence time control on hot moments of net nitrate production and uptake in the hyporheic zone

USGS Publications Warehouse

Briggs, Martin A.; Lautz, Laura K.; Hare, Danielle K.

2014-01-01

moments of net production and uptake, enhancing NO3- production as residence times approach the anaerobic threshold, and changing zones of net NO3- production to uptake as residence times increase past the net sink threshold. The anaerobic and net sink thresholds for beaver-influenced streambed morphology occur at much shorter residence times (1.3 h and 2.3 h, respectively) compared to other documented hyporheic systems, and the net sink threshold compares favorably to the lower boundary of the anaerobic threshold determined for this system with the new oxygen Damkohler number. The consistency of the residence time threshold values of NO3- cycling in this study, despite environmental variability and disparate morphology, indicates that NO3- hot moment dynamics are primarily driven by changes in physical hydrology and associated residence times.

The Residence Time of Water in the Atmosphere Revisited

NASA Astrophysics Data System (ADS)

van der Ent, Ruud; Tuinenburg, Obbe

2017-04-01

This paper revisits the knowledge on the residence time of water in the atmosphere. Based on state-of-the-art data of the hydrological cycle we derive a global average residence time of 8.9±0.4 days (uncertainty given as one standard deviation). We use two different atmospheric moisture tracking models (WAM-2layers and 3D-Trajectories) to obtain atmospheric residence time characteristics in time and space. The tracking models estimate the global average residence time to be around 8.5 days based on ERA-Interim data. We conclude that the statement of a recent study that the global average residence time of water in the atmosphere is 4-5 days, is not correct. We derive spatial maps of residence time, attributed to evaporation and precipitation, and age of atmospheric water, showing that there are different ways of looking at temporal characteristics of atmospheric water. Longer evaporation residence times often indicate larger distances towards areas of high precipitation. From our analysis we find that the residence time over the ocean is about 2 days lower than over land. It can be seen that in winter, the age of atmospheric moisture tends to be much lower than in summer. On the Northern Hemisphere, due to the contrast in ocean-to-land temperature and associated evaporation rates, the age of atmospheric moisture increases following atmospheric moisture flow inland in winter, and decreases in summer. Looking at the probability density functions of atmospheric residence time for precipitation and evaporation we find long-tailed distributions with the median around 5 days. Overall, our research confirms the 8-10 days traditional estimate for the global mean residence time of atmospheric water, and our research contributes to a more complete view on the characteristics of the turnover of water in the atmosphere in time and space. In the light of this session, our results show that the turnover of water is relatively fast, but water travels quite far, which explains why it is so hard to make both weather and hydrological predictions on time spans longer than a week.

Multi-institutional study of self-reported attitudes and behaviors of general surgery residents about ethical academic practices in test taking.

PubMed

Grignol, Valerie P; Grannan, Kevin; Sabra, John; Cromer, Robert M; Jarman, Benjamin; Dent, Daniel; Sticca, Robert P; Nelson, Timothy M; Kukora, John S; Daley, Brian J; Treat, Robert W; Termuhlen, Paula M

2013-01-01

Correlation exists between people who engage in academic dishonesty as students and unethical behavior once in practice. Previously, we assessed the attitudes of general surgery residents and ethical practices in test taking at a single institution. Most residents had not participated in activities they felt were unethical, yet what constituted unethical behavior was unclear. We sought to verify these results in a multi-institutional study. A scenario-based survey describing potentially unethical activities related to the American Board of Surgery In-training Examination (ABSITE) was administered. Participants were asked about their knowledge of or participation in the activities and whether the activity was unethical. Program directors were surveyed about the use of ABSITE results for resident evaluation and promotion. Ten programs participated in the study. The resident response rate was 67% (186/277). Of the respondents, 43% felt that memorizing questions to study for future examinations was unethical and 50% felt that using questions another resident memorized was unethical. Most felt that buying (86%) or selling (79%) questions was unethical. Significantly more senior than junior residents have memorized (30% vs 16%; p = 0.04) or used questions others memorized (33% vs 12%; p = 0.002) to study for future ABSITE examinations and know of other residents who have done so (42% vs 20%; p = 0.004). Most programs used results of the ABSITE in promotion (80%) and set minimum score expectations and consequences (70%). Similar to our single-institution study, residents had not participated in activities they felt to be unethical; however the definition of what constitutes cheating remains unclear. Differences were identified between senior and junior residents with regard to memorizing questions for study. Cheating and unethical behavior is not always clear to the learner and represents an area for further education. © 2013 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Anesthesia residents' global (departmental) evaluation of faculty anesthesiologists' supervision can be less than their average evaluations of individual anesthesiologists.

PubMed

Hindman, Bradley J; Dexter, Franklin; Smith, Thomas C

2015-01-01

Faculty anesthesiologists' supervision of anesthesiology residents is required for both postgraduate medical education and billing compliance. Previously, using the de Oliveira Filho et al. supervision question set, De Oliveira et al. found that residents who reported mean department-wide supervision scores <3.0 ("frequent") reported a significantly more frequent occurrence of mistakes with negative consequences to patients, as well as medication errors. In our department, residents provide daily evaluations of the supervision received by individual faculty. Using a survey study, we compared relationships between residents' daily supervision scores for individual faculty anesthesiologists and residents' supervision scores for the entire department (comprised these faculty). We studied all anesthesiology residents in clinical years 1, 2, and 3 (i.e., neither in the "base year" nor in fellowship). There were daily evaluations of individual faculty supervision of operative anesthesia for 36 weeks. Residents clicked a hyperlink on the invitation e-mail taking them to a secure Web page to provide their global (departmental) assessment of faculty supervision. We calculated the ratio of each resident's global (departmental) faculty supervision score (i.e., mean among 9 questions × 1 evaluation) to the same resident's daily evaluations of individual faculty (i.e., mean among 9 questions × many evaluations). All 39 of 39 residents chose to participate. The mean departmental supervision score was significantly less (P < 0.0001) than the mean of individual faculty scores. The median ratio of scores was 86% (95% confidence interval, 83%-89%). Kendall's rank correlation between global and (mean) individual faculty scores was τb = 0.34 ± 0.11 (P = 0.0032). The ratios were uniformly distributed (P = 0.64) between the observed minimums and maximums; were not correlated with the mean value of individual faculty scores previously provided by each resident (P = 0.64); were not correlated with the number of individual faculty evaluations previously provided by each resident (P = 0.49); and did not differ among the first, second, or third year residents (P = 0.37). Residents' perceptions of overall (departmental) faculty supervision were less than overall averages of their perceptions of individual faculty supervision. This should be considered when interpreting national survey results (e.g., of patient safety), residency program evaluations, and individual faculty anesthesiologist performance.

Risk Factors, Clinical Characteristics, and Treatment Differences Between Residents With and Without Nursing Home- and Non-Nursing Home-Acquired Clostridium difficile Infection.

PubMed

Zarowitz, Barbara J; Allen, Carrie; O'Shea, Terrence; Strauss, Marcie E

2015-07-01

The incidence of Clostridium difficile infection (CDI) in nursing home residents is believed to be high because of the prevalence of predisposing factors such as decreased immune response, multiple comorbidities, medications, increased risk of infection, close proximity of residents, and recent hospitalization. Yet, specific information on CDI in this population is scarce.  To investigate differences in clinical and demographic characteristics, treatment, and underlying comorbidities in residents who acquired CDI preadmission (non-nursing home-acquired [NNH-Acquired]) compared with those who acquired CDI after admission to a nursing home (nursing home-acquired [NH-Acquired]) and matched controls. We conducted a retrospective case-control study of CDI in nursing home residents with a cross-sectional and longitudinal aspect of linked and de-identified pharmacy claims and Minimum Data Set data (MDS) 2.0 records from October 1, 2009, to September 30, 2010. The control group was frequency matched 1:1 for gender, race, and age range to residents with CDI.  Of 195,498 residents, 5,044 (2.6%) had a diagnosis of CDI. Compared with controls, CDI patients had less severe cognitive impairment (P  less than  0.01) and more severe functional impairment (P  less than  0.01), incontinence (P  less than  0.01), and diarrhea (P  less than  0.01). They were more likely to (a) have diabetes, stroke, heart failure, cancer, renal failure, and infections; (b) be treated with antibiotics, corticosteroids, megestrol, and proton pump inhibitors; and (c) be discharged to the hospital (29.3% vs. 14.7%, P = 0.001) than controls. NNH-Acquired CDI was 3 times more prevalent than NH-Acquired CDI. Most residents with NNH-Acquired CDI (85.0%) came from acute care hospitals and were more likely to have heart disease, cancer, and infections, while those with NH-Acquired CDI tended to have more cognitive impairment, reliance on staff for activities of daily living, incontinence, and stroke. Thirty-day retreatment rates for NH-Acquired CDI and NNH-Acquired CDI with metronidazole were 72.7% and 68.4%, and with vancomycin were 83.9% and 69.3%, respectively. The facility (Medicare Part A) was the payer for 93.6% of NNH-Acquired CDI and 75% of NH-Acquired CDI treatment; Medicare Part D was the prevalent secondary payer for NNH-Aquired CDI (19.4%) and NH-Acquired CDI (37.5%). Residents with CDI had more comorbidities, and the NNH-Acquired group bore a higher burden of illness, resulting in differing treatment patterns and outcomes than the NH-Acquired CDI group.

Racial and ethnic comparisons of nursing home residents at admission.

PubMed

Buchanan, Robert J; Rosenthal, Mark; Graber, David R; Wang, Suojin; Kim, Myung Suk

2008-10-01

To present racial/ethnic comparisons of comprehensive profiles of nursing home residents at admission, including whites, African Americans, Hispanics, Asians/Pacific Islanders, and American Indians/Alaska Natives. More than 885,000 admission assessments recorded in the national Minimum Data Set (MDS) were analyzed. Racial and ethnic analyses of the MDS admission assessments were conducted using the software package SAS. There were significant racial/ethnic differences in gender and age, with minority residents more likely to be male and younger. African American, Hispanic, and Asian/Pacific Islanders were significantly more likely than white residents to exhibit total dependence in the self-performance of the ADLs and to have greater cognitive impairments, with Asian/Pacific Islanders the most physically dependent and cognitively impaired. The results illustrate significant and substantive differences among the racial/ethnic groups for many demographic characteristics, as well as health-related indicators and conditions. This analysis suggests that the general perspective that economically disadvantaged minorities enter nursing homes in worse condition than whites is too simplistic. More research, particularly qualitative studies of specific minority groups, will advance our understanding of why members of some racial/ethnic groups require nursing home placement sooner than other groups.

A primer on medical education in the United States through the lens of a current resident physician.

PubMed

Mowery, Yvonne M

2015-10-01

Physician training and standards for medical licensure differ widely across the globe. The medical education process in the United States (US) typically involves a minimum of 11 years of formal training and multiple standardized examinations between graduating from secondary school and becoming an attending physician with full medical licensure. Students in the US traditionally enter a 4-year medical school after completing an undergraduate bachelor's degree, in contrast to most other countries where medical training begins after graduation from high school. Medical school seniors planning to practice medicine in the US must complete postgraduate clinical training, referred to as residency, within the specialty of their choosing. The duration of residency varies depending on specialty, typically lasting between 3 and 7 years. For subspecialty fields, additional clinical training is often required in the form of a fellowship. Many experts have called for changes in the medical education system to shorten medical training in the US, and reforms are ongoing in some institutions. However, physician education in the US generally remains a progression from undergraduate premedical coursework to 4 years of medical school, followed by residency training with an optional subspecialty fellowship.

A primer on medical education in the United States through the lens of a current resident physician

PubMed Central

2015-01-01

Physician training and standards for medical licensure differ widely across the globe. The medical education process in the United States (US) typically involves a minimum of 11 years of formal training and multiple standardized examinations between graduating from secondary school and becoming an attending physician with full medical licensure. Students in the US traditionally enter a 4-year medical school after completing an undergraduate bachelor’s degree, in contrast to most other countries where medical training begins after graduation from high school. Medical school seniors planning to practice medicine in the US must complete postgraduate clinical training, referred to as residency, within the specialty of their choosing. The duration of residency varies depending on specialty, typically lasting between 3 and 7 years. For subspecialty fields, additional clinical training is often required in the form of a fellowship. Many experts have called for changes in the medical education system to shorten medical training in the US, and reforms are ongoing in some institutions. However, physician education in the US generally remains a progression from undergraduate premedical coursework to 4 years of medical school, followed by residency training with an optional subspecialty fellowship. PMID:26623123

A primer on medical education in the United States through the lens of a current resident physician

PubMed Central

2015-01-01

Physician training and standards for medical licensure differ widely across the globe. The medical education process in the United States (US) typically involves a minimum of 11 years of formal training and multiple standardized examinations between graduating from secondary school and becoming an attending physician with full medical licensure. Students in the US traditionally enter a 4-year medical school after completing an undergraduate bachelor’s degree, in contrast to most other countries where medical training begins after graduation from high school. Medical school seniors planning to practice medicine in the US must complete postgraduate clinical training, referred to as residency, within the specialty of their choosing. The duration of residency varies depending on specialty, typically lasting between 3 and 7 years. For subspecialty fields, additional clinical training is often required in the form of a fellowship. Many experts have called for changes in the medical education system to shorten medical training in the US, and reforms are ongoing in some institutions. However, physician education in the US generally remains a progression from undergraduate premedical coursework to 4 years of medical school, followed by residency training with an optional subspecialty fellowship. PMID:26605316

Effects of zebra mussels on food webs: Interactions with juvenile bluegill and water residence time

USGS Publications Warehouse

Richardson, W.B.; Bartsch, L.A.

1997-01-01

We evaluated how water residence time mediated the impact of zebra mussels Dreissena polymorpha and bluegill sunfish Lepomis macrochirus on experimental food webs established in 1100-1 outdoor mesocosms. Water residence time was manipulated as a surrogate for seston resupply - a critical variable affecting growth and survival of suspension-feeding invertebrates. We used a 2 x 2 x 2 factorial experimental design with eight treatment combinations (3 replicates/treatment) including the presence or absence of Dreissena (2000 per m2), juvenile bluegill (40 per mesocosm), and short (1100 1 per d) or long (220 1 per d) water residence time. Measures of seston concentration (chlorophyll a, turbidity and suspended solids) were greater in the short- compared to long water-residence mesocosms, but intermediate in short water-residence mesocosms containing Dreissena. Abundance of rotifers (Keratella and Polyarthra) was reduced in Dreissena mesocosms and elevated in short residence time mesocosms. Cladocera abundance, in general, was unaffected by the presence of Dreissena; densities were higher in short-residence time mesocosms, and reduced in the presence of Lepomis. The growth of juvenile Lepomis were unaffected by Dreissena because of abundant benthic food. The final total mass of Dreissena was significantly greater in short- than long-residence mesocosms. Impacts of Dreissena on planktonic food webs may not only depend on the density of zebra mussels but also on the residence time of the surrounding water and the resupply of seston. ?? 1997 Kluwer Academic Publishers.

Staged fluidized bed

DOEpatents

Mallon, Richard G.

1984-01-01

Method and apparatus for narrowing the distribution of residence times of any size particle and equalizing the residence times of large and small particles in fluidized beds. Particles are moved up one fluidized column and down a second fluidized column with the relative heights selected to equalize residence times of large and small particles. Additional pairs of columns are staged to narrow the distribution of residence times and provide complete processing of the material.

DNA residence time is a regulatory factor of transcription repression

PubMed Central

Clauß, Karen; Popp, Achim P.; Schulze, Lena; Hettich, Johannes; Reisser, Matthias; Escoter Torres, Laura; Uhlenhaut, N. Henriette

2017-01-01

Abstract Transcription comprises a highly regulated sequence of intrinsically stochastic processes, resulting in bursts of transcription intermitted by quiescence. In transcription activation or repression, a transcription factor binds dynamically to DNA, with a residence time unique to each factor. Whether the DNA residence time is important in the transcription process is unclear. Here, we designed a series of transcription repressors differing in their DNA residence time by utilizing the modular DNA binding domain of transcription activator-like effectors (TALEs) and varying the number of nucleotide-recognizing repeat domains. We characterized the DNA residence times of our repressors in living cells using single molecule tracking. The residence times depended non-linearly on the number of repeat domains and differed by more than a factor of six. The factors provoked a residence time-dependent decrease in transcript level of the glucocorticoid receptor-activated gene SGK1. Down regulation of transcription was due to a lower burst frequency in the presence of long binding repressors and is in accordance with a model of competitive inhibition of endogenous activator binding. Our single molecule experiments reveal transcription factor DNA residence time as a regulatory factor controlling transcription repression and establish TALE-DNA binding domains as tools for the temporal dissection of transcription regulation. PMID:28977492

Comparing Budget-based and Tracer-based Residence Times in Butte Basin, California

NASA Astrophysics Data System (ADS)

Moran, J. E.; Visser, A.; Esser, B.; Buck, C.

2017-12-01

The California Sustainable Groundwater Management Act of 2014 (SGMA) calls for basin-scale Groundwater Sustainability Plans (GSPs) that include a water budget covering a 50 year planning horizon. A nine layer, Integrated Water Flow Model (IWFM) developed for Butte Basin, California, allows examination of water budgets within 36 sub-regions having varying land and water use, to inform SGMA efforts. Detailed land use, soil type, groundwater pumping, and surface water delivery data were applied in the finite element IWFM calibration. In a sustainable system, the volume of storage does not change over a defined time period, and the residence time can be calculated from the water storage volume divided by the flux (recharge or discharge rate). Groundwater ages based on environmental tracer data reflect the mean residence time of groundwater, or its inverse, the turnover rate. Comparisons between budget-based residence times determined from storage and flux, and residence times determined from isotopic tracers of groundwater age, can provide insight into data quality, model reliability, and system sustainability. Budget-based groundwater residence times were calculated from IWFM model output by assuming constant storage and dividing by either averaged annual net recharge or discharge. Calculated residence times range between approximately 100 and 1000 years, with shorter times in subregions where pumping dominates discharge. Independently, 174 wells within the model boundaries were analyzed for tritium-helium groundwater age as part of the California Groundwater Ambient Monitoring and Assessment program. Age distributions from isotopic tracers were compared to model-derived groundwater residence times from groundwater budgets within the subregions of Butte Basin. Mean, apparent, tracer-based residence times are mostly between 20 and 40 years, but 25% of the long-screened wells that were sampled do not have detectable tritium, indicating residence times of more than about 60 years and broad age distributions. A key factor in making meaningful comparisons is to examine budget-based and tracer-based results over transmissive vertical sections, where pumping increases turnover time.

Nonideality in diffusion of ionic and hydrophobic solutes and pair dynamics in water-acetone mixtures of varying composition.

PubMed

Gupta, Rini; Chandra, Amalendu

2007-07-14

We have performed a series of molecular dynamics simulations of water-acetone mixtures containing either an ionic solute or a neutral hydrophobic solute to study the extent of nonideality in the dynamics of these solutes with variation of composition of the mixtures. The diffusion coefficients of the charged solutes, both cationic and anionic, are found to change nonmonotonically with the composition of the mixtures showing strong nonideality of their dynamics. Also, the extent of nonideality in the diffusion of these charged solutes is found to be similar to the nonideality that is observed for the diffusion and orientational relaxation of water and acetone molecules in these mixtures which show a somewhat similar changes in the solvation characteristics of charged and dipolar solutes with changes of composition of water-acetone mixtures. The diffusion of the hydrophobic solute, however, shows a monotonic increase with increase of acetone concentration showing its different solvation characteristics as compared to the charged and dipolar solutes. The links between the nonideality in diffusion and solvation structures are further confirmed through calculations of the relevant solute-solvent and solvent-solvent radial distribution functions for both ionic and hydrophobic solutes. We have also calculated various pair dynamical properties such as the relaxation of water-water and acetone-water hydrogen bonds and residence dynamics of water molecules in water and acetone hydration shells. The lifetimes of both water-water and acetone-water hydrogen bonds and also the residence times of water molecules are found to increase steadily with increase in acetone concentration. No maximum or minimum was found in the composition dependence of these pair dynamical quantities. The lifetimes of water-water hydrogen bonds are always found to be longer than that of acetone-water hydrogen bonds in these mixtures. The residence times of water molecules are also found to follow a similar trend.

Nursing home case-mix reimbursement in Mississippi and South Dakota.

PubMed

Arling, Greg; Daneman, Barry

2002-04-01

To evaluate the effects of nursing home case-mix reimbursement on facility case mix and costs in Mississippi and South Dakota. Secondary data from resident assessments and Medicaid cost reports from 154 Mississippi and 107 South Dakota nursing facilities in 1992 and 1994, before and after implementation of new case-mix reimbursement systems. The study relied on a two-wave panel design to examine case mix (resident acuity) and direct care costs in 1-year periods before and after implementation of a nursing home case-mix reimbursement system. Cross-lagged regression models were used to assess change in case mix and costs between periods while taking into account facility characteristics. Facility-level measures were constructed from Medicaid cost reports and Minimum Data Set-Plus assessment records supplied by each state. Resident case mix was based on the RUG-III classification system. Facility case-mix scores and direct care costs increased significantly between periods in both states. Changes in facility costs and case mix were significantly related in a positive direction. Medicare utilization and the rate of hospitalizations from the nursing facility also increased significantly between periods, particularly in Mississippi. The case-mix reimbursement systems appeared to achieve their intended goals: improved access for heavy-care residents and increased direct care expenditures in facilities with higher acuity residents. However, increases in Medicare utilization may have influenced facility case mix or costs, and some facilities may have been unprepared to care for higher acuity residents, as indicated by increased rates of hospitalization.

Perspective: limiting resident work hours is a moral concern.

PubMed

Higginson, Jason D

2009-03-01

The author outlines the cross-cultural and widespread expectation that the moral character of physicians is built on dual possession of skill and compassion. The details of the moral makeup of physicians are often hotly debated in the biomedical literature. Despite a lack of consensus regarding the required aspects of character, the author demonstrates that little debate exists that at a minimum physicians should possess not only knowledge but also a willingness to care for and comfort patients. The primacy of the patient in the physician's life is reflected in the panoply of oaths taken by new physicians despite great variability in other aspects of these oaths. The author details recent worrisome reports demonstrating the erosion of medical trainees' empathy and compassion by long work hours. Further, the continued linkage of these attitude changes and fatigue to poor medical outcomes is a call to action. Changes enacted by the Accreditation Council for Graduate Medical Education to reduce resident work hours are insufficient to achieve the goal of improved patient care while promoting moral development among resident physicians. The debate regarding resident work hours is often framed as an idealistic discussion of placing patients first. However, residents are used as an inexpensive labor force, and efforts to curtail this usage would have a significant economic impact. Economic concerns play a larger part in decision making than is generally discussed. The author calls for further alterations of resident work schedules to improve patient care and ensure the preservation of the moral ethos of medicine.

Vitamin D and plain type: a study of male patients with schizophrenia

NASA Astrophysics Data System (ADS)

Akbar, N. L.; Effendy, E.; Amin, MM

2018-03-01

Schizophrenia is a heterogeneous disorder in which there is an interaction between genetic and environmental factors. Evidence related to vitamin D deficiency and schizophrenia is aresidence. Because influenced by geographical location this can affect sun exposure to individuals living in the area because the source of vitamin D for humans is exposure to sunlight. For determining differences in serum levels of vitamin D based on residence in the highland and lowland male schizophrenic patient. This study was an analytical study, by RS Jiwa Prof. dr. M. Ildrem Medan, approach to see the comparison 60 samples (30 patients live in the Highland and Lowland). Sample inspection for serum vitamin D using ELFA method. The results showed median levels of vitamin D subjects living in high land Tanah Karo was 22.20ng/mL with minimum-maximum levels of 19.3-34.5ng/mL and in the low land Pemko Medan vitamin D levels higher with median 27.95ng/mL with the minimum-maximum level of vitamin D 20.4-42.6ng/mL. Analysis using the Mann Whitney U test showed significant differences between the levels of vitamin D based on residence with a value of p = 0.001.

Using soil residence time to delineate spatial and temporal patterns of transient landscape response

NASA Astrophysics Data System (ADS)

Almond, Peter; Roering, Josh; Hales, T. C.

2007-09-01

On hillslopes the balance between soil transport and production determines local soil thickness and the age distribution of particles that comprise the soil (where age refers to the time elapsed since detachment from bedrock). The mean of this age distribution is defined as the residence time, and in a landscape with time-invariant topography (i.e., morphologic steady state), the spatial uniformity of soil production ensures that the residence time of soils is spatially invariant. Thus, given constant soil-forming factors, spatial variation of soil properties reflects differences in residence time driven by nonuniform soil production. Spatially extensive soil databases, which are often freely available in electronic form, provide a cheap and accessible means of analyzing patterns of soil residence time and quantifying landscape dynamics. Here we use a soil chronosequence to calibrate a chronofunction describing the reddening of soils in the Oregon Coast Range, which is then used to quantify the spatial distribution of soil residence time. In contrast to the popular conception that the Oregon Coast Range experiences uniform erosion, we observe systematic variations in soil residence time driven by stream capture, deep-seated landsliding, and lateral channel migration. Large, contiguous areas with short residence time soils (hue 10YR) occur west of the Siuslaw River-Long Tom Creek drainage divide, whereas soil patches with redder hues of 7.5YR or 5YR indicate longer residence times and transient landscape conditions. These zones of red soils (5YR) occur east of the Siuslaw-Long Tom divide, coinciding with low-gradient ridge and valley topography and deeply alluviated valleys resulting from drainage reversal in the Quaternary. Patches of red soils are also associated with deep-seated landslides at various locations in our study area. Our calculated soil residence times appear subject to overestimation resulting from limitations of the simple weathering index used here and chronofunction calibration uncertainties. Nonetheless, our soil residence time estimates appear accurate to within an order of magnitude and provide a useful constraint on landscape dynamics over geomorphic timescales.

General surgery training without laparoscopic surgery fellows: the impact on residents and patients.

PubMed

Linn, John G; Hungness, Eric S; Clark, Sara; Nagle, Alexander P; Wang, Edward; Soper, Nathaniel J

2011-10-01

To evaluate resident case volume after discontinuation of a laparoscopic surgery fellowship, and to examine disparities in patient care over the same time period. Resident case logs were compared for a 2-year period before and 1 year after discontinuing the fellowship, using a 2-sample t test. Databases for bariatric and esophageal surgery were reviewed to compare operative time, length of stay (LOS), and complication rate by resident or fellow over the same time period using a 2-sample t test. Increases were seen in senior resident advanced laparoscopic (Mean Fellow Year = 21 operations vs Non Fellow Year = 61, P < 0.01), esophageal (1 vs 11, P < .01) and bariatric volume (9 vs 36, P < .01). Junior resident laparoscopic volume increased (P < 0.05). No difference in LOS or complication rate was seen with resident vs fellow assistant. Operative time was greater for gastric bypass with resident assistant (152 ± 51 minutes vs 138 ± 53, P < .05). Discontinuing a laparoscopic fellowship significantly increases resident case volume in laparoscopic surgery. Operative time for complex operations may increase in the absence of a fellow. Other patient outcomes are not affected by this change. Copyright © 2011 Mosby, Inc. All rights reserved.

Representation in the Care Planning Process for Nursing Home Residents With Dementia.

PubMed

McCreedy, Ellen; Loomer, Lacey; Palmer, Jennifer A; Mitchell, Susan L; Volandes, Angelo; Mor, Vincent

2018-05-01

Federally mandated assessments of nursing home (NH) residents drive individualized care planning. Residents with cognitive impairment may not be able to meaningfully communicate their care needs and preferences during this process-a gap that may be partially addressed by involving surrogates. We describe the prevalence of family participation in the care planning process for long-stay NH residents with varying degrees of cognitive impairment. Retrospective study using administrative data made available as part of an ongoing pragmatic cluster randomized controlled trial. A total of 292 NHs from 1 large for-profit NH system. Long-stay NH residents in 2016. We identified all care planning assessments conducted in 2016 for long-stay NH residents. Cognitive functioning was defined using the Cognitive Function Scale. The Minimum Data Set was used to determine whether a resident, family member, and/or legal guardian participated in the assessment process. Certification and Survey Provider Enhance Reporting system data was used to identify facility-level correlates of family participation. Bivariate and multivariable hierarchical regression results are presented. The analytic sample included 18,552 long-stay NH residents. Family member/representative participation varied by degree of resident cognitive impairment; 8% of residents with no cognitive impairment had family or representative participation in care planning during 2016, compared with 26% of residents with severe impairment. NHs with more social workers had greater family participation in care planning. Available NH characteristics do not explain most of the variation in family participation between NHs (residual intraclass correlation = .57). Only a minority of family members and surrogates participate in NH care planning, even for residents with severe cognitive impairment. The association between social work staffing and participation suggests family involvement may be a measure of quality improvement capacity. Our findings suggest a lack of voice for a vulnerable population that may have implications on the quality of care received at the end of life. Copyright © 2018 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Decision support using anesthesia information management system records and accreditation council for graduate medical education case logs for resident operating room assignments.

PubMed

Wanderer, Jonathan P; Charnin, Jonathan; Driscoll, William D; Bailin, Michael T; Baker, Keith

2013-08-01

Our goal in this study was to develop decision support systems for resident operating room (OR) assignments using anesthesia information management system (AIMS) records and Accreditation Council for Graduate Medical Education (ACGME) case logs and evaluate the implementations. We developed 2 Web-based systems: an ACGME case-log visualization tool, and Residents Helping in Navigating OR Scheduling (Rhinos), an interactive system that solicits OR assignment requests from residents and creates resident profiles. Resident profiles are snapshots of the cases and procedures each resident has done and were derived from AIMS records and ACGME case logs. A Rhinos pilot was performed for 6 weeks on 2 clinical services. One hundred sixty-five requests were entered and used in OR assignment decisions by a single attending anesthesiologist. Each request consisted of a rank ordered list of up to 3 ORs. Residents had access to detailed information about these cases including surgeon and patient name, age, procedure type, and admission status. Success rates at matching resident requests were determined by comparing requests with AIMS records. Of the 165 requests, 87 first-choice matches (52.7%), 27 second-choice matches (16.4%), and 8 third-choice matches (4.8%) were made. Forty-three requests were unmatched (26.1%). Thirty-nine first-choice requests overlapped (23.6%). Full implementation followed on 8 clinical services for 8 weeks. Seven hundred fifty-four requests were reviewed by 15 attending anesthesiologists, with 339 first-choice matches (45.0%), 122 second-choice matches (16.2%), 55 third-choice matches (7.3%), and 238 unmatched (31.5%). There were 279 overlapping first-choice requests (37.0%). The overall combined match success rate was 69.4%. Separately, we developed an ACGME case-log visualization tool that allows individual resident experiences to be compared against case minimums as well as resident peer groups. We conclude that it is feasible to use ACGME case-log data in decision support systems for informing resident OR assignments. Additional analysis will be necessary to assess the educational impact of these systems.

Measurement of nitrous acid (HONO) by external-cavity quantum cascade laser based quartz-enhanced photoacoustic absorption spectroscopy

NASA Astrophysics Data System (ADS)

Yi, Hongming; Maamary, Rabih; Gao, Xiaoming; Sigrist, Markus W.; Fertein, Eric; Chen, Weidong

2016-04-01

Spectroscopic detection of short-lived gaseous nitrous acid (HONO) at 1254.85 cm-1 was realized by off-beam coupled quartz-enhanced photoacoustic spectroscopy (QEPAS) in conjunction with an external cavity quantum cascade lasers (EC-QCL). High sensitivity monitoring of HONO was performed within a very small gas-sample volume (of ~40 mm3) allowing a significant reduction (of about 4 orders of magnitude) of air sampling residence time which is highly desired for accurate quantification of chemically reactive short-lived species. Calibration of the developed QEPAS-based HONO sensor was carried out by means of lab-generated HONO samples whose concentrations were determined by simultaneous measurements of direct HONO absorption spectra in a 109.5 m multipass cell using a distributed feedback (DBF) QCL. A minimum detection limit (MDL @ SNR=1) of 66 ppbv HONO was achieved at 70 mbar using a laser output power of 50 mW and 1 s integration time, which corresponded to a normalized noise equivalent absorption coefficient of 3.6×10-8 cm-1.W/Hz1/2. This MDL was down to 7 ppbv at the optimal integration time of 150 s. The corresponding minimum detected absorption coefficient (SNR=1) is ~1.1×10-7 cm-1 (MDL: ~3 ppbv) in 1 s and ~1.1×10-8 cm-1 (MDL~330 pptv) in 150 s, respectively, with 1 W laser power. Acknowledgements The authors acknowledge financial supports from the CaPPA project (ANR-10-LABX-005) and the CPER CLIMIBIO program. References H. Yi, R. Maamary, X. Gao, M. W. Sigrist, E. Fertein, W. Chen, "Short-lived species detection of nitrous acid by external-cavity quantum cascade laser based quartz-enhanced photoacoustic absorption spectroscopy", Appl. Phys. Lett. 106 (2015) 101109

Short-lived species detection of nitrous acid by external-cavity quantum cascade laser based quartz-enhanced photoacoustic absorption spectroscopy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Yi, Hongming; Laboratory of Atmospheric Physico-Chemistry, Anhui Institute of Optics and Fine Mechanics, Chinese Academy of Sciences, P.O. Box 1125, 350 Shushanhu Road, Hefei, Anhui 230031; Maamary, Rabih

2015-03-09

Spectroscopic detection of short-lived gaseous nitrous acid (HONO) at 1254.85 cm{sup −1} was realized by off-beam coupled quartz-enhanced photoacoustic spectroscopy (QEPAS) in conjunction with an external cavity quantum cascade lasers (EC-QCL). High sensitivity monitoring of HONO was performed within a very small gas-sample volume (of ∼40 mm{sup 3}) allowing a significant reduction (of about 4 orders of magnitude) of air sampling residence time which is highly desired for accurate quantification of chemically reactive short-lived species. Calibration of the developed QEPAS-based HONO sensor was carried out by means of lab-generated HONO samples whose concentrations were determined by direct absorption spectroscopy involving a ∼109.5 mmore » multipass cell and a distributed feedback QCL. A minimum detection limit (MDL) of 66 ppbv (1 σ) HONO was achieved at 70 mbar using a laser output power of 50 mW and 1 s integration time, which corresponded to a normalized noise equivalent absorption coefficient of 3.6 × 10{sup −8 }cm{sup −1} W/Hz{sup 1/2}. This MDL was down to 7 ppbv at the optimal integration time of 150 s. The corresponding 1σ minimum detected absorption coefficient is ∼1.1 × 10{sup −7 }cm{sup −1} (MDL ∼ 3 ppbv) in 1 s and ∼1.1 × 10{sup −8 }cm{sup −1} (MDL ∼ 330 pptv) in 150 s, respectively, with 1 W laser power.« less

Population structure and residency patterns of whale sharks, Rhincodon typus, at a provisioning site in Cebu, Philippines

PubMed Central

Lucey, Anna; Labaja, Jessica; So, Catherine Lee; Snow, Sally; Ponzo, Alessandro

2014-01-01

This study represents the first description of whale sharks, Rhincodon typus, occurring at a provisioning site in Oslob, Cebu, Philippines. Frequent observations of sharks are often difficult, even at tourism sites, giving rise to provisioning activities to attract them. The present study provides repeated longitudinal data at a site where daily provisioning activities took place, and whale sharks were present every day. A total of 158 individual whale sharks were photographically identified between Mar 2012 and Dec 2013, with 129 males (82%), 19 females (12%) and 10 (6%) of undetermined sex. Mean estimated total length was 5.5 m (±1.3 m S.D.). Twenty individuals were measured with laser photogrammetry to validate researchers’ estimated sizes, yielding a good correlation (r2 = 0.83). Fifty-four (34%) individuals were observed being hand-fed by local fishermen (provisioned), through in-water behavioural observations. Maximum likelihood methods were used to model mean residency time of 44.9 days (±20.6 days S.E.) for provisioned R. typus contrasting with 22.4 days (±8.9 days S.E.) for non-provisioned individuals. Propeller scars were observed in 47% of the animals. A mean of 12.7 (±4.3 S.D.) R. typus were present in the survey area daily, with a maximum of 26 individuals (Aug 10 2013) and a minimum of 2 (Dec 6 2012). Twelve (8%) individuals were seen on at least 50% of survey days (n = 621), with a maximum residency of 572 days for one individual (P-396). Twenty four individuals were photographically identified across regional hotsposts, highlighting the species’ migratory nature and distribution. Extended residency and differences in lagged identification rates suggest behavioural modification on provisioned individuals, underlying the necessity for proper management of this tourism activity. PMID:25279256

Using a composite grid approach in a complex coastal domain to estimate estuarine residence time

USGS Publications Warehouse

Warner, John C.; Geyer, W. Rockwell; Arango, Herman G.

2010-01-01

We investigate the processes that influence residence time in a partially mixed estuary using a three-dimensional circulation model. The complex geometry of the study region is not optimal for a structured grid model and so we developed a new method of grid connectivity. This involves a novel approach that allows an unlimited number of individual grids to be combined in an efficient manner to produce a composite grid. We then implemented this new method into the numerical Regional Ocean Modeling System (ROMS) and developed a composite grid of the Hudson River estuary region to investigate the residence time of a passive tracer. Results show that the residence time is a strong function of the time of release (spring vs. neap tide), the along-channel location, and the initial vertical placement. During neap tides there is a maximum in residence time near the bottom of the estuary at the mid-salt intrusion length. During spring tides the residence time is primarily a function of along-channel location and does not exhibit a strong vertical variability. This model study of residence time illustrates the utility of the grid connectivity method for circulation and dispersion studies in regions of complex geometry.

Maintaining social cohesion is a more important determinant of patch residence time than maximizing food intake rate in a group-living primate, Japanese macaque (Macaca fuscata).

PubMed

Kazahari, Nobuko

2014-04-01

Animals have been assumed to employ an optimal foraging strategy (e.g., rate-maximizing strategy). In patchy food environments, intake rate within patches is positively correlated with patch quality, and declines as patches are depleted through consumption. This causes patch-leaving and determines patch residence time. In group-foraging situations, patch residence times are also affected by patch sharing. Optimal patch models for groups predict that patch residence times decrease as the number of co-feeding animals increases because of accelerated patch depletion. However, group members often depart patches without patch depletion, and their patch residence time deviates from patch models. It has been pointed out that patch residence time is also influenced by maintaining social proximity with others among group-living animals. In this study, the effects of maintaining social cohesion and that of rate-maximizing strategy on patch residence time were examined in Japanese macaques (Macaca fuscata). I hypothesized that foragers give up patches to remain in the proximity of their troop members. On the other hand, foragers may stay for a relatively long period when they do not have to abandon patches to follow the troop. In this study, intake rate and foraging effort (i.e., movement) did not change during patch residency. Macaques maintained their intake rate with only a little foraging effort. Therefore, the patches were assumed to be undepleted during patch residency. Further, patch residence time was affected by patch-leaving to maintain social proximity, but not by the intake rate. Macaques tended to stay in patches for short periods when they needed to give up patches for social proximity, and remained for long periods when they did not need to leave to keep social proximity. Patch-leaving and patch residence time that prioritize the maintenance of social cohesion may be a behavioral pattern in group-living primates.

A METHOD TO INCORPORATE ECOLOGY INTO RESIDENCE TIME OF CHEMICALS IN EMBAYMENTS: LOCAL EFFECT TIME

EPA Science Inventory

Residence times are classically defined by the physical and chemical aspects of water bodies rather than by their ecological implications. Therefore, a more clear and direct connection between the residence times and ecological effects is necessary to quantitatively relate these ...

Surgical Training and the Early Specialization Program: Analysis of a National Program.

PubMed

Klingensmith, Mary E; Potts, John R; Merrill, Walter H; Eberlein, Timothy J; Rhodes, Robert S; Ashley, Stanley W; Valentine, R James; Hunter, John G; Stain, Steven C

2016-04-01

The Early Specialization Program (ESP) in surgery was designed by the American Board of Surgery, the American Board of Thoracic Surgery, and the Residency Review Committees for Surgery and Thoracic Surgery to allow surgical trainees dual certification in general surgery (GS) and either vascular surgery (VS) or cardiothoracic surgery (CTS) after 6 to 7 years of training. After more than 10 years' experience, this analysis was undertaken to evaluate efficacy. American Board of Surgery and American Board of Thoracic Surgery records of VS and CTS ESP trainees were queried to evaluate qualifying exam and certifying exam performance. Case logs were examined and compared with contemporaneous non-ESP trainees. Opinions of programs directors of GS, VS, and CTS and ESP participants were solicited via survey. Twenty-six CTS ESP residents have completed training at 10 programs and 16 VS ESP at 6 programs. First-time pass rates on American Board of Surgery qualifying and certifying exams were superior to time-matched peers; greater success in specialty specific examinations was also found. Trainees met required case minimums for GS despite shortened time in GS. By survey, 85% of programs directors endorsed satisfaction with ESP, and 90% endorsed graduate readiness for independent practice. Early Specialization Program participants report increased mentorship and independence, greater competence for practice, and overall satisfaction with ESP. Individuals in ESP programs in VS and CTS were successful in passing GS and specialty exams and achieving required operative cases, despite an accelerated training track. Programs directors and participants report satisfaction with the training and confidence that ESP graduates are prepared for independent practice. This documented success supports ESP training in any surgical subspecialty, including comprehensive GS. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Graduates-of-foreign-dermatology residencies and military dermatology residencies and women in academic dermatology.

PubMed

Wu, Jashin J; Davis, Kristy F; Ramirez, Claudia C; Alonso, Carol A; Berman, Brian; Tyring, Stephen K

2009-05-15

It is well known that there is a growing shortage of academic dermatologists in the U.S. The number of graduates of foreign dermatology residencies (GFDR) and graduates of military dermatology residencies (GMDR) who take full-time academic dermatology positions are currently unknown. It is likely that a higher proportion of GFDRs and GMDRs are more likely to enter academics and practice medical dermatology. The percentage of women in academic dermatology has not been reported since 1994. To determine the total number of GFDRs, GMDRs, and women who are full-time faculty members at U.S. dermatology residency programs. The educational background of all full-time faculty members of the 107 U.S. dermatology residency programs that were active as of December 2004 were determined through extensive Internet searches, telephone, and email correspondences with residency coordinators and faculty members. Pure PhDs, physicians who did not complete a dermatology residency program at an allopathic school, PharmDs, DDSs, and FNPs were excluded. The University of Puerto Rico was not considered a foreign residency program. As of December 2004, there were 988 full-time dermatology faculty members in the US, 813 of which met our inclusion criteria. There were 30 GFDRs, accounting for 3.7 percent of full-time academic dermatologists. There were 29 GMDRs, accounting for 3.6 percent of all full-time academic dermatologists. Women accounted for 44.42 percent of academic dermatologists and 15.9 percent (14/107) of dermatology chairs/chiefs. GFDRs, GMDRs, and women comprise important proportions of full-time faculty members at U.S. dermatology residency programs.

Comparable operative times with and without surgery resident participation.

PubMed

Uecker, John; Luftman, Kevin; Ali, Sadia; Brown, Carlos

2013-01-01

Both physicians and patients may perceive that having surgical residents participate in operative procedures may prolong operations and worsen outcomes. We hypothesized that resident participation would prolong operative times and potentially adversely affect postoperative outcomes. To evaluate the effect of general surgery resident participation in surgical procedures on operative times and postoperative patient outcomes. Retrospective study of general surgery procedures performed during two 1-year time periods, 2007 without residents and 2011 with residents. Procedures included laparoscopic appendectomy and cholecystectomy, thyroidectomy, breast procedure, hernia repair, lower extremity amputation, tunneled venous catheter, and percutaneous endoscopic gastrostomy. The primary outcome was operative time and secondary outcomes included length of stay (LOS) and mortality. Academic general surgery residency program. There were 2280 operative procedures performed during the 2 periods: 1150 with resident involvement (RES group) and 1130 without residents (NORES group). The RES and NORES groups were similar for patient age (42 vs 41, p = 0.14) and male gender (46% vs 45%, p = 0.68), and there was no difference in overall operative time (68min vs 66min, p = 0.58). More specifically there was no difference in operative time (minutes) for specific procedures including laparoscopic appendectomy (67 vs 71, p = 0.8), thyroidectomy (125 vs 109, p = 0.16), breast procedure (38 vs 26, p = 0.79), hernia repair (61 vs 60, p = 0.74), lower extremity amputation (65 vs 77, p = 0.16), tunneled venous catheter (49 vs 47, p = 0.75), and percutaneous endoscopic gastrostomy (49 vs 46, p = 0.76). However, laparoscopic cholecystectomy took slightly longer in the RES group (71 vs 66, p = 0.02). LOS was shorter during the year with resident involvement (2.6 days vs 3.7 days, p = 0.0004) and there was no difference in mortality (0.17% vs 0.35%, p = 0.45). There is no difference in operative time for common general surgery procedures with or without resident involvement. In addition, resident involvement is associated with a decrease in LOS. This information should be used to change physician and patient negative perceptions regarding resident involvement while performing surgical procedures. © 2013 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

New Initiation of Long-Acting Opioids in Long-Stay Nursing Home Residents

PubMed Central

Pimentel, Camilla B.; Gurwitz, Jerry H.; Tjia, Jennifer; Hume, Anne L.; Lapane, Kate L.

2016-01-01

BACKGROUND Despite known risks of overdose and respiratory depression when treating opioid-naïve individuals with long-acting opioids, use of these potent agents may be common in nursing homes. OBJECTIVES To estimate prevalence of new initiation of long-acting opioids since national efforts to increase prescriber and public awareness on safe use of transdermal fentanyl patches. DESIGN Cross-sectional. SETTING US nursing homes. PARTICIPANTS 22,253 Medicare-enrolled long-stay nursing home residents. MEASUREMENTS The Minimum Data Set 3.0 linked with Medicare enrollment, hospital claims, and prescription drug transaction data (January–December 2011) were used to determine the prevalence of new initiation among nursing home residents who were prescribed a long-acting opioid in the nursing home. RESULTS Of nursing home residents who were prescribed a long-acting opioid within 30 days of a nursing home admission (n = 12,278), 9.4% (95% confidence interval [CI]: 8.9–9.9%) lacked a prescription drug claim for a short-acting opioid in the previous 60 days. The most common initial prescriptions of long-acting opioids were fentanyl patch (51.9% of opioid-naïve nursing home residents), morphine sulfate (28.1%), and oxycodone (17.2%). CONCLUSION New initiation of long-acting opioids—especially fentanyl patches that have been the subject of safety communications—persists in nursing homes. PMID:27487158

The threat of funding cuts for graduate medical education: survey of decision makers.

PubMed

Kozak, R J; Kazzi, A A; Langdorf, M I; Martinez, C T

1997-07-01

To assess the potential actions of medical school deans, graduate medical education (GME) committee chairs, and hospital chief executive officers (CEOs) regarding future funding reductions for residency training. Specifically, institutions with emergency medicine (EM) residencies were surveyed to see whether EM training was disproportionally at risk for reductions. An anonymous 2-page survey was used. Ninety-eight EM residency programs were identified using the American Medical Association Graduate Medical Education Directory 1994-95. Seventy deans, 102 GME chairs, and 97 hospital CEOs were identified. The survey posed a hypothetical 25% forced reduction in residency positions and asked the decision makers for their responses. Options included: 1) proportional reductions of training positions from all residencies, 2) proportional reductions in either primary care or specialty residency positions, or 3) reduction or elimination of specific training programs. The survey asked for a first and second choice of residencies to be reduced or eliminated from an alphabetical list of 17. The survey elicited explanations for each program reduction. 200 (74%) of 269 surveys were returned. Eighty-four responders selected specific residencies to be reduced or eliminated. EM was selected 8 times, making EM the seventh most vulnerable residency to be targeted for reductions. The decision makers who selected proportional reductions chose to reduce across all residencies 32 times, among only the specialty residencies 129 times, and among only the primary care residencies 3 times. In the setting of anticipated residency cuts, favored proportional reductions in specialty residencies would likely affect EM training. However, most GME decision makers with an existing EM residency program do not consider the EM residency a top choice to be reduced or eliminated.

Patient- and ward-level determinants of nursing time in nursing facilities.

PubMed

Laine, Juha; Noro, Anja; Finne-Soveri, Harriet; Häkkinen, Unto

2005-10-01

To explore the patient- and ward-level determinants of wage-adjusted nursing time in long-term care wards for the elderly with a view to improving efficiency of the use of labour resources. The wage-adjusted nursing time given to patients was obtained from a time measurement study. Patient characteristics were based on the Minimum Data Set 2.0 of the Resident Assessment Instrument for nursing homes. Ordinary least-squares regression analysis and multilevel modelling were used to disentangle the effect of patient- and ward-level factors on nursing time. A significant difference in wage-adjusted nursing time between wards was detected, which was partly explained by characteristics of patients in wards. The combination of patients' physical functioning and cognition and the Resource Utilization Groups RUG-III/22 resource use classification explained 20-25% of patients' nursing time over a 24-hour period. Variables related to the operational environment of the ward did not explain differences in wage-adjusted nursing time once the patient profile of the ward had been controlled for. The results also showed notable unmeasured patient and ward level effects, inefficiency and randomness in the allocation of nursing time. By improving the allocation and use of labour resources, the substantial variation in nursing time between wards could be diminished. Managers should allocate their staff primarily according to patients' resource needs.

Computer usage and task-switching during resident's working day: Disruptive or not?

PubMed

Méan, Marie; Garnier, Antoine; Wenger, Nathalie; Castioni, Julien; Waeber, Gérard; Marques-Vidal, Pedro

2017-01-01

Recent implementation of electronic health records (EHR) has dramatically changed medical ward organization. While residents in general internal medicine use EHR systems half of their working time, whether computer usage impacts residents' workflow remains uncertain. We aimed to observe the frequency of task-switches occurring during resident's work and to assess whether computer usage was associated with task-switching. In a large Swiss academic university hospital, we conducted, between May 26 and July 24, 2015 a time-motion study to assess how residents in general internal medicine organize their working day. We observed 49 day and 17 evening shifts of 36 residents, amounting to 697 working hours. During day shifts, residents spent 5.4 hours using a computer (mean total working time: 11.6 hours per day). On average, residents switched 15 times per hour from a task to another. Task-switching peaked between 8:00-9:00 and 16:00-17:00. Task-switching was not associated with resident's characteristics and no association was found between task-switching and extra hours (Spearman r = 0.220, p = 0.137 for day and r = 0.483, p = 0.058 for evening shifts). Computer usage occurred more frequently at the beginning or ends of day shifts and was associated with decreased overall task-switching. Task-switching occurs very frequently during resident's working day. Despite the fact that residents used a computer half of their working time, computer usage was associated with decreased task-switching. Whether frequent task-switches and computer usage impact the quality of patient care and resident's work must be evaluated in further studies.

Running SINDA '85/FLUINT interactive on the VAX

NASA Technical Reports Server (NTRS)

Simmonds, Boris

1992-01-01

Computer software as engineering tools are typically run in three modes: Batch, Demand, and Interactive. The first two are the most popular in the SINDA world. The third one is not so popular, due probably to the users inaccessibility to the command procedure files for running SINDA '85, or lack of familiarity with the SINDA '85 execution processes (pre-processor, processor, compilation, linking, execution and all of the file assignment, creation, deletions and de-assignments). Interactive is the mode that makes thermal analysis with SINDA '85 a real-time design tool. This paper explains a command procedure sufficient (the minimum modifications required in an existing demand command procedure) to run SINDA '85 on the VAX in an interactive mode. To exercise the procedure a sample problem is presented exemplifying the mode, plus additional programming capabilities available in SINDA '85. Following the same guidelines the process can be extended to other SINDA '85 residence computer platforms.

Implementation of a "Flipped Classroom" for Neurosurgery Resident Education.

PubMed

Girgis, Fady; Miller, Jonathan P

2018-01-01

Engaging residents across a multiyear training spectrum is challenging given the heterogeneity of experience and limited time available for educational activities. A "flipped classroom" model, in which residents prepare ahead of time for mentored topic discussions, has potential advantages. We implemented a curriculum consisting of topics distributed across the specialty. Weekly, each resident was randomly assigned to research a specific aspect of an assigned topic appropriate to his or her level of experience: junior residents about what characterizes each clinical entity, midlevel residents about when to intervene, and chief residents about how to administer treatment. Residents completed an anonymous survey 6 months after implementation. Board examination performance was assessed before and after implementation. A total of 12 residents participated in the program. Weekly, 1.75±0.40 hours were spent in preparation, with senior residents reporting less time than junior residents. All residents indicated that the accumulation of experience across 7 years of residency was a major advantage of this program, and all preferred it to lectures. Performance on the board examination significantly increased after implementation (from 316±36 to 468±45, p<0.05). The flipped classroom is a viable approach to resident education and is associated with increased engagement and improved performance using validated knowledge-assessment tools.

Burden of Clostridium difficile-associated disease among patients residing in nursing homes: a population-based cohort study.

PubMed

Yu, Holly; Baser, Onur; Wang, Li

2016-11-25

Clostridium difficile (C. difficile) infection (CDI) is the leading cause of nosocomial diarrhea in the United States. This study aimed to examine the incidence of CDI and evaluate mortality and economic burden of CDI in an elderly population who reside in nursing homes (NHs). This was a population-based retrospective cohort study focusing on US NHs by linking Medicare 5% sample, Medicaid, Minimum Data Set (MDS) (2008-10). NH residents aged ≥65 years with continuous enrollment in Medicare and/or Medicaid Fee-for-Service plan for ≥12 months and ≥2 quarterly MDS assessments were eligible for the study. The incidence rate was calculated as the number of CDI episodes by 100,000 person-years. A 1:4 propensity score matched sample of cohorts with and without CDI was generated to assess mortality and health care costs following the first CDI. Among 32,807 NH residents, 941 residents had ≥1 episode of CDI in 2009, with an incidence of 3359.9 per 100,000 person-years. About 30% CDI episodes occurred in the hospital setting. NH residents with CDI (vs without CDI) were more likely to have congestive heart failure, renal disease, cerebrovascular disease, hospitalizations, and outpatient antibiotic use. During the follow-up period, the 30-day (14.7% vs 4.3%, P < 0.001), 60-day (22.7% vs 7.5%, P < 0.001), 6-month (36.3% vs 18.3%, P < 0.001), and 1-year mortality rates (48.2% vs 31.1%, P < 0.001) were significantly higher among the CDI residents vs non-CDI residents. Total health care costs within 2 months following the first CDI episode were also significantly higher for CDI residents ($28,621 vs $13,644, P < 0.001). CDI presents a serious public health issue in NHs. Mortality, health care utilization, and associated costs were significant following incident CDI episodes.

Age-period-cohort analysis of infectious disease mortality in urban-rural China, 1990-2010.

PubMed

Li, Zhi; Wang, Peigang; Gao, Ge; Xu, Chunling; Chen, Xinguang

2016-03-31

Although a number of studies on infectious disease trends in China exist, these studies have not distinguished the age, period, and cohort effects simultaneously. Here, we analyze infectious disease mortality trends among urban and rural residents in China and distinguish the age, period, and cohort effects simultaneously. Infectious disease mortality rates (1990-2010) of urban and rural residents (5-84 years old) were obtained from the China Health Statistical Yearbook and analyzed with an age-period-cohort (APC) model based on Intrinsic Estimator (IE). Infectious disease mortality is relatively high at age group 5-9, reaches a minimum in adolescence (age group 10-19), then rises with age, with the growth rate gradually slowing down from approximately age 75. From 1990 to 2010, except for a slight rise among urban residents from 2000 to 2005, the mortality of Chinese residents experienced a substantial decline, though at a slower pace from 2005 to 2010. In contrast to the urban residents, rural residents experienced a rapid decline in mortality during 2000 to 2005. The mortality gap between urban and rural residents substantially narrowed during this period. Overall, later birth cohorts experienced lower infectious disease mortality risk. From the 1906-1910 to the 1941-1945 birth cohorts, the decrease of mortality among urban residents was significantly faster than that of subsequent birth cohorts and rural counterparts. With the rapid aging of the Chinese population, the prevention and control of infectious disease in elderly people will present greater challenges. From 1990 to 2010, the infectious disease mortality of Chinese residents and the urban-rural disparity have experienced substantial declines. However, the re-emergence of previously prevalent diseases and the emergence of new infectious diseases created new challenges. It is necessary to further strengthen screening, immunization, and treatment for the elderly and for older cohorts at high risk.

Challenges Associated With Managing Suicide Risk in Long-Term Care Facilities.

PubMed

O'Riley, Alisa; Nadorff, Michael R; Conwell, Yeates; Edelstein, Barry

2013-06-01

Little information about suicidal ideation and behavior in long-term care (LTC) facilities is available. Nonetheless, the implementation of the Minimum Data Set 3.0 requires that LTC facilities screen their residents for suicide risk and have protocols in place to effectively manage residents' responses. In this article, the authors briefly discuss the risk factors of suicide in the elderly and the problems that suicidal ideation and behavior pose in the LTC environment. The authors explain issues that arise when trying to manage suicide risk in the elderly LTC population with general, traditional approaches. These inherent issues make it difficult to develop an effective protocol for managing suicide risk in LTC facilities, leading the authors to propose their own framework for assessing and managing suicide risk in the LTC setting.

Locality-Conscious Lock-Free Linked Lists

NASA Astrophysics Data System (ADS)

Braginsky, Anastasia; Petrank, Erez

We extend state-of-the-art lock-free linked lists by building linked lists with special care for locality of traversals. These linked lists are built of sequences of entries that reside on consecutive chunks of memory. When traversing such lists, subsequent entries typically reside on the same chunk and are thus close to each other, e.g., in same cache line or on the same virtual memory page. Such cache-conscious implementations of linked lists are frequently used in practice, but making them lock-free requires care. The basic component of this construction is a chunk of entries in the list that maintains a minimum and a maximum number of entries. This basic chunk component is an interesting tool on its own and may be used to build other lock-free data structures as well.

The pediatric resident training on tobacco project: baseline findings from the Parent/Guardian Tobacco Survey.

PubMed

Hymowitz, Norman; Schwab, Joseph; Haddock, Christopher keith; Pyle, Sara; Moore, Glenisha; Meshberg, Sarah

2005-07-01

Pediatricians have an important and unique role to play in the anti-tobacco arena. They may prevent relapse to smoking in women who stopped smoking during pregnancy, encourage parents to protect infants and young children from environmental tobacco smoke (ETS), prevent the onset of smoking in children and adolescents, and help patients and parents who smoke or use other forms of tobacco to quit. Unfortunately, few pediatricians intervene on tobacco use or ETS, and few pediatric residency training programs prepare residents to address tobacco. The Pediatric Residency Training on Tobacco Project is a 4-year randomized prospective study of the effectiveness of training pediatric residents to intervene on tobacco in patients and parents. In this paper, we present findings from the Baseline Parent/Guardian Tobacco Survey. Fifteen pediatric residency training programs participated in the Pediatric Residency Training on Tobacco Project, and they were assigned randomly to special and standard training conditions. The Baseline Parent/Guardian Tobacco Survey was administered to 1770 participants, a minimum of 100 from each site. The Parent/Guardian Survey was designed to describe the population under study. It addressed demographic information, family tobacco use, rules concerning smoking in the home and elsewhere, smoking behavior and beliefs, and parent/guardian reports of resident intervention on tobacco. Data analyses described the population served by Continuity Clinics associated with the pediatric residency training programs and determined the degree to which residents addressed tobacco in parents/guardians. The parents/guardians were primarily low-income African American and Hispanic females. Approximately 20% reported that they smoked cigarettes, and about 60% prohibited smoking in their home. Seventy percent of the parents reported that the resident asked about cigarette smoking, and about half indicated that the resident talked with them about ETS. However, only about 10% of the smokers stated that the doctor offered to help them stop smoking, and just 25% of all parents/guardians indicated that the doctor offered to help them stop exposing their children to ETS in the home or elsewhere. Parents of children brought to Continuity Clinic may benefit from advice and assistance on quitting cigarette smoking and protecting their children from ETS. While pediatric residents offer advice and encouragement, few provide the assistance parents require. These findings underscore the importance of training pediatric residents to address tobacco with the parents/guardians of the patients they serve.

Geo-mapping of time trends in childhood caries risk--a method for assessment of preventive care.

PubMed

Strömberg, Ulf; Holmn, Anders; Magnusson, Kerstin; Twetman, Svante

2012-06-11

Dental caries is unevenly distributed within populations with a higher burden in low socio-economy groups. Several attempts have been made to allocate resources to those that need them the most; there is a need for convenient approaches to population-based monitoring of caries risk over time. The aim of this study was to develop the geo-map concept, addressing time trends in caries risk, and demonstrate the novel approach by analyzing epidemiological data from preschool residents in the region of Halland, Sweden. The study population consisted of 9,973 (2006) and 10,927 (2010) children between 3 to 6 years of age (~77% of the eligible population) from whom caries data were obtained. Reported dmfs>0 for a child was considered as the primary caries outcome. Each study individual was geo-coded with respect to his/her residence parish (66 parishes in the region). Smoothed caries risk geo-maps, along with corresponding statistical certainty geo-maps, were produced by using the free software Rapid Inquiry Facility and the ESRI® ArcGIS system. Parish-level socioeconomic data were available. The overall proportion of caries-free (dmfs=0) children improved from 84.0% in 2006 to 88.6% in 2010. The ratio of maximum and minimum (parish-level) smoothed relative risks (SmRRs) increased from 1.76/0.44=4.0 in 2006 to 2.37/0.33=7.2 in 2010, which indicated an increased geographical polarization of early childhood caries in the population. Eight parishes showed evidential, positional changes in caries risk between 2006 and 2010; their corresponding SmRRs and statistical certainty ranks changed markedly. No considerable parallel changes in parish-level socioeconomic characteristics were seen during the same time period. Geo-maps based on caries risk can be used to monitor changes in caries risk over time. Thus, geo-mapping offers a convenient tool for evaluating the effectiveness of tailored health promotion and preventive care in child populations.

Land processes lead to surprising patterns in atmospheric residence time

NASA Astrophysics Data System (ADS)

van der Ent, R.; Tuinenburg, O.

2017-12-01

Our research using atmospheric moisture tracking methods shows that the global average atmospheric residence time of evaporation is 8-10 days. This residence time appears to be Gamma distributed with a higher probability of shorter than average residence times and a long tail. As a consequence the median of this residence time is around 5 days. In some places in the world the first few hours/days after evaporation there seems to be a little chance for a moisture particle to precipitate again, which is reflected by a Gamma distribution having a shape parameter below 1. In this study we present global maps of this parameter using different datasets (GLDAS and ERA-Interim). The shape parameter is as such also a measure for the land-atmospheric coupling strength along the path of the atmospheric water particle. We also find that different evaporation components: canopy interception, soil evaporation and transpiration appear to have different residence time distributions. We find a daily cycle in the residence time distribution over land, which is not present over the oceans. In this paper we will show which of the evaporation components is mainly responsible for this daily pattern and thus exhibits the largest daily cycle of land-atmosphere coupling strength.

The Application of Margin in Life Theory in Regard to Attrition and Remediation among Emergency Medicine Residents

ERIC Educational Resources Information Center

Kalynych, Colleen J.

2010-01-01

Medical residency is a time of high stress, long hours, high case loads, fatigue, and lack of free time. Burnout rates among residents have been reported to be between 25-76%. Scant literature exists in regard to resident stress and its impact on learning and attrition during residency. The theory of margin posits that a healthy margin is…

Moving Out: Transition to Non-Residence among Resident Fathers in the United States, 1968-1997

ERIC Educational Resources Information Center

Gupta, Sanjiv; Smock, Pamela J.; Manning, Wendy D.

2004-01-01

This article provides the first individual-level estimates of the change over time in the probability of non-residence for initially resident fathers in the United States. Drawing on the 1968-1997 waves of the Panel Study of Income Dynamics, we used discrete-time event history models to compute the probabilities of non-residence for six 5-year…

Does intentional support of degree programs in general surgery residency affect research productivity or pursuit of academic surgery?

PubMed

Joshua Smith, Jesse; Patel, Ravi K; Chen, Xi; Tarpley, Margaret J; Terhune, Kyla P

2014-01-01

Many residents supplement general surgery training with years of dedicated research, and an increasing number at our institution pursue additional degrees. We sought to determine whether it was worth the financial cost for residency programs to support degrees. We reviewed graduating chief residents (n = 69) in general surgery at Vanderbilt University from 2001 to 2010 and collected the data including research time and additional degrees obtained. We then compared this information with the following parameters: (1) total papers, (2) first-author papers, (3) Journal Citation Reports impact factors of journals in which papers were published, and (4) first job after residency or fellowship training. The general surgery resident training program at Vanderbilt University is an academic program, approved to finish training 7 chief residents yearly during the time period studied. Chief residents in general surgery at Vanderbilt who finished their training 2001 through 2010. We found that completion of a degree during residency was significantly associated with more total and first-author publications as compared with those by residents with only dedicated research time (p = 0.001 and p = 0.017). Residents completing a degree also produced publications of a higher caliber and level of authorship as determined by an adjusted resident impact factor score as compared with those by residents with laboratory research time only (p = 0.005). Degree completion also was significantly correlated with a first job in academia if compared to those with dedicated research time only (p = 0.046). Our data support the utility of degree completion when economically feasible and use of dedicated research time as an effective way to significantly increase research productivity and retain graduates in academic surgery. Aggregating data from other academic surgery programs would allow us to further determine association of funding of additional degrees as a means to encourage academic productivity and retention. Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

The effect of the 16-hour intern workday restriction on surgical residents' in-hospital activities.

PubMed

Dennis, Bradley M; Long, Eric L; Zamperini, Katherine M; Nakayama, Don K

2013-01-01

To observe the effects of the 2011 Accreditation Council on Graduate Medical Education 16-hour intern workday restrictions on surgical residents' clinical and educational activities. All the residents recorded the following weekly in-hospital activities during February and March 2011 (year before intern work restrictions) and 2012 (first year under new requirements): operating room (OR) and clinic; bedside procedures; rounds and ward work; on-call duties in hospital; communication (e.g., checkouts and family and patient discussions); education (conferences and study); and personal (rest and meals). Descriptive statistics were calculated in 3 resident groups (interns, first postgraduate year [PGY1]; junior, PGY2 and 3; and senior, PGY4 and 5). The unpaired t test was used to compare data between 2011 and 2012; significance was set at p< 0.05. Medical school affiliated hospital. Categorical resident trainees in surgery, PGY1-5, 4 residents per level, with all 20 residents participating in the study. From 2011 to 2012, time spent in the hospital by the intern did not change (all results in h/wk, mean±standard deviation: 68.5±13.8 to 72.8±15.8, respectively) but the time devoted to specific activities changed significantly. In-hospital personal time decreased by 50% (5.3±4.6 to 2.6±2.0, p = 0.004). Interns spent less time placing central lines (2.1±2.2 to 0.9±1.2, p = 0.006) and more on rounds (8.8±8.8 to 14.2±9.8, p = 0.027), which included supervision with upper level residents. There was no change in the total time spent in the OR, the clinic, performing bedside procedures, and educational activities. Changes in intern work did not affect the time junior and senior residents spent on bedside procedures, time spent in the clinic, and total time spent in the hospital. In 2012, junior residents spent less time in educational activities (11.4±8.5 to 7.0±4.5, p = 0.0007) and the seniors spent more time in the OR (13.7±7.5 to 20.6±10.7, p = 0.0002). The 16-hour restriction preserved interns' educational activities and time spent in the OR and clinic, but changed resident work activities at all levels. The time spent on rounds increased, time spent by the juniors on conferences decreased, and time spent by senior residents in the OR increased. Duty restrictions in general and intern supervision requirements demand ongoing adjustments in resident work schedules. Copyright © 2013 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Teachers' Perceptions of Difficulties in Teaching Ethics in Residencies.

ERIC Educational Resources Information Center

Strong, Carson; And Others

1992-01-01

Analysis of responses of 63 medical faculty involved in formal ethics teaching programs for medical residents indicated such perceived problems as time constraints resulting from residents' heavy schedules; attitudes of residents; logistical problems; time demands on faculty; lack of reinforcement for teaching ethics; and deficiencies in faculty…

Seasonal movement, residency, and migratory patterns of Wilson's Snipe (Gallinago delicata)

USGS Publications Warehouse

Cline, Brittany B.; Haig, Susan M.

2011-01-01

Cross-seasonal studies of avian movement establish links between geographically distinct wintering, breeding, and migratory stopover locations, or assess site fidelity and movement between distinct phases of the annual cycle. Far fewer studies have investigated individual movement patterns within and among seasons over an annual cycle. Within western Oregon's Willamette Valley throughout 2007, we quantified intra- and interseasonal movement patterns, fidelity (regional and local), and migratory patterns of 37 radiomarked Wilson's Snipe (Gallinago delicata) to elucidate residency in a region of breeding- and wintering-range overlap. Telemetry revealed complex regional population structure, including winter residents (74%), winter transients (14%), summer residents (9%), and one year-round resident breeder (3%). Results indicated a lack of connectivity between winter and summer capture populations, some evidence of partial migration, and between-season fidelity to the region (winter-resident return; subsequent fall). Across seasons, the extent of movements and use of multiple wetland sites suggested that Wilson's Snipe were capable of exploratory movements but more regularly perceived local and fine-scale segments of the landscape as connected. Movements differed significantly by season and residency; individuals exhibited contracted movements during late winter and more expansive movements during precipitation-limited periods (late spring, summer, fall). Mean home-range size was 3.5 ± 0.93 km2 (100% minimum convex polygon [MCP]) and 1.6 ± 0.42 km2 (95% fixed kernel) and did not vary by sex; however, home range varied markedly by season (range of 100% MCPs: 1.04–7.56 km2). The results highlight the need to consider seasonal and interspecific differences in shorebird life histories and space-use requirements when developing regional wetland conservation plans.

Bipolar Disorder in Nursing Homes: Impact on Antipsychotic Use, Diagnosis Patterns, and New Diagnoses in People with Dementia.

PubMed

Carnahan, Ryan M; Letuchy, Elena M

2018-01-01

Nursing home quality measures include the proportion of residents who receive antipsychotics. Residents with bipolar disorder are included even though antipsychotics are FDA-approved for this indication. We evaluated how including residents with bipolar disorder impacted the antipsychotic use quality measure for long-stay residents. We evaluated the agreement of minimum data set (MDS) bipolar disorder diagnoses with Medicare data, whether dementia was diagnosed before bipolar disorder, and how less-specific bipolar disorder diagnoses impacted findings. Cross-sectional study. Nursing homes in Iowa. 21,955 long-stay nursing home residents in the first quarter of 2014. We identified antipsychotic use and bipolar disorder using MDS data. We compared MDS bipolar disorder diagnoses with Chronic Conditions Warehouse (CCW) "ever" bipolar disorder indicators, and prior year claims. We compared CCW condition onset dates to identify bipolar disorder diagnosed after dementia. The mean (SD) proportion receiving antipsychotics was 19.6% (11.1%) with bipolar disorder and 18.3% (10.8%) without. The positive predictive value (PPV) of MDS bipolar disorder diagnoses was 80.2% versus CCW lifetime indicators, and 74.6% versus claims. PPV decreased by 27.1% when "bipolar disorder, unspecified" and "other bipolar disorders" diagnoses were excluded. Nearly three-quarters of residents with bipolar disorder had dementia. Over half of those with dementia had dementia first per CCW records. This proportion was lower among those with more specific bipolar disorder diagnoses or MDS bipolar disorder indicators. Bipolar disorder in nursing home residents is often first diagnosed after dementia using nonspecific diagnoses. This practice deserves further evaluation. Copyright © 2017 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.

Multidimensional team-based intervention using musical cues to reduce odds of facility-acquired pressure ulcers in long-term care: a paired randomized intervention study.

PubMed

Yap, Tracey L; Kennerly, Susan M; Simmons, Mark R; Buncher, Charles R; Miller, Elaine; Kim, Jay; Yap, Winston Y

2013-09-01

To test the effectiveness of a pressure ulcer (PU) prevention intervention featuring musical cues to remind all long-term care (LTC) staff (nursing and ancillary) to help every resident move or reposition every 2 hours. Twelve-month paired-facility two-arm (with one-arm crossover) randomized intervention trial. Ten midwestern U.S. LTC facilities. Four treatment facilities received intervention during Months 1 to 12, four comparison facilities received intervention during Months 7 to 12, and two pseudo-control facilities received no intervention. LTC facility residents (N = 1,928). All facility staff received in-person education, video, and handouts, and visiting family members received informational pamphlets on PU prevention and an intervention featuring musical cues. Nurse-led multidisciplinary staff teams presented the cues as prompts for staff and family to reposition residents or remind them to move. Musical selections (with and without lyrics) customized to facility preferences were played daily over the facility intercom or public address system every 2 hours for the 12-hour daytime period. Primary outcome measure was the frequency of new facility-acquired PUs divided by the total number of facility Minimum Data Set (MDS) resident assessments conducted during the study period. Odds of a new PU were lower in intervention facilities (P = .08) for MDS 2.0 assessments and were significantly lower (P = .05) for MDS 3.0. Mean odds ratios suggested intervention facility residents were 45% less likely than comparison facility residents to develop a new PU. Customized musical cues that prompt multidisciplinary staff teams to encourage or enable movement of all residents hold promise for reducing facility-acquired PUs in LTC settings. © 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.

Allocation of Internal Medicine Resident Time in a Swiss Hospital: A Time and Motion Study of Day and Evening Shifts.

PubMed

Wenger, Nathalie; Méan, Marie; Castioni, Julien; Marques-Vidal, Pedro; Waeber, Gérard; Garnier, Antoine

2017-04-18

Little current evidence documents how internal medicine residents spend their time at work, particularly with regard to the proportions of time spent in direct patient care versus using computers. To describe how residents allocate their time during day and evening hospital shifts. Time and motion study. Internal medicine residency at a university hospital in Switzerland, May to July 2015. 36 internal medicine residents with an average of 29 months of postgraduate training. Trained observers recorded the residents' activities using a tablet-based application. Twenty-two activities were categorized as directly related to patients, indirectly related to patients, communication, academic, nonmedical tasks, and transition. In addition, the presence of a patient or colleague and use of a computer or telephone during each activity was recorded. Residents were observed for a total of 696.7 hours. Day shifts lasted 11.6 hours (1.6 hours more than scheduled). During these shifts, activities indirectly related to patients accounted for 52.4% of the time, and activities directly related to patients accounted for 28.0%. Residents spent an average of 1.7 hours with patients, 5.2 hours using computers, and 13 minutes doing both. Time spent using a computer was scattered throughout the day, with the heaviest use after 6:00 p.m. The study involved a small sample from 1 institution. At this Swiss teaching hospital, internal medicine residents spent more time at work than scheduled. Activities indirectly related to patients predominated, and about half the workday was spent using a computer. Information Technology Department and Department of Internal Medicine of Lausanne University Hospital.

A novel modeling approach to the mixing process in twin-screw extruders

NASA Astrophysics Data System (ADS)

Kennedy, Amedu Osaighe; Penlington, Roger; Busawon, Krishna; Morgan, Andy

2014-05-01

In this paper, a theoretical model for the mixing process in a self-wiping co-rotating twin screw extruder by combination of statistical techniques and mechanistic modelling has been proposed. The approach was to examine the mixing process in the local zones via residence time distribution and the flow dynamics, from which predictive models of the mean residence time and mean time delay were determined. Increase in feed rate at constant screw speed was found to narrow the shape of the residence time distribution curve, reduction in the mean residence time and time delay and increase in the degree of fill. Increase in screw speed at constant feed rate was found to narrow the shape of the residence time distribution curve, decrease in the degree of fill in the extruder and thus an increase in the time delay. Experimental investigation was also done to validate the modeling approach.

Using just-in-time teaching and peer instruction in a residency program's core curriculum: enhancing satisfaction, engagement, and retention.

PubMed

Schuller, Mary C; DaRosa, Debra A; Crandall, Marie L

2015-03-01

To assess use of the combined just-in-time teaching (JiTT) and peer instruction (PI) instructional strategy in a residency program's core curriculum. In 2010-2011, JiTT/PI was piloted in 31 core curriculum sessions taught by 22 faculty in the Northwestern University Feinberg School of Medicine's general surgery residency program. JiTT/PI required preliminary and categorical residents (n=31) to complete Web-based study questions before weekly specialty topic sessions. Responses were examined by faculty members "just in time" to tailor session content to residents' learning needs. In the sessions, residents answered multiple-choice questions (MCQs) using clickers and engaged in PI. Participants completed surveys assessing their perceptions of JiTT/PI. Videos were coded to assess resident engagement time in JiTT/PI sessions versus prior lecture-based sessions. Responses to topic session MCQs repeated in review sessions were evaluated to study retention. More than 70% of resident survey respondents indicated that JiTT/PI aided in the learning of key points. At least 90% of faculty survey respondents reported positive perceptions of aspects of the JiTT/PI strategy. Resident engagement time for JiTT/PI sessions was significantly greater than for prior lecture-based sessions (z=-2.4, P=.016). Significantly more review session MCQ responses were correct for residents who had attended corresponding JiTT/PI sessions than for residents who had not (chi-square=13.7; df=1; P<.001). JiTT/PI increased learner participation, learner retention, and the amount of learner-centered time. JiTT/PI represents an effective approach for meaningful and active learning in core curriculum sessions.

Evaluation of Residence Time on Nitrogen Oxides Removal in Non-Thermal Plasma Reactor

PubMed Central

Talebizadeh, Pouyan; Rahimzadeh, Hassan; Babaie, Meisam; Javadi Anaghizi, Saeed; Ghomi, Hamidreza; Ahmadi, Goodarz; Brown, Richard

2015-01-01

Non-thermal plasma (NTP) has been introduced over the last few years as a promising after- treatment system for nitrogen oxides and particulate matter removal from diesel exhaust. NTP technology has not been commercialised as yet, due to its high rate of energy consumption. Therefore, it is important to seek out new methods to improve NTP performance. Residence time is a crucial parameter in engine exhaust emissions treatment. In this paper, different electrode shapes are analysed and the corresponding residence time and NOx removal efficiency are studied. An axisymmetric laminar model is used for obtaining residence time distribution numerically using FLUENT software. If the mean residence time in a NTP plasma reactor increases, there will be a corresponding increase in the reaction time and consequently the pollutant removal efficiency increases. Three different screw thread electrodes and a rod electrode are examined. The results show the advantage of screw thread electrodes in comparison with the rod electrode. Furthermore, between the screw thread electrodes, the electrode with the thread width of 1 mm has the highest NOx removal due to higher residence time and a greater number of micro-discharges. The results show that the residence time of the screw thread electrode with a thread width of 1 mm is 21% more than for the rod electrode. PMID:26496630

Residents as teachers: psychiatry and family medicine residents' self-assessment of teaching knowledge, skills, and attitudes.

PubMed

Brand, Michael W; Ekambaram, Vijayabharathi; Tucker, Phebe; Aggarwal, Ruchi

2013-09-01

Residents are one of the prime sources of information and education for medical students. As an initial step in supporting residents as teachers, a baseline self-assessment of residents' knowledge, skills, attitudes, and values related to teaching was conducted among psychiatry and family medicine residents to compare and improve their confidence and skills as teachers. Psychiatry residents (N=12) and family medicine residents (N=23) completed self-assessments of their knowledge, skills, attitudes, and values related to teaching. Residents also were asked to list steps used in the One-Minute Preceptor process and estimate the time each spent in teaching. Descriptive summary statistics were used for four main areas related to teaching; t-test and chi-square analyses were conducted to ascertain whether there was a significant difference in resident groups. In the current study, the perceived amount of time spent for teaching patients was significantly higher among family practice residents, whereas no group differences were found for time teaching medical students, peers, community members, non-physicians, or others. However, family medicine residents rated themselves higher than psychiatry residents in their understanding of their roles in teaching medical students and teaching patients. Also, family medicine residents' self-reported teaching skills were more advanced (82.4%) than psychiatry residents' (54.2%). They most likely applied at least two different teaching methods in inpatient and outpatient settings, as compared with psychiatry residents. No significant group differences were found in the other 15 items assessing teaching knowledge, skills, attitudes, and values. Results indicate that residents' knowledge, skills, attitudes, and values regarding teaching varies across institutions and training programs. The psychiatry residents in this study do not clearly understand their role as educators with patients and medical students; they have a less clear understanding of teaching techniques, and report spending less time educating patients than do family medicine residents. The differences might be due to different patient populations and treatment settings. The study suggests that psychiatry residents may have difficulty adapting the One-Minute Preceptor technique in psychiatric settings. Results serve as a benchmarking study in a performance-improvement program to enhance psychiatry residents' teaching skills.

42 CFR 84.83 - Timers; elapsed time indicators; remaining service life indicators; minimum requirements.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 1 2011-10-01 2011-10-01 false Timers; elapsed time indicators; remaining service life indicators; minimum requirements. 84.83 Section 84.83 Public Health PUBLIC HEALTH SERVICE... indicators; remaining service life indicators; minimum requirements. (a) Elapsed time indicators shall be...

42 CFR 84.83 - Timers; elapsed time indicators; remaining service life indicators; minimum requirements.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 1 2010-10-01 2010-10-01 false Timers; elapsed time indicators; remaining service life indicators; minimum requirements. 84.83 Section 84.83 Public Health PUBLIC HEALTH SERVICE... indicators; remaining service life indicators; minimum requirements. (a) Elapsed time indicators shall be...

Anthropogenic noise decreases urban songbird diversity and may contribute to homogenization.

PubMed

Proppe, Darren S; Sturdy, Christopher B; St Clair, Colleen Cassady

2013-04-01

More humans reside in urban areas than at any other time in history. Protected urban green spaces and transportation greenbelts support many species, but diversity in these areas is generally lower than in undeveloped landscapes. Habitat degradation and fragmentation contribute to lowered diversity and urban homogenization, but less is known about the role of anthropogenic noise. Songbirds are especially vulnerable to anthropogenic noise because they rely on acoustic signals for communication. Recent studies suggest that anthropogenic noise reduces the density and reproductive success of some bird species, but that species which vocalize at frequencies above those of anthropogenic noise are more likely to inhabit noisy areas. We hypothesize that anthropogenic noise is contributing to declines in urban diversity by reducing the abundance of select species in noisy areas, and that species with low-frequency songs are those most likely to be affected. To examine this relationship, we calculated the noise-associated change in overall species richness and in abundance for seven common songbird species. After accounting for variance due to vegetative differences, species richness and the abundance of three of seven species were reduced in noisier locations. Acoustic analysis revealed that minimum song frequency was highly predictive of a species' response to noise, with lower minimum song frequencies incurring greater noise-associated reduction in abundance. These results suggest that anthropogenic noise affects some species independently of vegetative conditions, exacerbating the exclusion of some songbird species in otherwise suitable habitat. Minimum song frequency may provide a useful metric to predict how particular species will be affected by noise. In sum, mitigation of noise may enhance habitat suitability for many songbird species, especially for species with songs that include low-frequency elements. © 2012 Blackwell Publishing Ltd.

Young driver licensing: examination of population-level rates using New Jersey's state licensing database.

PubMed

Curry, Allison E; Pfeiffer, Melissa R; Durbin, Dennis R; Elliott, Michael R; Kim, Konny H

2015-03-01

Recent surveys have provided insight on the primary reasons why US teens delay licensure but are limited in their ability to estimate licensing rates and trends. State administrative licensing data are the ideal source to provide this information but have not yet been analyzed for this purpose. Our objective was to analyze New Jersey's (NJ) licensing database to: (1) describe population-based rates of licensure among 17- to 20-year-olds, overall and by gender and zip code level indicators of household income, population density, and race/ethnicity; and (2) examine recent trends in licensure. We obtained records on all licensed NJ drivers through June 2012 from the NJ Motor Vehicle Commission's licensing database and determined each young driver's age at the time of intermediate and full licensure. Data from the US Census and American Community Survey were used to estimate a fixed cohort of NJ residents who turned 17 years old in 2006-2007 (n=255,833). Licensing data were used to estimate the number of these drivers who obtained an intermediate license by each month of age (numerators) and, among those who obtained an intermediate license, time to graduation to full licensure. Overall, 40% of NJ residents-and half of those who ultimately obtained a license by age 21-were licensed within a month of NJ's minimum licensing age of 17, 64% by their 18th birthday, and 81% by their 21st birthday. Starkly different patterns of licensure were observed by socioeconomic indicators; for example, 65% of 17-year-olds residing in the highest-income zip codes were licensed in the first month of eligibility compared with 13% of residents living in the lowest-income zip codes. The younger an individual obtained their intermediate license, the earlier they graduated to a full license. Finally, the rate and timing of licensure in NJ has been relatively stable from 2006 to 2012, with at most a 1-3% point decline in rates. These findings support the growing body of literature suggesting that teens delay licensure primarily for economic reasons and that a substantial proportion of potentially high-risk teens may be obtaining licenses outside the auspices of a graduated driver licensing system. Finally, our finding of a relatively stable trend in licensure in recent years is in contrast to national-level reports of a substantial decline in licensure rates. Copyright © 2015 Elsevier Ltd. All rights reserved.

Obstetrics and gynaecology chief resident attitudes toward teaching junior residents under normal working conditions.

PubMed

Gil, Karen M; Savitski, Jennifer L; Bazan, Sara; Patterson, Laurene R; Kirven, Melissa

2009-09-01

This study aimed to identify factors that chief residents believe impact the teaching of junior residents under normal working conditions and the areas in which they believe education on the role of resident as teacher would be beneficial. Obstetrics and gynaecology (O&G) chief residents were asked to rate the importance of teaching various skills, how often conflict situations arose, and to identify training that would be helpful through a national web-based survey. An e-mail was sent to coordinators of the Residency Review Committee (RRC) O&G residency programmes with a request that they forward the link to their chief residents three times from January through March 2006. Responses were received from 204 postgraduate Year 4 (PGY4) residents (18% of all PGY4 residents) from 133 programmes (54% of all residency programmes) and 33 states. Teaching junior residents how to prioritise patient care and obtain critical information in an emergent situation was considered very to extremely important by 97%. Conflict situations with junior residents were reported to occur between one and five times by 41-58%; an additional 26-28% reported that these situations occurred six or more times. Residents felt it would be helpful to extremely helpful to have training in resolving conflicts that involved patient care (48-59%), as well as in resolving conflict among junior residents, communicating effectively with them and becoming an effective leader (65-78%). The skills that chief residents considered most important to teach junior residents involved direct patient care. Chief residents would like training in how to resolve conflict with, and among, junior residents, and in how to become an effective leader.

Cigar Box Arthroscopy: A Randomized Controlled Trial Validates Nonanatomic Simulation Training of Novice Arthroscopy Skills.

PubMed

Sandberg, Rory P; Sherman, Nathan C; Latt, L Daniel; Hardy, Jolene C

2017-11-01

The goal of this study was to validate the cigar box arthroscopy trainer (CBAT) as a training tool and then compare its effectiveness to didactic training and to another previously validated low-fidelity but anatomic model, the anatomic knee arthroscopy trainer (AKAT). A nonanatomic knee arthroscopy training module was developed at our institution. Twenty-four medical students with no prior arthroscopic or laparoscopic experience were enrolled as subjects. Eight subjects served as controls. The remaining 16 subjects were randomized to participate in 4 hours of either the CBAT or a previously validated AKAT. Subjects' skills were assessed by 1 of 2 faculty members through repeated attempts at performing a diagnostic knee arthroscopy on a cadaveric specimen. Objective scores were given using a minimally adapted version of the Basic Arthroscopic Knee Skill Scoring System. Total cost differences were calculated. Seventy-five percent of subjects in the CBAT and AKAT groups succeeded in reaching minimum proficiency in the allotted time compared with 25% in the control group (P < .05). There was no significant difference in the number of attempts to reach proficiency between the CBAT and AKAT groups. The cost to build the CBAT was $44.12, whereas the cost was $324.33 for the AKAT. This pilot study suggests the CBAT is an effective knee arthroscopy trainer that may decrease the learning curve of residents without significant cost to a residency program. This study demonstrates the need for an agreed-upon objective scoring system to properly evaluate residents and compare the effectiveness of different training tools. Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Effect of protected research time on ABSITE scores during general surgery residency.

PubMed

Orkin, Bruce A; Poirier, Jennifer; Kowal-Vern, Areta; Chan, Edie; Ohara, Karen; Mendoza, Brian

2018-02-01

Objective - To determine whether residents with one or more years of dedicated research time (Research Residents, RR) improved their ABSITE scores compared to those without (Non-Research Residents, N-RR). A retrospective review of general surgery residents' ABSITE scores from 1995 to 2016 was performed. RR were compared to N-RR. Additional analysis of At Risk (AR) v Not At Risk residents (NAR) (35th percentile as PGY1-2) was also performed. Cohort - 147 residents (34 RR and 113 N-RR). There were no differences in initial ABSITE scores (p = 0.47). By definition, the AR group had lower scores than NAR. Overall, post-research RR v PGY-4 N-RR scores did not differ (p = 0.84). Only the AR residents improved their scores (p = 0.0009 v NAR p = 0.42), regardless of research group (p = 0.70). Protected research time did not improve residents' ABSITE scores, regardless of initial scores. At Risk residents improved regardless of research group status. Copyright © 2017 Elsevier Inc. All rights reserved.

Medicare Financing of Graduate Medical Education

PubMed Central

Rich, Eugene C; Liebow, Mark; Srinivasan, Malathi; Parish, David; Wolliscroft, James O; Fein, Oliver; Blaser, Robert

2002-01-01

The past decade has seen ongoing debate regarding federal support of graduate medical education, with numerous proposals for reform. Several critical problems with the current mechanism are evident on reviewing graduate medical education (GME) funding issues from the perspectives of key stakeholders. These problems include the following: substantial interinstitutional and interspecialty variations in per-resident payment amounts; teaching costs that have not been recalibrated since 1983; no consistent control by physician educators over direct medical education (DME) funds; and institutional DME payments unrelated to actual expenditures for resident education or to program outcomes. None of the current GME reform proposals adequately address all of these issues. Accordingly, we recommend several fundamental changes in Medicare GME support. We propose a re-analysis of the true direct costs of resident training (with appropriate adjustment for local market factors) to rectify the myriad problems with per-resident payments. We propose that Medicare DME funds go to the physician organization providing resident instruction, keeping DME payments separate from the operating revenues of teaching hospitals. To ensure financial accountability, we propose that institutions must maintain budgets and report expenditures for each GME program. To establish educational accountability, Residency Review Committees should establish objective, annually measurable standards for GME program performance; programs that consistently fail to meet these minimum standards should lose discretion over GME funds. These reforms will solve several long-standing, vexing problems in Medicare GME funding, but will also uncover the extent of undersupport of GME by most other health care payers. Ultimately, successful reform of GME financing will require “all-payer” support. PMID:11972725

Selection criteria for internal medicine residency applicants and professionalism ratings during internship.

PubMed

Cullen, Michael W; Reed, Darcy A; Halvorsen, Andrew J; Wittich, Christopher M; Kreuziger, Lisa M Baumann; Keddis, Mira T; McDonald, Furman S; Beckman, Thomas J

2011-03-01

To determine whether standardized admissions data in residents' Electronic Residency Application Service (ERAS) submissions were associated with multisource assessments of professionalism during internship. ERAS applications for all internal medicine interns (N=191) at Mayo Clinic entering training between July 1, 2005, and July 1, 2008, were reviewed by 6 raters. Extracted data included United States Medical Licensing Examination scores, medicine clerkship grades, class rank, Alpha Omega Alpha membership, advanced degrees, awards, volunteer activities, research experiences, first author publications, career choice, and red flags in performance evaluations. Medical school reputation was quantified using U.S. News & World Report rankings. Strength of comparative statements in recommendation letters (0 = no comparative statement, 1 = equal to peers, 2 = top 20%, 3 = top 10% or "best") were also recorded. Validated multisource professionalism scores (5-point scales) were obtained for each intern. Associations between application variables and professionalism scores were examined using linear regression. The mean ± SD (minimum-maximum) professionalism score was 4.09 ± 0.31 (2.13-4.56). In multivariate analysis, professionalism scores were positively associated with mean strength of comparative statements in recommendation letters (β = 0.13; P = .002). No other associations between ERAS application variables and professionalism scores were found. Comparative statements in recommendation letters for internal medicine residency applicants were associated with professionalism scores during internship. Other variables traditionally examined when selecting residents were not associated with professionalism. These findings suggest that faculty physicians' direct observations, as reflected in letters of recommendation, are useful indicators of what constitutes a best student. Residency selection committees should scrutinize applicants' letters for strongly favorable comparative statements.

Nurses' personal statements about factors that influence their decisions about the time they spend with residents with long-term mental illness living in psychiatric group dwellings.

PubMed

Hellzén, Ove

2004-09-01

One seldom-discussed issue is the factors that influence nurses' decisions about the time they spend with residents in psychiatric care. This study uses a qualitative naturalistic approach and consists of an analysis of focus-group interviews with nurses, which aimed to identify factors affecting nurses' decisions about being with or being nonattendant in their relationship with their residents. Two series of focus-group interviews were conducted, interpreted and analysed through content analysis. The study included all the staff (n=32) at two municipal psychiatric group dwellings housing residents mainly with a diagnosis of long-term schizophrenia. This study revealed that the main factor that determined nurses' nurse/resident time together or nonattendance time was whether they liked or disliked the individual resident. One possible explanation is the carers' change from a perspective in which the nursing care was given on the basis of each resident's needs and rights, based on the individual nurse's professional judgement, to a consumer perspective, which leads to a change in responsibility from themselves to the individual residents.

Number needed to eat: pizza and resident conference attendance.

PubMed

Cosimini, Michael J; Mackintosh, Liza; Chang, Todd P

2016-12-01

The didactic conference is a common part of the resident education curriculum. Given the demands of clinical responsibilities and restrictions on duty hours, maximising education is a challenge faced by all residency programmes. To date, little research exists with respect to how the provision of complimentary food affects physician and resident conference attendance. The objective of this study was to determine whether complimentary food improves resident arrival times and attendance at educational conferences and, furthermore, to test whether this provision is a potentially cost-effective tool for improving education. A retrospective review of 36 resident educational Friday noon conferences, including 1043 resident arrivals, was performed. Data were analysed for total attendance, arrival times, number needed to eat (NNE) and the percentage of residents arriving on time, and compared between days on which food was and was not provided. Median attendance was 3.7% higher (p = 0.04) on days on which food was provided, at a cost of US$46 for each additional resident in attendance. Arrival times were also statistically significantly improved when food was provided, with a median improvement of 0.7 minutes (p = 0.02) and an 11.0% increase in on-time arrivals (p < 0.001). The NNE was 10.6. Complimentary food improves both attendance and arrival times by a small, but statistically significant, degree. The provision of complimentary food can be considered as an incentive for attendance and on-time arrival at didactic educational sessions, although more cost-effective modalities may exist. © 2016 John Wiley & Sons Ltd and The Association for the Study of Medical Education.

Changes in Resident Well-Being at One Institution Across a Decade of Progressive Work Hours Limitations.

PubMed

Krug, Michael F; Golob, Anna L; Wander, Pandora L; Wipf, Joyce E

2017-10-01

To measure changes in markers of resident well-being over time as progressive work hours limitations (WHLs) were enforced, and to investigate resident perceptions of the 2011 WHLs. A survey study of internal medicine residents was conducted at the University of Washington's multihospital residency program in 2012. The survey included validated well-being questions: the Maslach Burnout Inventory, the two-question PRIME-MD depression screen, and career satisfaction questions. Chi-square tests were used to compare 2012 well-being questionnaire responses against nearly identical surveys conducted in 2001 and 2004 at the same institution. In addition, residents were asked to rate the impact of WHLs on resident well-being and education as well as patient care, and to state preferences for future WHLs. Significantly different proportions of residents met burnout criteria across time, with fewer meeting criteria in 2012 than in 2001 (2001: 76% [87/115]; 2004: 64% [75/118]; 2012: 61% [68/112]; P = .039). Depression screening results also differed across time, with fewer screening positive in 2012 than in 2004 (2001: 45% [52/115]; 2004: 55% [65/118]; 2012 [35/112]: 31%; P = .001). Residents, especially seniors, reported perceived negative impacts of WHLs on their well-being, education, and patient care. Most senior residents favored reverting to the pre-July 2011 system of WHLs. Interns were more divided. Validated measures of resident well-being changed across the three time points measured. Residents had the lowest rates of burnout and depression in 2012. Resident perceptions of the 2011 WHLs, however, were generally negative.

Residence time of symmetric random walkers in a strip with large reflective obstacles

NASA Astrophysics Data System (ADS)

Ciallella, Alessandro; Cirillo, Emilio N. M.; Sohier, Julien

2018-05-01

We study the effect of a large obstacle on the so-called residence time, i.e., the time that a particle performing a symmetric random walk in a rectangular (two-dimensional, 2D) domain needs to cross the strip. We observe complex behavior: We find out that the residence time does not depend monotonically on the geometric properties of the obstacle, such as its width, length, and position. In some cases, due to the presence of the obstacle, the mean residence time is shorter with respect to the one measured for the obstacle-free strip. We explain the residence time behavior by developing a one-dimensional (1D) analog of the 2D model where the role of the obstacle is played by two defect sites having smaller probability to be crossed with respect to all the other regular sites. The 1D and 2D models behave similarly, but in the 1D case we are able to compute exactly the residence time, finding a perfect match with the Monte Carlo simulations.

Pediatricians Working Part-Time Has Plateaued.

PubMed

Cull, William L; Frintner, Mary Pat; O'Connor, Karen G; Olson, Lynn M

2016-04-01

To examine trends in pediatricians working part-time and residents seeking part-time work and to examine associated characteristics. The American Academy of Pediatrics (AAP) Periodic Survey of Fellows and the AAP Annual Survey of Graduating Residents were used to examine part-time employment. Fourteen periodic surveys were combined with an overall response rate of 57%. Part-time percentages were compared for surveys conducted from 2006-2009 and 2010-2013. The AAP Annual Surveys of Graduating Residents (combined response rate = 60%) from 2006-2009 were compared with 2010-2013 surveys for residents seeking and obtaining part-time positions following training. Multivariable logistic regression models identified characteristics associated with part-time work. Comparable percentages of pediatricians worked part-time in 2006-2009 (23%) and 2010-2013 (23%). There was similarly no statistically significant difference in residents seeking part-time work (30%-28%), and there was a slight decline in residents accepting part-time work (16%-13%, aOR .75, 95% CI .56-.96). Increases in working part-time were not found for any subgroups examined. Women consistently were more likely than men to work part-time (35% vs 9%), but they showed different patterns of part-time work across age. Women in their 40s (40%) were more likely than other women (33%) and men in their 60s (20%) were more likely than other men (5%) to work part-time. There has been a levelling off in the number of pediatricians working part-time and residents seeking part-time work. Overall, women remain more likely to work part-time, although 1 in 5 men over 60 work part-time. Copyright © 2016 Elsevier Inc. All rights reserved.

Revising traditional theory on the link between plant body size and fitness under competition: evidence from old-field vegetation

PubMed Central

Tracey, Amanda J; Aarssen, Lonnie W

2014-01-01

The selection consequences of competition in plants have been traditionally interpreted based on a “size-advantage” hypothesis – that is, under intense crowding/competition from neighbors, natural selection generally favors capacity for a relatively large plant body size. However, this conflicts with abundant data, showing that resident species body size distributions are usually strongly right-skewed at virtually all scales within vegetation. Using surveys within sample plots and a neighbor-removal experiment, we tested: (1) whether resident species that have a larger maximum potential body size (MAX) generally have more successful local individual recruitment, and thus greater local abundance/density (as predicted by the traditional size-advantage hypothesis); and (2) whether there is a general between-species trade-off relationship between MAX and capacity to produce offspring when body size is severely suppressed by crowding/competition – that is, whether resident species with a larger MAX generally also need to reach a larger minimum reproductive threshold size (MIN) before they can reproduce at all. The results showed that MIN had a positive relationship with MAX across resident species, and local density – as well as local density of just reproductive individuals – was generally greater for species with smaller MIN (and hence smaller MAX). In addition, the cleared neighborhoods of larger target species (which had relatively large MIN) generally had – in the following growing season – a lower ratio of conspecific recruitment within these neighborhoods relative to recruitment of other (i.e., smaller) species (which had generally smaller MIN). These data are consistent with an alternative hypothesis based on a ‘reproductive-economy-advantage’ – that is, superior fitness under competition in plants generally requires not larger potential body size, but rather superior capacity to recruit offspring that are in turn capable of producing grand-offspring – and hence transmitting genes to future generations – despite intense and persistent (cross-generational) crowding/competition from near neighbors. Selection for the latter is expected to favor relatively small minimum reproductive threshold size and hence – as a tradeoff – relatively small (not large) potential body size. PMID:24772274

Temporal modulation transfer functions in auditory receptor fibres of the locust ( Locusta migratoria L.).

PubMed

Prinz, P; Ronacher, B

2002-08-01

The temporal resolution of auditory receptors of locusts was investigated by applying noise stimuli with sinusoidal amplitude modulations and by computing temporal modulation transfer functions. These transfer functions showed mostly bandpass characteristics, which are rarely found in other species at the level of receptors. From the upper cut-off frequencies of the modulation transfer functions the minimum integration times were calculated. Minimum integration times showed no significant correlation to the receptor spike rates but depended strongly on the body temperature. At 20 degrees C the average minimum integration time was 1.7 ms, dropping to 0.95 ms at 30 degrees C. The values found in this study correspond well to the range of minimum integration times found in birds and mammals. Gap detection is another standard paradigm to investigate temporal resolution. In locusts and other grasshoppers application of this paradigm yielded values of the minimum detectable gap widths that are approximately twice as large than the minimum integration times reported here.

Anesthesia preparation time is not affected by the experience level of the resident involved during his/her first month of adult cardiac surgery.

PubMed

Broussard, David M; Couch, Michael C

2011-10-01

This study was designed to answer the question of whether the experience level of the resident on his/her first month of adult cardiothoracic anesthesiology has an impact on operating room efficiency in a large academic medical center. Traditionally, the resident's 1st month of cardiac anesthesia had been reserved for the clinical anesthesia (CA)-2 year of training. This study analyzed the impact on operating room efficiency of moving the 1st month of cardiac anesthesia into the CA-1 year. The authors hypothesized that there would be no difference in anesthesia preparation times (defined as the interval between "in-room" and "anesthesia-ready" times) between CA-1 and CA-2 residents on their 1st month of cardiac anesthesia. This study was retrospective and used an electronic anesthesia information management system database. This study was conducted on care provided at a single 450-bed academic medical center. This study included 12 residents in their 1st month of cardiac anesthesia. The anesthesia preparation time (defined as the interval between "in-room" and "anesthesia-ready" times) was measured for cases involving residents on their first month of cardiac anesthesia. Anesthesia preparation times for 6 CA-1 resident months and 6 CA-2 resident months (100 adult cardiac procedures in total) were analyzed (49 for the CA-1 residents and 51 for the CA-2s). There were no differences in preparation time between CA-1 and CA-2 residents as a group (p = 0.8169). The CA-1 residents had an unadjusted mean (±standard error) of 51.1 ± 3.18 minutes, whereas the CA-2 residents' unadjusted mean was 50.2 ± 2.41 minutes. Adjusting for case mix (valves v coronary artery bypass graft surgery), the CA-1 mean was 49.1 ± 5.22 minutes, whereas the CA-2 mean was 49.1 ± 4.54 minutes. These findings suggest that operating room efficiency as measured by the anesthesia preparation time may not be affected by the level of the resident on his/her 1st month of adult cardiac anesthesia. Copyright © 2011 Elsevier Inc. All rights reserved.

A virtual reality endoscopic simulator augments general surgery resident cancer education as measured by performance improvement.

PubMed

White, Ian; Buchberg, Brian; Tsikitis, V Liana; Herzig, Daniel O; Vetto, John T; Lu, Kim C

2014-06-01

Colorectal cancer is the second most common cause of death in the USA. The need for screening colonoscopies, and thus adequately trained endoscopists, particularly in rural areas, is on the rise. Recent increases in required endoscopic cases for surgical resident graduation by the Surgery Residency Review Committee (RRC) further emphasize the need for more effective endoscopic training during residency to determine if a virtual reality colonoscopy simulator enhances surgical resident endoscopic education by detecting improvement in colonoscopy skills before and after 6 weeks of formal clinical endoscopic training. We conducted a retrospective review of prospectively collected surgery resident data on an endoscopy simulator. Residents performed four different clinical scenarios on the endoscopic simulator before and after a 6-week endoscopic training course. Data were collected over a 5-year period from 94 different residents performing a total of 795 colonoscopic simulation scenarios. Main outcome measures included time to cecal intubation, "red out" time, and severity of simulated patient discomfort (mild, moderate, severe, extreme) during colonoscopy scenarios. Average time to intubation of the cecum was 6.8 min for those residents who had not undergone endoscopic training versus 4.4 min for those who had undergone endoscopic training (p < 0.001). Residents who could be compared against themselves (pre vs. post-training), cecal intubation times decreased from 7.1 to 4.3 min (p < 0.001). Post-endoscopy rotation residents caused less severe discomfort during simulated colonoscopy than pre-endoscopy rotation residents (4 vs. 10%; p = 0.004). Virtual reality endoscopic simulation is an effective tool for both augmenting surgical resident endoscopy cancer education and measuring improvement in resident performance after formal clinical endoscopic training.

Ventilation rates and activity levels of juvenile jumbo squid under metabolic suppression in the oxygen minimum zone.

PubMed

Trübenbach, Katja; Pegado, Maria R; Seibel, Brad A; Rosa, Rui

2013-02-01

The Humboldt (jumbo) squid, Dosidicus gigas, is a part-time resident of the permanent oxygen minimum zone (OMZ) in the Eastern Tropical Pacific and, thereby, it encounters oxygen levels below its critical oxygen partial pressure. To better understand the ventilatory mechanisms that accompany the process of metabolic suppression in these top oceanic predators, we exposed juvenile D. gigas to the oxygen levels found in the OMZ (1% O(2), 1 kPa, 10 °C) and measured metabolic rate, activity cycling patterns, swimming mode, escape jet (burst) frequency, mantle contraction frequency and strength, stroke volume and oxygen extraction efficiency. In normoxia, metabolic rate varied between 14 and 29 μmol O(2) g(-1) wet mass h(-1), depending on the level of activity. The mantle contraction frequency and strength were linearly correlated and increased significantly with activity level. Additionally, an increase in stroke volume and ventilatory volume per minute was observed, followed by a mantle hyperinflation process during high activity periods. Squid metabolic rate dropped more than 75% during exposure to hypoxia. Maximum metabolic rate was not achieved under such conditions and the metabolic scope was significantly decreased. Hypoxia changed the relationship between mantle contraction strength and frequency from linear to polynomial with increasing activity, indicating that, under hypoxic conditions, the jumbo squid primarily increases the strength of mantle contraction and does not regulate its frequency. Under hypoxia, jumbo squid also showed a larger inflation period (reduced contraction frequency) and decreased relaxed mantle diameter (shortened diffusion pathway), which optimize oxygen extraction efficiency (up to 82%/34%, without/with consideration of 60% potential skin respiration). Additionally, they breathe 'deeply', with more powerful contractions and enhanced stroke volume. This deep-breathing behavior allows them to display a stable ventilatory volume per minute, and explains the maintenance of the squid's cycling activity under such O(2) conditions. During hypoxia, the respiratory cycles were shorter in length but increased in frequency. This was accompanied by an increase in the number of escape jets during active periods and a faster switch between swimming modes. In late hypoxia (onset ~170 ± 10 min), all the ventilatory processes were significantly reduced and followed by a lethargic state, a behavior that seems closely associated with the process of metabolic suppression and enables the squid to extend its residence time in the OMZ.

Staged fluidized bed

DOEpatents

Mallon, R.G.

1983-05-13

The invention relates to oil shale retorting and more particularly to staged fluidized bed oil shale retorting. Method and apparatus are disclosed for narrowing the distribution of residence times of any size particle and equalizing the residence times of large and small particles in fluidized beds. Particles are moved up one fluidized column and down a second fluidized column with the relative heights selected to equalize residence times of large and small particles. Additional pairs of columns are staged to narrow the distribution of residence times and provide complete processing of the material.

Comparison of the effectiveness of some common animal data scaling techniques in estimating human radiation dose

DOE Office of Scientific and Technical Information (OSTI.GOV)

Sparks, R.B.; Aydogan, B.

In the development of new radiopharmaceuticals, animal studies are typically performed to get a first approximation of the expected radiation dose in humans. This study evaluates the performance of some commonly used data extrapolation techniques to predict residence times in humans using data collected from animals. Residence times were calculated using animal and human data, and distributions of ratios of the animal results to human results were constructed for each extrapolation method. Four methods using animal data to predict human residence times were examined: (1) using no extrapolation, (2) using relative organ mass extrapolation, (3) using physiological time extrapolation, andmore » (4) using a combination of the mass and time methods. The residence time ratios were found to be log normally distributed for the nonextrapolated and extrapolated data sets. The use of relative organ mass extrapolation yielded no statistically significant change in the geometric mean or variance of the residence time ratios as compared to using no extrapolation. Physiologic time extrapolation yielded a statistically significant improvement (p < 0.01, paired t test) in the geometric mean of the residence time ratio from 0.5 to 0.8. Combining mass and time methods did not significantly improve the results of using time extrapolation alone. 63 refs., 4 figs., 3 tabs.« less

Analytic expressions for Atomic Layer Deposition: coverage, throughput, and materials utilization in cross-flow, particle coating, and spatial ALD

DOE Office of Scientific and Technical Information (OSTI.GOV)

Yanguas-Gil, Angel; Elam, Jeffrey W.

2014-05-01

In this work, the authors present analytic models for atomic layer deposition (ALD) in three common experimental configurations: cross-flow, particle coating, and spatial ALD. These models, based on the plug-flow and well-mixed approximations, allow us to determine the minimum dose times and materials utilization for all three configurations. A comparison between the three models shows that throughput and precursor utilization can each be expressed by universal equations, in which the particularity of the experimental system is contained in a single parameter related to the residence time of the precursor in the reactor. For the case of cross-flow reactors, the authorsmore » show how simple analytic expressions for the reactor saturation profiles agree well with experimental results. Consequently, the analytic model can be used to extract information about the ALD surface chemistry (e. g., the reaction probability) by comparing the analytic and experimental saturation profiles, providing a useful tool for characterizing new and existing ALD processes. (C) 2014 American Vacuum Society« less

Accurate evaluation for the biofilm-activated sludge reactor using graphical techniques

NASA Astrophysics Data System (ADS)

Fouad, Moharram; Bhargava, Renu

2018-05-01

A complete graphical solution is obtained for the completely mixed biofilm-activated sludge reactor (hybrid reactor). The solution consists of a series of curves deduced from the principal equations of the hybrid system after converting them in dimensionless form. The curves estimate the basic parameters of the hybrid system such as suspended biomass concentration, sludge residence time, wasted mass of sludge, and food to biomass ratio. All of these parameters can be expressed as functions of hydraulic retention time, influent substrate concentration, substrate concentration in the bulk, stagnant liquid layer thickness, and the minimum substrate concentration which can maintain the biofilm growth in addition to the basic kinetics of the activated sludge process in which all these variables are expressed in a dimensionless form. Compared to other solutions of such system these curves are simple, easy to use, and provide an accurate tool for analyzing such system based on fundamental principles. Further, these curves may be used as a quick tool to get the effect of variables change on the other parameters and the whole system.

Gait Speed rather than Dynapenia Is a Simple Indicator for Complex Care Needs: A Cross-sectional Study Using Minimum Data Set.

PubMed

Huang, Tzu-Ya; Liang, Chih-Kuang; Shen, Hsiu-Chu; Chen, Hon-I; Liao, Mei-Chen; Chou, Ming-Yueh; Lin, Yu-Te; Chen, Liang-Kung

2017-08-21

The impact of dynapenia on the complexity of care for residents of long-term care facilities (LTCF) remains unclear. The present study evaluated associations between dynapenia, care problems and care complexity in 504 residents of Veterans Care Homes (VCHs) in Taiwan. Subjects with dynapenia, defined as low muscle strength (handgrip strength <26 kg), were older adults with lower body mass index (BMI), slow gait speed, and higher numbers of Resident Assessment Protocol (RAP) triggers. After adjusting for age, education, BMI, and Charlson's comorbidity index (CCI), only age, education, BMI and gait speed were independently associated with higher numbers of RAP triggers, but not dynapenia or handgrip strength (kg). Dividing subjects into groups based on quartiles of gait speed, those with gait speed ≤0.803 m/s were significantly associated with higher complexity of care needs (defined as ≥4 RAP triggers) compared to the reference group (gait speed >1 m/s). Significantly slow gait speed was associated with RAP triggers, including cognitive loss, poor communication ability, rehabilitation needs, urinary incontinence, depressed mood, falls, pressure ulcers, and use of psychotropic drugs. In conclusion, slow gait speed rather than dynapenia is a simple indicator for higher complexity of care needs of older male LTCF residents.

Modification of Prim’s algorithm on complete broadcasting graph

NASA Astrophysics Data System (ADS)

Dairina; Arif, Salmawaty; Munzir, Said; Halfiani, Vera; Ramli, Marwan

2017-09-01

Broadcasting is an information dissemination from one object to another object through communication between two objects in a network. Broadcasting for n objects can be solved by n - 1 communications and minimum time unit defined by ⌈2log n⌉ In this paper, weighted graph broadcasting is considered. The minimum weight of a complete broadcasting graph will be determined. Broadcasting graph is said to be complete if every vertex is connected. Thus to determine the minimum weight of complete broadcasting graph is equivalent to determine the minimum spanning tree of a complete graph. The Kruskal’s and Prim’s algorithm will be used to determine the minimum weight of a complete broadcasting graph regardless the minimum time unit ⌈2log n⌉ and modified Prim’s algorithm for the problems of the minimum time unit ⌈2log n⌉ is done. As an example case, here, the training of trainer problem is solved using these algorithms.

Impact of duty-hour restriction on resident inpatient teaching.

PubMed

Mazotti, Lindsay A; Vidyarthi, Arpana R; Wachter, Robert M; Auerbach, Andrew D; Katz, Patricia P

2009-10-01

Education and patient care are essential to academic hospitalists, and residents are key partners in these goals. The Accreditation Council for Graduate Medical Education (ACGME) duty-hour restrictions (DHR) likely impacted aspects of resident teaching, well-being, and patient care practices that affect the duties of academic hospitalists. To determine the impact of DHR on resident teaching time and the factors associated with, and impacts of, time spent teaching. Cross-sectional survey. SETTING AND MEASUREMENTS: A total of 164 internal medicine residents at University of California, San Francisco (UCSF), San Francisco, CA were queried regarding their time spent teaching, completion of administrative tasks, number of hours worked, frequency of emotional exhaustion, and satisfaction with quality of patient care provided after DHR. Regression analyses identified factors associated with decreased teaching time and determined that there were associations between time spent teaching, emotional exhaustion, and satisfaction with quality of patient care. A total of 125 residents (76%) responded; 24% reported spending less time teaching. Less time teaching was associated with being a postgraduate year (PGY)-2 (odds ratio [OR], 7.14; 95% confidence interval [CI], 1.56-32.79) or PGY-3 (OR, 8.23; 95% CI, 1.44-47.09), reporting working <80 hours/week (OR, 5.99; 95% CI, 1.11-32.48) and spending a greater percentage of time on administrative tasks (OR, 1.03; 95% CI, 1.00-1.06). Those residents who spent less time teaching also reported less frequent emotional exhaustion (P = 0.003) and more satisfaction with quality of care (P = 0.006). DHR has decreased teaching time for some residents, and those residents are more likely to be less emotionally exhausted and deliver self-perceived higher quality of care. Academic hospitalists should consider these impacts of DHR and make adjustments such as educational and work-life innovations to account for these shifts. Copyright 2009 Society of Hospital Medicine

Time-motion studies of internal medicine residents' duty hours: a systematic review and meta-analysis.

PubMed

Leafloor, Cameron W; Lochnan, Heather A; Code, Catherine; Keely, Erin J; Rothwell, Deanna M; Forster, Alan J; Huang, Allen R

2015-01-01

Since the mid-1980s, medical residents' long duty hours have been under scrutiny as a factor affecting patient safety and the work environment for the residents. After several mandated changes in duty hours, it is important to understand how residents spend their time before proposing and implementing future changes. Time-motion methodology may provide reliable information on what residents do while on duty. The purpose of this study is to review all available literature pertaining to time-motion studies of internal medicine residents while on a medicine service and to understand how much of their time is apportioned to various categories of tasks, and also to determine the effects of the Accreditation Council for Graduate Medical Education (ACGME)-mandated duty hour changes on resident workflow in North America. Electronic bibliographic databases were searched for articles in English between 1941 and April 2013 reporting time-motion studies of internal medicine residents rotating through a general medicine service. Eight articles were included. Residents spent 41.8% of time in patient care activities, 18.1% communicating, 13.8% in educational activities, 19.7% in personal/other, and 6.6% in transit. North American data showed the following changes after the implementation of the ACGME 2003 duty hours standard: patient care activities from 41.8% to 40.8%, communication activities from 19.0% to 22.3%, educational activities from 17.7% to 11.6%, and personal/other activities from 21.5% to 17.1%. There was a paucity of time-motion data. There was great variability in the operational definitions of task categories reported in the studies. Implementation of the ACGME duty hour standards did not have a significant effect on the percentage of time spent in particular tasks. There are conflicting reports on how duty hour changes have affected patient safety. A low proportion of time spent in educational activities deserves further study and may point to a review of the educational models used.

Communication and effectiveness in a US nursing home quality-improvement collaborative.

PubMed

Arling, Priscilla A; Abrahamson, Kathleen; Miech, Edward J; Inui, Thomas S; Arling, Greg

2014-09-01

In this study, we explored the relationship between changes in resident health outcomes, practitioner communication patterns, and practitioner perceptions of group effectiveness within a quality-improvement collaborative of nursing home clinicians. Survey and interview data were collected from nursing home clinicians participating in a quality-improvement collaborative. Quality-improvement outcomes were evaluated using US Federal and State minimum dataset measures. Models were specified evaluating the relationships between resident outcomes, staff perceptions of communication patterns, and staff perceptions of collaborative effectiveness. Interview data provided deeper understanding of the quantitative findings. Reductions in fall rates were highest in facilities where respondents experienced the highest levels of communication with collaborative members outside of scheduled meetings, and where respondents perceived that the collaborative kept them informed and provided new ideas. Clinicians observed that participation in a quality-improvement collaborative positively influenced the ability to share innovative ideas and expand the quality-improvement program within their nursing home. For practitioners, a high level of communication, both inside and outside of meetings, was key to making measurable gains in resident health outcomes. © 2013 Wiley Publishing Asia Pty Ltd.

Association of Time to Attrition in Surgical Residency With Individual Resident and Programmatic Factors.

PubMed

Yeo, Heather L; Abelson, Jonathan S; Symer, Matthew M; Mao, Jialin; Michelassi, Fabrizio; Bell, Richard; Sedrakyan, Art; Sosa, Julie A

2018-02-21

Attrition in general surgery residency remains high, and attrition that occurs in the later years is the most worrisome. Although several studies have retrospectively investigated the timing of attrition, no study to date has prospectively evaluated a national cohort of residents to understand which residents are at risk for attrition and at what point during residency. To prospectively evaluate individual resident and programmatic factors associated with the timing of attrition during general surgery residency. This longitudinal, national cohort study administered a survey to all categorical general surgery interns from the class of 2007-2008 during their first 30 days of residency and linked the data with 9-year follow-up data assessing program completion. Data were collected from June 1, 2007, through June 30, 2016. Kaplan-Meier curves evaluating time to attrition during the 9 years after the start of residency. Among our sample of 836 residents (306 women [36.6%] and 528 men [63.2%]; gender unknown in 2), cumulative survival analysis demonstrated overall attrition for the cohort of 20.8% (n = 164). Attrition was highest in the first postgraduate year (67.6% [n = 111]; absolute rate, 13.3%) but continued during the next 6 years, albeit at a lower rate. Beginning in the first year, survival analysis demonstrated higher attrition among Hispanic compared with non-Hispanic residents (21.1% vs 12.4%; P = .04) and at military programs compared with academic or community programs after year 1 (32.3% vs 11.0% or 13.5%; P = .01). Beginning in year 4 of residency, higher attrition was encountered among women compared with men (23.3% vs 17.4%; P = .05); at year 5, at large compared with small programs (26.0% vs 18.4%; P = .04). Race and program location were not associated with attrition. Although attrition was highest during the internship year, late attrition persists, particularly among women and among residents in large programs. These results provide a framework for timing of interventions in graduate surgical training that target residents most at risk for late attrition.

Importance of First and Second Authorship in Assessing Citation-Based Scholarly Activity of US Radiation Oncology Residents and Subsequent Choice of Academic Versus Private Practice Career.

PubMed

McClelland, Shearwood; Mitin, Timur; Jagsi, Reshma; Thomas, Charles R; Jaboin, Jerry J

2018-06-20

The Hirsch index (h-index) has been shown to correlate with radiation oncology residents' having a first job in academics versus private practice, but it is limited by its inability to distinguish between the differing significance of coauthor roles in articles. A list of 2016 radiation oncology resident graduates and their postresidency career choices was compiled. The Scopus bibliometric citation database was then searched to collect h-index data for articles limited to first author only (h f ) and first or second-author only (h s ) for each resident. Mean h f was 2.06 for all resident graduates, and mean h s was 2.77. Residents with PhDs had significantly higher h f (3.11 versus 1.76, P < .01) and h s (4.50 versus 2.28, P < .01). There was no statistically significant difference between male and female residents for h f (2.19 versus 1.61, P = .11) or h s (2.91 versus 2.25, P = .15). Residents choosing academia had higher h f (2.72 versus 1.44, P < .01) and h s (3.57 versus 2.01, P < 0.01) than those in private practice. Fewer than 20% of graduates with h f  = 0 and only 10% of graduates with h s  = 0 secured academic jobs. The average radiation oncology resident graduate has published a minimum of two first- and/or second-author articles cited at least twice. Graduates with PhDs and/or choosing academic careers were more likely to have higher h f and h s scores; there was no significant score difference by gender. Only 10% of graduates without any first- and/or second-author articles cited at least once secured academic jobs. These findings indicate that stratifying publications by first or second authorship when developing benchmarks for evaluating resident productivity and postresidency career type may be useful. Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.

A new time-space accounting scheme to predict stream water residence time and hydrograph source components at the watershed scale

Treesearch

Takahiro Sayama; Jeffrey J. McDonnell

2009-01-01

Hydrograph source components and stream water residence time are fundamental behavioral descriptors of watersheds but, as yet, are poorly represented in most rainfall-runoff models. We present a new time-space accounting scheme (T-SAS) to simulate the pre-event and event water fractions, mean residence time, and spatial source of streamflow at the watershed scale. We...

A national study of prescribed drugs in institutions and community residential facilities for mentally retarded people.

PubMed

Hill, B K; Balow, E A; Bruininks, R H

1985-01-01

The prevalence of psychotropic and nonpsychotropic drug prescriptions in institutions and community residential facilities in 1978-79 was assessed. The data were gathered as an incidental part of a comprehensive national interview study of the characteristics of residential facilities and their residents. The study included 2271 retarded individuals in 236 residential facilities in the US. Facilities were selected through a 2-stage probability sample design in such a way that the probability of a facility's selection was proportionate to its size (number of residents) and so that the distribution of sample facilities across census regions and size classes was in close agreement with the distribution of facilities nationally. Interviews at 75 institutions and 161 private facilities were conducted between September 1978 and April 1979. Demographic information about individual residents, including date of birth, date of admission, previous type of residential placement, age, height, weight, diagnosed degree of retardation, and diagnosis of epilepsy, autism, or mental illness, was obtained from each resident's records. The staff person most familiar with each resident was then identified and interviewed about the resident. Care persons were asked whether and for what purpose drugs were prescribed for each resident. 75.8% of institutionalized residents and 54.3% of community facility residents were reported to be receiving at least 1 type of regularly prescribed medication. Percentages reported for specific drugs should be considered minimums, because drug names were not always elicited if the drug's purpose was known. Drugs not named, but reported to be prescribed for a chronic health condition, epilepsy, a psychiatric problem, for sleeping, or for birth control, were listed with "other" within tentative categories. Multiple regression was used to examine the relationships among drug use and several resident and facility characteristics. The institutionalized and community-based samples were combined for these analyses. Drugs reported to be prescribed for chronic health problems most frequently were used by older, nonambulatory residents who had health problems. Use of antiepilepsy drugs was most closely associated with a history of seizures. Only 1.3% of community facility residents and 1.6% of institutionalized residents whose records did not document epilepsy were reported to be receiving antiepilepsy drugs. Psychotropic drugs most often were prescribed for residents with behavior problems or for those with a recorded mention of mental illness or autism. Older, heavier, and more severely retarded residents also were more likely to receive psychotropic drugs. Contraceptive drugs were predicted by age, sex, ability, and minority status. Younger and less retarded women were more likely to receive birth control methods, as were minorities.

Dietary Diversity Is Not Associated with Haematological Status of Pregnant Women Resident in Rural Areas of Northern Ghana.

PubMed

Saaka, Mahama; Oladele, Jeremiah; Larbi, Asamoah; Hoeschle-Zeledon, Irmgard

2017-01-01

Background . Information regarding how dietary diversity is related to haematological status of the pregnant women in rural areas of Northern Ghana is limited. This study therefore evaluated maternal dietary intake and how it relates to the nutritional status of pregnant women belonging to different socioeconomic conditions in Northern Ghana. Methods . This study was cross-sectional in design involving 400 pregnant women. Midupper arm circumference (MUAC) and anaemia status were used to assess the nutritional status of pregnant women. Results . The mean dietary diversity score (DDS) of the study population from ten food groups was 4.2 ± 1.5 (95% CI: 4.08 to 4.37). Of the 400 women, 46.1% (95% CI: 40.0 to 52.2) met the new minimum dietary diversity for women (MDD-W). The mean haemoglobin concentration among the pregnant women studied was 10.1 g/dl ± 1.40 (95% CI: 9.8 to 10.3). The independent predictors of haemoglobin concentration were maternal educational attainment, gestational age, frequency of antenatal care (ANC) attendance, number of under-five children in the household, size of MUAC, and maternal height. Conclusions . Irrespective of the socioeconomic status, women minimum dietary diversity (MDD-W) was not associated with anaemia among pregnant women resident in the rural areas of Northern Ghana.

Water Residence Time estimation by 1D deconvolution in the form of a l2 -regularized inverse problem with smoothness, positivity and causality constraints

NASA Astrophysics Data System (ADS)

Meresescu, Alina G.; Kowalski, Matthieu; Schmidt, Frédéric; Landais, François

2018-06-01

The Water Residence Time distribution is the equivalent of the impulse response of a linear system allowing the propagation of water through a medium, e.g. the propagation of rain water from the top of the mountain towards the aquifers. We consider the output aquifer levels as the convolution between the input rain levels and the Water Residence Time, starting with an initial aquifer base level. The estimation of Water Residence Time is important for a better understanding of hydro-bio-geochemical processes and mixing properties of wetlands used as filters in ecological applications, as well as protecting fresh water sources for wells from pollutants. Common methods of estimating the Water Residence Time focus on cross-correlation, parameter fitting and non-parametric deconvolution methods. Here we propose a 1D full-deconvolution, regularized, non-parametric inverse problem algorithm that enforces smoothness and uses constraints of causality and positivity to estimate the Water Residence Time curve. Compared to Bayesian non-parametric deconvolution approaches, it has a fast runtime per test case; compared to the popular and fast cross-correlation method, it produces a more precise Water Residence Time curve even in the case of noisy measurements. The algorithm needs only one regularization parameter to balance between smoothness of the Water Residence Time and accuracy of the reconstruction. We propose an approach on how to automatically find a suitable value of the regularization parameter from the input data only. Tests on real data illustrate the potential of this method to analyze hydrological datasets.

Operative time and cost of resident surgical experience: effect of instituting an otolaryngology residency program.

PubMed

Pollei, Taylor R; Barrs, David M; Hinni, Michael L; Bansberg, Stephen F; Walter, Logan C

2013-06-01

Describe the procedure length difference between surgeries performed by an attending surgeon alone compared with the resident surgeon supervised by the same attending surgeon. Case series with chart review. Tertiary care center and residency program. Six common otolaryngologic procedures performed between August 1994 and May 2012 were divided into 2 cohorts: attending surgeon alone or resident surgeon. This division coincided with our July 2006 initiation of an otolaryngology-head and neck surgery residency program. Operative duration was compared between cohorts with confounding factors controlled. In addition, the direct result of increased surgical length on operating room cost was calculated and applied to departmental and published resident case log report data. Five of the 6 procedures evaluated showed a statistically significant increase in surgery length with resident involvement. Operative time increased 6.8 minutes for a cricopharyngeal myotomy (P = .0097), 11.3 minutes for a tonsillectomy (P < .0001), 27.4 minutes for a parotidectomy (P = .028), 38.3 minutes for a septoplasty (P < .0001), and 51 minutes for tympanomastoidectomy (P < .0021). Thyroidectomy showed no operative time difference. Cost of increased surgical time was calculated per surgery and ranged from $286 (cricopharyngeal myotomy) to $2142 (mastoidectomy). When applied to reported national case log averages for graduating residents, this resulted in a significant increase of direct training-related costs. Resident participation in the operating room results in increased surgical length and additional system cost. Although residency is a necessary part of surgical training, associated costs need to be acknowledged.

[Work satisfaction, quality of life and leisure time of residents at the Soroka University Medical Center, Beer Sheba, Israel].

PubMed

Acker, Asaf; Perry, Zvi; Reuveni, Haim; Toker, Asaf

2009-02-01

Work dissatisfaction among physicians worldwide continues to rise over the last few decades, mainly due to declining professional prestige, tack of self fulfillment, time pressure and tack of leisure time. Physicians' burnout is a major result of dissatisfaction, causing doctors to leave the medical profession, and to provide lower quality of care. To examine the work satisfaction, quality of life and leisure time of residents in the Soroka University Medical Center. A validated questionnaire was delivered during the second half of 2004 to 252 residents in the Soroka University Medical Center The data was analyzed using the SPSS 12 for windows program. Descriptive analysis, parametric Students' T Test [where p<0.05 was set to be considered valid) and a-parametric Mann Whitney and x2 tests were conducted. A total of 137 residents responded to the questionnaire (response rate of 54.36%]. The residents' satisfaction level was low, mainly due to dissatisfaction with their quality of life. There was no difference in satisfaction between male and female residents. Residents in the early stage of their internship were more satisfied than residents who had completed the first stage in regard to their income (p=0.005). Surgical residents were less satisfied than non-surgical residents (p=0.003), mainly from the work relations with their superiors (p=0.015). The residents at the Soroka University Medical Center were satisfied with their work environment but not with their quality of life and leisure time. Further attention must be given to these matters--a step which will eventually improve patient care, and delay, to some extent, the burnout of physicians.

Finding Value in Surgical Didactics: Longitudinal Resident Feedback From Case-Based and Traditional Lectures in an Orthopaedic Residency.

PubMed

Barnwell, Jonathan C; Halvorson, Jason J; Teasdall, Robert D; Carroll, Eben A

To evaluate orthopedic resident perceptions of a didactic curriculum presented in traditional and case-based formats. Prospective cohort study using anonymous web-based survey after each conference evaluating resident perceptions of faculty participation, didactic delivery, content, and overall conference value. Conferences were structured as primarily case-based or traditional lecture. Logistic analysis was performed to determine factors predictive of rating a conference as valuable time spent. Orthopedic residency training program at single institution over an academic year. Orthopedic residents in postgraduate training year 1 to 5 attending mandatory didactic conference. Cased-based conferences received higher Likert ratings on residents' perception of faculty participation, instructor delivery, and improvement in topic understanding when compared to traditional lecture-based conferences (p < 0.0001 for each factor). Residents also were more likely to rate case-based conferences as valuable time spent (p < 0.0001). In our logistic model, factors associated with a negative likelihood of rating a conference as valuable were lecture format (odds ratio [OR] = 0.155, 95% CI: 0.115-0.208), PGY-2 level presenter (OR = 0.288, 95% CI: 0.169-0.490), and PGY-3 level presenter (OR = 0.433, 95% CI: 0.269-0.696). Timing in the year, surgical subspeciality, and conference identity were not significant predictors of conference value rating. Longitudinal resident feedback demonstrates highly favorable resident perceptions toward case-based formats in didactic sessions. Junior levels residents are not perceived as effective as senior residents and faculty in presenting material in either format. These methods allow for a dynamic approach to identifying strengths and weaknesses in a resident curriculum as a well as a means for more focused and real-time improvements. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Effect of modest pay-for-performance financial incentive on time-to-discharge summary dictation among medical residents.

PubMed

Wolk, Adam; Wang, Erwin; Horak, Bernard; Cloonan, Patricia; Adams, Michael; Moore, Eileen; Jaipaul, Chitra Komal; Brown, Gabrielle; Dasgupta, Dabanjan; Deluca, Danielle; Grossman, Mila

2013-01-01

Evaluate the effect of a modest financial incentive on time-to-discharge summary dictation among medicine residents. Pay-for-performance incentives are used in a number of health care settings. Studies are lacking on their use with medical residents and other trainees. Timely completion of discharge summaries is necessary for effective follow-up after hospitalization, and residents perform the majority of discharge summary dictations in academic medical centers. Medicine residents with the lowest average discharge-to-dictation time during their 1-month inpatient medicine ward rotation were rewarded with a $50 gift card. Discharge data were captured using an autopopulating electronic database. The average discharge-to-dictation time was reduced from 7.44 to 1.84 days, representing a 75.3% decrease. Almost 90% of discharge summary dictations were performed on the day of discharge. A modest financial incentive resulted in a marked improvement in the time-to-discharge summary dictation by medicine residents. Pay-for-performance programs may be an effective strategy for improving the quality and efficiency of patient care in academic medical centers.

Online residence time distribution measurement of thermochemical biomass pretreatment reactors

DOE PAGES

Sievers, David A.; Kuhn, Erik M.; Stickel, Jonathan J.; ...

2015-11-03

Residence time is a critical parameter that strongly affects the product profile and overall yield achieved from thermochemical pretreatment of lignocellulosic biomass during production of liquid transportation fuels. The residence time distribution (RTD) is one important measure of reactor performance and provides a metric to use when evaluating changes in reactor design and operating parameters. An inexpensive and rapid RTD measurement technique was developed to measure the residence time characteristics in biomass pretreatment reactors and similar equipment processing wet-granular slurries. Sodium chloride was pulsed into the feed entering a 600 kg/d pilot-scale reactor operated at various conditions, and aqueous saltmore » concentration was measured in the discharge using specially fabricated electrical conductivity instrumentation. This online conductivity method was superior in both measurement accuracy and resource requirements compared to offline analysis. Experimentally measured mean residence time values were longer than estimated by simple calculation and screw speed and throughput rate were investigated as contributing factors. In conclusion, a semi-empirical model was developed to predict the mean residence time as a function of operating parameters and enabled improved agreement.« less

Innovative dementia care: functional status over time of persons with Alzheimer disease in a residential care centre compared to special care units.

PubMed

Warren, S; Janzen, W; Andiel-Hett, C; Liu, L; McKim, H R; Schalm, C

2001-01-01

Residential care centres (RCCs) for persons with Alzheimer disease are increasing worldwide, but there are few studies that compare the functional outcomes of RCC residents to residents of other types of continuing care settings. This study compared residents of the first Canadian RCC on physical, cognitive, behavioural and emotional functioning 6, 12 and 18 months after admission to residents of special care units (SCUs) operated by the same continuing care provider. SCU residents were initially functioning lower than RCC residents on most outcome measures and these differences persisted over time. Resident functioning declined over time regardless of care setting and, when the initial status was controlled for, the rates of decline were similar. However, RCC residents experienced greater independence/freedom of choice, fewer physical or psychotropic medication restraints and were more active, which may have enhanced their quality of life. Copyright 2001 S. Karger AG, Basel

Mixing and residence times of stormwater runoff in a detection system

USGS Publications Warehouse

Martin, Edward H.

1989-01-01

Five tracer runs were performed on a detention pond and wetlands system to determine mixing and residence times in the system. The data indicate that at low discharges and with large amounts of storage, the pond is moderately mixed with residence times not much less than the theoretical maximum possible under complete mixing. At higher discharges and with less storage in the pond, short-circuiting occurs, reducing the amount of mixing in the pond and appreciably reducing the residence times. The time between pond outlet peak concentrations and wetlands outlet peak concentrations indicate that in the wetlands, mixing increases with decreasing discharge and increasing storage.

Mortality and hospitalization at the end of life in newly admitted nursing home residents with and without dementia.

PubMed

Allers, Katharina; Hoffmann, Falk

2018-05-02

The proportion of deaths occurring in nursing homes is increasing and end of life hospitalizations in residents are common. This study aimed to obtain the time from nursing home admission to death and the frequency of hospitalizations prior to death among residents with and without dementia. This retrospective cohort study analyzed claims data of 127,227 nursing home residents aged 65 years and older newly admitted to a nursing home between 2010 and 2014. We analyzed hospitalizations during the last year of life and assessed mortality rates per 100 person-years. Factors potentially associated with time to death were analyzed in Cox proportional hazard models. The median time from nursing home admission to death was 777 and 635 days in residents with and without dementia, respectively. Being male, older age and a higher level of care decreased the survival time. Sex and age had a higher influence on survival time in residents with dementia, whereas level of care was found to have a higher influence in residents without dementia. Half of the residents of both groups were hospitalized during the last month and about 37% during the last week before death. Leading causes of hospitalizations were infections (with dementia: 20.6% vs. without dementia: 17.2%) and cardiovascular diseases (with dementia: 16.6% vs. without dementia: 19.0%). A high proportion of residents with and without dementia are hospitalized shortly before death. There should be an open debate about the appropriateness of hospitalizing nursing home residents especially those with dementia near death.

A break-even analysis of optimum faculty assignment for ambulatory primary care training.

PubMed

Xakellis, G C; Gjerde, C L; Xakellis, M G; Klitgaard, D

1996-12-01

The increased demand that faculty teach residents in ambulatory clinics necessitates the development of ambulatory care teaching models that are both educationally effective and financially viable. This study was designed to identify the resident-to-faculty ratios needed to provide financially viable faculty supervision of residents while maintaining acceptable resident waiting times for teaching. A computer simulation was developed to estimate the number of residents one or two faculty teachers could supervise in a university-based primary care teaching clinic. The number of residents was calculated for three waiting-time constraints and three scenarios of faculty tasks. A financial analysis of each model was performed. With no non-teaching tasks, two teachers were able to supervise 11 residents and keep waiting times under two minutes, while one teacher was able to supervise only three residents with this waiting-time constraint. The financial break-even point was achieved by all of the two-teacher models, but by none of the one-teacher models. In all three scenarios, using two teachers resulted in more than double the number of residents supervised and in higher utilization of faculty time (higher productivity) than did using one teacher. The two-teacher models of ambulatory supervision allowed for sufficient numbers of residents to be supervised so that teaching costs could be covered from patient care revenues; the one-teacher models did not break even financially. These simulations offer a viable option for academic institutions that are struggling to maintain teaching quality in the face of financial constraints.

Training for Efficiency: Work, Time and Systems-based Practice in Medical Residency*

PubMed Central

Szymczak, Julia E.; Bosk, Charles L.

2013-01-01

Medical residency is a period of intense socialization with a heavy workload. Previous sociological studies have identified efficiency as a practical skill necessary for success. However, many contextual features of the training environment have undergone dramatic change since these studies were conducted. What are the consequences of these changes for the socialization of residents to time management and the development of a professional identity? Based on observations of and interviews with internal medicine residents at 3 training programs, we find that efficiency is both a social norm and strategy that residents employ to manage a workload for which the demand for work exceeds the supply of time available to accomplish it. We found that residents struggle to be efficient in the face of seemingly intractable “systems” problems. Residents work around these problems, and in doing so develop a tolerance for organizational vulnerabilities. PMID:22863601

How Do Residents Spend Their Shift Time? A Time and Motion Study With a Particular Focus on the Use of Computers

PubMed Central

Mamykina, Lena; Vawdrey, David K.; Hripcsak, George

2016-01-01

Purpose To understand how much time residents spend using computers as compared with other activities, and what residents use computers for. Method This time and motion study was conducted in June and July 2010 at NewYork-Presbyterian/Columbia University Medical Center with seven residents (first-, second-, and third-year) on the general medicine service. An experienced observer shadowed residents during a single day shift, captured all their activities using an iPad application, and took field notes. The activities were captured using a validated taxonomy of clinical activities, expanded to describe computer-based activities with a greater level of detail. Results Residents spent 364.5 minutes (50.6%) of their shift time using computers, compared with 67.8 minutes (9.4%) interacting with patients. In addition, they spent 292.3 minutes (40.6%) talking with others in person, 186.0 minutes (25.8%) handling paper notes, 79.7 minutes (11.1%) in rounds, 80.0 minutes (11.1%) walking or waiting, and 54.0 minutes (7.5%) talking on the phone. Residents spent 685 minutes (59.6%) multitasking. Computer-based documentation activities amounted to 189.9 minutes (52.1%) of all computer-based activities time, with 128.7 minutes (35.3%) spent writing notes and 27.3 minutes (7.5%) reading notes composed by others. Conclusions The study showed residents spent considerably more time interacting with computers (over 50% of their shift time), than in direct contact with patients (less than 10% of their shift time). Some of this may be due to an increasing reliance on computing systems for access to patient data, further exacerbated by inefficiencies in the design of the electronic health record. PMID:27028026

How Do Residents Spend Their Shift Time? A Time and Motion Study With a Particular Focus on the Use of Computers.

PubMed

Mamykina, Lena; Vawdrey, David K; Hripcsak, George

2016-06-01

To understand how much time residents spend using computers compared with other activities, and what residents use computers for. This time and motion study was conducted in June and July 2010 at NewYork-Presbyterian/Columbia University Medical Center with seven residents (first-, second-, and third-year) on the general medicine service. An experienced observer shadowed residents during a single day shift, captured all their activities using an iPad application, and took field notes. The activities were captured using a validated taxonomy of clinical activities, expanded to describe computer-based activities with a greater level of detail. Residents spent 364.5 minutes (50.6%) of their shift time using computers, compared with 67.8 minutes (9.4%) interacting with patients. In addition, they spent 292.3 minutes (40.6%) talking with others in person, 186.0 minutes (25.8%) handling paper notes, 79.7 minutes (11.1%) in rounds, 80.0 minutes (11.1%) walking or waiting, and 54.0 minutes (7.5%) talking on the phone. Residents spent 685 minutes (59.6%) multitasking. Computer-based documentation activities amounted to 189.9 minutes (52.1%) of all computer-based activities time, with 128.7 minutes (35.3%) spent writing notes and 27.3 minutes (7.5%) reading notes composed by others. The study showed that residents spent considerably more time interacting with computers (over 50% of their shift time) than in direct contact with patients (less than 10% of their shift time). Some of this may be due to an increasing reliance on computing systems for access to patient data, further exacerbated by inefficiencies in the design of the electronic health record.

PDA usage and training: targeting curriculum for residents and faculty.

PubMed

Morris, Carl G; Church, Lili; Vincent, Chris; Rao, Ashwin

2007-06-01

Utilization of personal digital assistants (PDAs) in residency education is common, but information about their use and how residents are trained to use them is limited. Better understanding of resident and faculty PDA use and training is needed. We used a cross-sectional survey of 598 residents and faculty from the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) Family Medicine Residency Network regarding PDA usage and training. Use of PDAs is common among residents (94%) and faculty (79%). Ninety-six percent of faculty and residents report stable or increasing frequency of use over time. The common barriers to PDA use relate to lack of time, knowledge, and formal education. Approximately half of PDA users (52%) have received some formal training; however, the majority of users report being self-taught. Faculty and residents prefer either small-group or one-on-one settings with hands-on, self-directed, interactive formats for PDA training. Large-group settings in lecture, written, or computer program formats were considered less helpful or desirable. PDAs have become a commonly used clinical tool. Lack of time and adequate training present a barrier to optimal application of PDAs in family medicine residency education.

Temporal dynamics of instream wood in headwater streams draining mixed Carpathian forests

NASA Astrophysics Data System (ADS)

Galia, Tomáš; Šilhán, Karel; Ruiz-Villanueva, Virginia; Tichavský, Radek; Stoffel, Markus

2017-09-01

Instream wood can reside in fluvial systems over varying periods depending on its geographical context, instream position, tree species, piece size, and fluvial environment. In this paper, we investigate the residence time of two typical species representing a majority of instream wood in steep headwaters of the Carpathians and located under mixed forest canopy. Residence times of individual logs were then confronted with other wood parameters (i.e., wood dimensions, mean annual increment rate, tree age, class of wood stabilisation and decay, geomorphic function of wood pieces, and the proportion of the log length within the active channel). Norway spruce (Picea abies (L.) Karst.) samples indicated more than two times longer mean and maximal residence times as compared to European beech (Fagus sylvatica L.) based on the successful cross-dating of 127 logs. Maximum residence time in the headwaters was 128 years for P. abies and 59 years for F. sylvatica. We demonstrate that log age and log diameter played an important role in the preservation of wood in the fluvial system, especially in the case of F. sylvatica instream wood. By contrast, we did not observe any significant trends between wood residence time and total wood length. Instream wood with geomorphic functions (i.e., formation of steps and jams) did not show any differences in residence time as compared to nonfunctional wood. Nevertheless, we found shorter residence times for hillslope-stabilised pieces when compared to pieces located entirely in the channel (either unattached or stabilised by other wood or bed sediments). We also observed changes of instream wood orientation with respect to wood residence time. This suggests some movement of instream wood (i.e., its turning or short-distance transport), including pieces longer than channel width in the steep headwaters studied here (1.5 ≤ W ≤ 3.5 m), over the past few decades.

Drinking Water Residence Time in Distribution Networks and Emergency Department Visits for Gastrointestinal Illness in Metro Atlanta, Georgia

PubMed Central

Moe, Christine L.; Klein, Mitchel; Flanders, W. Dana; Uber, Jim; Amirtharajah, Appiah; Singer, Philip; Tolbert, Paige E.

2013-01-01

We examined whether the average water residence time, the time it takes water to travel from the treatment plant to the user, for a zip code was related to the proportion of emergency department (ED) visits for gastrointestinal (GI) illness among residents of that zip code. Individual-level ED data were collected from all hospitals located in the five-county metro Atlanta area from 1993 to 2004. Two of the largest water utilities in the area, together serving 1.7 million people, were considered. People served by these utilities had almost three million total ED visits, 164,937 of them for GI illness. The relationship between water residence time and risk for GI illness was assessed using logistic regression, controlling for potential confounding factors, including patient age and markers of socioeconomic status (SES). We observed a modestly increased risk for GI illness for residents of zip codes with the longest water residence times compared to intermediate residence times (odds ratio (OR) for Utility 1 = 1.07, 95% confidence interval (CI) = 1.03, 1.10; OR for Utility 2 = 1.05, 95% CI = 1.02, 1.08). The results suggest that drinking water contamination in the distribution system may contribute to the burden of endemic GI illness. PMID:19240359

Drinking water residence time in distribution networks and emergency department visits for gastrointestinal illness in Metro Atlanta, Georgia.

PubMed

Tinker, Sarah C; Moe, Christine L; Klein, Mitchel; Flanders, W Dana; Uber, Jim; Amirtharajah, Appiah; Singer, Philip; Tolbert, Paige E

2009-06-01

We examined whether the average water residence time, the time it takes water to travel from the treatment plant to the user, for a zip code was related to the proportion of emergency department (ED) visits for gastrointestinal (GI) illness among residents of that zip code. Individual-level ED data were collected from all hospitals located in the five-county metro Atlanta area from 1993 to 2004. Two of the largest water utilities in the area, together serving 1.7 million people, were considered. People served by these utilities had almost 3 million total ED visits, 164,937 of them for GI illness. The relationship between water residence time and risk for GI illness was assessed using logistic regression, controlling for potential confounding factors, including patient age and markers of socioeconomic status (SES). We observed a modestly increased risk for GI illness for residents of zip codes with the longest water residence times compared with intermediate residence times (odds ratio (OR) for Utility 1 = 1.07, 95% confidence interval (CI) = 1.03, 1.10; OR for Utility 2 = 1.05, 95% CI = 1.02, 1.08). The results suggest that drinking water contamination in the distribution system may contribute to the burden of endemic GI illness.

The effects of the addition of a pediatric surgery fellow on the operative experience of the general surgery resident.

PubMed

Raines, Alexander; Garwe, Tabitha; Adeseye, Ademola; Ruiz-Elizalde, Alejandro; Churchill, Warren; Tuggle, David; Mantor, Cameron; Lees, Jason

2015-06-01

Adding fellows to surgical departments with residency programs can affect resident education. Our specific aim was to evaluate the effect of adding a pediatric surgery (PS) fellow on the number of index PS cases logged by the general surgery (GS) residents. At a single institution with both PS and GS programs, we examined the number of logged cases for the fellows and residents over 10 years [5 years before (Time 1) and 5 years after (Time 2) the addition of a PS fellow]. Additionally, the procedure related relative value units (RVUs) recorded by the faculty were evaluated. The fellows averaged 752 and 703 cases during Times 1 and 2, respectively, decreasing by 49 (P = 0.2303). The residents averaged 172 and 161 cases annually during Time 1 and Time 2, respectively, decreasing by 11 (P = 0.7340). The total number of procedure related RVUs was 4627 and 6000 during Times 1 and 2, respectively. The number of cases logged by the PS fellows and GS residents decreased after the addition of a PS fellow; however, the decrease was not significant. Programs can reasonably add an additional PS fellow, but care should be taken especially in programs that are otherwise static in size.

How does Australia's largest dolphin-watching industry affect the behaviour of a small and resident population of Indo-Pacific bottlenose dolphins?

PubMed

Steckenreuter, Andre; Möller, Luciana; Harcourt, Robert

2012-04-30

The small, genetically distinct population of Indo-Pacific bottlenose dolphins (Tursiops aduncus) in Port Stephens, New South Wales (NSW), is the target of the largest dolphin-watching industry in Australia and is located within the Port Stephens - Great Lakes Marine Park that was created in 2005. The effects of this industry have been identified as of significant management importance by the Marine Parks Authority NSW. Accordingly, the impact of commercial dolphin-watching boats was investigated from boat-based surveys from August 2008 to August 2009. Presence of dolphin-watching boats altered both the dolphins' behavioural states and activity budgets. Dolphins spent 66.5% less time feeding and 44.2% less time socialising, spent four times more milling, and were never observed to rest in the presence of dolphin-watching boats. Moreover, dolphin groups were more cohesive during dolphin-watching boat encounters and dolphins tended to avoid tour boats. These effects were exacerbated as the number of boats increased and the distance from boats decreased. The rate of approach was high with boats approaching each dolphin group three times per day in winter and six times in summer. Moreover, groups of dolphins with newborns were approached closer than state regulated minimum approach distances in nine out of ten encounters. Globally, dolphin-watching industries frequent small resident groups of coastal dolphins and effects are likely to be similar. We suggest that existing controls are inadequate and that these together with additional regulations be enforced by a regular presence of authorities. We suggest no more than one dolphin-watching boat within 50 m of a group of dolphins, or 100 m if calves are present. Operating times of dolphin-watching boats should be restricted in numbers after 1 pm, i.e., during preferred foraging times for dolphins. Additionally, exclusion zones should be considered to reduce pressure on dolphins undertaking critical activities such as feeding and resting. We recommend monitoring the effectiveness of new regulations that are incorporated in the reviewed marine park management plan in 2012 for a period of three years. Copyright © 2011 Elsevier Ltd. All rights reserved.

Surgical Pathology Resident Rotation Restructuring at a Tertiary Care Academic Center.

PubMed

Mehr, Chelsea R; Obstfeld, Amrom E; Barrett, Amanda C; Montone, Kathleen T; Schwartz, Lauren E

2017-01-01

Changes in the field of pathology and resident education necessitate ongoing evaluation of residency training. Evolutionary change is particularly important for surgical pathology rotations, which form the core of anatomic pathology training programs. In the past, we organized this rotation based on subjective insight. When faced with the recent need to restructure the rotation, we strove for a more evidence-based process. Our approach involved 2 primary sources of data. We quantified the number of cases and blocks submitted per case type to estimate workload and surveyed residents about the time required to gross specimens in all organ systems. A multidisciplinary committee including faculty, residents, and staff evaluated the results and used the data to model how various changes to the rotation would affect resident workload, turnaround time, and other variables. Finally, we identified rotation structures that equally distributed work and created a point-based system that capped grossing time for residents of different experience. Following implementation, we retrospectively compared turnaround time and duty hour violations before and after these changes and surveyed residents about their experiences with both systems. We evaluated the accuracy of the point-based system by examining grossing times and comparing them to the assigned point values. We found overall improvement in the rotation following the implementation. As there is essentially no literature on the subject of surgical pathology rotation organization, we hope that our experience will provide a road map to improve pathology resident education at other institutions.

26 CFR 301.7701(b)-4 - Residency time periods.

Code of Federal Regulations, 2010 CFR

2010-04-01

... for tax purposes on the alien's residency starting date. The residency starting date for an alien who... present in the United States. The residency starting date for an alien who meets the lawful permanent... permanent resident. The residency starting date for an alien who satisfies both the substantial presence...

New Media for Educating Urology Residents: An Interview Study in Canada and Germany.

PubMed

Salem, Johannes; Borgmann, Hendrik; MacNeily, Andrew; Boehm, Katharina; Schmid, Marianne; Groeben, Christer; Baunacke, Martin; Huber, Johannes

To investigate the usage and perceived usefulness of new media for educating urology residents in Canada and Germany. We designed an 11-item online survey to assess the use and perceived usefulness of new media for education. We performed a comparative analysis. The survey was distributed via e-mail to 143 Canadian and 721 German urology residents. The survey included 58 urology residents from Canada and 170 from Germany. A total of 58 residents from Canada (41% response rate) and 170 from Germany (24% response rate) responded to this survey. Residents spent 45% of their education time on new media. The Internet was used by 91% (n = 208) of the residents for professional education purposes, with a median time of 270 minutes (interquartile range [IQR]: 114-540) per month. Apps were used by 54% (n = 118) of the residents, with a median time of 101 minutes (IQR: 45-293) per month. A total of 23% (n = 47) of the residents used social media (SoMe) for education, with a median time of 90 minutes (IQR: 53-80) per month. In all, 100% (n = 228) rated the Internet, 76% (n = 173) apps, and 43% (n = 97) SoMe as being useful for professional education purposes. A total of 90% (n = 205) watched medical videos for education, and 89% (n = 203) of these videos were on surgical procedures. Canadian urology residents used more new media sources for professional education than did the Germans (58% vs. 41%, p < 0.001). The time spent for education on new media was higher among Canadian residents for the Internet (p < 0.001), apps (p < 0.001), and SoMe (p = 0.033). Canadian residents reported more privacy concerns (p < 0.001). New media play a dominant role in the education of urology residents. The primary source for personal education in urology is the Internet. Future studies and technological developments should investigate and improve new media tools to optimize education during residency. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

26 CFR 301.6362-6 - Requirements relating to residence.

Code of Federal Regulations, 2010 CFR

2010-04-01

... time of creation of the trust, less than 50 percent in value of the trust corpus consists of real.... C, a dependent of his parents who are residents of State X, is a full-time student in a 4-year... a brief period of time, with no definite present intention of later removing therefrom. Residence...

Pediatric resident perceptions of family-friendly benefits.

PubMed

Berkowitz, Carol D; Frintner, Mary Pat; Cull, William L

2010-01-01

The aim of this study was to examine the importance of family-friendly features in residency program selection, benefits offered to and used by residents, and importance of benefits in future job selection. A survey of a random, national sample of 1000 graduating pediatric residents in 2008 was mailed and e-mailed. Survey response rate for graduating resident respondents was 59%. Among the respondents, 76% were women. Thirty-seven percent of men and 32% of women were parents. Residents with children were more likely than residents without children to rate family-friendly characteristics as very important in their residency selection (P < .05). Many residents reported that their programs offered maternity leave (88%), paternity leave (59%), individual flexibility with schedule (63%), and lactation rooms (55%), but fewer reported on-site child care (24%), care for ill children (19%), and part-time residency positions (12%). Among residents reporting availability, 77% of women with children used maternity leave and lactation rooms. Few held part-time residency positions (2%), but many expressed interest (23% of women with children). The majority of residents with and without children reported that flexibility with schedule was important in their future job selection. Most women with children (71%) and many women without children (52%) considered part-time work to be very important in their job selection. Family-friendly benefits are important to residents, particularly those with children. The data provides a benchmark for the availability and use of family-friendly features at pediatric training programs. The data also shows that many residents are unaware if benefits are offered, which suggests a need to make available benefits more transparent to residents. Copyright 2010 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Psychotherapy Training: Residents' Perceptions and Experiences.

PubMed

Kovach, Jessica G; Dubin, William R; Combs, Christopher J

2015-10-01

This survey examined actual training hours in psychotherapy modalities as reported by residents, residents' perceptions of training needs, and residents' perceptions of the importance of different aspects of psychotherapy training. A brief, voluntary, anonymous, Internet-based survey was developed. All 14 program directors for Accreditation Council for Graduate Medical Education accredited programs in Pennsylvania, New Jersey, and Delaware provided email addresses for current categorical residents. The survey inquired about hours of time spent in various aspects of training, value assigned to aspects of training, residents' involvement in their own psychotherapy, and overall resident wellness. The survey was e-mailed to 328 residents. Of the 328 residents contacted, 133 (40.5%) responded. Median reported number of PGY 3 and 4 performed versus perceived ideal hours of supportive therapy, cognitive behavioral therapy (CBT), and psychodynamic therapy did not differ. Answers for clinical time utilizing these modalities ranged from "none or less than 1 h" per month to 20+ h per month. PGY 3 and 4 residents reported a median of "none or less than 1 h" per month performed of interpersonal, dialectical behavior therapy, couples/family/group, and child therapies but preferred more time using these therapies. Residents in all years of training preferred more hours of didactic instruction for all psychotherapies and for medication management. Residents ranked teaching modalities in the following order of importance: supervision, hours of psychotherapy performed, personal psychotherapy, readings, and didactic instruction. Residents engaged in their own psychotherapy were significantly more likely to rank the experiential aspects of psychotherapy training (personal psychotherapy, supervision, and hours performed) higher than residents not in psychotherapy. Current psychotherapy training for psychiatry residents is highly variable, but overall, residents want more psychotherapy education than they are receiving. Further research and discussion about how much psychotherapy training is feasible in an evolving field is required.

Seasonal variation of residence time in spring and groundwater evaluated by CFCs and numerical simulation in mountainous headwater catchment

NASA Astrophysics Data System (ADS)

Tsujimura, Maki; Watanabe, Yasuto; Ikeda, Koichi; Yano, Shinjiro; Abe, Yutaka

2016-04-01

Headwater catchments in mountainous region are the most important recharge area for surface and subsurface waters, additionally time information of the water is principal to understand hydrological processes in the catchments. However, there have been few researches to evaluate variation of residence time of subsurface water in time and space at the mountainous headwaters especially with steep slope. We investigated the temporal variation of the residence time of the spring and groundwater with tracing of hydrological flow processes in mountainous catchments underlain by granite, Yamanashi Prefecture, central Japan. We conducted intensive hydrological monitoring and water sampling of spring, stream and ground waters in high-flow and low-flow seasons from 2008 through 2013 in River Jingu Watershed underlain by granite, with an area of approximately 15 km2 and elevation ranging from 950 m to 2000 m. The CFCs, stable isotopic ratios of oxygen-18 and deuterium, inorganic solute constituent concentrations were determined on all water samples. Also, a numerical simulation was conducted to reproduce of the average residence times of the spring and groundwater. The residence time of the spring water estimated by the CFCs concentration ranged from 10 years to 60 years in space within the watershed, and it was higher (older) during the low flow season and lower (younger) during the high flow season. We tried to reproduce the seasonal change of the residence time in the spring water by numerical simulation, and the calculated residence time of the spring water and discharge of the stream agreed well with the observed values. The groundwater level was higher during the high flow season and the groundwater dominantly flowed through the weathered granite with higher permeability, whereas that was lower during the low flow season and that flowed dominantly through the fresh granite with lower permeability. This caused the seasonal variation of the residence time of the spring water, older in low flow season and younger in the high flow season in the watershed. As a result, the numerical model simulated successfully the dynamics of the groundwater flow and residence time in the spring water.

A method of estimating in-stream residence time of water in rivers

NASA Astrophysics Data System (ADS)

Worrall, F.; Howden, N. J. K.; Burt, T. P.

2014-05-01

This study develops a method for estimating the average in-stream residence time of water in a river channel and across large catchments, i.e. the time between water entering a river and reaching a downstream monitoring point. The methodology uses river flow gauging data to integrate Manning's equation along a length of channel for different percentile flows. The method was developed and tested for the River Tees in northern England and then applied across the United Kingdom (UK). The study developed methods to predict channel width and main channel length from catchment area. For an 818 km2 catchment with a channel length of 79 km, the in-stream residence time at the 50% exceedence flow was 13.8 h. The method was applied to nine UK river basins and the results showed that in-stream residence time was related to the average slope of a basin and its average annual rainfall. For the UK as a whole, the discharge-weighted in-stream residence time was 26.7 h for the median flow. At median flow, 50% of the discharge-weighted in-stream residence time was due to only 6 out of the 323 catchments considered. Since only a few large rivers dominate the in-stream residence time, these rivers will dominate key biogeochemical processes controlling export at the national scale. The implications of the results for biogeochemistry, especially the turnover of carbon in rivers, are discussed.

Air-Parcel Residence Times Within Forest Canopies

NASA Astrophysics Data System (ADS)

Gerken, Tobias; Chamecki, Marcelo; Fuentes, Jose D.

2017-10-01

We present a theoretical model, based on a simple model of turbulent diffusion and first-order chemical kinetics, to determine air-parcel residence times and the out-of-canopy export of reactive gases emitted within forest canopies under neutral conditions. Theoretical predictions of the air-parcel residence time are compared to values derived from large-eddy simulation for a range of canopy architectures and turbulence levels under neutral stratification. Median air-parcel residence times range from a few sec in the upper canopy to approximately 30 min near the ground and the distribution of residence times is skewed towards longer times in the lower canopy. While the predicted probability density functions from the theoretical model and large-eddy simulation are in good agreement with each other, the theoretical model requires only information on canopy height and eddy diffusivities inside the canopy. The eddy-diffusivity model developed additionally requires the friction velocity at canopy top and a parametrized profile of the standard deviation of vertical velocity. The theoretical model of air-parcel residence times is extended to include first-order chemical reactions over a range of of Damköhler numbers ( Da) characteristic of plant-emitted hydrocarbons. The resulting out-of-canopy export fractions range from near 1 for Da =10^{-3} to less than 0.3 at Da = 10. These results highlight the necessity for dense and tall forests to include the impacts of air-parcel residence times when calculating the out-of-canopy export fraction for reactive trace gases.

Evaluation of Oral and Maxillofacial Surgery Residents' Operative Skills: Feasibility and Engagement Study Using SIMPL Software for a Mobile Phone.

PubMed

Kaban, Leonard B; Cappetta, Alyssa; George, Brian C; Lahey, Edward T; Bohnen, Jordan D; Troulis, Maria J

2017-10-01

There are no universally accepted tools to evaluate operative skills of surgical residents in a timely fashion. The purpose of this study was to determine the feasibility of using a smartphone application, SIMPL (System for Improving and Measuring Procedural Learning), developed by a multi-institutional research collaborative, to achieve a high rate of timely operative evaluations and resident communication and to collect performance data. The authors hypothesized that these goals would be achieved because the process is convenient and efficient. This was a prospective feasibility and engagement study using SIMPL to evaluate residents' operative skills. SIMPL requires the attending surgeon to answer 3 multiple-choice questions: 1) What level of help (Zwisch Scale) was required by the trainee? 2) What was the level of performance? 3) How complex was the case? The evaluator also can dictate a narrative. The sample was composed of 3 faculty members and 3 volunteer senior residents. Predictor variables were the surgeons, trainees, and procedures performed. Outcome variables included number and percentage of procedures performed by faculty-and-resident pairs assessed, time required to complete assessments, time lapsed to submission, percentage of assessments with narratives, and residents' response rates. From March through June 2016, 151 procedures were performed in the operating room by the faculty-and-resident teams. There were 107 assessments submitted (71%). Resident response (self-assessment) to faculty evaluations was 81%. Recorded time to complete assessments (n = 75 of 107) was shorter than 2 minutes. The time lapsed to submission was shorter than 72 hours (100%). Dictations were submitted for 35 evaluations (33%). Data for the type of help, performance, and complexity of cases were collected for each resident. SIMPL facilitates timely intraoperative evaluations of surgical skills, engagement by faculty and residents, and collection of detailed procedural data. Additional prospective trials to assess this tool further are planned. Copyright © 2017 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Increase in Cesarean Operative Time Following Institution of the 80-Hour Workweek

PubMed Central

Smrtka, Michael P.; Gunatilake, Ravindu P.; Harris, Benjamin; Yu, Miao; Lan, Lan; Brancazio, Leo R.; Valea, Fidel A.; Grotegut, Chad A.; Brown, Haywood L.

2015-01-01

Background  In 2003, the Accreditation Council for Graduate Medical Education limited resident duty hours to 80 hours per week. More than a decade later, the effect of the limits on resident clinical competence is not fully understood. Objective  We sought to assess the effect of duty hour restrictions on resident performance of an uncomplicated cesarean delivery. Methods  We reviewed unlabored primary cesarean deliveries at Duke University Hospital after 34 weeks gestation, between 2003 and 2011. Descriptive statistics and linear regression were used to compare total operative time with incision to delivery time as a function of years since institution of the 80-hour workweek. Resident training level, subject body mass index, estimated blood loss, and skin closure method were controlled for in the regression model. Results  We identified 444 deliveries that met study criteria. The mean (SD) total operative time in 2003–2004 was 43.3 (14.3) minutes and 59.6 (10.7) minutes in 2010–2011 (P < .001). Multivariable regression demonstrated an increase in total operative time of 1.9 min/y (P < .001) but no change in incision to delivery time (P = .05). The magnitude of increased operative time was seen among junior residents (2.0 min/y, P < .001) compared to that of senior residents (1.2 min/y, P = .06). Conclusions  Since introduction of the 2003 duty hour limits, there has been an increase of nearly 20 minutes in the time required for a routine cesarean delivery. It is unclear if the findings are due to a change in residency duty hours or to another aspect of residency training. PMID:26457141

Results of the 2005-2008 Association of Residents in Radiation Oncology Survey of Chief Residents in the United States: Clinical Training and Resident Working Conditions

DOE Office of Scientific and Technical Information (OSTI.GOV)

Gondi, Vinai, E-mail: gondi@humonc.wisc.edu; Bernard, Johnny Ray; Jabbari, Siavash

2011-11-15

Purpose: To document clinical training and resident working conditions reported by chief residents during their residency. Methods and Materials: During the academic years 2005 to 2006, 2006 to 2007, and 2007 to 2008, the Association of Residents in Radiation Oncology conducted a nationwide survey of all radiation oncology chief residents in the United States. Chi-square statistics were used to assess changes in clinical training and resident working conditions over time. Results: Surveys were completed by representatives from 55 programs (response rate, 71.4%) in 2005 to 2006, 60 programs (75.9%) in 2006 to 2007, and 74 programs (93.7%) in 2007 tomore » 2008. Nearly all chief residents reported receiving adequate clinical experience in commonly treated disease sites, such as breast and genitourinary malignancies; and commonly performed procedures, such as three-dimensional conformal radiotherapy and intensity-modulated radiotherapy. Clinical experience in extracranial stereotactic radiotherapy increased over time (p < 0.001), whereas clinical experience in endovascular brachytherapy (p <0.001) decreased over time. The distribution of gynecologic and prostate brachytherapy cases remained stable, while clinical case load in breast brachytherapy increased (p = 0.006). A small but significant percentage of residents reported receiving inadequate clinical experience in pediatrics, seeing 10 or fewer pediatric cases during the course of residency. Procedures involving higher capital costs, such as particle beam therapy and intraoperative radiotherapy, and infrequent clinical use, such as head and neck brachytherapy, were limited to a minority of institutions. Most residency programs associated with at least one satellite facility have incorporated resident rotations into their clinical training, and the majority of residents at these programs find them valuable experiences. The majority of residents reported working 60 or fewer hours per week on required clinical duties. Conclusions: Trends in clinical training and resident working conditions over 3 years are documented to allow residents and program directors to assess their residency training.« less

Orthopedic resident work-shift analysis: are we making the best use of resident work hours?

PubMed

Hamid, Kamran S; Nwachukwu, Benedict U; Hsu, Eugene; Edgerton, Colston A; Hobson, David R; Lang, Jason E

2014-01-01

Surgery programs have been tasked to meet rising demands in patient surgical care while simultaneously providing adequate resident training in the midst of increasing resident work-hour restrictions. The purpose of this study was to quantify orthopedic surgery resident workflow and identify areas needing improved resident efficiency. We hypothesize that residents spend a disproportionate amount of time involved in activities that do not relate directly to patient care or maximize resident education. We observed 4 orthopedic surgery residents on the orthopedic consult service at a major tertiary care center for 72 consecutive hours (6 consecutive shifts). We collected minute-by-minute data using predefined work-task criteria: direct new patient contact, direct existing patient contact, communications with other providers, documentation/administrative time, transit time, and basic human needs. A seventh category comprised remaining less-productive work was termed as standby. In a 720-minute shift, residents spent on an average: 191 minutes (26.5%) performing documentation/administrative duties, 167.0 minutes (23.2%) in direct contact with new patient consults, 129.6 minutes (17.1%) in communication with other providers regarding patients, 116.2 (16.1%) minutes in standby, 63.7 minutes (8.8%) in transit, 32.6 minutes (4.5%) with existing patients, and 20 minutes (2.7%) attending to basic human needs. Residents performed an additional 130 minutes of administrative work off duty. Secondary analysis revealed residents were more likely to perform administrative work rather than directly interact with existing patients (p = 0.006) or attend to basic human needs (p = 0.003). Orthopedic surgery residents spend a large proportion of their time performing documentation/administrative-type work and their workday can be operationally optimized to minimize nonvalue-adding tasks. Formal workflow analysis may aid program directors in systematic process improvements to better align resident skills with tasks. III. Published by Elsevier Inc.

Well-Being among Emergency Medicine Resident Physicians: Results from the ABEM Longitudinal Study of Emergency Medicine Residents.

PubMed

Perina, Debra G; Marco, Catherine A; Smith-Coggins, Rebecca; Kowalenko, Terry; Johnston, Mary M; Harvey, Anne

2018-05-11

The Longitudinal Study of Emergency Medicine Residents (LSEMR) conducted by the American Board of Emergency Medicine queries a randomized cohort of emergency medicine (EM) residents. It is designed to identify residents' perceptions of their training, sources of stress, well-being level, and career choice satisfaction over time. This study utilizes LSEMR to identify resident well-being levels, career satisfaction, factors producing stress, and whether a specific cohort is more stressed than the overall respondent group. Data from five longitudinal cohorts were analyzed using descriptive statistics to assess stressors, career satisfaction, and self-reported resident well-being. Participants' answers were reported on a 5-point Likert scale. There were 766 residents who completed the survey in five cohorts. Respondents were 30 years old (median 29), male (66%), and predominantly White (79%). The most frequently encountered problems included "time devoted to documentation and bureaucratic issues," "knowing enough," and "crowding in the emergency department." In contrast, the least frequently reported problems included "gender discrimination," "EMS support," "minority discrimination," and "other residents." Respondents thought being an EM resident was fun and would select EM again. Less than 20% indicated they had seriously considered transferring to another EM program. Resident reports of health concerns changed over time, with fewer residents reporting they were exceptionally healthy in 2016. Residents are, overall, happy with their career choice. However, concern was expressed regarding continued well-being in training. Sources of stress in training are identified. Strategies should be developed to decrease identified stressors and increase well-being among EM residents. Copyright © 2018 Elsevier Inc. All rights reserved.

Partial migration and transient coexistence of migrants and residents in animal populations.

PubMed

Singh, Navinder J; Leonardsson, Kjell

2014-01-01

Partial migration, whereby a proportion of the population migrates, is common across the animal kingdom. Much of the focus in the literature has been on trying to explain the underlying mechanisms for the coexistence of migrants and residents. In addition, there has been an increasing number of reports on the prevalence and frequency of partially migratory populations. One possible explanation for the occurrence of partial migration, which has received no attention in the literature, is that of 'transient coexistence' during the invasion phase of a superior behaviour. In this study we develop a theoretical basis for explaining partial migration as a transient coexistence and derive a method to predict the frequency of residents and migrants in partially migrating populations. This method is useful to predict the frequencies of migrants and residents in a small set of populations as a complementing hypothesis to 'an Evolutionary Stable Strategy (ESS)'. We use the logistic growth equation to derive a formula for predicting the frequencies of residents and migrants. We also use simulations and empirical data from white perch (Morone americana), moose (Alces alces) and red deer (Cervus elaphus) to demonstrate our approach. We show that the probability of detecting partial migration due to transient coexistence depends upon a minimum number of tracked or marked individuals for a given number of populations. Our approach provides a starting point in searching for explanations to the observed frequencies, by contrasting the observed pattern with both the predicted transient and the uniform random pattern. Aggregating such information on observed patterns (proportions of migrants and residents) may eventually lead to the development of a quantitative theory for the equilibrium (ESS) populations as well.

Relationships, Expertise, Incentives, and Governance: Supporting Care Home Residents' Access to Health Care. An Interview Study From England

PubMed Central

Goodman, Claire; Davies, Sue L.; Gordon, Adam L.; Meyer, Julienne; Dening, Tom; Gladman, John R.F.; Iliffe, Steve; Zubair, Maria; Bowman, Clive; Victor, Christina; Martin, Finbarr C.

2015-01-01

Objectives To explore what commissioners of care, regulators, providers, and care home residents in England identify as the key mechanisms or components of different service delivery models that support the provision of National Health Service (NHS) provision to independent care homes. Methods Qualitative, semistructured interviews with a purposive sample of people with direct experience of commissioning, providing, and regulating health care provision in care homes and care home residents. Data from interviews were augmented by a secondary analysis of previous interviews with care home residents on their personal experience of and priorities for access to health care. Analysis was framed by the assumptions of realist evaluation and drew on the constant comparative method to identify key themes about what is required to achieve quality health care provision to care homes and resident health. Results Participants identified 3 overlapping approaches to the provision of NHS that they believed supported access to health care for older people in care homes: (1) Investment in relational working that fostered continuity and shared learning between visiting NHS staff and care home staff, (2) the provision of age-appropriate clinical services, and (3) governance arrangements that used contractual and financial incentives to specify a minimum service that care homes should receive. Conclusion The 3 approaches, and how they were typified as working, provide a rich picture of the stakeholder perspectives and the underlying assumptions about how service delivery models should work with care homes. The findings inform how evidence on effective working in care homes will be interrogated to identify how different approaches, or specifically key elements of those approaches, achieve different health-related outcomes in different situations for residents and associated health and social care organizations. PMID:25687930

Sulfonylureas and risk of falls and fractures among nursing home residents with type 2 diabetes mellitus.

PubMed

Lapane, Kate L; Jesdale, Bill M; Dubé, Catherine E; Pimentel, Camilla B; Rajpathak, Swapnil N

2015-08-01

Although sulfonylureas increase the risk of hypoglycemia which may lead to fall-associated fractures, studies quantifying the association between sulfonylureas and falls and/or fractures are sparse and existing studies have yielded inconsistent results. Our objective is to evaluate the extent to which sulfonylurea use was associated with fractures and falls among nursing home residents with type 2 diabetes mellitus. We performed a propensity-matched retrospective new user cohort study of 12,327 Medicare Parts A/B/D eligible long-stay NH residents. Medicare Part D data provided information on sulfonylurea and biguanide use initiated as monotherapy (nsulfonylurea=5807 and nbiguanide=6151) after NH entry. Medicare hospitalizations were used to identify hypoglycemic events (ICD-9-CM codes 250.8, 251.1, 251.2) and fall-associated fractures (ICD-9-CM codes 800, 804, 812-817, 820, 823, 824). Minimum Data Set 2.0 (2008-2010) provided information on falls and potential confounders. Cox models conducted on propensity-matched samples provided adjusted hazard ratio (aHR) estimates and 95% confidence intervals (CI). Falls were common (37.4 per 100 person-years). Fractures were not associated with initiation of sulfonylureas. Sulfonylurea initiation was associated with an excess risk of falls among residents with moderate activities of daily living limitations (aHR: 1.13; 95% CI: 1.00-1.26), but not among those with minimal limitations or dependence in activities of daily living. Nursing home residents with moderate limitations in activities of daily living are at increased risk of falls upon initiation of sulfonylureas. Initiating sulfonylurea use in NH residents must be done with caution. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Dual Use of Bladder Anticholinergics and Cholinesterase Inhibitors: Long-Term Functional and Cognitive Outcomes

PubMed Central

Sink, Kaycee M.; Thomas, Joseph; Xu, Huiping; Craig, Bruce; Kritchevsky, Steven; Sands, Laura P.

2015-01-01

OBJECTIVES To determine the cognitive and functional consequences of dual use of cholinesterase inhibitors (ChIs) and the bladder anticholinergics oxybutynin or tolterodine. DESIGN Prospective cohort study. SETTING Nursing homes (NHs) in the state of Indiana. PARTICIPANTS Three thousand five hundred thirty-six Medicaid-eligible NH residents aged 65 and older taking a ChI between January 1, 2003, and December 31, 2004. Residents were excluded if they were taking an anticholinergic other than oxybutynin or tolterodine. MEASUREMENTS Indiana Medicaid claims data were merged with data from the Minimum Data Set (MDS). Repeated-measures analyses were performed to assess the effects of dual therapy on change in cognitive function measured using the MDS Cognition Scale (MDS-COGS; scored 0–10) and change in activity of daily living (ADL) function using the seven ADL items in the MDS (scored 0–28). Potential covariates included age, sex, race, number of medications, and Charlson Comorbidity Index score. RESULTS Three hundred seventy-six (10.6%) residents were prescribed oxybutynin or tolterodine concomitantly with a ChI. In residents in the top quartile of ADL function, ADL function declined an average of 1.08 points per quarter when not taking bladder anticholinergics (ChI alone), compared with 1.62 points per quarter when taking dual therapy, a 50% greater rate in quarterly decline in ADL function (P =.01). There was no excess decline attributable to dual therapy in MDS-COGS scores or in ADL function for residents who started out with lower functioning. CONCLUSION In higher-functioning NH residents, dual use of ChIs and bladder anticholinergics may result in greater rates of functional decline than use of ChIs alone. The MDS-COGS may not be sensitive enough to detect differences in cognition due to dual use. PMID:18384584

Improving prediction of fall risk among nursing home residents using electronic medical records.

PubMed

Marier, Allison; Olsho, Lauren E W; Rhodes, William; Spector, William D

2016-03-01

Falls are physically and financially costly, but may be preventable with targeted intervention. The Minimum Data Set (MDS) is one potential source of information on fall risk factors among nursing home residents, but its limited breadth and relatively infrequent updates may limit its practical utility. Richer, more frequently updated data from electronic medical records (EMRs) may improve ability to identify individuals at highest risk for falls. The authors applied a repeated events survival model to analyze MDS 3.0 and EMR data for 5129 residents in 13 nursing homes within a single large California chain that uses a centralized EMR system from a leading vendor. Estimated regression parameters were used to project resident fall probability. The authors examined the proportion of observed falls within each projected fall risk decile to assess improvements in predictive power from including EMR data. In a model incorporating fall risk factors from the MDS only, 28.6% of observed falls occurred among residents in the highest projected risk decile. In an alternative specification incorporating more frequently updated measures for the same risk factors from the EMR data, 32.3% of observed falls occurred among residents in the highest projected risk decile, a 13% increase over the base MDS-only specification. Incorporating EMR data improves ability to identify those at highest risk for falls relative to prediction using MDS data alone. These improvements stem chiefly from the greater frequency with which EMR data are updated, with minimal additional gains from availability of additional risk factor variables. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Interaction effect of Medicaid census and nursing home characteristics on quality of psychosocial care for residents.

PubMed

Kang-Yi, Christina D; Mandell, David S; Mui, Ada C; Castle, Nicholas G

2011-01-01

Numerous studies have identified disparities in nursing home quality of care. Although previous studies have found the overlap among Medicaid census, nursing home characteristics, and negative quality of care outcomes, few studies have examined how the psychosocial well-being of nursing home residents is associated with Medicaid census and other nursing home characteristics. The purpose of this study was to elucidate the intertwined relationships between Medicaid census and other important nursing home factors and its impact on psychosocial care for residents. This study examined the interactive effects of (1) nursing home ownership status and Medicaid census, (2) staffing level and Medicaid census, and (3) resident ethnic mix and Medicaid census on psychosocial well-being outcomes. The sample, derived from a combined data set of New York State nursing homes' Online Survey Certification and Reporting System and Minimum Data Set, included 565 nursing homes in rural and urban areas of the state. Medicaid census had no main effect on psychosocial well-being outcomes of nursing home care but had a significant interactive effect with other nursing home characteristics. High Medicaid census was associated with lower level of psychosocial symptom detection in nonprofit nursing homes and nursing homes with a higher proportion of ethnic minority residents. Nursing staff training on better psychosocial well-being care, in particular, better psychosocial assessment, is important. To obtain the training resources, nursing homes with high Medicaid census can collaborate with other nursing homes or social service agencies. Considering that nursing homes with a high proportion of ethnic minority residents have lower level of detection rate for psychosocial well-being issues, culturally competent care should be a component of quality improvement plans.

Selection Criteria for Internal Medicine Residency Applicants and Professionalism Ratings During Internship

PubMed Central

Cullen, Michael W.; Reed, Darcy A.; Halvorsen, Andrew J.; Wittich, Christopher M.; Kreuziger, Lisa M. Baumann; Keddis, Mira T.; McDonald, Furman S.; Beckman, Thomas J.

2011-01-01

OBJECTIVE: To determine whether standardized admissions data in residents' Electronic Residency Application Service (ERAS) submissions were associated with multisource assessments of professionalism during internship. PARTICIPANTS AND METHODS: ERAS applications for all internal medicine interns (N=191) at Mayo Clinic entering training between July 1, 2005, and July 1, 2008, were reviewed by 6 raters. Extracted data included United States Medical Licensing Examination scores, medicine clerkship grades, class rank, Alpha Omega Alpha membership, advanced degrees, awards, volunteer activities, research experiences, first author publications, career choice, and red flags in performance evaluations. Medical school reputation was quantified using U.S. News & World Report rankings. Strength of comparative statements in recommendation letters (0 = no comparative statement, 1 = equal to peers, 2 = top 20%, 3 = top 10% or “best”) were also recorded. Validated multisource professionalism scores (5-point scales) were obtained for each intern. Associations between application variables and professionalism scores were examined using linear regression. RESULTS: The mean ± SD (minimum-maximum) professionalism score was 4.09±0.31 (2.13-4.56). In multivariate analysis, professionalism scores were positively associated with mean strength of comparative statements in recommendation letters (β=0.13; P=.002). No other associations between ERAS application variables and professionalism scores were found. CONCLUSION: Comparative statements in recommendation letters for internal medicine residency applicants were associated with professionalism scores during internship. Other variables traditionally examined when selecting residents were not associated with professionalism. These findings suggest that faculty physicians' direct observations, as reflected in letters of recommendation, are useful indicators of what constitutes a best student. Residency selection committees should scrutinize applicants' letters for strongly favorable comparative statements. PMID:21364111

Simulation center training as a means to improve resident performance in percutaneous noncontinuous CT-guided fluoroscopic procedures with dose reduction.

PubMed

Mendiratta-Lala, Mishal; Williams, Todd R; Mendiratta, Vivek; Ahmed, Hafeez; Bonnett, John W

2015-04-01

The purpose of this study was to evaluate the effectiveness of a multifaceted simulation-based resident training for CT-guided fluoroscopic procedures by measuring procedural and technical skills, radiation dose, and procedure times before and after simulation training. A prospective analysis included 40 radiology residents and eight staff radiologists. Residents took an online pretest to assess baseline procedural knowledge. Second-through fourth-year residents' baseline technical skills with a procedural phantom were evaluated. First-through third-year residents then underwent formal didactic and simulation-based procedural and technical training with one of two interventional radiologists and followed the training with 1 month of supervised phantom-based practice. Thereafter, residents underwent final written and practical examinations. The practical examination included essential items from a 20-point checklist, including site and side marking, consent, time-out, and sterile technique along with a technical skills portion assessing pedal steps, radiation dose, needle redirects, and procedure time. The results indicated statistically significant improvement in procedural and technical skills after simulation training. For residents, the median number of pedal steps decreased by three (p=0.001), median dose decreased by 15.4 mGy (p<0.001), median procedure time decreased by 4.0 minutes (p<0.001), median number of needle redirects decreased by 1.0 (p=0.005), and median number of 20-point checklist items successfully completed increased by three (p<0.001). The results suggest that procedural skills can be acquired and improved by simulation-based training of residents, regardless of experience. CT simulation training decreases procedural time, decreases radiation dose, and improves resident efficiency and confidence, which may transfer to clinical practice with improved patient care and safety.

Report of Block Field Experience at Jefferson County Department of Health Bureau of Nutrition, Birmingham, Alabama.

DTIC Science & Technology

1985-01-01

Despite the recent economic growth of Jefferson County, poverty * still abounds. In 1980, 12% of the families lived below the poverty level and some...residents with the charge for services being based on a sliding fee scale. Those at or below 150% of poverty level are charged only a minimum fee. F...be at risk? 1. Poor dietary calcium intake - average intake for American women is less than 500 grams per day. 2. Smoking - nicotine hurries the

Improving Nursing Home Care through Feedback On PerfoRMance Data (INFORM): Protocol for a cluster-randomized trial.

PubMed

Hoben, Matthias; Norton, Peter G; Ginsburg, Liane R; Anderson, Ruth A; Cummings, Greta G; Lanham, Holly J; Squires, Janet E; Taylor, Deanne; Wagg, Adrian S; Estabrooks, Carole A

2017-01-10

Audit and feedback is effective in improving the quality of care. However, methods and results of international studies are heterogeneous, and studies have been criticized for a lack of systematic use of theory. In TREC (Translating Research in Elder Care), a longitudinal health services research program, we collect comprehensive data from care providers and residents in Canadian nursing homes to improve quality of care and life of residents, and quality of worklife of caregivers. The study aims are to a) systematically feed back TREC research data to nursing home care units, and b) compare the effectiveness of three different theory-based feedback strategies in improving performance within care units. INFORM (Improving Nursing Home Care through Feedback On PerfoRMance Data) is a 3.5-year pragmatic, three-arm, parallel, cluster-randomized trial. We will randomize 67 Western Canadian nursing homes with 203 care units to the three study arms, a standard feedback strategy and two assisted and goal-directed feedback strategies. Interventions will target care unit managerial teams. They are based on theory and evidence related to audit and feedback, goal setting, complex adaptive systems, and empirical work on feeding back research results. The primary outcome is the increased number of formal interactions (e.g., resident rounds or family conferences) involving care aides - non-registered caregivers providing up to 80% of direct care. Secondary outcomes are a) other modifiable features of care unit context (improved feedback, social capital, slack time) b) care aides' quality of worklife (improved psychological empowerment, job satisfaction), c) more use of best practices, and d) resident outcomes based on the Resident Assessment Instrument - Minimum Data Set 2.0. Outcomes will be assessed at baseline, immediately after the 12-month intervention period, and 18 months post intervention. INFORM is the first study to systematically assess the effectiveness of different strategies to feed back research data to nursing home care units in order to improve their performance. Results of this study will enable development of a practical, sustainable, effective, and cost-effective feedback strategy for routine use by managers, policy makers and researchers. The results may also be generalizable to care settings other than nursing homes. ClinicalTrials.gov Identifier: NCT02695836 . Date of registration: 24 February 2016.

Defining and measuring the mean residence time of lateral surface transient storage zones in small streams

Treesearch

T.R. Jackson; R. Haggerty; S.V. Apte; A. Coleman; K.J. Drost

2012-01-01

Surface transient storage (STS) has functional significance in stream ecosystems because it increases solute interaction with sediments. After volume, mean residence time is the most important metric of STS, but it is unclear how this can be measured accurately or related to other timescales and field-measureable parameters. We studied mean residence time of lateral...

SUBSURFACE RESIDENCE TIMES AS AN ALGORITHM FOR AQUIFER SENSITIVITY MAPPING: TESTING THE CONCEPT WITH ANALYTIC ELEMENT GROUND WATER MODELS IN THE CONTENTNEA CREEK BASIN, NORTH CAROLINA, USA

EPA Science Inventory

The objective of this research is to test the utility of simple functions of spatially integrated and temporally averaged ground water residence times in shallow "groundwatersheds" with field observations and more detailed computer simulations. The residence time of water in the...

Examining Time Use of Dutch Nursing Staff in Long-Term Institutional Care: A Time-Motion Study.

PubMed

Tuinman, Astrid; de Greef, Mathieu H G; Krijnen, Wim P; Nieweg, Roos M B; Roodbol, Petrie F

2016-02-01

Increasing residents' acuity levels and available resources in long-term institutional care requires insight into the care provided by nursing staff so as to guide task allocation and optimal use of resources, and enhance quality of care. The purpose of this study was to examine the relationship between time use and type of nursing staff, residents' acuity levels, and unit type by using a standardized nursing intervention classification. A multicenter cross-sectional observational study was performed using time-motion technique. Five Dutch long-term institutional care facilities participated. In total, 4 residential care units, 3 somatic units, and 6 psycho-geriatric units were included. Data were collected from 136 nursing staff members: 19 registered nurses, 89 nursing assistants, 9 primary caregivers, and 19 health care assistants. A structured observation list was used based on the Nursing Interventions Classification (NIC). Residents' acuity levels, representing residents' needs, were based on the Dutch Care Severity Index. Medians and interquartile ranges were calculated for time spent on interventions per type of nursing staff and units. Linear mixed models were used to examine the relationship between time spent on nursing interventions and the type of nursing staff, residents' acuity levels, and unit type. Observations resulted in 52,628 registered minutes for 102 nursing interventions categorized into 6 NIC domains for 335 residents. Nursing staff spent the most time on direct care interventions, particularly in the domain of basic physiological care. Variances in time spent on interventions between types of nursing staff were minimal. Unit type was more significantly (P < .05) associated with time spent on interventions in domains than the type of nursing staff. Residents' acuity levels did not affect time spent by nursing staff (P > .05). The current study found limited evidence for task allocation between the types of nursing staff, which may suggest a blurring of role differentiation. Also, findings suggest that residents received similar care regardless of their needs, implying that care is predominantly task-oriented instead of person-centered. Managers may reconsider whether the needs of residents are adequately met by qualified nursing staff, considering the differences in education and taking into account increasing acuity levels of residents and available resources. Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Automated external defibrillators and simulated in-hospital cardiac arrests.

PubMed

Rossano, Joseph W; Jefferson, Larry S; Smith, E O'Brian; Ward, Mark A; Mott, Antonio R

2009-05-01

To test the hypothesis that pediatric residents would have shorter time to attempted defibrillation using automated external defibrillators (AEDs) compared with manual defibrillators (MDs). A prospective, randomized, controlled trial of AEDs versus MDs was performed. Pediatric residents responded to a simulated in-hospital ventricular fibrillation cardiac arrest and were randomized to using either an AED or MD. The primary end point was time to attempted defibrillation. Sixty residents, 21 (35%) interns, were randomized to 2 groups (AED = 30, MD = 30). Residents randomized to the AED group had a significantly shorter time to attempted defibrillation [median, 60 seconds (interquartile range, 53 to 71 seconds)] compared with those randomized to the MD group [median, 103 seconds (interquartile range, 68 to 288 seconds)] (P < .001). All residents in the AED group attempted defibrillation at <5 minutes compared with 23 (77%) in the MD group (P = .01). AEDs improve the time to attempted defibrillation by pediatric residents in simulated cardiac arrests. Further studies are needed to help determine the role of AEDs in pediatric in-hospital cardiac arrests.

Minimum-Time Consensus-Based Approach for Power System Applications

DOE Office of Scientific and Technical Information (OSTI.GOV)

Yang, Tao; Wu, Di; Sun, Yannan

2016-02-01

This paper presents minimum-time consensus based distributed algorithms for power system applications, such as load shedding and economic dispatch. The proposed algorithms are capable of solving these problems in a minimum number of time steps instead of asymptotically as in most of existing studies. Moreover, these algorithms are applicable to both undirected and directed communication networks. Simulation results are used to validate the proposed algorithms.

Modeling residence-time distribution in horizontal screw hydrolysis reactors

DOE Office of Scientific and Technical Information (OSTI.GOV)

Sievers, David A.; Stickel, Jonathan J.

The dilute-acid thermochemical hydrolysis step used in the production of liquid fuels from lignocellulosic biomass requires precise residence-time control to achieve high monomeric sugar yields. Difficulty has been encountered reproducing residence times and yields when small batch reaction conditions are scaled up to larger pilot-scale horizontal auger-tube type continuous reactors. A commonly used naive model estimated residence times of 6.2-16.7 min, but measured mean times were actually 1.4-2.2 the estimates. Here, this study investigated how reactor residence-time distribution (RTD) is affected by reactor characteristics and operational conditions, and developed a method to accurately predict the RTD based on key parameters.more » Screw speed, reactor physical dimensions, throughput rate, and process material density were identified as major factors affecting both the mean and standard deviation of RTDs. The general shape of RTDs was consistent with a constant value determined for skewness. The Peclet number quantified reactor plug-flow performance, which ranged between 20 and 357.« less

Modeling residence-time distribution in horizontal screw hydrolysis reactors

DOE PAGES

Sievers, David A.; Stickel, Jonathan J.

2017-10-12

The dilute-acid thermochemical hydrolysis step used in the production of liquid fuels from lignocellulosic biomass requires precise residence-time control to achieve high monomeric sugar yields. Difficulty has been encountered reproducing residence times and yields when small batch reaction conditions are scaled up to larger pilot-scale horizontal auger-tube type continuous reactors. A commonly used naive model estimated residence times of 6.2-16.7 min, but measured mean times were actually 1.4-2.2 the estimates. Here, this study investigated how reactor residence-time distribution (RTD) is affected by reactor characteristics and operational conditions, and developed a method to accurately predict the RTD based on key parameters.more » Screw speed, reactor physical dimensions, throughput rate, and process material density were identified as major factors affecting both the mean and standard deviation of RTDs. The general shape of RTDs was consistent with a constant value determined for skewness. The Peclet number quantified reactor plug-flow performance, which ranged between 20 and 357.« less

Maternity leave: existing policies in obstetrics and gynecology residency programs.

PubMed

Davis, J L; Baillie, S; Hodgson, C S; Vontver, L; Platt, L D

2001-12-01

To survey program directors in obstetrics and gynecology regarding maternity leave and to determine how programs are dealing with maternity leave coverage. Questionnaires regarding impact and policy on maternity leave were mailed to accredited obstetrics and gynecology residency programs. A total of 188 of 274 (69%) questionnaires were returned completed. Respectively, 80% and 69% of respondents indicated that they have a formal maternity (maximum mean 8.7 weeks) and paternity (mean 5.27 days) leave policy. Approximately 75% of programs require residents to make up time if their leave exceeds 8 weeks during the first 3 years. Eighty-five percent of programs require residents to make up time if their leave exceeds 6 weeks during the fourth year. Ninety-three percent of programs require residents to make up time if their leave exceeds 20 weeks over the 4 years. Seventy-seven percent of respondents have other residents in their program cover for the absent resident. Thirty-seven percent of programs have schedules flexible enough to allow rearrangement so that some rotations go uncovered. Eighty-three percent of programs surveyed stated that maternity leave has a somewhat to very significant impact on the residents' schedules. Most residency programs have written maternity/paternity leave policies. A more flexible curriculum may help to accommodate the residents on leave without overburdening the residents who are left to cover.

50 CFR 259.34 - Minimum and maximum deposits; maximum time to deposit.

Code of Federal Regulations, 2010 CFR

2010-10-01

... B objective. A time longer than 10 years, either by original scheduling or by subsequent extension... OCEANIC AND ATMOSPHERIC ADMINISTRATION, DEPARTMENT OF COMMERCE AID TO FISHERIES CAPITAL CONSTRUCTION FUND...) Minimum annual deposit. The minimum annual (based on each party's taxable year) deposit required by the...

Practice quality improvement during residency: where do we stand and where can we improve?

PubMed

Choudhery, Sadia; Richter, Michael; Anene, Alvin; Xi, Yin; Browning, Travis; Chason, David; Morriss, Michael Craig

2014-07-01

Completing a systems-based practice project, equivalent to a practice quality improvement project (PQI), is a residency requirement by the Accreditation Council for Graduate Medical Education and an American Board of Radiology milestone. The aim of this study was to assess the residents' perspectives on quality improvement projects in radiology. Survey data were collected from 154 trainee members of the Association of University Radiologists to evaluate the residents' views on PQI. Most residents were aware of the requirement of completing a PQI project and had faculty mentors for their projects. Residents who thought it was difficult to find a mentor were more likely to start their project later in residency (P < .0001). Publication rates were low overall, and lack of time was considered the greatest obstacle. Having dedicated time for a PQI project was associated with increased likelihood of publishing or presenting the data (P = .0091). Residents who rated the five surveyed PQI steps (coming up with an idea, finding a mentor, designing a project, finding resources, and finding time) as difficult steps were more likely to not have initiated a PQI project (P < .0001 for the first four and P = .0046 for time). We present five practical areas of improvement to make PQI a valuable learning experience: 1) Increasing awareness of PQI and providing ideas for projects, 2) encouraging faculty mentorship and publication, 3) educating residents about project design and implementation, 4) providing resources such as books and funds, and 5) allowing dedicated time. Copyright © 2014 AUR. Published by Elsevier Inc. All rights reserved.

A Checklist Intervention to Assess Resident Diagnostic Knee and Shoulder Arthroscopic Efficiency.

PubMed

Nwachukwu, Benedict; Gaudiani, Michael; Hammann-Scala, Jennifer; Ranawat, Anil

The purpose of this investigation was to apply an arthroscopic shoulder and knee checklist in the evaluation of orthopedic resident arthroscopic skill efficiency and to demonstrate the use of a surgical checklist for assessing resident surgical efficiency over the course of a surgical rotation. Orthopedic surgery residents rotating on the sports medicine service at our institution between 2011 and 2015 were enrolled in this study. Residents were administered a shoulder and knee arthroscopy assessment tool at the beginning and end of their 6-week rotation. The assessment tools consisted of checklist items for knee and shoulder arthroscopy skills. Residents were timed while performing these checklist tasks. The primary outcome measure was resident improvement as a function of time to completion for the checklist items, and the intervention was participation in a 6-week resident rotation with weekly arthroscopy didactics, cadaver simulator work, and operating room experience. A paired t test was used to compare means. Mean time to checklist completion during week 1 among study participants for the knee checklist was 787.4 seconds for the knee checklist and 484.4 seconds at the end of the rotation. Mean time to checklist completion during week 1 among study participants for the shoulder checklist was 1655.3 seconds and 832.7 seconds for the shoulder checklist at the end of the rotation. Mean improvement in time to completion was 303 seconds (p = 0.0006, SD = 209s) and 822.6 seconds (p = 0.00008, SD = 525.2s) for the arthroscopic knee and shoulder assessments, respectively. An arthroscopic checklist is 1 method to evaluate and assess resident efficiency and improvement during surgical training. Among residents participating in this study, we found statistically significant improvements in time for arthroscopic task completion. II. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

A Novel Approach to Practice-Based Learning and Improvement Using a Web-Based Audit and Feedback Module.

PubMed

Boggan, Joel C; Cheely, George; Shah, Bimal R; Heffelfinger, Randy; Springall, Deanna; Thomas, Samantha M; Zaas, Aimee; Bae, Jonathan

2014-09-01

Systematically engaging residents in large programs in quality improvement (QI) is challenging. To coordinate a shared QI project in a large residency program using an online tool. A web-based QI tool guided residents through a 2-phase evaluation of performance of foot examinations in patients with diabetes. In phase 1, residents completed reviews of health records with online data entry. Residents were then presented with personal performance data relative to peers and were prompted to develop improvement plans. In phase 2, residents again reviewed personal performance. Rates of performance were compared at the program and clinic levels for each phase, with data presented for residents. Acceptability was measured by the number of residents completing each phase. Feasibility was measured by estimated faculty, programmer, and administrator time and costs. Seventy-nine of 86 eligible residents (92%) completed improvement plans and reviewed 1471 patients in phase 1, whereas 68 residents (79%) reviewed 1054 patient charts in phase 2. Rates of performance of examination increased significantly between phases (from 52% to 73% for complete examination, P < .001). Development of the tool required 130 hours of programmer time. Project analysis and management required 6 hours of administrator and faculty time monthly. An online tool developed and implemented for program-wide QI initiatives successfully engaged residents to participate in QI activities. Residents using this tool demonstrated improvement in a selected quality target. This tool could be adapted by other graduate medical education programs or for faculty development.

Redfield Ratios in Inland Waters: Higher Biological Control of C:N:P Ratios in Tropical Semi-arid High Water Residence Time Lakes

PubMed Central

They, Ng H.; Amado, André M.; Cotner, James B.

2017-01-01

The canonical Redfield C:N:P ratio for algal biomass is often not achieved in inland waters due to higher C and N content and more variability when compared to the oceans. This has been attributed to much lower residence times and higher contributions of the watershed to the total organic matter pool of continental ecosystems. In this study we examined the effect of water residence times in low latitude lakes (in a gradient from humid to a semi-arid region) on seston elemental ratios in different size fractions. We used lake water specific conductivity as a proxy for residence time in a region of Eastern Brazil where there is a strong precipitation gradient. The C:P ratios decreased in the seston and bacterial size-fractions and increased in the dissolved fraction with increasing water retention time, suggesting uptake of N and P from the dissolved pool. Bacterial abundance, production and respiration increased in response to increased residence time and intracellular nutrient availability in agreement with the growth rate hypothesis. Our results reinforce the role of microorganisms in shaping the chemical environment in aquatic systems particularly at long water residence times and highlights the importance of this factor in influencing ecological stoichiometry in all aquatic ecosystems. PMID:28848518

Assessing the Benefits Provided by SWOT Data Towards Estimating Reservoir Residence Time in the Mekong River Basin

NASA Astrophysics Data System (ADS)

Bonnema, M.; Hossain, F.

2016-12-01

The Mekong River Basin is undergoing rapid hydropower development. Nine dams are planned on the main stem of the Mekong and many more on its extensive tributaries. Understanding the effects that current and future dams have on the river system and water cycle as a whole is vital for the millions of people living in the basin. reservoir residence time, the amount of time water spends stored in a reservoir, is a key parameter in investigating these impacts. The forthcoming Surface Water and Ocean Topography (SWOT) mission is poised to provide an unprecedented amount of surface water observations. SWOT, when augmented by current satellite missions, will provide the necessary information to estimate the residence time of reservoirs across the entire basin in a more comprehensive way than ever before. In this study, we first combine observations from current satellite missions (altimetry, spectral imaging, precipitation) to estimate the residence times of existing reservoirs. We then use this information to project how future reservoirs will increase the residence time of the river system. Next, we explore how SWOT observations can be used to improve residence time estimation by examining the accuracy of reservoir surface area and elevation observations as well as the accuracy of river discharge observations.

Pediatricians working part-time: past, present, and future.

PubMed

Cull, William L; Mulvey, Holly J; O'Connor, Karen G; Sowell, Debra R; Berkowitz, Carol D; Britton, Carmelita V

2002-06-01

Pediatrics has consistently attracted a large number of women. Although the majority of practicing pediatricians are male, female pediatricians will soon constitute the majority. The challenge to balance personal and professional life is of particular concern to women, and part-time positions may provide a potential solution. To examine how many pediatricians currently work part-time, to examine trends in part-time employment from 1993 to present, to determine pediatric residents' interest in part-time employment, and to identify perceived barriers to part-time work. Two data sources were used for these analyses. The first was an American Academy of Pediatrics Periodic Survey from 1993 and 2000 asking a combined national sample of 3218 American Academy of Pediatrics members about their employment status. Multiple mailings were conducted for each survey producing an overall response rate of 62%. The second data source was a survey asking a national random sample of 500 pediatric residents completing training in 2000 about their job search experiences and attitudes toward part-time employment. Four mailings of this survey were completed, and responses were obtained from 71% of residents. The percentage of pediatricians working part-time increased from 11% in 1993 to 15% in 2000. This increase did not exceed what would be expected based on the rise in the percentage of pediatricians who are female from 36% in 1993 to 45% in 2000. On average, pediatricians working part-time provided 36% fewer direct patient care hours than full-time pediatricians (42 hours vs 27 hours). No statistically significant difference in direct patient care hours was apparent between male and female pediatricians working full-time. Female residents were more likely than male residents to consider part-time or reduced-hours positions (42% vs 14%) and to accept part-time or reduced-hours positions (14% vs 3%). Also, considerably more female residents (58%) than male residents (15%) indicated that they would be interested in arranging a part-time position within the next 5 years. The most commonly perceived barriers to working part-time by both male and female residents included loss of income (70%), reduction in job benefits such as health insurance (47%), and loan repayment (46%). When those who reported some interest in part-time employment were asked how they would spend their extra time, most reported that they would address family needs related to children (females: 92%; males: 63%). Finally, residents interested in working part-time were more likely to be without a position when surveyed than residents not interested in part-time work (15% vs 2%). The relative percentages of female pediatricians and pediatricians working part-time will likely continue to grow. As a result, the total direct patient care hours available for children may be reduced. Pediatric practices will benefit by better accommodating the needs of pediatricians to balance work and family goals, and future workforce projections and training decisions must begin taking part-time employment rates into account.

Resident involvement in laparoscopic procedures does not worsen clinical outcomes but may increase operative times and length of hospital stay.

PubMed

Jolley, Jennifer; Lomelin, Daniel; Simorov, Anton; Tadaki, Carl; Oleynikov, Dmitry

2016-09-01

Surgical procedures have a learning curve regarding the number of cases required for proficiency. Consequently, involvement of less experienced resident surgeons may impact patients and the healthcare system. This study examines basic and advanced laparoscopic procedures performed between 2010 and 2011 and evaluates the resident surgeon participation effect. Basic laparoscopic procedures (BL), appendectomy (LA), cholecystectomy (LC), and advanced Nissen fundoplication (LN) were queried from the American College of Surgeons National Surgical Quality Improvement Program database. Cases were identified using Current Procedural Terminology codes. Analyses were performed using IBM SPSS Statistics v.22, α-level = 0.05. Multiple logistic regression was used, accounting for age, race, gender, admission status, wound classification, and ASA classification. In total, 71,819 surgeries were reviewed, 66,327 BL (37,636 LC and 28,691 LA) and 5492 LN. Median age was 48 years for LC and 37 years for LA. In sum, 72.2 % of LC and 49.5 % of LA patients were female. LN median age was 59 years, and 67.7 % of patients were female. For BL, resident involvement was not significantly associated with mortality, morbidity, and return to the OR. Readmission was not related to resident involvement in LC. In LA, resident-involved surgeries had increased readmission and longer OR time, but decreased LOS. In LC, resident involvement was associated with longer LOS and OR time. Resident involvement was not a significant factor in the odds of mortality, morbidity, return to OR, or readmission in LN. Surgeries involving residents had increased odds of having longer LOS, and of lengthier surgery time. We demonstrate resident involvement is safe and does not result in poorer patient outcomes. Readmissions and LOS were higher in BL, and operative times were longer in all surgeries. Resident operations do appear to have real consequences for patients and may impact the healthcare system financially.

Contribution of alcohol in accident related mortality in Belarus: a time series approach

PubMed Central

Razvodovsky, Yury Evgeny

2012-01-01

Abstract: Background: High accidental death rates in the former Soviet republics (FSR) and its profound fluctuation over the past decades have attracted considerable interest. The research evidences emphasize binge drinking pattern as a potentially important contributor to accident mortality crisis in FSR. In line with this evidence we assume that higher level of alcohol consumption in conjunction with binge drinking pattern results in close aggregate-level association between alcohol psychoses and accidental death rates in the former Soviet Slavic republic Belarus. Methods: Trends in alcohol psychoses rate (as a proxy for alcohol consumption) from 1979 to 2007 were analyzed employing a distributed lag analysis in order to asses bivariate relationship between the two time series. Results: According to the Bureau of Forensic Medicine autopsy reports the number of deaths due to accidents and injuries increased by 52.5% (from 62.3 to 95.0 per 100.000 of residents), and fatal alcohol poisoning rate increased by 108.6% (from 12.8 to 26.7 per 100.000 of residents) in Belarus between 1979 and 2007. Alcohol in blood was found in 50.1% victims of deaths from accidents and injuries for the whole period, with the minimum figure 40% in 1986 and maximum 58.2% in 2005. The outcome of distributed lags analysis indicated statistically significant association between the number of alcohol psychoses cases and the number BAC-positive deaths from accidents at zero lag. Conclusion: The outcome of this study supports previous findings suggesting that alcohol and deaths from accidents are closely connected in a culture with prevailing intoxication-oriented drinking pattern, and add to growing body of evidence that a substantial proportion of accidental deaths in Belarus are due to effects of binge drinking. PMID:21502784

Change in hyporheic zone residence time under different surface flow states

NASA Astrophysics Data System (ADS)

Liu, Suning; Chui, Ting Fong May

2017-04-01

Hyporheic zone (HZ), which is the ecotone immediately below or adjacent to a stream, plays an important role in a stream ecological system. One of the most common metrics in evaluating the functioning of an HZ is residence time (RT) which is the duration a water molecule or a solute remains within the HZ. Many factors, such as meandering of a stream, heterogeneity of streambed, can influence the RT of an HZ. Stream discharge is another governing but less discussed factor. Different discharge values produce different flow states (i.e.., subcritical, critical and supercritical) and alluvial stream bed forms. This study examined the changes of RT in discharges of different states and their corresponding induced bed forms. It employed a toolbox developed by Stonedahl et al. (2015) within Netlogo to simulate the RT of an HZ, considering three discharge values in each of the supercritical, critical and subcritical states. It approximated the bed forms as sinusoidal waves with amplitudes and periods selected for each flow state. The simulated results suggest that the RT is minimum when the flow is critical, and it is longer for both subcritical and supercritical flows. For subcritical flow, the RT, as well as the fraction remained within the streambed during particle tracing, increases with the increase in discharge value. However, there is no such variation among the different discharge values of supercritical flow. Therefore, for supercritical flow, one combination of discharge value and bed form might be sufficient and representative. However, for subcritical flow, the variations of discharge values and their induced bed forms should be considered. Reference: Stonedahl, S.H., Roche, K.R., Stonedahl, F., & Packman, A.I. (2015). Visualizing Hyporheic Flow Through Bedforms Using Dye Experiments and Simulation. J. Vis. Exp. (105), e53285. doi: 10.3791/53285

Prevalence and Cost of Full-Time Research Fellowships During General Surgery Residency – A National Survey

PubMed Central

Robertson, Charles M.; Klingensmith, Mary E.; Coopersmith, Craig M.

2009-01-01

Structured Abstract Objective To quantify the prevalence, outcomes, and cost of surgical resident research. Summary Background Data General surgery is unique among graduate medical education programs because a large percentage of residents interrupt their clinical training to spend 1-3 years performing full-time research. No comprehensive data exists on the scope of this practice. Methods Survey sent to all 239 program directors of general surgery residencies participating in the National Resident Matching Program. Results Response rate was 200/239 (84%). A total of 381 out of 1052 trainees (36%) interrupt residency to pursue full-time research. The mean research fellowship length is 1.7 years, with 72% of trainees performing basic science research. A significant association was found between fellowship length and post-residency activity, with a 14.7% increase in clinical fellowship training and a 15.2% decrease in private practice positions for each year of full-time research (p<0.0001). Program directors at 31% of programs reported increased clinical duties for research fellows as a result of ACGME work hour regulations for clinical residents, while a further 10% of programs are currently considering such changes. It costs $41.5 million to pay the 634 trainees who perform research fellowships each year, the majority of which is paid for by departmental funds (40%) and institutional training grants (24%). Conclusions Interrupting residency to perform a research fellowship is a common and costly practice among general surgery residents. While performing a research fellowship is associated with clinical fellowship training after residency, it is unclear to what extent this practice leads to the development of surgical investigators after post-graduate training. PMID:19106692

24/7/365 in-house radiologist coverage: effect on resident education.

PubMed

Collins, Jannette; Gruppen, Larry D; Bailey, Janet E; Bokhari, Syed Ahmad Jamal; Paladin, Angelisa M; Robbins, Jessica; White, Richard D

2014-07-01

To compare programs with and without 24-hour/7 days a week/365 days a year (24/7/365) in-house radiologist coverage regarding resident perceptions of their on-call experience, volume of resident dictations on call, and report turnaround time. Residents from six academic radiology departments were invited to participate in an 11-item online survey. Survey items were related to workload, level of autonomy, faculty feedback, comfort level, faculty supervision, and overall educational experience while on call from 8 pm to 8 am. Each site provided data on imaging volume, radiologist coverage, volume of examinations dictated by residents, number of residents on call, and report turnaround time from 8 pm to 8 am. F-ratios and eta-squares were calculated to determine the relationships between dependent and independent variables. A P value < .05 was considered statistically significant. A total of 146 (67%) of 217 residents responded. Residents in programs with 24/7/365 in-house radiologist coverage dictated a lower percentage of examinations (46%) compared with other residents (81%) and rated faculty feedback more positively (mean 3.8 vs. 3.3) but rated their level of autonomy (mean 3.6 vs. 4.5) and educational experience (mean 3.6 vs. 4.2) more negatively (all P < .05). Report turnaround time was lower in programs with 24/7/365 coverage than those without (mean 1.7 hours vs. 9.1 hours). The majority of resident comments were negative and related to loss of autonomy with 24/7/365 coverage. More rapid report turnaround time related to 24/7/365 coverage may come at the expense of resident education. Copyright © 2014 AUR. Published by Elsevier Inc. All rights reserved.

Psychiatric Emergency Services - Can Duty-Hour Changes Help Residents and Patients?

PubMed

Brainch, Navjot; Schule, Patrick; Laurel, Faith; Bodic, Maria; Jacob, Theresa

2018-04-14

Limitations on resident duty hours have been widely introduced with the intention of decreasing resident fatigue and improving patient outcomes. While there is evidence of improvement in resident well-being and education following such initiatives, they have inadvertently resulted in increased number of hand-offs between clinicians leading to potential errors in patient care. Current literature emphasizes need for more specialty/setting-specific scheduling, while considering residents' opinions when implementing duty-hour reforms. There are no reports examining the impact of duty-hour changes on residents or patients in psychiatric emergency service (PES) settings. Our purpose was to assess the impact of a recent scheduling change and decrease in overall duty hours, on resident well-being and sense of burnout, while also evaluating changes to patient wait-time and length of stay (LOS) in PES. Residents completed Maslach Burnout Inventory and anonymous surveys focusing on: fatigue, sleep, life outside work for shifts - regular (8 am-8 pm) and swing shifts (12 pm-10 pm). Data from the electronic medical records were collected for 6 months pre- and post-schedule change (January 2016-February 2017), for LOS and patient wait-time. Residents' preference for shifts was split. However, 86% reported getting enough sleep during swing shifts, while 83% reported lack of sleep during regular shifts. The average patient wait-time and LOS significantly decreased from 169 to 147 and 690 to 515 min, respectively. The change to swing shifts significantly impacts LOS and patient wait-time. The short shifts demonstrated an improvement in well-being for residents, but were not the singular factor for overall resident satisfaction.

Geochronologic evidence for a possible MIS-11 emergent barrier/beach-ridge in southeastern Georgia, USA

USGS Publications Warehouse

Markewich, H.W.; Pavich, M.J.; Schultz, A.P.; Mahan, S.A.; Aleman-Gonzalez, W. B.; Bierman, P.R.

2013-01-01

Predominantly clastic, off-lapping, transgressive, near-shore marine sediment packages that are morphologically expressed as subparallel NE-trending barriers, beach ridges, and associated back-barrier areas, characterize the near-surface stratigraphic section between the Savannah and the Ogeechee Rivers in Effingham County, southeastern Georgia. Each barrier/back-barrier (shoreline) complex is lower than and cut into a higher/older complex. Each barrier or shoreline complex overlies Miocene strata. No direct age data are available for these deposits. Previous researchers have disagreed on their age and provenance. Using luminescence and meteoric beryllium-10 (10Be) inventory analyses, we estimated a minimum age for the largest, westernmost, morphologically identifiable, and topographically-highest, barrier/beach-ridge (the Wicomico shoreline barrier) and constrained the age of a suite of younger barrier/beach-ridges that lie adjacent and seaward of the Wicomico shoreline barrier. At the study site, the near-shore marine/estuarine deposits underlying the Wicomico shoreline barrier are overlain by eolian sand and an intervening zone-of-mixing. Optically stimulated luminescence (OSL) data indicate ages of ≤43 ka for the eolian sand and 116 ka for the zone-of-mixing. Meteoric 10Be and pedostratigraphic data indicate minimum residence times of 33.4 ka for the eolian sand, 80.6 ka for the zone-of-mixing, and 247 ka for the paleosol. The combined OSL and 10Be age data indicate that, at this locality, the barrier/beach ridge has a minimum age of about 360 ka. This age for the Wicomico shoreline-barrier deposit is the first for any Pleistocene near-shore marine/estuarine deposit in southeast Georgia that is conclusively older than 80 ka. The 360-ka minimum age is in agreement with other geochronologic data for near-coastline deposits in Georgia and South Carolina. The geomorphic position of this barrier/beach-ridge is similar to deposits in South Carolina considered to be ~450 ka to >1 Ma. The age and geomorphic data for Georgia and South Carolina possibly suggest the presence of MIS-11 (~420−360 ka) shoreline deposits between 15 m and 28 m above present sea level in the Southeastern Atlantic Coastal Plain.

Computerized rounding in a community hospital surgery residency program.

PubMed

Park, John; Tymitz, Kevin; Engel, Amy M; Welling, Richard E

2007-01-01

With the institution of the 80-hour work week, residency programs have worked to institute programs that decrease the time that residents spend in the hospital while maintaining patient safety. This study was intended to assess the amount of time saved using computerized patient information in the form of a personal data assistant (PDA). A community hospital surgical residency program with 22 residents initially collected data daily for 4 weeks without PDA use. Data included preround time, check-out time, total number of patients, number of medical/surgical patients, and number of intensive care unit patients. The definition of prerounding time was started when residents first began collecting information on their patients in the morning until 6:00 am. Check-out time started at 5:00 pm and lasted until the discussion of patient care with the night team had finished. Residents were then given PDAs allowing immediate up-to-date access to patient information, which most importantly included current vital signs, laboratory data, radiological dictations, medication lists, and fluid intake and output. After a 4-week acquaintance period with the PDA had passed, data were again collected from the residents daily for 4 weeks. Daily averages for each week and an overall total average were calculated. Daily averages were also calculated for each PGY level. Paired t-tests compared the pre-PDA and post-PDA total averages. No significant difference was found between the total number of patients pre-PDA and post-PDA (7.6 and 7.6, respectively, p = 0.98), the average number of medical/surgical patients (4.7 and 7.1, respectively, p = 0.16), or the average number of intensive care unit patients (2.6 and 0.4, respectively, p = 0.06). Also, no significant difference was found between pre-PDA and post-PDA with average check-out time (24.5 minutes and 21.9 minutes, respectively, p = 0.06). However, a significant decrease in rounding time occurred with pre-PDA round time at 50.5 minutes and post-PDA round time at 40.7 minutes (p = 0.02). Results of this study support the hypothesis that the prerounding time dramatically decreases with the PDA compared to without. Not only does this decrease in time help to keep residents under the 80-hour work week rule, but also it helps to eliminate much of the confusion that can cause patient safety issues.

Dirac dispersion generates unusually large Nernst effect in Weyl semimetals

NASA Astrophysics Data System (ADS)

Watzman, Sarah J.; McCormick, Timothy M.; Shekhar, Chandra; Wu, Shu-Chun; Sun, Yan; Prakash, Arati; Felser, Claudia; Trivedi, Nandini; Heremans, Joseph P.

2018-04-01

Weyl semimetals contain linearly dispersing electronic states, offering interesting features in transport yet to be thoroughly explored thermally. Here we show how the Nernst effect, combining entropy with charge transport, gives a unique signature for the presence of Dirac bands and offers a diagnostic to determine if trivial pockets play a role in this transport. The Nernst thermopower of NbP exceeds its conventional thermopower by a 100-fold, and the temperature dependence of the Nernst effect has a pronounced maximum. The charge-neutrality condition dictates that the Fermi level shifts with increasing temperature toward the energy that has the minimum density of states (DOS). In NbP, the agreement of the Nernst and Seebeck data with a model that assumes this minimum DOS resides at the Dirac points is taken as strong experimental evidence that the trivial (non-Dirac) bands play no role in high-temperature transport.

Sea Ice Prediction Has Easy and Difficult Years

NASA Technical Reports Server (NTRS)

Hamilton, Lawrence C.; Bitz, Cecilia M.; Blanchard-Wrigglesworth, Edward; Cutler, Matthew; Kay, Jennifer; Meier, Walter N.; Stroeve, Julienne; Wiggins, Helen

2014-01-01

Arctic sea ice follows an annual cycle, reaching its low point in September each year. The extent of sea ice remaining at this low point has been trending downwards for decades as the Arctic warms. Around the long-term downward trend, however, there is significant variation in the minimum extent from one year to the next. Accurate forecasts of yearly conditions would have great value to Arctic residents, shipping companies, and other stakeholders and are the subject of much current research. Since 2008 the Sea Ice Outlook (SIO) (http://www.arcus.org/search-program/seaiceoutlook) organized by the Study of Environmental Arctic Change (SEARCH) (http://www.arcus.org/search-program) has invited predictions of the September Arctic sea ice minimum extent, which are contributed from the Arctic research community. Individual predictions, based on a variety of approaches, are solicited in three cycles each year in early June, July, and August. (SEARCH 2013).

Collection of ultrafine diesel particulate matter (DPM) in cylindrical single-stage wet electrostatic precipitators.

PubMed

Saiyasitpanich, Phirun; Keener, Tim C; Lu, Mingming; Khang, Soon-Jai; Evans, Douglas E

2006-12-15

Long-term exposures to diesel particulate matter (DPM) emissions are linked to increasing adverse human health effects due to the potential association of DPM with carcinogenicity. Current diesel vehicular particulate emission regulations are based solely upon total mass concentration, albeit it is the submicrometer particles that are highly respirable and the most detrimental to human health. In this study, experiments were performed with a tubular single-stage wet electrostatic precipitator (wESP) to evaluate its performance for the removal of number-based DPM emissions. A nonroad diesel generator utilizing a low sulfur diesel fuel (500 ppmw) operating under varying load conditions was used as a stationary DPM emission source. An electrical low-pressure impactor (ELPI) was used to quantify the number concentration distributions of diesel particles in the diluted exhaust gas at each tested condition. The wESP was evaluated with respect to different operational control parameters such as applied voltage, gas residence time, etc., to determine their effect on overall collection efficiency, as well as particle size dependent collection efficiency. The results show that the total DPM number concentrations in the untreated diesel exhaust are in the magnitude of approximately108/cm(3) at all engine loads with the particle diameter modes between 20 and 40 nm. The measured collection efficiency of the wESP operating at 70 kV based on total particle numbers was 86% at 0 kW engine load and the efficiency decreased to 67% at 75 kW due to a decrease in gas residence time and an increase in particle concentrations. At a constant wESP voltage of 70 kV and at 75 kW engine load, the variation of gas residence time within the wESP from approximately 0.1 to approximately 0.4 s led to a substantial increase in the collection efficiency from 67% to 96%. In addition, collection efficiency was found to be directly related to the applied voltage, with increasing collection efficiency measured for increases in applied voltage. The collection efficiency based on particle size had a minimum for sizes between 20 and 50 nm, but at optimal wESP operating conditions it was possible to remove over 90% of all particle sizes. A comparison of measured and calculated collection efficiencies reveals that the measured values are significantly higher than the predicted values based on the well-known Deutsch equation.

The costs and quality of operative training for residents in tympanoplasty type I.

PubMed

Wang, Mao-Che; Yu, Eric Chen-Hua; Shiao, An-Suey; Liao, Wen-Huei; Liu, Chia-Yu

2009-05-01

A teaching hospital would incur more operation room costs on training surgical residents. To evaluate the increased operation time and the increased operation room costs of operations performed by surgical residents. As a model we used a very common surgical otology procedure -- tympanoplasty type I. From January 1, 2004 to December 31, 2004, we included in this study 100 patients who received tympanoplasty type I in Taipei Veterans General Hospital. Fifty-six procedures were performed by a single board-certified surgeon and 44 procedures were performed by residents. We analyzed the operation time and surgical outcomes in these two groups of patients. The operation room cost per minute was obtained by dividing the total operation room expenses by total operation time in the year 2004. The average operation time of residents was 116.47 min, which was significantly longer (p<0.0001) than that of the board-certified surgeon (average 81.07 min). It cost USD $40.36 more for each operation performed by residents in terms of operation room costs. The surgical success rate of residents was 81.82%, which was significantly lower (p=0.016) than that of the board-certified surgeon (96.43%).

Recovery of Sleep or Recovery of Self? A Grounded Theory Study of Residents' Decision Making Regarding How to Spend Their Nonclinical Postcall Time.

PubMed

Taylor, Taryn S; Nisker, Jeff; Teunissen, Pim W; Dornan, Tim; Lingard, Lorelei

2016-03-01

As resident work hours policies evolve, residents' off-duty time remains poorly understood. Despite assumptions about how residents should be using their postcall, off-duty time, there is little research on how residents actually use this time and the reasoning underpinning their activities. This study sought to understand residents' nonclinical postcall activities when they leave the hospital, their decision-making processes, and their perspectives on the relationship between these activities and their well-being or recovery. The study took place at a Liaison Committee on Medical Education-accredited Canadian medical school from 2012 to 2014. The authors recruited a purposive and convenience sample of postgraduate year 1-5 residents from six surgical and nonsurgical specialties at three hospitals affiliated with the medical school. Using a constructivist grounded theory approach, semistructured interviews were conducted, audio-taped, transcribed, anonymized, and combined with field notes. The authors analyzed interview transcripts using constant comparative analysis and performed post hoc member checking. Twenty-four residents participated. Residents characterized their predominant approach to postcall decision making as one of making trade-offs between multiple, competing, seemingly incompatible, but equally valuable, activities. Participants exhibited two different trade-off orientations: being oriented toward maintaining a normal life or toward mitigating fatigue. The authors' findings on residents' trade-off orientations suggest a dual recovery model with postcall trade-offs motivated by the recovery of sleep or of self. This model challenges the dominant viewpoint in the current duty hours literature and suggests that the duty hours discussion must be broadened to include other recovery processes.

Efforts of the occupant to change physical quality of residential unit through the change of building material at low cost flats in Jakarta

NASA Astrophysics Data System (ADS)

Nurdiani, N.

2018-03-01

Low cost flats in Jakarta – Indonesia is provided by the government for low-income people in urban areas, in line with the program to redevelop or renew slum areas. Low cost flat is built with the minimum standard of building materials. The purpose of this study is to know efforts of the occupants to change of building materials at residential unit of low cost flats. The research was conducted by descriptive method at four of low cost housing in Jakarta: Rusuna Bendungan Hilir 1, Rusuna Tambora IIIA, Rusuna Bidara Cina, and Rusuna Sukapura. The results showed that physical changes which happened in low cost flats are aesthetic (residence paint color change), or improvement of physical quality of residential unit (change of building material), become dominant aspects done by residents in four rusuna.

Incorporating simulation in vascular surgery education.

PubMed

Bismuth, Jean; Donovan, Michael A; O'Malley, Marcia K; El Sayed, Hosam F; Naoum, Joseph J; Peden, Eric K; Davies, Mark G; Lumsden, Alan B

2010-10-01

The traditional apprenticeship model introduced by Halsted of "learning by doing" may just not be valid in the modern practice of vascular surgery. The model is often criticized for being somewhat unstructured because a resident's experience is based on what comes through the "door." In an attempt to promote uniformity of training, multiple national organizations are currently delineating standard curricula for each trainee to govern the knowledge and cases required in a vascular residency. However, the outcomes are anything but uniform. This means that we graduate vascular specialists with a surprisingly wide spectrum of abilities. Use of simulation may benefit trainees in attaining a level of technical expertise that will benefit themselves and their patients. Furthermore, there is likely a need to establish a simulation-based certification process for graduating trainees to further ascertain minimum technical abilities. Copyright © 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Maintaining Continuity of Care for Nursing Home Residents: Effect of States’ Medicaid Bed-Hold Policies and Reimbursement Rates

PubMed Central

Intrator, Orna; Schleinitz, Mark; Grabowski, David C; Zinn, Jacqueline; Mor, Vincent

2009-01-01

Objective Recent public concern in response to states’ intended repeal of Medicaid bed-hold policies and report of their association with higher hospitalization rates prompts examination of these policies in ensuring continuity of care within the broader context of Medicaid policies. Data Sources/Study Design Minimum Data Set assessments of long-stay nursing home residents in April–June 2000 linked to Medicare claims enabled tracking residents’ hospitalizations during the ensuing 5 months and determining hospital discharge destination. Multinomial multilevel models estimated the effect of state policies on discharge destination controlling for resident, hospitalization, nursing home, and market characteristics. Results Among 77,955 hospitalizations, 5,797 (7.4 percent) were not discharged back to the baseline nursing home. Bed-hold policies were associated with lower odds of transfer to another nursing home (AOR=0.55, 95 percent CI 0.52–0.58) and higher odds of hospitalization (AOR=1.36), translating to 9.5 fewer nursing home transfers and 77.9 more hospitalizations per 1,000 residents annually, and costing Medicaid programs about $201,311. Higher Medicaid reimbursement rates were associated with lower odds of transfer. Conclusions Bed-hold policies were associated with greater continuity of NH care; however, their high cost compared with their small impact on transfer but large impact on increased hospitalizations suggests that they may not be effective. PMID:18783452

Resident operative experience in general surgery, plastic surgery, and urology 5 years after implementation of the ACGME duty hour policy.

PubMed

Simien, Christopher; Holt, Kathleen D; Richter, Thomas H; Whalen, Thomas V; Coburn, Michael; Havlik, Robert J; Miller, Rebecca S

2010-08-01

Resident duty hour restrictions were implemented in 2002-2003. This study examines changes in resident surgical experience since these restrictions were put into place. Operative log data for 3 specialties were examined: general surgery, urology, and plastic surgery. The academic year immediately preceding the duty hour restrictions, 2002-2003, was used as a baseline for comparison to subsequent academic years. Operative log data for graduating residents through 2007-2008 were the primary focus of the analysis. Examination of associated variables that may moderate the relationship between fewer duty hours and surgical volume was also included. Plastic surgery showed no changes in operative volume following duty hour restrictions. Operative volume increased in urology programs. General surgery showed a decrease in volume in some operative categories but an increase in others. Specifically the procedures in vascular, plastic, and thoracic areas showed a consistent decrease. There was no increase in the percentage of programs' graduates falling below minimum requirements. Procedures in pancreas, endocrine, and laparoscopic areas demonstrated an increase in volume. Graduates in larger surgical programs performed fewer procedures than graduates in smaller programs; this was not the case for urology or plastic surgery programs. The reduction of duty hours has not resulted in an across the board decrease in operative volume. Factors other than duty hour reforms may be responsible for some of the observed findings.

42 CFR 415.208 - Services of moonlighting residents.

Code of Federal Regulations, 2010 CFR

2010-10-01

... IN TEACHING SETTINGS, AND RESIDENTS IN CERTAIN SETTINGS Services of Residents § 415.208 Services of... payment is made for services of a “teaching physician” associated with moonlighting services, and the time spent furnishing these services is not included in the teaching hospital's full-time equivalency count...

Linear and Nonlinear Time-Frequency Analysis for Parameter Estimation of Resident Space Objects

DTIC Science & Technology

2017-02-22

AFRL-AFOSR-UK-TR-2017-0023 Linear and Nonlinear Time -Frequency Analysis for Parameter Estimation of Resident Space Objects Marco Martorella...estimated to average 1 hour per response, including the time for reviewing instructions, searching existing   data sources, gathering and maintaining the...Nonlinear Time -Frequency Analysis for Parameter Estimation of Resident Space Objects 5a.  CONTRACT NUMBER 5b.  GRANT NUMBER FA9550-14-1-0183 5c.  PROGRAM

Suicidal thoughts among medical residents with burnout.

PubMed

van der Heijden, Frank; Dillingh, Gea; Bakker, Arnold; Prins, Jelle

2008-01-01

Recent research showed that medical residents have a high risk for developing burnout. The present study investigates the prevalence of burnout and its relationship with suicidal thoughts among medical residents. All Dutch medical residents (n = 5126) received a self-report questionnaire. Burnout was measured with the Maslach Burnout Inventory. Residents were asked about the frequency of suicidal thoughts. Response rate was 41.3% (n = 2115). 432 Residents (20.6%) were classified as burnout. 12% reported having suicidal thoughts at least 1 time during their residency, and 1% many times. Suicidal thoughts were substantially more prevalent in the group with burnout in comparison to non-burnout (20.5% vs. 7.6%; chi(2) = 182.9, p < .001). Knowledge about the relationship between burnout and suicidal thoughts among these young medical professionals could be important for suicide prevention.

Leadership education, certification and resident outcomes in US nursing homes: cross-sectional secondary data analysis.

PubMed

Trinkoff, Alison M; Lerner, Nancy B; Storr, Carla L; Han, Kihye; Johantgen, Mary E; Gartrell, Kyungsook

2015-01-01

Leadership is a key consideration in improving nursing home care quality. Previous research found nursing homes with more credentialed leaders had lower rates of care deficiencies than nursing homes with less credentialed leaders. Evidence that nursing home administrator (NHA) and director of nursing (DON) education and certification is related to resident outcomes is limited. To examine associations of education and certification among NHAs and DONs with resident outcomes. Cross-sectional secondary data analysis. This study used National Nursing Home Survey data on leadership education and certification and Nursing Home Compare quality outcomes (e.g. pain, catheter use). 1142 nursing homes in the survey which represented 16628 nursing homes in the US. Leadership education and certification were assessed separately for NHAs and DONs. Nursing home resident outcomes were measured using facility-level nursing home quality indicator rates selected from the Minimum Data Set. Facility-level quality indicators were regressed onto leadership variables in models that also held constant facility size and ownership status. Nursing homes led by NHAs with both Master's degrees or higher and certification had significantly better outcomes for pain. Nursing homes led by DONs with Bachelor's degrees or higher plus certification also had significantly lower pain and catheter use. Whereas pressure ulcer rates were higher in facilities led by DONs with more education. Selected outcomes for nursing home residents might be improved by increasing the education and certification requirements for NHAs and DONs. Additional research is needed to clarify these relationships. Copyright © 2014 Elsevier Ltd. All rights reserved.

APPENDIX C - ADDITIONAL INFORMATION ON FLUSHING IN ESTUARIES

EPA Science Inventory

Water residence time is an important determinant of the sensitivity of the response of estuaries and other water bodies to nutrient loading. A variety of terms such as residence time, flushing time, transit time, turnover time, and age are used to describe time scales for transpo...

Molecular Dynamics Simulations and Kinetic Measurements to Estimate and Predict Protein-Ligand Residence Times.

PubMed

Mollica, Luca; Theret, Isabelle; Antoine, Mathias; Perron-Sierra, Françoise; Charton, Yves; Fourquez, Jean-Marie; Wierzbicki, Michel; Boutin, Jean A; Ferry, Gilles; Decherchi, Sergio; Bottegoni, Giovanni; Ducrot, Pierre; Cavalli, Andrea

2016-08-11

Ligand-target residence time is emerging as a key drug discovery parameter because it can reliably predict drug efficacy in vivo. Experimental approaches to binding and unbinding kinetics are nowadays available, but we still lack reliable computational tools for predicting kinetics and residence time. Most attempts have been based on brute-force molecular dynamics (MD) simulations, which are CPU-demanding and not yet particularly accurate. We recently reported a new scaled-MD-based protocol, which showed potential for residence time prediction in drug discovery. Here, we further challenged our procedure's predictive ability by applying our methodology to a series of glucokinase activators that could be useful for treating type 2 diabetes mellitus. We combined scaled MD with experimental kinetics measurements and X-ray crystallography, promptly checking the protocol's reliability by directly comparing computational predictions and experimental measures. The good agreement highlights the potential of our scaled-MD-based approach as an innovative method for computationally estimating and predicting drug residence times.

The business case for nursing in long-term care.

PubMed

Horn, Susan D

2008-05-01

Lower nurse staffing in hospitals has been associated with adverse patient outcomes; results in nursing homes (NHs) are less clear. We examined the association between nurses' direct care time and outcomes in long-stay NH residents and potential cost savings from decreased adverse outcomes versus additional wages for adequate nurse staffing. Data were from the National Pressure Ulcer Long-Term Care Study of 1,376 at-risk residents from 82 NHs. Primary data came from medical records. Hospital, pressure ulcer (PrU) treatment, and urinary tract infection (UTI) costs were from national statistics or cost-identification studies. Time horizon was 1 year. More registered nurse (RN) direct care time/resident/day was associated with fewer PrUs, hospitalizations, and UTIs. Annual net societal benefit was $3,191/resident/year in high-risk NH units with 30-40 min of RN time/resident/day versus units with <10 min. Thus, after controlling for important variables, more RN time/day was strongly associated with better outcomes and lower societal cost.

Redefining the Surgical Council of Resident Education (SCORE) Curriculum: A Comparison with the Operative Experiences of Graduated General Surgical Residents.

PubMed

Strosberg, David S; Quinn, Kristen M; Abdel-Misih, Sherif R; Harzman, Alan E

2018-04-01

Our objective was to investigate the number and classify surgical operations performed by general surgery residents and compare these with the updated Surgical Council on Resident Education (SCORE) curriculum. We performed a retrospective review of logged surgical cases from general surgical residents who completed training at a single center from 2011 to 2015. The logged cases were correlated with the operations extracted from the SCORE curriculum. Hundred and fifty-one procedures were examined; there were 98 "core" and 53 "advanced" cases as determined by the SCORE. Twenty-eight residents graduated with an average of 1017 major cases. Each resident completed 66 (67%) core cases and 17 (32%) advanced cases an average of one or more times with 39 (40%) core cases and 6 (11%) advanced cases completed five or more times. Core procedures that are infrequently or not performed by residents should be identified in each program to focus on resident education.