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Hospitalized patients placed in isolation due to a carrier state or infection with resistant or highly communicable organisms report higher rates of anxiety and loneliness and have fewer physician encounters, room entries, and vital sign records. We hypothesized that isolation status might adversely impact patient experience as reported through Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, particularly regarding communication.
Retrospective analysis of HCAHPS survey results over 5 years.
A 1,165-bed, tertiary-care, academic medical center.
Patients on any type of isolation for at least 50% of their stay were the exposure group. Those never in isolation served as controls.
Multivariable logistic regression, adjusting for age, race, gender, payer, severity of illness, length of stay and clinical service were used to examine associations between isolation status and “top-box” experience scores. Dose response to increasing percentage of days in isolation was also analyzed.
Patients in isolation reported worse experience, primarily with staff responsiveness (help toileting 63% vs 51%; adjusted odds ratio [aOR], 0.77; P = .0009) and overall care (rate hospital 80% vs 73%; aOR, 0.78; P < .0001), but they reported similar experience in other domains. No dose-response effect was observed.
Isolated patients do not report adverse experience for most aspects of provider communication regarded to be among the most important elements for safety and quality of care. However, patients in isolation had worse experiences with staff responsiveness for time-sensitive needs. The absence of a dose-response effect suggests that isolation status may be a marker for other factors, such as illness severity. Regardless, hospitals should emphasize timely staff response for this population.
Six snow-pit records recovered from Siple Dome, West Antarctica, during 1994 are used to study seasonal variations in chemical (major ion and H202), isotopic (deuterium) and physical stratigraphic properties during the 1988-94 period. Comparison of δD measurements and satellite-derived brightness temperature for the Siple Dome area suggests that most seasonal SD maxima occur within ±4 weeks of each 1 January. Several other chemical species (H2O2, non-sea-salt (nss) SO42-, methanesulfonic acid and NO3-) show coeval peaks with SD, together providing an accurate method for identifying summer accumulation. Sea-salt-derived species generally peak during winter/spring, but episodic input is noted throughout some years. No reliable seasonal signal is identified in species with continental sources (nssCa2+ nss Mg2+), NH4+ or nssCl-. Visible strata such as large depth-hoar layers (>5 cm) are associated with summer accumulation and its metamorphosis, but smaller hoar layers and crusts are more difficult to interpret. A multi-parameter approach is found to provide the most accurate dating of these snow-pit records, and is used to determine annual layer thicknesses at each site Significant spatial accumulation variability exists on an annual basis, but mean accumulation in the sampled 10 km2 grid for the 1988-94 period is fairly uniform.
Patterns in radar-detected internal layers in glaciers and ice streams can be tracked hundreds of kilometers downstream. We use distinctive patterns to delineate flowbands of Thwaites Glacier in the Amundsen Sea sector of West Antarctica. Flowbands contain information for the past century to millennium, the approximate time for ice to flow through the study region. GPS-detected flow directions (acquired in 2007/08) agree within uncertainty (~4°) with the radar-detected flowlines, indicating that the flow direction has not changed significantly in recent centuries. In contrast, InSAR-detected directions (from 1996) differ from the radar- and GPS-detected flowlines in all but the middle tributary, indicating caution is needed when using InSAR velocities to define flow directions. There is agreement between all three datasets in the middle tributary. We use two radar-detected flowlines to define a 95 km long flowband and perform a flux balance analysis using InSAR-derived velocities, radar-detected ice thickness, and estimates of the accumulation rate. Inferred thinning of 0.49 ± 0.34 m a–1 is consistent with satellite altimetry measurements, but has higher uncertainty due mainly to the velocity uncertainty. The uncertainty is underestimated because InSAR velocities often differ from GPS velocities by more than the stated uncertainties.
THE LIVELY CURRENT DEBATE about developing programs of study which will raise women's consciousness and bring them into American intellectual life on a level of equality with men tends to be ahistorical and to subscribe to many of the unexamined assumptions of American educational history. Among the most revered of these is the interpretation unhesitatingly advanced by historians (1) of education that coeducation automatically was a “liberating experience” for American women and that access to professional education naturally placed women on a level with male professional peers. Advocates of increased participation for women in the creation and transmission of American culture had better examine these assumptions with the skepticism which feminists normally extend to male interpretations of women's experience if they are not to devise a faulty strategy for reform through inability to perceive some of the concealed hazards of the landscape. Although cultural historians have universally concluded that the development of educational institutions in colonial America and in the young republic of the early national period played a decisive role in the creation of an American democratic culture, little effort has been expended in analysing the impact of these institutions on women's social role or on their consciousness of themselves as independent intellects. To understand the dimensions of this impact we must begin, as in all questions of American cultural history, with the colonial period and the Puritan heritage. Governor Winthrop of Massachusetts Bay gave as succinct an expression of Puritan attitudes to women with aspirations to learning as it would be possible to find in his diary entry after meeting the emotionally disturbed wife of a friend.
Previously we have studied the jet of the quasar 3C 273 at optical and radio frequencies. In our first set of X-ray data with 17.2 ksec integration time obtained with the ROSAT HRI, the jet is easily visible extending out from the bright quasar core. The total number of counts in the jet lies in the range 200 to 300, depending on the details of the background model. This corresponds to an X-ray flux fv(2.9 × 1017 Hz) = 65 … 140 nJy (lower limit, synchrotron radiation α = −0.8 … upper limit, bremsstrahlung α = 0, NHI = 1.8 × 1020 cm−2), in good agreement with the value derived from the EINSTEIN observations.
Effects of soil tillage systems and nitrogen (N) fertilizer management on spring wheat yield components, grain yield and N-use efficiency (NUE) were evaluated in contrasting weather of 2013 and 2014 on a clay soil at the Royal Agricultural University's Harnhill Manor Farm, Cirencester, UK. Three tillage systems – conventional plough tillage (CT), high intensity non-inversion tillage (HINiT) and low intensity non-inversion tillage (LINiT) for seedbed preparation – were compared at four rates of N fertilizer (0, 70, 140 and 210 kg N/ha). Responses to the effects of the management practices were strongly influenced by weather conditions and varied across seasons. Grain yields were similar between LINiT and CT in 2013, while CT produced higher yields in 2014. Nitrogen fertilization effects also varied across the years with no significant effects observed on grain yield in 2013, while in 2014 applications up to 140 kg N/ha increased yield. Grain protein ranged from 10·1 to 14·5% and increased with N rate in both years. Nitrogen-use efficiency ranged from 12·6 to 49·1 kg grain per kg N fertilizer and decreased as N fertilization rate increased in both years. There was no tillage effect on NUE in 2013, while in 2014 NUE under CT was similar to LINiT and higher than HINiT. The effect of tillage and N fertilization on soil moisture and soil mineral N (SMN) fluctuated across years. In 2013, LINiT showed significantly higher soil moisture than CT, while soil moisture did not differ between tillage systems in 2014. Conventional tillage had significantly higher SMN at harvest time in 2014, while no significant differences on SMN were observed between tillage systems in 2013. These results indicate that LINiT can be used to produce similar spring wheat yield to CT on this particular soil type, if a dry cropping season is expected. Crop response to N fertilization is limited when soil residual N is higher, while in conditions of lower residual SMN, a higher N supply is needed to increase yield and improve grain protein content.
This study describes psychometric properties of the NIH Toolbox Cognition Battery (NIHTB-CB) Composite Scores in an adult sample. The NIHTB-CB was designed for use in epidemiologic studies and clinical trials for ages 3 to 85. A total of 268 self-described healthy adults were recruited at four university-based sites, using stratified sampling guidelines to target demographic variability for age (20–85 years), gender, education, and ethnicity. The NIHTB-CB contains seven computer-based instruments assessing five cognitive sub-domains: Language, Executive Function, Episodic Memory, Processing Speed, and Working Memory. Participants completed the NIHTB-CB, corresponding gold standard validation measures selected to tap the same cognitive abilities, and sociodemographic questionnaires. Three Composite Scores were derived for both the NIHTB-CB and gold standard batteries: “Crystallized Cognition Composite,” “Fluid Cognition Composite,” and “Total Cognition Composite” scores. NIHTB Composite Scores showed acceptable internal consistency (Cronbach’s alphas=0.84 Crystallized, 0.83 Fluid, 0.77 Total), excellent test–retest reliability (r: 0.86–0.92), strong convergent (r: 0.78–0.90) and discriminant (r: 0.19–0.39) validities versus gold standard composites, and expected age effects (r=0.18 crystallized, r=−0.68 fluid, r=−0.26 total). Significant relationships with self-reported prior school difficulties and current health status, employment, and presence of a disability provided evidence of external validity. The NIH Toolbox Cognition Battery Composite Scores have excellent reliability and validity, suggesting they can be used effectively in epidemiologic and clinical studies. (JINS, 2014, 20, 1–11)
This study introduces a special series on validity studies of the Cognition Battery (CB) from the U.S. National Institutes of Health Toolbox for the Assessment of Neurological and Behavioral Function (NIHTB) (Gershon, Wagster et al., 2013) in an adult sample. This first study in the series describes the sample, each of the seven instruments in the NIHTB-CB briefly, and the general approach to data analysis. Data are provided on test–retest reliability and practice effects, and raw scores (mean, standard deviation, range) are presented for each instrument and the gold standard instruments used to measure construct validity. Accompanying papers provide details on each instrument, including information about instrument development, psychometric properties, age and education effects on performance, and convergent and discriminant construct validity. One study in the series is devoted to a factor analysis of the NIHTB-CB in adults and another describes the psychometric properties of three composite scores derived from the individual measures representing fluid and crystallized abilities and their combination. The NIHTB-CB is designed to provide a brief, comprehensive, common set of measures to allow comparisons among disparate studies and to improve scientific communication. (JINS, 2014, 20, 1–12)
Insurance accounting has for many years proved a challenging topic for standard setters, preparers and users, often described as a “black box”. Will recent developments, in particular the July 2010 Insurance Contracts Exposure Draft, herald a new era?
This paper reviews these developments, setting out key issues and implications. It concentrates on issues relevant to life insurers, although much of the content is also relevant to non-life insurers.
The paper compares certain IFRS and Solvency II developments, recognising that UK insurers face challenges in implementing new financial and regulatory reporting requirements in similar timeframes. The paper considers resulting external disclosure requirements and a possible future role for supplementary information.
Children frequently are the victims of disasters due to natural hazards or terrorist attacks. However, there is a lack of specific pediatric emergency preparedness planning worldwide. To address these gaps, the federal grant-funded New York City Pediatric Disaster Coalition (PDC) established guidelines for creating Pediatric Critical care (PCC) surge plans and assisted hospitals in creating their plans. To date, five hospitals completed plans, thereby adding 92 beds to surge capacity. On 01 May 2010, 18:00h, there was an attempt to detonate a car bomb in Times Square, a large urban attraction in the heart of New York City. The perpetrator was later convicted of the attempted use of a weapon of mass destruction. Had the bomb exploded, given the location and time of day, it is possible that many critically injured victims would have been children.
The unit director or a senior attending of nine major hospitals in the NYC area (five in close proximity and four at secondary sites) were surveyed for the number of their vacant pediatric critical care beds at the time of the event before activation of surge plans.
At the time the car bomb was discovered, the nine hospitals, which have a total of 141 PCC beds, had only 29 vacant approved pediatric critical care beds.
Had the event resulted in many pediatric casualties, the existing PCC vacant beds at these hospitals may not have satisfied the need. Activating surge plans at five of these hospitals would have added 92 to the 29 available PCC beds for a total of 121. In order to provide PCC to a large number of victims, it is crucial that hospitals prepare PCC surge plans.
The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) has supported a federal grant establishing a Pediatric Disaster Coalition (PDC) comprised of pediatric critical care (PCC) and emergency preparedness consultants from major city hospitals and health agencies. One of the PDC's goals was to develop recommendation for hospital-based PCC surge plans.
Members of the PDC convened bi-weekly and among other projects, developed guidelines for creating PCC surge capacity plans. The PDC members, acting as consultants, conducted scheduled visits to hospitals in NYC and actively assisted in drafting PCC surge plans as annexes to existing hospital disaster plans. The support ranged from facilitating meetings to providing draft language and content, based on each institutions request.
New York City has 25 hospitals with PCC services with a total of 244 beds. Five major hospitals have completed plans, thereby adding 92 PCC beds to surge capacity. Thirteen additional hospitals are in the process of developing a plan. The PDC consultants participated in meetings at 11 of the planning hospitals, and drafted language for 10 institutions. The PDC continues to reach out to all hospitals with the goal of initiating plans at all 25 PCC hospitals.
Providing surge guidelines and the utilization of on-site PDC consultants was a successful model for the development and implementation of citywide PCC surge capacity planning. Visiting hospitals and actively assisting them in creating their plans was an effective, efficient and well received, method to create increased PCC surge capacity. By first planning with major hospitals, a significant increase of surge beds (92 or 38%) was created, from a minimal number of hospitals. Once hospitals complete plans, it is anticipated that there will be the addition of at least 200 PCC surge beds that can be incorporated in to regional city-wide response to pediatric mass-casualty incident.
There remains a lack of comprehensive pediatric emergency preparedness planning worldwide. A disaster or mass-casualty incident (MCI) involving pediatric patients could overwhelm existing pediatric resources within the New York City (NYC) metropolitan region. The NYC Department of Health and Mental Hygiene (DOHMH) recognizing the importance to plan for a MCI with a large number of pediatric victims, implemented a project (the Pediatric Disaster Coalition; PDC), to address gaps in the healthcare system to provide effective and timely pediatric care during a MCI.
The PDC includes experts in emergency preparedness, critical care, surgery, and emergency medicine from the NYC pediatric/children's hospitals, DOHMH, Office of Emergency Management, and Fire Department (FDNY). Two committees addressed pediatric prehospital triage, transport, and pediatric critical care (PCC) surge capacities. They developed guidelines and recommendations for pediatric field triage and transport, matching patients' needs to resources, and increasing PCC Surge Capacities.
Surge recommendations were formulated. The algorithm developed provides specific pediatric triage criteria that identify severity of illness using the traditional Red, Yellow, and Green categories plus an Orange designation for continual reassessments that has been adopted by FDNY that has trained > 3,000 FDNY EMS personnel in its use. Triaged patients can be transported to appropriate resources based on a tiered system that defines pediatric hospital capabilities. The Surge Committee has created PCC Surge Capacity Guideline that can be used by hospitals to create their individual PCC surge plans. 15 of 25 NYC hospitals with PCC capabilities are participating with PDC planning; 5 have completed surge plans, 3 are nea completion, and 7 are in development. The completed plans add 92 surge beds to 244 regularly available PICU beds. The goal is to increase the PCC surge bed capacity by 200 + beds.
The project is an effective, multidisciplinary group approach to planning for a regional, large-scale pediatric MCI. Regional lead agencies must emphasize pediatric emergency preparedness in their disaster plans.
Ion implantation can produce open volume defects in silicon by one of two
methods, either by H or He implantation followed by annealing to create a
band of nanocavities and also by direct implantation to reasonably high
doses, which results in a vacancy excess region at depths less than about
half the projected ion range. This paper reviews three interesting aspects
of open volume defects. In the first case, the very efficient gettering of
fast diffusing metals to nanocavities formed by H-implantation is
illustrated. In addition, the non-equilibrium behaviour of Cu3Si
precipitation and dissolution at cavities is examined. The second example
treats the interaction of irradiation-induced defects with nanocavities,
particularly preferential amorphisation at open volume defects and
subsequent cavity shrinkage. The final example illustrates the coalescence
of excess vacancies into small voids on annealing and the use of gettering
of Au to detect such open volume defects.
Secondary ion mass spectrometry and Rutherford backscattering/channeling analysis have been used to study the segregation of Au at moving Si-SiO2 interfaces during bombardment of Si with 15 keV O- ions. Essentially 100% of the Au is found to segregate at a bombardment temperature of 250°C, whereas only partial segregation occurs for room temperature bombardment. Up to 10 monolayers of Au can be segregated in disordered Si behind an SiO2 layer at 250°C. These results are discussed in terms of ion-assisted migration of Au in disordered Si and extremely low solubilities of Au in SiO2.