Number Of Previous Visits Research Articles

Prediction of Antibiotic Resistance in Patients With a Urinary Tract Infection: Algorithm Development and Validation.

The early prediction of antibiotic resistance in patients with a urinary tract infection (UTI) is important to guide appropriate antibiotic therapy selection. In this study, we aimed to predict antibiotic resistance in patients with a UTI. Additionally, we aimed to interpret the machine learning models we developed. The electronic medical records of patients who were admitted to Yongin Severance Hospital, South Korea were used. A total of 71 features extracted from patients' admission, diagnosis, prescription, and microbiology records were used for classification. UTI pathogens were classified as either sensitive or resistant to cephalosporin, piperacillin-tazobactam (TZP), carbapenem, trimethoprim-sulfamethoxazole (TMP-SMX), and fluoroquinolone. To analyze how each variable contributed to the machine learning model's predictions of antibiotic resistance, we used the Shapley Additive Explanations method. Finally, a prototype machine learning-based clinical decision support system was proposed to provide clinicians the resistance probabilities for each antibiotic. The data set included 3535, 737, 708, 1582, and 1365 samples for cephalosporin, TZP, TMP-SMX, fluoroquinolone, and carbapenem resistance prediction models, respectively. The area under the receiver operating characteristic curve values of the random forest models were 0.777 (95% CI 0.775-0.779), 0.864 (95% CI 0.862-0.867), 0.877 (95% CI 0.874-0.880), 0.881 (95% CI 0.879-0.882), and 0.884 (95% CI 0.884-0.885) in the training set and 0.638 (95% CI 0.635-0.642), 0.630 (95% CI 0.626-0.634), 0.665 (95% CI 0.659-0.671), 0.670 (95% CI 0.666-0.673), and 0.721 (95% CI 0.718-0.724) in the test set for predicting resistance to cephalosporin, TZP, carbapenem, TMP-SMX, and fluoroquinolone, respectively. The number of previous visits, first culture after admission, chronic lower respiratory diseases, administration of drugs before infection, and exposure time to these drugs were found to be important variables for predicting antibiotic resistance. The study results demonstrated the potential of machine learning to predict antibiotic resistance in patients with a UTI. Machine learning can assist clinicians in making decisions regarding the selection of appropriate antibiotic therapy in patients with a UTI.

Identifying the Key Hazards behind Website Drop-Offs by Solving a Survival Problem

Within the modern era, corporates are compelled to own an appealing and effective website to survive and thrive within the competitive global digital marketplace. Whilst there are several web metrics to focus on, a key focus area of web analytics is the level of drop-offs. The drop-off rate represents the proportion of visitors that prematurely drop-off a website. Whilst the exact reason behind the drop-off may only be assumed (could be due to the loss of Internet connectivity or dis-interest), this study attempted to identify the triggers behind website drop-offs through a survival problem. Each person entering the website, at a given instance, can view any number of web pages (such as home, contact us, about us, etc.). However, on the studied website, roughly one in five visitors have prematurely dropped-off. The study was conducted on an engineering corporate website with the data collected via the Google Analytics tracking tool. The aim was to determine the key hazards that contributed to the observed drop-off rate through the use of a cox proportional hazard model and a survival random forest model. On the studied website, based on empirical evidence, the online visitors were censored so that those who viewed three or more webpages within the visit were labelled as ‘survived’. Visitors who viewed two or less webpages before leaving the website were labelled as ‘did not survive’. Thereby, the ‘did not survive’ observations represented the visits that prematurely dropped off the website. Using the visitor’s physical and behavioral characteristics, as tracked by Google Analytics, the cox-proportional hazard and survival random forest models were employed to determine the hazards that influence survival. Visitor’s physical characteristics include the device used to access the website, geolocation at the time of the visit, number of previous visits, etc., whilst the behavioral characteristics include the landing page on website, level of engagement, whether entry into the website originated through an organic search or not. Whilst both models have identified similar features as being key hazards, the survival random forest model has been shown to out-perform on the non-linear features relative to the cox proportional hazard model and obtained a higher classification accuracy. During the validation process, the survival random forest model (63%) outperformed the cox model (58%) on classification accuracy. The features that were identified as hazardous indicated that some webpages needed further attention, the visitor’s level of engagement with the website (the degree of scrolling and clicks), the distance between a visitor’s location and the studied corporate’s location, the historic frequency of visiting the website, and if the website entry point was through an organic search. Whilst the study of drop-offs has been a commonly researched problem, this study details the investigation of key hazards through the use of survival models and compares the outcomes of a regression-based model to a machine learning survival model.

Does Camera Type Affect Patient Comfort? An Analysis of Patient Opinions of Office Photography

Purpose: Photography is an essential part to plastic surgery in terms of procedural planning and documentation. With the increasing quality of commercially available digital cameras, an investigation of the effect of camera type on patient perception of the office visit is necessary. Therefore, we aim to investigate the impact of using a traditional DSLR style camera versus a smartphone in office-based patient photography. Method: A Likert scale survey was completed by patients following office visits to assess comfort with office photography. Key points included: sex, age, number of previous visits, comfort with photographic experience, and camera type used. Results: 100 patients (78 F, 21 M) were included; 47 had photographs taken with a DSLR camera and 52 had photos taken with a smartphone. The mean decade of cohort age was 40 to 49 years old. No statistical difference in patient comfort between DSLR camera and smartphone use was observed (4.71 ± 0.72 vs 4.64 ± 0.57, P: .58). When data was stratified by sex or number of previous visits, there was still no difference in comfort across camera types. There was no significant main effect of age on comfort level ( P = .109); However, a post-hoc Tukey’s analysis showed significant comfort differences between the <18 and 18-29 subgroups and the <18 and 60 to 69 subgroups ( P = .040 and P = .041 respectively). Conclusion: Patients were overall equally comfortable with their photographic experience when providers used either camera. Smartphone cameras, therefore, should be regarded as a suitable alternative for office use without fear of invoking negative perceptions in patients.

Study on Peak Travel Avoidance Behavior of Car Travelers during Holidays

Traveling during off-peak season can mean cheaper flights, cheaper hotels, and the chance to see a destination at a less frenetic time of year. To alleviate the congestion of roads and tourist attractions, a better demand management plan is needed to guide tourists to avoid travel during holidays. This study takes holiday tourists’ peak travel avoidance behavior as the research object, and a Nested Logit (NL) model of travel time and destination joint decisions was established based on Utility Maximization Theory. Model calibration and elastic analysis were carried out using Revealed Preference/Stated Preference (RP/SP) survey data. Results show that tourist attributes such as the number of tourists traveling together, travel companion, duration of the visit, the number of previous visits, tourism motivation, type of tourist attraction, quality grade of tourist attraction, and degree of congestion significantly influence destination decisions. Travel scope, travel duration, age, and other factors significantly influence travel time decisions. The traffic congestion around tourist attractions, holiday admission ticket prices, and non-holiday admission ticket prices significantly influence travel time and destination decisions. Holiday admission ticket price increases have a strong impact on the decision to change the travel destination, while non-holiday admission ticket discounts have a weak impact on travel time decision behavior. The findings of this study offer a theoretical basis for holiday travel management and tourism management. It is practical and significant to reasonably guide tourists to travel during the off-peak season and to understand the travel needs and characteristics of holiday tourists, thus adjusting the distribution of holiday tourist flow.

Translation and cultural adaptation of a romanian version of the communication assessment tool (CAT_Ro)

BackgroundThe communication between health providers and patients influences the quality of medical care. The Communication Skills Assessment (CAT) is a reliable, validated tool, which was developed to assess interpersonal communication skills between physicians and patients. The purpose of this study was to obtain a Romanian version of the CAT (CAT_Ro), using a controlled and systematic process to translate and cross-culturally adapt the original questionnaire, since there are no validated instruments to assess healthcare professionals’ communication capability in Romania.MethodsThe study was conducted in two Departments of Internal Medicine and Rheumatology from Bucharest, Romania, using a rigorous scientific methodology for the translation process, according to literature recommendations, implicating conceptual evaluation, semantics, and cultural adaptation, which involved several steps. The updated version was pre-tested in a pilot study, which included 89 outpatients.ResultsThe results showed a narrow range of variability in item interpretation, without differences in patients’ responses according to variables such as age, gender, education, disease type, number of previous visits with the same doctor.ConclusionCAT-Ro is the result of a comprehensive process study. It represents the first translation and cultural adaptation in Romanian of an instrument able to assess the health providers’ communication skills, which was validated in a pilot study and is to be used in more extensive studies with patients from several specialties.

In-water observations highlight the effects of provisioning on whale shark behaviour at the world's largest whale shark tourism destination.

The whale shark is the world's largest fish that forms predictable aggregations across its range, many of which support tourism industries. The largest non-captive provisioned whale shark destination globally is at Oslob, Philippines, where more than 500 000 tourists visit yearly. There, the sharks are provisioned daily, year-round, allowing the human–shark interaction in nearshore waters. We used in-water behavioural observations of whale sharks between 2015 and 2017 to understand the relationship between external stimuli and shark behaviour, whether frequency of visits at the site can act as a predictor of behaviour, and the tourist compliance to the code of conduct. Mixed effects models revealed that the number of previous visits at the site was a strong predictor of whale shark behaviour, and that provisioned sharks were less likely to exhibit avoidance. Compliance was poor, with 93% of surveys having people less than 2 m from the animal, highlighting overcrowding of whale sharks at Oslob. Given the behavioural implications to whale sharks highlighted here and the local community's reliance on the tourism industry, it is imperative to improve management strategies to increase tourist compliance and strive for sustainable tourism practices.

Reason To Exercise In Diabetic Populations: Use Of Rapid-acting Insulin Predicts Falls In At-risk Patients

Diabetes is present in 9.4% of American adults. Insulin is used in Type 1 and Type 2 cases, but without lifestyle change, it can hasten the progression of the disease. Limited data supports an association between diabetes and fall risk in older adults, with greater risk found among insulin-treated patients. Little is known about different insulin classes. PURPOSE: To evaluate the effect of insulin classes on incidence of falls in older adults. METHODS: We conducted retrospective and prospective analyses of 615 hospital patients age ≥65 years who sustained a fall in 2015. Data was extracted from their first fall-related admission that year, including demographic reports, health history, injury characteristics, relevant diagnoses, and home medications. We exported the number of previous falls since 2010 and used logistic and Poisson regressions to test the effect of insulin on the odds of experiencing falls and the total number experienced. We then tracked patients forward until August 2016 and tested the effect of insulin on return visits for new fall-related admissions. RESULTS: Patients were 80.0±9.1 years old, 6.2% used long-acting insulin, 0.5% used intermediate insulin, and 4.2% used rapid-acting insulin. They were admitted 1.9±1.3 times previously and had 0.5±0.9 return visits. There was no relationship with intermediate insulin and the number of previous (P=0.223) or future (P=0.383) falls. Long-acting insulin associated with modest increases in the number of previous (P=0.053) and return (P=0.050) falls. Rapid-acting insulin significantly predicted both. Controlling for weather, age, balance, and cognitive condition, patients using rapid-acting insulin had a 4.2-fold increase in the odds of sustaining multiple previous falls (P=0.002; 95% CI of odds ratio=1.68-10.54), a 37.2% increase in the number of previous visits (P=0.012; 95% CI of IRR: 1.07-1.76), a 2.4-fold increase in the odds of readmission (P=0.033; 95% CI of odds ratio: 1.07-5.50), and a 64.3% increase in the number of return visits (P=0.026; 95% CI of IRR: 1.06-2.54). CONCLUSIONS: Diabetics taking rapid-acting insulin express an elevated risk of falls. Exercise may serve two functions in this population: it can mitigate the acute and chronic effects of diabetes via non-insulin dependent glucose uptake, and it can protect against fall risk.

Deferral rate variability in blood donor eligibility assessment.

BACKGROUNDBoth donors and the blood bank rely on the result of the donor health interview. However, survey data suggest that substantial variability in deferral rates among interviewers exist. We studied whether variability remained after adjusting for conditional factors.STUDY DESIGN AND METHODSThe data set included Dutch interview data on whole blood donor visits in 2015, where one of their visits was selected randomly. We applied logistic regression and multilevel regression analyses with the donor visit, with the interviewer representing the levels. We set up four models: 1) all reasons deferral, 2) low‐hemoglobin‐level deferral, 3) infectious disease risk deferral and 4) other medical reasons deferral.RESULTSIn total, 138,398 visits were included in the study, of which 60,534 (43.7%) related to male donors. The overall deferral rate for men was 7.91% and for women 12.25%. Deferral rates among interviewers ranged from as low as 1.19% up to 28.8%. Models 2 (low hemoglobin level) and particularly 4 (other medical reasons), for both men and women, showed significant intraclass correlation coefficients, implying considerable deferral rate variability among interviewers. Donor age, the number of previous visits, and the season had relatively large effects. However, explained variances of the logistic regression models were relatively low, ranging from 2.53% to 7.35%.CONCLUSIONDeferral appears to be a random process, while substantial variability was found among interviewer deferral rates, suggesting that some interviewers are more cautious than others. Our results suggest heuristic and subjective diagnosing to be prevalent. Steps should be taken to improve interview result validity.

Why do They Come Back? The Effects of Winery Tourists’ Motivations and Satisfaction on the Number of Visits and Revisit Intentions

ABSTRACT Few studies have examined the influence of winery tourists’ motivations and satisfaction on number of visits and revisit intentions. This study examined these relationships through 1602 online survey responses from former winery visitors. The data were analyzed through a series of multiple regression analyses. Findings show that among tourists’ motivations, the reputation, reviews, and perceived quality of the winery and its wines significantly affect the number of visits and revisit intentions, while media exposure affects revisit intentions. Further, visitors’ satisfaction with the winery significantly impacts revisit intentions. While visitors’ geographic proximity to the winery increased the number of visits, as expected, distance from the winery is shown to increase revisit intentions. Finally, the number of previous visits had a significant positive effect on revisit intentions.

The Impact of Customer Relationship Management on Tourist Satisfaction: The Case of Radisson Blue Resort in Aqaba City

Aims: This paper aims at investigating the effects of customer relationship management in terms of tourist attractions and facilities, outlets (F&B), and front office services on tourist satisfaction.
 Design: A total of 136 questionnaires containing 34 items was used to collect information from tourists in Radisson resort in Aqaba city located in Jordan. Multiple regression analysis was conducted to test the research hypotheses.
 Findings: Results of the current study revealed that there is a significant impact of tourist attractions and facilities, and front office services on tourist satisfaction, whereas outlets (F&B), has no significant impact on it. Results of T-test showed that there is no significant difference in the impact of tourist satisfaction that in favor of gender. Also, results of ANOVA test indicated that there is no significant difference in the impact of tourist satisfaction that can be attributed to age, occupation, educational level, the purpose of the visit, holiday booked a date and a number of previous visits.
 Implications: this study will contribute a better understanding of tourist’s satisfaction through proper customer relationship management in terms of tourist facilities, outlets, and front office services.
 Originality: This study is considered the first case study that links tourist satisfaction with the prober management of the hotel facilities and outlets

Flight initiation by Ferruginous Hawks depends on disturbance type, experience, and the anthropogenic landscape.

The expansion of humans and their related infrastructure is increasing the likelihood that wildlife will interact with humans. When disturbed by humans, animals often change their behaviour, which can result in time and energetic costs to that animal. An animal's decision to change behaviour is likely related to the type of disturbance, the individual's past experience with disturbance, and the landscape in which the disturbance occurs. In southern Alberta and Saskatchewan, we quantified probability of flight initiation from the nest by Ferruginous Hawks (Buteo regalis) during approaches to nests by investigators. We tested if probability of flight was related to different disturbance types, previous experience, and the anthropogenic landscape in which individual Ferruginous Hawks nested. Probability of flight was related to the type of approach by the investigator, the number of previous visits by investigators, and the vehicular traffic around the nest. Approaches by humans on foot resulted in a greater probability of flight than those in a vehicle. Approaches in a vehicle via low traffic volume access roads were related to increased probability of flight relative to other road types. The number of previous investigator approaches to the nest increased the probability of flight. Overall, we found support that Ferruginous Hawks show habituation to vehicles and the positive reinforcement hypotheses as probability of flight was negatively related to an index of traffic activity near the nest. Our work emphasizes that complex, dynamic processes drive the decision to initiate flight from the nest, and contributes to the growing body of work explaining how responses to humans vary within species.

Graphical models for estimating network determinants of multi-destination trips in Sicily

This paper proposes a two-step approach for analysing the main determinants of multi-destination trip behaviour. It is based on a combination of graphical models and of a multinomial logistic regression model; the aim is to analyse direct and indirect effects of a wide set of tourist- and trip-related characteristics on multi-destination trip behaviour. Empirical data have been derived from a frontier survey of approximately 4000 incoming tourists in Sicily (Italy) at the end of their trip. Results suggest that multi-destination trips depend directly on the length of stay, the number of previous visits and motivation for the trip, and only indirectly on the interview month, travel party, organization of the trip, and country of origin. The role of other socio-demographic characteristics, such as age or gender is confirmed to be marginal or even irrelevant.

Effectiveness and Cost of a Personalized Reminder Intervention to Improve Adherence to Glaucoma Care.

Glaucoma is the leadi ng cause of irreversible blindness in the USA. Glaucomatous vision loss is preventable with proper eye care, including appointment adherence. Therefore, interventions that improve appointment adherence can reduce the number of patients with more severe glaucoma. The primary study aim was to determine the efficacy and cost-effectiveness of a multifaceted personal reminder intervention, which included a customized letter and personal telephone outreach, in improving appointment adherence of patients with glaucoma. A secondary study aim was to identify patient characteristics that were associated with non-adherence. This prospective, randomized, controlled study included a cost-effectiveness analysis completed using a decision analytic model. The subjects included 256 patients with glaucoma. Study measures included appointment adherence and incremental cost effectiveness ratios. Patients in the intervention group were more likely to adhere to appointments (82.31 vs. 69.05 %; RR 1.23; 95 % CI 1.04-1.37, p < 0.012) than patients in the usual care group. Patients in the intervention group were 23 % more likely to adhere to appointments (RR 1.23; 95 % CI 1.08-1.41, p < 0.0021) than patients in the usual care group, when adjusting for age, secondary insurance, primary open angle glaucoma diagnosis, number of previous visits at Wills Eye Hospital, and follow-up recommendation using Poisson regression. Per-patient cost of the program was US$11.32, and cost per follow-up attended within the adherence window was US$73.56. A low cost reminder intervention consisting of a personalized letter and telephone outreach significantly improved appointment adherence of patients with glaucoma.

Motivations of wine travelers in rural Northeast Iowa

Purpose – The purpose of this exploratory consumer research study was to examine demographic and behavioral characteristics and motivations of wine travelers on the recently established Iowa Wine Trail in rural Northeast Iowa. An array of data on visitor lifestyles, interests, attitudes and values can provide more powerful and actionable research information than demographics alone. Equipped with an understanding of visitor motivations, wineries and vineyards can provide their customers the experience they want and expect, and not products and services they are assumed to desire. Design/methodology/approach – Data for this study were collected using a questionnaire-based survey administered at three participating wineries over the period of April-November 2005. Findings – The demographic profile of visitors on the Iowa Wine Trail falls within a common stereotype of a wine tourist: middle aged (36-55 years old), highly educated (college or postgraduate), in the moderate to high income bracket (higher than the median household income in Iowa), living in close proximity to the Iowa Wine Trail (mostly Iowa residents). The main motives for visiting the wineries were (in order by mean scores) “to taste wine”, “to enjoy the scenery”, “to have a good time with friends and family”, “to relax”, “to support local wine producers”, and “to taste locally produced foods”. This finding supports the statement that wine tourists are often drawn by the whole “local experience package”, and not only by the wine product itself. Research limitations/implications – Findings of this study provide demographic and behavioral characteristics and motivations of wine tourists in rural Northeast Iowa only and should not be generalized to other rural areas. Practical implications – The Iowa Wine Trail attracts typical wine customers, but also younger visitors and females. Rather high incidence of repeat visitors for a trail that is still in its infancy (52 percent), with the mean number of previous visits being 2.64. Importance of word of mouth and eMarketing: over 40 percent of visitors to the Iowa Wine Trail based their choice on word of mouth (to include prior recommendations, suggestions, or reputation), and almost a third of travelers indicated utilizing web sites for information seeking – a number that is higher when compared to other specialized markets in Iowa. The Iowa Wine Trail appeals both to stereotypical wine tourists and those visitors who are not primarily involved with the wine product but nonetheless still visit wineries. Power of rural ambience and appeal of the Iowa landscape: while wine tasting appeared to be the main motive of visiting the wineries, scenery and landscape of the Upper Mississippi River, along with the opportunity to enjoy time with friends and family and taste local foods, scored similarly high. Originality/value – While demographic characteristics of wine tourists have been explored, few studies focused on visitor motivations. In addition, most of wine tourism research has focused on established and functioning wine regions/appellations. Not much is known about the emerging wine culture in rural Midwestern states embracing opportunities of wine and tourism development, en route to diversification from traditional agriculture.

Capitated Payments to Primary Care Providers and the Delivery of Patient Education

Patient education is a critical component of the patient-centered medical home and is a powerful and effective tool in chronic disease management. However, little is known about the effect of practice payment on rates of patient education during office encounters. For this study we took data from the 2009 National Ambulatory Medical Care Survey. This was a cross-sectional analysis of patient visits to primary care providers to determine whether practice payment in the form of capitated payments is associated within patient education being included more frequently during office visits compared with other payment methods. In a sample size of 9863 visits in which capitation status was available and the provider was the patient's primary care provider, the weighted percentages of visits including patient education were measured as a percentages of education (95% confidence intervals): <25% capitation, 42.7% (38.3-47.3); 26% to 50% capitation, 37.6% (23.5-54.2); 51% to 75% capitation, 38.4% (28.1-49.8); >75% capitation, 74.0% (52.2-88.1). In an adjusted logistic model controlling for new patients (yes/no), number of chronic conditions, number of medications managed, number of previous visits within the year, and age and sex of the patients, the odds of receiving education were reported as odds ratios (95% confidence intervals): <25% capitation, 1.00 (1.00-1.00); 26% to 50% capitation, 0.77 (0.38-1.58); 51% to 75% capitation, 0.81 (0.53-1.25); and >75% capitation, 3.38 (1.23-9.30). Patients are more likely to receive education if their primary care providers receive primarily capitated payment. This association is generally important for health policymakers constructing payment strategies for patient populations who would most benefit from interventions that incorporate or depend on patient education, such as populations requiring management of chronic diseases.

Effect of patient and patient–oncologist relationship characteristics on communication about health‐related quality of life

To test the effects of patient and patient-oncologist relationship factors on the time spent communicating about health-related quality of life (HRQOL) during outpatient clinic encounters between oncologists and their patients with advanced cancer. Using mixed methods, we coded for duration of HRQOL talk in a subset of audio-recorded conversations from the Study of Communication in Oncologist-Patient Encounters (SCOPE) Trial. Multivariable linear regression modeling was used to investigate the relationship between duration of HRQOL talk and gender concordance, race concordance, patient education status, patient marital status, and length of the patient-oncologist relationship (i.e. number of previous visits). Sixty-six encounters were analyzed that involved 63 patients and 34 oncologists. Patients were more likely to be female (51%), white (86%), married (78%), and possess a college or more advanced degree (33%). Most oncologists were male (82%) and white (82%). Mean ages were 58.8 years for patients and 44.9 years for oncologists. Regression results showed that the number of a patient's previous visits with their oncologist was significantly associated with a longer duration of HRQOL talk during their audio-recorded clinic visit. The remaining independent variables, gender concordance, race concordance, patient education status, and patient marital status were not significant predictors of duration of HRQOL talk. Our findings suggest that length of the patient-oncologist relationship is related to duration of HRQOL talk. Improvements in HRQOL communication may best be achieved through efforts directed at those in earlier stages of the doctor-patient relationship.

Analysing the effect of satisfaction and previous visits on tourist intentions to return

PurposeThe purpose of this paper is to analyse the determinants of tourist intentions to revisit a destination, paying special attention to the effects of satisfaction and the number of previous visits. In order to guarantee an incentive to improve the product, satisfaction must be the main determinant. A second objective is to analyse the contribution that satisfaction with different aspects of a destination makes on overall satisfaction.Design/methodology/approachA structural equation model (SEM) has been estimated. Some of the variables involved in the model are ordinal. Thus, tetrachoric, polychoric and polyserial correlations were calculated and then used as the input for structural equation modelling.FindingsBoth satisfaction and the number of previous visits have a positive effect on intention to return. However, the main determinant is satisfaction. Satisfaction with different aspects of the destination has a differing effect on overall satisfaction. Attributes associated with the basic sun and sand tourist product are the main determinants of overall satisfaction.Practical implicationsTo promote repeat visits, it is crucial to identify the determinants of the intention to return. The factors that influence this variable can be improved in order to increase the likelihood of repeat visits.Originality/valueMethods to estimate SEM with categorical variables have not been applied before to the field of tourism. In comparison with previous studies of repeat visitation, the main contribution of the model is that it simultaneously takes into consideration two causal links with the number of previous visits, the first affecting overall satisfaction and the second having a direct effect on a tourist's intention to return.

Influence of feeding flavouring-appetizing substances on activity of cows in an automatic milking system

Cow behaviour and milk production were evaluated depending on the presence or absence of flavouring and appetizing substances in the diet. Fifty-two Italian Friesian cows were blocked according to parity, DIM, milk yield and average number of previous visits during a two-week period before the start of the trial and divided into two groups. The experimental design was a change over, with two groups and two periods lasting four weeks. The compared treatments were: concentrate with addition of flavouring and appetizing substances (FAS) or without (C). Each experimental group including low (L) (<21 kg/d), mid (M) (21-28 kg/d), and high (H) (>28 kg/d) yielding cows at which were offered 1.5, 2.5, 3.5 kg/d of concentrate, respectively, in the automatic milking system (AMS) throughout the experiment. The cows generally consumed all the distributed FAS or C concentrate. The experiment showed that cow’s behaviour was modified through the use of a appetizing component of the concentrate fed in the automatic dispenser of the AMS. Cows fed FAS concentrate increased the weekly visits without milking and milking frequency and decreased milking interval. Moreover, the use of the FAS concentrate reduced the number of milkings with intervals >11 hours by 5%. The greater milk yield of cows fed FAS could be a consequence of behaviour shift.

Discussion of Maternal Stress During Pediatric Primary Care Visits

To determine whether the discussion of maternal stress in pediatric primary care is associated with the mother's satisfaction with her child's provider. Children ages 5-16 and their mothers (N=747) were recruited from the waiting rooms of 13 geographically diverse pediatric primary care sites from 2002 to 2005. Directly after the visit, the mother reported her satisfaction with the attention that the provider gave to her and her child's problems and also reported whether the provider understood the problems that she wanted to discuss during the visit. The mother also reported whether the visit included discussion of her "stresses and strains" and the discussion of child mood or behavior. Thirty-five percent of mothers discussed their stresses and strains with their child's provider. The mother was more likely to be "completely" satisfied with the attention that she and her child received from the provider (odds ratio [OR] 2.43, 95% confidence interval [95% CI], 1.43-4.11) and to agree "strongly" that the provider understood the problems she wanted to discuss (OR 1.95, 95% CI, 1.32-2.93) when the visit included the discussion of maternal stress after controlling for the reason for the visit, number of previous visits, provider specialty (family practice or pediatrics), youth mental health status, whether the visit included the discussion of child mood or behavior, and maternal distress measured with a standard screening tool. The mother was more satisfied with her child's primary care provider when maternal stress was discussed during the visit. This finding should somewhat alleviate fears that mothers will react negatively to discussion of their stress during pediatric visits.

Trombocitosis en la consulta de oncohematología. Descripción, diagnóstico etiológico y evolución

Thrombocytosis is a common cause of patient referral to a paediatric haematologist specialist which requires a significant number of laboratory tests and visits to confirm the diagnosis. The aim of our study has been to analyse the characteristics of patients referred to our centre for specialised thrombocytosis assessment. Based on this assessment we established the criteria patients must fulfil to be recommend for further hospital study. We categorised the 33 patients referred for thrombocytosis assessment according to sex, age, origin, personal and family history, platelet count at diagnosis and the reason why the red and white blood count at diagnosis (Haemoglobin, mean corpuscular volume, mean corpuscular haemoglobin, leukocyte, neutrophils, lymphocyte and monocyte count), maximum platelet count during follow-up and other complementary examinations were done. The final diagnosis itself and number of previous visits before were also considered. The classification used to grade thrombocytosis was: low (500-700 X 10(3)/microl), mild (700-900 x 10(3)/microl), severe (900-1.000 x 10(3)/microl) and extreme (> 1.000 x 10(3)/microl). There was no predominance of males or females. 45 % of patients were under 2 years old and 55 % of them came from their primary care centre. The mean platelet count at the first medical visit was 669,000 (mild thrombocytosis). During follow-up, 24 % of the patients reached extreme platelets levels. In 28 % the initial blood count was performed because of an infection. The most frequently requested laboratory test was iron metabolism (82 % of the cases). All cases correspond to secondary thrombocytosis (48 % were reactive to infections, 24 % secondary to iron deficiency, and 15 % were associated to both causes). The mean number of visits before hospital discharge was 5.12. The finding of thrombocytosis in the majority of the cases studied was casual or in the context of an infectious process. Most of the thrombocytosis were mild. Due to the extremely low incidence of primary thrombocytosis in childhood and the fact that diagnosis is made by exclusion of other possibilities, the initial study of these patients should be done in primary care centres. The first conditions to be ruled out are infectious, inflammatory or bleeding processes. Once these causes are excluded, the most useful complementary test is to measure iron level given the relation between iron deficiency and thrombocytosis. Once these causes are ruled out and thrombocytosis persists, it would then be indicated to refer the patient to a paediatric oncology-haematology department for a more exhaustive follow-up.