Entire Encounter Research Articles

Bayesian estimate of Australian humpback whale calving interval under sparse resighting rates: 1987–2009

This study estimates a calving interval for humpback whales from a longterm photo-ID catalogue of 2,973 individuals resighted in Hervey Bay, East Australia. The study proposes a modification of two existing methods to handle partial identification of sex and age-classes of whales from visual surveys. One method truncates the data to just breeding females and discards all resighting events prior to the first observed breeding event. The second method utilises the multi-stage mark recapture (MSMR) framework and multi-event extension to include all resighted individuals and their entire encounter history. The performance of each method is assessed and the conditioning required to handle ambiguity of sex and age-classes is detailed, which is subtly different from most other mark-recapture methods. Both truncation and the multi-event methods led to similar estimates of calving intervals: 2.98 years (95% CI: 2.27–3.51) and 2.78 years (95% CI: 2.23–3.68) respectively. More importantly, estimates were more sensitive to the exact specification of resighting probabilities among age and sex classes than to the type of conditioning. However, the multi-event framework resulted in more precise estimates of other important life-history parameters such as apparent survival, and included a wider constituency of age and sex classes.

The role of music in shaping children’s self-knowledge and identity: Perspectives from an African setting1

Music-making is a natural childhood activity. This is evidenced by the increase in research and scholarship covering diverse aspects of children’s interaction with music. This keynote address invites us to reflect on the ways in which music shapes young children’s self-knowledge and identity by considering their musical needs, their interactions with music, what they and their adult caregivers experience as they participate in musicking and how this entire encounter may nurture their growing musicality. Acknowledging the influence of context in nurturing musical childhoods, four settings of home, school, church and the community activity of Isukuti performing arts are examined through lenses of social and cultural psychology and African Indigenous knowledge systems. The discussion ends with a call for educators, researchers and practitioners to consolidate ongoing and future efforts in nurturing musical childhoods, particularly by adding the sub-Saharan Africa perspective to the kaleidoscope of global activities that constitute children’s musical journeys

Addressing Health Inequities for Limited English Proficiency Patients: Interpreter Use and Beyond.

The limited English proficiency (LEP) status of parents is associated with poor health care outcomes in children.1–3 The use of professional interpretation has been associated with improvement in communication errors, patient comprehension, health care use, clinical outcomes, and patient satisfaction.4,5 Yet, professional interpretation continues to be underused.6,7In this issue of Pediatrics, Lion et al8 aim to understand interpreter underuse, with a deeper look into factors associated with interpreter use among health care providers in the pediatric emergency department. They found that physicians and nurse practitioners used interpreters more often than registered nurses and that interpreters were used more frequently for detailed history taking and discharge, in comparison with medication delivery and procedures.In the study, the researchers add to the growing literature questioning how we define and collect data related to medical interpretation. The study reveals how dichotomous terms, such as “interpreter used” and “interpreter not used,” do not accurately encapsulate interpreter use and frequently overestimate time spent with an interpreter. As a result, the benefits of professional interpretation may be even larger than reported because many events are measured as “interpreted,” when, in reality, they are not or not to the extent desirable to achieve the full benefit.Most notably, with the study’s results, the researchers highlight how, even when health care providers recognize the need for an interpreter, they do not always use one. In the majority of encounters with Spanish LEP parents, a professional interpreter was used at least once. By looking at the individual “communication event level,” the authors were able to show that interpreters were only used for only about one-third of the time for the entire encounter. Therefore, even when health care providers recognize the need for an interpreter, evidence bears that there continues to be gaps in their use.Previous work has revealed that these lapses in interpreter services occur because of actual and perceived time constraints by providers and provider perceptions on interpreter quality and role and because families often prefer that a family member conducts the interpretation.9 Although it is important to address these issues through adequate training for interpreters and education for providers on how to use interpreters appropriately and effectively, we must also look at the diversity of our own health care workforce to address these issues.Patient–physician concordance, in which the patient and physician are fluent in the same language, has been shown to improve patient outcomes, including medical adherence, pain management, medical understanding, patient satisfaction, and mental health.10 Yet, there is a discrepancy between the languages physicians and patients speak11 that, if left unaddressed, will continue to grow, as the percentage of LEP patients and families rises.12 Increasing outreach to underrepresented-in-medicine students, dismantling systemic bias in recruitment, valuing multilingual skills,13 and developing inclusive work environments can improve the diversity of our workforce. We must all work together to make sure health care providers can communicate directly with the patients they are caring for so that they are best able to provide high quality care to all, no matter what language they speak.

Prediction models for COVID-19 clinical decision making

Prediction models for COVID-19 clinical decision making

The Conspiracy Exposed

The Conspiracy Exposed Richard Jeffrey Newman (bio) Antisemitism: Here and Now Deborah E. Lipstadt Schocken Books www.knopfdoubleday.com/imprint/schocken/ 304 Pages; Cloth, $16.99 Over and over again, as I read Antisemitism: Here and Now, by Deborah E. Lipstadt, my mind kept returning to a year or so ago, when my wife, my son, and I were having dinner with other members of my wife's family at my sister-in-law's house. As we sat around the table drinking tea, the conversation turned to the Trump administration's open hostility towards Muslims—something my wife and her family take very personally, since they were all born and raised Muslim in Iran. Perhaps to lighten the mood, my brother-in-law's wife decided to tell a joke, which involved poking fun at the relative positions of privilege, or lack thereof, occupied by Christians, Jews, and Muslims in United States society. When she got to the part about Jews, she said, "And Jews fund the United States government." "No, we don't," I interrupted her. "It's a joke," my brother-in-law's wife responded, her tone suggesting I ought not to take it so seriously. I don't remember exactly what I said in response, but my sister-in-law, trying to defuse the tension that was starting to build, turned to her brother's wife and said, "You can't say that about Jews—about Israel, yes, but not about Jews." "Israel does not fund the United States government," I gave my sister-in-law a pointed look. "I know," she said, a slightly pleading tone creeping into her voice. She did not want me to make a big deal out of this, "But at least there's a connection…" "No!" I interrupted her, "There's not…" and I was going to say a good deal more, but then two things happened at once. My brother-in-law's wife turned to him and, in Persian, said, "But Israel is Jewish, isn't it?" Then my wife cut in with a much more measured, but no less appropriate response than I would have continued with, and I decided, in the interests of family harmony, hers was the wiser tack to take. In the end, it didn't matter. My brother-in-law's wife told her joke anyway, either (at this point willfully) oblivious to its antisemitic content or, having been perfectly aware of that content from the start, determined not to let my "overly delicate sensibilities" get in the way of her making her point. Given enough time and more patience than I had at that moment, I could have unraveled for all who were present the knot of antisemitism that exchange was tied up in, but now that I've read Deboarh Lipstadt's book—she is Dorot Professor of Modern Jewish History and Holocaust Studies at Emory University—I just wish I'd been able to hand each of the people at that table a copy. Antisemitism: Here and Now takes the form of a correspondence between Professor Lipstadt and two composite characters she has created—Abigail, a Jewish student, and Joe, a non-Jewish colleague. Through these two characters, Lipstadt gives voice to "the confusion, worries, and distress about antisemitism" that people have expressed to her over the years. While I personally found the letters Lipstadt wrote for these characters somewhat stilted and emotionless, the epistolary convention serves her well nonetheless, in that it constructs for her letters a well-defined audience with a practical need she is being asked to address. Abigail, after describing an experience not unlike the one I had at my sister-in-law's, articulates this need in the very first letter: The most distressing part of the entire encounter was that I didn't know what to say to [the people expressing antisemitic views] without sounding defensive. I guess I am asking for your help in both understanding what is happening and figuring out how to respond. Joe's letters express a similar need for both understanding and an "action plan," though from a non-Jewish perspective. Antisemitism Here and Now...

Mechanism Change in the Dynamics of the O' + O2 → O'O + O Atom Exchange Reaction at High Collision Energies.

The extreme velocity and the large available energy of atoms with hyperthermal kinetic energies can give rise to novel mechanisms and behavior of chemical reactions unseen at thermal conditions. Crossed-molecular-beams experiments combined with isotope labeling on the reaction of hyperthermal O atoms with O2 molecules have provided an example of the arising complexity of such systems. Quasiclassical trajectory (QCT) calculations proved to be instructive in the exploration of the microscopic mechanism of the reactive and inelastic scattering observed, and a new mechanism has been identified: there are reactive collisions in which the potential energy remains repulsive during the entire encounter ("direct" reactions in which, in a sense, no complex is formed). In this work, the effect of the magnitude of the collision energy on this mechanism is explored. At hyperthermal collision energies, the reaction is characterized by a unique impact parameter window favorable for reaction through complex formation, while the direct collisions take place exclusively at small impact parameters. In direct reactive collisions, contributing as much as 12% to the reaction cross section, first the existing bond is broken, and the new bond is formed afterward. This kind of collision is unique to extremely high collision energies. Analysis of various correlations was used to find out the details of the reaction dynamics. The observed phenomena indicate that when the collision energy is extremely high, one can expect deviation from what an extrapolation from the more familiar energy ranges would predict.

Predicting the Structure of the Solar Corona and Inner Heliosphere during Parker Solar Probe's First Perihelion Pass

Abstract NASA’s Parker Solar Probe (PSP) spacecraft reached its first perihelion of 35.7 solar radii on 2018 November 5. To aid in mission planning, and in anticipation of the unprecedented measurements to be returned, in late October, we developed a three-dimensional magnetohydrodynamic (MHD) solution for the solar corona and inner heliosphere, driven by the then available observations of the Sun’s photospheric magnetic field. Our model incorporates a wave-turbulence-driven model to heat the corona. Here, we present our predictions for the structure of the solar corona and the likely in situ measurements that PSP will be returning over the next few months. We infer that, in the days prior to first encounter, PSP was immersed in wind emanating from a well-established, positive-polarity northern polar coronal hole. During the encounter, however, field lines from the spacecraft mapped to a negative-polarity equatorial coronal hole, within which it remained for the entire encounter, before becoming magnetically connected to a positive-polarity equatorial coronal hole. When the PSP data become available, these model results can be used to assist in their calibration and interpretation, and, additionally, provide a global context for interpreting the localized in situ measurements. In particular, we can identify what types of solar wind PSP encountered, what the underlying magnetic structure was, and how complexities in the orbital trajectory can be interpreted within a global, inertial frame. Ultimately, the measurements returned by PSP can be used to constrain current theories for heating the solar corona and accelerating the solar wind.

Rescue Sedation When Treating Acute Agitation in the Emergency Department With Intramuscular Antipsychotics.

Rapid treatment of agitation in the emergency department (ED) is critical to avoid injury to patients and providers. Treatment with intramuscular antipsychotics is often utilized, but there is a paucity of comparative effectiveness evidence available. The purpose of this investigation was to compare the effectiveness of droperidol, olanzapine, and haloperidol for treating agitation in the ED. This was a retrospective observational study of adult patients who received intramuscular medication to treat agitation. Patients were classified based on the initial antipsychotic they received. The primary effectiveness outcome was the rate of additional sedation administered (rescue medication) within 1h. Secondary outcomes included rescue sedation for the entire encounter and adverse events. There were 15,918 patients included (median age 37years, 75% male). Rescue rates at 1h were: 547/4947 for droperidol (11%, 95% confidence interval [CI] 10-12%), 988/8825 olanzapine (11%, 95% CI 10-12%), and 390/2146 for haloperidol (18%, 95% CI 17-20%). Rescue rates for the entire ED encounter were: 832/4947 for droperidol (17%, 95% CI 16-18%), 1665/8825 for olanzapine (19%, 95% CI 18-20%), and 560/2146 for haloperidol (26%, 95% CI 24-28%). Adverse events were uncommon: intubation (49, 0.3%), akathisia (7, 0.04%), dystonia (5, 0.03%), respiratory arrest (1, 0.006%), and torsades de pointes (0), with no significant differences between drugs. Olanzapine and droperidol lead to lower rates of rescue sedation at 1h and overall, compared with haloperidol. There were no significant differences in major adverse events.

Impact of a Shared Decision Making Intervention on Health Care Utilization: A Secondary Analysis of the Chest Pain Choice Multicenter Randomized Trial.

Patients at low risk for acute coronary syndrome are frequently admitted for observation and cardiac testing, resulting in substantial burden and cost to the patient and the health care system. The purpose of this investigation was to measure the effect of the Chest Pain Choice (CPC) decision aid on overall health care utilization as well as utilization of specific services both during the index emergency department (ED) visit and in the subsequent 45 days. This was a planned secondary analysis of data from a pragmatic multicenter randomized trial of shared decision making in adults presenting to the ED with chest pain who were being considered for observation unit admission for cardiac stress testing or coronary computed tomography angiography. The trial compared an intervention group engaged in shared decision making facilitated by the CPC decision aid to a control group receiving usual care. Hospital-level billing data were used to measure utilization for the index ED visit and during the following 45 days. Patients in both groups also were asked to keep a diary recording health care utilization over the same 45-day period. Outcomes assessed included length of time in the ED and observation, ED visits, office visits, hospitalizations, testing, imaging, and procedures. Of the 898 patients included in the original trial, we were able to contact 834 (92.9%) patients for 45-day health care diary review. There was no difference in patient-reported health care utilization between the study arms. Hospital-level billing data were obtained for all 898 (100%) patients. During the initial ED visit the length of stay (LOS) was similar, and there was no difference in the frequency of observation unit admission between study arms. However, the mean observation unit LOS was 95 minutes (95% confidence interval [CI]= 40.8-149.8) shorter in the CPC arm and the mean number of tests was lower in the CPC arm (decrease in 19.4 imaging studies per 100 patients, 95% CI= 15.5-23.3). When evaluating the entire encounter and follow-up period, the intervention arm underwent fewer tests (decrease in 125.6 tests per 100 patients, 95% CI= 29.3-221.6). More specifically, there were fewer advanced cardiac imaging tests completed (25.8 fewer per 100 patients, 95% CI= 3.74-47.9) in the intervention arm. Shared decision making in low-risk chest pain can lead to decreased diagnostic testing without worsening outcomes measured over 45 days.

Agenda Setting During Follow-Up Encounters in a University Primary Care Outpatient Clinic

ABSTRACTAt the beginning of the medical encounter, clinicians should elicit patients’ agendas several times using open-ended questions. Little is known, however, about how many times physicians really solicit a patient’s agenda during follow-up encounters. The objective was to analyze the number of agenda solicitations by physicians, of agendas initiated by physicians, and of patients’ spontaneous agendas during the beginning and the entire encounter. We analyzed 68 videotaped follow-up encounters at a university primary care outpatient clinic. The number of different types of agenda setting was searched for and analyzed using negative binomial regression or logistic regression models. Physicians solicited agendas a mean ± SD of 0.8 ± 0.7 times/patient during the first 5 minutes and 1.7 ± 1.2 times/patient during the entire encounter. Physicians in 32.4% of encounters did not solicit the patient agenda, and there were never more than two physician’s solicitations during the first 5 minutes. The mean number of physician’s solicitations of the patients’ agenda was 42% lower among female physicians during the first 5 minutes and 34% lower during the entire encounter. The number of agendas initiated by physicians was 1.2 ± 1.2/patient during the beginning and 3.2 ± 2.3/patient during the entire encounter. In 58.8% of the encounters, patients communicated their agendas spontaneously. There were twice as many patient spontaneous agendas (IRR = 2.12, p = .002) with female physicians than with males. This study showed that agenda solicitation with open-ended questions in follow-up encounters does not occur as often as recommended. There is thus a risk of missing new agendas or agendas that are important to the patient.

The social context of a territorial dispute differentially influences the way individuals in breeding pairs coordinate their aggressive tactics

In diverse species, individuals coordinate behavior to accomplish shared goals or tasks. Such coordination, however, often occurs selectively, and the contextual information animals use to determine when they coordinate and when they do not is unclear. We investigate this issue in the highly territorial downy woodpecker (Picoides pubescens) by exploring how individuals within a social breeding pair differentially modulate coordinated aggressive responses during graded simulated territorial intrusions (STIs). Analyses show that resident pairs mount a more robust aggressive response to STIs that represent a greater threat. Moreover, in this social context, pair members produce contact vocalizations in a way that predicts their partner’s aggressive behavior. We also show that, when presented with a low threat, individuals that first respond to intrusions decrease their aggressive output once their partner attends to the stimulus; the partner, in turn, increases their levels of aggressive behavior. This does not occur in high-threat STIs, where both partners maintain high levels of aggression throughout the entire encounter. Together, these results show that individuals within a pair flexibly adjust their aggressive tactics in response to different social competitive contexts, and this includes adjusting the way in which individuals coordinate certain aspects of their agonistic repertoire. We speculate that this ability reflects an adaptive mechanism that allows individuals to fine-tune territorial tactics to reduce overall costs of aggression. Although research has demonstrated that individuals often coordinate their behavior to accomplish common tasks, little is known about the factors that determine when such coordination occurs and when it does not. We address this issue for the first time in the highly territorial downy woodpecker by testing how the level of threat associated with a territorial interaction influences the coordination of defensive behavior. We find that, when facing intruders that pose a greater threat, residents adjust levels of aggressive output in response to the number of vocalizations produced by their breeding partner. By contrast, this relationship is not observed when pairs face intruders that pose a relatively lower threat. Our data therefore provide striking evidence that coordination in defensive tactics depends on the residents’ appraisal of the social context, such that fiercer competition is associated with greater behavioral coordination.

Perioperative and Anesthesia Guidelines for Children with Autism: A Nationwide Survey from Sweden.

The overall aim of this study was to describe the current set of guidelines for the preparation and care for children with autism spectrum disorder (ASD) in the perioperative setting across Sweden and explore the content of these guidelines in detail. An online questionnaire was distributed to the chairpersons of all anesthesia departments (n = 68) and pediatric departments (n = 38) throughout Sweden. Follow-up phone calls were made to those departments that did not return the questionnaire. The presence of guidelines was analyzed through descriptive statistics. These guidelines and comments on routines used in these departments were analyzed inspired by conventional content analysis. Seven of the 68 anesthesia departments and none of the 38 pediatric departments across Sweden have guidelines for preparing and/or administering care to children with ASD within the perioperative setting. From the guidelines and routines used, 3 categories emerge: "lacking the necessary conditions," "no extra considerations needed," and "care with specific consideration for children with ASD." These 3 categories span a continuum in the care. In the first category, the anesthesia induction could result in the child with ASD being physically restrained. In the last category, the entire encounter with the health care service would be adapted to the specific needs of the child. There is a lack of evidence-based guidelines specifically designed to meet the needs of children with ASD in the preoperative period in Sweden. Further research is needed to understand if children with ASD would benefit from evidence-based guidelines.

P153 – 2931: A comparison of the informal & formal suggested clinical immobilization test (SCIT) results for diagnosing familial Willis Ekbom disease/restless legs syndrome (WED/RLS) in clinical practice

Objective WED/RLS is a clinical diagnosis, which requires descriptions of the individually experienced symptoms causing an urge to move, in their own words. These criteria make it difficult to assess WED/RLS in children/youth with neurodevelopmental conditions (NDCs). We hypothesize that a clinic-based SCIT, using structured behavioural observations of movement patterns in conjunction with parental reporting, might become a new diagnostic concept. Methods 31 patients with NDCs, experiencing chronic early-onset insomnia, were seen together with their mothers who had previously been diagnosed with WED/RLS. Aside from clinical (family) history, we investigated behavioural observations of movement patterns in conjunction with sensorimotor symptoms (reported by the patient or parents) during the SCIT. Patients were asked to (1) remove shoes/socks, (2) get up/“shake-out”; (3) sit relaxed with feet flat on the floor without moving; and (4) describe sensations. Formal SCIT: Patients could actively participate. Informal SCIT: Observations and parental reporting during the entire clinical encounter were documented, in order to include those who could not actively participate. Results 29/31 participated in the formal and/or informal SCIT. Formal SCIT: 15/31 tested positive: 87% reported sensations and 80% had observable individual repetitive movement patterns (IRMPs). Informal SCIT: 25/26 tested positive: 19% had parental reporting of sensations and 100% had observable IRMPs. Conclusion The formal SCIT, as previously suggested, supports patients' reporting of sensorimotor symptoms in their own words; not all patients could verbalize that. The informal SCIT explores parental understanding of sensorimotor symptoms (and associated sensory processing challenges), and observations of IRMPs in a structured way. The concept of SCIT was helpful in diagnosing definite and probable familial WED/RLS in children/adolescents with NDCs and major insomnia. Acknowledgments: TIDE-BC (Treatable Intellectual Disability Endeavour – British Columbia), Vancouver, Canada; BC Children's Foundation, Vancouver, Canada; Children's Sleep Network, Vancouver, Canada.

Time and Motion Study of Influenza Diagnostic Testing in a Community Pharmacy

Background: It has been shown that use of rapid diagnostic tests (RDTs) is able to reduce costs and improve the prescribing practice of antivirals (i.e. oseltamivir) among patients with influenza-like illnesses (ILIs). Using existing Clinical Laboratory Improvement Amendment (CLIA)-waived RDTs and collaborative practice agreements, similar to those used to allow pharmacists to administer vaccines, it is possible for patients to seek point-of-care treatment for influenza or flu-like symptoms at a local pharmacy. Following a review of the patient's symptoms by a trained pharmacist, the qualified patient is offered an RDT to determine if the influenza virus is the cause of the symptoms. Based on the results of the RDT, the patient is provided with the appropriate treatment as defined by an approved practice agreement.
 Objective: The aim of this study was to evaluate the feasibility of incorporating an RDT for influenza into community pharmacy practice.
 Methods: This time and motion study was conducted at three community pharmacy locations, and a total of eight simulated patient visits were completed utilizing a standardized patient. In addition to determining a total time of the encounter, each simulation was divided into nine timed sub-categories. For data analysis, the time spent in each of the nine sub-categories was assigned to the pharmacist, pharmacy technician, or patient. Time and motion methodologies were used to estimate the total time required to provide the RDT service, to determine the amount of active time required of the pharmacist and pharmacy technician, and to evaluate the ability of the staff to provide the service within its existing workflow.
 Results: The average total time to complete the entire patient encounter for an influenza assessment utilizing an RDT was 35.5 minutes (± 3.1 minutes). On average, the pharmacist spent 9.4 minutes (± 3 minutes) per encounter or about 26.5% of the entire encounter. When the pharmacy technician collected the vital signs, the pharmacist-required time was reduced to 4.95 minutes (± 2.7 minutes), which was about a 48% reduction.
 Conclusions: The results indicate that an RDT program for influenza assessment required no more than a modest amount of pharmacist time and could be successfully incorporated into regular workflow with little to no disruption of other activities. As such, this approach to influenza management may be a feasible service for community pharmacies to offer patients. This was especially true if the pharmacy had well-trained technicians on staff that could support the service with collection of patient histories and vital signs.
 
 Type: Original Research

The parallels between parenting and patient care.

Soon after my medicine residency, while on faculty at a large academic medical center, I crossed paths with a complicated patient. Middle aged, homeless, and struggling with substance abuse, he was as well known to the staff for his disruptive behavior as he was for being discharged AMA. His behavior continued after he was admitted to my inpatient service for alcohol withdrawal. Late Friday afternoon, his nurse called me, distressed. “This patient needs to be transferred off this unit. He’s just too disruptive.” Shortly thereafter when I arrived on the floor, he was at the nurses’ station, stumbling and screaming to be discharged. He was largely incoherent, unable to reason, and it became clear relatively quickly that he lacked decisional capacity to choose to leave the hospital. During our discussion, though he continued to yell, I remained calm and even-handed about how we were going to care for him. I told him why he was here, sick in the hospital, and I listened to his frustrations about the staff, his room, and the food. The entire encounter, which ended amicably, lasted about 5 minutes. As I left him and returned to the nurses’ station, his nurse came up to me and said, “You handled that so well. How come you didn’t get angry?” And I said “I’ve seen worse. I’m a parent.”

Patient Satisfaction as a Function of Emergency Department Previsit Expectations

This study measures the effect of meeting emergency department (ED) patients' expectations for diagnostic and therapeutic interventions on patient satisfaction. This was a cross-sectional study of consecutive patients during block enrollment periods surveyed at the beginning and end of their ED visits. On arrival patients or their surrogates were surveyed about the specific interventions they expected during their visit. After completion of ED care, they were surveyed about their level of satisfaction with the entire encounter, assessment of their provider's interpersonal skills, impression of time spent waiting in the ED, and perceived waiting time. Satisfaction was assessed with categorical responses. The degree of concordance of interventions expected and interventions provided was analyzed to determine their effect on overall ED visit satisfaction. Nine hundred eighty-seven patients presented during enrollment periods, 821 met inclusion criteria, and complete data were collected on 504 patient encounters. Twenty-nine percent had no previsit expectations of diagnostic or therapeutic interventions, 24% had a single reported expectation, 47% had multiple intervention expectations. After adjusting for potential confounders, we could not demonstrate a relationship between fulfillment of expectations and satisfaction. We did find a very strong relationship between highly ranked provider interpersonal skills and ED satisfaction (probability ratio of being "very satisfied" 8.6; 95% confidence interval 4.7 to 15.6). Other factors associated with high ED encounter satisfaction were adequate explanations for waiting times and perception of total time in the ED. Overall satisfaction was strongly correlated with patient's assessment of the physician's interpersonal skills and was not correlated with whether the physician had met expectations about diagnostic and therapeutic interventions.

The Deep Impact oblique impact cratering experiment

The Deep Impact probe collided with 9P Tempel 1 at an angle of about 30° from the horizontal. This impact angle produced an evolving ejecta flow field very similar to much smaller scale oblique-impact experiments in porous particulate targets in the laboratory. Similar features and phenomena include a decoupled vapor/dust plume at the earliest times, a pronounced downrange bias of the ejecta, an uprange “zone of avoidance” (ZoA), heart-shaped ejecta ray system (cardioid pattern), and a conical (but asymmetric) ejecta curtain. Departures from nominal cratering evolution, however, provide clues on the nature of the impact target. These departures include: fainter than expected flash at first contact, delayed emergence of the self-luminous vapor/dust plume, uprange-directed plume, narrow early-time uprange ray followed by a late-stage uprange plume, persistence of ejecta asymmetries (and the uprange ZoA) throughout the approach sequence, emergence of a downrange ZoA at late times, detachment of uprange curved rays, very long lasting non-radial ejecta rays, and high-angle ejecta plume lasting over the entire encounter. The first second of crater formation most closely resembles the consequences of a highly porous target, while later evolution indicates that the target may be layered as well. Experiments also reveal that impacts into highly porous targets produce a vapor/dust plume directed back up the incoming trajectory. This uprange plume is attributed to cavitation within a narrow penetration funnel. The observed lateral expansion speed of the initial vapor plume downrange provides an estimate for the total vaporized mass equal to ∼ 5 m p (projectile masses) of water ice or 6 m p of CO 2. The downrange plume speed is consistent with the gas expansion added to the downrange horizontal component of the DI probe. Based on high-speed spectroscopy of experimental impacts, the observed delay in brightening of the DI plume may be the result of delayed condensation of carbon, in addition to silicates. Observed molecular species in the initial self-luminous vapor plume likely represent recombination products from completely dissociated target materials. The crater produced by the impact can be estimated from Earth-based observations of total ejected mass to be 130–220 m in diameter. This size range is consistent with a 220 m-diameter circular feature at the point of impact visible in highly processed, deconvolved HRI images. The final crater, however, may resemble an inverted sombrero-hat, with a deep central pit surrounded by a shallow excavation crater. Excavated distal material observed from the Earth was likely from the upper few meters contrasted with ballistic ejecta observed from the DI flyby, which included deep materials (10–30 m) within the diffuse plume above the crater and shallower (5–10 m) materials within the ejecta curtain.

The Deep Impact oblique impact cratering experiment

The Deep Impact probe collided with 9P Tempel 1 at an angle of about 30° from the horizontal. This impact angle produced an evolving ejecta flow field very similar to much smaller scale oblique-impact experiments in porous particulate targets in the laboratory. Similar features and phenomena include a decoupled vapor/dust plume at the earliest times, a pronounced downrange bias of the ejecta, an uprange “zone of avoidance” (ZoA), heart-shaped ejecta ray system (cardioid pattern), and a conical (but asymmetric) ejecta curtain. Departures from nominal cratering evolution, however, provide clues on the nature of the impact target. These departures include: fainter than expected flash at first contact, delayed emergence of the self-luminous vapor/dust plume, uprange-directed plume, narrow early-time uprange ray followed by a late-stage uprange plume, persistence of ejecta asymmetries (and the uprange ZoA) throughout the approach sequence, emergence of a downrange ZoA at late times, detachment of uprange curved rays, very long lasting non-radial ejecta rays, and high-angle ejecta plume lasting over the entire encounter. The first second of crater formation most closely resembles the consequences of a highly porous target, while later evolution indicates that the target may be layered as well. Experiments also reveal that impacts into highly porous targets produce a vapor/dust plume directed back up the incoming trajectory. This uprange plume is attributed to cavitation within a narrow penetration funnel. The observed lateral expansion speed of the initial vapor plume downrange provides an estimate for the total vaporized mass equal to ∼ 5 m p (projectile masses) of water ice or 6 m p of CO 2. The downrange plume speed is consistent with the gas expansion added to the downrange horizontal component of the DI probe. Based on high-speed spectroscopy of experimental impacts, the observed delay in brightening of the DI plume may be the result of delayed condensation of carbon, in addition to silicates. Observed molecular species in the initial self-luminous vapor plume likely represent recombination products from completely dissociated target materials. The crater produced by the impact can be estimated from Earth-based observations of total ejected mass to be 130–220 m in diameter. This size range is consistent with a 220 m-diameter circular feature at the point of impact visible in highly processed, deconvolved HRI images. The final crater, however, may resemble an inverted sombrero-hat, with a deep central pit surrounded by a shallow excavation crater. Excavated distal material observed from the Earth was likely from the upper few meters contrasted with ballistic ejecta observed from the DI flyby, which included deep materials (10–30 m) within the diffuse plume above the crater and shallower (5–10 m) materials within the ejecta curtain.

Superior student chart notes challenge Medicare documentation policies.

Superior student chart notes challenge Medicare documentation policies.

The Fertilization Dance: A Mechanical View of the Egg Rotation During the Initial Spermatozoa–Ovum Interaction

The motion of the ovum and the spermatozoa toward each other in the oviduct culminates in a meeting that ultimately results in fertilization. This encounter is characterized by a slow rotation of the sperms–egg cluster while the sperms attempt a penetration. The mysterious rotation was observed in vivo and in vitro for homologous and heterologous systems. It lacks a satisfactory biological explanation while it seems to be correlated with the efficiency of fertilization. A simple bio-mechanical model presented here predicts that the slow rotation of the sperms–egg cluster is a natural consequence of the encounter in most cases. A linear stability analysis of the system suggests a quantitative explanation of the rotation causes, its intensity and its direction. The entire encounter seems as a micro-scale process of courting of the ovum by the spermatozoa, which is expressed as circular dance.