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Numerous studies reported on the frequency of, and factors associated with inappropriate or unnecessary emergency department (ED) visits using clinician judgment as the gold standard of appropriateness. This study evaluated the reliability of clinician judgment for assessing appropriateness of pediatric ED visit.
We conducted a retrospective cohort study comparing 3 clinicians’ determination of ED visit appropriateness with and without guidance from a three-question structured algorithm. We used a cohort of scheduled ED return visits deemed appropriate by the index treating clinician between May 1, 2012, and April 30, 2013. We measured the level of agreement among three clinician investigators with and without use of the structured algorithm.
A total of 207 scheduled ED return visits were reviewed by the primary clinician reviewer who agreed with the index treating clinician for 79/207 visits (38.2%). Among a random subset of 90 return visits reviewed by all three clinicians, agreement was 67% with a Fleiss’ Kappa of 0.30 (0.17–0.44). Using a three-question algorithm based on objective criteria, agreement with the index treating provider increased to 115/207 (55.6%).
Although an important contributor to pediatric ED overcrowding, unnecessary or inappropriate visits are difficult to identify. We demonstrated poor reliability of clinician judgment to determine appropriateness of ED return visits, likely due to variability in clinical decision-making and risk-tolerance, social and systems factors impacting access and use of health care. We recommend that future studies evaluating the appropriateness of ED use standardized, objective criteria rather than clinician judgment alone.
The Bovine Respiratory Disease Coordinated Agricultural Project (BRD CAP) is a 5-year project funded by the United States Department of Agriculture (USDA), with an overriding objective to use the tools of modern genomics to identify cattle that are less susceptible to BRD. To do this, two large genome wide association studies (GWAS) were conducted using a case:control design on preweaned Holstein dairy heifers and beef feedlot cattle. A health scoring system was used to identify BRD cases and controls. Heritability estimates for BRD susceptibility ranged from 19 to 21% in dairy calves to 29.2% in beef cattle when using numerical scores as a semi-quantitative definition of BRD. A GWAS analysis conducted on the dairy calf data showed that single nucleotide polymorphism (SNP) effects explained 20% of the variation in BRD incidence and 17–20% of the variation in clinical signs. These results represent a preliminary analysis of ongoing work to identify loci associated with BRD. Future work includes validation of the chromosomal regions and SNPs that have been identified as important for BRD susceptibility, fine mapping of chromosomes to identify causal SNPs, and integration of predictive markers for BRD susceptibility into genetic tests and national cattle genetic evaluations.
The Newark-APTS established a high-resolution framework for the Late Triassic and Early Jurassic. Palaeomagnetic polarity correlations to marine sections show that stage-level correlations of continental sequences were off by as much as 10 million years. New U–Pb ages show the new correlations and the Newark basin astrochronology to be accurate. Correlation of Newark-APTS to the Chinle Formation/Dockum Group, Glen Canyon Group, Fleming Fjord Formation and Ischigualasto Formation led to the following conclusions: (1) there are no unequivocal Carnian-age dinosaurs; (2) the Norian Age was characterised by a slowly increasing saurischian diversity but no unequivocal ornithischians; (3) there was profound Norian and Rhaetian continental provinciality; (4) the classic Chinle-, Germanic- and Los Colorados-type assemblages may have persisted to the close of the Rhaetian; (5) the distinct genus-level biotic transition traditionally correlated with the marine Carnian–Norian is in fact mid-Norian in age and within published error of the Manicouagan impact; (6) the end-Triassic marine and continental extinctions as seen in eastern North America were contemporaneous; and (7) compared to Triassic communities, Hettangian and Sinemurian age terrestrial communities were nearly globally homogenous and of low diversity. Consequently, the complex emerging picture of dinosaur diversification demands biostratigraphically-independent geochronologies in each of the faunally-important regions.
New poly(fluorene-thiophene) alternating copolymers are described in which either the dioctylfluorene or bithiophene units in poly(9,9-dioctylfluorene-alt-bithiophene) (F8T2) are replaced by other fluorene or thiophene-based groups, respectively. Improvements in solubility are realized when the bithiophene unit of F8T2 is replaced by dihexylterthiophene or dihexylpentathiophene units. Melting temperatures are also lowered by 50 – 100°C in these polymers when compared to F8T2. Replacement of the bithiophene unit of F8T2 with a dihexylpentathiophene unit also results in a significant improvement in hysteresis (< 2 V vs. 3.5 – 5 V for F8T2). Initial results are also reported on the thermal cleavage of the C8 side groups of F8T2, which yields an insoluble polymeric semiconductor film that continues to exhibit transistor switching characteristics as part of a bottom gate device.
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