A packet replication algorithm for delay tolerant networks based on multi-metric

Utility function of packet is often used to decide how to replicate packet in DTN networks. But this method has more uncertainty and relies on a single performance metric. For this problem, in order to reduce the impact of a single metric uncertainty, multiple utility metrics are introduced in the new algorithm. A packet replication probability calculation method based on entropy weight is designed. By calculating the entropy weight of each metric, the algorithm obtains the replication probability of each packet and takes the probability as the priority of packet replication. Because of considering the two metrics of packet expected transmission delay and node encounter possibility, the algorithm effectively reduces the influence of encounter time distribution problem and direction prediction problem in the original algorithm, and reduces the uncertainty of utility function. Simulation results show that the algorithm reduces the packet replication number and the average delay, improves the successful packet delivery rate. The overall performance of the network is further improved.

Ritualzeit – Zeitwahrnehmungen und Zeitpraktiken am Hof um 1000

A notable feature of courtly life in Japan were its ritualized procedures, which not only included periodical religious ceremonies but also political activities. Time at the court was of the essence for its ceremonial routine. Yet how did courtiers perceive their daily occupations in temporal regards, and to what extent did they evaluate their personal time, while the communal time was objectively measured and pronounced? How did those involved in courtly ceremonies encounter time in terms of its availability and its symbolic qualities, e.g. bemoaning a lack of time or adjusting to auspicious as well as ominous dates? Research so far has provided a profound understanding of time calculations, the courtly ritual calendar and especially the divination office, whose task it was to determine favourable days for the various activities at the court. In contrast, concrete political and religious acts at court have received less consideration as temporal processes. In order to find some answers to the outlined questions, I will focus on rituals as a case study of conceptions and practises of time. Information on courtiers’ dealings with their individual as well as social time can be obtained from various sources, among which I examine courtly diaries, with a special focus on Fujiwara no Yukinari’s diary Gonki. The author’s statements about time will help to elucidate some temporal aspects of courtly rituals as well as to deepen our knowledge of time perceptions at the Japanese court during its heydays.

Beyond Hemoglobin A1c: A Videographic Analysis of Conversations About Quality of Life and Treatment Burden During Clinical Encounters for Diabetes Care

Purpose: Diabetes care has largely focused on reducing the risk of complications by achieving hemoglobin A1c (HbA1c) targets; yet, whole-person care may be more effective and desirable. We sought to determine the nature of discussions about quality of life, burden of treatment, hypoglycemia, sexual function, and social support during diabetes-focused clinical encounters.Methods: We analyzed 41 previously recorded clinical encounters with patients with type 2 diabetes from the control arms of practice-based trials of shared decision making. Two coders evaluated videos for discussions about aspects of life with diabetes: quality of life, burden of treatment, hypoglycemia, sexual function, and social supports. When an aspect was raised, coders evaluated the nature of the conversation, clinician responses, and time spent on discussing the aspect. Results: Median length of the encounter was 15 minutes, 6 seconds (IQR: 11:16 – 20:23 minutes). Thirty five of 41 encounters (85.4%), included some discussion of quality of life (58.5%), burden of treatment (51.2%), social support (2.4%), or hypoglycemia (9.8%). Sexual function was not discussed. On average, 4.5% (1.4%-5.5%) of the encounter time involved conversations about HbA1c whereas 15.0% (0%-25%) of the encounter was spent on some aspect of quality of life, burden of treatment, social support, or hypoglycemia. If a topic related to quality of life was raised, clinicians most often responded by acknowledging patient’s concern without providing a solution (45.8%). Conclusions: A significant part of the patient-clinician encounter involves discussion of quality of life and burden of treatment, but clinicians rarely address these issues by providing solutions.

Behind the clock: elucidating factors contributing to longer clinic appointment duration and patient wait time

Background Longer wait time in ambulatory clinics can disrupt schedules and decrease satisfaction. We investigated factors associated with patient wait time (WT, check-in to examination room placement), approximate clinician time (ACT, completion of nurse assessment to check-out), and total appointment length (TAL, check-in to check-out). Methods A single-institution retrospective study was conducted of breast surgery clinic patients, 2017–2019, using actual encounter times. A before/after analysis compared a five-day 8 hour/day (from a four-day 10 hour/day) advanced practice provider (APP) work-week. Non-parametric tests were used, and medians with interquartile ranges (IQRs) reported. Results 15,265 encounters were identified. Overall WT was 15.0 minutes (IQR:6.0–32.0), ACT 49.0 minutes (IQR:31.0–79.0) and TAL 84.0 minutes (IQR:57.0-124.0). Trainees were associated with 30.0 minutes longer ACT (p < 0.0001); this increased time was greatest for follow-up appointments, least for new patients. Patients arriving > 5 minutes late (versus on-time) experienced shorter WT (11.0 vs. 15.0 minutes, p < 0.0001) and ACT (43.0 vs. 53.0 minutes, p < 0.0001). Busier days (higher encounter volume:APP ratios) demonstrated increased encounter times. After transitioning to a five-day APP work-week, ACT decreased. Conclusions High-volume clinics and trainee involvement prolong ambulatory encounters. Increasing APP assistance, altering work schedules, and assigning follow-up appointments to non-trainees may decrease encounter time.

An Integrated Heuristic Approach for the Long-Distance Heterogeneous Vehicle Routing Problem

In this chapter, a single depot, long-distance heterogeneous vehicle routing problem is studied with fixed costs and vehicle-dependent routing costs (LD-HVRPFD). The LD-HVRPFD considers retailers far away from the single depot and hence route durations could exceed a day. Thus, the number of available vehicles changes through the course of the multi-day planning horizon. Moreover, it is typical to encounter time-variant demand from retailers. To solve the LD-HVRPFD, the authors developed an iterative heuristic solution methodology integrated into a programming platform. The solution method consists of decomposing the VRP into sequential daily problems, model building using macro programming, obtaining a solution using a solver, determining the route-vehicle pairs and time durations, and dynamically updating the truck availability for the next day. The method is illustrated using real data from one of the biggest retail companies in the ready-to-wear sector of textile supply chains. The performance of the heuristic optimization procedure based on time and gap restriction criteria is presented.

Conducting Goals-of-Care Discussions Takes Less Time Than Imagined

PURPOSE: To describe the length of encounter during visits where goals-of-care (GoC) discussions were expected to take place. METHODS: Oncologists from community, academic, municipal, and rural hospitals were randomly assigned to receive a coaching model of communication skills to facilitate GoC discussions with patients with newly diagnosed advanced solid-tumor cancer with a prognosis of < 2 years. Patients were surveyed after the first restaging visit regarding the quality of the GoC discussion on a scale of 0-10 (0 = worst; 10 = best), with ≥ 8 indicating a high-quality GoC discussion. Visits were audiotaped, and total encounter time was measured. RESULTS: The median face-to-face time oncologists spent during a GoC discussion was 15 minutes (range, 10-20 minutes). Among the different hospital types, there was no significant difference in encounter time. There was no difference in the length of the encounter whether a high-quality GoC discussion took place or not (15 v 14 minutes; P = .9). If there was imaging evidence of cancer progression, the median encounter time was 18 minutes compared with 13 minutes for no progression ( P = .03). In a multivariate model, oncologist productivity, patient age, and Medicare coverage affected duration of the encounter. CONCLUSION: Oncologists can complete high-quality GoC discussions in 15 minutes. These data refute the common misperception that discussing such matters with patients with advanced cancer requires significant time.

Virtual Scribe Services Decrease Documentation Burden Without Affecting Patient Satisfaction: A Randomized Controlled Trial

Background Virtual scribe services (VSS) are a contemporary take on the in-person scribes utilized as a means to reduce administrative burden on physicians and enhance the physician-patient interaction. The purpose of this study was to determine whether VSS use could decrease the time an orthopaedic foot and ankle surgeon spends on documentation without diminishing the patient experience as compared with traditional postencounter dictation (TD). Methods Fifty patients presenting for first-time visits with a single orthopaedic foot and ankle surgeon were prospectively enrolled and randomized to VSS or TD prior to the physician-patient encounter. Time spent with the patient in the exam room and time spent documenting away from the patient were recorded. A postencounter survey assessed patient satisfaction, perception of physician empathy, understanding of the plan, and perception of the amount of time spent with the physician. Results Of 50 patients enrolled, 25 were randomized to VSS. Time spent documenting away from the patient differed significantly between VSS and TD (1.2 ± 0.7 minutes for VSS vs 5.8 ± 1.7 minutes for TD, P < .001) as did time elapsed between the end of the visit and the start of dictation (0 ± 0 for VSS vs 118.2 ± 72.7 minutes for TD, P < .001). There was a trend toward more time spent with the patient in the VSS group than in the TD group (14.2 ± 5.9 minutes for VSS vs 11.4 ± 5.1 minutes for TD, P = .069). There were no differences between groups in survey responses regarding satisfaction, empathy, understanding, or perception of sufficient time spent with the physician ( P > .05 for each). Conclusions VSS use in an orthopaedic foot and ankle practice significantly decreased documentation time and allowed for completion of documentation during patient visits without differences in quality metrics as compared to TD. Orthopaedic surgeons can consider VSS a HIPAA-compliant documentation option with time savings and no measurable difference in patient satisfaction. Levels of Evidence: Level II: Randomized controlled trial

Effect of Scribes on Efficiency in Academic Ophthalmology Practice

Objective The aim of the study is to determine the effects of scribes on efficiency in an academic ophthalmology practice. Design This is a quality improvement study conducted by two ophthalmologists at an academic ophthalmology practice at UT Health San Antonio from January 2018 to April 2018. Implementation of scribes in practice was the primary intervention. Session time, patient encounter time, and template time adherence were recorded pre- and post-intervention. A second retrospective arm of the study at the same institution was performed to evaluate long-term effects of scribes on efficiency in ophthalmology practice on session times and patient volume 12 to 18 months after intervention. Main Outcome Measures Primary study outcomes and measures were the effect of scribes in academic ophthalmology practice on physician efficiency in terms of clinic session time, individual encounter time, and amount of patients seen per session, in addition to time adherence based on type of patient encounter. Results Eighty-three patients and 17 half-day clinic sessions and 169 patients and 21 half-day clinic sessions were included in the preintervention and post-intervention datasets, respectively. Number of patients per session was approximately 15 and was kept similar pre- and post-intervention (p = 0.45). Mean preintervention session time was 265.0 ± 31.4 minutes, in contrast to 223.4 ± 19.9 minutes after intervention (p < 0.001). Mean preintervention patient encounter time was 15.0 ± 8.3 minutes, while the mean encounter time after intervention was 10.9 ± 7.0 minutes (p < 0.005). In a retrospective analysis of 20 clinic sessions and 438 patients 12 to 18 months after intervention, session time increased to 266.0 ± 22.0 minutes on average, but the average number of patients per session increased to 21.9 ± 2.8 minutes. Conclusion Utilizing scribes in an ophthalmology practice can increase efficiency, allowing more patients to be seen or allowing time for other activities such as teaching or research.