Effectiveness of an emergency nurse practitioner service for adults presenting to rural hospitals with chest pain : Protocol for a multicentre, longitudinal nested cohort study

Introduction Chest pain is common in emergency department (ED) patients and represents a considerable burden for rural health services. Health services reforms to improve access to care need appropriately skilled and supported clinicians in the delivery of safe and effective care, including the use of emergency nurse practitioners (ENPs). Despite increasing use of ENPs, little is known about the safety and quality of the service in the rural ED context. The aims of this study are (1) to examine the safety and quality of the ENP service model in the provision of care in the rural environment and (2) to evaluate the effectiveness of the service in the management of patients presenting with undifferentiated chest pain. Methods and analysis This is the protocol for a prospective longitudinal nested cohort study to compare the effectiveness of ENP service with that of standard care. Adults presenting to three rural EDs in Queensland, Australia with a primary presenting complaint of atraumatic chest pain will be eligible for enrolment. We will measure (1) clinician's use of evidence-based guidelines (2) diagnostic accuracy of ECG interpretation for the management of patients with suspected or confirmed ACS (3) service indicators of waiting times, length-of-stay and did-not-wait rates and (4) clinician's diagnostic accuracy as measured by rates of unplanned representation within 7 days (5) satisfaction with care, (6) quality-of-life and (7) functional status. To assess these outcomes we will use a combination of measures collected from routinely collected data, medical record review and questionnaires (with 30-day follow-up). Ethics and dissemination Queensland Health Human Research Ethics Committee (HREC) has approved this protocol. The results will be published in peer-reviewed scientific journals and presented at one or more scientific conferences.

Multi-action recognition via stochastic modelling of optical flow and gradients

In this paper we propose a novel approach to multi-action recognition that performs joint segmentation and classification. This approach models each action using a Gaussian mixture using robust low-dimensional action features. Segmentation is achieved by performing classification on overlapping temporal windows, which are then merged to produce the final result. This approach is considerably less complicated than previous methods which use dynamic programming or computationally expensive hidden Markov models (HMMs). Initial experiments on a stitched version of the KTH dataset show that the proposed approach achieves an accuracy of 78.3%, outperforming a recent HMM-based approach which obtained 71.2%.

Prediction of GMA welding characteristic parameter by artificial neural network system

Nowadays, demand for automated Gas metal arc welding (GMAW) is growing and consequently need for intelligent systems is increased to ensure the accuracy of the procedure. To date, welding pool geometry has been the most used factor in quality assessment of intelligent welding systems. But, it has recently been found that Mahalanobis Distance (MD) not only can be used for this purpose but also is more efficient. In the present paper, Artificial Neural Networks (ANN) has been used for prediction of MD parameter. However, advantages and disadvantages of other methods have been discussed. The Levenberg–Marquardt algorithm was found to be the most effective algorithm for GMAW process. It is known that the number of neurons plays an important role in optimal network design. In this work, using trial and error method, it has been found that 30 is the optimal number of neurons. The model has been investigated with different number of layers in Multilayer Perceptron (MLP) architecture and has been shown that for the aim of this work the optimal result is obtained when using MLP with one layer. Robustness of the system has been evaluated by adding noise into the input data and studying the effect of the noise in prediction capability of the network. The experiments for this study were conducted in an automated GMAW setup that was integrated with data acquisition system and prepared in a laboratory for welding of steel plate with 12 mm in thickness. The accuracy of the network was evaluated by Root Mean Squared (RMS) error between the measured and the estimated values. The low error value (about 0.008) reflects the good accuracy of the model. Also the comparison of the predicted results by ANN and the test data set showed very good agreement that reveals the predictive power of the model. Therefore, the ANN model offered in here for GMA welding process can be used effectively for prediction goals.

Behaviour of LSF floor systems with improved joist sections under fire conditions

Fire safety design of buildings is essential to safeguard lives and minimize the loss of damage to properties. Light-weight cold-formed steel channel sections along with fire resistive plasterboards are used to construct light gauge steel frame floor systems to provide the required fire resistance rating. However, simply adding more plasterboard layers is not an efficient method to increase FRR. Hence this research focuses on using joists with improved joist section profiles such as hollow flange sections to increase the structural capacity of floor systems under fire conditions and thus their FRR. In this research, the structural and thermal behaviour of LSF floor systems made of LiteSteel Beams with different plasterboard and insulation configurations was investigated using four full scale tests under standard fires. Based on the ultimate failure load of the floor joist at ambient temperature, transient state fire tests were conducted for different Load Ratios. These fire tests showed that the new LSF floor system has improved the FRR well above that of those made of lipped channel sections. The joist failure was predominantly due to local buckling of LSB compression flanges near mid-span with severe yielding of tension flanges. Fire tests have provided valuable structural and thermal performance data of tested floor systems that included time-temperature profiles, and failure times and temperatures. Average failure temperatures of LSB joists and reduced yield strengths were used to predict their ultimate moment capacities, which were compared with corresponding test capacities. This allowed an assessment in relation to the accuracy of current design rules for steel joists at elevated temperatures. This paper presents the details of full scale fire tests of LSF floor systems made of LSB joists with different plasterboard and insulation configurations and their results along with some important findings.

Experimental studies of cold-formed steel hollow section columns at elevated temperatures

This paper reports the details of an experimental study of cold-formed steel hollow section columns at ambient and elevated temperatures. In this study the global buckling behaviour of cold-formed Square Hollow Section (SHS) slender columns under axial compression was investigated at various uniform elevated temperatures up to 700℃. The results of these column tests are reported in this paper, which include the buckling/failure modes at elevated temperatures, and ultimate load versus temperature curves. Finite element models of tested columns were also developed and their behaviour and ultimate capacities at ambient and elevated temperatures were studied. Fire design rules given in European and American standards including the Direct Strength Method (DSM) based design rules were used to predict the ultimate capacities of tested columns at elevated temperatures. Elevated temperature mechanical properties and stress-strain models given in European steel design standards and past researches were used with design rules and finite element models to investigate their effects on SHS column capacities. Comparisons of column capacities from tests and finite element analyses with those predicted by current design rules were used to determine the accuracy of currently available column design rules in predicting the capacities of SHS columns at elevated temperatures and the need to use appropriate elevated temperature material stress-strain models. This paper presents the important findings derived from the comparisons of these column capacities.

Frequency of convergence and accommodative disorders in a clinical population of Mashhad, Iran

Purpose To investigate the frequency of convergence and accommodation anomalies in an optometric clinical setting in Mashhad, Iran, and to determine tests with highest accuracy in diagnosing these anomalies. Methods From 261 patients who came to the optometric clinics of Mashhad University of Medical Sciences during a month, 83 of them were included in the study based on the inclusion criteria. Near point of convergence (NPC), near and distance heterophoria, monocular and binocular accommodative facility (MAF and BAF, respectively), lag of accommodation, positive and negative fusional vergences (PFV and NFV, respectively), AC/A ratio, relative accommodation, and amplitude of accommodation (AA) were measured to diagnose the convergence and accommodation anomalies. The results were also compared between symptomatic and asymptomatic patients. The accuracy of these tests was explored using sensitivity (S), specificity (Sp), and positive and negative likelihood ratios (LR+, LR−). Results Mean age of the patients was 21.3 ± 3.5 years and 14.5% of them had specific binocular and accommodative symptoms. Convergence and accommodative anomalies were found in 19.3% of the patients; accommodative excess (4.8%) and convergence insufficiency (3.6%) were the most common accommodative and convergence disorders, respectively. Symptomatic patients showed lower values for BAF (p = .003), MAF (p = .001), as well as AA (p = .001) compared with asymptomatic patients. Moreover, BAF (S = 75%, Sp = 62%) and MAF (S = 62%, Sp = 89%) were the most accurate tests for detecting accommodative and convergence disorders in terms of both sensitivity and specificity. Conclusions Convergence and accommodative anomalies are the most common binocular disorders in optometric patients. Including tests of monocular and binocular accommodative facility in routine eye examinations as accurate tests to diagnose these anomalies requires further investigation.

Copula-based spatial modelling of geometallurgical variables

The most important aspect of modelling a geological variable, such as metal grade, is the spatial correlation. Spatial correlation describes the relationship between realisations of a geological variable sampled at different locations. Any method for spatially modelling such a variable should be capable of accurately estimating the true spatial correlation. Conventional kriged models are the most commonly used in mining for estimating grade or other variables at unsampled locations, and these models use the variogram or covariance function to model the spatial correlations in the process of estimation. However, this usage assumes the relationships of the observations of the variable of interest at nearby locations are only influenced by the vector distance between the locations. This means that these models assume linear spatial correlation of grade. In reality, the relationship with an observation of grade at a nearby location may be influenced by both distance between the locations and the value of the observations (ie non-linear spatial correlation, such as may exist for variables of interest in geometallurgy). Hence this may lead to inaccurate estimation of the ore reserve if a kriged model is used for estimating grade of unsampled locations when nonlinear spatial correlation is present. Copula-based methods, which are widely used in financial and actuarial modelling to quantify the non-linear dependence structures, may offer a solution. This method was introduced by Bárdossy and Li (2008) to geostatistical modelling to quantify the non-linear spatial dependence structure in a groundwater quality measurement network. Their copula-based spatial modelling is applied in this research paper to estimate the grade of 3D blocks. Furthermore, real-world mining data is used to validate this model. These copula-based grade estimates are compared with the results of conventional ordinary and lognormal kriging to present the reliability of this method.

Application of higher-order spectra for automated grading of diabetic maculopathy

Diabetic macular edema (DME) is one of the most common causes of visual loss among diabetes mellitus patients. Early detection and successive treatment may improve the visual acuity. DME is mainly graded into non-clinically significant macular edema (NCSME) and clinically significant macular edema according to the location of hard exudates in the macula region. DME can be identified by manual examination of fundus images. It is laborious and resource intensive. Hence, in this work, automated grading of DME is proposed using higher-order spectra (HOS) of Radon transform projections of the fundus images. We have used third-order cumulants and bispectrum magnitude, in this work, as features, and compared their performance. They can capture subtle changes in the fundus image. Spectral regression discriminant analysis (SRDA) reduces feature dimension, and minimum redundancy maximum relevance method is used to rank the significant SRDA components. Ranked features are fed to various supervised classifiers, viz. Naive Bayes, AdaBoost and support vector machine, to discriminate No DME, NCSME and clinically significant macular edema classes. The performance of our system is evaluated using the publicly available MESSIDOR dataset (300 images) and also verified with a local dataset (300 images). Our results show that HOS cumulants and bispectrum magnitude obtained an average accuracy of 95.56 and 94.39 % for MESSIDOR dataset and 95.93 and 93.33 % for local dataset, respectively.

Utility of assessing nerve morphology in central cornea versus whorl area for diagnosing diabetic peripheral neuropathy

Purpose To compare small nerve fiber damage in the central cornea and whorl area in participants with diabetic peripheral neuropathy (DPN) and to examine the accuracy of evaluating these 2 anatomical sites for the diagnosis of DPN. Methods A cohort of 187 participants (107 with type 1 diabetes and 80 controls) was enrolled. The neuropathy disability score (NDS) was used for the identification of DPN. The corneal nerve fiber length at the central cornea (CNFLcenter) and whorl (CNFLwhorl) was quantified using corneal confocal microscopy and a fully automated morphometric technique and compared according to the DPN status. Receiver operating characteristic analyses were used to compare the accuracy of the 2 corneal locations for the diagnosis of DPN. Results CNFLcenter and CNFLwhorl were able to differentiate all 3 groups (diabetic participants with and without DPN and controls) (P < 0.001). There was a weak but significant linear relationship for CNFLcenter and CNFLwhorl versus NDS (P < 0.001); however, the corneal location x NDS interaction was not statistically significant (P = 0.17). The area under the receiver operating characteristic curve was similar for CNFLcenter and CNFLwhorl (0.76 and 0.77, respectively, P = 0.98). The sensitivity and specificity of the cutoff points were 0.9 and 0.5 for CNFLcenter and 0.8 and 0.6 for CNFLwhorl. Conclusions Small nerve fiber pathology is comparable at the central and whorl anatomical sites of the cornea. Quantification of CNFL from the corneal center is as accurate as CNFL quantification of the whorl area for the diagnosis of DPN.

Problems with the coronial determination of ‘suicide’

After over 100 years of constant dissatisfaction with the accuracy of suicide data, this paper suggests that the problem may actually lie with the category of suicide itself. In almost all previous research, ‘suicide’ is taken to be a self-evidently valid category of death, not an object of study in its own right. Instead, the focus in this paper is upon the presupposition that how a social fact like suicide is counted depends upon norms for its governmental regulation, leading to a reciprocal relationship between social norms and statistical norms. Since this relationship is centred almost entirely in the coroner’s office, this paper examines governmental, definitional and categorisational issues relating to how coroners reach findings of suicide. The intention of this paper is to contribute to international debates over how suicide can best be conceptualised and adjudged.

Validity of the geriatric depression scale and the collateral source version of the geriatric depression scale in nursing homes

Background Depression is a common psychiatric disorder in older people. The study aimed to examine the screening accuracy of the Geriatric Depression Scale (GDS) and the Collateral Source version of the Geriatric Depression Scale (CS-GDS) in the nursing home setting. Methods Eighty-eight residents from 14 nursing homes were assessed for depression using the GDS and the CS-GDS, and validated against clinician diagnosed depression using the Semi-structured Clinical Diagnostic Interview for DSM-IV-TR Axis I Disorders (SCID) for residents without dementia and the Provisional Diagnostic Criteria for Depression in Alzheimer Disease (PDCdAD) for those with dementia. The screening performances of five versions of the GDS (30-, 15-, 10-, 8-, and 4-item) and two versions of the CS-GDS (30- and 15-item) were analyzed using receiver operating characteristic (ROC) curves. Results Among residents without dementia, both the self-rated (AUC = 0.75–0.79) and proxy-rated (AUC = 0.67) GDS variations performed significantly better than chance in screening for depression. However, neither instrument adequately identified depression among residents with dementia (AUC between 0.57 and 0.70). Among the GDS variations, the 4- and 8-item scales had the highest AUC and the optimal cut-offs were >0 and >3, respectively. Conclusions The validity of the GDS in detecting depression requires a certain level of cognitive functioning. While the CS-GDS is designed to remedy this issue by using an informant, it did not have adequate validity in detecting depression among residents with dementia. Further research is needed on informant selection and other factors that can potentially influence the validity of proxy-based measures in the nursing home setting.

Reliability of point-of-care testing of INR in acute stroke

Background In the emergency department, portable point-of-care testing (POCT) coagulation devices may facilitate stroke patient care by providing rapid International Normalized Ratio (INR) measurement. The objective of this study was to evaluate the reliability, validity, and impact on clinical decision-making of a POCT device for INR testing in the setting of acute ischemic stroke (AIS). Methods A total of 150 patients (50 healthy volunteers, 51 anticoagulated patients, 49 AIS patients) were assessed in a tertiary care facility. The INR's were measured using the Roche Coaguchek S and the standard laboratory technique. Results The interclass correlation coefficient and 95% confidence interval between overall POCT device and standard laboratory value INRs was high (0.932 (0.69 - 0.78). In the AIS group alone, the correlation coefficient and 95% CI was also high 0.937 (0.59 - 0.74) and diagnostic accuracy of the POCT device was 94%. Conclusions When used by a trained health professional in the emergency department to assess INR in acute ischemic stroke patients, the CoaguChek S is reliable and provides rapid results. However, as concordance with laboratory INR values decreases with higher INR values, it is recommended that with CoaguChek S INRs in the > 1.5 range, a standard laboratory measurement be used to confirm the results.

Development of a new ultrasound-based system for tracking motion of the human lumbar spine: Reliability, stability and repeatability during forward bending movement trials

The aim of this study was to develop a new method for quantifying intersegmental motion of the spine in an instrumented motion segment L4–L5 model using ultrasound image post-processing combined with an electromagnetic device. A prospective test–retest design was employed, combined with an evaluation of stability and within- and between-day intra-tester reliability during forward bending by 15 healthy male patients. The accuracy of the measurement system using the model was calculated to be ± 0.9° (standard deviation = 0.43) over a 40° range and ± 0.4 cm (standard deviation = 0.28) over 1.5 cm. The mean composite range of forward bending was 15.5 ± 2.04° during a single trial (standard error of the mean = 0.54, coefficient of variation = 4.18). Reliability (intra-class correlation coefficient = 2.1) was found to be excellent for both within-day measures (0.995–0.999) and between-day measures (0.996–0.999). Further work is necessary to explore the use of this approach in the evaluation of biomechanics, clinical assessments and interventions.

In search of good probability assessors: An experimental comparison of elicitation rules for confidence judgments

In this paper, we use an experimental design to compare the performance of elicitation rules for subjective beliefs. Contrary to previous works in which elicited beliefs are compared to an objective benchmark, we consider a purely subjective belief framework (confidence in one’s own performance in a cognitive task and a perceptual task). The performance of different elicitation rules is assessed according to the accuracy of stated beliefs in predicting success. We measure this accuracy using two main factors: calibration and discrimination. For each of them, we propose two statistical indexes and we compare the rules’ performances for each measurement. The matching probability method provides more accurate beliefs in terms of discrimination, while the quadratic scoring rule reduces overconfidence and the free rule, a simple rule with no incentives, which succeeds in eliciting accurate beliefs. Nevertheless, the matching probability appears to be the best mechanism for eliciting beliefs due to its performances in terms of calibration and discrimination, but also its ability to elicit consistent beliefs across measures and across tasks, as well as its empirical and theoretical properties.

Frequent (flier) frustration and the dark side of word‐of‐web: exploring online dysfunctional behavior in online feedback forums

Purpose Following the perspective of frustration theory customer frustration incidents lead to frustration behavior such as protest (negative word‐of‐mouth). On the internet customers can express their emotions verbally and non‐verbally in numerous web‐based review platforms. The purpose of this study is to investigate online dysfunctional customer behavior, in particular negative “word‐of‐web” (WOW) in online feedback forums, among customers who participate in frequent‐flier programs in the airline industry. Design/methodology/approach The study employs a variation of the critical incident technique (CIT) referred to as the critical internet feedback technique (CIFT). Qualitative data of customer reviews of 13 different frequent‐flier programs posted on the internet were collected and analyzed with regard to frustration incidents, verbal and non‐verbal emotional effects and types of dysfunctional word‐of‐web customer behavior. The sample includes 141 negative customer reviews based on non‐recommendations and low program ratings. Findings Problems with loyalty programs evoke negative emotions that are expressed in a spectrum of verbal and non‐verbal negative electronic word‐of‐mouth. Online dysfunctional behavior can vary widely from low ratings and non‐recommendations to voicing switching intentions to even stronger forms such as manipulation of others and revenge intentions. Research limitations/implications Results have to be viewed carefully due to methodological challenges with regard to the measurement of emotions, in particular the accuracy of self‐report techniques and the quality of online data. Generalization of the results is limited because the study utilizes data from only one industry. Further research is needed with regard to the exact differentiation of frustration from related constructs. In addition, large‐scale quantitative studies are necessary to specify and test the relationships between frustration incidents and subsequent dysfunctional customer behavior expressed in negative word‐of‐web. Practical implications The study yields important implications for the monitoring of the perceived quality of loyalty programs. Management can obtain valuable information about program‐related and/or relationship‐related frustration incidents that lead to online dysfunctional customer behavior. A proactive response strategy should be developed to deal with severe cases, such as sabotage plans. Originality/value This study contributes to knowledge regarding the limited research of online dysfunctional customer behavior as well as frustration incidents of loyalty programs. Also, the article presents a theoretical “customer frustration‐defection” framework that describes different levels of online dysfunctional behavior in relation to the level of frustration sensation that customers have experienced. The framework extends the existing perspective of the “customer satisfaction‐loyalty” framework developed by Heskett et al.