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For 76 annual, biennial, and perennial species common in the grasslands of central Minnesota, USA, we determined the patterns of correlations among seven organ-level traits (specific leaf area, leaf thickness, leaf tissue density, leaf angle, specific root length, average fine root diameter, and fine root tissue density) and their relationships with two traits relating to growth form (whether species existed for part of the growing season in basal, non-caulescent form and whether species were rhizomatous or not). The first correlation of traits showed that grasses had thin, dense leaves and thin roots while forbs had thick, low-density leaves and thick roots without any significant differences in growth form or life history. The second correlation of traits showed a gradient of species from those with high-density roots and high-density erect leaves to species with low-density roots and low-density leaves that were held parallel to the ground. High tissue density species were more likely to exist as a basal rosette for part of the season, were less likely to be rhizomatous, and less likely to be annuals. We examined the relationships between the two axes that represent the correlations of traits and previously collected data on the relative abundance of species across gradients of nitrogen addition and disturbance. Grasses were generally more abundant than forbs and the relative abundance of grasses and forbs did not change with increasing nitrogen addition or soil disturbance. High tissue density species became less common as fertility and disturbance increased.

In outpatient healthcare clinics, capacity, patient flow, and scheduling are rarely managed in an integrated fashion, so a question of interest is whether clinic performance can be improved if the policies that guide these decisions are set jointly. Despite the potential importance of this issue, we find surprisingly few studies that look at how the allocation of capacity, paired with various appointment scheduling policies and different patient flow configurations, affects patient flow and clinical efficiency. In this paper, we develop an empirically based discrete‐event simulation to examine the interactions between patient appointment policies and capacity allocation policies (i.e., the number of available examination rooms) and how they jointly affect various performance measures, such as resource utilization and patient waiting time. Findings suggest that scheduling lower‐variance, shorter appointments earlier in the clinic (and, conversely, higher‐variance, longer appointments later) results in less overall patient waiting without reducing physician utilization or increasing clinic duration. Additionally, exam rooms exhibited classic bottleneck behavior: there was no effect on physician utilization by adding exam rooms beyond a certain threshold, but too few exam rooms were devastating to clinic throughput. Some significant interactions between these variables were observed, but were not influential to the level of managerial concern. Clinicians' intuition about managing capacity in healthcare settings may differ substantially from best policies.

The FASStR framework can be used to provide an objective, systematic approach to ensure that metrics are defined and documented in a clear, consistent manner. * Poorly defined measurement impairs interinstitutional comparison, interpretation of results, and process improvement in health care operations. * Inconsistent and incomplete performance metrics are common deficiencies in health care operations metrics. * The FASStR framework provides a systematic approach to metric development, definition, and evaluation. [...]a metric must be clear and unambiguous in its definition and use. [...]it must be relevant to practice and aid in managerial decision-making; metrics that do not directly contribute to the management of the organization or are not sufficiently sensitive to detect meaningful operational changes are, at best, potential distractions from more critical information. [...]organizations may not understand or be able to communicate what is being measured and/or why it changed, thereby potentially reducing buy-in from staff and stakeholders. METHODS Literature Review First, we sampled the literature from the medical, health systems research, and health care operations (business and engineering) disciplines to assemble a representative sample of papers in which performance metrics were the focus of the research.

Purpose: The goal of this study was to compare our institution’s recently implemented enhanced recovery after surgery (ERAS) protocol to previous post-operative management for adolescent idiopathic scoliosis patients undergoing posterior spinal fusion, specifically assessing length of stay, opioid consumption, and pain scores.Methods: This is a retrospective analysis that compares the length of stay, opioid consumption, and pain scores of patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis. Patients were analyzed prior to the implementation of our ERAS protocol, deemed the traditional pain pathway (TPP), to those who underwent the ERAS pathway. All patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis were included. Patients were excluded if they weighed less than 40kg, had significant comorbidities, or had non-idiopathic causes of scoliosis.Results: We examined 22 patients in the TPP cohort and 20 in the ERAS cohort. Length of stay in the ERAS cohort was significantly reduced compared to the TPP by 1.7 days (P<0.01). Overall opioid consumption was also significantly reduced in the ERAS with 1.4 ± 0.7 morphine equivalents (ME)/kg compared to the TPP 2.4 ± 1.1 ME/kg (P < 0.01). We found no difference in pain scores between the two groups.Conclusion: Implementation of an ERAS pathway at our institution significantly reduced length of stay and opioid consumption in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion. These outcomes reduce morbidity and costs associated with posterior spinal fusion and provide an overall improvement in the quality of care for our patients.

Future global mean sea level rise (SLR) will affect coastlines and estuaries in the North Sea and therefore also coastal protection structures, unique local ecosystems and important waterways. SLR will not only raise water levels but also influence tidal dynamics and morphodynamics, which is why the tidal flats of the Wadden Sea can grow to a certain extent with SLR. Investigations on the effects of climate-change-induced SLR and the related potential bathymetric changes inside of estuaries form an important basis for identifying vulnerabilities and developing appropriate adaptation strategies. To analyse the influence of potential SLR and tidal flat elevation scenarios on the tidal dynamics in the Elbe estuary, we used a highly resolved hydrodynamic numerical model of the German Bight. The analysis results show increasing tidal range in the Elbe estuary solely due to SLR. They also reveal strongly varying changes with different tidal flat growth scenarios: while tidal flat elevation up to the mouth of the estuary can cause tidal range to decrease relative to SLR alone, tidal flat elevation in the entire estuary can lead to an increase in tidal range relative to SLR alone. Further analyses show how the geometric parameters of the Elbe estuary are changing due to SLR and tidal flat elevation. We discuss how these changes in estuarine geometry can provide an explanation for the changes in tidal range.

Operational data are often used to make systems changes in real time. Inaccurate data, however, transiently, can result in inappropriate operational decision making. Implementing electronic health records (EHRs) is fraught with the possibility of data errors, but the frequency and magnitude of transient errors during this fast-evolving systems upheaval are unknown. This study was done to assess operational data quality in an emergency department (ED) immediately before and after an EHR implementation. Direct observations of standard ED timestamps (arrival, bed placement, clinician evaluation, disposition decision, and exit from ED) were conducted in a suburban ED for 4 weeks immediately before and 4 weeks after EHR implementation. Direct observations were compared with electronic timestamps to assess data quality. Differences in proportions and medians with 95% confidence intervals (CIs) were used to estimate the magnitude of effect. There were 260 observations: 122 before and 138 after implementation. We found that more systematic data errors were introduced after EHR implementation. The proportion of discrepancies where the observed and electronic timestamp differed by more than 10 minutes was reduced for the disposition timestamp (29.3% vs 16.1%; difference in proportions, −13.2%; 95% CI, −24.4% to −1.9%). The accuracy of the clinician-evaluation timestamp was reduced after implementation (median difference of 3 minutes earlier than observed; 95% CI, −5.02 to −0.98). Multiple service intervals were less accurate after implementation. This single-center study raises questions about operational data quality in the peri-implementation period of EHRs. Using electronic timestamps for operational assessment and decision making following implementation should recognize the magnitude and compounding of errors when computing service times.

Sarcopenia is an age-related loss of muscle mass and strength that has a multitude of adverse sequelae. Similar to other aging-related phenomenon, sarcopenia is likely the product of inputs that begin in utero and continue throughout the lifespan. We hypothesized that patterns of childhood skeletal growth predict sarcopenia status later in life. Data are from N=202 lifelong participants of the Fels Longitudinal Study (median lifetime visits=33). At the sarcopenia measure visit, participants were aged 65.8 + 10.3 years, 54% female, with body mass index of 27.5 + 4.9. Sarcopenia was defined using published sex-specific cutpoints from dual energy x-ray absorptiometry quantified appendicular lean mass/height2. Childhood skeletal age was calculated from serial hand-wrist radiographs (FELS method). Residual skeletal aging (RSA) was calculated as skeletal age minus predicted chronological age at peak height growth velocity during adolescence. RSA variance was similar in both sexes, with a range of -2 (delayed skeletal aging) to +2 years (accelerated skeletal aging). In older age, 6% of males and 22% of females exhibited sarcopenia. In multivariate logistic regression models controlling for age, self-reported physical activity, and grip strength (all measured at sarcopenia visit), accelerated RSA was protective of sarcopenia (Adjusted OR=0.58; 95% CI: 0.35-0.94). This is the first study to link childhood skeletal maturation to sarcopenia later in life. Biological pathways that explain this association likely include physiological, environmental, and genetic factors that facilitate communication between bone and muscle, and span the life course. Determining their influence is the next important step in this work.

Sarcopenia is an age-related loss of muscle mass and strength that has a multitude of adverse sequelae. Similar to other aging-related phenomenon, sarcopenia is likely the product of inputs that begin in utero and continue throughout the lifespan. We hypothesized that patterns of childhood skeletal growth predict sarcopenia status later in life. Data are from N=202 lifelong participants of the Fels Longitudinal Study (median lifetime visits=33). At the sarcopenia measure visit, participants were aged 65.8 + 10.3 years, 54% female, with body mass index of 27.5 + 4.9. Sarcopenia was defined using published sex-specific cutpoints from dual energy x-ray absorptiometry quantified appendicular lean mass/height2. Childhood skeletal age was calculated from serial hand-wrist radiographs (FELS method). Residual skeletal aging (RSA) was calculated as skeletal age minus predicted chronological age at peak height growth velocity during adolescence. RSA variance was similar in both sexes, with a range of -2 (delayed skeletal aging) to +2 years (accelerated skeletal aging). In older age, 6% of males and 22% of females exhibited sarcopenia. In multivariate logistic regression models controlling for age, self-reported physical activity, and grip strength (all measured at sarcopenia visit), accelerated RSA was protective of sarcopenia (Adjusted OR=0.58; 95% CI: 0.35-0.94). This is the first study to link childhood skeletal maturation to sarcopenia later in life. Biological pathways that explain this association likely include physiological, environmental, and genetic factors that facilitate communication between bone and muscle, and span the life course. Determining their influence is the next important step in this work.

The North Atlantic Deep Water (NADW) is a crucial component of the Atlantic meridional overturning circulation and is therefore an important factor of the climate system. In order to estimate the mean relative contributions, sources, and pathways of the NADW at the southern exit of the Labrador Sea, a Lagrangian particle experiment is performed. The particles were seeded according to the strength of the velocity field along the 53∘ N section and traced 40 years backward in time in the three-dimensional velocity and hydrography field. The resulting transport pathways, their sources and corresponding transit timescales were inferred. Our experiment shows that, of the 30.1 Sv of NADW passing 53∘ N on average, the majority of this water is associated with a diapycnal mass flux without contact to the atmosphere, accounting for 14.3 Sv (48 %), where 6.2 Sv originate from the Labrador Sea, compared to 4.7 Sv from the Irminger Sea. The second-largest contribution originates from the mixed layer with 7.2 Sv (24 %), where the Labrador Sea contribution (5.9 Sv) dominates over the Irminger Sea contribution (1.0 Sv). Another 5.7 Sv (19 %) of NADW crosses the Greenland–Scotland Ridge within the NADW density class, where about two-thirds pass the Denmark Strait, while one-third crosses the Iceland–Scotland Ridge. The NADW exported at 53∘ N is hence dominated by entrainment through the diapycnal mass flux and mixed-layer origin in the Labrador Sea.

Through literature review and collaborative design, we propose the FASStR framework to provide a systematic approach to healthcare operation metric definition and use.