Evaluating the effect of a patient education brochure on patients’ expectations and satisfaction with emergency department service

Introduction: The purpose of this study was to assess the capacity of a written intervention, in this case a patient information brochure, to improve patient satisfaction during an Emergency Department (ED) visit. For the purpose of measuring the effect of the intervention the ED journey was conceptualised as a series of distinct areas of service comprising waiting time, service by the triage nurse, care from doctors and nurses and information giving Background of study: Research into patient satisfaction has become a widespread activity endorsed by both governments and hospital administrations. The literature on ED patient satisfaction has consistently indicated three primary areas of patient dissatisfaction: waiting time, nursing care and communication. Recent developments in the literature on patient satisfaction studies however have highlighted the relationship between patients. expectations of a service encounter and their consequent assessment of the experience as dissatisfying or satisfying. Disconfirmation theory posits that the degree to which expectations are confirmed will affect subsequent levels of satisfaction. The conceptual framework utilised in this study is Coye.s (2004) model of disconfirmation. Coye while reiterating satisfaction is a consequence of the degree expectations are either confirmed or disconfirmed also posits that expectations can be modified by interventions. Coye.s work conceptualises these interventions as intra encounter experiences (cues) which function to adjust expectations. Coye suggests some cues are unintended and may have a negative impact which also reinforces the value of planned cues intended to meet or exceed consumer expectations. Consequently the brochure can be characterized as a potentially positive cue, encouraging the patient to understand processes and to orient them in what can be a confronting environment. Only a limited number of studies have examined the effect of written interventions within an ED. No studies could be located which have tested the effect of ED interventions using a conceptual framework which relates the effect of the degree to which expectations are confirmed or disconfirmed in terms of satisfaction with services. Method: Two studies were conducted. Study One used qualitative methods to explore patients. expectations of the ED from the perspective of both patients and health care professionals. Study One was used in part to direct the development of the intervention (brochure) in Study Two. The brochure was an intervention designed to modify patients. expectations thus increasing their satisfaction with the provision of ED service. As there was no existing tools to measure ED patients. expectations and satisfaction a new tool was also developed based on the findings and the literature of Study One. Study Two used a non-randomised, quasi-experimental approach using a non-equivalent post-test only comparison group design used to investigate the effect of the patient education brochure (Stommel and Wills, 2004). The brochure was disseminated to one of two study groups (the intervention group). The effect of the brochure was assessed by comparing the data obtained from both the intervention and control group. These two groups consisted of 150 participants each. It was expected that any differences in the relevant domains selected for examination would indicate the effect of the brochure both on expectation and potentially satisfaction. Results: Study One revealed several areas of common ground between patients and nurses in terms of relevant content for the written intervention, including the need for information on the triage system and waiting times. Areas of difference were also found with patients emphasizing communication issues, whereas focus group members expressed concern that patients were often unable to assimilate verbal information. The findings suggested the potential utility of written material to reinforce verbal communication particularly in terms of the triage process and other ED protocols. This material was synthesized within the final version of the written intervention. Overall the results of Study Two indicated no significant differences between the two groups. The intervention group did indicate a significant number of participants who viewed the brochure of having changed their expectations. The effect of the brochure may have been obscured by a lack of parity between the two groups as the control group presented with statistically significantly higher levels of acuity and experienced significantly shorter waiting times. In terms of disconfirmation theory this would suggest expectations that had been met or exceeded. The results confirmed the correlation of expectations with satisfaction. Several domains also indicated age as a significant predictor with older patients tending to score higher satisfaction results. Other significant predictors of satisfaction established were waiting time and care from nurses, reinforcing the combination of efficient service and positive interpersonal experiences as being valued by patients. Conclusions: Information presented in written form appears to benefit a significant number of ED users in terms of orientation and explaining systems and procedures. The degree to which these effects may interact with other dimensions of satisfaction however is likely to be limited. Waiting time and interpersonal behaviours from staff also provide influential cues in determining satisfaction. Written material is likely to be one element in a series of coordinated strategies to improve patient satisfaction during periods of peak demand.

Nitrogen fertilizer rate management as a nitrous oxide mitigation strategy: Development of a nitrous oxide emission reduction protocol (NERP)

Nitrous oxide (N2O) is a potent agricultural greenhouse gas (GHG). More than 50% of the global anthropogenic N2O flux is attributable to emissions from soil, primarily due to large fertilizer nitrogen (N) applications to corn and other non-leguminous crops. Quantification of the trade–offs between N2O emissions, fertilizer N rate, and crop yield is an essential requirement for informing management strategies aiming to reduce the agricultural sector GHG burden, without compromising productivity and producer livelihood. There is currently great interest in developing and implementing agricultural GHG reduction offset projects for inclusion within carbon offset markets. Nitrous oxide, with a global warming potential (GWP) of 298, is a major target for these endeavours due to the high payback associated with its emission prevention. In this paper we use robust quantitative relationships between fertilizer N rate and N2O emissions, along with a recently developed approach for determining economically profitable N rates for optimized crop yield, to propose a simple, transparent, and robust N2O emission reduction protocol (NERP) for generating agricultural GHG emission reduction credits. This NERP has the advantage of providing an economic and environmental incentive for producers and other stakeholders, necessary requirements in the implementation of agricultural offset projects.

Nitrogen fertilizer management for nitrous oxide (N2O) mitigation in intensive corn (Maize) production: an emissions reduction protocol for US Midwest agriculture

Nitrous oxide (N2O) is a major greenhouse gas (GHG) product of intensive agriculture. Fertilizer nitrogen (N) rate is the best single predictor of N2O emissions in row-crop agriculture in the US Midwest. We use this relationship to propose a transparent, scientifically robust protocol that can be utilized by developers of agricultural offset projects for generating fungible GHG emission reduction credits for the emerging US carbon cap and trade market. By coupling predicted N2O flux with the recently developed maximum return to N (MRTN) approach for determining economically profitable N input rates for optimized crop yield, we provide the basis for incentivizing N2O reductions without affecting yields. The protocol, if widely adopted, could reduce N2O from fertilized row-crop agriculture by more than 50%. Although other management and environmental factors can influence N2O emissions, fertilizer N rate can be viewed as a single unambiguous proxy—a transparent, tangible, and readily manageable commodity. Our protocol addresses baseline establishment, additionality, permanence, variability, and leakage, and provides for producers and other stakeholders the economic and environmental incentives necessary for adoption of agricultural N2O reduction offset projects.

Randomized trial of effect of bifocal and prismatic bifocal spectacles on myopic progression

Objective: To determine whether bifocal and prismatic bifocal spectacles could control myopia in children with high rates of myopic progression. ---------- Methods: This was a randomized controlled clinical trial. One hundred thirty-five (73 girls and 62 boys) myopic Chinese Canadian children (myopia of 1.00 diopters [D]) with myopic progression of at least 0.50 D in the preceding year were randomly assigned to 1 of 3 treatments: (1) single-vision lenses (n = 41), (2) +1.50-D executive bifocals (n = 48), or (3) +1.50-D executive bifocals with a 3–prism diopters base-in prism in the near segment of each lens (n = 46). ---------- Main Outcome Measures: Myopic progression measured by an automated refractor under cycloplegia and increase in axial length (secondary) measured by ultrasonography at 6-month intervals for 24 months. Only the data of the right eye were used. ---------- Results: Of the 135 children (mean age, 10.29 years [SE, 0.15 years]; mean visual acuity, –3.08 D [SE, 0.10 D]), 131 (97%) completed the trial after 24 months. Myopic progression averaged –1.55 D (SE, 0.12 D) for those who wore single-vision lenses, –0.96 D (SE, 0.09 D) for those who wore bifocals, and –0.70 D (SE, 0.10 D) for those who wore prismatic bifocals. Axial length increased an average of 0.62 mm (SE, 0.04 mm), 0.41 mm (SE, 0.04 mm), and 0.41 mm (SE, 0.05 mm), respectively. The treatment effect of bifocals (0.59 D) and prismatic bifocals (0.85 D) was significant (P < .001) and both bifocal groups had less axial elongation (0.21 mm) than the single-vision lens group (P < .001). ---------- Conclusions: Bifocal lenses can moderately slow myopic progression in children with high rates of progression after 24 months.

A comparative study of the effect of calibration conditions on the water equivalence of a range of gel dosimeters

Gel dosimeters are of increasing interest in the field of radiation oncology as the only truly three-dimensional integrating radiation dosimeter. There are a range of ferrous-sulphate and polymer gel dosimeters. To be of use, they must be water-equivalent. On their own, this relates to their radiological properties as determined by their composition. In the context of calibration of gel dosimeters, there is the added complexity of the calibration geometry; the presence of containment vessels may influence the dose absorbed. Five such methods of calibration are modelled here using the Monte Carlo method. It is found that the Fricke gel best matches water for most of the calibration methods, and that the best calibration method involves the use of a large tub into which multiple fields of different dose are directed. The least accurate calibration method involves the use of a long test tube along which a depth dose curve yields multiple calibration points.

A comparative study of the effect of calibration conditions on the water equivalence of a range of gel dosimeters

Gel dosimeters are of increasing interest in the field of radiation oncology as the only truly three-dimensional integrating radiation dosimeter. There are a range of ferrous-sulphate and polymer gel dosimeters. To be of use, they must be water-equivalent. On their own, this relates to their radiological properties as determined by their composition. In the context of calibration of gel dosimeters, there is the added complexity of the calibration geometry; the presence of containment vessels may influence the dose absorbed. Five such methods of calibration are modelled here using the Monte Carlo method. It is found that the Fricke gel best matches water for most of the calibration methods, and that the best calibration method involves the use of a large tub into which multiple fields of different dose are directed. The least accurate calibration method involves the use of a long test tube along which a depth dose curve yields multiple calibration points.

Nitrogen pools and fluxes in grassland soils sequestering carbon

Carbon sequestration in agricultural, forest, and grassland soils has been promoted as a means by which substantial amounts of CO2 may be removed from the atmosphere, but few studies have evaluated the associated impacts on changes in soil N or net global warming potential (GWP). The purpose of this research was to ( 1) review the literature to examine how changes in grassland management that affect soil C also impact soil N, ( 2) assess the impact of different types of grassland management on changes in soil N and rates of change, and (3) evaluate changes in N2O fluxes from differently managed grassland ecosystems to assess net impacts on GWP. Soil C and N stocks either both increased or both decreased for most studies. Soil C and N sequestration were tightly linked, resulting in little change in C: N ratios with changes in management. Within grazing treatments N2O made a minor contribution to GWP (0.1-4%), but increases in N2O fluxes offset significant portions of C sequestration gains due to fertilization (10-125%) and conversion (average = 27%). Results from this work demonstrate that even when improved management practices result in considerable rates of C and N sequestration, changes in N2O fluxes can offset a substantial portion of gains by C sequestration. Even for cases in which C sequestration rates are not entirely offset by increases in N2O fluxes, small increases in N2O fluxes can substantially reduce C sequestration benefits. Conversely, reduction of N2O fluxes in grassland soils brought about by changes in management represents an opportunity to reduce the contribution of grasslands to net greenhouse gas forcing.

Shoot growth dynamics and photosynthetic response to increased nitrogen availability in the alpine willow salix-glauca

Plants subjected to increases in the supply of resource(s) limiting growth may allocate more of those resources to existing leaves, increasing photosynthetic capacity, and/or to production of more leaves, increasing whole-plant photosynthesis. The responses of three populations of the alpine willow, Salix glauca, growing along an alpine topographic sequence representing a gradient in soil moisture and organic matter, and thus potential N supply, to N amendments, were measured over two growing seasons, to elucidate patterns of leaf versus shoot photosynthetic responses. Leaf-(foliar N, photosynthesis rates, photosynthetic N-use efficiency) and shoot-(leaf area per shoot, number of leaves per shoot, stem weight, N resorption efficiency) level measurements were made to examine the spatial and temporal variation in these potential responses to increased N availability. The predominant response of the willows to N fertilization was at the shoot-level, by production of greater leaf area per shoot. Greater leaf area occurred due to production of larger leaves in both years of the experiment and to production of more leaves during the second year of fertilization treatment. Significant leaf-level photosynthetic response occurred only during the first year of treatment, and only in the dry meadow population. Variation in photosynthesis rates was related more to variation in stomatal conductance than to foliar N concentration. Stomatal conductance in turn was significantly related to N fertilization. Differences among the populations in photosynthesis, foliar N, leaf production, and responses to N fertilization indicate N availability may be lowest in the dry meadow population, and highest in the ridge population. This result is contrary to the hypothesis that a gradient of plant available N corresponds with a snowpack/topographic gradient.

Influence of iodine value on combustion and NOx emission characteristics of a DI diesel engine

Biodiesel is a renewable fuel that has been shown to reduce many exhaust emissions, except oxides of nitrogen (NOx), in diesel engine cars. This is of special concern in inner urban areas that are subject to strict environmental regulations, such as EURO norms. Also, the use of pure biodiesel (B100) is inhibited because of its higher NOx emissions compared to petroleum diesel fuel. The aim of this present work is to investigate the effect of the iodine value and cetane number of various biodiesel fuels obtained from different feed stocks on the combustion and NOx emission characteristics of a direct injection (DI) diesel engine. The biodiesel fuels were chosen from various feed stocks such as coconut, palm kernel, mahua (Madhuca indica), pongamia pinnata, jatropha curcas, rice bran, and sesame seed oils. The experimental results show an approximately linear relationship between iodine value and NOx emissions. The biodiesels obtained from coconut and palm kernel showed lower NOx levels than diesel, but other biodiesels showed an increase in NOx. It was observed that the nature of the fatty acids of the biodiesel fuels had a significant influence on the NOx emissions. Also, the cetane numbers of the biodiesel fuels are affected both premixed combustion and the combustion rate, which further affected the amount of NOx formation. It was concluded that NOx emissions are influenced by many parameters of biodiesel fuels, particularly the iodine value and cetane number.

The effect of rhBMP-2 on canine osteoblasts seeded onto 3D bioactive polycaprolactone scaffolds

Our strategy entails investigating the influence of varied concentrations (0, 10, 100 and 1000 ng/ml) of human recombinant bone morphogenetic protein-2 (rhBMP-2) on the osteogenic expression of canine osteoblasts, seeded onto poly-caprolactone 20% tricalcium phosphate (PCL-TCP) scaffolds in vitro. Biochemical assay revealed that groups with rhBMP-2 displayed an initial burst in cell growth that was not dose-dependent. However, after 13 days, cell growth declined to a value similar to control. Significantly less cell growth was observed for construct with 1000 ng/ml of rhBMP-2 from 20 days onwards. Confocal microscopy confirmed viability of osteoblasts and at day 20, groups seeded with rhBMP-2 displayed heightened cell death as compared to control. Phase contrast and scanning electron microscopy revealed that osteoblasts heavily colonized surfaces, rods and pores of the PCL-TCP scaffolds. This was consistent for all groups. Finally, Von Kossa and osteocalcin assays demonstrated that cells from all groups maintained their osteogenic phenotype throughout the experiment. Calcification was observed as early as four days after stimulation for groups seeded with rhBMP-2. In conclusion, rhBMP-2 seems to enhance the differentiated function of canine osteoblasts in a non-dose dependent manner. This resulted in accelerated mineralization, followed by death of osteoblasts as they underwent terminal differentiation. Notably, PCL-TCP scaffolds seeded only with canine osteoblasts could sustain excellent osteogenic expression in vitro. Hence, the synergy of PCL with bioactive TCP and rhBMP-2 in a novel composite scaffold, could offer an exciting approach for bone regeneration.

Indentation size effect and strain rate sensitivity of nanocrystalline Mg-Al alloys

Deformation Behaviour of microcrystalline (mc) and nanocrystalline (nc) Mg-5%Al alloys produced by hot extrusion of ball-milled powders were investigated using instrumented indentation tests. The hardness values of the mc and nc metals exhibited indentation size effect (ISE), with nc alloys showing weaker ISE. The highly localized dislocation activities resulted in a small activation volume, hence enhanced strain rate sensitivity. Relative higher strain rate sensitivity and the negative Hall-Petch Relationship suggested the increasingly important role of grain boundary mediated mechanisms when the grain size decreased to nanometer region.

Raman spectroscopic study of the uranyl titanate mineral betafite (Ca,U)2(Ti,Nb)2O6(OH) –Effect of Metamictization

Raman spectra of the uranyl titanate mineral betafite were obtained and related to the mineral structure. A comparison is made with the spectra of uranyl oxyhydroxide hydrates. Observed bands are attributed to the (UO2)2+ stretching and bending vibrations, U-OH bending vibrations, H2O and (OH)- stretching, bending and libration modes. U-O bond lengths in uranyls and O-H…O bond lengths are calculated from the wavenumbers assigned to the stretching vibrations. Raman bands of betafite are comparable with those of the uranyl oxyhydroxides. The mineral betafite is metamict as is evidenced by the intensity of the UO stretching and bending modes being of lower intensity than expected and with bands that are significantly broader.

The impact of gender diversity on turnover : the moderating effect of human resource policies and practices

Demography theory suggests that high gender diversity leads to high turnover. As turnover is costly for organizations, we examined whether HR policies and practices influence the expected gender diversity-turnover relationship. Survey data were collected from 198 HR decision makers at publicly listed organizations. We found that HR policies and practices that are supportive of diversity moderate the gender diversity-turnover relationship, such that high gender diversity leads to low turnover in organizations with many diversity supportive policies and practices. Results suggest that organizations can avoid the negative consequences of high gender diversity by implementing diversity supportive HR polices and practices.

Effect of the Summer Months on Body Weight and Composition in College Women

BACKGROUND AND OBJECTIVES: College students and young adults are experiencing the greatest increases in rates of obesity, and 20% of college students are classified as obese. The objective of this study was to compare changes and rates of change in body weight and body composition between the freshman academic year and the summer after the freshman year among female college students. METHODS: Participants were recruited early in their freshman year of college to participate in a prospective longitudinal study examining changes in body weight and composition over the college years. Height and weight were measured, and body composition was assessed using dual energy x-ray absorptiometry (DEXA) at the beginning and end of the freshman year. Upon return from the summer for their sophomore year, participants returned to have all measurements repeated. Sixty-nine female participants completed all three visits. RESULTS: Body weight increased 1.3 kg during the academic period and an additional 0.1 kg during the summer period. Body mass index (BMI) increased between the first two visits but did not change between the last two visits. However, percent fat increased at each visit. Fat-free mass significantly increased 0.5 kg over the academic year but decreased by 1.1 kg over the summer (p<0.05). Greater rates of change were detected in percent fat, fat-free mass, and BMI during the summer compared with the academic year (p<0.05). CONCLUSIONS: Differences in body composition between the academic and summer periods may reflect changes in living situations between these periods. Unfavorable changes during the summer suggest the need to promote healthy lifestyles to freshman women before they leave campus for the summer

A CFD study of Hong Kong refuge floor design : floor height effect

Since 1996, ther provision of a refuge floor has been a mandatory feature for all new tall buildings in Hong Kong. These floors are designed to provide for building occupants a fire safe environment that is also free from smoke. However, the desired cross ventilation on these floors to achieve the removal of smoke, assumed by the Building Codes of Hong Kong, is still being questioned so that a further scientific study of the wind-induced ventilation of a refuge fllor is needed. This paper presents an investigation into this issue. The developed computational technique used in this paper was adopted to study the wind-induced natural ventilation on a refuge floor. The aim of the investigation was to establish whether a refuge floor with a cetnral core and having cross ventilation produced by only two open opposite external side walls on the refuge floor would provide the required protection in all situations taking into account behaviour of wind due to different floor heights, wall boundary conditions and turbulence intensity profiles. The results revealed that natural ventilation can be increased by increasng the floor heigh provided the wind angle to the building is less than 90 degrees. The effectiveness of the solution was greatly reduced when the wind was blowing at 90 degrees to the refuge floor opening.