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Crowding
Kinds of Crowding Selected AbstractsThe Left-without-being-seen Rate: An Imperfect Measure of Emergency Department CrowdingACADEMIC EMERGENCY MEDICINE, Issue 7 2006Jesse M. Pines MD No abstract is available for this article. [source] Crowding and disease: effects of host density on response to infection in a butterfly,parasite interactionECOLOGICAL ENTOMOLOGY, Issue 5 2009ELIZABETH LINDSEY Abstract. 1. Hosts experiencing frequent variation in density are thought to benefit from allocating more resources to parasite defence when density is high (,density-dependent prophylaxis'). However, high density conditions can increase intra-specific competition and induce physiological stress, hence increasing host susceptibility to infection (,crowding-stress hypothesis'). 2. We studied monarch butterflies (Danaus plexippus) and quantified the effects of larval rearing density on susceptibility to the protozoan parasite Ophryocystis elektroscirrha. Larvae were inoculated with parasite spores and reared at three density treatments: low, moderate, and high. We examined the effects of larval density on parasite loads, host survival, development rates, body size, and wing melanism. 3. Results showed an increase in infection probability with greater larval density. Monarchs in the moderate and high density treatments also suffered the greatest negative effects of parasite infection on body size, development rate, and adult longevity. 4. We observed greater body sizes and shorter development times for monarchs reared at moderate densities, and this was true for both unparasitised and parasite-treated monarchs. We hypothesise that this effect could result from greater larval feeding rates at moderate densities, combined with greater physiological stress at the highest densities. 5. Although monarch larvae are assumed to occur at very low densities in the wild, an analysis of continent-wide monarch larval abundance data showed that larval densities can reach high levels in year-round resident populations and during the late phase of the breeding season. Treatment levels used in our experiment captured ecologically-relevant variation in larval density observed in the wild. [source] Bis(fluoromesityl) Palladium Complexes, Archetypes of Steric Crowding and Axial Protection by ortho Effect , Evidence for Dissociative Substitution Processes , Observation of 19F,19F Through-Space CouplingsEUROPEAN JOURNAL OF INORGANIC CHEMISTRY, Issue 11 2004Camino Bartolomé Abstract Bisarylated complexes trans -[Pd(Fmes)2(SR2)2] [Fmes = 2,4,6-tris(trifluoromethyl)phenyl (fluoromesityl); SR2 = SMe2, tht; tht = tetrahydrothiophene] are precursors for various bisarylated fluoromesityl palladium(II) complexes by ligand-substitution reactions. Boiling under reflux in acetonitrile gives the mixed complexes trans -[Pd(Fmes)2(NCMe)(SR2)], whereas boiling under reflux in toluene leads to trans -[PdCl2L2] (L = PMe3, tBuNC, pTol-NC, 4-MePy), in the presence of neutral monodentate ligands, or to (NnBu4)[trans -Pd(Fmes)2I(SR2)] when treated with (NnBu4)I. trans -[Pd(Fmes)2(SMe2)2] reacts with bidentate ligands, also boiling under reflux in toluene, to give [Pd(Fmes)2(L,L)] [L,L = Me2bipy, 2,2, - biquinolyl, ,2N,N, -OCPy2, dppm (Ph2PCH2PPh2), dppe (Ph2PCH2CH2PPh2), pte (PhSCH2CH2SPh), ,2S,N -SPPh2Py, ,2O,N -OPPhPy2], or the bimetallic complex [Pd(Fmes)2(,-1,N:1,2,O:2,N -Py2MeCO)Pd(Fmes)(SMe2)] (characterized by X-ray diffractometry) when treated with (OH)(CH3)CPy2. The crowding associated with two Fmes groups produces several interesting features: (1) trans complexes are preferred over cis complexes, against the expected electronic preferences; (2) the low-temperature NMR spectra of several complexes, or the X-ray diffraction structure of [Pd(Fmes)2(2,2, - biquinolyl)], reveal significant structural distortions associated with steric crowding; (3) the need for boiling under reflux in the synthesis suggests a dissociative substitution mechanism, which is unknown so far for Pd; (4) some of the complexes show 19F,19F through-space couplings. (© Wiley-VCH Verlag GmbH & Co. KGaA, 69451 Weinheim, Germany, 2004) [source] Factors Related to Helicobacter pylori Prevalence in an Adult Population in BrazilHELICOBACTER, Issue 1 2007Schlioma Zaterka Abstract Background:, The prevalence of Helicobacter pylori is higher in developing countries. Sanitary facilities, crowding and ethnic group are some of the factors related to H. pylori infection. The aim of this study was to investigate in blood donors, free of dyspeptic symptoms, the prevalence and factors influencing H. pylori infection. Materials and Methods:, This study was conducted in São Paulo, a city known to have a mixed population coming from all over the country. A total of 1008 blood donors were initially included in the study. After a final revision of all the questionnaires, 993 were included in the final analysis (746 males). H. pylori status was checked by an ELISA test. The following associations to infection were analyzed: sex, age, ethnic group, previous upper gastrointestinal (GI) endoscopy, smoking, alcoholism, drug addiction, type of drinking water, crowding, sanitary facilities, and family income. Results:, Infection was observed in 496 of 746 male (66.5%) and in 156 of 247 female (63.2%) blood donors. Infection prevalence increased according to age group, regardless of sex. Prevalence was lower in White population than in non-White. No relationship was observed between infection and smoking, drug addiction, and alcohol. A positive relation was observed between infection and previous upper GI endoscopy, and type of drinking water, regardless if currently or during childhood. Crowding and lack of toilet in the house during childhood resulted in a higher infection rate. Lower familial income and educational level showed a positive association to infection. Conclusions:, Prevalence of H. pylori is higher in non-White population, independent of gender. A positive association was observed in aging, previous upper GI endoscopy, crowding, type of drinking water, lack of toilet during childhood, lower family income, and lower educational level. [source] The Effect of Emergency Department Crowding on Analgesia in Patients with Back Pain in Two HospitalsACADEMIC EMERGENCY MEDICINE, Issue 3 2010Jesse M. Pines MD Abstract Objectives:, The authors assessed the association between measures of emergency department (ED) crowding and treatment with analgesia and delays to analgesia in ED patients with back pain. Methods:, This was a retrospective cohort study of nonpregnant patients who presented to two EDs (an academic ED and a community ED in the same health system) from July 1, 2003, to February 28, 2007, with a chief complaint of "back pain." Each patient had four validated crowding measures assigned at triage. Main outcomes were the use of analgesia and delays in time to receiving analgesia. Delays were defined as greater than 1 hour to receive any analgesia from the triage time and from the room placement time. The Cochrane-Armitage test for trend, the Cuzick test for trend, and relative risk (RR) regression were used to test the effects of crowding on outcomes. Results:, A total of 5,616 patients with back pain presented to the two EDs over the study period (mean ± SD age = 44 ± 17 years, 57% female, 62% black or African American). Of those, 4,425 (79%) received any analgesia while in the ED. A total of 3,589 (81%) experienced a delay greater than 1 hour from triage to analgesia, and 2,985 (67%) experienced a delay more than 1 hour from room placement to analgesia. When hospitals were analyzed separately, a higher proportion of patients experienced delays at the academic site compared with the community site for triage to analgesia (87% vs. 74%) and room to analgesia (71% vs. 63%; both p < 0.001). All ED crowding measures were associated with a higher likelihood for delays in both outcomes. At the academic site, patients were more likely to receive analgesia at the highest waiting room numbers. There were no other differences in ED crowding and likelihood of receiving medications in the ED at the two sites. These associations persisted in the adjusted analysis after controlling for potential confounders of analgesia administration. Conclusions:, As ED crowding increases, there is a higher likelihood of delays in administration of pain medication in patients with back pain. Analgesia administration was not related to three measures of ED crowding; however, patients were actually more likely to receive analgesics when the waiting room was at peak levels in the academic ED. ACADEMIC EMERGENCY MEDICINE 2010; 17:276,283 © 2010 by the Society for Academic Emergency Medicine [source] International Pricing in a Generalized Model of Ideal VarietyJOURNAL OF MONEY, CREDIT AND BANKING, Issue 2009DAVID HUMMELS Lancaster ideal variety; price to market We examine international markups and pricing in a generalized version of an "ideal variety" model. In this model, entry causes crowding in variety space, so that the marginal utility of new varieties falls as market size grows. Crowding is partially offset by income effects, as richer consumers will pay more for varieties closer matched to their ideal types. We show theoretically and confirm empirically that declining marginal utility of new varieties results in: a higher own-price elasticity of demand (and lower prices) in large countries and a lower own-price elasticity of demand (and higher prices) in rich countries. The model is also useful for generating facts from the literature regarding cross-country differences in the rate of variety expansion. [source] Global Crowding: Opportunities for Regionalization in Emergency CareACADEMIC EMERGENCY MEDICINE, Issue 12 2009Sandra M. Schneider MD No abstract is available for this article. [source] Spacing and crowding among African and Caucasian childrenORTHODONTICS & CRANIOFACIAL RESEARCH, Issue 2 2008EA Mugonzibwa Structured Abstract Authors,,, Mugonzibwa EA, Eskeli R, Laine-Alava MT, Kuijpers-Jagtman AM, Katsaros C Objective,,, To determine spacing and crowding according to ethnic group, gender and dental emergence stage among Tanzanian African and Caucasian children. Design,,, Cross-sectional epidemiological clinical study. Setting,,, A total of 869 African (428 boys, 441 girls) and 706 Caucasian (319 boys, 387 girls) school children, aged 3½,16 years. Main Outcome Measures,,, Comparison of spacing and crowding between African and Caucasian children according to gender and dental emergence stage. Results,,, Spacing was more often found in the maxilla, while crowding was more common in the mandible. Only during the transition of the maxillary permanent front teeth was there significantly more spacing in Caucasians. No gender differences were found. In both samples spacing decreased during later emergence stages. Crowding was more often found in Caucasian children than in African children. In Caucasian children the frequency of crowding increased with advanced emergence stages, while for Africans the trend was not consistent. Conclusion,,, When planning resources for orthodontic treatment for different populations as well as planning treatment for individuals, ethnic background and emergence stage of the dentition need to be considered. [source] Predictors for wheezing phenotypes in the first decade of lifeRESPIROLOGY, Issue 4 2008William K. MIDODZI Background and objective: This study examined prenatal, perinatal and early childhood predictors of wheezing phenotypes in the first decade of life. Methods: Information on current wheezing, was collected prospectively from five surveys conducted every 2 years over the first decade of life. Five wheezing phenotypes were defined: non-wheezers, preschool, primary-school, intermittent and persistent wheezers. Logistic regression with adjustment for survey design was used to determine the predictors of wheezing phenotypes. Results: Data on 2711 children were used in the analysis. Early respiratory infection, the child's allergy and parental asthma were significant risk factors for preschool, intermittent and persistent wheeze. The child's allergy and parental asthma had stronger associations with persistent wheeze than with preschool wheeze. Breastfeeding was a significant predictor of both preschool and intermittent wheezing. Daycare attendance was a risk factor for preschool wheeze but a protective factor for primary-school wheezing. Crowding at home was a protective factor for both preschool and primary-school wheeze. Parental smoking was a significant factor for preschool wheeze. Conclusion: This study identified different predictors for each wheezing phenotype with some degree of overlap. The observed differential effects for these conditions raises the possibility that there are different aetiologies for asthma among children. [source] The Association between Emergency Department Crowding and Analgesia Administration in Acute Abdominal Pain PatientsACADEMIC EMERGENCY MEDICINE, Issue 7 2009Angela M. Mills MD Abstract Objectives:, The authors assessed the effect of emergency department (ED) crowding on the nontreatment and delay in treatment for analgesia in patients who had acute abdominal pain. Methods:, This was a secondary analysis of prospectively enrolled nonpregnant adult patients presenting to an urban teaching ED with abdominal pain during a 9-month period. Each patient had four validated crowding measures assigned at triage. Main outcomes were the administration of and delays in time to analgesia. A delay was defined as waiting more than 1 hour for analgesia. Relative risk (RR) regression was used to test the effects of crowding on outcomes. Results:, A total of 976 abdominal pain patients (mean [±standard deviation] age = 41 [±16.6] years; 65% female, 62% black) were enrolled, of whom 649 (67%) received any analgesia. Of those treated, 457 (70%) experienced a delay in analgesia from triage, and 320 (49%) experienced a delay in analgesia after room placement. After adjusting for possible confounders of the ED administration of analgesia (age, sex, race, triage class, severe pain, final diagnosis of either abdominal pain not otherwise specified or gastroenteritis), increasing delays in time to analgesia from triage were independently associated with all four crowding measures, comparing the lowest to the highest quartile of crowding (total patient-care hours RR = 1.54, 95% confidence interval [CI] = 1.32 to 1.80; occupancy rate RR = 1.64, 95% CI = 1.42 to 1.91; inpatient number RR = 1.57, 95% CI = 1.36 to 1.81; and waiting room number RR = 1.53, 95% CI = 1.31 to 1.77). Crowding measures were not associated with the failure to treat with analgesia. Conclusions:, Emergency department crowding is associated with delays in analgesic treatment from the time of triage in patients presenting with acute abdominal pain. [source] The Association Between Emergency Department Crowding and Adverse Cardiovascular Outcomes in Patients with Chest PainACADEMIC EMERGENCY MEDICINE, Issue 7 2009Jesse M. Pines MD Abstract Objectives:, While emergency department (ED) crowding is a worldwide problem, few studies have demonstrated associations between crowding and outcomes. The authors examined whether ED crowding was associated with adverse cardiovascular outcomes in patients with chest pain syndromes (chest pain or related complaints of possible cardiac origin). Methods:, A retrospective analysis was performed for patients ,30 years of age with chest pain syndrome admitted to a tertiary care academic hospital from 1999 through 2006. The authors compared rates of inpatient adverse outcomes from ED triage to hospital discharge, defined as delayed acute myocardial infarction (AMI), heart failure, hypotension, dysrhythmias, and cardiac arrest, which occurred after ED arrival using five separate crowding measures. Results:, Among 4,574 patients, 251 (4%) patients developed adverse outcomes after ED arrival; 803 (18%) had documented acute coronary syndrome (ACS), and of those, 273 (34%) had AMI. Compared to less crowded times, ACS patients experienced more adverse outcomes at the highest waiting room census (odds ratio [OR] = 3.7, 95% confidence interval [CI] = 1.3 to 11.0) and patient-hours (OR = 5.2, 95% CI = 2.0 to 13.6) and trended toward more adverse outcomes during time of high ED occupancy (OR = 3.1, 95% CI = 1.0 to 9.3). Adverse outcomes were not significantly more frequent during times with the highest number of admitted patients (OR = 1.6, 95% CI = 0.6 to 4.1) or the highest trailing mean length of stay (LOS) for admitted patients transferred to inpatient beds within 6 hours (OR = 1.5, 95% CI = 0.5 to 4.0). Patients with non-ACS chest pain experienced more adverse outcomes during the highest waiting room census (OR = 3.5, 95% CI = 1.4 to 8.4) and patient-hours (OR = 4.3, 95% CI = 2.6 to 7.3), but not occupancy (OR = 1.8, 95% CI = 0.9 to 3.3), number of admitted patients (OR = 0.6, 95% CI 0.4 to 1.1), or trailing LOS for admitted patients (OR = 1.2, 95% CI = 0.6 to 2.0). Conclusions:, There was an association between some measures of ED crowding and a higher risk of adverse cardiovascular outcomes in patients with both ACS-related and non,ACS-related chest pain syndrome. [source] The Effect of Emergency Department Crowding on Length of Stay and Medication Treatment Times in Discharged Patients With Acute AsthmaACADEMIC EMERGENCY MEDICINE, Issue 8 2010Jesse M. Pines MD ACADEMIC EMERGENCY MEDICINE 2010; 17:834,839 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives:, This study sought to determine if emergency department (ED) crowding was associated with longer ED length of stay (LOS) and time to ordering medications (nebulizers and steroids) in patients treated and discharged with acute asthma and to study how delays in ordering may affect the relationship between ED crowding and ED LOS. Methods:, A retrospective cohort study was performed in adult ED patients aged 18 years and older with a primary International Classification of Diseases, 9th Revision (ICD-9), diagnosis of asthma who were treated and discharged from two EDs from January 1, 2007, to January 1, 2009. Four validated measures of ED crowding (ED occupancy, waiting patients, admitted patients, and patient-hours) were assigned at the time of triage. The associations between the level of ED crowding and overall LOS and time to treatment orders were tested by analyzing trends across crowding quartiles, testing differences between the highest and lowest quartiles using Hodges-Lehmann distances, and using relative risk (RR) regression for multivariable analysis. Results:, A total of 1,716 patients were discharged with asthma over the study period (932 at the academic site and 734 at the community site). LOS was longer at the academic site than the community site for asthma patients by 90 minutes (95% confidence interval [CI] = 79 to 101 minutes). All four measures of ED crowding were associated with longer LOS and time to treatment order at both sites (p < 0.001). At the highest level of ED occupancy, patients spent 75 minutes (95% CI = 58 to 93 minutes) longer in the ED compared to the lowest quartile of ED occupancy. In addition, comparing the highest and lowest quartiles of ED occupancy, time to nebulizer order was 6 minutes longer (95% CI = 1 to 13 minutes), and time to steroid order was 16 minutes longer (95% CI = 0 to 38 minutes). In the multivariable analysis, the association between ED crowding and LOS remained significant. Delays in nebulizer and steroid orders explained some, but not all, of the relationship between ED crowding and ED LOS. Conclusions:, Emergency department crowding is associated with longer ED LOS (by more than 1 hour) in patients who ultimately get discharged with asthma flares. Some but not all of longer LOS during crowded times is explained by delays in ordering asthma medications. [source] Forecasting Models of Emergency Department CrowdingACADEMIC EMERGENCY MEDICINE, Issue 4 2009Lisa M. Schweigler MD Abstract Objectives:, The authors investigated whether models using time series methods can generate accurate short-term forecasts of emergency department (ED) bed occupancy, using traditional historical averages models as comparison. Methods:, From July 2005 through June 2006, retrospective hourly ED bed occupancy values were collected from three tertiary care hospitals. Three models of ED bed occupancy were developed for each site: 1) hourly historical average, 2) seasonal autoregressive integrated moving average (ARIMA), and 3) sinusoidal with an autoregression (AR)-structured error term. Goodness of fits were compared using log likelihood and Akaike's Information Criterion (AIC). The accuracies of 4- and 12-hour forecasts were evaluated by comparing model forecasts to actual observed bed occupancy with root mean square (RMS) error. Sensitivity of prediction errors to model training time was evaluated, as well. Results:, The seasonal ARIMA outperformed the historical average in complexity adjusted goodness of fit (AIC). Both AR-based models had significantly better forecast accuracy for the 4- and the 12-hour forecasts of ED bed occupancy (analysis of variance [ANOVA] p < 0.01), compared to the historical average. The AR-based models did not differ significantly from each other in their performance. Model prediction errors did not show appreciable sensitivity to model training times greater than 7 days. Conclusions:, Both a sinusoidal model with AR-structured error term and a seasonal ARIMA model were found to robustly forecast ED bed occupancy 4 and 12 hours in advance at three different EDs, without needing data input beyond bed occupancy in the preceding hours. [source] Ambulance Diversion as a Proxy for Emergency Department Crowding: The Effect on Pediatric Mortality in a Metropolitan AreaACADEMIC EMERGENCY MEDICINE, Issue 2 2009Rohit P. Shenoi MD Abstract Objectives:, The objective was to determine the prevalence of emergency department (ED) ambulance diversion among Houston pediatric hospitals and its association with mortality of pediatric patients. Methods:, Hospital diversion and patient data between August 2002 and December 2004 were used to examine the impact of diversion on mortality of children under age 18 years. Patients were assumed to be exposed to ED crowding if diversion and admission or ED arrival times overlapped. Univariate and logistic regression were performed to determine if diversion was associated with mortality while controlling for age, illness severity, injury, and transfer status. Results:, Mean hospital diversion hours as a percentage of operating hours were 10.58 (standard deviation [SD] ± 9). Overall, of 63,780 admissions, there were 4,095 (6.4%) children admitted during diversion. Fewer severely ill patients were admitted during diversion than nondiversion times (odds ratio [OR] = 0.72; 95% confidence interval [CI] = 0.66 to 0.78). The presence of diversion was protective for mortality (OR = 0.51; 95% CI = 0.34 to 0.77) in bivariate analysis. Mortality was associated with presence of major or extreme illness (OR = 60.7; 95% CI = 45.2 to 81.5), injury (OR=1.7; 95% CI = 1.4 to 2.1), and transfer status (OR = 6.3; 95% CI = 5.4 to 7.3). Using conditional logistic regression, major or extreme illness (OR = 50.7; 95% CI = 37.7 to 68.3), injury (OR 3.7; 95% CI = 2.9 to 4.7), and transfer (OR = 2.7; 95% CI = 2.2, 3.2) were associated with mortality, but diversion did not show any association with mortality. After combining ED and inpatient deaths, no association between diversion and mortality was observed. Conclusions:, Hospital diversion due to ED crowding is common in pediatrics. The authors found no evidence of an association between diversion and ED and inpatient pediatric mortality. [source] The Effect of Emergency Department Crowding on Clinically Oriented OutcomesACADEMIC EMERGENCY MEDICINE, Issue 1 2009Steven L. Bernstein MD Abstract Background:, An Institute of Medicine (IOM) report defines six domains of quality of care: safety, patient-centeredness, timeliness, efficiency, effectiveness, and equity. The effect of emergency department (ED) crowding on these domains of quality has not been comprehensively evaluated. Objectives:, The objective was to review the medical literature addressing the effects of ED crowding on clinically oriented outcomes (COOs). Methods:, We reviewed the English-language literature for the years 1989,2007 for case series, cohort studies, and clinical trials addressing crowding's effects on COOs. Keywords searched included "ED crowding,""ED overcrowding,""mortality,""time to treatment,""patient satisfaction,""quality of care," and others. Results:, A total of 369 articles were identified, of which 41 were kept for inclusion. Study quality was modest; most articles reflected observational work performed at a single institution. There were no randomized controlled trials. ED crowding is associated with an increased risk of in-hospital mortality, longer times to treatment for patients with pneumonia or acute pain, and a higher probability of leaving the ED against medical advice or without being seen. Crowding is not associated with delays in reperfusion for patients with ST-elevation myocardial infarction. Insufficient data were available to draw conclusions on crowding's effects on patient satisfaction and other quality endpoints. Conclusions:, A growing body of data suggests that ED crowding is associated both with objective clinical endpoints, such as mortality, as well as clinically important processes of care, such as time to treatment for patients with time-sensitive conditions such as pneumonia. At least two domains of quality of care, safety and timeliness, are compromised by ED crowding. [source] The Effect of Emergency Department Crowding on Education: Blessing or Curse?ACADEMIC EMERGENCY MEDICINE, Issue 1 2009Philip Shayne MD Abstract Emergency department (ED) crowding is a national crisis that contributes to medical error and system inefficiencies. There is a natural concern that crowding may also adversely affect undergraduate and graduate emergency medicine (EM) education. ED crowding stems from a myriad of factors, and individually these factors can present both challenges and opportunities for education. Review of the medical literature demonstrates a small body of evidence that education can flourish in difficult clinical environments where faculty have a high clinical load and to date does not support a direct deleterious effect of crowding on education. To provide a theoretical framework for discussing the impact of crowding on education, the authors present a conceptual model of the effect of ED crowding on education and review possible positive and negative effects on each of the six recognized Accreditation Council for Graduate Medical Education (ACGME) core competencies. [source] Emergency Department Crowding and Decreased Quality of Pain CareACADEMIC EMERGENCY MEDICINE, Issue 12 2008Ula Hwang MD Abstract Objectives:, The objective of this study was to evaluate the association of emergency department (ED) crowding factors with the quality of pain care. Methods:, This was a retrospective observational study of all adult patients (,18 years) with conditions warranting pain care seen at an academic, urban, tertiary care ED from July 1 to July 31, 2005, and December 1 to December 31, 2005. Patients were included if they presented with a chief complaint of pain and a final ED diagnosis of a painful condition. Predictor ED crowding variables studied were 1) census, 2) number of admitted patients waiting for inpatient beds (boarders), and 3) number of boarders divided by ED census (boarding burden). The outcomes of interest were process of pain care measures: documentation of clinician pain assessment, medications ordered, and times of activities (e.g., arrival, assessment, ordering of medications). Results:, A total of 1,068 patient visits were reviewed. Fewer patients received analgesic medication during periods of high census (>50th percentile; parameter estimate = ,0.47; 95% confidence interval [CI] = ,0.80 to ,0.07). There was a direct correlation with total ED census and increased time to pain assessment (Spearman r = 0.33, p < 0.0001), time to analgesic medication ordering (r = 0.22, p < 0.0001), and time to analgesic medication administration (r = 0.25, p < 0.0001). There were significant delays (>1 hour) for pain assessment and the ordering and administration of analgesic medication during periods of high ED census and number of boarders, but not with boarding burden. Conclusions:, ED crowding as measured by patient volume negatively impacts patient care. Greater numbers of patients in the ED, whether as total census or number of boarders, were associated with worse pain care. [source] The Effect of Emergency Department Crowding on Patient Satisfaction for Admitted PatientsACADEMIC EMERGENCY MEDICINE, Issue 9 2008Jesse M. Pines MD Abstract Objectives:, The objective was to study the association between factors related to emergency department (ED) crowding and patient satisfaction. Methods:, The authors performed a retrospective cohort study of all patients admitted through the ED who completed Press-Ganey patient satisfaction surveys over a 2-year period at a single academic center. Ordinal and binary logistic regression was used to study the association between validated ED crowding factors (such as hallway placement, waiting times, and boarding times) and patient satisfaction with both ED care and assessment of satisfaction with the overall hospitalization. Results:, A total of 1,501 hospitalizations for 1,469 patients were studied. ED hallway use was broadly predictive of a lower likelihood of recommending the ED to others, lower overall ED satisfaction, and lower overall satisfaction with the hospitalization (p < 0.05). Prolonged ED boarding times and prolonged treatment times were also predictive of lower ED satisfaction and lower satisfaction with the overall hospitalization (p < 0.05). Measures of ED crowding and ED waiting times predicted ED satisfaction (p < 0.05), but were not predictive of satisfaction with the overall hospitalization. Conclusions:, A poor ED service experience as measured by ED hallway use and prolonged boarding time after admission are adversely associated with ED satisfaction and predict lower satisfaction with the entire hospitalization. Efforts to decrease ED boarding and crowding might improve patient satisfaction. [source] Spontaneous Protein Crowding in Liposomes: A New Vista for the Origin of Cellular MetabolismCHEMBIOCHEM, Issue 14 2010Prof. Pier Luigi Luisi Ferritin encapsulation inside lipid vesicles reveals the spontaneous formation of protein-rich vesicles. The solute distribution inside the vesicles follows a power law. The important conclusion for origins-of-life scenarios is that the dynamics of membrane closure allow the accumulation of solutes inside primitive cells, thus providing an explanation for the origins of early functional cells. [source] Emergency Department Crowding: An Ethical PerspectiveACADEMIC EMERGENCY MEDICINE, Issue 8 2007MPhil, Shantanu Agrawal MD No abstract is available for this article. [source] Commentary: Emergency Department Crowding as an Ethical IssueACADEMIC EMERGENCY MEDICINE, Issue 8 2007Gabor D. Kelen MD First page of article [source] Orthodontic rehabilitation for anterior teeth lost due to trauma with crowding malocclusionDENTAL TRAUMATOLOGY, Issue 4 2010Masayoshi Kawakami The central incisors were immediately replaced and fixed with application of a semi-rigid splint for 12 days, then endodontically treated. Severe root resorption and degeneration of periodontal tissue were noted after 4 years and the teeth were extracted, while the patient had also developed maxillary protrusion with severe crowding in the lower arch. The treatment objectives were to close the spaces by mesial movement of the buccal segment in the upper arch and eliminate crowding by extraction of the lower bicuspids. Favorable occlusion was achieved as was substitution with the lateral incisors for the lost central teeth. [source] An Independent Evaluation of Four Quantitative Emergency Department Crowding ScalesACADEMIC EMERGENCY MEDICINE, Issue 11 2006Spencer S. Jones MStat Background Emergency department (ED) overcrowding has become a frequent topic of investigation. Despite a significant body of research, there is no standard definition or measurement of ED crowding. Four quantitative scales for ED crowding have been proposed in the literature: the Real-time Emergency Analysis of Demand Indicators (READI), the Emergency Department Work Index (EDWIN), the National Emergency Department Overcrowding Study (NEDOCS) scale, and the Emergency Department Crowding Scale (EDCS). These four scales have yet to be independently evaluated and compared. Objectives The goals of this study were to formally compare four existing quantitative ED crowding scales by measuring their ability to detect instances of perceived ED crowding and to determine whether any of these scales provide a generalizable solution for measuring ED crowding. Methods Data were collected at two-hour intervals over 135 consecutive sampling instances. Physician and nurse agreement was assessed using weighted , statistics. The crowding scales were compared via correlation statistics and their ability to predict perceived instances of ED crowding. Sensitivity, specificity, and positive predictive values were calculated at site-specific cut points and at the recommended thresholds. Results All four of the crowding scales were significantly correlated, but their predictive abilities varied widely. NEDOCS had the highest area under the receiver operating characteristic curve (AROC) (0.92), while EDCS had the lowest (0.64). The recommended thresholds for the crowding scales were rarely exceeded; therefore, the scales were adjusted to site-specific cut points. At a site-specific cut point of 37.19, NEDOCS had the highest sensitivity (0.81), specificity (0.87), and positive predictive value (0.62). Conclusions At the study site, the suggested thresholds of the published crowding scales did not agree with providers' perceptions of ED crowding. Even after adjusting the scales to site-specific thresholds, a relatively low prevalence of ED crowding resulted in unacceptably low positive predictive values for each scale. These results indicate that these crowding scales lack scalability and do not perform as designed in EDs where crowding is not the norm. However, two of the crowding scales, EDWIN and NEDOCS, and one of the READI subscales, bed ratio, yielded good predictive power (AROC >0.80) of perceived ED crowding, suggesting that they could be used effectively after a period of site-specific calibration at EDs where crowding is a frequent occurrence. [source] The Effects of Ambulance Diversion: A Comprehensive ReviewACADEMIC EMERGENCY MEDICINE, Issue 11 2006Julius Cuong Pham MD Objectives To review the current literature on the effects of ambulance diversion (AD). Methods The authors performed a systematic review of AD and its effects. PubMed, EMBASE, the Cochrane database, societal meeting abstracts, and references from relevant articles were searched. All articles were screened for relevance to AD. Results The authors examined 600 citations and reviewed the 107 articles relevant to AD. AD is a common occurrence that is increasing in frequency. AD is associated with periods of emergency department (ED) crowding (Mondays, mid-afternoon to early evening, influenza season, and when hospitals are at capacity). Interventions that redesign the AD process or that provide additional hospital or ED resources reduce diversion frequency. AD is associated with increased patient transport times and time to thrombolytics but not with mortality. AD is associated with loss of estimated hospital revenues. Short of anecdotal or case reports, no studies measured the effect of AD on ED crowding, morbidity, patient and provider satisfaction, or EMS resource utilization. Conclusions Despite its common use, there is a relative paucity of studies on the effects of AD. Further research into these effects should be performed so that we may understand the role of AD in the health system. [source] Fine-needle aspiration cytology of Hürthle cell carcinoma of the thyroidDIAGNOSTIC CYTOPATHOLOGY, Issue 3 2008Howard Her-Juing Wu M.D. Abstract Specific criteria for the diagnosis of fine-needle aspiration (FNA) of Hürthle Cell Carcinoma (HCC) have rarely been discussed in the literature. A retrospective review of 35 FNA cases with the diagnosis of Hürthle cell lesion or Hürthle cell neoplasm was performed. In each case, there was a subsequent surgical excision. The FNA specimens were divided according to histologic diagnoses as HCC (12 cases), Hürthle cell adenoma (HCA) (14 cases), and benign nonneoplastic Hürthle cell lesions (BNHCL) (9 cases). Each case was examined using a semiquantitative scoring system for the following 11 features: presence or absence of colloid, lymphocytes, and transgressed blood vessels (each scored 0 or 1); the percentage of nuclear enlargement, small cell dysplasia, large cell dysplasia, nuclear crowding, and cellular dyshesion (each scored 0,3); and age, gender, and size of lesion. When diagnosed by FNA as either Hürthle cell neoplasm or Hürthle cell lesion, males were much more likely to have malignant tumors than females. Statistically significant cytologic features that favored malignant (HCC) over benign lesions (HCA and BNHCL) included small cell dysplasia, large cell dysplasia, nuclear crowding, and cellular dyshesion. The presence of colloid and lymphocytes favored a benign lesion. Nuclear enlargement and large tumor size are significantly more common in neoplasms than BNHCL. Diagn. Cytopathol. 2008;36:149,154. © 2008 Wiley-Liss, Inc. [source] Pancreatic mucinous lesions: A retrospective analysis with cytohistological correlationDIAGNOSTIC CYTOPATHOLOGY, Issue 11 2006Jing Zhai M.D., Ph.D. Abstract The diagnosis of mucinous pancreatic lesions, which include mucinous noncystic adenocarcinoma, intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), and mucinous metaplasia, is critical, given different clinical management and prognosis. This retrospective study is done to assess the cytological features and pitfalls associated with these entities in cytological samples. A search for pancreatic cytology specimens with histological confirmation of the various pancreatic mucinous lesions was done from 1988 to 2005: 9 mucinous adenocarcinoma, 14 IPMN, 11 MCN, and 3 mucinous metaplasia. The majority (35/37) had been endoscopic ultrasound-guided fine-needle aspirations. The cellularity, background extracellular mucin, epithelial architecture, mucinous nature of the epithelium, cell shape, and nuclear features were evaluated on the cytology material. Of the 22 cytological features evaluated, the presence of three-dimensional clusters, micropapillary structures, and nuclear atypia, which includes nuclear crowding, increased N/C ratio, anisonucleosis, nuclear membrane contour irregularity, clumpy chromatin, and prominent nucleoli, was found to be consistently associated with mucinous adenocarcinoma. There were no statistically significant cytological features, which helped in differentiating IPMN, MCN, and mucinous metaplasia. There was a relatively high false-positive rate in the IPMN group (5/14, 36%). Review of the histological specimen showed severe dysplastic epithelial change in these cases. One false-positive case of mucinous metaplasia (1/3, 33%) showed marked intraepithelial acute inflammation. The cytological diagnosis of mucinous pancreatic lesions remains challenging, except for mucinous noncystic adenocarcinoma. The findings were largely nonspecific in the differentiation between IPMN, MCN, mucinous metaplasia, and incidentally sampled gastrointestinal epithelium. False-positive diagnosis of adenocarcinoma occurs not infrequently in the setting of IPMN with severe dysplastic epithelial change and in lesions with associated acute inflammation, and can be a pitfall in the diagnosis of these lesions. Diagn. Cytopathol. 2006;34: 724,730. © 2006 Wiley-Liss, Inc. [source] Public employment and labour market performanceECONOMIC POLICY, Issue 34 2002Yann Algan Summary We explore the consequences of public employment for labour market performance. Theory suggests that public employment may not only crowd out private employment, but also increase overall unemployment if, by offering attractive working conditions, it draws additional individuals into the labour force. Empirical evidence from a sample of OECD countries in the 1960,2000 period suggests that, on average, creation of 100 public jobs may have eliminated about 150 private sector jobs, slightly decreased labour market participation, and increased by about 33 the number of unemployed workers. Theoretical considerations and empirical evidence, however, suggest that the crowding out effect of public jobs on private jobs is only significant in countries where public production is highly substitutable to private activities and the public sector offers more attractive wages and/or other benefits than the private labour market. [source] The Effect of R&D Subsidies on Private R&DECONOMICA, Issue 294 2007HOLGER GÖRG This paper investigates the relationship between government support for R&D and R&D expenditure financed privately by firms using a comprehensive plant level data set for the manufacturing sector in the Republic of Ireland. We find that for domestic plants small grants serve to increase private R&D spending, while too large a grant may crowd out private financing of R&D. In contrast, evidence for foreign establishments suggests that grant provision causes neither additionality nor crowding out effects of private R&D financing, regardless of the size of the subsidy. [source] Effects of crowding on populations of Aedes albifasciatus larvae under laboratory conditionsENTOMOLOGIA EXPERIMENTALIS ET APPLICATA, Issue 2 2000Raquel M. Gleiser Abstract Aedes (Ochlerotatus) albifasciatus (Macquart 1838) (Diptera: Culicidae) is a neotropical flood water mosquito, incriminated as the main vector of the western equine encephalitis virus, and which affects beef and milk production in central Argentina. The short time required to hatch and develop from egg to adult, usually in temporary pools, suggests a strategy which allows for exploitation of transient pools, thus evading predation and interspecific competition. Under these conditions intra specific competition could represent a major density-dependent source of larval mortality, but the relative importance of density-dependent regulation of mosquito populations has generated controversy. Therefore we examined the effects of larval density on basic population characteristics of Ae. albifasciatus in the laboratory. Larvae were obtained by synchronous hatching of eggs laid by field-trapped females. Emerging larvae (L1) were used to build cohorts of different initial densities, kept in plastic trays with 400 ml of distilled water, and food supplied daily during the first 10 days (0.1 g per larvae day,1). Age-specific development time and specific and relative mortality were estimated, and their relation to initial larval density was assessed through linear and non-linear regressions and correlation analysis. First hatching was registered 3 h after flooding the eggs. Higher levels of pre-adult mortality were detected in groups with higher densities. Specific mortality and average time to enter a stage of L1 to L3 could directly be related to initial larval density, but no significant relations were found for L4 and pupae. Results suggest that crowding could be a factor capable of regulating the density of natural populations of Ae. albifasciatus. [source] Evaluating theories of alcohol-related aggression using observations of young adults in barsADDICTION, Issue 6 2000Kathryn Graham Aims. The objective of the present study is to evaluate 36 explanations of alcohol-related aggression that have been proposed in the research literature in terms of their relevance to naturally-occurring incidents of aggression involving alcohol. Design. The study involved content analysis of descriptions of 105 incidents of aggression. Setting and participants. Bars frequented by young adults. Measurements. Step-by-step descriptions of incidents of aggression reported by researcher-observers based on 93 nights of observation in bars between midnight and 3 a.m. Findings. Some explanations relating to the effects of alcohol (e.g. focused on the present, reduced anxiety about sanctions or danger, heightened emotionality) and the environment (e.g. generally permissive environment, expectation by patrons that aggression will be tolerated) were found to be relevant to most incidents, while other explanations (e.g. crowding, release of pent-up anger) were directly relevant to only a few or no incidents. Incidents involving male-to-male aggression were more likely than incidents involving both males and females to be attributable to expectations, acceptance of aggression, power concerns, male honor and "macho" values. Principal components analysis identified five groupings of explanations: risk-taking effects of alcohol, cognitive impairment from alcohol, hyperemotional effects of alcohol, "macho" subculture, and permissive environment. Conclusions. The findings are consistent with a model of alcohol-related aggression that involves multiple contributing factors including alcohol effects and situational contexts. The greater relevance of certain explanations and the natural groupings of explanations point to directions for future research. [source] |