After-hours telephone coverage: the application of an area-wide telephone triage and advice system for pediatric practices

BACKGROUND: After-hours telephone calls are a stressful and frustrating aspect of pediatric practice. At the request of private practice pediatricians in Denver, a metropolitan area-wide system was created to manage after-hours pediatric telephone calls and after-hours patient care. This system, the After-Hours Program (AHP), uses specially trained pediatric nurses with standardized protocols to provide after-hours telephone triage and advice for the patients of 92 Denver pediatricians, representing 56 practices. OBJECTIVES: This report describes the AHP, presents data from 4 years' experience with the program, and describes results of our evaluation of the following aspects of the program: subscribing physician satisfaction, parent satisfaction, the accuracy and appropriateness of telephone triage, and program costs. METHODS: After-Hours Program records (including quality assurance data) for all 4 years of operation were retrospectively reviewed, tabulated, and analyzed. The results of two subscribing physician surveys and one parent caller satisfaction survey are presented. A retrospective review of after-hours patient care encounter forms assessed the necessity for after-hours visits triaged by the AHP. An analysis of the total cost of this program to 10 randomly selected subscribing physicians was conducted using current AHP data and a survey of the 10 physicians. RESULTS: In 4 years, 107,938 calls have been successfully managed without an adverse clinical outcome. Minor errors in using protocols occurred in one call out of 1450 after-hours calls. After-hours phoen calls necessitated an after-hours patient visit 20% of the time and generated one after-hours hospital admission out of every 88 calls. Just over half of the patients were managed with home care advice only, and 28% were given home care advice after-hours and seen the next day in the primary physician's office. Of all patients directed by the telephone triage nurses to be seen after hours, 78% were determined to have a condition necessitating after-hours care. Data are presented regarding call volumes by time of day, day of week, patient age, and patient's initial complaint. The 6 most common complaints accounted for more than one half of the calls, and 38 complaints accounted for more than 95% of all after-hours calls. Utilization by subscribing physicians is described. Satisfaction among subscribing pediatricians was 100%, and among parents was 96% to 99% on a variety of issues. The total cost to participating Denver pediatricians (which includes revenues "given up" as a result of not seeing patients after hours) ranged from 1% to 12% of their annual net income, depending on a variety of factors. CONCLUSIONS: Large-scale after-hours telephone coverage systems can be effective and well-received by patients, parents, and primary physicians. Data presented in this report can assist in planning the training of personnel who provide after-hours telephone advice and triage. Controversies associated with this type of program are discussed. Suggestions are made regarding the direction of future programs and research.     

Working memory capacity and the top-down control of visual search: Exploring the boundaries of "executive attention".

The executive attention theory of working memory capacity (WMC) proposes that measures of WMC broadly predict higher order cognitive abilities because they tap important and general attention capabilities (R. W. Engle & M. J. Kane, 2004). Previous research demonstrated WMC-related differences in attention tasks that required restraint of habitual responses or constraint of conscious focus. To further specify the executive attention construct, the present experiments sought boundary conditions of the WMC-attention relation. Three experiments correlated individual differences in WMC, as measured by complex span tasks, and executive control of visual search. In feature-absence search, conjunction search, and spatial configuration search, WMC was unrelated to search slopes, although they were large and reliably measured. Even in a search task designed to require the volitional movement of attention (J. M. Wolfe, G. A. Alvarez, & T. S. Horowitz, 2000), WMC was irrelevant to performance. Thus, WMC is not associated with all demanding or controlled attention processes, which poses problems for some general theories of WMC. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Individual Differences in Susceptibility to False Memory in the Deese-Roediger-McDermott Paradigm.

The authors addressed whether individual differences in the working memory capacity (WMC) of young adults influence susceptibility to false memories for nonpresented critical words in the Deese-Roediger-McDermott associative list paradigm. The results of 2 experiments indicated that individuals with greater WMC recalled fewer critical words than individuals with reduced WMC when participants were forewarned about the tendency of associative lists (e.g., bed, rest, . . .) to elicit illusory memories for critical words (e.g., sleep). In contrast, both high and low WMC participants used repeated study-test trials to reduce recall of critical words. These findings suggest that individual differences in WMC influence cognitive control and the ability to actively maintain task goals in the face of interfering information or habit. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Austenite formation during intercritical annealing

A systematic experimental study has been conducted on ferrite recrystallization and intercritical austenite formation for two low-carbon steels with chemical compositions typically used for dual-phase and transformation-induced plasticity (TRIP) steels. Different initial heating rates, holding temperatures, and times were applied to the materials to examine the ferrite recrystallization and austenite formation kinetics. An Avrami model was developed to describe the isothermal ferrite recrystallization behavior and was applied successfully to the nonisothermal conditions. It was found that the initial heating rate affects the isothermal austenite formation kinetics for both the hot-rolled and cold-rolled materials albeit the effect is more pronounced for the cold-rolled material. This can be attributed to the interaction between the ferrite recrystallization and austenite formation processes. Furthermore, it was found that the distribution of austenite phase is also affected by the ferrite recrystallization process. When ferrite recrystallization is completed before the austenite formation (i.e., under sufficiently slow heating rate conditions), austenite is to a large extent randomly distributed in the ferrite matrix. On the other hand, incomplete recrystallization of ferrite due to higher heating rates leads to the formation of banded austenite grains. It is proposed that this observation is characteristic of simultaneous recrystallization and austenite formation where moving ferrite grain boundaries do not provide suitable sites for austenite nucleation.     

Quorum sensing in Escherichia coli, Salmonella typhimurium, and Vibrio harveyi: a new family of genes responsible for autoinducer production

In bacteria, the regulation of gene expression in response to changes in cell density is called quorum sensing. Quorum-sensing bacteria produce, release, and respond to hormone-like molecules (autoinducers) that accumulate in the external environment as the cell population grows. In the marine bacterium Vibrio harveyi two parallel quorum-sensing systems exist, and each is composed of a sensor-autoinducer pair. V. harveyi reporter strains capable of detecting only autoinducer 1 (AI-1) or autoinducer 2 (AI-2) have been constructed and used to show that many species of bacteria, including Escherichia coli MG1655, E. coli O157:H7, Salmonella typhimurium 14028, and S. typhimurium LT2 produce autoinducers similar or identical to the V. harveyi system 2 autoinducer AI-2. However, the domesticated laboratory strain E. coli DH5alpha does not produce this signal molecule. Here we report the identification and analysis of the gene responsible for AI-2 production in V. harveyi, S. typhimurium, and E. coli. The genes, which we have named luxSV.h., luxSS.t., and luxSE.c. respectively, are highly homologous to one another but not to any other identified gene. E. coli DH5alpha can be complemented to AI-2 production by the introduction of the luxS gene from V. harveyi or E. coli O157:H7. Analysis of the E. coli DH5alpha luxSE.c. gene shows that it contains a frameshift mutation resulting in premature truncation of the LuxSE.c. protein. Our results indicate that the luxS genes define a new family of autoinducer-production genes.     

Effects of antimicrobial use in agricultural animals on drug-resistant foodborne salmonellosis in humans: A systematic literature review

Controversy continues concerning antimicrobial use in food animals and its relationship to drug-resistant infections in humans. We systematically reviewed published literature for evidence of a relationship between antimicrobial use in agricultural animals and drug-resistant meat or dairy-borne non-typhoidal salmonellosis in humans. Based on publications from the United States (U.S.), Canada, and Denmark from January 2010 to July 2014, 858 articles received title and abstract review, 104 met study criteria for full article review with 68 retained for which data are presented. Antibiotic exposure in both cattle and humans found an increased likelihood of Salmonella colonization, whereas in chickens, animals not exposed to antibiotics (organic) were more likely to be Salmonella positive and those that had antibiotic exposure were more likely to harbor antimicrobial resistant Salmonella organisms. In swine literature, only tylosin exposure was examined and no correlation was found among exposure, Salmonella colonization, or antimicrobial resistance. No studies that identified farm antimicrobial use also traced antimicrobial-resistant Salmonella from farm to fork.     

Microstructure–strength models for heat treatment of Al–Si–Mg casting alloys I: microstructure evolution and precipitation kinetics

A comprehensive microstructure–strength mathematical model for the heat treatment of Al–Si–Mg casting alloys is presented. As part of the model development, the evolution of microstructure and mechanical properties during heat treatment of an industrially cast A356 aluminium alloy was studied in an extensive experimental investigation. For the solution treatment process, the changes in dendritic composition and eutectic morphology in the temperature range 773–833 K (500–560°C) were quantified using microprobe and image analysis techniques. For natural and artificial ageing, the kinetics of precipitation/clustering was determined using an isothermal calorimetry technique in conjunction with hardness and mechanical property measurements. Two other Al–Si–Mg model alloy compositions were used to study the effects of alloy chemistry on microstructure response during heat treatment. The overall aim of the experimental work presented here is to facilitate the development of a comprehensive microstructure–strength model for the heat treatment of Al–Si–Mg casting alloys that will be presented in part II of this paper.

On présente un modèle mathématique détaillé de la microstructure-résistance du traitement thermique des alliages de moulage d'Al–Si–Mg. Faisant partie du développement du modèle, on a étudié l'évolution de la microstructure et des propriétés mécaniques lors du traitement thermique d'un alliage d'aluminium A356 moulé industriellement lors d'un examen expérimental de grande envergure. Pour le traitement de mise en solution, on a quantifié les changements de la composition dendritique et la morphologie de l'eutectique dans la gamme de température de 773 à 833 K (500 à 560 °C) en utilisant les techniques de la microsonde et de l'analyse d'image. Pour le vieillissement naturel et artificiel, on a déterminé la cinétique de précipitation/agrégation en utilisant une technique de calorimétrie isotherme en conjonction avec les mesures de dureté et de propriétés mécaniques. On a utilisé deux autres compositions de l'alliage modèle d'Al–Si–Mg pour étudier les effets de la chimie de l'alliage sur la réponse de la microstructure lors du traitement thermique. Le but global du travail expérimental présenté ici est de faciliter le développement d'un modèle détaillé de microstructure-résistance du traitement thermique des alliages de moulage d'Al–Si–Mg qui sera présenté dans la seconde partie de cet article.