Do different case-mix measures affect assessments of provider efficiency? Lessons from the Department of Veterans Affairs.

PubMed

Rosen, Amy K; Loveland, Susan A; Rakovski, Carter C; Christiansen, Cindy L; Berlowitz, Dan R

2003-01-01

Although case-mix adjustment is critical for provider profiling, little is known regarding whether different case-mix measures affect assessments of provider efficiency. We examine whether two case-mix measures, Adjusted Clinical Groups (ACGs) and Diagnostic Cost Groups (DCGs), result in different assessments of efficiency across service networks within the Department of Veterans Affairs (VA). Three profiling indicators examine variation in resource use. Although results from the ACGs and DCGs generally agree on which networks have greater or lesser efficiency than average, assessments of individual network efficiency vary depending upon the case-mix measure used. This suggests that caution should be used so that providers are not misclassified based on reported efficiency.

A balanced perspective: using nonfinancial measures to assess financial performance.

PubMed

Watkins, Ann L

2003-11-01

Assessments of hospitals' financial performance have traditionally been based exclusively on analysis of a concise set of key financial ratios. One study, however, demonstrates that analysis of a hospital's financial condition can be significantly enhanced with the addition of several nonfinancial measures, including case-mix adjusted admissions, case-mix adjusted admissions per full-time equivalent, and case-mix adjusted admissions per beds in service.

Case Mix Management Systems: An Opportunity to Integrate Medical Records and Financial Management System Data Bases

PubMed Central

Rusnak, James E.

1987-01-01

Due to previous systems selections, many hospitals (health care facilities) are faced with the problem of fragmented data bases containing clinical, demographic and financial information. Projects to select and implement a Case Mix Management System (CMMS) provide an opportunity to reduce the number of separate physical files and to migrate towards systems with an integrated data base. The number of CMMS candidate systems is often restricted due to data base and system interface issues. The hospital must insure the CMMS project provides a means to implement an integrated on-line hospital information data base for use by departments in operating under a DRG-based Prospective Payment System. This paper presents guidelines for use in selecting a Case Mix Mangement System to meet the hospital's financial and operations planning, budgeting, marketing, and other management needs, while considering the data base implications of the implementation.

Case mix adjusted nursing-home reimbursement: a critical review of the evidence.

PubMed

Weissert, W G; Musliner, M C

1992-01-01

Nursing-home case mix adjusted payment systems typically base payments on estimates of patients' care needs, but to date the data on their effectiveness are ambiguous. Studies mainly show that access for patients most in need of care appears to improve under these systems. Case mix based payment systems have both positive and negative effects on quality of care and require compensating mechanisms for the potentially harmful incentives they can generate. On the positive side, nursing homes are paid more equitably; the negative aspect is reflected in higher costs, particularly for administration. A Health Care Financing Administration (HCFA) demonstration project may provide insights, but its limited number of predominantly small, rural, participating states, its tandem quality assurance system, and potentially confounding market variables may restrict the value of this project. We do not yet have the data to assess the impact of instituting case mix adjustment systems.

Study on Chinese common allergens of contact dermatitis.

PubMed

Fan, W X; Zhao, B

1990-01-01

Patch tests were performed according to the European Standard Allergens (ESA) in 204 cases suspected of contact dermatitis. The reaction was positive in 58.33% of the cases. The common allergens were nickel (15.7%), fragrance mix (11.8%) p-phenylenediamine (8.8%), colophony (6.9%), benzocaine (6.4%), formaldehyde (5.9%), black rubber mix (4.9%), cobalt (4.4%), balsam of Peru (3.9%), potassium dichromate (3.4%), thiuram mix (2.9%) and mercapto mix (2.9%). In 85 cases of negative reaction to the European Standard Allergens, 36 were patch tested to suspected agents based on the individual case histories, of which 21 positively reacted. The common sensitizing agents were ampicillin and thiomersal. Of 204 cases, 107 were cases of facial contact dermatitis. Patch tests showed that the most common allergens were p-phenylenediamine (15.9%), nickel (13.1%) and fragrance mix (14.95%).

Using existing case-mix methods to fund trauma cases.

PubMed

Monakova, Julia; Blais, Irene; Botz, Charles; Chechulin, Yuriy; Picciano, Gino; Basinski, Antoni

2010-01-01

Policymakers frequently face the need to increase funding in isolated and frequently heterogeneous (clinically and in terms of resource consumption) patient subpopulations. This article presents a methodologic solution for testing the appropriateness of using existing grouping and weighting methodologies for funding subsets of patients in the scenario where a case-mix approach is preferable to a flat-rate based payment system. Using as an example the subpopulation of trauma cases of Ontario lead trauma hospitals, the statistical techniques of linear and nonlinear regression models, regression trees, and spline models were applied to examine the fit of the existing case-mix groups and reference weights for the trauma cases. The analyses demonstrated that for funding Ontario trauma cases, the existing case-mix systems can form the basis for rational and equitable hospital funding, decreasing the need to develop a different grouper for this subset of patients. This study confirmed that Injury Severity Score is a poor predictor of costs for trauma patients. Although our analysis used the Canadian case-mix classification system and cost weights, the demonstrated concept of using existing case-mix systems to develop funding rates for specific subsets of patient populations may be applicable internationally.

A case-mix in-service education program.

PubMed

Arons, R R

1985-01-01

The new case-mix in-service education program at the Presbyterian Hospital in the City of New York is a fine example of physicians and administration working together to achieve success under the new prospective pricing system. The hospital's office of Case-Mix Studies has developed an accurate computer-based information system with historical, clinical, and demographic data for patients discharged from the hospital over the past five years. Reports regarding the cases, diagnoses, finances, and characteristics are shared in meetings with the hospital administration and directors of sixteen clinical departments, their staff, attending physicians, and house officers in training. The informative case-mix reports provide revealing sociodemographic summaries and have proven to be an invaluable tool for planning, marketing, and program evaluation.

The effect of state medicaid case-mix payment on nursing home resident acuity.

PubMed

Feng, Zhanlian; Grabowski, David C; Intrator, Orna; Mor, Vincent

2006-08-01

To examine the relationship between Medicaid case-mix payment and nursing home resident acuity. Longitudinal Minimum Data Set (MDS) resident assessments from 1999 to 2002 and Online Survey Certification and Reporting (OSCAR) data from 1996 to 2002, for all freestanding nursing homes in the 48 contiguous U.S. states. We used a facility fixed-effects model to examine the effect of introducing state case-mix payment on changes in nursing home case-mix acuity. Facility acuity was measured by aggregating the nursing case-mix index (NCMI) from the MDS using the Resource Utilization Group (Version III) resident classification system, separately for new admits and long-stay residents, and by an OSCAR-derived index combining a range of activity of daily living dependencies and special treatment measures. We followed facilities over the study period to create a longitudinal data file based on the MDS and OSCAR, respectively, and linked facilities with longitudinal data on state case-mix payment policies for the same period. Across three acuity measures and two data sources, we found that states shifting to case-mix payment increased nursing home acuity levels over the study period. Specifically, we observed a 2.5 percent increase in the average acuity of new admits and a 1.3 to 1.4 percent increase in the acuity of long-stay residents, following the introduction of case-mix payment. The adoption of case-mix payment increased access to care for higher acuity Medicaid residents.

Does case-mix based reimbursement stimulate the development of process-oriented care delivery?

PubMed

Vos, Leti; Dückers, Michel L A; Wagner, Cordula; van Merode, Godefridus G

2010-11-01

Reimbursement based on the total care of a patient during an acute episode of illness is believed to stimulate management and clinicians to reduce quality problems like waiting times and poor coordination of care delivery. Although many studies already show that this kind of case-mix based reimbursement leads to more efficiency, it remains unclear whether care coordination improved as well. This study aims to explore whether case-mix based reimbursement stimulates development of care coordination by the use of care programmes, and a process-oriented way of working. Data for this study were gathered during the winter of 2007/2008 in a survey involving all Dutch hospitals. Descriptive and structural equation modelling (SEM) analyses were conducted. SEM reveals that adoption of the case-mix reimbursement within hospitals' budgeting processes stimulates hospitals to establish care programmes by the use of process-oriented performance measures. However, the implementation of care programmes is not (yet) accompanied by a change in focus from function (the delivery of independent care activities) to process (the delivery of care activities as being connected to a chain of interdependent care activities). This study demonstrates that hospital management can stimulate the development of care programmes by the adoption of case-mix reimbursement within hospitals' budgeting processes. Future research is recommended to confirm this finding and to determine whether the establishment of care programmes will in time indeed lead to a more process-oriented view of professionals. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

The PIG in sPrInG: evidence on letter grouping from the reading of buried words.

PubMed

Humphreys, Glyn W; Mayall, Kate; Cooper, Adam C G

2003-12-01

We introduce a novel procedure for investigating factors that determine selective attention to letters in words. Participants were presented with words (in Experiments 1 and 3) and nonwords (in Experiment 2) that contained a buried word whose letters differed in color relative to the other letters present (e.g., pig, in spring). The strings were presented in single case or mixed case, keeping the letters of the buried words in one case (SpRiNg). The time in which the whole stimulus was named was shorter for same-case than for mixed-case strings (for spring: spring < SpRiNg). In contrast, the time in which buried words were named was shorter in mixed- than in same-case strings (for pig: spring > SpRiNg). Across items, the effects of case mixing were negatively correlated across the two tasks. The positive effect of case mixing for buried words also occurred irrespective of whether the whole string was a word or a nonword, and there were contributions from similarity of both letter size and case. The results suggest that case mixing can facilitate selective attention to letters, which is otherwise disrupted by size- and case-based grouping across letter strings. The study provides evidence for letter grouping using size and case information.

Mixed Model Association with Family-Biased Case-Control Ascertainment.

PubMed

Hayeck, Tristan J; Loh, Po-Ru; Pollack, Samuela; Gusev, Alexander; Patterson, Nick; Zaitlen, Noah A; Price, Alkes L

2017-01-05

Mixed models have become the tool of choice for genetic association studies; however, standard mixed model methods may be poorly calibrated or underpowered under family sampling bias and/or case-control ascertainment. Previously, we introduced a liability threshold-based mixed model association statistic (LTMLM) to address case-control ascertainment in unrelated samples. Here, we consider family-biased case-control ascertainment, where case and control subjects are ascertained non-randomly with respect to family relatedness. Previous work has shown that this type of ascertainment can severely bias heritability estimates; we show here that it also impacts mixed model association statistics. We introduce a family-based association statistic (LT-Fam) that is robust to this problem. Similar to LTMLM, LT-Fam is computed from posterior mean liabilities (PML) under a liability threshold model; however, LT-Fam uses published narrow-sense heritability estimates to avoid the problem of biased heritability estimation, enabling correct calibration. In simulations with family-biased case-control ascertainment, LT-Fam was correctly calibrated (average χ 2 = 1.00-1.02 for null SNPs), whereas the Armitage trend test (ATT), standard mixed model association (MLM), and case-control retrospective association test (CARAT) were mis-calibrated (e.g., average χ 2 = 0.50-1.22 for MLM, 0.89-2.65 for CARAT). LT-Fam also attained higher power than other methods in some settings. In 1,259 type 2 diabetes-affected case subjects and 5,765 control subjects from the CARe cohort, downsampled to induce family-biased ascertainment, LT-Fam was correctly calibrated whereas ATT, MLM, and CARAT were again mis-calibrated. Our results highlight the importance of modeling family sampling bias in case-control datasets with related samples. Copyright © 2017 American Society of Human Genetics. Published by Elsevier Inc. All rights reserved.

The Effect of State Medicaid Case-Mix Payment on Nursing Home Resident Acuity

PubMed Central

Feng, Zhanlian; Grabowski, David C; Intrator, Orna; Mor, Vincent

2006-01-01

Objective To examine the relationship between Medicaid case-mix payment and nursing home resident acuity. Data Sources Longitudinal Minimum Data Set (MDS) resident assessments from 1999 to 2002 and Online Survey Certification and Reporting (OSCAR) data from 1996 to 2002, for all freestanding nursing homes in the 48 contiguous U.S. states. Study Design We used a facility fixed-effects model to examine the effect of introducing state case-mix payment on changes in nursing home case-mix acuity. Facility acuity was measured by aggregating the nursing case-mix index (NCMI) from the MDS using the Resource Utilization Group (Version III) resident classification system, separately for new admits and long-stay residents, and by an OSCAR-derived index combining a range of activity of daily living dependencies and special treatment measures. Data Collection/Extraction Methods We followed facilities over the study period to create a longitudinal data file based on the MDS and OSCAR, respectively, and linked facilities with longitudinal data on state case-mix payment policies for the same period. Principal Findings Across three acuity measures and two data sources, we found that states shifting to case-mix payment increased nursing home acuity levels over the study period. Specifically, we observed a 2.5 percent increase in the average acuity of new admits and a 1.3 to 1.4 percent increase in the acuity of long-stay residents, following the introduction of case-mix payment. Conclusions The adoption of case-mix payment increased access to care for higher acuity Medicaid residents. PMID:16899009

Case-Mix Adjusting Performance Measures in a Veteran Population: Pharmacy- and Diagnosis-Based Approaches

PubMed Central

Liu, Chuan-Fen; Sales, Anne E; Sharp, Nancy D; Fishman, Paul; Sloan, Kevin L; Todd-Stenberg, Jeff; Nichol, W Paul; Rosen, Amy K; Loveland, Susan

2003-01-01

Objective To compare the rankings for health care utilization performance measures at the facility level in a Veterans Health Administration (VHA) health care delivery network using pharmacy- and diagnosis-based case-mix adjustment measures. Data Sources/Study Setting The study included veterans who used inpatient or outpatient services in Veterans Integrated Service Network (VISN) 20 during fiscal year 1998 (October 1997 to September 1998; N=126,076). Utilization and pharmacy data were extracted from VHA national databases and the VISN 20 data warehouse. Study Design We estimated concurrent regression models using pharmacy or diagnosis information in the base year (FY1998) to predict health service utilization in the same year. Utilization measures included bed days of care for inpatient care and provider visits for outpatient care. Principal Findings Rankings of predicted utilization measures across facilities vary by case-mix adjustment measure. There is greater consistency within the diagnosis-based models than between the diagnosis- and pharmacy-based models. The eight facilities were ranked differently by the diagnosis- and pharmacy-based models. Conclusions Choice of case-mix adjustment measure affects rankings of facilities on performance measures, raising concerns about the validity of profiling practices. Differences in rankings may reflect differences in comparability of data capture across facilities between pharmacy and diagnosis data sources, and unstable estimates due to small numbers of patients in a facility. PMID:14596393

The effect of initial flow nonuniformity on second-stage fuel injection and combustion in a supersonic duct. [supersonic combustion ramjet engine

NASA Technical Reports Server (NTRS)

Russin, W. R.

1975-01-01

The effects of flow nonuniformity on second-stage hydrogen fuel injection and combustion in supersonic flow were evaluated. The first case, second-stage fuel injection into a uniform duct flow, produced data indicating that fuel mixing is considerably slower than estimates based on an empirical mixing correlation. The second-case, two-stage fuel injection (or second-stage fuel injection into a nonuniform duct flow), produced a large interaction between stages with extensive flow separation. For this case the measured wall pressure, heat transfer, and amount of reaction at the duct exit were significantly greater than estimates based on the mixing correlation. Substantially more second-stage fuel burned in the second case than in the first case. Overall effects of unmixedness/chemical kinetics were found not to be significant at the exit for stoichiometric fuel injection.

Physician-owned Surgical Hospitals Outperform Other Hospitals in the Medicare Value-based Purchasing Program

PubMed Central

Ramirez, Adriana G; Tracci, Margaret C; Stukenborg, George J; Turrentine, Florence E; Kozower, Benjamin D; Jones, R Scott

2016-01-01

Background The Hospital Value-Based Purchasing Program measures value of care provided by participating Medicare hospitals while creating financial incentives for quality improvement and fostering increased transparency. Limited information is available comparing hospital performance across healthcare business models. Study Design 2015 hospital Value-Based Purchasing Program results were used to examine hospital performance by business model. General linear modeling assessed differences in mean total performance score, hospital case mix index, and differences after adjustment for differences in hospital case mix index. Results Of 3089 hospitals with Total Performance Scores (TPS), categories of representative healthcare business models included 104 Physician-owned Surgical Hospitals (POSH), 111 University HealthSystem Consortium (UHC), 14 US News & World Report Honor Roll (USNWR) Hospitals, 33 Kaiser Permanente, and 124 Pioneer Accountable Care Organization affiliated hospitals. Estimated mean TPS for POSH (64.4, 95% CI 61.83, 66.38) and Kaiser (60.79, 95% CI 56.56, 65.03) were significantly higher compared to all remaining hospitals while UHC members (36.8, 95% CI 34.51, 39.17) performed below the mean (p < 0.0001). Significant differences in mean hospital case mix index included POSH (mean 2.32, p<0.0001), USNWR honorees (mean 2.24, p 0.0140) and UHC members (mean =1.99, p<0.0001) while Kaiser Permanente hospitals had lower case mix value (mean =1.54, p<0.0001). Re-estimation of TPS did not change the original results after adjustment for differences in hospital case mix index. Conclusions The Hospital Value-Based Purchasing Program revealed superior hospital performance associated with business model. Closer inspection of high-value hospitals may guide value improvement and policy-making decisions for all Medicare Value-Based Purchasing Program Hospitals. PMID:27502368

Case-Mix for Performance Management: A Risk Algorithm Based on ICD-10-CM.

PubMed

Gao, Jian; Moran, Eileen; Almenoff, Peter L

2018-06-01

Accurate risk adjustment is the key to a reliable comparison of cost and quality performance among providers and hospitals. However, the existing case-mix algorithms based on age, sex, and diagnoses can only explain up to 50% of the cost variation. More accurate risk adjustment is desired for provider performance assessment and improvement. To develop a case-mix algorithm that hospitals and payers can use to measure and compare cost and quality performance of their providers. All 6,048,895 patients with valid diagnoses and cost recorded in the US Veterans health care system in fiscal year 2016 were included in this study. The dependent variable was total cost at the patient level, and the explanatory variables were age, sex, and comorbidities represented by 762 clinically homogeneous groups, which were created by expanding the 283 categories from Clinical Classifications Software based on ICD-10-CM codes. The split-sample method was used to assess model overfitting and coefficient stability. The predictive power of the algorithms was ascertained by comparing the R, mean absolute percentage error, root mean square error, predictive ratios, and c-statistics. The expansion of the Clinical Classifications Software categories resulted in higher predictive power. The R reached 0.72 and 0.52 for the transformed and raw scale cost, respectively. The case-mix algorithm we developed based on age, sex, and diagnoses outperformed the existing case-mix models reported in the literature. The method developed in this study can be used by other health systems to produce tailored risk models for their specific purpose.

Medicaid prospective payment: Case-mix increase

PubMed Central

Baker, Samuel L.; Kronenfeld, Jennie J.

1990-01-01

South Carolina Medicaid implemented prospective payment by diagnosis-related group (DRG) for inpatient care. The rate of complications among newborns and deliveries doubled immediately. The case-mix index for newborns increased 66.6 percent, which increased the total Medicaid hospital expenditure 5.5 percent. Outlier payments increased total expenditure further. DRG distribution change among newborns has a large impact on spending because newborn complication DRGs have high weights. States adopting a DRG-based payment system for Medicaid should anticipate a greater increase in case mix than Medicare experienced. PMID:10113463

Re-resection rates after breast-conserving surgery as a performance indicator: introduction of a case-mix model to allow comparison between Dutch hospitals.

PubMed

Talsma, A K; Reedijk, A M J; Damhuis, R A M; Westenend, P J; Vles, W J

2011-04-01

Re-resection rate after breast-conserving surgery (BCS) has been introduced as an indicator of quality of surgical treatment in international literature. The present study aims to develop a case-mix model for re-resection rates and to evaluate its performance in comparing results between hospitals. Electronic records of eligible patients diagnosed with in-situ and invasive breast cancer in 2006 and 2007 were derived from 16 hospitals in the Rotterdam Cancer Registry (RCR) (n = 961). A model was built in which prognostic factors for re-resections after BCS were identified and expected re-resection rate could be assessed for hospitals based on their case mix. To illustrate the opportunities of monitoring re-resections over time, after risk adjustment for patient profile, a VLAD chart was drawn for patients in one hospital. In general three out of every ten women had re-surgery; in about 50% this meant an additive mastectomy. Independent prognostic factors of re-resection after multivariate analysis were histological type, sublocalisation, tumour size, lymph node involvement and multifocal disease. After correction for case mix, one hospital was performing significantly less re-resections compared to the reference hospital. On the other hand, two were performing significantly more re-resections than was expected based on their patient mix. Our population-based study confirms earlier reports that re-resection is frequently required after an initial breast-conserving operation. Case-mix models such as the one we constructed can be used to correct for variation between hospitals performances. VLAD charts are valuable tools to monitor quality of care within individual hospitals. Copyright © 2011 Elsevier Ltd. All rights reserved.

Validation of ACG Case-mix for equitable resource allocation in Swedish primary health care.

PubMed

Zielinski, Andrzej; Kronogård, Maria; Lenhoff, Håkan; Halling, Anders

2009-09-18

Adequate resource allocation is an important factor to ensure equity in health care. Previous reimbursement models have been based on age, gender and socioeconomic factors. An explanatory model based on individual need of primary health care (PHC) has not yet been used in Sweden to allocate resources. The aim of this study was to examine to what extent the ACG case-mix system could explain concurrent costs in Swedish PHC. Diagnoses were obtained from electronic PHC records of inhabitants in Blekinge County (approx. 150,000) listed with public PHC (approx. 120,000) for three consecutive years, 2004-2006. The inhabitants were then classified into six different resource utilization bands (RUB) using the ACG case-mix system. The mean costs for primary health care were calculated for each RUB and year. Using linear regression models and log-cost as dependent variable the adjusted R2 was calculated in the unadjusted model (gender) and in consecutive models where age, listing with specific PHC and RUB were added. In an additional model the ACG groups were added. Gender, age and listing with specific PHC explained 14.48-14.88% of the variance in individual costs for PHC. By also adding information on level of co-morbidity, as measured by the ACG case-mix system, to specific PHC the adjusted R2 increased to 60.89-63.41%. The ACG case-mix system explains patient costs in primary care to a high degree. Age and gender are important explanatory factors, but most of the variance in concurrent patient costs was explained by the ACG case-mix system.

Foundations of chaotic mixing.

PubMed

Wiggins, Stephen; Ottino, Julio M

2004-05-15

The simplest mixing problem corresponds to the mixing of a fluid with itself; this case provides a foundation on which the subject rests. The objective here is to study mixing independently of the mechanisms used to create the motion and review elements of theory focusing mostly on mathematical foundations and minimal models. The flows under consideration will be of two types: two-dimensional (2D) 'blinking flows', or three-dimensional (3D) duct flows. Given that mixing in continuous 3D duct flows depends critically on cross-sectional mixing, and that many microfluidic applications involve continuous flows, we focus on the essential aspects of mixing in 2D flows, as they provide a foundation from which to base our understanding of more complex cases. The baker's transformation is taken as the centrepiece for describing the dynamical systems framework. In particular, a hierarchy of characterizations of mixing exist, Bernoulli --> mixing --> ergodic, ordered according to the quality of mixing (the strongest first). Most importantly for the design process, we show how the so-called linked twist maps function as a minimal picture of mixing, provide a mathematical structure for understanding the type of 2D flows that arise in many micromixers already built, and give conditions guaranteeing the best quality mixing. Extensions of these concepts lead to first-principle-based designs without resorting to lengthy computations.

Estimation of the contribution of private providers in tuberculosis case notification and treatment outcome in Pakistan.

PubMed

Chughtai, A A; Qadeer, E; Khan, W; Hadi, H; Memon, I A

2013-03-01

To improve involvement of the private sector in the national tuberculosis (TB) programme in Pakistan various public-private mix projects were set up between 2004 and 2009. A retrospective analysis of data was made to study 6 different public-private mix models for TB control in Pakistan and estimate the contribution of the various private providers to TB case notification and treatment outcome. The number of TB cases notified through the private sector increased significantly from 77 cases in 2004 to 37,656 in 2009. Among the models, the nongovernmental organization model made the greatest contribution to case notification (58.3%), followed by the hospital-based model (18.9%). Treatment success was highest for the district-led model (94.1%) and lowest for the hospital-based model (74.2%). The private sector made an important contribution to the national data through the various public-private mix projects. Issues of sustainability and the lack of treatment supporters are discussed as reasons for lack of success of some projects.

[Clinical characteristics of aerobic vaginitis and its mixed infections].

PubMed

Fan, Ai-Ping; Xue, Feng-Xia

2010-12-01

To investigate clinical characteristics of aerobic vaginitis (AV) and its mixed infections for diagnosis efficiently. From April 2008 to December 2008, 516 patients with vaginitis treated in Tianjin Medical University General Hospital were enrolled in this study. AV, bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), trichomonal vaginitis (TV), and cytolytic vaginosis (CV) were diagnosed based on symptoms, sign and vaginal discharge examination. Among 516 cases, AV cases were found in 14.7% (76/516), and AV was common vaginal infection. AV mixed infections was diagnosed in 58% (44/76), including mixed with BV (45%, 20/44), mixed with VVC (30%, 13/44), and mixed with TV (25%, 11/44). Those common symptom of AV were yellow vaginal discharge (63%, 20/32), more vaginal discharge (44%, 14/32). Vaginal pH value was usually more than 4.5 (84%, 27/32). Vaginal cleanliness mainly was grade III - IV (88%, 28/32). Six cases with enterococcus faecium and 4 cases with streptococci were frequently isolated. The symptom and sign of mixed AV infection was atypical. Aerobic vaginitis is a common lower vaginal infection and easily mixed with other pathogens, especially with BV, VVC or TV. When patients were diagnosed with AV or other vaginal infection, it should be mentioned whether those patients have mixed vaginal infection or AV.

Determination of mixed mode (I/II) SIFs of cracked orthotropic materials

NASA Astrophysics Data System (ADS)

Chakraborty, D.; Chakraborty, Debaleena; Murthy, K. S. R. K.

2018-05-01

Strain gage techniques have been successfully but sparsely used for the determination of stress intensity factors (SIFs) of orthotropic materials. For mode I cases, few works have been reported on the strain gage based determination of mode I SIF of orthotropic materials. However, for mixed mode (I/II) cases, neither a theoretical development of a strain gage based technique nor any recommended guidelines for minimum number of strain gages and their locations were reported in the literature for determination of mixed mode SIFs. The authors for the first time came up with a theoretical proposition to successfully use strain gages for determination of mixed mode SIFs of orthotropic materials [1]. Based on these formulations, the present paper discusses a finite element (FE) based numerical simulation of the proposed strain gage technique employing [902/0]10S carbon-epoxy laminates with a slant edge crack. An FE based procedure has also been presented for determination of the optimal radial locations of the strain gages apriori to actual experiments. To substantiate the efficacy of the proposed technique, numerical simulations for strain gage based determination of mixed mode SIFs have been conducted. Results show that it is possible to accurately determine the mixed mode SIFs of orthotropic laminates when the strain gages are placed within the optimal radial locations estimated using the present formulation.

Case mix adjustment of health outcomes, resource use and process indicators in childbirth care: a register-based study.

PubMed

Mesterton, Johan; Lindgren, Peter; Ekenberg Abreu, Anna; Ladfors, Lars; Lilja, Monica; Saltvedt, Sissel; Amer-Wåhlin, Isis

2016-05-31

Unwarranted variation in care practice and outcomes has gained attention and inter-hospital comparisons are increasingly being used to highlight and understand differences between hospitals. Adjustment for case mix is a prerequisite for meaningful comparisons between hospitals with different patient populations. The objective of this study was to identify and quantify maternal characteristics that impact a set of important indicators of health outcomes, resource use and care process and which could be used for case mix adjustment of comparisons between hospitals. In this register-based study, 139 756 deliveries in 2011 and 2012 were identified in regional administrative systems from seven Swedish regions, which together cover 67 % of all deliveries in Sweden. Data were linked to the Medical birth register and Statistics Sweden's population data. A number of important indicators in childbirth care were studied: Caesarean section (CS), induction of labour, length of stay, perineal tears, haemorrhage > 1000 ml and post-partum infections. Sociodemographic and clinical characteristics deemed relevant for case mix adjustment of outcomes and resource use were identified based on previous literature and based on clinical expertise. Adjustment using logistic and ordinary least squares regression analysis was performed to quantify the impact of these characteristics on the studied indicators. Almost all case mix factors analysed had an impact on CS rate, induction rate and length of stay and the effect was highly statistically significant for most factors. Maternal age, parity, fetal presentation and multiple birth were strong predictors of all these indicators but a number of additional factors such as born outside the EU, body mass index (BMI) and several complications during pregnancy were also important risk factors. A number of maternal characteristics had a noticeable impact on risk of perineal tears, while the impact of case mix factors was less pronounced for risk of haemorrhage > 1000 ml and post-partum infections. Maternal characteristics have a large impact on care process, resource use and outcomes in childbirth care. For meaningful comparisons between hospitals and benchmarking, a broad spectrum of sociodemographic and clinical maternal characteristics should be accounted for.

Physician-Owned Surgical Hospitals Outperform Other Hospitals in Medicare Value-Based Purchasing Program.

PubMed

Ramirez, Adriana G; Tracci, Margaret C; Stukenborg, George J; Turrentine, Florence E; Kozower, Benjamin D; Jones, R Scott

2016-10-01

The Hospital Value-Based Purchasing Program measures value of care provided by participating Medicare hospitals and creates financial incentives for quality improvement and fosters increased transparency. Limited information is available comparing hospital performance across health care business models. The 2015 Hospital Value-Based Purchasing Program results were used to examine hospital performance by business model. General linear modeling assessed differences in mean total performance score, hospital case mix index, and differences after adjustment for differences in hospital case mix index. Of 3,089 hospitals with total performance scores, categories of representative health care business models included 104 physician-owned surgical hospitals, 111 University HealthSystem Consortium, 14 US News & World Report Honor Roll hospitals, 33 Kaiser Permanente, and 124 Pioneer accountable care organization affiliated hospitals. Estimated mean total performance scores for physician-owned surgical hospitals (64.4; 95% CI, 61.83-66.38) and Kaiser Permanente (60.79; 95% CI, 56.56-65.03) were significantly higher compared with all remaining hospitals, and University HealthSystem Consortium members (36.8; 95% CI, 34.51-39.17) performed below the mean (p < 0.0001). Significant differences in mean hospital case mix index included physician-owned surgical hospitals (mean 2.32; p < 0.0001), US News & World Report honorees (mean 2.24; p = 0.0140), and University HealthSystem Consortium members (mean 1.99; p < 0.0001), and Kaiser Permanente hospitals had lower case mix value (mean 1.54; p < 0.0001). Re-estimation of total performance scores did not change the original results after adjustment for differences in hospital case mix index. The Hospital Value-Based Purchasing Program revealed superior hospital performance associated with business model. Closer inspection of high-value hospitals can guide value improvement and policy-making decisions for all Medicare Value-Based Purchasing Program Hospitals. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

The Case for Mixed Methodologies in Researching the Teacher's Use of Humour in Adult Education

ERIC Educational Resources Information Center

Struthers, John

2011-01-01

Inconsistencies within the literature result in teachers not having sufficient guidance to develop their humour use in support of learning without risking their professionalism. This article argues for more comprehensive evidence to guide teachers' use of humour, based on mixed methodological approaches. The case is also made for the Interpersonal…

Crude versus case-mix-adjusted control charts for safety monitoring in thyroid surgery.

PubMed

Duclos, Antoine; Voirin, Nicolas; Touzet, Sandrine; Soardo, Pietro; Schott, Anne-Marie; Colin, Cyrille; Peix, Jean-Louis; Lifante, Jean-Christophe

2010-12-01

Patient-safety monitoring based on health-outcome indicators can lead to misinterpretation of changes in case mix. This study aimed to compare the detection of indicator variations between crude and case-mix-adjusted control charts using data from thyroid surgeries. The study population included each patient who underwent thyroid surgery in a teaching hospital from January 2006 to May 2008. Patient safety was monitored according to two indicators, which are immediately recognisable postoperative complications: recurrent laryngeal nerve palsy and hypocalcaemia. Each indicator was plotted monthly on a p-control chart using exact limits. The weighted κ statistic was calculated to measure the agreement between crude and case-mix-adjusted control charts. We evaluated the outcomes of 1405 thyroidectomies. The overall proportions of immediate recurrent laryngeal nerve palsy and hypocalcaemia were 7.4% and 20.5%, respectively. The proportion of agreement in the detection of indicator variations between the crude and case-mix-adjusted p-charts was 95% (95% CI 85% to 99%). The strength of the agreement was κ = 0.76 (95% CI 0.54 to 0.98). The single special cause of variation that occurred was only detected by the case-mix-adjusted p-chart. There was good agreement in the detection of indicator variations between crude and case-mix-adjusted p-charts. The joint use of crude and adjusted charts seems to be a reasonable approach to increase the accuracy of interpretation of variations in outcome indicators.

Nursing home case mix in Wisconsin. Findings and policy implications.

PubMed

Arling, G; Zimmerman, D; Updike, L

1989-02-01

Along with many other states, Wisconsin is considering a case mix approach to Medicaid nursing home reimbursement. To support this effort, a nursing home case mix model was developed from a representative sample of 410 Medicaid nursing home residents from 56 facilities in Wisconsin. The model classified residents into mutually exclusive groups that were homogeneous in their use of direct care resources, i.e., minutes of direct care time (weighted for nurse skill level) over a 7-day period. Groups were defined initially by intense, Special, or Routine nursing requirements. Within these nursing requirement categories, subgroups were formed by the presence/absence of behavioral problems and dependency in activities of daily living (ADL). Wisconsin's current Skilled/Intermediate Care (SNF/ICF) classification system was analyzed in light of the case mix model and found to be less effective in distinguishing residents by resource use. The case mix model accounted for 48% of the variance in resource use, whereas the SNF/ICF classification system explained 22%. Comparisons were drawn with nursing home case mix models in New York State (RUG-II) and Minnesota. Despite progress in the study of nursing home case mix and its application to reimbursement reform, methodologic and policy issues remain. These include the differing operational definitions for nursing requirements and ADL dependency, the inconsistency in findings concerning psychobehavioral problems, and the problem of promoting positive health and functional outcomes based on models that may be insensitive to change in resident conditions over time.

Evaluating performance of local case-mix system by international comparison: a case study in Beijing, China.

PubMed

Jian, Wei-Yan; Lu, Ming; Cui, Tao; Hu, Mu

2011-01-01

Case-mix is an important tool for health planning and management in many countries. As a major developing country, China is considering the introduction of the case-mix system in the health reform. Beijing, the capital of China, developed a local case-mix version whose performance needs to be evaluated before utilization. The objective of this study was to evaluate the performance of the case-mix system developed in Beijing by comparing it with those used in Australia and the U.S.A. A total of 1.3 million inpatient records from 154 hospitals in Beijing in 2008 were grouped respectively using three case-mix systems: (i) Beijing Diagnosis Related Groups (BJ-DRGs); (ii) US-based All Patient DRGs; and (iii) Australian Refined DRGs. Coefficient of variation (CV) and reduction in variance (RIV) were used to measure the performance of DRGs system. The BJ-DRGs produced the best CV and RIV results for expenditure. However, at the level of Major Diagnostic Category (MDC), three MDCs of BJ-DRGs gave the poorest RIVs for both expenditure and length of stay. Although the performance of BJ-DRGs was acceptable, further revision and improvement is needed. Comparisons with other mature DRGs versions can assist in identifying the improvement priorities of the local version. Copyright © 2011 John Wiley & Sons, Ltd.

A computational investigation of fuel mixing in a hypersonic scramjet

NASA Technical Reports Server (NTRS)

Fathauer, Brett W.; Rogers, R. C.

1993-01-01

A parabolized, Navier-Stokes code, SHIP3D, is used to numerically investigate the mixing between air injection and hydrogen injection from a swept ramp injector configuration into either a mainstream low-enthalpy flow or a hypervelocity test flow. The mixing comparisons between air and hydrogen injection reveal the importance of matching injectant-to-mainstream mass flow ratios. In flows with the same injectant-to-mainstream dynamic pressure ratio, the mixing definition was altered for the air injection cases. Comparisons of the computed results indicate that the air injection cases overestimate the mixing performance associated with hydrogen injection simulation. A lifting length parameter, to account for the time a fluid particle transverses through the mixing region, is defined and used to establish a connection of injectant mixing in hypervelocity flows, based on nonreactive, low-enthalpy flows.

Hospital financing reform and case-mix measurement: An international review

PubMed Central

Wiley, Miriam M.

1992-01-01

A review of reforms in the financing of hospital services in eight European countries and Australia reveals a commitment to a common objective of relating resource use to hospital workload by means of a standardized case-mix framework in the pursuit of greater efficiency. While this objective is also shared with the U.S. prospective payment system (PPS), it is noteworthy that the majority of countries reviewed favor a global budgeting approach to financing hospital services. Ongoing evaluation of these reforms should facilitate an assessment of the merits of case-mix adjusted global budgeting relative to the patient-based alternative. PMID:10122001

Financial modeling/case-mix analysis.

PubMed

Heck, S; Esmond, T

1983-06-01

The authors describe a case mix system developed by users which goes beyond DRG requirements to respond to management's clinical/financial data needs for marketing, planning, budgeting and financial analysis as well as reimbursement. Lessons learned in development of the system and the clinical/financial base will be helpful to those currently contemplating the implementation of such a system or evaluating available software.

Case mix measures and diagnosis-related groups: opportunities and threats for inpatient dermatology.

PubMed

Hensen, P; Fürstenberg, T; Luger, T A; Steinhoff, M; Roeder, N

2005-09-01

The changing healthcare environment world-wide is leading to extensive use of per case payment systems based on diagnosis-related groups (DRG). The aim of this study was to examine the impact of application of different DRG systems used in the German healthcare system. We retrospectively analysed 2334 clinical data sets of inpatients discharged from an academic dermatological inpatient unit in 2003. Data were regarded as providing high coding quality in compliance with the diagnosis and procedure classifications as well as coding standards. The application of the Australian AR-DRG version 4.1, the German G-DRG version 1.0, and the German G-DRG version 2004 was considered in detail. To evaluate more specific aspects, data were broken down into 11 groups based on the principle diagnosis. DRG cost weights and case mix index were used to compare coverage of inpatient dermatological services. Economic impacts were illustrated by case mix volumes and calculation of DRG payments. Case mix index results and the pending prospective revenues vary tremendously from the application of one or another of the DRG systems. The G-DRG version 2004 provides increased levels of case mix index that encourages, in particular, medical dermatology. The AR-DRG version 4.1 and the first German DRG version 1.0 appear to be less suitable to adequately cover inpatient dermatology. The G-DRG version 2004 has been greatly improved, probably due to proceeding calculation standards and DRG adjustments. The future of inpatient dermatology is subject to appropriate depiction of well-established treatment standards.

Developing a case mix classification for child and adolescent mental health services: the influence of presenting problems, complexity factors and service providers on number of appointments.

PubMed

Martin, Peter; Davies, Roger; Macdougall, Amy; Ritchie, Benjamin; Vostanis, Panos; Whale, Andy; Wolpert, Miranda

2017-09-01

Case-mix classification is a focus of international attention in considering how best to manage and fund services, by providing a basis for fairer comparison of resource utilization. Yet there is little evidence of the best ways to establish case mix for child and adolescent mental health services (CAMHS). To develop a case mix classification for CAMHS that is clinically meaningful and predictive of number of appointments attended and to investigate the influence of presenting problems, context and complexity factors and provider variation. We analysed 4573 completed episodes of outpatient care from 11 English CAMHS. Cluster analysis, regression trees and a conceptual classification based on clinical best practice guidelines were compared regarding their ability to predict number of appointments, using mixed effects negative binomial regression. The conceptual classification is clinically meaningful and did as well as data-driven classifications in accounting for number of appointments. There was little evidence for effects of complexity or context factors, with the possible exception of school attendance problems. Substantial variation in resource provision between providers was not explained well by case mix. The conceptually-derived classification merits further testing and development in the context of collaborative decision making.

A preliminary case-mix classification system for Medicare home health clients.

PubMed

Branch, L G; Goldberg, H B

1993-04-01

In this study, a hierarchical case-mix model was developed for grouping Medicare home health beneficiaries homogeneously, based on the allowed charges for their home care. Based on information from a two-page form from 2,830 clients from ten states and using the classification and regression trees method, a four-component model was developed that yielded 11 case-mix groups and explained 22% of the variance for the test sample of 1,929 clients. The four components are rehabilitation, special care, skilled-nurse monitoring, and paralysis; each are categorized as present or absent. The range of mean-allowed charges for the 11 groups in the total sample was $473 to $2,562 with a mean of $847. Of the six groups with mean charges above $1,000, none exceeded 5.2% of clients; thus, the high-cost groups are relatively rare.

Validating the Johns Hopkins ACG Case-Mix System of the elderly in Swedish primary health care.

PubMed

Halling, Anders; Fridh, Gerd; Ovhed, Ingvar

2006-06-28

Individualbased measures for comorbidity are of increasing importance for planning and funding health care services. No measurement for individualbased healthcare costs exist in Sweden. The aim of this study was to validate the Johns Hopkins ACG Case-Mix System's predictive value of polypharmacy (regular use of 4 or more prescription medicines) used as a proxy for health care costs in an elderly population and to study if the prediction could be improved by adding variables from a population based study i.e. level of education, functional status indicators and health perception. The Johns Hopkins ACG Case-Mix System was applied to primary health care diagnoses of 1402 participants (60-96 years) in a cross-sectional community based study in Karlskrona, Sweden (the Swedish National study on Ageing and Care) during a period of two years before they took part in the study. The predictive value of the Johns Hopkins ACG Case-Mix System was modeled against the regular use of 4 or more prescription medicines, also using age, sex, level of education, instrumental activity of daily living- and measures of health perception as covariates. In an exploratory biplot analysis the Johns Hopkins ACG Case-Mix System, was shown to explain a large part of the variance for regular use of 4 or more prescription medicines. The sensitivity of the prediction was 31.9%, whereas the specificity was 88.5%, when the Johns Hopkins ACG Case-Mix System was adjusted for age. By adding covariates to the model the sensitivity was increased to 46.3%, with a specificity of 90.1%. This increased the number of correctly classified by 5.6% and the area under the curve by 11.1%. The Johns Hopkins ACG Case-Mix System is an important factor in measuring comorbidity, however it does not reflect an individual's capability to function despite a disease burden, which has importance for prediction of comorbidity. In this study we have shown that information on such factors, which can be obtained from short questionnaires increases the probability to correctly predict an individual's use of resources, such as medications.

Simulating the impact of case-mix adjusted hospice rates.

PubMed

Mor, V; Laliberte, L

1986-01-01

The Medicare hospice benefit prospectively reimburses hospices based on the inpatient status of the patient, whether or not the patient is at home, and whether the patient is receiving round-the-clock nursing. Using national Hospice Study data, two case-mix adjusters based on patient functioning and living arrangement were found to be significantly related to per diem cost. These were tested by simulating their impact on hospice revenues. Increasing per diem reimbursements 35 percent for nonambulatory patients living alone only increases hospice revenues by 4 percent; hospices with sicker patients benefit the most.

Quantification of chaotic strength and mixing in a micro fluidic system

NASA Astrophysics Data System (ADS)

Kim, Ho Jun; Beskok, Ali

2007-11-01

Comparative studies of five different techniques commonly employed to identify the chaotic strength and mixing efficiency in micro fluidic systems are presented to demonstrate the competitive advantages and shortcomings of each method. The 'chaotic electroosmotic stirrer' of Qian and Bau (2002 Anal. Chem. 74 3616-25) is utilized as the benchmark case due to its well-defined flow kinematics. Lagrangian particle tracking methods are utilized to study particle dispersion in the conceptual device using spectral element and fourth-order Runge-Kutta discretizations in space and time, respectively. Stirring efficiency is predicted using the stirring index based on the box counting method, and Poincaré sections are utilized to identify the chaotic and regular regions under various actuation conditions. Finite time Lyapunov exponents are calculated to quantify the chaotic strength, while the probability density function of the stretching field is utilized as an alternative method to demonstrate the statistical analysis of chaotic and partially chaotic cases. Mixing index inverse, based on the standard deviation of scalar species distribution, is utilized as a metric to quantify the mixing efficiency. Series of numerical simulations are performed by varying the Peclet number (Pe) at fixed kinematic conditions. The mixing time (tm) is characterized as a function of the Pe number, and tm ~ ln(Pe) scaling is demonstrated for fully chaotic cases, while tm ~ Peα scaling with α ≈ 0.33 and α = 0.5 are observed for partially chaotic and regular cases, respectively. Employing the aforementioned techniques, optimum kinematic conditions and the actuation frequency of the stirrer that result in the highest mixing/stirring efficiency are identified.

Community-Involved Learning to Expand Possibilities for Vulnerable Children: A Critical Communicative, Sen's Capability, and Action Research Approach

ERIC Educational Resources Information Center

Kim, Kyung Hi

2014-01-01

This research, based on a case study of vulnerable children in Korea, used a mixed methods transformative approach to explore strategies to support and help disadvantaged children. The methodological approach includes three phases: a mixed methods contextual analysis, a qualitative dominant analysis based on Sen's capability approach and critical…

The operating room case-mix problem under uncertainty and nurses capacity constraints.

PubMed

Yahia, Zakaria; Eltawil, Amr B; Harraz, Nermine A

2016-12-01

Surgery is one of the key functions in hospitals; it generates significant revenue and admissions to hospitals. In this paper we address the decision of choosing a case-mix for a surgery department. The objective of this study is to generate an optimal case-mix plan of surgery patients with uncertain surgery operations, which includes uncertainty in surgery durations, length of stay, surgery demand and the availability of nurses. In order to obtain an optimal case-mix plan, a stochastic optimization model is proposed and the sample average approximation method is applied. The proposed model is used to determine the number of surgery cases to be weekly served, the amount of operating rooms' time dedicated to each specialty and the number of ward beds dedicated to each specialty. The optimal case-mix selection criterion is based upon a weighted score taking into account both the waiting list and the historical demand of each patient category. The score aims to maximizing the service level of the operating rooms by increasing the total number of surgery cases that could be served. A computational experiment is presented to demonstrate the performance of the proposed method. The results show that the stochastic model solution outperforms the expected value problem solution. Additional analysis is conducted to study the effect of varying the number of ORs and nurses capacity on the overall ORs' performance.

Improving and Measuring Inpatient Documentation of Medical Care within the MS-DRG System: Education, Monitoring, and Normalized Case Mix Index

PubMed Central

Rosenbaum, Benjamin P.; Lorenz, Robert R.; Luther, Ralph B.; Knowles-Ward, Lisa; Kelly, Dianne L.; Weil, Robert J.

2014-01-01

Documentation of the care delivered to hospitalized patients is a ubiquitous and important aspect of medical care. The majority of references to documentation and coding are based on the Centers for Medicare and Medicaid Services (CMS) Medicare Severity Diagnosis Related Group (MS-DRG) inpatient prospective payment system (IPPS). We educated the members of a clinical care team in a single department (neurosurgery) at our hospital. We measured subsequent documentation improvements in a simple, meaningful, and reproducible fashion. We created a new metric to measure documentation, termed the “normalized case mix index,” that allows comparison of hospitalizations across multiple unrelated MS-DRG groups. Compared to one year earlier, the traditional case mix index, normalized case mix index, severity of illness, and risk of mortality increased one year after the educational intervention. We encourage other organizations to implement and systematically monitor documentation improvement efforts when attempting to determine the accuracy and quality of documentation achieved. PMID:25214820

Improving and measuring inpatient documentation of medical care within the MS-DRG system: education, monitoring, and normalized case mix index.

PubMed

Rosenbaum, Benjamin P; Lorenz, Robert R; Luther, Ralph B; Knowles-Ward, Lisa; Kelly, Dianne L; Weil, Robert J

2014-01-01

Documentation of the care delivered to hospitalized patients is a ubiquitous and important aspect of medical care. The majority of references to documentation and coding are based on the Centers for Medicare and Medicaid Services (CMS) Medicare Severity Diagnosis Related Group (MS-DRG) inpatient prospective payment system (IPPS). We educated the members of a clinical care team in a single department (neurosurgery) at our hospital. We measured subsequent documentation improvements in a simple, meaningful, and reproducible fashion. We created a new metric to measure documentation, termed the "normalized case mix index," that allows comparison of hospitalizations across multiple unrelated MS-DRG groups. Compared to one year earlier, the traditional case mix index, normalized case mix index, severity of illness, and risk of mortality increased one year after the educational intervention. We encourage other organizations to implement and systematically monitor documentation improvement efforts when attempting to determine the accuracy and quality of documentation achieved.

Medicare home health care patient case-mix before and after the Balanced Budget Act of 1997: effect on dual eligible beneficiaries.

PubMed

Shih, Huai-Che; Temkin-Greener, Helena; Votava, Kathryn; Friedman, Bruce

2014-01-01

The Balanced Budget Act (BBA) of 1997 changed the payment system for Medicare home health care (HHC) from cost-based to prospective reimbursement. We used Medical Expenditure Panel Survey data to assess the impact of the BBA on Medicare HHC patient case-mix measured by the Centers for Medicare and Medicaid Services Hierarchical Condition Categories (CMS-HCC) model. There was a significant increase in Medicare HHC patient case-mix between the pre-BBA and Prospective Payment System (PPS) periods. The increase in the standardized-predicted risk score from the Interim Payment System period to PPS was nearly 4 times greater for the dual eligibles (Medicare-Medicaid) than for the Medicare-only population. This significantly greater rise in the HHC resources required by dual eligibles as compared to nonduals could be due to a shift in HHC payers from Medicare only to Medicaid rather than be an actual increase in case-mix per se.

Medicare and Medicaid Programs; CY 2018 Home Health Prospective Payment System Rate Update and CY 2019 Case-Mix Adjustment Methodology Refinements; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements. Final rule.

PubMed

2017-11-07

This final rule updates the home health prospective payment system (HH PPS) payment rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor, effective for home health episodes of care ending on or after January 1, 2018. This rule also: Updates the HH PPS case-mix weights using the most current, complete data available at the time of rulemaking; implements the third year of a 3-year phase-in of a reduction to the national, standardized 60-day episode payment to account for estimated case-mix growth unrelated to increases in patient acuity (that is, nominal case-mix growth) between calendar year (CY) 2012 and CY 2014; and discusses our efforts to monitor the potential impacts of the rebasing adjustments that were implemented in CY 2014 through CY 2017. In addition, this rule finalizes changes to the Home Health Value-Based Purchasing (HHVBP) Model and to the Home Health Quality Reporting Program (HH QRP). We are not finalizing the implementation of the Home Health Groupings Model (HHGM) in this final rule.

Combining Advanced Turbulent Mixing and Combustion Models with Advanced Multi-Phase CFD Code to Simulate Detonation and Post-Detonation Bio-Agent Mixing and Destruction

DTIC Science & Technology

2017-10-01

perturbations in the energetic material to study their effects on the blast wave formation. The last case also makes use of the same PBX, however, the...configuration, Case A: Spore cloud located on the top of the charge at an angle 45 degree, Case B: Spore cloud located at an angle 45 degree from the charge...theoretical validation. The first is the Sedov case where the pressure decay and blast wave front are validated based on analytical solutions. In this test

Factors predicting rehabilitation outcomes of elderly patients with hip fracture.

PubMed

Chin, Raymond P H; Ng, Bobby H P; Cheung, Lydia P C

2008-06-01

To identify predictors of rehabilitation outcomes for the development of a case-mix system to rehabilitate patients suffering from hip fractures. Prospective cohort study. Two hospitals in Hong Kong. A cohort of hip fracture patients in 2005 (n=303) with a mean age of 82 years was studied. Rehabilitation outcomes were defined as: mortality, length of stay, placement, ambulation status, activity of daily living at the time of discharge and at 6-month follow-up. A comparison between groups and multivariate analysis was conducted to validate the best predictors. Potential predictors and rehabilitation outcomes. Two predictors, the Abbreviated Mental Test score of lower than 6 (odds ratio=0.19, P<0.05) and the Functional Independence Measures score of lower than 75 (odds ratio=38.0, P<0.05), at the time of admission to the rehabilitation setting were found to be related to outcomes. Our findings provided further support for a case-mix system based on these two factors, as they could correctly assign patients into three groups with different baseline characteristics and outcomes. A review of the possible limitations of the existing service with respect to each case-mix group was also conducted. A case-mix system utilising the cognition and activity of daily living function is recommended. Revisions of respective care plans are advocated with more realistic outcome expectations and specific actions for the respective case-mix groups. An evaluation study on the usefulness of this case-mix classification could then follow.

[A new methodological approach for leptospira persistence studies in case of mixed leptospirosis].

PubMed

Samsonova, A P; Petrov, E M; Vyshivkina, N V; Anan'ina, Iu V

2003-01-01

A new methodical approach for Leptospira persistence studies in case of mixed leptospirosis, based on the use of PCR test systems with different taxonomic specificity for the indication and identification of leptospires, was developed. Two PCR test systems (G and B) were used in experiments on BALB/c white mice to study patterns of the development of mixed infection caused by leptospires of serovar poi (genomospecies L. borgpeterseni) and grippotyphosa (genomospecies L. kirschneri). The conclusion was made of good prospects of this method application in studies on symbiotic relationships of leptospires both in vivo and in vitro.

Case-mix reimbursement for nursing home services: Simulation approach

PubMed Central

Adams, E. Kathleen; Schlenker, Robert E.

1986-01-01

Nursing home reimbursement based on case mix is a matter of growing interest. Several States either use or are considering this reimbursement method. In this article, we present a method for evaluating key outcomes of such a change for Connecticut nursing homes. A simulation model is used to replicate payments under the case-mix systems used in Maryland, Ohio, and West Virginia. The findings indicate that, compared with the system presently used in Connecticut, these systems would better relate dollar payments to measure patient need, and for-profit homes would benefit relative to nonprofit homes. The Ohio methodology would impose the most additional costs, the West Virginia system would actually be somewhat less expensive in terms of direct patient care payments. PMID:10311776

Case-mix reimbursement for nursing home services: simulation approach.

PubMed

Adams, E K; Schlenker, R E

1986-01-01

Nursing home reimbursement based on case mix is a matter of growing interest. Several States either use or are considering this reimbursement method. In this article, we present a method for evaluating key outcomes of such a change for Connecticut nursing homes. A simulation model is used to replicate payments under the case-mix systems used in Maryland, Ohio, and West Virginia. The findings indicate that, compared with the system presently used in Connecticut, these systems would better relate dollar payments to measure patient need, and for-profit homes would benefit relative to nonprofit homes. The Ohio methodology would impose the most additional costs, the West Virginia system would actually be somewhat less expensive in terms of direct patient care payments.

Simulating the impact of case-mix adjusted hospice rates

PubMed Central

Mor, Vincent; Laliberte, Linda

1986-01-01

The Medicare hospice benefit prospectively reimburses hospices based on the inpatient status of the patient, whether or not the patient is at home, and whether the patient is receiving round-the-clock nursing. Using National Hospice Study data, two case-mix adjusters based on patient functioning and living arrangement were found to be significantly related to per diem cost. These were tested by simulating their impact on hospice revenues. Increasing per diem reimbursements 35 percent for nonambulatory patients living alone only increases hospice revenues by 4 percent; hospices with sicker patients benefit the most. PMID:10312012

Improving ethical knowledge and sensemaking from cases through elaborative interrogation and outcome valence.

PubMed

Johnson, James F; Bagdasarov, Zhanna; MacDougall, Alexandra E; Steele, Logan; Connelly, Shane; Devenport, Lynn D; Mumford, Michael D

2014-01-01

The case-based approach to learning is popular among many applied fields. However, results of case-based education vary widely on case content and case presentation. This study examined two aspects of case-based education-outcome valence and case elaboration methods-in a two-day case-based Responsible Conduct of Research (RCR) ethics education program. Results suggest that outcome information is an integral part of a quality case. Furthermore, valence consistent outcomes may have certain advantages over mixed valence outcome information. Finally, students enjoy and excel working with case material, and the use of elaborative interrogation techniques can significantly improve internally-focused ethical sensemaking strategies associated with personal biases, constraints, and emotions.

An ocean large-eddy simulation of Langmuir circulations and convection in the surface mixed layer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Skyllingstad, E.D.; Denbo, D.W.

Numerical experiments were performed using a three-dimensional large-eddy simulation model of the ocean surface mixed layer that includes the Craik-Leibovich vortex force to parameterize the interaction of surface waves with mean currents. Results from the experiments show that the vortex force generates Langmuir circulations that can dominate vertical mixing. The simulated vertical velocity fields show linear, small-scale, coherent structures near the surface that extend downwind across the model domain. In the interior of the mixed layer, scales of motion increase to eddy sizes that are roughly equivalent to the mixed-layer depth. Cases with the vortex force have stronger circulations nearmore » the surface in contrast to cases with only heat flux and wind stress, particularly when the heat flux is positive. Calculations of the velocity variance and turbulence dissipation rates for cases with and without the vortex force, surface cooling, and wind stress indicate that wave-current interactions are a dominant mixing process in the upper mixed layer. Heat flux calculations show that the entrainment rate at the mixed-layer base can be up to two times greater when the vortex force is included. In a case with reduced wind stress, turbulence dissipation rates remained high near the surface because of the vortex force interaction with preexisting inertial currents. In deep mixed layers ({approximately}250 m) the simulations show that Langmuir circulations can vertically transport water 145 m during conditions of surface heating. Observations of turbulence dissipation rates and the vertical temperature structure support the model results. 42 refs., 20 figs., 21 tabs.« less

Prospective payment based on case mix: will it work in nursing homes?

PubMed

Rosko, M D; Broyles, R W; Aaronson, W E

1987-01-01

This article evaluates the potential efficacy of implementing a prospective payment system based on case mix in the nursing home industry. The analysis of structural differences between the nursing home and hospital industries suggests that the mechanism of compensating long-term care facilities should be based on functional health status rather than on diagnosis and that incentives to improve quality and access should be strengthened. The article assesses several systems of classifying patients that have been proposed as the basis for implementing a prospective payment system in the nursing home industry. The article concludes with a discussion of policy issues related to the appropriate unit of payment and the scope of regulatory authority.

Hospital accreditation, reimbursement and case mix: links and insights for contractual systems.

PubMed

Ammar, Walid; Khalife, Jade; El-Jardali, Fadi; Romanos, Jenny; Harb, Hilda; Hamadeh, Ghassan; Dimassi, Hani

2013-12-05

Resource consumption is a widely used proxy for severity of illness, and is often measured through a case-mix index (CMI) based on Diagnosis Related Groups (DRGs), which is commonly linked to payment. For countries that do not have DRGs it has been suggested to use CMIs derived from International Classification of Diseases (ICD). Our research objective was to use ICD-derived case-mix to evaluate whether or not the current accreditation-based hospital reimbursement system in Lebanon is appropriate. Our study population included medical admissions to 122 hospitals contracted with the Lebanese Ministry of Public Health (MoPH) between June 2011 and May 2012. Applying ICD-derived CMI on principal diagnosis cost (CMI-ICDC) using weighing similar to that used in Medicare DRG CMI, analyses were made by hospital accreditation, ownership and size. We examined two measures of 30-day re-admission rate. Further analysis was done to examine correlation between principal diagnosis CMI and surgical procedure cost CMI (CMI-CPTC), and three proxy measures on surgical complexity, case complexity and surgical proportion. Hospitals belonging to the highest accreditation category had a higher CMI than others, but no difference was found in CMI among the three other categories. Private hospitals had a higher CMI than public hospitals, and those more than 100 beds had a higher CMI than smaller hospitals. Re-admissions rates were higher in accreditation category C hospitals than category D hospitals. CMI-ICDC was fairly correlated with CMI-CPTC, and somehow correlated with the proposed proxies. Our results indicate that the current link between accreditation and reimbursement rate is not appropriate, and leads to unfairness and inefficiency in the system. Some proxy measures are correlated with case-mix but are not good substitutes for it. Policy implications of our findings propose the necessity for changing the current reimbursement system by including case mix and outcome indicators in addition to accreditation in hospital contracting. Proxies developed may be used to detect miss-use and provider adverse behavior. Research using ICD-derived case mix is limited and our findings may be useful to inform similar initiatives and other limited-setting countries in the region.

The Effects of Instructional Implementation on Learning with Interactive Multimedia Case-Based Instruction

ERIC Educational Resources Information Center

Mitchem, Katherine; Koury, Kevin; Fitzgerald, Gail; Hollingsead, Candice; Miller, Kevin; Tsai, Hui-Hsien; Zha, Shenghua

2009-01-01

Interactive, multimedia cases with technology supports present new ways of teaching and learning in teacher education. In this mixed-methods, naturalistic study, the authors investigate how and what participants learn from multimedia cases and, in particular, how instructional implementation affects learning outcomes from multimedia cases.…

Case mix-adjusted cost of colectomy at low-, middle-, and high-volume academic centers.

PubMed

Chang, Alex L; Kim, Young; Ertel, Audrey E; Hoehn, Richard S; Wima, Koffi; Abbott, Daniel E; Shah, Shimul A

2017-05-01

Efforts to regionalize surgery based on thresholds in procedure volume may have consequences on the cost of health care delivery. This study aims to delineate the relationship between hospital volume, case mix, and variability in the cost of operative intervention using colectomy as the model. All patients undergoing colectomy (n = 90,583) at 183 academic hospitals from 2009-2012 in The University HealthSystems Consortium Database were studied. Patient and procedure details were used to generate a case mix-adjusted predictive model of total direct costs. Observed to expected costs for each center were evaluated between centers based on overall procedure volume. Patient and procedure characteristics were significantly different between volume tertiles. Observed costs at high-volume centers were less than at middle- and low-volume centers. According to our predictive model, high-volume centers cared for a less expensive case mix than middle- and low-volume centers ($12,786 vs $13,236 and $14,497, P < .01). Our predictive model accounted for 44% of the variation in costs. Overall efficiency (standardized observed to expected costs) was greatest at high-volume centers compared to middle- and low-volume tertiles (z score -0.16 vs 0.02 and -0.07, P < .01). Hospital costs and cost efficiency after an elective colectomy varies significantly between centers and may be attributed partially to the patient differences at those centers. These data demonstrate that a significant proportion of the cost variation is due to a distinct case mix at low-volume centers, which may lead to perceived poor performance at these centers. Copyright © 2016 Elsevier Inc. All rights reserved.

Design optimization of single mixed refrigerant LNG process using a hybrid modified coordinate descent algorithm

NASA Astrophysics Data System (ADS)

Qyyum, Muhammad Abdul; Long, Nguyen Van Duc; Minh, Le Quang; Lee, Moonyong

2018-01-01

Design optimization of the single mixed refrigerant (SMR) natural gas liquefaction (LNG) process involves highly non-linear interactions between decision variables, constraints, and the objective function. These non-linear interactions lead to an irreversibility, which deteriorates the energy efficiency of the LNG process. In this study, a simple and highly efficient hybrid modified coordinate descent (HMCD) algorithm was proposed to cope with the optimization of the natural gas liquefaction process. The single mixed refrigerant process was modeled in Aspen Hysys® and then connected to a Microsoft Visual Studio environment. The proposed optimization algorithm provided an improved result compared to the other existing methodologies to find the optimal condition of the complex mixed refrigerant natural gas liquefaction process. By applying the proposed optimization algorithm, the SMR process can be designed with the 0.2555 kW specific compression power which is equivalent to 44.3% energy saving as compared to the base case. Furthermore, in terms of coefficient of performance (COP), it can be enhanced up to 34.7% as compared to the base case. The proposed optimization algorithm provides a deep understanding of the optimization of the liquefaction process in both technical and numerical perspectives. In addition, the HMCD algorithm can be employed to any mixed refrigerant based liquefaction process in the natural gas industry.

Robotic and open radical prostatectomy in the public health sector: cost comparison.

PubMed

Hall, Rohan Matthew; Linklater, Nicholas; Coughlin, Geoff

2014-06-01

During 2008, the Royal Brisbane and Women's Hospital became the first public hospital in Australia to have a da Vinci Surgical Robot purchased by government funding. The cost of performing robotic surgery in the public sector is a contentious issue. This study is a single centre, cost analysis comparing open radical prostatectomy (RRP) and robotic-assisted radical prostatectomy (RALP) based on the newly introduced pure case-mix funding model. A retrospective chart review was performed for the first 100 RALPs and the previous 100 RRPs. Estimates of tangible costing and funding were generated for each admission and readmission, using the Royal Brisbane Hospital Transition II database, based on pure case-mix funding. The average cost for admission for RRP was A$13 605, compared to A$17 582 for the RALP. The average funding received for a RRP was A$11 781 compared to A$5496 for a RALP based on the newly introduced case-mix model. The average length of stay for RRP was 4.4 days (2-14) and for RALP, 1.2 days (1-4). The total cost of readmissions for RRP patients was A$70 487, compared to that of the RALP patients, A$7160. These were funded at A$55 639 and A$7624, respectively. RALP has shown a significant advantage with respect to length of stay and readmission rate. Based on the case-mix funding model RALP is poorly funded compared to its open equivalent. Queensland Health needs to plan on how robotic surgery is implemented and assess whether this technology is truly affordable in the public sector. © 2013 The Authors. ANZ Journal of Surgery © 2013 Royal Australasian College of Surgeons.

Joint physical and numerical modeling of water distribution networks.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zimmerman, Adam; O'Hern, Timothy John; Orear, Leslie Jr.

2009-01-01

This report summarizes the experimental and modeling effort undertaken to understand solute mixing in a water distribution network conducted during the last year of a 3-year project. The experimental effort involves measurement of extent of mixing within different configurations of pipe networks, measurement of dynamic mixing in a single mixing tank, and measurement of dynamic solute mixing in a combined network-tank configuration. High resolution analysis of turbulence mixing is carried out via high speed photography as well as 3D finite-volume based Large Eddy Simulation turbulence models. Macroscopic mixing rules based on flow momentum balance are also explored, and in somemore » cases, implemented in EPANET. A new version EPANET code was developed to yield better mixing predictions. The impact of a storage tank on pipe mixing in a combined pipe-tank network during diurnal fill-and-drain cycles is assessed. Preliminary comparison between dynamic pilot data and EPANET-BAM is also reported.« less

Trends in managed care contracting among U.S. hospitals.

PubMed

Gautam, K; Campbell, C; Arrington, B

1995-01-01

This article describes the changing profile of hospitals initiating managed care contracts as of 1992. Based on statistical tests, early contractors rank higher on profitability, case mix, bed size, affiliation, and urban location. In contrast, recent and noncontractors are predominantly rural, freestanding hospitals with low case mix, low profitability, high subacute services, and government ownership. A number of lessons for the future are drawn and a stage-by-stage approach to studying managed care issues is proposed.

Developing a case-mix model for PPS.

PubMed

Goldberg, H B; Delargy, D

2000-01-01

Agencies are pinning hopes for success under PPS on an accurate case-mix adjustor. The Health Care Financing Administration (HCFA) tasked Abt Associates Inc. to develop a system to accurately predict the volume and type of home health services each patient requires, based on his or her characteristics (not the service actually received). HCFA wanted this system to be feasible, clinically logical, and valid and accurate. Authors Goldberg and Delargy explain how Abt approached this daunting task.

29 CFR 1614.302 - Mixed case complaints.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 29 Labor 4 2012-07-01 2012-07-01 false Mixed case complaints. 1614.302 Section 1614.302 Labor... EMPLOYMENT OPPORTUNITY Related Processes § 1614.302 Mixed case complaints. (a) Definitions—(1) Mixed case complaint. A mixed case complaint is a complaint of employment discrimination filed with a federal agency...

29 CFR 1614.302 - Mixed case complaints.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 29 Labor 4 2014-07-01 2014-07-01 false Mixed case complaints. 1614.302 Section 1614.302 Labor... EMPLOYMENT OPPORTUNITY Related Processes § 1614.302 Mixed case complaints. (a) Definitions—(1) Mixed case complaint. A mixed case complaint is a complaint of employment discrimination filed with a federal agency...

29 CFR 1614.302 - Mixed case complaints.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 29 Labor 4 2013-07-01 2013-07-01 false Mixed case complaints. 1614.302 Section 1614.302 Labor... EMPLOYMENT OPPORTUNITY Related Processes § 1614.302 Mixed case complaints. (a) Definitions—(1) Mixed case complaint. A mixed case complaint is a complaint of employment discrimination filed with a federal agency...

29 CFR 1614.302 - Mixed case complaints.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 29 Labor 4 2011-07-01 2011-07-01 false Mixed case complaints. 1614.302 Section 1614.302 Labor... EMPLOYMENT OPPORTUNITY Related Processes § 1614.302 Mixed case complaints. (a) Definitions—(1) Mixed case complaint. A mixed case complaint is a complaint of employment discrimination filed with a federal agency...

29 CFR 1614.302 - Mixed case complaints.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 29 Labor 4 2010-07-01 2010-07-01 false Mixed case complaints. 1614.302 Section 1614.302 Labor... EMPLOYMENT OPPORTUNITY Related Processes § 1614.302 Mixed case complaints. (a) Definitions—(1) Mixed case complaint. A mixed case complaint is a complaint of employment discrimination filed with a federal agency...

A novel Sin Nombre virus DNA vaccine and its inclusion in a candidate pan-hantavirus vaccine against hantavirus pulmonary syndrome (HPS) and hemorrhagic fever with renal syndrome (HFRS).

PubMed

Hooper, Jay W; Josleyn, Matthew; Ballantyne, John; Brocato, Rebecca

2013-09-13

Sin Nombre virus (SNV; family Bunyaviridae, genus Hantavirus) causes a hemorrhagic fever known as hantavirus pulmonary syndrome (HPS) in North America. There have been approximately 200 fatal cases of HPS in the United States since 1993, predominantly in healthy working-age males (case fatality rate 35%). There are no FDA-approved vaccines or drugs to prevent or treat HPS. Previously, we reported that hantavirus vaccines based on the full-length M gene segment of Andes virus (ANDV) for HPS in South America, and Hantaan virus (HTNV) and Puumala virus (PUUV) for hemorrhagic fever with renal syndrome (HFRS) in Eurasia, all elicited high-titer neutralizing antibodies in animal models. HFRS is more prevalent than HPS (>20,000 cases per year) but less pathogenic (case fatality rate 1-15%). Here, we report the construction and testing of a SNV full-length M gene-based DNA vaccine to prevent HPS. Rabbits vaccinated with the SNV DNA vaccine by muscle electroporation (mEP) developed high titers of neutralizing antibodies. Furthermore, hamsters vaccinated three times with the SNV DNA vaccine using a gene gun were completely protected against SNV infection. This is the first vaccine of any kind that specifically elicits high-titer neutralizing antibodies against SNV. To test the possibility of producing a pan-hantavirus vaccine, rabbits were vaccinated by mEP with an HPS mix (ANDV and SNV plasmids), or HFRS mix (HTNV and PUUV plasmids), or HPS/HFRS mix (all four plasmids). The HPS mix and HFRS mix elicited neutralizing antibodies predominantly against ANDV/SNV and HTNV/PUUV, respectively. Furthermore, the HPS/HFRS mix elicited neutralizing antibodies against all four viruses. These findings demonstrate a pan-hantavirus vaccine using a mixed-plasmid DNA vaccine approach is feasible and warrants further development. Copyright © 2013 The Authors. Published by Elsevier Ltd.. All rights reserved.

Case-mix payment for nursing home care: lessons from Maryland.

PubMed

Feder, J; Scanlon, W

1989-01-01

Even before Medicare adopted case-based payments for hospitals, some state Medicaid programs employed case-mix payment systems for nursing home care. Their purpose was less to promote cost containment than to improve access to nursing homes for the most costly patients. This paper evaluates one such system, adopted by the state of Maryland in 1983 as part of an overall reimbursement reform. Using data on nursing home patient characteristics, costs, and staffing, as well as interviews with officials and various providers of care, the article shows that Maryland's system was successful in shifting nursing home service away from light-care and toward heavy-care patients. Furthermore, the shift occurred without inducing readily measurable declines in quality of care and with little additional administrative cost (partly because the state built its case-mix system on preexisting patient review activities). Although states could learn from and improve upon Maryland's experience--most notably in offering incentives to improve quality of care and in targeting community care on the light-care patients that nursing homes become less willing to serve--Maryland demonstrates that case-mix payment can change nursing home behavior in desired directions without substantial negative consequences.

12 CFR 268.302 - Mixed case complaints.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 12 Banks and Banking 4 2014-01-01 2014-01-01 false Mixed case complaints. 268.302 Section 268.302... (CONTINUED) RULES REGARDING EQUAL OPPORTUNITY Related Processes § 268.302 Mixed case complaints. A mixed case... discrimination or it may contain additional allegations that the MSPB has jurisdiction to address. A mixed case...

12 CFR 268.302 - Mixed case complaints.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 12 Banks and Banking 4 2013-01-01 2013-01-01 false Mixed case complaints. 268.302 Section 268.302... (CONTINUED) RULES REGARDING EQUAL OPPORTUNITY Related Processes § 268.302 Mixed case complaints. A mixed case... discrimination or it may contain additional allegations that the MSPB has jurisdiction to address. A mixed case...

12 CFR 268.302 - Mixed case complaints.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 12 Banks and Banking 4 2012-01-01 2012-01-01 false Mixed case complaints. 268.302 Section 268.302... (CONTINUED) RULES REGARDING EQUAL OPPORTUNITY Related Processes § 268.302 Mixed case complaints. A mixed case... discrimination or it may contain additional allegations that the MSPB has jurisdiction to address. A mixed case...

Case-Based Learning as Pedagogy for Teaching Information Ethics Based on the Dervin Sense-Making Methodology

ERIC Educational Resources Information Center

Dow, Mirah J.; Boettcher, Carrie A.; Diego, Juana F.; Karch, Marziah E.; Todd-Diaz, Ashley; Woods, Kristine M.

2015-01-01

The purpose of this mixed methods study is to determine the effectiveness of case-based pedagogy in teaching basic principles of information ethics and ethical decision making. Study reports results of pre- and post-assessment completed by 49 library and information science (LIS) graduate students at a Midwestern university. Using Creswell's…

An adjoint-based framework for maximizing mixing in binary fluids

NASA Astrophysics Data System (ADS)

Eggl, Maximilian; Schmid, Peter

2017-11-01

Mixing in the inertial, but laminar parameter regime is a common application in a wide range of industries. Enhancing the efficiency of mixing processes thus has a fundamental effect on product quality, material homogeneity and, last but not least, production costs. In this project, we address mixing efficiency in the above mentioned regime (Reynolds number Re = 1000 , Peclet number Pe = 1000) by developing and demonstrating an algorithm based on nonlinear adjoint looping that minimizes the variance of a passive scalar field which models our binary Newtonian fluids. The numerical method is based on the FLUSI code (Engels et al. 2016), a Fourier pseudo-spectral code, which we modified and augmented by scalar transport and adjoint equations. Mixing is accomplished by moving stirrers which are numerically modeled using a penalization approach. In our two-dimensional simulations we consider rotating circular and elliptic stirrers and extract optimal mixing strategies from the iterative scheme. The case of optimizing shape and rotational speed of the stirrers will be demonstrated.

Large outbreak of Legionnaires' disease and Pontiac fever at a military base.

PubMed

Ambrose, J; Hampton, L M; Fleming-Dutra, K E; Marten, C; McClusky, C; Perry, C; Clemmons, N A; McCormic, Z; Peik, S; Mancuso, J; Brown, E; Kozak, N; Travis, T; Lucas, C; Fields, B; Hicks, L; Cersovsky, S B

2014-11-01

We investigated a mixed outbreak of Legionnaires' disease (LD) and Pontiac fever (PF) at a military base to identify the outbreak's environmental source as well as known legionellosis risk factors. Base workers with possible legionellosis were interviewed and, if consenting, underwent testing for legionellosis. A retrospective cohort study collected information on occupants of the buildings closest to the outbreak source. We identified 29 confirmed and probable LD and 38 PF cases. All cases were exposed to airborne pathogens from a cooling tower. Occupants of the building closest to the cooling tower were 6·9 [95% confidence interval (CI) 2·2-22·0] and 5·5 (95% CI 2·1-14·5) times more likely to develop LD and PF, respectively, than occupants of the next closest building. Thorough preventive measures and aggressive responses to outbreaks, including searching for PF cases in mixed legionellosis outbreaks, are essential for legionellosis control.

Can Mixed Parasite Infections Thwart Targeted Malaria Elimination Program in India?

PubMed

Singh, Upasana Shyamsunder; Siwal, Nisha; Pande, Veena; Das, Aparup

2017-01-01

India is highly endemic to malaria with prevalence of all five species of human malaria parasites of Plasmodium genus. India is set for malaria elimination by 2030. Since cases of mixed Plasmodium species infections remain usually undetected but cause huge disease burden, in order to understand the distributional prevalence of both monospecies infections and mixed species infections in India, we collated published data on the differential infection incidences of the five different malaria parasites based on PCR diagnostic assay. About 11% of total cases were due to mixed species infection. Among several interesting observations on both single and mixed parasitic infections, incidences of Plasmodium falciparum monoinfection were found to be significantly higher than P. vivax monoinfection. Also, P. malariae seems to be emerging as a potential malaria threat in India. Putting all the facts together, it appears that the dream of achieving malaria elimination in India will not be completely successful without dealing with mixed species infection.

Target space pseudoduality in supersymmetric sigma models on symmetric spaces

NASA Astrophysics Data System (ADS)

Sarisaman, Mustafa

We discuss the target space pseudoduality in supersymmetric sigma models on symmetric spaces. We first consider the case where sigma models based on real compact connected Lie groups of the same dimensionality and give examples using three dimensional models on target spaces. We show explicit construction of nonlocal conserved currents on the pseudodual manifold. We then switch the Lie group valued pseudoduality equations to Lie algebra valued ones, which leads to an infinite number of pseudoduality equations. We obtain an infinite number of conserved currents on the tangent bundle of the pseudo-dual manifold. Since pseudoduality imposes the condition that sigma models pseudodual to each other are based on symmetric spaces with opposite curvatures (i.e. dual symmetric spaces), we investigate pseudoduality transformation on the symmetric space sigma models in the third chapter. We see that there can be mixing of decomposed spaces with each other, which leads to mixings of the following expressions. We obtain the pseudodual conserved currents which are viewed as the orthonormal frame on the pullback bundle of the tangent space of G˜ which is the Lie group on which the pseudodual model based. Hence we obtain the mixing forms of curvature relations and one loop renormalization group beta function by means of these currents. In chapter four, we generalize the classical construction of pseudoduality transformation to supersymmetric case. We perform this both by component expansion method on manifold M and by orthonormal coframe method on manifold SO( M). The component method produces the result that pseudoduality transformation is not invertible at all points and occurs from all points on one manifold to only one point where riemann normal coordinates valid on the second manifold. Torsion of the sigma model on M must vanish while it is nonvanishing on M˜, and curvatures of the manifolds must be constant and the same because of anticommuting grassmann numbers. We obtain the similar results with the classical case in orthonormal coframe method. In case of super WZW sigma models pseudoduality equations result in three different pseudoduality conditions; flat space, chiral and antichiral pseudoduality. Finally we study the pseudoduality transformations on symmetric spaces using two different methods again. These two methods yield similar results to the classical cases with the exception that commuting bracket relations in classical case turns out to be anticommuting ones because of the appearance of grassmann numbers. It is understood that constraint relations in case of non-mixing pseudoduality are the remnants of mixing pseudoduality. Once mixing terms are included in the pseudoduality the constraint relations disappear.

Case-Based Reasoning in Mixed Paradigm Settings and with Learning

DTIC Science & Technology

1994-04-30

Learning Prototypical Cases OFF-BROADWAY, MCI and RMHC -* are three CBR-ML systems that learn case prototypes. We feel that methods that enable the...at Irvine Machine Learning Repository, including heart disease and breast cancer databases. OFF-BROADWAY, MCI and RMHC -* made the following notable

Detection of Mixed Infection from Bacterial Whole Genome Sequence Data Allows Assessment of Its Role in Clostridium difficile Transmission

PubMed Central

Eyre, David W.; Cule, Madeleine L.; Griffiths, David; Crook, Derrick W.; Peto, Tim E. A.

2013-01-01

Bacterial whole genome sequencing offers the prospect of rapid and high precision investigation of infectious disease outbreaks. Close genetic relationships between microorganisms isolated from different infected cases suggest transmission is a strong possibility, whereas transmission between cases with genetically distinct bacterial isolates can be excluded. However, undetected mixed infections—infection with ≥2 unrelated strains of the same species where only one is sequenced—potentially impairs exclusion of transmission with certainty, and may therefore limit the utility of this technique. We investigated the problem by developing a computationally efficient method for detecting mixed infection without the need for resource-intensive independent sequencing of multiple bacterial colonies. Given the relatively low density of single nucleotide polymorphisms within bacterial sequence data, direct reconstruction of mixed infection haplotypes from current short-read sequence data is not consistently possible. We therefore use a two-step maximum likelihood-based approach, assuming each sample contains up to two infecting strains. We jointly estimate the proportion of the infection arising from the dominant and minor strains, and the sequence divergence between these strains. In cases where mixed infection is confirmed, the dominant and minor haplotypes are then matched to a database of previously sequenced local isolates. We demonstrate the performance of our algorithm with in silico and in vitro mixed infection experiments, and apply it to transmission of an important healthcare-associated pathogen, Clostridium difficile. Using hospital ward movement data in a previously described stochastic transmission model, 15 pairs of cases enriched for likely transmission events associated with mixed infection were selected. Our method identified four previously undetected mixed infections, and a previously undetected transmission event, but no direct transmission between the pairs of cases under investigation. These results demonstrate that mixed infections can be detected without additional sequencing effort, and this will be important in assessing the extent of cryptic transmission in our hospitals. PMID:23658511

The Validity of Uniform Chart of Accounts as a Measure of Resource Consumption at the Patient Level.

DTIC Science & Technology

1984-05-20

required to meet the projected rates of demand based on the DIE case-mix concept . However, this is futuristic and the concern of today’s military...on the DRG case-mix concept . However, ihis is futuristic and the concern of today’s military health care manager is with the Uniform Chart of Accounts...product of a healthcare institution. This concept is vastly different from the one which considers the proxy measure of the number of institutional

Development of MY-DRG casemix pharmacy service weights in UKM Medical Centre in Malaysia.

PubMed

Ali Jadoo, Saad Ahmed; Aljunid, Syed Mohamed; Nur, Amrizal Muhammad; Ahmed, Zafar; Van Dort, Dexter

2015-02-10

The service weight is among several issues and challenges in the implementation of case-mix in developing countries, including Malaysia. The aim of this study is to develop the Malaysian Diagnosis Related Group (MY-DRG) case-mix pharmacy service weight in University Kebangsaan Malaysia-Medical Center (UKMMC) by identifying the actual cost of pharmacy services by MY-DRG groups in the hospital. All patients admitted to UKMMC in 2011 were recruited in this study. Combination of Step-down and Bottom-up costing methodology has been used in this study. The drug and supplies cost; the cost of staff; the overhead cost; and the equipment cost make up the four components of pharmacy. Direct costing approach has been employed to calculate Drugs and supplies cost from electronic-prescription system; and the inpatient pharmacy staff cost, while the overhead cost and the pharmacy equipments cost have been calculated indirectly from MY-DRG data base. The total pharmacy cost was obtained by summing the four pharmacy components' cost per each MY-DRG. The Pharmacy service weight of a MY-DRG was estimated by dividing the average pharmacy cost of the investigated MY-DRG on the average of a specified MY-DRG (which usually the average pharmacy cost of all MY-DRGs). Drugs and supplies were the main component (86.0%) of pharmacy cost compared o overhead cost centers (7.3%), staff cost (6.5%) and pharmacy equipments (0.2%) respectively. Out of 789 inpatient MY-DRGs case-mix groups, 450 (57.0%) groups were utilized by the UKMMC. Pharmacy service weight has been calculated for each of these 450 MY-DRGs groups. MY-DRG case-mix group of Lymphoma & Chronic Leukemia group with severity level three (C-4-11-III) has the highest pharmacy service weight of 11.8 equivalents to average pharmacy cost of RM 5383.90. While the MY-DRG case-mix group for Circumcision with severity level one (V-1-15-I) has the lowest pharmacy service weight of 0.04 equivalents to average pharmacy cost of RM 17.83. A mixed approach which is based partly on top-down and partly on bottom up costing methodology has been recruited to develop MY-DRG case-mix pharmacy service weight for 450 groups utilized by the UKMMC in 2011.

Parameterization of large-scale turbulent diffusion in the presence of both well-mixed and weakly mixed patchy layers

NASA Astrophysics Data System (ADS)

Osman, M. K.; Hocking, W. K.; Tarasick, D. W.

2016-06-01

Vertical diffusion and mixing of tracers in the upper troposphere and lower stratosphere (UTLS) are not uniform, but primarily occur due to patches of turbulence that are intermittent in time and space. The effective diffusivity of regions of patchy turbulence is related to statistical parameters describing the morphology of turbulent events, such as lifetime, number, width, depth and local diffusivity (i.e., diffusivity within the turbulent patch) of the patches. While this has been recognized in the literature, the primary focus has been on well-mixed layers, with few exceptions. In such cases the local diffusivity is irrelevant, but this is not true for weakly and partially mixed layers. Here, we use both theory and numerical simulations to consider the impact of intermediate and weakly mixed layers, in addition to well-mixed layers. Previous approaches have considered only one dimension (vertical), and only a small number of layers (often one at each time step), and have examined mixing of constituents. We consider a two-dimensional case, with multiple layers (10 and more, up to hundreds and even thousands), having well-defined, non-infinite, lengths and depths. We then provide new formulas to describe cases involving well-mixed layers which supersede earlier expressions. In addition, we look in detail at layers that are not well mixed, and, as an interesting variation on previous models, our procedure is based on tracking the dispersion of individual particles, which is quite different to the earlier approaches which looked at mixing of constituents. We develop an expression which allows determination of the degree of mixing, and show that layers used in some previous models were in fact not well mixed and so produced erroneous results. We then develop a generalized model based on two dimensional random-walk theory employing Rayleigh distributions which allows us to develop a universal formula for diffusion rates for multiple two-dimensional layers with general degrees of mixing. We show that it is the largest, most vigorous and less common turbulent layers that make the major contribution to global diffusion. Finally, we make estimates of global-scale diffusion coefficients in the lower stratosphere and upper troposphere. For the lower stratosphere, κeff ≈ 2x10-2 m2 s-1, assuming no other processes contribute to large-scale diffusion.

Ignition and Performance Tests of Rocket-Based Combined Cycle Propulsion System

NASA Technical Reports Server (NTRS)

Anderson, William E.

2005-01-01

The ground testing of a Rocket Based Combined Cycle engine implementing the Simultaneous Mixing and Combustion scheme was performed at the direct-connect facility of Purdue University's High Pressure Laboratory. The fuel-rich exhaust of a JP-8/H2O2 thruster was mixed with compressed, metered air in a constant area, axisymmetric duct. The thruster was similar in design and function to that which will be used in the flight test series of Dryden's Ducted-Rocket Experiment. The determination of duct ignition limits was made based on the variation of secondary air flow rates and primary thruster equivalence ratios. Thrust augmentation and improvements in specific impulse were studied along with the pressure and temperature profiles of the duct to study mixing lengths and thermal choking. The occurrence of ignition was favored by lower rocket equivalence ratios. However, among ignition cases, better thrust and specific impulse performance were seen with higher equivalence ratios owing to the increased fuel available for combustion. Thrust and specific impulse improvements by factors of 1.2 to 1.7 were seen. The static pressure and temperature profiles allowed regions of mixing and heat addition to be identified. The mixing lengths were found to be shorter at lower rocket equivalence ratios. Total pressure measurements allowed plume-based calculation of thrust, which agreed with load-cell measured values to within 6.5-8.0%. The corresponding Mach Number profile indicated the flow was not thermally choked for the highest duct static pressure case.

Case-Based Instruction in Different Delivery Contexts: The Impact of Time in Cases

ERIC Educational Resources Information Center

Koury, Kevin; Hollingsead, Candice; Fitzgerald, Gail; Miller, Kevin; Mitchem, Katherine; Tsai, Hui-Hsien; Zha, Shenghua

2009-01-01

The focus of this article is a mixed methods naturalistic research project investigating the relationship between learners' time working within multimedia cases and learners' outcomes. Research was conducted across multiple delivery contexts in four universities. Participants were undergraduate and graduate teacher education students completing…

Case-mix and quality indicators in Chinese elder care homes: are there differences between government-owned and private-sector facilities?

PubMed

Liu, Chang; Feng, Zhanlian; Mor, Vincent

2014-02-01

To assess the association between ownership of Chinese elder care facilities and their performance quality and to compare the case-mix profile of residents and facility characteristics in government-owned and private-sector homes. Cross-sectional study. Census of elder care homes surveyed in Nanjing (2009) and Tianjin (2010). Elder care facilities located in urban Nanjing (n = 140, 95% of all) and urban Tianjin (n = 157, 97% of all). A summary case-mix index based on activity of daily living (ADL) limitations and cognitive impairment was created to measure levels of care needs of residents in each facility. Structure, process, and outcome measures were selected to assess facility-level quality of care. A structural quality measure, understaffing relative to resident levels of care needs, which indicates potentially inadequate staffing given resident case-mix, was also developed. Government-owned homes had significantly higher occupancy rates, presumably reflecting popular demand for publicly subsidized beds, but served residents who, on average, have fewer ADL and cognitive functioning limitations than those in private-sector facilities. Across a range of structure, process, and outcome measures of quality, there is no clear evidence suggesting advantages or disadvantages of either ownership type, although when staffing-to-resident ratio is gauged relative to resident case-mix, private-sector facilities were more likely to be understaffed than government-owned facilities. In Nanjing and Tianjin, private-sector homes were more likely to be understaffed, although their residents were sicker and frailer on average than those in government facilities. It is likely that the case-mix differences are the result of selective admission policies that favor healthier residents in government facilities than in private-sector homes. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.

Nursing home costs, Medicaid rates, and profits under alternative Medicaid payment systems.

PubMed Central

Schlenker, R E

1991-01-01

This analysis compares nursing home costs, Medicaid payment rates, and profits under three Medicaid nursing home payment systems: case-mix, facility-specific, and class-rate systems. Data used were collected from 135 nursing homes in seven states. The association of case mix with costs, rates, and profits under the three payment systems was of particular interest. Case mix was more strongly associated (positively) with patient care cost and the Medicaid rate for the case-mix systems than for the other systems, particularly the class-rate systems. In contrast, case mix and profits were not associated in the case-mix or facility-specific systems, but were negatively associated in the class rate systems. Overall, the results suggest that case-mix systems have some important advantages over other payment systems, but further research is needed on larger samples and involving the newer case-mix systems. PMID:1743972

Case mix, quality, and cost relationships in Colorado nursing homes.

PubMed

Schlenker, R E; Shaughessy, P W

1984-01-01

The analyses reported in this article assessed the cost, case mix, and quality interrelationships among Colorado nursing homes. A unique set of patient-level data was collected specifically to measure case mix and quality. Case mix was found to be strongly associated with cost, accounting for up to 45 percent of the variation in cost per patient day. The relationship between quality and cost was weaker; quality variables accounted for only about 10 percent of the cost per day variation. Case mix was also associated with several facility characteristics found to be significant in other cost studies, suggesting that such facility characteristics serve as partial proxy measures for case mix. The cost-case mix relationships appear to be strong enough to justify incorporating case mix directly in nursing home reimbursement systems. In contrast, the weaker cost-quality association implies that it may not (yet) be appropriate to incorporate quality directly in reimbursement.

42 CFR 484.220 - Calculation of the adjusted national prospective 60-day episode payment rate for case-mix and...

Code of Federal Regulations, 2014 CFR

2014-10-01

...-day episode payment rate for case-mix and area wage levels. 484.220 Section 484.220 Public Health... Calculation of the adjusted national prospective 60-day episode payment rate for case-mix and area wage levels... case-mix using a case-mix index to explain the relative resource utilization of different patients. To...

42 CFR 484.220 - Calculation of the adjusted national prospective 60-day episode payment rate for case-mix and...

Code of Federal Regulations, 2013 CFR

2013-10-01

...-day episode payment rate for case-mix and area wage levels. 484.220 Section 484.220 Public Health... Calculation of the adjusted national prospective 60-day episode payment rate for case-mix and area wage levels... case-mix using a case-mix index to explain the relative resource utilization of different patients. To...

42 CFR 484.220 - Calculation of the adjusted national prospective 60-day episode payment rate for case-mix and...

Code of Federal Regulations, 2011 CFR

2011-10-01

...-day episode payment rate for case-mix and area wage levels. 484.220 Section 484.220 Public Health... Calculation of the adjusted national prospective 60-day episode payment rate for case-mix and area wage levels... case-mix using a case-mix index to explain the relative resource utilization of different patients. To...

42 CFR 484.220 - Calculation of the adjusted national prospective 60-day episode payment rate for case-mix and...

Code of Federal Regulations, 2012 CFR

2012-10-01

...-day episode payment rate for case-mix and area wage levels. 484.220 Section 484.220 Public Health... Calculation of the adjusted national prospective 60-day episode payment rate for case-mix and area wage levels... case-mix using a case-mix index to explain the relative resource utilization of different patients. To...

An Observational Analysis of Coaching Behaviors for Career Development Event Teams: A Mixed Methods Study

ERIC Educational Resources Information Center

Ball, Anna L.; Bowling, Amanda M.; Sharpless, Justin D.

2016-01-01

School Based Agricultural Education (SBAE) teachers can use coaching behaviors, along with their agricultural content knowledge to help their Career Development Event (CDE) teams succeed. This mixed methods, collective case study observed three SBAE teachers preparing multiple CDEs throughout the CDE season. The teachers observed had a previous…

Trends in prevalence of patient case-mix adjusters used in the Medicare dialysis payment system.

PubMed

Hollenbeak, Christopher S; Rubin, Robert J; Tzivelekis, Spiros; Stephens, J Mark

2015-06-01

The Medicare End-Stage Renal Disease Prospective Payment System (PPS) used data from 2006-08 to set weights for each case-mix adjuster that is part of the bundled payment formula. The details of the population case-mix were not made public, and little is known about consistency of case-mix over time. This study estimated the prevalence of case-mix adjusters during 2006-2008 and analyzed changes in case-mix prevalence from 2000-2008. Cross-sectional cohort study using United States Renal Data System data for Medicare dialysis patients. Three 3-year cohorts (2000-02, 2003-05, 2006-08) were analyzed for changes over time in case-mix prevalence. Double-digit trends were observed in many case-mix categories between 2000-02 and 2006-08. Large declines were observed in prevalence of patients with low BMI, pericarditis, new to dialysis, and ages 18-44. Large increases were observed in chronic co-morbidities, pneumonia and age cohort 80+. Substantial changes in case-mix adjuster prevalence suggest the PPS payment formula should be regularly updated.

Mental dysfunction and resource use in nursing homes.

PubMed

Fries, B E; Mehr, D R; Schneider, D; Foley, W J; Burke, R

1993-10-01

The role of dementia and other mental disorders in nursing home case-mix classification systems has been an area of controversy. The role of mental dysfunctions was considered in developing a new case-mix measurement system for facility payment in a national demonstration to understand staff time use in nursing homes. Nursing staff (nurses and aides) time and resident assessment data were collected for 6,663 nursing home residents in 6 states. Measures of signs and symptoms of cognitive impairment (dementia), depression, and delirium were created based on items from the new National Minimum Data Set. These measures then were used to determine whether mental dysfunctions were predictive of resource use (nursing staff times and costs) when controlling for other case-mix variables. Cognitive impairment was associated with slightly higher staff time only in less physically-impaired residents without serious medical conditions and not receiving heavy rehabilitation. Similarly, depression and delirium were associated with higher resource use only in selected types of residents. Based on these findings, the new Resource Utilization Groups Version III (RUG-III) contain a major category of residents who are cognitively impaired but not severely dependent in Activities of Daily Living. Depression is used to differentiate subgroups of residents with major medical conditions such as hemiplegia and aphasia. Delirium, when used together with other resident characteristics, was not found useful in explaining resource use. Case-mix groups defined by mental dysfunctions can foster improved care, but careful consideration must be given to appropriate incentives and documentation requirements for providers.

A comparison of home care clients and nursing home residents: can community based care keep the elderly and disabled at home?

PubMed

Shugarman, L R; Fries, B E; James, M

1999-01-01

Admission cohorts from the Michigan Medicaid Home and Community-Based Waiver program and Ohio nursing homes were compared on measures of resource utilization including a modified Resource Utilization Groups (RUG-III) system, Activities of Daily Living (ADLs), and overall case mix. We found that, contrary to previous research, the two samples were remarkably similar across RUG-III categories. However, the nursing home sample was more functionally impaired on measures of ADL functioning and overall case mix. Results of this study may inform policymakers and providers of the potential for maintaining the appropriate population in the home with government-funded home care.

Reclassification of Mixed Oligoastrocytic Tumors Using a Genetically Integrated Diagnostic Approach

PubMed Central

Kim, Seong-Ik; Lee, Yujin; Won, Jae-Kyung; Park, Chul-Kee; Choi, Seung Hong; Park, Sung-Hye

2018-01-01

Background Mixed gliomas, such as oligoastrocytomas (OA), anaplastic oligoastrocytomas, and glioblastomas (GBMs) with an oligodendroglial component (GBMO) are defined as tumors composed of a mixture of two distinct neoplastic cell types, astrocytic and oligodendroglial. Recently, mutations ATRX and TP53, and codeletion of 1p/19q are shown to be genetic hallmarks of astrocytic and oligodendroglial tumors, respectively. Subsequent molecular analyses of mixed gliomas preferred the reclassification to either oligodendroglioma or astrocytoma. This study was designed to apply genetically integrated diagnostic criteria to mixed gliomas and determine usefulness and prognostic value of new classification in Korean patients. Methods Fifty-eight cases of mixed OAs and GBMOs were retrieved from the pathology archives of Seoul National University Hospital from 2004 to 2015. Reclassification was performed according to genetic and immunohistochemical properties. Clinicopathological characteristics of each subgroup were evaluated. Overall survival was assessed and compared between subgroups. Results We could reclassify all mixed OAs and GBMOs into either astrocytic or oligodendroglial tumors. Notably, 29 GBMOs could be reclassified into 11 cases of GBM, IDH-mutant, 16 cases of GBM, IDH-wildtype, and two cases of anaplastic oligodendroglioma, IDH mutant. Overall survival was significantly different among these new groups (p<.001). Overall survival and progression-free survival were statistically better in gliomas with IDH mutation, ATRX mutation, no microscopic necrosis, and young patient age (cut off, 45 years old). Conclusions Our results strongly suggest that a genetically integrated diagnosis of glioma better reflects prognosis than former morphology-based methods. PMID:28958143

Functional mapping of hospitals by diagnosis-dominant case-mix analysis.

PubMed

Fushimi, Kiyohide; Hashimoto, Hideki; Imanaka, Yuichi; Kuwabara, Kazuaki; Horiguchi, Hiromasa; Ishikawa, Kohichi B; Matsuda, Shinya

2007-04-10

Principles and methods for the allocation of healthcare resources among healthcare providers have long been health policy research issues in many countries. Healthcare reforms including the development of a new case-mix system, Diagnosis Procedure Combination (DPC), and the introduction of a DPC-based payment system are currently underway in Japan, and a methodology for adequately assessing the functions of healthcare providers is needed to determine healthcare resource allocations. By two-dimensional mapping of the rarity and complexity of diagnoses for patients receiving treatment, we were able to quantitatively demonstrate differences in the functions of different healthcare service provider groups. On average, inpatients had diseases that were 3.6-times rarer than those seen in outpatients, while major teaching hospitals treated inpatients with diseases 3.0-times rarer on average than those seen at small hospitals. We created and evaluated a new indicator for DPC, the diagnosis-dominant case-mix system developed in Japan, whereby the system was used to assess the functions of healthcare service providers. The results suggest that it is possible to apply the case-mix system to the integrated evaluation of outpatient and inpatient healthcare services and to the appropriate allocation of healthcare resources among health service providers.

Building Action Research Teams: A Case of Struggles and Successes

ERIC Educational Resources Information Center

Du, Fengning

2009-01-01

Teaching teams can hold the promise of being an ideal vehicle in which collaborative action research is conducted. This case documents the mixed results of a team leader's efforts to improve teaching and introduce inquiry-based professional development through action research in a community college. This case paints a realistic and…

Case-Mix Adjustment of the Bereaved Family Survey.

PubMed

Kutney-Lee, Ann; Carpenter, Joan; Smith, Dawn; Thorpe, Joshua; Tudose, Alina; Ersek, Mary

2018-01-01

Surveys of bereaved family members are increasingly being used to evaluate end-of-life (EOL) care and to measure organizational performance in EOL care quality. The Bereaved Family Survey (BFS) is used to monitor EOL care quality and benchmark performance in the Veterans Affairs (VA) health-care system. The objective of this study was to develop a case-mix adjustment model for the BFS and to examine changes in facility-level scores following adjustment, in order to provide fair comparisons across facilities. We conducted a cross-sectional secondary analysis of medical record and survey data from veterans and their family members across 146 VA medical centers. Following adjustment using model-based propensity weighting, the mean change in the BFS-Performance Measure score across facilities was -0.6 with a range of -2.6 to 0.6. Fifty-five (38%) facilities changed within ±0.5 percentage points of their unadjusted score. On average, facilities that benefited most from adjustment cared for patients with greater comorbidity burden and were located in urban areas in the Northwest and Midwestern regions of the country. Case-mix adjustment results in minor changes to facility-level BFS scores but allows for fairer comparisons of EOL care quality. Case-mix adjustment of the BFS positions this National Quality Forum-endorsed measure for use in public reporting and internal quality dashboards for VA leadership and may inform the development and refinement of case-mix adjustment models for other surveys of bereaved family members.

Mixing weight determination for retrieving optical properties of polluted dust with MODIS and AERONET data

NASA Astrophysics Data System (ADS)

Chang, Kuo-En; Hsiao, Ta-Chih; Hsu, N. Christina; Lin, Neng-Huei; Wang, Sheng-Hsiang; Liu, Gin-Rong; Liu, Chian-Yi; Lin, Tang-Huang

2016-08-01

In this study, an approach in determining effective mixing weight of soot aggregates from dust-soot aerosols is proposed to improve the accuracy of retrieving properties of polluted dusts by means of satellite remote sensing. Based on a pre-computed database containing several variables (such as wavelength, refractive index, soot mixing weight, surface reflectivity, observation geometries and aerosol optical depth (AOD)), the fan-shaped look-up tables can be drawn out accordingly for determining the mixing weights, AOD and single scattering albedo (SSA) of polluted dusts simultaneously with auxiliary regional dust properties and surface reflectivity. To validate the performance of the approach in this study, 6 cases study of polluted dusts (dust-soot aerosols) in Lower Egypt and Israel were examined with the ground-based measurements through AErosol RObotic NETwork (AERONET). The results show that the mean absolute differences could be reduced from 32.95% to 6.56% in AOD and from 2.67% to 0.83% in SSA retrievals for MODIS aerosol products when referenced to AERONET measurements, demonstrating the soundness of the proposed approach under different levels of dust loading, mixing weight and surface reflectivity. Furthermore, the developed algorithm is capable of providing the spatial distribution of the mixing weights and removing the requirement to assume that the dust plume properties are uniform. The case study further shows the spatially variant dust-soot mixing weight would improve the retrieval accuracy in AODmixture and SSAmixture about 10.0% and 1.4% respectively.

Two patients with rare mixed adenoneuroendocrine carcinomas of the rectum.

PubMed

Gül-Klein, Safak; Sinn, Marianne; Jurmeister, Philipp Sebastian; Biebl, Matthias; Weiß, Sascha; Rau, Beate; Bläker, Hendrik; Pratschke, Johann; Aigner, Felix

2018-01-01

Mixed adenoneuroendocrine carcinomas of the gastrointestinal tract are until today poorly understood and thus very challenging for interdisciplinary therapy. We herewith report the first case series of patients with a primary mixed adenoneuroendocrine carcinoma of the rectum. Both cases were initially diagnosed as adenocarcinoma and only secondarily with mixed adenoneuroendocrine carcinoma and had a poor outcome due to a rapid tumor progression and resistance to chemotherapy. A 65-year-old female presented with local tumor recurrence and hepatopulmonary metastasis 1 year after primary surgery for adenocarcinoma of the rectum and consecutive radiochemotherapy regimen. Fluorouracil (5-FU) was followed by bevacizumab- and capecitabine-based chemotherapy but had to be discontinued due to side effects and progressive disease. Progressive local pain syndrome accompanied by recurrent bleeding episodes led to a local tumor-debulking operation. Afterward, mixed adenoneuroendocrine carcinoma as the underlying diagnosis in the final histopathological examination was detected. The patient died 3 months after the operation in the context of a fulminant tumor progress. A 63-year-old male patient underwent neoadjuvant radiochemotherapy and laparoscopic rectum resection. After 5 months, postoperative oxaliplatin/capecitabine-based adjuvant chemotherapy was switched to carboplatin/etopsid due to a progressive polyneuropathy and biopsy-proven pulmonary metastasis. The patient then had to be switched to local radiation of cerebral metastases and Topotecan due to cerebral bleeding episodes but died 18 months after the initial diagnosis. In conclusion of our case series, mixed adenoneuroendocrine carcinomas of the rectum should be considered as a rare but aggressive tumor entity. An early and detailed histopathological diagnosis is required in order to establish an individual interdisciplinary treatment concept.

The impact of sedimentary anisotropy on solute mixing in stacked scour-pool structures

NASA Astrophysics Data System (ADS)

Bennett, Jeremy P.; Haslauer, Claus P.; Cirpka, Olaf A.

2017-04-01

The spatial variability of hydraulic conductivity is known to have a strong impact on solute spreading and mixing. In most investigations, its local anisotropy has been neglected. Recent studies have shown that spatially varying orientation in sedimentary anisotropy can lead to twisting flow enhancing transverse mixing, but most of these studies used geologically implausible geometries. We use an object-based approach to generate stacked scour-pool structures with either isotropic or anisotropic filling which are typically reported in glacial outwash deposits. We analyze how spatially variable isotropic conductivity and variation of internal anisotropy in these features impacts transverse plume deformation and both longitudinal and transverse spreading and mixing. In five test cases, either the scalar values of conductivity or the spatial orientation of its anisotropy is varied between the scour-pool structures. Based on 100 random configurations, we compare the variability of velocity components, stretching and folding metrics, advective travel-time distributions, one and two-particle statistics in advective-dispersive transport, and the flux-related dilution indices for steady state advective-dispersive transport among the five test cases. Variation in the orientation of internal anisotropy causes strong variability in the lateral velocity components, which leads to deformation in transverse directions and enhances transverse mixing, whereas it hardly affects the variability of the longitudinal velocity component and thus longitudinal spreading and mixing. The latter is controlled by the spatial variability in the scalar values of hydraulic conductivity. Our results demonstrate that sedimentary anisotropy is important for transverse mixing, whereas it may be neglected when considering longitudinal spreading and mixing.

Games policy makers and providers play: introducing case-mix-based payment to hospital chronic care units in Japan.

PubMed

Ikegami, Naoki

2009-06-01

Case-mix-based payment was developed for hospital chronic care units in Japan to replace the flat per diem rate and encourage the admission of patients with higher medical acuity and was part of a policy initiative to make the tariff more evidence based. However, although the criteria for grouping patients were developed from a statistical analysis of resource use, the tariff was subsequently set below costs, particularly for the groups with the lowest medical acuity, both because of the prime minister's decision to decrease total health expenditures and because of the health ministry's decision to target the reductions on chronic care units. Providers quickly adapted to the new payment system mainly by reclassifying their patients to higher medical acuity groups. Some hospitals reported high prevalence rates of urinary tract infections and pressure ulcers. The government responded by issuing directives to providers to calculate the prevalence rates and document the care that has been mandated for the patients at risk. However, in order to monitor compliance and to evaluate whether the patient is being billed for the appropriate case-mix group, the government must invest in developing a comprehensive patient-level database and in training staff for making on-site inspections.

Medicaid case-mix nursing home reimbursement in three states.

PubMed

Swan, James H; Pickard, Ruth B

2003-01-01

Case-mix nursing facility payment raises issues of access, quality, equity, and cost. Case-mix should better match payment to costs, improve access, and provide incentives to increased staffing and quality of care; but it may also increase costs. This paper reports analysis of Medicaid cost-report data from three case-mix states. Case-mix did not discourage capacity building and was more equitable for providers. Medicaid access declined in one state but increased in another. There were shifts toward greater skilled care in two states, with evidence of greater focus of resources on patient care. Case-mix showed no evidence of cost-constraint and some signs of increased costs. Whether such mixed outcomes are viable in the current era remains to be seen.

Naturally-Emerging Technology-Based Leadership Roles in Three Independent Schools: A Social Network-Based Case Study Using Fuzzy Set Qualitative Comparative Analysis

ERIC Educational Resources Information Center

Velastegui, Pamela J.

2013-01-01

This hypothesis-generating case study investigates the naturally emerging roles of technology brokers and technology leaders in three independent schools in New York involving 92 school educators. A multiple and mixed method design utilizing Social Network Analysis (SNA) and fuzzy set Qualitative Comparative Analysis (FSQCA) involved gathering…

Correlations and risk contagion between mixed assets and mixed-asset portfolio VaR measurements in a dynamic view: An application based on time varying copula models

NASA Astrophysics Data System (ADS)

Han, Yingying; Gong, Pu; Zhou, Xiang

2016-02-01

In this paper, we apply time varying Gaussian and SJC copula models to study the correlations and risk contagion between mixed assets: financial (stock), real estate and commodity (gold) assets in China firstly. Then we study the dynamic mixed-asset portfolio risk through VaR measurement based on the correlations computed by the time varying copulas. This dynamic VaR-copula measurement analysis has never been used on mixed-asset portfolios. The results show the time varying estimations fit much better than the static models, not only for the correlations and risk contagion based on time varying copulas, but also for the VaR-copula measurement. The time varying VaR-SJC copula models are more accurate than VaR-Gaussian copula models when measuring more risky portfolios with higher confidence levels. The major findings suggest that real estate and gold play a role on portfolio risk diversification and there exist risk contagion and flight to quality between mixed-assets when extreme cases happen, but if we take different mixed-asset portfolio strategies with the varying of time and environment, the portfolio risk will be reduced.

National outbreak of Yersinia enterocolitica infections in military and civilian populations associated with consumption of mixed salad, Norway, 2014.

PubMed

MacDonald, Emily; Einöder-Moreno, Margot; Borgen, Katrine; Thorstensen Brandal, Lin; Diab, Lore; Fossli, Øivind; Guzman Herrador, Bernardo; Hassan, Ammar Ali; Johannessen, Gro S; Johansen, Eva Jeanette; Jørgensen Kimo, Roger; Lier, Tore; Paulsen, Bjørn Leif; Popescu, Rodica; Tokle Schytte, Charlotte; Sæbø Pettersen, Kristin; Vold, Line; Ørmen, Øyvind; Wester, Astrid Louise; Wiklund, Marit; Nygård, Karin

2016-08-25

In May 2014, a cluster of Yersinia enterocolitica (YE) O9 infections was reported from a military base in northern Norway. Concurrently, an increase in YE infections in civilians was observed in the Norwegian Surveillance System for Communicable Diseases. We investigated to ascertain the extent of the outbreak and identify the source in order to implement control measures. A case was defined as a person with laboratory-confirmed YE O9 infection with the outbreak multilocus variable-number tandem repeat analysis (MLVA)-profile (5-6-9-8-9-9). We conducted a case-control study in the military setting and calculated odds ratios (OR) using logistic regression. Traceback investigations were conducted to identify common suppliers and products in commercial kitchens frequented by cases. By 28 May, we identified 133 cases, of which 117 were linked to four military bases and 16 were civilians from geographically dispersed counties. Among foods consumed by cases, multivariable analysis pointed to mixed salad as a potential source of illness (OR 10.26; 95% confidence interval (CI): 0.85-123.57). The four military bases and cafeterias visited by 14/16 civilian cases received iceberg lettuce or radicchio rosso from the same supplier. Secondary transmission cannot be eliminated as a source of infection in the military camps. The most likely source of the outbreak was salad mix containing imported radicchio rosso, due to its long shelf life. This outbreak is a reminder that fresh produce should not be discounted as a vehicle in prolonged outbreaks and that improvements are still required in the production and processing of fresh salad products. This article is copyright of The Authors, 2016.

A Mixed Methods Sampling Methodology for a Multisite Case Study

ERIC Educational Resources Information Center

Sharp, Julia L.; Mobley, Catherine; Hammond, Cathy; Withington, Cairen; Drew, Sam; Stringfield, Sam; Stipanovic, Natalie

2012-01-01

The flexibility of mixed methods research strategies makes such approaches especially suitable for multisite case studies. Yet the utilization of mixed methods to select sites for these studies is rarely reported. The authors describe their pragmatic mixed methods approach to select a sample for their multisite mixed methods case study of a…

Age and case mix-standardised survival for all cancer patients in Europe 1999-2007: Results of EUROCARE-5, a population-based study.

PubMed

Baili, Paolo; Di Salvo, Francesca; Marcos-Gragera, Rafael; Siesling, Sabine; Mallone, Sandra; Santaquilani, Mariano; Micheli, Andrea; Lillini, Roberto; Francisci, Silvia

2015-10-01

Overall survival after cancer is frequently used when assessing a health care service's performance as a whole. It is mainly used by the public, politicians and the media, and is often dismissed by clinicians because of the heterogeneous mix of different cancers, risk factors and treatment modalities. Here we give survival details for all cancers combined in Europe, correlating it with economic variables to suggest reasons for differences. We computed age and cancer site case-mix standardised relative survival for all cancers combined (ACRS) for 29 countries participating in the EUROCARE-5 project with data on more than 7.5million cancer cases from 87 population-based cancer registries, using complete and period approach. Denmark, United Kingdom (UK) and Eastern European countries had lower survival than neighbouring countries. Five-year ACRS has been increasing throughout Europe, and substantial increases, between 1999-2001 and 2005-2007, have been achieved in countries where survival was lower in the past. Five-year ACRS for men and women are positively correlated with macro-economic variables like the Gross Domestic Product (GDP) and Total National Expenditure on Health (TNEH) (R 2 about 70%). Countries with recent larger increases in GDP and TNEH had greater increases in cancer survival. ACRS serves to compare all cancer survival in Europe taking account of the geographical variability in case-mixes. The EUROCARE-5 data on ACRS confirm previous EUROCARE findings. Survival appears to correlate with macro-economic determinants, particularly with investments in the health care system. Copyright © 2015 Elsevier Ltd. All rights reserved.

Acceptance of routine or case-based inquiry for intimate partner violence: a mixed method study.

PubMed

Stöckl, Heidi; Hertlein, Linda; Himsl, Isabelle; Ditsch, Nina; Blume, Carolin; Hasbargen, Uwe; Friese, Klaus; Stöckl, Doris

2013-03-26

The prevalence and detrimental health effects of intimate partner violence have resulted in international discussions and recommendations that health care professionals should screen women for intimate partner violence during general and antenatal health care visits. Due to the lack of discussion on routine or case-based inquiry for intimate partner violence during antenatal care in Germany, this study seeks to explore its acceptability among pregnant German women. A mixed methods approach was used, utilizing a self-administered survey on the acceptability of routine or case-based inquiry for intimate partner violence in a university hospital's maternity ward in Munich and in-depth interviews with seven women who experienced violence during pregnancy. Of the 401 women who participated in the survey, 92 percent were in favor of routine or case-based inquiry for intimate partner violence during antenatal care. Acceptance of routine or case-based inquiry for intimate partner violence during antenatal care was significantly associated with women's experiences of child sexual abuse, being young, less educated, single or divorced and smoking during pregnancy. Open-ended survey questions and in-depth interviews stressed adequate training for screening, sufficient time and provision of referral information as important conditions for routine or case-based inquiry for intimate partner violence. Women in this study showed an overwhelming support for routine or case-based screening for intimate partner violence in antenatal care in Germany. Until adequate training is in place to allow providers to inquire for intimate partner violence in a professional manner, this study recommends that health care providers are made aware of the prevalence and health consequences of violence during pregnancy.

Acceptance of routine or case-based inquiry for intimate partner violence: a mixed method study

PubMed Central

2013-01-01

Background The prevalence and detrimental health effects of intimate partner violence have resulted in international discussions and recommendations that health care professionals should screen women for intimate partner violence during general and antenatal health care visits. Due to the lack of discussion on routine or case-based inquiry for intimate partner violence during antenatal care in Germany, this study seeks to explore its acceptability among pregnant German women. Methods A mixed methods approach was used, utilizing a self-administered survey on the acceptability of routine or case-based inquiry for intimate partner violence in a university hospital’s maternity ward in Munich and in-depth interviews with seven women who experienced violence during pregnancy. Results Of the 401 women who participated in the survey, 92 percent were in favor of routine or case-based inquiry for intimate partner violence during antenatal care. Acceptance of routine or case-based inquiry for intimate partner violence during antenatal care was significantly associated with women’s experiences of child sexual abuse, being young, less educated, single or divorced and smoking during pregnancy. Open-ended survey questions and in-depth interviews stressed adequate training for screening, sufficient time and provision of referral information as important conditions for routine or case-based inquiry for intimate partner violence. Conclusions Women in this study showed an overwhelming support for routine or case-based screening for intimate partner violence in antenatal care in Germany. Until adequate training is in place to allow providers to inquire for intimate partner violence in a professional manner, this study recommends that health care providers are made aware of the prevalence and health consequences of violence during pregnancy. PMID:23531127

Mixing-controlled reactive transport on travel times in heterogeneous media

NASA Astrophysics Data System (ADS)

Luo, J.; Cirpka, O.

2008-05-01

Modeling mixing-controlled reactive transport using traditional spatial discretization of the domain requires identifying the spatial distributions of hydraulic and reactive parameters including mixing-related quantities such as dispersivities and kinetic mass-transfer coefficients. In most applications, breakthrough curves of conservative and reactive compounds are measured at only a few locations and models are calibrated by matching these breakthrough curves, which is an ill posed inverse problem. By contrast, travel-time based transport models avoid costly aquifer characterization. By considering breakthrough curves measured on different scales, one can distinguish between mixing, which is a prerequisite for reactions, and spreading, which per se does not foster reactions. In the travel-time based framework, the breakthrough curve of a solute crossing an observation plane, or ending in a well, is interpreted as the weighted average of concentrations in an ensemble of non-interacting streamtubes, each of which is characterized by a distinct travel-time value. Mixing is described by longitudinal dispersion and/or kinetic mass transfer along individual streamtubes, whereas spreading is characterized by the distribution of travel times which also determines the weights associated to each stream tube. Key issues in using the travel-time based framework include the description of mixing mechanisms and the estimation of the travel-time distribution. In this work, we account for both apparent longitudinal dispersion and kinetic mass transfer as mixing mechanisms, thus generalizing the stochastic-convective model with or without inter-phase mass transfer and the advective-dispersive streamtube model. We present a nonparametric approach of determining the travel-time distribution, given a breakthrough curve integrated over an observation plane and estimated mixing parameters. The latter approach is superior to fitting parametric models in cases where the true travel-time distribution exhibits multiple peaks or long tails. It is demonstrated that there is freedom for the combinations of mixing parameters and travel-time distributions to fit conservative breakthrough curves and describe the tailing. Reactive transport cases with a bimolecular instantaneous irreversible reaction and a dual Michaelis-Menten problem demonstrate that the mixing introduced by local dispersion and mass transfer may be described by apparent mean mass transfer with coefficients evaluated by local breakthrough curves.

Hawks, doves, and mixed-symmetry games.

PubMed

Crowley, P H

2000-06-21

The hawk-dove game has proved to be an important tool for understanding the role of aggression in social interactions. Here, the game is presented in a more general form (GHD) to facilitate analyses of interactions between individuals that may differ in "size", where size is interpreted as a surrogate for resource holding power. Three different situations are considered, based on the availability and use of information that interacting individuals have about their sizes: the classical symmetric case, in which no information about sizes is used, the asymmetric case, in which the individuals know their relative sizes and thus their chances of prevailing in combat, and a mixed-symmetry case, in which each individual only knows its own size (or only knows its opponent's size). I describe and use some recently developed methods for multitype games-evolutionary games involving two or more categories of players. With these methods and others, the evolutionarily stable strategies (ESSs) that emerge for the three different cases are identified and compared. A proof of the form and uniqueness of the ESS for the mixed-symmetry case is presented. In this situation, one size category at most can play a mixed strategy; larger individuals are aggressive and smaller individuals are not. As the number of size categories approaches infinity and the size distribution becomes continuous, there is a threshold size, above which all individuals are aggressive, and below which they are not. Copyright 2000 Academic Press.

Dietary factors and the risk of testicular cancer.

PubMed

Bonner, Matthew R; McCann, Susan E; Moysich, Kirsten B

2002-01-01

The etiology of testicular cancer (TC) remains largely unknown. Few studies have investigated the role diet may play in the etiology of TC. We report on a hospital-based case-control study of TC and selected nutrients and food groups. Cases included 117 patients with primary, incident TC treated at Roswell Park Cancer Institute between 1982 and 1998. A total of 334 hospital controls were frequency matched on age to cases. Cases were categorized by histology (seminoma, nonseminoma, and mixed germ cell TC), and multinomial logistic regression and unconditional logistic regression were used to compute odds ratios (ORs) and 95% confidence intervals (CIs) comparing each histological type with the controls. For nonseminoma and mixed germ cell TC, vitamin E intake was suggestive of reduced risk (OR = 0.51, 95% CI = 0.15-1.76 and OR = 0.36, 95% CI = 0.01-1.31, respectively); for seminoma, it was suggestive of an increased risk (OR = 2.94, 95% CI = 0.99-8.78). Fat intakes were not associated with nonseminoma or mixed germ cell risk; high saturated, animal, and total fat intakes were suggestive of an increase in risk of seminoma. Overall, diet was not associated with TC. However, risk seemed to differ by histology, suggesting that seminoma, nonseminoma, and mixed germ cell TC may have different etiologies. We suggest that future investigations should continue to stratify cases by histology.

Case-Mix and Quality Indicators in Chinese Elder Care Homes: Are There Differences between Government-owned and Private-sector Facilities?

PubMed Central

Liu, Chang

2015-01-01

Objective To assess the association between ownership of Chinese elder care facilities and their performance quality; and to compare the case-mix profile of residents and facility characteristics in government-owned and private-sector homes. Design Cross-sectional study. Setting Census of elder care homes surveyed in Nanjing (in 2009) and Tianjin (in 2010). Population 140 (or 95% of all) elder care facilities located in urban Nanjing, and 157 (or 97% of all) facilities in urban Tianjin. Main study outcome measures We created a summary case-mix index based on activities of daily living (ADL) limitations and cognitive impairment to measure levels of care needs among residents in each facility. We selected structure, process, and outcome measures to assess facility-level quality of care. We also developed a structural quality measure, under-staffing relative to residents’ levels of care needs, which indicates potentially inadequate staffing given the residents’ case-mix. Results Government-owned homes have significantly higher occupancy rates, presumably reflecting popular demand for publicly subsidized beds, but they serve residents who, on average, have fewer ADL and cognitive functioning limitations than do private-sector facilities. Across a range of structure, process, and outcome measures of quality, there is no clear evidence suggesting advantages or disadvantages to either ownership type. However, when staffing to resident ratio is gauged relative to residents’ case-mix, private-sector facilities were more likely to be under-staffed than government-owned facilities. Conclusions In Nanjing and Tianjin, private-sector homes were more likely to be understaffed, although their residents were sicker and frailer, on average, than those in government facilities. The case-mix differences are likely the result of selective admission policies that favor relatively healthier residents in government facilities than in private-sector homes. PMID:24433350

Observations of mixed-aged litters in brown bears

USGS Publications Warehouse

Swenson, J.E.; Haroldson, M.A.

2008-01-01

We report on 3 cases of mixed-aged litters (young born in different years) in brown bears (Ursus arctos); in 1 instance the cub-of-the-year (hereafter called cubs) died in the den. Two cases occurred in Sweden after mothers were separated from their young during the breeding season. In one, the mother was separated from the accompanying cub for at least 12.5 hours and possibly up to 3.3 days, and later possibly separated for 4 days. In the other, the mother was separated from her yearling at least 3 times for 1-14, 1-6 and 1-6 days. She was with a male during the first separation. Specific events that produced the mixed-aged litter observed in Greater Yellowstone Ecosystem were unknown and our interpretation is based on estimates of ages of accompanying young from photographs. The observation of only 2 mixed-aged litters, after den emergence, from a sample of 406 observed cub litters accompanying radiomarked females confirms the rarity of this phenomenon. The mechanism apparently includes a short separation of mother and young, and, in the case of cubs, the mother must mate while lactating. Better understanding of the physiological mechanisms that allow mixed-age litters would help us in the debate about the occurrence of sexually selected infanticide in bears.

Should measures of patient experience in primary care be adjusted for case mix? Evidence from the English General Practice Patient Survey

PubMed Central

Paddison, Charlotte; Elliott, Marc; Parker, Richard; Staetsky, Laura; Lyratzopoulos, Georgios; Campbell, John L

2012-01-01

Objectives Uncertainties exist about when and how best to adjust performance measures for case mix. Our aims are to quantify the impact of case-mix adjustment on practice-level scores in a national survey of patient experience, to identify why and when it may be useful to adjust for case mix, and to discuss unresolved policy issues regarding the use of case-mix adjustment in performance measurement in health care. Design/setting Secondary analysis of the 2009 English General Practice Patient Survey. Responses from 2 163 456 patients registered with 8267 primary care practices. Linear mixed effects models were used with practice included as a random effect and five case-mix variables (gender, age, race/ethnicity, deprivation, and self-reported health) as fixed effects. Main outcome measures Primary outcome was the impact of case-mix adjustment on practice-level means (adjusted minus unadjusted) and changes in practice percentile ranks for questions measuring patient experience in three domains of primary care: access; interpersonal care; anticipatory care planning, and overall satisfaction with primary care services. Results Depending on the survey measure selected, case-mix adjustment changed the rank of between 0.4% and 29.8% of practices by more than 10 percentile points. Adjusting for case-mix resulted in large increases in score for a small number of practices and small decreases in score for a larger number of practices. Practices with younger patients, more ethnic minority patients and patients living in more socio-economically deprived areas were more likely to gain from case-mix adjustment. Age and race/ethnicity were the most influential adjustors. Conclusions While its effect is modest for most practices, case-mix adjustment corrects significant underestimation of scores for a small proportion of practices serving vulnerable patients and may reduce the risk that providers would ‘cream-skim’ by not enrolling patients from vulnerable socio-demographic groups. PMID:22626735

Should measures of patient experience in primary care be adjusted for case mix? Evidence from the English General Practice Patient Survey.

PubMed

Paddison, Charlotte; Elliott, Marc; Parker, Richard; Staetsky, Laura; Lyratzopoulos, Georgios; Campbell, John L; Roland, Martin

2012-08-01

Uncertainties exist about when and how best to adjust performance measures for case mix. Our aims are to quantify the impact of case-mix adjustment on practice-level scores in a national survey of patient experience, to identify why and when it may be useful to adjust for case mix, and to discuss unresolved policy issues regarding the use of case-mix adjustment in performance measurement in health care. Secondary analysis of the 2009 English General Practice Patient Survey. Responses from 2 163 456 patients registered with 8267 primary care practices. Linear mixed effects models were used with practice included as a random effect and five case-mix variables (gender, age, race/ethnicity, deprivation, and self-reported health) as fixed effects. Primary outcome was the impact of case-mix adjustment on practice-level means (adjusted minus unadjusted) and changes in practice percentile ranks for questions measuring patient experience in three domains of primary care: access; interpersonal care; anticipatory care planning, and overall satisfaction with primary care services. Depending on the survey measure selected, case-mix adjustment changed the rank of between 0.4% and 29.8% of practices by more than 10 percentile points. Adjusting for case-mix resulted in large increases in score for a small number of practices and small decreases in score for a larger number of practices. Practices with younger patients, more ethnic minority patients and patients living in more socio-economically deprived areas were more likely to gain from case-mix adjustment. Age and race/ethnicity were the most influential adjustors. While its effect is modest for most practices, case-mix adjustment corrects significant underestimation of scores for a small proportion of practices serving vulnerable patients and may reduce the risk that providers would 'cream-skim' by not enrolling patients from vulnerable socio-demographic groups.

Reimbursement in hospital-based vascular surgery: Physician and practice perspective.

PubMed

Perri, Jennifer L; Zwolak, Robert M; Goodney, Philip P; Rutherford, Gretchen A; Powell, Richard J

2017-07-01

The purpose of this study was to determine change in value of a vascular surgery division to the health care system during 6 years at a hospital-based academic practice and to compare physician vs hospital revenue earned during this period. Total revenue generated by the vascular surgery service line at an academic medical center from 2010 through 2015 was evaluated. Total revenue was measured as the sum of physician (professional) and hospital (technical) net revenue for all vascular-related patient care. Adjustments were made for work performed, case complexity, and inflation. To reflect the effect of these variables, net revenue was indexed to work relative value units (wRVUs), case mix index, and consumer price index, which adjusted for work, case complexity, and inflation, respectively. Differences in physician and hospital net revenue were compared over time. Physician work, measured in RVUs per year, increased by 4%; case complexity, assessed with case mix index, increased by 10% for the 6-year measurement period. Despite stability in payer mix at 64% to 69% Medicare, both physician and hospital vascular-related revenue/wRVU decreased during this period. Unadjusted professional revenue/wRVU declined by 14.1% (P = .09); when considering case complexity, physician revenue/wRVU declined by 20.6% (P = .09). Taking into account both case complexity and inflation, physician revenue declined by 27.0% (P = .04). Comparatively, hospital revenue for vascular surgery services decreased by 13.8% (P = .07) when adjusting for unit work, complexity, and inflation. At medical centers where vascular surgeons are hospital based, vascular care reimbursement decreased substantially from 2010 to 2015 when case complexity and inflation were considered. Physician reimbursement (professional fees) decreased at a significantly greater rate than hospital reimbursement for vascular care. This trend has significant implications for salaried vascular surgeons in hospital-based settings, where the majority of revenue generated by vascular surgery care is the technical component received by the facility. Appropriate care for patients with vascular disease is increasingly resource intensive, and as a corollary, reimbursement levels must reflect this situation if high-quality care is to be maintained. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Functional mapping of hospitals by diagnosis-dominant case-mix analysis

PubMed Central

Fushimi, Kiyohide; Hashimoto, Hideki; Imanaka, Yuichi; Kuwabara, Kazuaki; Horiguchi, Hiromasa; Ishikawa, Kohichi B; Matsuda, Shinya

2007-01-01

Background Principles and methods for the allocation of healthcare resources among healthcare providers have long been health policy research issues in many countries. Healthcare reforms including the development of a new case-mix system, Diagnosis Procedure Combination (DPC), and the introduction of a DPC-based payment system are currently underway in Japan, and a methodology for adequately assessing the functions of healthcare providers is needed to determine healthcare resource allocations. Methods By two-dimensional mapping of the rarity and complexity of diagnoses for patients receiving treatment, we were able to quantitatively demonstrate differences in the functions of different healthcare service provider groups. Results On average, inpatients had diseases that were 3.6-times rarer than those seen in outpatients, while major teaching hospitals treated inpatients with diseases 3.0-times rarer on average than those seen at small hospitals. Conclusion We created and evaluated a new indicator for DPC, the diagnosis-dominant case-mix system developed in Japan, whereby the system was used to assess the functions of healthcare service providers. The results suggest that it is possible to apply the case-mix system to the integrated evaluation of outpatient and inpatient healthcare services and to the appropriate allocation of healthcare resources among health service providers. PMID:17425788

Brief Report: Maternal Smoking during Pregnancy and Autism Spectrum Disorders

ERIC Educational Resources Information Center

Lee, Brian K.; Gardner, Renee M.; Dal, Henrik; Svensson, Anna; Galanti, Maria Rosaria; Rai, Dheeraj; Dalman, Christina; Magnusson, Cecilia

2012-01-01

Prenatal exposure to tobacco smoke is suggested as a potential risk factor for autism spectrum disorders (ASD). Previous epidemiological studies of this topic have yielded mixed findings. We performed a case-control study of 3,958 ASD cases and 38,983 controls nested in a large register-based cohort in Sweden. ASD case status was measured using a…

Improving tuberculosis control through public-private collaboration in India: literature review.

PubMed

Dewan, Puneet K; Lal, S S; Lonnroth, Knut; Wares, Fraser; Uplekar, Mukund; Sahu, Suvanand; Granich, Reuben; Chauhan, Lakhbir Singh

2006-03-11

To review the characteristics of public-private mix projects in India and their effect on case notification and treatment outcomes for tuberculosis. Literature review. Review of surveillance records from Indian tuberculosis programme project, evaluation reports, and medical literature for public-private mix projects in India. Project characteristics, tuberculosis case notification of new patients with sputum smear results positive for acid fast bacilli, and treatment outcome. Of 24 identified public-private mix projects, data were available from 14 (58%), involving private practitioners, corporations, and non-governmental organisations. In all reviewed projects, the public sector tuberculosis programme provided training and supervision of private providers. Among the five projects with available data on historical controls, case notification rates were higher after implementation of a public-private mix project. Among seven projects involving private practitioners, 2796 of 12 147 (23%) new patients positive for acid fast bacilli were attributed to private providers. Corporate based and non-governmental organisations served as the main source for tuberculosis programme services in seven project areas, detecting 9967 new patients positive for acid fast bacilli. In nine of 12 projects with data on treatment outcomes, private providers exceeded the programme target of 85% treatment success for new patients positive for acid fast bacilli. Public-private mix activities were associated with increased case notification, while maintaining acceptable treatment outcomes. Collaborations between public and private providers of health care hold considerable potential to improve tuberculosis control in India.

National outbreak of Yersinia enterocolitica infections in military and civilian populations associated with consumption of mixed salad, Norway, 2014

PubMed Central

MacDonald, Emily; Einöder-Moreno, Margot; Borgen, Katrine; Thorstensen Brandal, Lin; Diab, Lore; Fossli, Øivind; Guzman Herrador, Bernardo; Hassan, Ammar Ali; Johannessen, Gro S; Johansen, Eva Jeanette; Jørgensen Kimo, Roger; Lier, Tore; Paulsen, Bjørn Leif; Popescu, Rodica; Tokle Schytte, Charlotte; Sæbø Pettersen, Kristin; Vold, Line; Ørmen, Øyvind; Wester, Astrid Louise; Wiklund, Marit; Nygård, Karin

2016-01-01

In May 2014, a cluster of Yersinia enterocolitica (YE) O9 infections was reported from a military base in northern Norway. Concurrently, an increase in YE infections in civilians was observed in the Norwegian Surveillance System for Communicable Diseases. We investigated to ascertain the extent of the outbreak and identify the source in order to implement control measures. A case was defined as a person with laboratory-confirmed YE O9 infection with the outbreak multilocus variable-number tandem repeat analysis (MLVA)-profile (5-6-9-8-9-9). We conducted a case–control study in the military setting and calculated odds ratios (OR) using logistic regression. Traceback investigations were conducted to identify common suppliers and products in commercial kitchens frequented by cases. By 28 May, we identified 133 cases, of which 117 were linked to four military bases and 16 were civilians from geographically dispersed counties. Among foods consumed by cases, multivariable analysis pointed to mixed salad as a potential source of illness (OR 10.26; 95% confidence interval (CI): 0.85–123.57). The four military bases and cafeterias visited by 14/16 civilian cases received iceberg lettuce or radicchio rosso from the same supplier. Secondary transmission cannot be eliminated as a source of infection in the military camps. The most likely source of the outbreak was salad mix containing imported radicchio rosso, due to its long shelf life. This outbreak is a reminder that fresh produce should not be discounted as a vehicle in prolonged outbreaks and that improvements are still required in the production and processing of fresh salad products. PMID:27588690

A Comparative Analysis of Reynolds-Averaged Navier-Stokes Model Predictions for Rayleigh-Taylor Instability and Mixing with Constant and Complex Accelerations

NASA Astrophysics Data System (ADS)

Schilling, Oleg

2016-11-01

Two-, three- and four-equation, single-velocity, multicomponent Reynolds-averaged Navier-Stokes (RANS) models, based on the turbulent kinetic energy dissipation rate or lengthscale, are used to simulate At = 0 . 5 Rayleigh-Taylor turbulent mixing with constant and complex accelerations. The constant acceleration case is inspired by the Cabot and Cook (2006) DNS, and the complex acceleration cases are inspired by the unstable/stable and unstable/neutral cases simulated using DNS (Livescu, Wei & Petersen 2011) and the unstable/stable/unstable case simulated using ILES (Ramaprabhu, Karkhanis & Lawrie 2013). The four-equation models couple equations for the mass flux a and negative density-specific volume correlation b to the K- ɛ or K- L equations, while the three-equation models use a two-fluid algebraic closure for b. The lengthscale-based models are also applied with no buoyancy production in the L equation to explore the consequences of neglecting this term. Predicted mixing widths, turbulence statistics, fields, and turbulent transport equation budgets are compared among these models to identify similarities and differences in the turbulence production, dissipation and diffusion physics represented by the closures used in these models. This work was performed under the auspices of the U.S. Department of Energy by Lawrence Livermore National Laboratory under Contract DE-AC52-07NA27344.

RUGs and "Medi-Cal" systems for classifying nursing home patients.

PubMed

Grimaldi, P L

1985-12-01

Medicare and most state Medicaid programs currently use indirect case-mix measures to determine reimbursement for nursing home care. In the future, however, they probably will incorporate more direct case-mix measures into their payment systems. Care must be exercised in designing a case-based prospective payment system to ensure that its financial incentives motivate providers to expedite recovery, prevent deterioration, and admit heavy-care patients. For example, although use of a services-rendered approach helps guarantee that care will be provided when needed, it also offers providers an incentive to furnish a service regardless of whether it is in the patient's best interest. Consideration must be given to the frequency with which patients are reassessed. The implications of the timing of reassessments for quality of care also must be studied. Ideally, quality would be measured on an outcome basis--that is, payment would depend on whether targeted goals for individual patients are reached--rather than on structural or process measures alone. Two recent classification systems--Resource Utilization Groups and Medi-Cal groups--may serve as models for case-based prospective payment systems. Each method classifies patients into distinct, meaningful categories based on activities of daily living and services received.

42 CFR 484.220 - Calculation of the adjusted national prospective 60-day episode payment rate for case-mix and...

Code of Federal Regulations, 2010 CFR

2010-10-01

... address changes to the case-mix that are a result of changes in the coding or classification of different...-day episode payment rate for case-mix and area wage levels. 484.220 Section 484.220 Public Health... Calculation of the adjusted national prospective 60-day episode payment rate for case-mix and area wage levels...

Construction Material-Based Methodology for Military Contingency Base Construction: Case Study of Maiduguri, Nigeria

DTIC Science & Technology

2016-09-01

NSDA Nigerian Steel Development Authority OPC ordinary Portland cement PDF population density factor RCC Reynolds Construction Company RHA rice...construction. Byproducts include blast furnace slag cement and gas. The increased use of steel scrap in production creates less dependence on the raw...The construction resources are gravel, cement , ready-mix concrete, lumber, steel , and brick. In some cases, there are multiple central areas in a

Appendiceal goblet cell carcinoid: common errors in staging and clinical interpretation with a proposal for an improved terminology.

PubMed

Wen, Kwun Wah; Hale, Gillian; Shafizadeh, Nafis; Hosseini, Mojgan; Huang, Anne; Kakar, Sanjay

2017-07-01

Goblet cell carcinoid (GCC) is staged and treated as adenocarcinoma (AC) and not as neuroendocrine tumor (NET) or neuroendocrine carcinoma. The term carcinoid may lead to incorrect interpretation as NET. The aim of the study was to explore pitfalls in staging and clinical interpretation of GCC and mixed GCC-AC, and propose strategies to avoid common errors. Diagnostic terminology, staging, and clinical interpretation were evaluated in 58 cases (27 GCCs, 31 mixed GCC-ACs). Opinions were collected from 23 pathologists using a survey. Clinical notes were reviewed to assess the interpretation of pathology diagnoses by oncologists. NET staging was incorrectly used for 25% of GCCs and 5% of mixed GCC-ACs. In the survey, 43% of pathologists incorrectly indicated that NET staging is applicable to GCCs, and 43% incorrectly responded that Ki-67 proliferation index is necessary for GCC grading. Two cases each of GCC and mixed GCC-AC were incorrectly interpreted as neuroendocrine neoplasms by oncologists, and platinum-based therapy was considered for 2 GCC-AC cases because of the mistaken impression of neuroendocrine carcinoma created by use of the World Health Organization 2010 term mixed adenoneuroendocrine carcinoma. The term carcinoid in GCC and use of mixed adenoneuroendocrine carcinoma for mixed GCC-AC lead to errors in staging and treatment. We propose that goblet cell carcinoid should be changed to goblet cell carcinoma, whereas GCC with AC should be referred to as mixed GCC-AC with a comment about the proportion of each component and the histologic subtype of AC. This terminology will facilitate appropriate staging and clinical management, and avoid errors in interpretation. Copyright © 2017 Elsevier Inc. All rights reserved.

Effects of Jet Swirl on Mixing of a Light Gas Jet in a Supersonic Airstream

NASA Technical Reports Server (NTRS)

Doerner, Steven E.; Cutler, Andrew D.

1999-01-01

A non reacting experiment was performed to investigate the effects of jet swirl on mixing of a light gas jet in a supersonic airstream. The experiment consisted of two parts. The first part was an investigation of the effects of jet swirl and skew on the mixing and penetration of a 25 deg. supersonic jet injected from a flat surface (flush wall injection) into a supersonic ducted airflow. Specifically, the objective was to determine whether the jet would mix more rapidly if the jet were swirling, and whether swirl, with and without skew, causes the injectant-air plume to have a net circulation (i.e., a single or dominant vortex). The second part was a preliminary study of the mixing of swirling jets injected from the base of a skewed ramp. The hypothesis was that favorable interactions between vorticity generated by the swirling jet and vortices generated by the ramp could produce mixing enhancements. Both parts of the experiment were conducted at equal injectant mass flow rate and total pressure. The results for the flush wall injection cases indicate that, except relatively close to the injection point, swirl, with or without skew, does not enhance the mixing of the jet, and can in fact reduce penetration. In addition, a plume with significant net circulation is not generated, as had previously been believed. The results for the ramp cases indicated no improvements in mixing in comparison with the baseline (swept ramp injector) case. However, it was not possible to determine the vorticity mechanisms underlying the poor performance, since no measurements of vorticity were made. Thus, since many geometric parameters were chosen arbitrarily, the results are inconclusive for this class of injector.

Congenital Heart Surgery Case Mix Across North American Centers and Impact on Performance Assessment.

PubMed

Pasquali, Sara K; Wallace, Amelia S; Gaynor, J William; Jacobs, Marshall L; O'Brien, Sean M; Hill, Kevin D; Gaies, Michael G; Romano, Jennifer C; Shahian, David M; Mayer, John E; Jacobs, Jeffrey P

2016-11-01

Performance assessment in congenital heart surgery is challenging due to the wide heterogeneity of disease. We describe current case mix across centers, evaluate methodology inclusive of all cardiac operations versus the more homogeneous subset of Society of Thoracic Surgeons benchmark operations, and describe implications regarding performance assessment. Centers (n = 119) participating in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2010 through 2014) were included. Index operation type and frequency across centers were described. Center performance (risk-adjusted operative mortality) was evaluated and classified when including the benchmark versus all eligible operations. Overall, 207 types of operations were performed during the study period (112,140 total cases). Few operations were performed across all centers; only 25% were performed at least once by 75% or more of centers. There was 7.9-fold variation across centers in the proportion of total cases comprising high-complexity cases (STAT 5). In contrast, the benchmark operations made up 36% of cases, and all but 2 were performed by at least 90% of centers. When evaluating performance based on benchmark versus all operations, 15% of centers changed performance classification; 85% remained unchanged. Benchmark versus all operation methodology was associated with lower power, with 35% versus 78% of centers meeting sample size thresholds. There is wide variation in congenital heart surgery case mix across centers. Metrics based on benchmark versus all operations are associated with strengths (less heterogeneity) and weaknesses (lower power), and lead to differing performance classification for some centers. These findings have implications for ongoing efforts to optimize performance assessment, including choice of target population and appropriate interpretation of reported metrics. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

[Clinical and economic analysis of an internal medicine-infectious disease department at a university general hospital (2005-2006)].

PubMed

Gómez, Joaquín; García-Vázquez, Elisa; Antonio Puertas, José; Ródenas, Julio; Herrero, José Antonio; Albaladejo, Carmen; Baños, Víctor; Canteras, Manuel; Alcaraz, Manolo

2009-02-01

Comparative study in patients with infectious diseases admitted to a specialized Internal Medicine-Infectious Diseases Department (IMID) versus those admitted to other medical departments in a university general hospital, investigating quality and cost-effectiveness. Analysis of patients in 10 principle diagnosis-related groups (DRGs) of infectious diseases admitted to the IMID were compared to those admitted to other medical departments (2005-2006). The DRG were divided in 4 main groups: respiratory infections (DGR 88, 89, 90, 540), urinary infections (DRG 320, 321), sepsis (DRG 416, 584), and skin infections (DRG 277, 278). For each group, quality variables (mortality and readmission rate), efficacy variables (mean hospital stay and mean DRG-based cost per patient) and complexity variables (case mix, relative weight, and functional index) were analyzed. 542 patients included in the 10 main infectious disease DRGs were admitted to IMID and 2404 to other medical departments. After adjusting for DRG case mix (case mix 0.99 for IMID and 0.89 for others), mean hospital stay (5.11 days vs. 7.65 days), mortality (3.5% vs. 7.9%) and mean DRG-based economic cost per patient (1521euro/patient vs. 2952euro/patient) was significantly lower in the group of patients hospitalized in IMID than the group in other medical departments (p<0.05). The readmission rate was similar in the 2 groups (5.5% and 6.5%, respectively). The results per each DRG group were similar to the overall results. For a similar case mix, hospitalization in IMID departments had a positive influence on the variables analyzed as compared to hospitalization in other departments, with a shorter mean stay, lower mortality, and lower mean DRG-based economic cost per patient. Creation and development of IMID departments should be an essential objective to improve healthcare quality and respond to social demands.

Cost-Effectiveness of Chagas Disease Vector Control Strategies in Northwestern Argentina

PubMed Central

Vazquez-Prokopec, Gonzalo M.; Spillmann, Cynthia; Zaidenberg, Mario; Kitron, Uriel; Gürtler, Ricardo E.

2009-01-01

Background Control and prevention of Chagas disease rely mostly on residual spraying of insecticides. In Argentina, vector control shifted from a vertical to a fully horizontal strategy based on community participation between 1992 and 2004. The effects of such strategy on Triatoma infestans, the main domestic vector, and on disease transmission have not been assessed. Methods and Findings Based on retrospective (1993–2004) records from the Argentinean Ministry of Health for the Moreno Department, Northwestern Argentina, we performed a cost-effectiveness (CE) analysis and compared the observed CE of the fully horizontal vector control strategy with the expected CE for a vertical or a mixed (i.e., vertical attack phase followed by horizontal surveillance) strategy. Total direct costs (in 2004 US$) of the horizontal and mixed strategies were, respectively, 3.3 and 1.7 times lower than the costs of the vertical strategy, due to reductions in personnel costs. The estimated CE ratios for the vertical, mixed and horizontal strategies were US$132, US$82 and US$45 per averted human case, respectively. When per diems were excluded from the costs (i.e., simulating the decentralization of control activities), the CE of vertical, mixed and horizontal strategies was reduced to US$60, US$42 and US$32 per averted case, respectively. Conclusions and Significance The mixed strategy would have averted between 1.6 and 4.0 times more human cases than the fully horizontal strategy, and would have been the most cost-effective option to interrupt parasite transmission in the Department. In rural and dispersed areas where waning vertical vector programs cannot accomplish full insecticide coverage, alternative strategies need to be developed. If properly implemented, community participation represents not only the most appealing but also the most cost-effective alternative to accomplish such objectives. PMID:19156190

National outbreak of Shiga toxin-producing Escherichia coli O157:H7 linked to mixed salad leaves, United Kingdom, 2016.

PubMed

Gobin, Maya; Hawker, Jeremy; Cleary, Paul; Inns, Thomas; Gardiner, Daniel; Mikhail, Amy; McCormick, Jacquelyn; Elson, Richard; Ready, Derren; Dallman, Tim; Roddick, Iain; Hall, Ian; Willis, Caroline; Crook, Paul; Godbole, Gauri; Tubin-Delic, Drazenka; Oliver, Isabel

2018-05-01

We investigated a large outbreak of Escherichia coli O157 in the United Kingdom (UK) with 165 cases between 31 May and 29 July 2016. No linked cases were reported in other countries. Cases were predominately female (n = 128) and adult (n = 150), 66 attended hospital and nine had features of haemorrhagic uraemic syndrome. A series of epidemiological studies (case-control, case-case, ingredients-based and venue-based studies) and supply chain investigations implicated mixed salad leaves from Supplier A as the likely outbreak vehicle. Whole genome sequencing (WGS) indicated a link with strains from the Mediterranean and informed the outbreak control team to request that Supplier A cease distributing salad leaves imported from Italy. Microbiological tests of samples of salad leaves from Supplier A were negative. We were unable to confirm the source of contamination or the contaminated constituent leaf although our evidence pointed to red batavia received from Italy as the most likely vehicle. Variations in Shiga toxin-producing E. coli surveillance and diagnosis may have prevented detection of cases outside the UK and highlights a need for greater standardisation. WGS was useful in targeting investigations, but greater coverage across Europe is needed to maximise its potential.

Study of effects of injector geometry on fuel-air mixing and combustion

NASA Technical Reports Server (NTRS)

Bangert, L. H.; Roach, R. L.

1977-01-01

An implicit finite-difference method has been developed for computing the flow in the near field of a fuel injector as part of a broader study of the effects of fuel injector geometry on fuel-air mixing and combustion. Detailed numerical results have been obtained for cases of laminar and turbulent flow without base injection, corresponding to the supersonic base flow problem. These numerical results indicated that the method is stable and convergent, and that significant savings in computer time can be achieved, compared with explicit methods.

Research misconduct oversight: defining case costs.

PubMed

Gammon, Elizabeth; Franzini, Luisa

2013-01-01

This study uses a sequential mixed method study design to define cost elements of research misconduct among faculty at academic medical centers. Using time driven activity based costing, the model estimates a per case cost for 17 cases of research misconduct reported by the Office of Research Integrity for the period of 2000-2005. Per case cost of research misconduct was found to range from $116,160 to $2,192,620. Research misconduct cost drivers are identified.

Do financial incentives of introducing case mix reimbursement increase feeding tube use in nursing home residents?

PubMed

Teno, Joan M; Feng, Zhanlian; Mitchell, Susan L; Kuo, Sylvia; Intrator, Orna; Mor, Vincent

2008-05-01

To determine whether adoption of Medicaid case mix reimbursement is associated with greater prevalence of feeding tube use in nursing home (NH) residents. Secondary analysis of longitudinal administrative data about the prevalence of feeding tube insertion and surveys of states' adoption of case mix reimbursement. NHs in the United States. NH residents at the time of NH inspection between 1993 and 2004. Facility prevalence of feeding tubes reported at the state inspection of NHs reported in the Online Survey, Certification and Reporting database and interviews with state policy makers regarding the adoption of case mix reimbursement. Between 1993 and 2004, 16 states adopted Resource Utilization Group case mix reimbursement. States varied in the prevalence of feeding tubes in their NHs. Although the use of feeding tube increased substantially over the years of the study, once temporal trends and facility fixed effects were accounted for, case mix reimbursement was not associated with greater prevalence of feeding tube use. The adoption of Medicaid case mix reimbursement was not associated with an increase in the prevalence of feeding tube use.

Case-mix analysis and variation in rates of non-surgical treatment of older women with operable breast cancer.

PubMed

Morgan, J; Richards, P; Ward, S; Francis, M; Lawrence, G; Collins, K; Reed, M; Wyld, L

2015-08-01

Non-surgical management of older women with oestrogen receptor (ER)-positive operable breast cancer is common in the UK, with up to 40 per cent of women aged over 70 years receiving primary endocrine therapy. Although this may be appropriate for frailer patients, for some it may result in treatment failure, contributing to the poor outcomes seen in this age group. Wide variation in the rates of non-operative management of breast cancer in older women exists across the UK. Case mix may explain some of this variation in practice. Data from two UK regional cancer registries were analysed to determine whether variation in treatment observed between 2002 and 2010 at hospital and clinician level persisted after adjustment for case mix. Expected case mix-adjusted surgery rates were derived by logistic regression using the variables age, proxy Charlson co-morbidity score, deprivation quintile, method of cancer detection, tumour size, stage, grade and node status. Data on 17,129 women aged 70 years or more with ER-positive operable breast cancer were analysed. There was considerable variation in rates of surgery at both hospital and clinician level. Despite adjusting for case mix, this variation persisted at hospital level, although not at clinician level. This study demonstrates variation in selection criteria for older women for operative treatment of early breast cancer, indicating that some older women may be undertreated or overtreated, and may partly explain the inferior disease outcomes in this age group. It emphasizes the urgent need for evidence-based guidelines for treatment selection criteria in older women with breast cancer. © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd.

Two extreme types of mixing of dust with urban aerosols observed in Kosa particles: ‘After’ mixing and ‘on-the-way’ mixing

NASA Astrophysics Data System (ADS)

Suzuki, Issei; Igarashi, Yasuhito; Dokiya, Yukiko; Akagi, Tasuku

2010-02-01

Besides well-known episodic Kosa during spring, high concentrations of Ca 2+ in aerosols were observed early in summer as well as in the semi-continuous data of the aerosols at the summit of Mt. Fuji. We further analysed the data to study the chemical characteristics of the high calcium event during early summer. The back trajectory analyses of the event indicated that Ca was transported from arid and semi-arid regions (e.g. the Taklamakan desert) through the westerly-dominated troposphere higher than the height of the summit of Fuji. The amount of SO 42- was always equivalent to that of NH 4+ unlike the case of the normal Kosa period where SO 42- is in excess with respect to NH 4+. This shows the 'after' mixing of unreacted CaCO 3 of Kosa origin with (NH 4) 2SO 4, which was only realized by the downward injection of Kosa particles from higher altitudes to the air masses of different origin. In the case of normal Kosa, the air bearing Kosa particles passed through the polluted area to absorb unneutralized acids ('on-the-way' mixing), whereas in the case of the Kosa-like phenomena in summer, the acids from the polluted area have been neutralized by NH 4+ and become inactive before mixing with CaCO 3 ("after" mixing). We have simplified the chemistry of aerosols using their three major components, Ca 2+, SO 42- and NH 4+, and introduced a new triangle diagram with the three assumed end-members of CaCO 3, CaSO 4 and (NH 4) 2SO 4 to quantify the contribution of the 'after' mixing to the aerosols (AMI; 'after' mixing index). Based on the back trajectories of some high AMI cases, CaCO 3 in Kosa particles was transported through the middle troposphere (5000-7000 m) and descended to meet another air mass where SO 42- had been already neutralized by NH 3.

Case Series: Mental Health Needs and Perspectives of Rural Children Reared by Parents Who Abuse Methamphetamine

ERIC Educational Resources Information Center

Ostler, Teresa; Haight, Wendy; Black, James; Choi, Ga-Young; Kingery, Linda; Sheridan, Kathryn

2007-01-01

Objective: This case-based, mixed-methods study was undertaken to understand the perspectives and mental health needs of rural children exposed to parental methamphetamine abuse. Method: Participants were 23 children involved with a state child protective agency because of parental methamphetamine abuse. A semistructured interview provided…

Syrians' Acceptance of Digital Lectures: A Case Study

ERIC Educational Resources Information Center

Ramadan, Reem

2016-01-01

Technology-based learning modules are mostly challenged by their acceptance. A single-case study and mixed research method are used to explore a unique situation of applying digital lectures at the postgraduate Programmes at the Faculty of Tourism at Damascus University as a solution for brain drain in the Syrian higher education system. Results…

Modelling, fabrication and characterization of a polymeric micromixer based on sequential segmentation.

PubMed

Nguyen, Nam-Trung; Huang, Xiaoyang

2006-06-01

Effective and fast mixing is important for many microfluidic applications. In many cases, mixing is limited by molecular diffusion due to constrains of the laminar flow in the microscale regime. According to scaling law, decreasing the mixing path can shorten the mixing time and enhance mixing quality. One of the techniques for reducing mixing path is sequential segmentation. This technique divides solvent and solute into segments in axial direction. The so-called Taylor-Aris dispersion can improve axial transport by three orders of magnitudes. The mixing path can be controlled by the switching frequency and the mean velocity of the flow. Mixing ratio can be controlled by pulse width modulation of the switching signal. This paper first presents a simple time-dependent one-dimensional analytical model for sequential segmentation. The model considers an arbitrary mixing ratio between solute and solvent as well as the axial Taylor-Aris dispersion. Next, a micromixer was designed and fabricated based on polymeric micromachining. The micromixer was formed by laminating four polymer layers. The layers are micro machined by a CO(2) laser. Switching of the fluid flows was realized by two piezoelectric valves. Mixing experiments were evaluated optically. The concentration profile along the mixing channel agrees qualitatively well with the analytical model. Furthermore, mixing results at different switching frequencies were investigated. Due to the dynamic behavior of the valves and the fluidic system, mixing quality decreases with increasing switching frequency.

Incremental cost of postacute care in nursing homes.

PubMed

Spector, William D; Limcangco, Maria Rhona; Ladd, Heather; Mukamel, Dana

2011-02-01

To determine whether the case mix index (CMI) based on the 53-Resource Utilization Groups (RUGs) captures all the cross-sectional variation in nursing home (NH) costs or whether NHs that have a higher percent of Medicare skilled care days (%SKILLED) have additional costs. DATA AND SAMPLE: Nine hundred and eighty-eight NHs in California in 2005. Data are from Medicaid cost reports, the Minimum Data Set, and the Economic Census. We estimate hybrid cost functions, which include in addition to outputs, case mix, ownership, wages, and %SKILLED. Two-stage least-square (2SLS) analysis was used to deal with the potential endogeneity of %SKILLED and CMI. On average 11 percent of NHs days were due to skilled care. Based on the 2SLS model, %SKILLED is associated with costs even when controlling for CMI. The marginal cost of a one percentage point increase in %SKILLED is estimated at U.S.$70,474 or about 1.2 percent of annual costs for the average cost facility. Subanalyses show that the increase in costs is mainly due to additional expenses for nontherapy ancillaries and rehabilitation. The 53-RUGs case mix does not account completely for all the variation in actual costs of care for postacute patients in NHs. © Health Research and Educational Trust.

Incremental Cost of Postacute Care in Nursing Homes

PubMed Central

Spector, William D; Limcangco, Maria Rhona; Ladd, Heather; Mukamel, Dana A

2011-01-01

Objectives To determine whether the case mix index (CMI) based on the 53-Resource Utilization Groups (RUGs) captures all the cross-sectional variation in nursing home (NH) costs or whether NHs that have a higher percent of Medicare skilled care days (%SKILLED) have additional costs. Data and Sample Nine hundred and eighty-eight NHs in California in 2005. Data are from Medicaid cost reports, the Minimum Data Set, and the Economic Census. Research Design We estimate hybrid cost functions, which include in addition to outputs, case mix, ownership, wages, and %SKILLED. Two-stage least-square (2SLS) analysis was used to deal with the potential endogeneity of %SKILLED and CMI. Results On average 11 percent of NHs days were due to skilled care. Based on the 2SLS model, %SKILLED is associated with costs even when controlling for CMI. The marginal cost of a one percentage point increase in %SKILLED is estimated at U.S.$70,474 or about 1.2 percent of annual costs for the average cost facility. Subanalyses show that the increase in costs is mainly due to additional expenses for nontherapy ancillaries and rehabilitation. Conclusion The 53-RUGs case mix does not account completely for all the variation in actual costs of care for postacute patients in NHs. PMID:21029085

Evaluation Criteria for Competency-Based Syllabi: A Chilean Case Study Applying Mixed Methods

ERIC Educational Resources Information Center

Jerez, Oscar; Valenzuela, Leslier; Pizarro, Veronica; Hasbun, Beatriz; Valenzuela, Gabriela; Orsini, Cesar

2016-01-01

In recent decades, higher education institutions worldwide have been moving from knowledge-based to competence-based curricula. One of the greatest challenges in this transition is the difficulty in changing the knowledge-oriented practices of teachers. This study evaluates the consistency between syllabus design and the requirements imposed by a…

Hybrid Problem-Based Learning in Digital Image Processing: A Case Study

ERIC Educational Resources Information Center

Tan, Songxin; Shen, Zixing

2018-01-01

Contribution: This paper reports a curriculum development in hybrid problem-based learning (h-PBL), addresses the design, implementation, effectiveness, and assessment issues of h-PBL, and explains the mixed results observed regarding the impact of problem-based learning (PBL) on student grades from a hybrid perspective. Background: The effect of…

The Case for Case-Mix: A New Construct for Hospital Management

PubMed Central

Plomann, Marilyn Peacock; Garzino, Fred R.

1981-01-01

Case-mix is a useful methodology for health care management, planning and control. It provides managers with a powerful tool by providing a framework for relating resource consumption profiles with specific treatment patterns. In the long run, it will assist hospital planners in analyzing the demands which different classes of patients bring to the hospital. Decisions concerning capital financing, facilities planning, new services, and the medical and financial implications of physician activities are more efficiently analyzed within a case-mix framework. In the near term, inventory management, staffing policies and the on-going need for the astute management of cash flow will be postively and decisively affected by the use of case-mix measures. The benefits derived from a case-mix system are not limited to hospitals possessing sophisticated management information systems. The case-mix methodology also provides a useful tool for hospitals with less advanced data processing systems and management practices in applying a variety of management science techniques to their planning and control activities.

Effects of operator splitting and low Mach-number correction in turbulent mixing transition simulations

DOE Office of Scientific and Technical Information (OSTI.GOV)

Grinstein, F. F.; Saenz, J. A.; Dolence, J. C.

Inmore » this paper, transition and turbulence decay with the Taylor–Green vortex have been effectively used to demonstrate emulation of high Reynolds-number ( R e ) physical dissipation through numerical convective effects of various non-oscillatory finite-volume algorithms for implicit large eddy simulation (ILES), e.g. using the Godunov-based Eulerian adaptive mesh refinement code xRAGE. The inverse-chevron shock tube experiment simulations have been also used to assess xRAGE based ILES for shock driven turbulent mixing, compared with available simulation and laboratory data. The previous assessments are extended to evaluate new directionally-unsplit high-order algorithms in xRAGE, including a correction to address the well-known issue of excessive numerical diffusion of shock-capturing (e.g., Godunov-type) schemes for low Mach numbers. The unsplit options for hydrodynamics in xRAGE are discussed in detail, followed by fundamental tests with representative shock problems. Basic issues of transition to turbulence and turbulent mixing are discussed, and results of simulations of high- R e turbulent flow and mixing in canonical test cases are reported. Finally, compared to the directional-split cases, and for each grid resolution considered, unsplit results exhibit transition to turbulence with much higher effective R e —and significantly more so with the low Mach number correction.« less

Effects of operator splitting and low Mach-number correction in turbulent mixing transition simulations

DOE PAGES

Grinstein, F. F.; Saenz, J. A.; Dolence, J. C.; ...

2018-06-07

Inmore » this paper, transition and turbulence decay with the Taylor–Green vortex have been effectively used to demonstrate emulation of high Reynolds-number ( R e ) physical dissipation through numerical convective effects of various non-oscillatory finite-volume algorithms for implicit large eddy simulation (ILES), e.g. using the Godunov-based Eulerian adaptive mesh refinement code xRAGE. The inverse-chevron shock tube experiment simulations have been also used to assess xRAGE based ILES for shock driven turbulent mixing, compared with available simulation and laboratory data. The previous assessments are extended to evaluate new directionally-unsplit high-order algorithms in xRAGE, including a correction to address the well-known issue of excessive numerical diffusion of shock-capturing (e.g., Godunov-type) schemes for low Mach numbers. The unsplit options for hydrodynamics in xRAGE are discussed in detail, followed by fundamental tests with representative shock problems. Basic issues of transition to turbulence and turbulent mixing are discussed, and results of simulations of high- R e turbulent flow and mixing in canonical test cases are reported. Finally, compared to the directional-split cases, and for each grid resolution considered, unsplit results exhibit transition to turbulence with much higher effective R e —and significantly more so with the low Mach number correction.« less

Classification of residents in nursing homes in Tuscany (Italy) using Resource Utilization Groups Version III (RUG-III).

PubMed

Francesconi, Paolo; Cantini, Elisabetta; Bavazzano, Emanuela; Lauretani, Fabrizio; Bandinelli, Stefania; Buiatti, Eva; Ferrucci, Luigi

2006-04-01

Samples of nursing homes in Tuscany (Italy) classify their residents and determine their case-mix according to the Resource Utilization Groups System, Version III (RUG-III). A large sample of nursing homes was selected, based on willingness to participate, representation of both public and private institutions, and wide geographic representation. Two registered nurses assessed all residents using the RUG questionnaire. The information collected was then used to group residents into 44 RUGs, and facility-specific case-mix indices were calculated using the RUG-specific weights previously validated in Italy. A total of 3981 residents from 93 nursing homes were assessed. Most residents were over 75 years old (87.4%) and women (68.6%). A large percentage was classified into RUGs within the following primary categories: reduced physical function (33.6%), impaired cognition (17.6%) and clinically complex (17.6%). The resulting nursing home case-mix indices ranged from 0.627 to 1.108 (mean 0.807+/-0.110). No significant association was found between type of facility, level of fees, or extent of staff in the nursing homes and their case-mix indices. RUGIII can provide information on types of nursing home residents and their care needs. This is useful for monitoring and evaluating long-term care services for the elderly, and allows for more effective planning and allocation of staffing and financial resources.

HIV quality report cards: impact of case-mix adjustment and statistical methods.

PubMed

Ohl, Michael E; Richardson, Kelly K; Goto, Michihiko; Vaughan-Sarrazin, Mary; Schweizer, Marin L; Perencevich, Eli N

2014-10-15

There will be increasing pressure to publicly report and rank the performance of healthcare systems on human immunodeficiency virus (HIV) quality measures. To inform discussion of public reporting, we evaluated the influence of case-mix adjustment when ranking individual care systems on the viral control quality measure. We used data from the Veterans Health Administration (VHA) HIV Clinical Case Registry and administrative databases to estimate case-mix adjusted viral control for 91 local systems caring for 12 368 patients. We compared results using 2 adjustment methods, the observed-to-expected estimator and the risk-standardized ratio. Overall, 10 913 patients (88.2%) achieved viral control (viral load ≤400 copies/mL). Prior to case-mix adjustment, system-level viral control ranged from 51% to 100%. Seventeen (19%) systems were labeled as low outliers (performance significantly below the overall mean) and 11 (12%) as high outliers. Adjustment for case mix (patient demographics, comorbidity, CD4 nadir, time on therapy, and income from VHA administrative databases) reduced the number of low outliers by approximately one-third, but results differed by method. The adjustment model had moderate discrimination (c statistic = 0.66), suggesting potential for unadjusted risk when using administrative data to measure case mix. Case-mix adjustment affects rankings of care systems on the viral control quality measure. Given the sensitivity of rankings to selection of case-mix adjustment methods-and potential for unadjusted risk when using variables limited to current administrative databases-the HIV care community should explore optimal methods for case-mix adjustment before moving forward with public reporting. Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2014. This work is written by (a) US Government employee(s) and is in the public domain in the US.

[Effects of residents' care needs classification (and misclassification) in nursing homes: the example of SOSIA classification].

PubMed

Nebuloni, G; Di Giulio, P; Gregori, D; Sandonà, P; Berchialla, P; Foltran, F; Renga, G

2011-01-01

Since 2003, the Lombardy region has introduced a case-mix reimbursement system for nursing homes based on the SOSIA form which classifies residents into eight classes of frailty. In the present study the agreement between SOSIA classification and other well documented instruments, including Barthel Index, Mini Mental State Examination and Clinical Dementia Rating Scale is evaluated in 100 nursing home residents. Only 50% of residents with severe dementia have been recognized as seriously impaired when assessed with SOSIA form; since misclassification errors underestimate residents' care needs, they determine an insufficient reimbursement limiting nursing home possibility to offer care appropriate for the case-mix.

Comparing colon cancer outcomes: The impact of low hospital case volume and case-mix adjustment.

PubMed

Fischer, C; Lingsma, H F; van Leersum, N; Tollenaar, R A E M; Wouters, M W; Steyerberg, E W

2015-08-01

When comparing performance across hospitals it is essential to consider the noise caused by low hospital case volume and to perform adequate case-mix adjustment. We aimed to quantify the role of noise and case-mix adjustment on standardized postoperative mortality and anastomotic leakage (AL) rates. We studied 13,120 patients who underwent colon cancer resection in 85 Dutch hospitals. We addressed differences between hospitals in postoperative mortality and AL, using fixed (ignoring noise) and random effects (incorporating noise) logistic regression models with general and additional, disease specific, case-mix adjustment. Adding disease specific variables improved the performance of the case-mix adjustment models for postoperative mortality (c-statistic increased from 0.77 to 0.81). The overall variation in standardized mortality ratios was similar, but some individual hospitals changed considerably. For the standardized AL rates the performance of the adjustment models was poor (c-statistic 0.59 and 0.60) and overall variation was small. Most of the observed variation between hospitals was actually noise. Noise had a larger effect on hospital performance than extended case-mix adjustment, although some individual hospital outcome rates were affected by more detailed case-mix adjustment. To compare outcomes between hospitals it is crucial to consider noise due to low hospital case volume with a random effects model. Copyright © 2015 Elsevier Ltd. All rights reserved.

Jet stability and wall impingement flow field in a thermal striping experiment

DOE PAGES

Lomperski, S.; Obabko, A.; Merzari, E.; ...

2017-08-10

We present velocity and temperature field measurements for a 0.9 x 0.9 x 1.7 m glass tank in which two air jets at Re=10000 mix and impinge upon the lid at ambient temperature and pressure. Flow patterns are characterized across a 350 x 200 mm plane located 3 mm below the lid for two inlet geometries: 1) “extended”, in which inlet channels protrude above the tank base, and 2) “flush”, a flat base without protrusions. This minor geometry variation produced distinct changes in the lid flow field, appearing as three stagnant regions for the extended case and only one formore » flush. The dichotomy is attributed to system stability characteristics: jets are stable in the extended case and unstable for flush. In a separate set of nonisothermal tests, the impingement temperature field was measured for inlet temperature mismatches of 4 oC and jets near Re=10000. A 50 m-long fiber optic distributed temperature sensor positioned 2 mm below the lid measured at 1350 locations. Like the velocity fields, the temperature fields differ for the two inlet geometries: good thermal mixing for the flush case and subdued mixing for the extended case. Simulations with the spectral element code Nek5000 replicated the observed stability dichotomy, duplicating the number of stagnant regions observed in the experiment and matching their locations within ±10 mm. Simulation data suggests that flush case instability is due to interactions between jets and wall flows at the bottom of the tank. The clear flow dichotomy exhibited by this two-jet setup presents an unambiguous case to test the ability of CFD tools to predict subtle flow field changes driven by minor modifications in geometry in the context of thermal striping.« less

Jet stability and wall impingement flow field in a thermal striping experiment

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lomperski, S.; Obabko, A.; Merzari, E.

We present velocity and temperature field measurements for a 0.9 x 0.9 x 1.7 m glass tank in which two air jets at Re=10000 mix and impinge upon the lid at ambient temperature and pressure. Flow patterns are characterized across a 350 x 200 mm plane located 3 mm below the lid for two inlet geometries: 1) “extended”, in which inlet channels protrude above the tank base, and 2) “flush”, a flat base without protrusions. This minor geometry variation produced distinct changes in the lid flow field, appearing as three stagnant regions for the extended case and only one formore » flush. The dichotomy is attributed to system stability characteristics: jets are stable in the extended case and unstable for flush. In a separate set of nonisothermal tests, the impingement temperature field was measured for inlet temperature mismatches of 4 oC and jets near Re=10000. A 50 m-long fiber optic distributed temperature sensor positioned 2 mm below the lid measured at 1350 locations. Like the velocity fields, the temperature fields differ for the two inlet geometries: good thermal mixing for the flush case and subdued mixing for the extended case. Simulations with the spectral element code Nek5000 replicated the observed stability dichotomy, duplicating the number of stagnant regions observed in the experiment and matching their locations within ±10 mm. Simulation data suggests that flush case instability is due to interactions between jets and wall flows at the bottom of the tank. The clear flow dichotomy exhibited by this two-jet setup presents an unambiguous case to test the ability of CFD tools to predict subtle flow field changes driven by minor modifications in geometry in the context of thermal striping.« less

Evaluation of cement and fly ash treated recycled asphalt pavement and aggregates for base construction : tech summary.

DOT National Transportation Integrated Search

2011-12-01

INTRODUCTION: Many entities currently use recycled asphalt pavement (RAP) and other aggregates as base materials, temporary haul roads, and, in the case of RAP, hot mix asphalt construction. Several : states currently allow the use of RAP combined wi...

Evaluation of cement and fly ash treated recycled asphalt pavement and aggregates for base construction.

DOT National Transportation Integrated Search

2011-12-01

Many entities currently use recycled asphalt pavement (RAP) and other aggregates as base material, temporary haul roads, : and, in the case of RAP, hot mix asphalt construction. Several states currently allow the use of RAP combined with cement : for...

Oral mite anaphylaxis caused by mite-contaminated okonomiyaki/ pancake-mix in Japan: 8 case reports and a review of 28 reported cases.

PubMed

Takahashi, Kentaro; Taniguchi, Masami; Fukutomi, Yuma; Sekiya, Kiyoshi; Watai, Kentaro; Mitsui, Chihiro; Tanimoto, Hidenori; Oshikata, Chiyako; Tsuburai, Takahiro; Tsurikisawa, Naomi; Minoguchi, Kenji; Nakajima, Hiroshi; Akiyama, Kazuo

2014-03-01

Anaphylaxis after the ingestion of foods contaminated with mites has recently been recognized. Case series and case reports thus far have shown that mite-contaminated wheat flour is the major cause of oral mite anaphylaxis. However, we have found 8 cases of oral mite anaphylaxis which were caused by mite-contaminated okonomiyaki-mix, a savory Japanese style pancake mix, in our hospital. In addition to our 8 cases, the databases of MEDLINE and ICHUSHI were systematically searched for patients with oral mite anaphylaxis in Japan. Thirty-six patients including our 8 cases with oral mite anaphylaxis were identified. Thirty-four out of 36 cases (94%) ingested okonomiyaki or takoyaki, prepared at home using okonomiyaki-mix or takoyaki-mix which was previously opened and stored for months at ambient temperature. Microscopic examination of culprit mixes of 16 cases including our 1 case revealed contamination of mites such as Dermatophagoides farina (Der f) (5 cases), Tyrophagus putrescentiae (Tyr p) (4 cases), and Dermatophagoides pteronyssinus (Der p) (3 cases). The specific IgE to each mite is generally upregulated in these patients. Especially, the titers of specific IgE to Der p and Der f were more than class 2 in all cases. Mite-contaminated flavored flour is the major cause of oral mite anaphylaxis in Japan.

Oral Mite Anaphylaxis Caused by Mite-Contaminated Okonomiyaki/Pancake-Mix in Japan: 8 Case Reports and a Review of 28 Reported Cases.

PubMed

Takahashi, Kentaro; Taniguchi, Masami; Fukutomi, Yuma; Sekiya, Kiyoshi; Watai, Kentaro; Mitsui, Chihiro; Tanimoto, Hidenori; Oshikata, Chiyako; Tsuburai, Takahiro; Tsurikisawa, Naomi; Minoguchi, Kenji; Nakajima, Hiroshi; Akiyama, Kazuo

2014-01-01

Anaphylaxis after the ingestion of foods contaminated with mites has recently been recognized. Case series and case reports thus far have shown that mite-contaminated wheat flour is the major cause of oral mite anaphylaxis. However, we have found 8 cases of oral mite anaphylaxis which were caused by mitecontaminated okonomiyaki-mix, a savory Japanese style pancake mix, in our hospital. In addition to our 8 cases, the databases of MEDLINE and ICHUSHI were systematically searched for patients with oral mite anaphylaxis in Japan. Thirty-six patients including our 8 cases with oral mite anaphylaxis were identified. Thirty-four out of 36 cases (94%) ingested okonomiyaki or takoyaki, prepared at home using okonomiyaki-mix or takoyaki-mix which was previously opened and stored for months at ambient temperature. Microscopic examination of culprit mixes of 16 cases including our 1 case revealed contamination of mites such as Dermatophagoides farina (Der f) (5 cases), Tyrophagus putrescentiae (Tyr p) (4 cases), and Dermatophagoides pteronyssinus (Der p) (3 cases). The specific IgE to each mite is generally upregulated in these patients. Especially, the titers of specific IgE to Der p and Der f were more than class 2 in all cases. Mite-contaminated flavored flour is the major cause of oral mite anaphylaxis in Japan. © 2014 Japanese Society of Allergology.

Oral Mite Anaphylaxis Caused by Mite-Contaminated Okonomiyaki/Pancake-Mix in Japan: 8 Case Reports and a Review of 28 Reported Cases.

PubMed

Takahashi, Kentaro; Taniguchi, Masami; Fukutomi, Yuma; Sekiya, Kiyoshi; Watai, Kentaro; Mitsui, Chihiro; Tanimoto, Hidenori; Oshikata, Chiyako; Tsuburai, Takahiro; Tsurikisawa, Naomi; Minoguchi, Kenji; Nakajima, Hiroshi; Akiyama, Kazuo

2013-12-25

Background: Anaphylaxis after the ingestion of foods contaminated with mites has recently been recognized. Case series and case reports thus far have shown that mite-contaminated wheat flour is the major cause of oral mite anaphylaxis. However, we have found 8 cases of oral mite anaphylaxis which were caused by mite-contaminated okonomiyaki-mix, a savory Japanese style pancake mix, in our hospital. Methods: In addition to our 8 cases, the databases of MEDLINE and ICHUSHI were systematically searched for patients with oral mite anaphylaxis in Japan. Results: Thirty-six patients including our 8 cases with oral mite anaphylaxis were identified. Thirty-four out of 36 cases (94%) ingested okonomiyaki or takoyaki, prepared at home using okonomiyaki-mix or takoyaki-mix which was previously opened and stored for months at ambient temperature. Microscopic examination of culprit mixes of 16 cases including our 1 case revealed contamination of mites such as Dermatophagoides farina (Der f) (5 cases), Tyrophagus putrescentiae (Tyr p) (4 cases), and Dermatophagoides pteronyssinus (Der p) (3 cases). The specific IgE to each mite is generally upregulated in these patients. Especially, the titers of specific IgE to Der p and Der f were more than class 2 in all cases. Conclusions: Mite-contaminated flavored flour is the major cause of oral mite anaphylaxis in Japan.

Convective Overshoot in Stellar Interior

NASA Astrophysics Data System (ADS)

Zhang, Q. S.

2015-07-01

In stellar interiors, the turbulent thermal convection transports matters and energy, and dominates the structure and evolution of stars. The convective overshoot, which results from the non-local convective transport from the convection zone to the radiative zone, is one of the most uncertain and difficult factors in stellar physics at present. The classical method for studying the convective overshoot is the non-local mixing-length theory (NMLT). However, the NMLT bases on phenomenological assumptions, and leads to contradictions, thus the NMLT was criticized in literature. At present, the helioseismic studies have shown that the NMLT cannot satisfy the helioseismic requirements, and have pointed out that only the turbulent convection models (TCMs) can be accepted. In the first part of this thesis, models and derivations of both the NMLT and the TCM were introduced. In the second part, i.e., the work part, the studies on the TCM (theoretical analysis and applications), and the development of a new model of the convective overshoot mixing were described in detail. In the work of theoretical analysis on the TCM, the approximate solution and the asymptotic solution were obtained based on some assumptions. The structure of the overshoot region was discussed. In a large space of the free parameters, the approximate/asymptotic solutions are in good agreement with the numerical results. We found an important result that the scale of the overshoot region in which the thermal energy transport is effective is 1 HK (HK is the scale height of turbulence kinetic energy), which does not depend on the free parameters of the TCM. We applied the TCM and a simple overshoot mixing model in three cases. In the solar case, it was found that the temperature gradient in the overshoot region is in agreement with the helioseismic requirements, and the profiles of the solar lithium abundance, sound speed, and density of the solar models are also improved. In the low-mass stars of open clusters Hyades, Praesepe, NGC6633, NGC752, NGC3680, and M67, using the model and parameter same to the solar case to deal with the convective envelope overshoot mixing, the lithium abundances on the surface of the stellar models were consistent with the observations. In the case of the binary HY Vir, the same model and parameter also make the radii and effective temperatures of HY Vir stars with convective cores be consistent with the observations. Based on the implications of the above results, we found that the simple overshoot mixing model may need to be improved significantly. Motivated by those implications, we established a new model of the overshoot mixing based on the fluid dynamic equations, and worked out the diffusion coefficient of convective mixing. The diffusion coefficient shows different behaviors in convection zone and overshoot region. In the overshoot region, the buoyancy does negative works on flows, thus the fluid flows around the equilibrium location, which leads to a small scale and low efficiency of overshoot mixing. The physical properties are significantly different from the classical NMLT, and consistent with the helioseismic studies and numerical simulations. The new model was tested in stellar evolution, and its parameter was calibrated.

Do Financial Incentives of Introducing Case Mix Reimbursement Increase Feeding Tube Use in Nursing Home Residents?

PubMed Central

Teno, Joan M.; Feng, Zhanlian; Mitchell, Susan L.; Kuo, Sylvia; Intrator, Orna; Mor, Vincent

2013-01-01

OBJECTIVES To determine whether adoption of Medicaid case mix reimbursement is associated with greater prevalence of feeding tube use in nursing home (NH) residents. DESIGN Secondary analysis of longitudinal administrative data about the prevalence of feeding tube insertion and surveys of states’ adoption of case mix reimbursement. SETTING NHs in the United States. PARTICIPANTS NH residents at the time of NH inspection between 1993 and 2004. MEASUREMENTS Facility prevalence of feeding tubes reported at the state inspection of NHs reported in the Online Survey, Certification and Reporting database and interviews with state policy makers regarding the adoption of case mix reimbursement. RESULTS Between 1993 and 2004, 16 states adopted Resource Utilization Group case mix reimbursement. States varied in the prevalence of feeding tubes in their NHs. Although the use of feeding tube increased substantially over the years of the study, once temporal trends and facility fixed effects were accounted for, case mix reimbursement was not associated with greater prevalence of feeding tube use. CONCLUSION The adoption of Medicaid case mix reimbursement was not associated with an increase in the prevalence of feeding tube use. PMID:18331293

Distinguishing between tertiary and secondary facilities: a case study of cardiac diagnostic-related groups (DRGs).

PubMed

Rouse, Paul; Arulambalam, Ajit; Correa, Ralph; Ullman, Cornelia

2010-05-14

To develop a classification of tertiary cardiac DRGs in order to investigate differences in tertiary/secondary product mix across New Zealand district health boards (DHBs). 67 DRGs from 85,442 cardiac cases were analysed using cost weights and patient comorbidity complexity levels, which were used as a proxy for complexity. The research found high variability of severity within some DRGs. 5 DHBs are the main providers of 27 DRGs which are high cost and identified as tertiary by several ADHB clinicians; the same 5 DHBs have on average higher severity by DRG than the other DHBs. NZ tertiary hospitals have a product mix of DRGs with higher complexity than secondary hospitals. Funding based on case weights needs to recognise the additional resource requirements for this higher complexity.

An S 4 model inspired from self-complementary neutrino mixing

NASA Astrophysics Data System (ADS)

Zhang, Xinyi

2018-03-01

We build an S 4 model for neutrino masses and mixings based on the self-complementary (SC) neutrino mixing pattern. The SC mixing is constructed from the self-complementarity relation plus {δ }CP}=-\\tfrac{π }{2}. We elaborately construct the model at a percent level of accuracy to reproduce the structure given by the SC mixing. After performing a numerical study on the model’s parameter space, we find that in the case of normal ordering, the model can give predictions on the observables that are compatible with their 3σ ranges, and give predictions for the not-yet observed quantities like the lightest neutrino mass m 1 ∈ [0.003, 0.010] eV and the Dirac CP violating phase {δ }CP}\\in [256.72^\\circ ,283.33^\\circ ].

42 CFR 484.240 - Methodology used for the calculation of the outlier payment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... for each case-mix group. (b) The outlier threshold for each case-mix group is the episode payment... the same for all case-mix groups. (c) The outlier payment is a proportion of the amount of estimated...

A 1H NMR-based metabolomics approach to evaluate the geographical authenticity of herbal medicine and its application in building a model effectively assessing the mixing proportion of intentional admixtures: A case study of Panax ginseng: Metabolomics for the authenticity of herbal medicine.

PubMed

Nguyen, Huy Truong; Lee, Dong-Kyu; Choi, Young-Geun; Min, Jung-Eun; Yoon, Sang Jun; Yu, Yun-Hyun; Lim, Johan; Lee, Jeongmi; Kwon, Sung Won; Park, Jeong Hill

2016-05-30

Ginseng, the root of Panax ginseng has long been the subject of adulteration, especially regarding its origins. Here, 60 ginseng samples from Korea and China initially displayed similar genetic makeup when investigated by DNA-based technique with 23 chloroplast intergenic space regions. Hence, (1)H NMR-based metabolomics with orthogonal projections on the latent structure-discrimination analysis (OPLS-DA) were applied and successfully distinguished between samples from two countries using seven primary metabolites as discrimination markers. Furthermore, to recreate adulteration in reality, 21 mixed samples of numerous Korea/China ratios were tested with the newly built OPLS-DA model. The results showed satisfactory separation according to the proportion of mixing. Finally, a procedure for assessing mixing proportion of intentionally blended samples that achieved good predictability (adjusted R(2)=0.8343) was constructed, thus verifying its promising application to quality control of herbal foods by pointing out the possible mixing ratio of falsified samples. Copyright © 2016 Elsevier B.V. All rights reserved.

Striving towards efficiency in the Greek hospitals by reviewing case mix classifications.

PubMed

Polyzos, Nicholas M

2002-09-01

In order to verify the efficiency level of Greek public hospitals, this paper evaluates the most recent indicators. Relevant data were collected from the two following databases: (a) hospitals' utilisation data generally and per clinical speciality [Ministry of Health, Athens, (Data based) 1995]; (b) Patients' and hospitals' characteristics per diagnosis [National Statistical Office, Athens, (Data based) 1993]. As explanatory variables, the study examines supply and demand factors following case mix classifications. Firstly, average length of stay (ALOS) and secondly, cost per case were regressed as dependent variables. The study highlights the extent of variability across hospitals for different groups of patients with the same condition. The results specify the most important factors that affect ALOS and cost pertaining to efficiency. Per speciality analysis shows occupancy, size-type of the hospital, beds and doctors per speciality, access and use of outpatient services, and surgical operations, etc. as the most significant factors. Per disease-diagnosis analysis shows age of over 65 years, gender, residence, marital status, surgical operation and insurance as the most important factors. General cost analysis in all National Health Systems (NHS) hospitals shows that economies of scale appear in: (a) district and/or specialised hospitals of 250-400 beds; (b) regional and/or teaching hospitals of over but near to 400 beds. Consequently, the author determines the 'Greek' Diagnostic Related Groups (DRGs), based on the cost per clinical speciality in the nine basic specialities and on the cost per diagnosis of the top 15 diagnoses. Further to the scientific results, such studies will enhance much necessary discussions on the organisation of service delivery and financing, by following case mix classification. Copyright 2002 Elsevier Science Ireland Ltd.

Providing Culturally Responsive Teaching in Field-Based and Student Teaching Experiences: A Case Study

ERIC Educational Resources Information Center

Kea, Cathy D.; Trent, Stanley C.

2013-01-01

This mixed design study chronicles the yearlong outcomes of 27 undergraduate preservice teacher candidates' ability to design and deliver culturally responsive lesson plans during field-based experience lesson observations and student teaching settings after receiving instruction in a special education methods course. While components of…

The effects of Medicaid reimbursement method and ownership on nursing home costs, case mix, and staffing.

PubMed

Cohen, J W; Dubay, L C

1990-01-01

In this study we analyze the effects of ownership and Medicaid cost containment initiatives on nursing home costs, payer mix, case mix, and staffing, using 1981 Medicare cost reports and Medicare/Medicaid Automated Certification files. As Medicaid cost containment incentives become stronger, nursing homes respond by decreasing case mix and commensurately decreasing staffing. When these incentives are especially strong, staffing is reduced beyond the apparently appropriate level, given the case mix. In addition, while chain facilities have lower costs than other types of facilities, these lower costs do not appear to come from either increased cream-skimming or reduced staffing levels.

Advanced scatter search approach and its application in a sequencing problem of mixed-model assembly lines in a case company

NASA Astrophysics Data System (ADS)

Liu, Qiong; Wang, Wen-xi; Zhu, Ke-ren; Zhang, Chao-yong; Rao, Yun-qing

2014-11-01

Mixed-model assembly line sequencing is significant in reducing the production time and overall cost of production. To improve production efficiency, a mathematical model aiming simultaneously to minimize overtime, idle time and total set-up costs is developed. To obtain high-quality and stable solutions, an advanced scatter search approach is proposed. In the proposed algorithm, a new diversification generation method based on a genetic algorithm is presented to generate a set of potentially diverse and high-quality initial solutions. Many methods, including reference set update, subset generation, solution combination and improvement methods, are designed to maintain the diversification of populations and to obtain high-quality ideal solutions. The proposed model and algorithm are applied and validated in a case company. The results indicate that the proposed advanced scatter search approach is significant for mixed-model assembly line sequencing in this company.

Traveltime-based descriptions of transport and mixing in heterogeneous domains

NASA Astrophysics Data System (ADS)

Luo, Jian; Cirpka, Olaf A.

2008-09-01

Modeling mixing-controlled reactive transport using traditional spatial discretization of the domain requires identifying the spatial distributions of hydraulic and reactive parameters including mixing-related quantities such as dispersivities and kinetic mass transfer coefficients. In most applications, breakthrough curves (BTCs) of conservative and reactive compounds are measured at only a few locations and spatially explicit models are calibrated by matching these BTCs. A common difficulty in such applications is that the individual BTCs differ too strongly to justify the assumption of spatial homogeneity, whereas the number of observation points is too small to identify the spatial distribution of the decisive parameters. The key objective of the current study is to characterize physical transport by the analysis of conservative tracer BTCs and predict the macroscopic BTCs of compounds that react upon mixing from the interpretation of conservative tracer BTCs and reactive parameters determined in the laboratory. We do this in the framework of traveltime-based transport models which do not require spatially explicit, costly aquifer characterization. By considering BTCs of a conservative tracer measured on different scales, one can distinguish between mixing, which is a prerequisite for reactions, and spreading, which per se does not foster reactions. In the traveltime-based framework, the BTC of a solute crossing an observation plane, or ending in a well, is interpreted as the weighted average of concentrations in an ensemble of non-interacting streamtubes, each of which is characterized by a distinct traveltime value. Mixing is described by longitudinal dispersion and/or kinetic mass transfer along individual streamtubes, whereas spreading is characterized by the distribution of traveltimes, which also determines the weights associated with each stream tube. Key issues in using the traveltime-based framework include the description of mixing mechanisms and the estimation of the traveltime distribution. In this work, we account for both apparent longitudinal dispersion and kinetic mass transfer as mixing mechanisms, thus generalizing the stochastic-convective model with or without inter-phase mass transfer and the advective-dispersive streamtube model. We present a nonparametric approach of determining the traveltime distribution, given a BTC integrated over an observation plane and estimated mixing parameters. The latter approach is superior to fitting parametric models in cases wherein the true traveltime distribution exhibits multiple peaks or long tails. It is demonstrated that there is freedom for the combinations of mixing parameters and traveltime distributions to fit conservative BTCs and describe the tailing. A reactive transport case of a dual Michaelis-Menten problem demonstrates that the reactive mixing introduced by local dispersion and mass transfer may be described by apparent mean mass transfer with coefficients evaluated by local BTCs.

Realization of a twin beam source based on four-wave mixing in Cesium

NASA Astrophysics Data System (ADS)

Adenier, G.; Calonico, D.; Micalizio, S.; Samantaray, N.; Degiovanni, I. P.; Berchera, I. Ruo

2016-05-01

Four-wave mixing (4WM) is a known source of intense non-classical twin beams. It can be generated when an intense laser beam (the pump) and a weak laser beam (the seed) overlap in a χ(3) medium (here Cesium vapor), with frequencies close to resonance with atomic transitions. The twin beams generated by 4WM have frequencies naturally close to atomic transitions, and can be intense (gain ≫1) even in the CW pump regime, which is not the case for PDC χ(2) phenomenon in nonlinear crystals. So, 4WM is well suited for atom-light interaction and atom-based quantum-protocols. Here, we present the first realization of a source of 4-wave mixing exploiting D2 line of Cesium atoms.

Optimal mix of renewable power generation in the MENA region as a basis for an efficient electricity supply to europe

NASA Astrophysics Data System (ADS)

Alhamwi, Alaa; Kleinhans, David; Weitemeyer, Stefan; Vogt, Thomas

2014-12-01

Renewable Energy sources are gaining importance in the Middle East and North Africa (MENA) region. The purpose of this study is to quantify the optimal mix of renewable power generation in the MENA region, taking Morocco as a case study. Based on hourly meteorological data and load data, a 100% solar-plus-wind only scenario for Morocco is investigated. For the optimal mix analyses, a mismatch energy modelling approach is adopted with the objective to minimise the required storage capacities. For a hypothetical Moroccan energy supply system which is entirely based on renewable energy sources, our results show that the minimum storage capacity is achieved at a share of 63% solar and 37% wind power generations.

Do diagnosis-related group-based payments incentivise hospitals to adjust output mix?

PubMed

Liang, Li-Lin

2015-04-01

This study investigates whether the diagnosis-related group (DRG)-based payment method motivates hospitals to adjust output mix in order to maximise profits. The hypothesis is that when there is an increase in profitability of a DRG, hospitals will increase the proportion of that DRG (own-price effects) and decrease those of other DRGs (cross-price effects), except in cases where there are scope economies in producing two different DRGs. This conjecture is tested in the context of the case payment scheme (CPS) under Taiwan's National Health Insurance programme over the period of July 1999 to December 2004. To tackle endogeneity of DRG profitability and treatment policy, a fixed-effects three-stage least squares method is applied. The results support the hypothesised own-price and cross-price effects, showing that DRGs which share similar resources appear to be complements rather substitutes. For-profit hospitals do not appear to be more responsive to DRG profitability, possibly because of their institutional characteristics and bonds with local communities. The key conclusion is that DRG-based payments will encourage a type of 'product-range' specialisation, which may improve hospital efficiency in the long run. However, further research is needed on how changes in output mix impact patient access and pay-outs of health insurance. Copyright © 2014 John Wiley & Sons, Ltd.

The comparative economic performance of investor-owned chain and not-for-profit hospitals.

PubMed

Watt, J M; Derzon, R A; Renn, S C; Schramm, C J; Hahn, J S; Pillari, G D

1986-01-09

We examined the differences in the economic performance of 80 matched pairs of investor-owned chain and not-for-profit hospitals in eight states during 1978 and 1980, and considered how their operating strategies might affect their relative success in a more price-conscious market. We found that total charges (adjusted for case mix) and net revenues per case were both significantly higher in the investor-owned chain hospitals, mainly because of higher charges for ancillary services; there were no significant differences between the two groups of hospitals in regard to patient-care costs per case (adjusted for case mix), but the investor-owned hospitals had significantly higher administrative overhead costs; investor-owned hospitals were more profitable; investor-owned hospitals had fewer employees per occupied bed but paid more per employee; investor-owned hospitals had funded more of their capital through debt and had significantly higher capital costs in proportion to their operating costs; and the two groups did not differ in patient mix, as measured by their Medicare case-mix indexes or the proportions of their patients covered by Medicare or Medicaid. We conclude that investor-owned chain hospitals generated higher profits through more aggressive pricing practices rather than operating efficiencies - a result not unexpected in view of past cost-based reimbursement policies. Recent changes in these policies are creating new pressures for cost control and moderation in charges, to which both types of hospitals must adapt. Neither type has a clear-cut advantage in the ability to make the necessary changes.

Molecular Analysis of Mixed Endometrial Carcinomas Shows Clonality in Most Cases.

PubMed

Köbel, Martin; Meng, Bo; Hoang, Lien N; Almadani, Noorah; Li, Xiaodong; Soslow, Robert A; Gilks, C Blake; Lee, Cheng-Han

2016-02-01

Mixed endometrial carcinoma refers to a tumor that comprises 2 or more distinct histotypes. We studied 18 mixed-type endometrial carcinomas-11 mixed serous and low-grade endometrioid carcinomas (SC/EC), 5 mixed clear cell and low-grade ECs (CCC/EC), and 2 mixed CCC and SCs (CCC/SC), using targeted next-generation sequencing and immunohistochemistry to compare the molecular profiles of the different histotypes present in each case. In 16 of 18 cases there was molecular evidence that both components shared a clonal origin. Eight cases (6 EC/SC, 1 EC/CCC, and 1 SC/CCC) showed an SC molecular profile that was the same in both components. Five cases (3 CCC/EC and 2 SC/EC) showed a shared endometrioid molecular profile and identical mismatch-repair protein deficiency in both components. A single SC/EC case harbored the same POLE exonuclease domain mutation in both components. One SC/CCC and 1 EC/CCC case showed both shared and unique molecular features in the 2 histotype components, suggesting early molecular divergence from a common clonal origin. In 2 cases, there were no shared molecular features, and these appear to be biologically unrelated synchronous tumors. Overall, these results show that the different histologic components in mixed endometrial carcinomas typically share the same molecular aberrations. Mixed endometrial carcinomas most commonly occur through morphologic mimicry, whereby tumors with serous-type molecular profile show morphologic features of EC or CCC, or through underlying deficiency in DNA nucleotide repair, with resulting rapid accrual of mutations and intratumoral phenotypic heterogeneity. Less commonly, mixed endometrial carcinomas are the result of early molecular divergence from a common progenitor clone or are synchronous biologically unrelated tumors (collision tumors).

Molecular analysis of mixed endometrial carcinomas shows clonality in most cases

PubMed Central

Hoang, Lien N.; Almadani, Noorah; Li, Xiaodong; Soslow, Robert A; Gilks, C. Blake; Lee, Cheng-Han

2016-01-01

Mixed endometrial carcinoma refers to a tumor that is comprised of two or more distinct histotypes. We studied 18 mixed-type endometrial carcinomas - 11 mixed serous and low-grade endometrioid carcinomas (SC/EC), 5 mixed clear cell and low-grade endometrioid carcinomas (CCC/EC), and 2 mixed clear cell and serous carcinoma (CCC/SC), using targeted next generation sequencing and immunohistochemistry to compare the molecular profiles of the different histotypes present in each case. In 16 of 18 cases there was molecular evidence that both components shared a clonal origin. Eight cases (6 EC/SC, 1 EC/CCC and 1 SC/CCC) showed a serous carcinoma molecular profile that was the same in both components. Five cases (3 CCC/EC and 2 SC/EC) showed a shared endometrioid molecular profile and identical mismatch repair protein (MMR) deficiency in both components. A single SC/EC case harbored the same POLE exonuclease domain mutation in both components. One SC/CCC and one EC/CCC case showed both shared and unique molecular features in the two histotype components, suggesting early molecular divergence from a common clonal origin. In two cases, there were no shared molecular features and these appear to be biologically unrelated synchronous tumors. Overall, these results show that the different histologic components in mixed endometrial carcinomas typically share the same molecular aberrations. Mixed endometrial carcinomas most commonly occur through morphological mimicry, whereby tumors with serous-type molecular profile show morphological features of endometrioid or clear cell carcinoma, or through underlying deficiency in DNA nucleotide repair, with resulting rapid accrual of mutations and intratumoral phenotypic heterogeneity. Less commonly, mixed endometrial carcinomas are the result of early molecular divergence from a common progenitor clone or are synchronous biologically unrelated tumors (collision tumors). PMID:26492180

Are the uterine serous carcinomas underdiagnosed? Histomorphologic and immunohistochemical correlates and clinical follow up in high-grade endometrial carcinomas initially diagnosed as high-grade endometrioid carcinoma.

PubMed

Hu, Shaomin; Hinson, Jeff L; Matnani, Rahul; Cibull, Michael L; Karabakhtsian, Rouzan G

2018-02-01

Histologic subclassification of high-grade endometrial carcinomas can sometimes be a diagnostic challenge when based on histomorphology alone. Here we utilized immunohistochemical markers to determine the immunophenotype in histologically ambiguous high-grade endometrial carcinomas that were initially diagnosed as pure or mixed high-grade endometrioid carcinoma, aiming to determine the utility of selected immunohistochemical panel in accurate classification of these distinct tumor types, while correlating these findings with the clinical outcome. A total of 43 high-grade endometrial carcinoma cases initially classified as pure high-grade endometrioid carcinoma (n=32), mixed high-grade endometrioid carcinoma/serous carcinoma (n=9) and mixed high-grade endometrioid carcinoma/clear cell carcinoma (n=2) were retrospectively stained with a panel of immunostains, including antibodies for p53, p16, estrogen receptor, and mammaglobin. Clinical follow-up data were obtained, and stage-to-stage disease outcomes were compared for different tumor types. Based on aberrant staining for p53 and p16, 17/43 (40%) of the high-grade endometrial carcinoma cases initially diagnosed as high-grade endometrioid carcinoma were re-classified as serous carcinoma. All 17 cases showed negative staining for mammaglobin, while estrogen receptor was positive in only 6 (35%) cases. The remaining 26 cases of high-grade endometrioid carcinoma showed wild-type staining for p53 in 25 (96%) cases, patchy staining for p16 in 20 (77%) cases, and were positive for mammaglobin and estrogen receptor in 8 (31%) and 19 (73%) cases, respectively, thus the initial diagnosis of high-grade endometrioid carcinoma was confirmed in these cases. In addition, the patients with re-classified serous carcinoma had advanced clinical stages at diagnosis and poorer overall survival on clinical follow-up compared to that of the remaining 26 high-grade endometrioid carcinoma cases. These results indicate that selected immunohistochemical panel, including p53, p16, and mammaglobin can be helpful in reaching accurate diagnosis in cases of histomorphologically ambiguous endometrial carcinomas, and can assist in providing guidance for appropriate therapeutic options for the patients.

Sesquiterpene lactone dermatitis in the young: is atopy a risk factor?

PubMed

Paulsen, Evy; Otkjaer, Aksel; Andersen, Klaus E

2008-07-01

Screening for Compositae contact allergy has documented fairly high prevalence in adults, and recent studies indicate that the allergy may be more common in children than previously believed. However, detailed information on sensitization in this age group is sparse. The objective of this study was to present another 2 cases in children and review the literature. Screening with sesquiterpene lactone (SL) mix has shown prevalence of 0.5% and 1.8% in 2 studies, while screening with 2 different Compositae mixes detected 4.2% and 2.6% positives among children and adolescents. All individual case reports describe sensitization in atopic children, and the largest screening study showed a prevalence of Compositae mix sensitization that was significantly higher in children with atopic dermatitis compared with non-atopics. Compositae sensitization should be considered in children with a family or personal history of atopy, summer-related, or -exacerbated dermatitis of any kind, and a history of plant exposure. Screening with SL mix is recommended but should be supplemented with plant extracts based on exposure history. Compositae weeds, especially dandelions, seem to be important sensitizers in children.

Assessing and evaluating multidisciplinary translational teams: a mixed methods approach.

PubMed

Wooten, Kevin C; Rose, Robert M; Ostir, Glenn V; Calhoun, William J; Ameredes, Bill T; Brasier, Allan R

2014-03-01

A case report illustrates how multidisciplinary translational teams can be assessed using outcome, process, and developmental types of evaluation using a mixed-methods approach. Types of evaluation appropriate for teams are considered in relation to relevant research questions and assessment methods. Logic models are applied to scientific projects and team development to inform choices between methods within a mixed-methods design. Use of an expert panel is reviewed, culminating in consensus ratings of 11 multidisciplinary teams and a final evaluation within a team-type taxonomy. Based on team maturation and scientific progress, teams were designated as (a) early in development, (b) traditional, (c) process focused, or (d) exemplary. Lessons learned from data reduction, use of mixed methods, and use of expert panels are explored.

A novel passive micromixer based on unbalanced splits and collisions of fluid streams

NASA Astrophysics Data System (ADS)

Ansari, Mubashshir Ahmad; Kim, Kwang-Yong; Anwar, Khalid; Kim, Sun Min

2010-05-01

A new passive micromixer based on the concept of unbalanced splits and cross-collisions of fluid streams is designed and fabricated. Experimental and numerical studies have been carried out on the micromixer at Reynolds numbers ranging from 10 to 80. The three-dimensional Navier-Stokes equations have been used to analyze the mixing and flow behavior of the micromixer, which is composed of two sub-channels of unequal widths which repeatedly undergo splitting and recombination. The difference between the mass flow rates in the two sub-channels creates an unbalanced collision of the two fluid streams. Mixing is mainly due to the combined effect of unbalanced collisions of the fluid streams and Dean vortices. The micromixer shows interesting mixing behavior for different ratios of the widths of the two split sub-channels. The sub-channels wherein the major sub-channel is twice as wide as the minor sub-channel exhibit the highest mixing performance at Reynolds numbers larger than 40. The results show the lowest mixing performance for the case of uniform width, where balanced collisions occur.

Constrained minimization problems for the reproduction number in meta-population models.

PubMed

Poghotanyan, Gayane; Feng, Zhilan; Glasser, John W; Hill, Andrew N

2018-02-14

The basic reproduction number ([Formula: see text]) can be considerably higher in an SIR model with heterogeneous mixing compared to that from a corresponding model with homogeneous mixing. For example, in the case of measles, mumps and rubella in San Diego, CA, Glasser et al. (Lancet Infect Dis 16(5):599-605, 2016. https://doi.org/10.1016/S1473-3099(16)00004-9 ), reported an increase of 70% in [Formula: see text] when heterogeneity was accounted for. Meta-population models with simple heterogeneous mixing functions, e.g., proportionate mixing, have been employed to identify optimal vaccination strategies using an approach based on the gradient of the effective reproduction number ([Formula: see text]), which consists of partial derivatives of [Formula: see text] with respect to the proportions immune [Formula: see text] in sub-groups i (Feng et al. in J Theor Biol 386:177-187, 2015.  https://doi.org/10.1016/j.jtbi.2015.09.006 ; Math Biosci 287:93-104, 2017.  https://doi.org/10.1016/j.mbs.2016.09.013 ). These papers consider cases in which an optimal vaccination strategy exists. However, in general, the optimal solution identified using the gradient may not be feasible for some parameter values (i.e., vaccination coverages outside the unit interval). In this paper, we derive the analytic conditions under which the optimal solution is feasible. Explicit expressions for the optimal solutions in the case of [Formula: see text] sub-populations are obtained, and the bounds for optimal solutions are derived for [Formula: see text] sub-populations. This is done for general mixing functions and examples of proportionate and preferential mixing are presented. Of special significance is the result that for general mixing schemes, both [Formula: see text] and [Formula: see text] are bounded below and above by their corresponding expressions when mixing is proportionate and isolated, respectively.

Testing a diagnosis-related group index for skilled nursing facilities

PubMed Central

Cotterill, Philip G.

1986-01-01

Interest in case-mix measures for use in nursing home payment systems has been stimulated by the Medicare prospective payment system (PPS) for short-term acute-care hospitals. Appropriately matching payment with care needs is important to equitably compensate providers and to encourage them to admit patients who are most in need of nursing home care. The skilled nursing facility (SNF) Medicare benefit covers skilled convalescent or rehabilitative care following a hospital stay. Therefore, it might appear that diagnosis-related groups (DRG's), the basis for patient classification in PPS, could also be used for the Medicare SNF program. In this study, a DRG-based case-mix index (CMI) was developed and tested to determine how well it explains cost differences among SNF's. The results suggest that a DRG-based SNF payment system would be highly problematic. Incentives of this system would appear to discourage placement of patients who require relatively expensive care. PMID:10311674

Testing a diagnosis-related group index for skilled nursing facilities.

PubMed

Cotterill, P G

1986-01-01

Interest in case-mix measures for use in nursing home payment systems has been stimulated by the Medicare prospective payment system (PPS) for short-term acute-care hospitals. Appropriately matching payment with care needs is important to equitably compensate providers and to encourage them to admit patients who are most in need of nursing home care. The skilled nursing facility (SNF) Medicare benefit covers skilled convalescent or rehabilitative care following a hospital stay. Therefore, it might appear that diagnosis-related groups (DRG's), the basis for patient classification in PPS, could also be used for the Medicare SNF program. In this study, a DRG-based case-mix index (CMI) was developed and tested to determine how well it explains cost differences among SNF's. The results suggest that a DRG-based SNF payment system would be highly problematic. Incentives of this system would appear to discourage placement of patients who require relatively expensive care.

Integration of Case Mix and Drug Utilization Data in the Long Term Care Setting

PubMed Central

Miller, R. Paul; Coblio, Nick; Bellnier, Terrance J.; Veneron, John P.

1989-01-01

Federal and state regulations mandate that a pharmacist perform a monthly review of the medical chart of residents at nursing homes. The review focuses on 31 quality issues which center on nursing and physician practice. We have computerized the data gathered by the pharmacist review with microcomputer technology and a relational data base manager. By introducing a “severity code” for each quality issue, we are able to pinpoint those data elements which physician staff can choose to focus on. The data can be studied longitudinally for trend analysis. The data was linked to that captured during the reimbursement case mix screens. Thus, two disparate data bases were integrated to allow further insights into our patient population. We conclude that computerization of disparate federal or state mandated data sets at nursing homes can be linked to aid patient care and quality assurance programs.

Barriers to Implementation of Case Management for Patients With Dementia: A Systematic Mixed Studies Review

PubMed Central

Khanassov, Vladimir; Vedel, Isabelle; Pluye, Pierre

2014-01-01

PURPOSE Results of case management designed for patients with dementia and their caregivers in community-based primary health care (CBPHC) were inconsistent. Our objective was to identify the relationships between key outcomes of case management and barriers to implementation. METHODS We conducted a systematic mixed studies review (including quantitative and qualitative studies). Literature search was performed in MEDLINE, PsycINFO, Embase, and Cochrane Library (1995 up to August 2012). Case management intervention studies were used to assess clinical outcomes for patients, service use, caregiver outcomes, satisfaction, and cost-effectiveness. Qualitative studies were used to examine barriers to case management implementation. Patterns in the relationships between barriers to implementation and outcomes were identified using the configurational comparative method. The quality of studies was assessed using the Mixed Methods Appraisal Tool. RESULTS Forty-three studies were selected (31 quantitative and 12 qualitative). Case management had a limited positive effect on behavioral symptoms of dementia and length of hospital stay for patients and on burden and depression for informal caregivers. Interventions that addressed a greater number of barriers to implementation resulted in increased number of positive outcomes. Results suggested that high-intensity case management was necessary and sufficient to produce positive clinical outcomes for patients and to optimize service use. Effective communication within the CBPHC team was necessary and sufficient for positive outcomes for caregivers. CONCLUSIONS Clinicians and managers who implement case management in CBPHC should take into account high-intensity case management (small caseload, regular proactive patient follow-up, regular contact between case managers and family physicians) and effective communication between case managers and other CBPHC professionals and services. PMID:25354410

Barriers to implementation of case management for patients with dementia: a systematic mixed studies review.

PubMed

Khanassov, Vladimir; Vedel, Isabelle; Pluye, Pierre

2014-01-01

Results of case management designed for patients with dementia and their caregivers in community-based primary health care (CBPHC) were inconsistent. Our objective was to identify the relationships between key outcomes of case management and barriers to implementation. We conducted a systematic mixed studies review (including quantitative and qualitative studies). Literature search was performed in MEDLINE, PsycINFO, Embase, and Cochrane Library (1995 up to August 2012). Case management intervention studies were used to assess clinical outcomes for patients, service use, caregiver outcomes, satisfaction, and cost-effectiveness. Qualitative studies were used to examine barriers to case management implementation. Patterns in the relationships between barriers to implementation and outcomes were identified using the configurational comparative method. The quality of studies was assessed using the Mixed Methods Appraisal Tool. Forty-three studies were selected (31 quantitative and 12 qualitative). Case management had a limited positive effect on behavioral symptoms of dementia and length of hospital stay for patients and on burden and depression for informal caregivers. Interventions that addressed a greater number of barriers to implementation resulted in increased number of positive outcomes. Results suggested that high-intensity case management was necessary and sufficient to produce positive clinical outcomes for patients and to optimize service use. Effective communication within the CBPHC team was necessary and sufficient for positive outcomes for caregivers. Clinicians and managers who implement case management in CBPHC should take into account high-intensity case management (small caseload, regular proactive patient follow-up, regular contact between case managers and family physicians) and effective communication between case managers and other CBPHC professionals and services. © 2014 Annals of Family Medicine, Inc.

Different Trophic Tracers Give Different Answers for the Same Bugs - Comparing a Stable Isotope and Fatty Acid Based Analysis of Resource Utilization in a Marine Isopod

NASA Astrophysics Data System (ADS)

Galloway, A. W. E.; Eisenlord, M. E.; Brett, M. T.

2016-02-01

Stable isotope (SI) based mixing models are the most common approach used to infer resource pathways in consumers. However, SI based analyses are often underdetermined, and consumer SI fractionation is usually unknown. The use of fatty acid (FA) tracers in mixing models offers an alternative approach that can resolve the underdetermined constraint. A limitation to both methods is the considerable uncertainty about consumer `trophic modification' (TM) of dietary FA or SI, which occurs as consumers transform dietary resources into tissues. We tested the utility of SI and FA approaches for inferring the diets of the marine benthic isopod (Idotea wosnesenskii) fed various marine macroalgae in controlled feeding trials. Our analyses quantified how the accuracy and precision of Bayesian mixing models was influenced by choice of algorithm (SIAR vs MixSIR), fractionation (assumed or known), and whether the model was under or overdetermined (seven sources and two vs 26 tracers) for cases where isopods were fed an exclusive diet of one of the seven different macroalgae. Using the conventional approach (i.e., 2 SI with assumed TM) resulted in average model outputs, i.e., the contribution from the exclusive resource = 0.20 ± 0.23 (0.00-0.79), mean ± SD (95% credible interval), that only differed slightly from the prior assumption. Using the FA based approach with known TM greatly improved model performance, i.e., the contribution from the exclusive resource = 0.91 ± 0.10 (0.58-0.99). The choice of algorithm only made a difference when fractionation was known and the model was overdetermined (FA approach). In this case SIAR and MixSIR had outputs of 0.86 ± 0.11 (0.48-0.96) and 0.96 ± 0.05 (0.79-1.00), respectively. This analysis shows the choice of dietary tracers and the assumption of consumer trophic modification greatly influence the performance of mixing model dietary reconstructions, and ultimately our understanding of what resources actually support aquatic consumers.

Reliability evaluation of high-performance, low-power FinFET standard cells based on mixed RBB/FBB technique

NASA Astrophysics Data System (ADS)

Wang, Tian; Cui, Xiaoxin; Ni, Yewen; Liao, Kai; Liao, Nan; Yu, Dunshan; Cui, Xiaole

2017-04-01

With shrinking transistor feature size, the fin-type field-effect transistor (FinFET) has become the most promising option in low-power circuit design due to its superior capability to suppress leakage. To support the VLSI digital system flow based on logic synthesis, we have designed an optimized high-performance low-power FinFET standard cell library based on employing the mixed FBB/RBB technique in the existing stacked structure of each cell. This paper presents the reliability evaluation of the optimized cells under process and operating environment variations based on Monte Carlo analysis. The variations are modelled with Gaussian distribution of the device parameters and 10000 sweeps are conducted in the simulation to obtain the statistical properties of the worst-case delay and input-dependent leakage for each cell. For comparison, a set of non-optimal cells that adopt the same topology without employing the mixed biasing technique is also generated. Experimental results show that the optimized cells achieve standard deviation reduction of 39.1% and 30.7% at most in worst-case delay and input-dependent leakage respectively while the normalized deviation shrinking in worst-case delay and input-dependent leakage can be up to 98.37% and 24.13%, respectively, which demonstrates that our optimized cells are less sensitive to variability and exhibit more reliability. Project supported by the National Natural Science Foundation of China (No. 61306040), the State Key Development Program for Basic Research of China (No. 2015CB057201), the Beijing Natural Science Foundation (No. 4152020), and Natural Science Foundation of Guangdong Province, China (No. 2015A030313147).

Paediatric case mix in a rural clinical school is relevant to future practice.

PubMed

Wright, Helen M; Maley, Moira A L; Playford, Denese E; Nicol, Pam; Evans, Sharon F

2017-11-29

Exposure to a representative case mix is essential for clinical learning, with logbooks established as a way of demonstrating patient contacts. Few studies have reported the paediatric case mix available to geographically distributed students within the same medical school. Given international interest in expanding medical teaching locations to rural contexts, equitable case exposure in rural relative to urban settings is topical. The Rural Clinical School of Western Australia locates students up to 3500 km from the urban university for an academic year. There is particular need to examine paediatric case mix as a study reported Australian graduates felt unprepared for paediatric rotations. We asked: Does a rural clinical school provide a paediatric case mix relevant to future practice? How does the paediatric case mix as logged by rural students compare with that by urban students? The 3745 logs of 76 urban and 76 rural consenting medical students were categorised by presenting symptoms and compared to the Australian Institute of Health and Welfare (AIHW) database Major Diagnostic Categories (MDCs). Rural and urban students logged core paediatric cases, in similar order, despite the striking difference in geographic locations. The pattern of overall presenting problems closely corresponded to Australian paediatric hospital admissions. Rural students logged 91% of cases in secondary healthcare settings; urban students logged 90% of cases in tertiary settings. The top four presenting problems were ENT/respiratory, gastrointestinal/urogenital, neurodevelopmental and musculoskeletal; these made up 60% of all cases. Rural and urban students logged similar proportions of infants, children and adolescents, with a variety of case morbidity. Rural clinical school students logged a mix of core paediatric cases relevant to illnesses of Australian children admitted to public hospitals, with similar order and pattern by age group to urban students, despite major differences in clinical settings. Logged cases met the curriculum learning outcomes of graduates. Minor variations were readily addressed via recommendations about logging. This paper provides evidence of the legitimacy of student logs as useful tools in affirming appropriate paediatric case mix. It validates the rural clinical school context as appropriate for medical students to prepare for future clinical paediatric practice.

Literature Search through Mixed-Membership Community Discovery

NASA Astrophysics Data System (ADS)

Eliassi-Rad, Tina; Henderson, Keith

We introduce a new approach to literature search that is based on finding mixed-membership communities on an augmented co-authorship graph (ACA) with a scalable generative model. An ACA graph contains two types of edges: (1) coauthorship links and (2) links between researchers with substantial expertise overlap. Our solution eliminates the biases introduced by either looking at citations of a paper or doing a Web search. A case study on PubMed shows the benefits of our approach.

Simulation of one-dimensional heat transfer system based on the blended coal combustion

NASA Astrophysics Data System (ADS)

Jin, Y. G.; Li, W. B.; Cheng, Z. S.; Cheng, J. W.; liu, Y.

2017-12-01

In this paper, the supercritical boiler thermodynamic calculation model is studied. Three types of heat exchangers are proposed, namely furnace (total radiation type), semi-radiation and convection, and discussed. Two cases were simulated - mixing of two bituminous coals and mixing of a bituminous coal and lignite- order to analyze the performance on the flue gas side. The study shows that the influence of flue air leakage and gas distribution coefficient on the system.

Productivity--a key to managing cost-per-case. Part 1.

PubMed

Orefice, J J; Jennings, M C

1983-08-01

Productivity and productivity management are critical to effective case-mix management. Case-mix management expands on traditional productivity management to include the relationship between such intermediate products as patient days, tests and meals, and the ultimate end product, the case. As hospitals search to increase the profitability of specific case types, they must focus on two critical productivity control points. First, they must examine length of stay and ancillary utilization as one level of productivity. Then they must turn to more traditional analyses and review departmental productivity in the production of the intermediate products. No case-mix management system is complete unless it focuses on both of these critical relationships. Part two of this article will explore performance reporting and its role in managing both productivity and case mix.

Developing a dashboard to help measure and achieve the triple aim: a population-based cohort study.

PubMed

Seow, Hsien-Yeang; Sibley, Lyn M

2014-08-30

Health system planners aim to pursue the three goals of Triple Aim: 1) reduce health care costs; 2) improve population health; and 3) improve the care experience. Moreover, they also need measures that can reliably predict future health care needs in order to manage effectively the health system performance. Yet few measures exist to assess Triple Aim and predict future needs at a health system level. The purpose of this study is to explore the novel application of a case-mix adjustment method in order to measure and help improve the Triple Aim of health system performance. We applied a case-mix adjustment method to a population-based analysis to assess its usefulness as a measure of health system performance and Triple Aim. The study design was a retrospective, cohort study of adults from Ontario, Canada using administrative databases: individuals were assigned a predicted illness burden score using a case-mix adjustment system from diagnoses and health utilization data in 2008, and then followed forward to assess the actual health care utilization and costs in the following year (2009). We applied the Johns Hopkins Adjusted Clinical Group (ACG) Case-Mix System to categorize individuals into 60 levels of healthcare need, called ACGs. The outcomes were: 1) Number of individuals per ACG; 2) Total system costs per ACG; and 3) Mean cost per person per ACG, which together formed a health system "dashboard". We identified 11.4 million adults. 16.1% were aged 65 or older, 3.2 million (28%) did not use health care services that year, and 45,000 (0.4%) were in the highest acuity ACG category using 12 times more than an average adult. The sickest 1%, 5% and 15% of the population use about 10%, 30% and 50% of total health system costs respectively. The dashboard measures 2 dimensions of Triple Aim: 1) reduced costs: when total system costs per ACG or when average costs per person is reduced; and 2) improved population health: when more people move into healthier rather than sicker ACGs. It can help to achieve the third aim, improved care experience, when ACG utilization predictions are reported to providers to proactively develop care plans. The dashboard, developed via case-mix methods, measures 2 of the Triple Aim goals and can help health system planners better manage their health delivery systems.

Practice patterns, case mix, Medicare payment policy, and dialysis facility costs.

PubMed Central

Hirth, R A; Held, P J; Orzol, S M; Dor, A

1999-01-01

OBJECTIVE: To evaluate the effects of case mix, practice patterns, features of the payment system, and facility characteristics on the cost of dialysis. DATA SOURCES/STUDY SETTING: The nationally representative sample of dialysis units in the 1991 U.S. Renal Data System's Case Mix Adequacy (CMA) Study. The CMA data were merged with data from Medicare Cost Reports, HCFA facility surveys, and HCFA's end-stage renal disease patient registry. STUDY DESIGN: We estimated a statistical cost function to examine the determinants of costs at the dialysis unit level. PRINCIPAL FINDINGS: The relationship between case mix and costs was generally weak. However, dialysis practices (type of dialysis membrane, membrane reuse policy, and treatment duration) did have a significant effect on costs. Further, facilities whose payment was constrained by HCFA's ceiling on the adjustment for area wage rates incurred higher costs than unconstrained facilities. The costs of hospital-based units were considerably higher than those of freestanding units. Among chain units, only members of one of the largest national chains exhibited significant cost savings relative to independent facilities. CONCLUSIONS: Little evidence showed that adjusting dialysis payment to account for differences in case mix across facilities would be necessary to ensure access to care for high-cost patients or to reimburse facilities equitably for their costs. However, current efforts to increase dose of dialysis may require higher payments. Longer treatments appear to be the most economical method of increasing the dose of dialysis. Switching to more expensive types of dialysis membranes was a more costly means of increasing dose and hence must be justified by benefits beyond those of higher dose. Reusing membranes saved money, but the savings were insufficient to offset the costs associated with using more expensive membranes. Most, but not all, of the higher costs observed in hospital-based units appear to reflect overhead cost allocation rather than a difference in real resources devoted to treatment. The economies experienced by the largest chains may provide an explanation for their recent growth in market share. The heterogeneity of results by chain size implies that characterizing units using a simple chain status indicator variable is inadequate. Cost differences by facility type and the effects of the ongoing growth of large chains are worthy of continued monitoring to inform both payment policy and antitrust enforcement. PMID:10029498

Practice patterns, case mix, Medicare payment policy, and dialysis facility costs.

PubMed

Hirth, R A; Held, P J; Orzol, S M; Dor, A

1999-02-01

To evaluate the effects of case mix, practice patterns, features of the payment system, and facility characteristics on the cost of dialysis. The nationally representative sample of dialysis units in the 1991 U.S. Renal Data System's Case Mix Adequacy (CMA) Study. The CMA data were merged with data from Medicare Cost Reports, HCFA facility surveys, and HCFA's end-stage renal disease patient registry. We estimated a statistical cost function to examine the determinants of costs at the dialysis unit level. The relationship between case mix and costs was generally weak. However, dialysis practices (type of dialysis membrane, membrane reuse policy, and treatment duration) did have a significant effect on costs. Further, facilities whose payment was constrained by HCFA's ceiling on the adjustment for area wage rates incurred higher costs than unconstrained facilities. The costs of hospital-based units were considerably higher than those of freestanding units. Among chain units, only members of one of the largest national chains exhibited significant cost savings relative to independent facilities. Little evidence showed that adjusting dialysis payment to account for differences in case mix across facilities would be necessary to ensure access to care for high-cost patients or to reimburse facilities equitably for their costs. However, current efforts to increase dose of dialysis may require higher payments. Longer treatments appear to be the most economical method of increasing the dose of dialysis. Switching to more expensive types of dialysis membranes was a more costly means of increasing dose and hence must be justified by benefits beyond those of higher dose. Reusing membranes saved money, but the savings were insufficient to offset the costs associated with using more expensive membranes. Most, but not all, of the higher costs observed in hospital-based units appear to reflect overhead cost allocation rather than a difference in real resources devoted to treatment. The economies experienced by the largest chains may provide an explanation for their recent growth in market share. The heterogeneity of results by chain size implies that characterizing units using a simple chain status indicator variable is inadequate. Cost differences by facility type and the effects of the ongoing growth of large chains are worthy of continued monitoring to inform both payment policy and antitrust enforcement.

42 CFR 412.328 - Determining and updating the hospital-specific rate.

Code of Federal Regulations, 2012 CFR

2012-10-01

...-year cost reporting period—(1) Last 12 month cost reporting period ending on or before December 31... intermediary updates the case-mix adjusted base period costs per discharge to FY 1992 based on the national... determined under paragraph (d) of this section by the following factors: (1) Update factor. After FY 1992...

42 CFR 412.328 - Determining and updating the hospital-specific rate.

Code of Federal Regulations, 2013 CFR

2013-10-01

...-year cost reporting period—(1) Last 12 month cost reporting period ending on or before December 31... intermediary updates the case-mix adjusted base period costs per discharge to FY 1992 based on the national... determined under paragraph (d) of this section by the following factors: (1) Update factor. After FY 1992...

42 CFR 412.328 - Determining and updating the hospital-specific rate.

Code of Federal Regulations, 2011 CFR

2011-10-01

...-year cost reporting period—(1) Last 12 month cost reporting period ending on or before December 31... intermediary updates the case-mix adjusted base period costs per discharge to FY 1992 based on the national... determined under paragraph (d) of this section by the following factors: (1) Update factor. After FY 1992...

42 CFR 412.328 - Determining and updating the hospital-specific rate.

Code of Federal Regulations, 2014 CFR

2014-10-01

...-year cost reporting period—(1) Last 12 month cost reporting period ending on or before December 31... intermediary updates the case-mix adjusted base period costs per discharge to FY 1992 based on the national... determined under paragraph (d) of this section by the following factors: (1) Update factor. After FY 1992...

The Case of Lobster Shell Disease

ERIC Educational Resources Information Center

Hollen, Shawna; Toney, Jaime L.; Bisaccio, Daniel; Haberstroh, Karen Marie; Herbert, Timothy

2011-01-01

The authors combined content-driven and inquiry-based lessons into the framework of problem-based learning (PBL). They did this in eight third- through sixth-grade classrooms--two each from grades 3-5, one from sixth grade, and one mixed-grade special education. These older elementary students explored a local problem of lobsters infected by…

Technology-Based Professional Development for Teaching and Learning in K-12 Classrooms

ERIC Educational Resources Information Center

Byrd, Nijia

2017-01-01

In an urban Georgia school district, teacher satisfaction surveys revealed that technology-based professional development was not equipping teachers with the skills or support needed to implement technology into their teaching practices. The purpose of this mixed-methods case study was to explore teachers' experiences and perceptions of…

Inter-provider comparison of patient-reported outcomes: developing an adjustment to account for differences in patient case mix.

PubMed

Nuttall, David; Parkin, David; Devlin, Nancy

2015-01-01

This paper describes the development of a methodology for the case-mix adjustment of patient-reported outcome measures (PROMs) data permitting the comparison of outcomes between providers on a like-for-like basis. Statistical models that take account of provider-specific effects form the basis of the proposed case-mix adjustment methodology. Indirect standardisation provides a transparent means of case mix adjusting the PROMs data, which are updated on a monthly basis. Recently published PROMs data for patients undergoing unilateral knee replacement are used to estimate empirical models and to demonstrate the application of the proposed case-mix adjustment methodology in practice. The results are illustrative and are used to highlight a number of theoretical and empirical issues that warrant further exploration. For example, because of differences between PROMs instruments, case-mix adjustment methodologies may require instrument-specific approaches. A number of key assumptions are made in estimating the empirical models, which could be open to challenge. The covariates of post-operative health status could be expanded, and alternative econometric methods could be employed. © 2013 Crown copyright.

Modulation of aerosol radiative forcing due to mixing state in clear and cloudy-sky: A case study from Delhi National Capital Region, India

NASA Astrophysics Data System (ADS)

Srivastava, Parul; Dey, Sagnik; Srivastava, Atul K.; Singh, Sachchidanand; Tiwari, Suresh; Agarwal, Poornima

2016-04-01

Aerosol properties change with the change in mixing state of aerosols and therefore it is a source of uncertainty in estimated aerosol radiative forcing (ARF) from observations or by models assuming a specific mixing state. The problem is important in the Indo-Gangetic Basin, Northern India, where various aerosol types mix and show strong seasonal variations. Quantifying the modulation of ARF by mixing state is hindered by lack of knowledge about proper aerosol composition. Hence, first a detailed chemical composition analysis of aerosols for Delhi National capital region (NCR) is carried out. Aerosol composition is arranged quantitatively into five major aerosol types - accumulation dust, coarse dust, water soluble (WS), water insoluble (WINS), and black carbon (BC) (directly measured by Athelometer). Eight different mixing cases - external mixing, internal mixing, and six combinations of core- shell mixing (BC over dust, WS over dust, WS over BC, BC over WS, WS over WINS, and BC over WINS; each of the combinations externally mixed with other species) have been considered. The spectral aerosol optical properties - extinction coefficient, single scattering albedo (SSA) and asymmetry parameter (g) for each of the mixing cases are calculated and finally 'clear-sky' and 'cloudy-sky' ARF at the top-of-the-atmosphere (TOA) and surface are estimated using a radiative transfer model. Comparison of surface-reaching flux for each of the cases with MERRA downward shortwave surface flux reveals the most likely mixing state. 'BC-WINS+WS+Dust' show least deviation relative to MERRA during the pre-monsoon (MAMJ) and monsoon (JAS) seasons and hence is the most probable mixing states. During the winter season (DJF), 'BC-Dust+WS+WINS' case shows the closest match with MERRA, while external mixing is the most probable mixing state in the post-monsoon season (ON). Lowest values for both TOA and surface 'clear-sky' ARF is observed for 'BC-WINS+WS+ Dust' mixing case. TOA ARF is 0.28±2.4, 2.2±1.1, -1.4±1.4, -0.15±0.13, while, surface ARF is -16.4±3.1, -7.6±1.7, -31.5±4.7, -17.1±8.4, respectively for the MAMJ, JAS, ON and DJF seasons. Post-monsoon and winter season shows negative values of TOA ARF, hence suggest 'cooling'. The associated heating rate profiles show higher values for 'WS-BC+Dust+WINS' case as compared to other cases, with relatively large values during the winter and post-monsoon seasons, while lower value was observed for 'BC-WINS+WS+Dust'. We examined the modulation of clear sky ARF by 'water-cloud' and 'ice-cloud' separately. The seasonal mean ARF for both water and ice clouds show nearly similar characteristics as observed for clear-sky case, with relatively large ARF at TOA and surface in water cloud case as compared to ice cloud during all the seasons. As a result, the associated heating rate is also relatively higher in water cloud case as compared to ice cloud. Such large modulation of ARF due to mixing state calls for a coordinated effort to create a mixing state database for this region to reduce the uncertainty in climate forcing.

Using Online Digital Tools and Video to Support International Problem-Based Learning

ERIC Educational Resources Information Center

Lajoie, Susanne P.; Hmelo-Silver, Cindy; Wiseman, Jeffrey; Chan, Lap Ki; Lu, Jingyan; Khurana, Chesta; Cruz-Panesso, Ilian; Poitras, Eric; Kazemitabar, Maedeh

2014-01-01

The goal of this study is to examine how to facilitate cross-cultural groups in problem-based learning (PBL) using online digital tools and videos. The PBL consisted of two video-based cases used to trigger student-learning issues about giving bad news to HIV-positive patients. Mixed groups of medical students from Canada and Hong Kong worked with…

A comparison of patient-centered and case-mix reimbursement for nursing home care.

PubMed Central

Willemain, T R

1980-01-01

The trend in payment for nursing home services has been toward making finer distinctions amont patients and the rates at which their care is reimbursed. The ultimate in differentiation is patient-centered reimbursement, whereas each patient's rate is individually determined. This paper introduces a model of overpayment and under-payment for comparing the potential performance of alternative reimbursement schemes. The model is used in comparing the patient-centered approach with case-mix reimbursement, which assigns a single rate to all patients in a nursing home on the basis of the facility's case mix. Roughly speaking, the case-mix approach is preferable whenever the differences between patient's needs are smaller than the errors in needs assessment. Since this condition appears to hold in practice today, case-mix reimbursement seems preferable for the short term. PMID:7461971

Case mix planning in hospitals: a review and future agenda.

PubMed

Hof, Sebastian; Fügener, Andreas; Schoenfelder, Jan; Brunner, Jens O

2017-06-01

The case mix planning problem deals with choosing the ideal composition and volume of patients in a hospital. With many countries having recently changed to systems where hospitals are reimbursed for patients according to their diagnosis, case mix planning has become an important tool in strategic and tactical hospital planning. Selecting patients in such a payment system can have a significant impact on a hospital's revenue. The contribution of this article is to provide the first literature review focusing on the case mix planning problem. We describe the problem, distinguish it from similar planning problems, and evaluate the existing literature with regard to problem structure and managerial impact. Further, we identify gaps in the literature. We hope to foster research in the field of case mix planning, which only lately has received growing attention despite its fundamental economic impact on hospitals.

A comparison of patient-centered and case-mix reimbursement for nursing home care.

PubMed

Willemain, T R

1980-01-01

The trend in payment for nursing home services has been toward making finer distinctions amont patients and the rates at which their care is reimbursed. The ultimate in differentiation is patient-centered reimbursement, whereas each patient's rate is individually determined. This paper introduces a model of overpayment and under-payment for comparing the potential performance of alternative reimbursement schemes. The model is used in comparing the patient-centered approach with case-mix reimbursement, which assigns a single rate to all patients in a nursing home on the basis of the facility's case mix. Roughly speaking, the case-mix approach is preferable whenever the differences between patient's needs are smaller than the errors in needs assessment. Since this condition appears to hold in practice today, case-mix reimbursement seems preferable for the short term.

Risk adjustment for case mix and the effect of surgeon volume on morbidity.

PubMed

Maas, Matthew B; Jaff, Michael R; Rordorf, Guy A

2013-06-01

Retrospective studies of large administrative databases have shown higher mortality for procedures performed by low-volume surgeons, but the adequacy of risk adjustment in those studies is in doubt. To determine whether the relationship between surgeon volume and outcomes is an artifact of case mix using a prospective sample of carotid endarterectomy cases. Observational cohort study from January 1, 2008, through December 31, 2010, with preoperative, immediate postoperative, and 30-day postoperative assessments acquired by independent monitors. Urban, tertiary academic medical center. All 841 patients who underwent carotid endarterectomy performed by a vascular surgeon or cerebrovascular neurosurgeon at the institution. Carotid endarterectomy without another concurrent surgery. Stroke, death, and other surgical complications occurring within 30 days of surgery along with other case data. A low-volume surgeon performed 40 or fewer cases per year. Variables used in a comparison administrative database study, as well as variables identified by our univariate analysis, were used for adjusted analyses to assess for an association between low-volume surgeons and the rate of stroke and death as well as other complications. RESULTS The rate of stroke and death was 6.9% for low-volume surgeons and 2.0% for high-volume surgeons (P = .001). Complications were similarly higher (13.4% vs 7.2%, P = .008). Low-volume surgeons performed more nonelective cases. Low-volume surgeons were significantly associated with stroke and death in the unadjusted analysis as well as after adjustment with variables used in the administrative database study (odds ratio, 3.61; 95% CI, 1.70-7.67, and odds ratio, 3.68; 95% CI, 1.72-7.89, respectively). However, adjusting for the significant disparity of American Society of Anesthesiologists Physical Status classification in case mix eliminated the effect of surgeon volume on the rate of stroke and death (odds ratio, 1.65; 95% CI, 0.59-4.64) and other complications. Variables selected for risk adjustment in studies using administrative databases appear to be inadequate to control for case mix bias between low-volume and high-volume surgeons. Risk adjustment should empirically analyze for case mix imbalances between surgeons to identify meaningful risk modifiers in clinical practice such as the American Society of Anesthesiologists Physical Status classification. A true relationship between surgeon volume and outcomes remains uncertain, and caution is advised in developing policies based on these findings.

Transition mixing study empirical model report

NASA Technical Reports Server (NTRS)

Srinivasan, R.; White, C.

1988-01-01

The empirical model developed in the NASA Dilution Jet Mixing Program has been extended to include the curvature effects of transition liners. This extension is based on the results of a 3-D numerical model generated under this contract. The empirical model results agree well with the numerical model results for all tests cases evaluated. The empirical model shows faster mixing rates compared to the numerical model. Both models show drift of jets toward the inner wall of a turning duct. The structure of the jets from the inner wall does not exhibit the familiar kidney-shaped structures observed for the outer wall jets or for jets injected in rectangular ducts.

Solar neutrino masses and mixing from bilinear R-parity broken supersymmetry: Analytical versus numerical results

NASA Astrophysics Data System (ADS)

Díaz, M.; Hirsch, M.; Porod, W.; Romão, J.; Valle, J.

2003-07-01

We give an analytical calculation of solar neutrino masses and mixing at one-loop order within bilinear R-parity breaking supersymmetry, and compare our results to the exact numerical calculation. Our method is based on a systematic perturbative expansion of R-parity violating vertices to leading order. We find in general quite good agreement between the approximate and full numerical calculations, but the approximate expressions are much simpler to implement. Our formalism works especially well for the case of the large mixing angle Mikheyev-Smirnov-Wolfenstein solution, now strongly favored by the recent KamLAND reactor neutrino data.

Simultaneous occurrence of focal nodular hyperplasia and HNF1A-inactivated hepatocellular adenoma: a collision tumor simulating a composite FNH-HCA.

PubMed

Shih, Angela; Lauwers, Gregory Y; Balabaud, Charles; Bioulac-Sage, Paulette; Misdraji, Joseph

2015-09-01

Mixed focal nodular hyperplasia (FNH) and hepatocellular adenoma (HCA) within a single tumor mass is rarely reported, and most of these cases are examples of tumors with features intermediate between FNH and HCA. Although a few reported cases are probably examples of true mixed tumors, none was evaluated immunohistochemically or confirmed by molecular analysis. We report a mixed FNH and HCA arising in a woman with several HNF1A-inactivated adenomas. Our case is the first case of mixed FNH and HNF1A-inactivated HCA documented by immunohistochemistry.

The Denaturation Transition of DNA in Mixed Solvents

PubMed Central

Hammouda, Boualem; Worcester, David

2006-01-01

The helix-to-coil denaturation transition in DNA has been investigated in mixed solvents at high concentration using ultraviolet light absorption spectroscopy and small-angle neutron scattering. Two solvents have been used: water and ethylene glycol. The “melting” transition temperature was found to be 94°C for 4% mass fraction DNA/d-water and 38°C for 4% mass fraction DNA/d-ethylene glycol. The DNA melting transition temperature was found to vary linearly with the solvent fraction in the mixed solvents case. Deuterated solvents (d-water and d-ethylene glycol) were used to enhance the small-angle neutron scattering signal and 0.1M NaCl (or 0.0058 g/g mass fraction) salt concentration was added to screen charge interactions in all cases. DNA structural information was obtained by small-angle neutron scattering, including a correlation length characteristic of the inter-distance between the hydrogen-containing (desoxyribose sugar-amine base) groups. This correlation length was found to increase from 8.5 to 12.3 Å across the melting transition. Ethylene glycol and water mixed solvents were found to mix randomly in the solvation region in the helix phase, but nonideal solvent mixing was found in the melted coil phase. In the coil phase, solvent mixtures are more effective solvating agents than either of the individual solvents. Once melted, DNA coils behave like swollen water-soluble synthetic polymer chains. PMID:16815902

Do prices reflect the costs of cardiac surgery in the elderly?

PubMed

Coelho, Pedro; Rodrigues, Vanessa; Miranda, Luís; Fragata, José; Pita Barros, Pedro

2017-01-01

Payment for cardiac surgery in Portugal is based on a contract agreement between hospitals and the health ministry. Our aim was to compare the prices paid according to this contract agreement with calculated costs in a population of patients aged ≥65 years undergoing cardiac surgery in one hospital department. Data on 250 patients operated between September 2011 and September 2012 were prospectively collected. The procedures studied were coronary artery bypass graft surgery (CABG) (n=67), valve surgery (n=156) and combined CABG and valve surgery (n=27). Costs were calculated by two methods: micro-costing when feasible and mean length of stay otherwise. Price information was provided by the hospital administration and calculated using the hospital's mean case-mix. Thirty-day mortality was 3.2%. Mean EuroSCORE I was 5.97 (standard deviation [SD] 4.5%), significantly lower for CABG (p<0.01). Mean intensive care unit stay was 3.27 days (SD 4.7) and mean hospital stay was 9.92 days (SD 6.30), both significantly shorter for CABG. Calculated costs for CABG were €6539.17 (SD 3990.26), for valve surgery €8289.72 (SD 3319.93) and for combined CABG and valve surgery €11 498.24 (SD 10 470.57). The payment for each patient was €4732.38 in 2011 and €4678.66 in 2012 based on the case-mix index of the hospital group, which was 2.06 in 2011 and 2.21 in 2012; however, the case-mix in our sample was 6.48 in 2011 and 6.26 in 2012. The price paid for each patient was lower than the calculated costs. Prices would be higher than costs if the case-mix of the sample had been used. Costs were significantly lower for CABG. Copyright © 2016 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.

Reconciling incongruous qualitative and quantitative findings in mixed methods research: exemplars from research with drug using populations.

PubMed

Wagner, Karla D; Davidson, Peter J; Pollini, Robin A; Strathdee, Steffanie A; Washburn, Rachel; Palinkas, Lawrence A

2012-01-01

Mixed methods research is increasingly being promoted in the health sciences as a way to gain more comprehensive understandings of how social processes and individual behaviours shape human health. Mixed methods research most commonly combines qualitative and quantitative data collection and analysis strategies. Often, integrating findings from multiple methods is assumed to confirm or validate the findings from one method with the findings from another, seeking convergence or agreement between methods. Cases in which findings from different methods are congruous are generally thought of as ideal, whilst conflicting findings may, at first glance, appear problematic. However, the latter situation provides the opportunity for a process through which apparently discordant results are reconciled, potentially leading to new emergent understandings of complex social phenomena. This paper presents three case studies drawn from the authors' research on HIV risk amongst injection drug users in which mixed methods studies yielded apparently discrepant results. We use these case studies (involving injection drug users [IDUs] using a Needle/Syringe Exchange Program in Los Angeles, CA, USA; IDUs seeking to purchase needle/syringes at pharmacies in Tijuana, Mexico; and young street-based IDUs in San Francisco, CA, USA) to identify challenges associated with integrating findings from mixed methods projects, summarize lessons learned, and make recommendations for how to more successfully anticipate and manage the integration of findings. Despite the challenges inherent in reconciling apparently conflicting findings from qualitative and quantitative approaches, in keeping with others who have argued in favour of integrating mixed methods findings, we contend that such an undertaking has the potential to yield benefits that emerge only through the struggle to reconcile discrepant results and may provide a sum that is greater than the individual qualitative and quantitative parts. Copyright © 2011 Elsevier B.V. All rights reserved.

Reconciling incongruous qualitative and quantitative findings in mixed methods research: exemplars from research with drug using populations

PubMed Central

Wagner, Karla D.; Davidson, Peter J.; Pollini, Robin A.; Strathdee, Steffanie A.; Washburn, Rachel; Palinkas, Lawrence A.

2011-01-01

Mixed methods research is increasingly being promoted in the health sciences as a way to gain more comprehensive understandings of how social processes and individual behaviours shape human health. Mixed methods research most commonly combines qualitative and quantitative data collection and analysis strategies. Often, integrating findings from multiple methods is assumed to confirm or validate the findings from one method with the findings from another, seeking convergence or agreement between methods. Cases in which findings from different methods are congruous are generally thought of as ideal, while conflicting findings may, at first glance, appear problematic. However, the latter situation provides the opportunity for a process through which apparently discordant results are reconciled, potentially leading to new emergent understandings of complex social phenomena. This paper presents three case studies drawn from the authors’ research on HIV risk among injection drug users in which mixed methods studies yielded apparently discrepant results. We use these case studies (involving injection drug users [IDUs] using a needle/syringe exchange program in Los Angeles, California, USA; IDUs seeking to purchase needle/syringes at pharmacies in Tijuana, Mexico; and young street-based IDUs in San Francisco, CA, USA) to identify challenges associated with integrating findings from mixed methods projects, summarize lessons learned, and make recommendations for how to more successfully anticipate and manage the integration of findings. Despite the challenges inherent in reconciling apparently conflicting findings from qualitative and quantitative approaches, in keeping with others who have argued in favour of integrating mixed methods findings, we contend that such an undertaking has the potential to yield benefits that emerge only through the struggle to reconcile discrepant results and may provide a sum that is greater than the individual qualitative and quantitative parts. PMID:21680168

Specifying Quality of Service for Distributed Systems Based Upon Behavior Models

DTIC Science & Technology

2002-06-01

Leave blank) 2. REPORT DATE June 2002 3 . REPORT TYPE AND DATES COVERED Dissertation 4. TITLE AND SUBTITLE: Title (Mix case letters) Specifying...213 3 . Linux .................................................................................................214 5. Ensemble...FIGURE 3 . RESOURCE MANAGEMENT SCOPE............................................................................................................. 18

Relevance of the c-statistic when evaluating risk-adjustment models in surgery.

PubMed

Merkow, Ryan P; Hall, Bruce L; Cohen, Mark E; Dimick, Justin B; Wang, Edward; Chow, Warren B; Ko, Clifford Y; Bilimoria, Karl Y

2012-05-01

The measurement of hospital quality based on outcomes requires risk adjustment. The c-statistic is a popular tool used to judge model performance, but can be limited, particularly when evaluating specific operations in focused populations. Our objectives were to examine the interpretation and relevance of the c-statistic when used in models with increasingly similar case mix and to consider an alternative perspective on model calibration based on a graphical depiction of model fit. From the American College of Surgeons National Surgical Quality Improvement Program (2008-2009), patients were identified who underwent a general surgery procedure, and procedure groups were increasingly restricted: colorectal-all, colorectal-elective cases only, and colorectal-elective cancer cases only. Mortality and serious morbidity outcomes were evaluated using logistic regression-based risk adjustment, and model c-statistics and calibration curves were used to compare model performance. During the study period, 323,427 general, 47,605 colorectal-all, 39,860 colorectal-elective, and 21,680 colorectal cancer patients were studied. Mortality ranged from 1.0% in general surgery to 4.1% in the colorectal-all group, and serious morbidity ranged from 3.9% in general surgery to 12.4% in the colorectal-all procedural group. As case mix was restricted, c-statistics progressively declined from the general to the colorectal cancer surgery cohorts for both mortality and serious morbidity (mortality: 0.949 to 0.866; serious morbidity: 0.861 to 0.668). Calibration was evaluated graphically by examining predicted vs observed number of events over risk deciles. For both mortality and serious morbidity, there was no qualitative difference in calibration identified between the procedure groups. In the present study, we demonstrate how the c-statistic can become less informative and, in certain circumstances, can lead to incorrect model-based conclusions, as case mix is restricted and patients become more homogenous. Although it remains an important tool, caution is advised when the c-statistic is advanced as the sole measure of a model performance. Copyright © 2012 American College of Surgeons. All rights reserved.

Using multilevel modeling to assess case-mix adjusters in consumer experience surveys in health care.

PubMed

Damman, Olga C; Stubbe, Janine H; Hendriks, Michelle; Arah, Onyebuchi A; Spreeuwenberg, Peter; Delnoij, Diana M J; Groenewegen, Peter P

2009-04-01

Ratings on the quality of healthcare from the consumer's perspective need to be adjusted for consumer characteristics to ensure fair and accurate comparisons between healthcare providers or health plans. Although multilevel analysis is already considered an appropriate method for analyzing healthcare performance data, it has rarely been used to assess case-mix adjustment of such data. The purpose of this article is to investigate whether multilevel regression analysis is a useful tool to detect case-mix adjusters in consumer assessment of healthcare. We used data on 11,539 consumers from 27 Dutch health plans, which were collected using the Dutch Consumer Quality Index health plan instrument. We conducted multilevel regression analyses of consumers' responses nested within health plans to assess the effects of consumer characteristics on consumer experience. We compared our findings to the results of another methodology: the impact factor approach, which combines the predictive effect of each case-mix variable with its heterogeneity across health plans. Both multilevel regression and impact factor analyses showed that age and education were the most important case-mix adjusters for consumer experience and ratings of health plans. With the exception of age, case-mix adjustment had little impact on the ranking of health plans. On both theoretical and practical grounds, multilevel modeling is useful for adequate case-mix adjustment and analysis of performance ratings.

Mixed squamous cell and glandular papilloma of the lung: a case study and literature review.

PubMed

Inamura, Kentaro; Kumasaka, Toshio; Furuta, Reiko; Shimada, Kei; Hiyama, Noriko; Furuhata, Yoshiaki; Tanaka, Isao; Takemura, Tamiko

2011-04-01

Mixed squamous cell and glandular papilloma (mixed papilloma) of the lung is an extremely rare neoplasm, with only 10 cases reported so far in the English literature. We present a case study of endobronchial mixed papilloma with immunohistochemical and etiological investigations. A 49-year-old male with a smoking history complained of hemoptysis, presented with a lung mass closely adjacent to large vessels in the computed tomography findings, and underwent lobectomy. The 3.0-cm sized polypoid tumor was histologically diagnosed as endobronchial mixed papilloma. Immunohistochemically, intracellular mucin was positive for MUC5AC, which is expressed in tracheobronchial goblet cells. CAM5.2 and CK19 were diffusely positive, indicating that the tumor originated from the columnar epithelium by squamous metaplasia. CEA and CA19-9 were focally positive. A human papillomavirus (HPV) investigation with in situ hybridization using a wide spectrum probe and a newly-developed PCR system did not detect any HPV infection. Including this case with a detailed HPV investigation, all of the reported cases of mixed papilloma were HPV-negative, and a literature review including newly-reported cases indicated a high frequency of smoking in such cases. Endobronchial mixed papillomas might have a smoking-related etiology. © 2011 The Authors. Pathology International © 2011 Japanese Society of Pathology and Blackwell Publishing Asia Pty Ltd.

Frequent homozygosity in both mature and immature ovarian teratomas: a shared genetic basis of tumorigenesis.

PubMed

Snir, Olivia L; DeJoseph, Maura; Wong, Serena; Buza, Natalia; Hui, Pei

2017-10-01

Although homozygosity is well documented in mature teratomas, the genetic zygosity of ovarian immature teratomas and mixed germ cell tumors is less well studied. Ten cases of mature cystic teratomas, eleven cases of grade 2 or 3 immature teratomas, and seven cases of mixed germ cell tumors with an immature teratoma component were investigated by short tandem repeat genotyping to interrogate their genetic zygosity. DNA genotyping was informative in eight mature teratomas, seven immature teratomas and six cases of mixed germ cell tumors. Out of the eight mature teratomas, five cases showed partial or complete homozygosity (63%) with two cases demonstrating complete homozygosity (25%). Of the immature teratomas, six cases showed partial or complete homozygosity (86%) with two cases demonstrating complete homozygosity (29%). For the mixed germ cell tumors, two cases showed partial homozygosity (33%) and none displayed complete homozygosity. Long-term clinical follow-up was available for five immature teratomas (mean follow-up 110 months) and five mixed germ cell tumors (mean follow-up 66 months). None of the five patients with pure immature teratoma had a recurrence; in contrast, four out of five mixed ovarian germ cell tumors recurred between 4 months to 8 years (P=0.048). In conclusion, both immature and mature teratomas harbor frequent genetic homozygosity suggesting a common cellular origin involving germ cells at the same developmental stage. The difference in the rate of homozygosity and tumor recurrence between pure immature teratomas and mixed germ cell tumors suggests that the two entities may involve different pathogenetic pathways and likely pursue different biological behaviors.

Attribution of horizontal and vertical contributions to spurious mixing in an Arbitrary Lagrangian-Eulerian ocean model

NASA Astrophysics Data System (ADS)

Gibson, Angus H.; Hogg, Andrew McC.; Kiss, Andrew E.; Shakespeare, Callum J.; Adcroft, Alistair

2017-11-01

We examine the separate contributions to spurious mixing from horizontal and vertical processes in an ALE ocean model, MOM6, using reference potential energy (RPE). The RPE is a global diagnostic which changes only due to mixing between density classes. We extend this diagnostic to a sub-timestep timescale in order to individually separate contributions to spurious mixing through horizontal (tracer advection) and vertical (regridding/remapping) processes within the model. We both evaluate the overall spurious mixing in MOM6 against previously published output from other models (MOM5, MITGCM and MPAS-O), and investigate impacts on the components of spurious mixing in MOM6 across a suite of test cases: a lock exchange, internal wave propagation, and a baroclinically-unstable eddying channel. The split RPE diagnostic demonstrates that the spurious mixing in a lock exchange test case is dominated by horizontal tracer advection, due to the spatial variability in the velocity field. In contrast, the vertical component of spurious mixing dominates in an internal waves test case. MOM6 performs well in this test case owing to its quasi-Lagrangian implementation of ALE. Finally, the effects of model resolution are examined in a baroclinic eddies test case. In particular, the vertical component of spurious mixing dominates as horizontal resolution increases, an important consideration as global models evolve towards higher horizontal resolutions.

Synchronized and mixed outbreaks of coupled recurrent epidemics.

PubMed

Zheng, Muhua; Zhao, Ming; Min, Byungjoon; Liu, Zonghua

2017-05-25

Epidemic spreading has been studied for a long time and most of them are focused on the growing aspect of a single epidemic outbreak. Recently, we extended the study to the case of recurrent epidemics (Sci. Rep. 5, 16010 (2015)) but limited only to a single network. We here report from the real data of coupled regions or cities that the recurrent epidemics in two coupled networks are closely related to each other and can show either synchronized outbreak pattern where outbreaks occur simultaneously in both networks or mixed outbreak pattern where outbreaks occur in one network but do not in another one. To reveal the underlying mechanism, we present a two-layered network model of coupled recurrent epidemics to reproduce the synchronized and mixed outbreak patterns. We show that the synchronized outbreak pattern is preferred to be triggered in two coupled networks with the same average degree while the mixed outbreak pattern is likely to show for the case with different average degrees. Further, we show that the coupling between the two layers tends to suppress the mixed outbreak pattern but enhance the synchronized outbreak pattern. A theoretical analysis based on microscopic Markov-chain approach is presented to explain the numerical results. This finding opens a new window for studying the recurrent epidemics in multi-layered networks.

Velocity Measurement in a Dual-Mode Supersonic Combustor using Particle Image Velocimetry

NASA Technical Reports Server (NTRS)

Goyne, C. P.; McDaniel, J. C.; Krauss, R. H.; Day, S. W.; Reubush, D. E. (Technical Monitor); McClinton, C. R. (Technical Monitor); Reubush, D. E.

2001-01-01

Temporally and spatially-resolved, two-component measurements of velocity in a supersonic hydrogen-air combustor are reported. The combustor had a single unswept ramp fuel injector and operated with an inlet Mach number of 2 and a flow total temperature approaching 1200 K. The experiment simulated the mixing and combustion processes of a dual-mode scramjet operating at a flight Mach number near 5. The velocity measurements were obtained by seeding the fuel with alumina particles and performing Particle Image Velocimetry on the mixing and combustion wake of the ramp injector. To assess the effects of combustion on the fuel air-mixing process, the distribution of time-averaged velocity and relative turbulence intensity was determined for the cases of fuel-air mixing and fuel-air reacting. Relative to the mixing case, the near field core velocity of the reacting fuel jet had a slower streamwise decay. In the far field, downstream of 4 to 6 ramp heights from the ramp base, the heat release of combustion resulted in decreased flow velocity and increased turbulence levels. The reacting measurements were also compared with a computational fluid dynamics solution of the flow field. Numerically predicted velocity magnitudes were higher than that measured and the jet penetration was lower.

Preparing Teachers for Prison Schools: A Case Study of the Challenges, Attitudes, and Motivations of Correctional Educators

ERIC Educational Resources Information Center

Lawton, Lucile

2012-01-01

The purpose of this case study using a mixed method approach was to examine the role of that correctional educators in an Arizona state prison based on their challenges, attitudes, and motivations in order to learn how best to prepare people for that role. Although the research on public school teachers and teaching in adult education practices in…

An academic practice's transition to the business of medicine in the community. A case study.

PubMed

Griffin, S L; Schryver, D L

2000-01-01

This case study highlights the problems confronting a clinical practice corporation affiliated with a major medical school, and the business realizations it made in the acquisition of a community-based clinic. Launching a financially viable enterprise requires careful planning, determination of formal goals and expectations, an appropriate mix of physicians and services, a specific marketing campaign and community support.

Assessing and Evaluating Multidisciplinary Translational Teams: A Mixed Methods Approach

PubMed Central

Wooten, Kevin C.; Rose, Robert M.; Ostir, Glenn V.; Calhoun, William J.; Ameredes, Bill T.; Brasier, Allan R.

2014-01-01

A case report illustrates how multidisciplinary translational teams can be assessed using outcome, process, and developmental types of evaluation using a mixed methods approach. Types of evaluation appropriate for teams are considered in relation to relevant research questions and assessment methods. Logic models are applied to scientific projects and team development to inform choices between methods within a mixed methods design. Use of an expert panel is reviewed, culminating in consensus ratings of 11 multidisciplinary teams and a final evaluation within a team type taxonomy. Based on team maturation and scientific progress, teams were designated as: a) early in development, b) traditional, c) process focused, or d) exemplary. Lessons learned from data reduction, use of mixed methods, and use of expert panels are explored. PMID:24064432

Mix-infection of S. Typhi and ParaTyphi A in Typhoid Fever and Chronic Typhoid Carriers: A Nested PCR Based Study in North India

PubMed Central

Pratap, Chandra Bhan; Kumar, Gopal; Patel, Saurabh Kumar; Shukla, Vijay K; Kumar, Kailash; Singh, Tej Bali

2014-01-01

Introduction: Enteric fever is a systemic disease caused by Salmonella organism such as serotypes Typhi and ParaTyphi A, B, C. Salmonella ParaTyphi A contributes more than 50% of all the enteric fever cases and it has recently been projected as an emerging pathogen. Materials and Methods: The present study was aimed to detect Salmonella Typhi and ParaTyphi A in urine, blood and stool specimens collected from cases of enteric fever (110), chronic typhoid carriers (46) and healthy controls (75) to explore the possibility of mixed infection by nested PCR. A new nested PCR primer was designed targeting putative fimbrial protein (stkG) gene which is one of the fimbrial gene families to Salmonella ParaTyphi A and for S. Typhi already reported primers targeting flagellin (fliC) gene. Results: Large volume of urine specimens (15 ml) was found to be the best for detection of Salmonella serotypes. The urine sample was found to have mixed-infection by both the serotypes in 40.9% of the cases but lower in blood (27.3%) and stool (13.6%). Conclusion: The present study concludes that occurrence of mixed infection may be quite frequent in typhoid and chronic typhoid carriers’ individuals, although the reported recent rise in ParaTyphi A incidence may not be real. PMID:25584217

A Case Study of a Mixed Methods Study Engaged in Integrated Data Analysis

ERIC Educational Resources Information Center

Schiazza, Daniela Marie

2013-01-01

The nascent field of mixed methods research has yet to develop a cohesive framework of guidelines and procedures for mixed methods data analysis (Greene, 2008). To support the field's development of analytical frameworks, this case study reflects on the development and implementation of a mixed methods study engaged in integrated data analysis.…

Calcium-based stabilizer induced heave in Oklahoma sulfate-bearing soils.

DOT National Transportation Integrated Search

2011-06-01

The addition of lime stabilizers can create problems in soils containing sulfates. In most cases, lime is mixed with expansive soils rendering them non-expansive; however, when a certain amount of sulfate is present naturally in expansive soils, the ...

Hospital branding in Italy: A pilot study based on the case method.

PubMed

Esposito, Annamaria

2017-01-01

The article investigates if, and in affirmative case how, Italian hospitals are managing corporate brand communication. Thanks to results of qualitative research, this article offers insights on Italian hospital branding. The pilot study based in the case method is to be considered a starting point for wider investigations on this topic, and it is useful for managers and practitioners who want to understand the role of corporate brand in hospital communication management and to connect health care professionals with the audience in a meaningful way in those countries in which the health care system is a mix of both public and private institutions.

29 CFR 1614.303 - Petitions to the EEOC from MSPB decisions on mixed case appeals and complaints.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 29 Labor 4 2012-07-01 2012-07-01 false Petitions to the EEOC from MSPB decisions on mixed case appeals and complaints. 1614.303 Section 1614.303 Labor Regulations Relating to Labor (Continued) EQUAL... Petitions to the EEOC from MSPB decisions on mixed case appeals and complaints. (a) Who may file...

29 CFR 1614.303 - Petitions to the EEOC from MSPB decisions on mixed case appeals and complaints.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 29 Labor 4 2010-07-01 2010-07-01 false Petitions to the EEOC from MSPB decisions on mixed case appeals and complaints. 1614.303 Section 1614.303 Labor Regulations Relating to Labor (Continued) EQUAL... Petitions to the EEOC from MSPB decisions on mixed case appeals and complaints. (a) Who may file...

29 CFR 1614.303 - Petitions to the EEOC from MSPB decisions on mixed case appeals and complaints.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 29 Labor 4 2013-07-01 2013-07-01 false Petitions to the EEOC from MSPB decisions on mixed case appeals and complaints. 1614.303 Section 1614.303 Labor Regulations Relating to Labor (Continued) EQUAL... Petitions to the EEOC from MSPB decisions on mixed case appeals and complaints. (a) Who may file...

29 CFR 1614.303 - Petitions to the EEOC from MSPB decisions on mixed case appeals and complaints.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 29 Labor 4 2014-07-01 2014-07-01 false Petitions to the EEOC from MSPB decisions on mixed case appeals and complaints. 1614.303 Section 1614.303 Labor Regulations Relating to Labor (Continued) EQUAL... Petitions to the EEOC from MSPB decisions on mixed case appeals and complaints. (a) Who may file...

29 CFR 1614.303 - Petitions to the EEOC from MSPB decisions on mixed case appeals and complaints.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 29 Labor 4 2011-07-01 2011-07-01 false Petitions to the EEOC from MSPB decisions on mixed case appeals and complaints. 1614.303 Section 1614.303 Labor Regulations Relating to Labor (Continued) EQUAL... Petitions to the EEOC from MSPB decisions on mixed case appeals and complaints. (a) Who may file...

Single-Case Designs and Qualitative Methods: Applying a Mixed Methods Research Perspective

ERIC Educational Resources Information Center

Hitchcock, John H.; Nastasi, Bonnie K.; Summerville, Meredith

2010-01-01

The purpose of this conceptual paper is to describe a design that mixes single-case (sometimes referred to as single-subject) and qualitative methods, hereafter referred to as a single-case mixed methods design (SCD-MM). Minimal attention has been given to the topic of applying qualitative methods to SCD work in the literature. These two…

Decision-case mix model for analyzing variation in cesarean rates.

PubMed

Eldenburg, L; Waller, W S

2001-01-01

This article contributes a decision-case mix model for analyzing variation in c-section rates. Like recent contributions to the literature, the model systematically takes into account the effect of case mix. Going beyond past research, the model highlights differences in physician decision making in response to obstetric factors. Distinguishing the effects of physician decision making and case mix is important in understanding why c-section rates vary and in developing programs to effect change in physician behavior. The model was applied to a sample of deliveries at a hospital where physicians exhibited considerable variation in their c-section rates. Comparing groups with a low versus high rate, the authors' general conclusion is that the difference in physician decision tendencies (to perform a c-section), in response to specific obstetric factors, is at least as important as case mix in explaining variation in c-section rates. The exact effects of decision making versus case mix depend on how the model application defines the obstetric condition of interest and on the weighting of deliveries by their estimated "risk of Cesarean." The general conclusion is supported by an additional analysis that uses the model's elements to predict individual physicians' annual c-section rates.

Problem-Based Learning--Buginese Cultural Knowledge Model--Case Study: Teaching Mathematics at Junior High School

ERIC Educational Resources Information Center

Cheriani, Cheriani; Mahmud, Alimuddin; Tahmir, Suradi; Manda, Darman; Dirawan, Gufran Darma

2015-01-01

This study aims to determine the differences in learning output by using Problem Based Model combines with the "Buginese" Local Cultural Knowledge (PBL-Culture). It is also explores the students activities in learning mathematics subject by using PBL-Culture Models. This research is using Mixed Methods approach that combined quantitative…

Examining the Characteristics of Student Postings That Are Liked and Linked in a CSCL Environment

ERIC Educational Resources Information Center

Makos, Alexandra; Lee, Kyungmee; Zingaro, Daniel

2015-01-01

This case study is the first iteration of a large-scale design-based research project to improve Pepper, an interactive discussion-based learning environment. In this phase, we designed and implemented two social features to scaffold positive learner interactivity behaviors: a "Like" button and linking tool. A mixed-methods approach was…

Perceptions of State-Funded, School District-Based Principal Preparation Programs in Virginia 2004-2006

ERIC Educational Resources Information Center

Kirk, Kathryn Gordy

2010-01-01

The mixed methods case study described and analyzed the 2004-2006 district-based principal preparation programs in Virginia. This dissertation explored goals stated in proposals for funding as well as program director and program completer perceptions of goals, content, processes, and outcomes for the 10 principal preparation programs that stemmed…

Contributions of Early Work-Based Learning: A Case Study of First Year Pharmacy Students

ERIC Educational Resources Information Center

Ting, Kang Nee; Wong, Kok Thong; Thang, Siew Ming

2009-01-01

Generally work-based learning opportunities are only offered to students in their penultimate year of undergraduate study. Little is known about the benefits and shortcomings of such experiential learning for students in the early stages of their undergraduate education. This is a mixed method study investigating first year undergraduate pharmacy…

Prognosis of children with mixed phenotype acute leukemia treated on the basis of consistent immunophenotypic criteria

PubMed Central

Mejstrikova, Ester; Volejnikova, Jana; Fronkova, Eva; Zdrahalova, Katerina; Kalina, Tomas; Sterba, Jaroslav; Jabali, Yahia; Mihal, Vladimir; Blazek, Bohumir; Cerna, Zdena; Prochazkova, Daniela; Hak, Jiri; Zemanova, Zuzana; Jarosova, Marie; Oltova, Alexandra; Sedlacek, Petr; Schwarz, Jiri; Zuna, Jan; Trka, Jan; Stary, Jan; Hrusak, Ondrej

2010-01-01

Background Mixed phenotype acute leukemia (MPAL) represents a diagnostic and therapeutic dilemma. The European Group for the Immunological Classification of Leukemias (EGIL) scoring system unambiguously defines MPAL expressing aberrant lineage markers. Discussions surrounding it have focused on scoring details, and information is limited regarding its biological, clinical and prognostic significance. The recent World Health Organization classification is simpler and could replace the EGIL scoring system after transformation into unambiguous guidelines. Design and Methods Simple immunophenotypic criteria were used to classify all cases of childhood acute leukemia in order to provide therapy directed against acute lymphoblastic leukemia or acute myeloid leukemia. Prognosis, genotype and immunoglobulin/T-cell receptor gene rearrangement status were analyzed. Results The incidences of MPAL were 28/582 and 4/107 for children treated with acute lymphoblastic leukemia and acute myeloid leukemia regimens, respectively. In immunophenotypic principal component analysis, MPAL treated as T-cell acute lymphoblastic leukemia clustered between cases of non-mixed T-cell acute lymphoblastic leukemia and acute myeloid leukemia, while other MPAL cases were included in the respective non-mixed B-cell progenitor acute lymphoblastic leukemia or acute myeloid leukemia clusters. Analogously, immunoglobulin/T-cell receptor gene rearrangements followed the expected pattern in patients treated as having acute myeloid leukemia (non-rearranged, 4/4) or as having B-cell progenitor acute lymphoblastic leukemia (rearranged, 20/20), but were missing in 3/5 analyzed cases of MPAL treated as having T-cell acute lymphobastic leukemia. In patients who received acute lymphoblastic leukemia treatment, the 5-year event-free survival of the MPAL cases was worse than that of the non-mixed cases (53±10% and 76±2% at 5 years, respectively, P=0.0075), with a more pronounced difference among B lineage cases. The small numbers of MPAL cases treated as T-cell acute lymphoblastic leukemia or as acute myeloid leukemia hampered separate statistics. We compared prognosis of all subsets with the prognosis of previously published cohorts. Conclusions Simple immunophenotypic criteria are useful for therapy decisions in MPAL. In B lineage leukemia, MPAL confers poorer prognosis. However, our data do not justify a preferential use of current acute myeloid leukemia-based therapy in MPAL. PMID:20145275

Nursing: the hospital's competitive edge.

PubMed

Shaffer, F A; Preziosi, P

1988-09-01

The health care marketplace is becoming increasingly competitive. The hospital has a built-in marketing force with the nursing department, because nurses are in constant, direct contact with the customer. Nursing must identify the case mix profile of the community and focus the hospital product lines to meet community needs. The nursing department should decentralize, change, measure, and innovate the staff mix needed to operationalize these product lines. The development of nursing practice standards for the case mix will help to identify the staff mix needed and create systems to efficiently manage the product lines. Nursing management must become aware of cross-subsidization and downward skill substitution of nursing personnel. Nursing information systems must generate quality reports that invoke cost consciousness on the part of nursing staff. Quality assurance programs must become unit based and complete with frequent audits to correlate length of stay with nursing quality. Correlations must be determined between nursing productivity and case mix to determine the hospital's niche in the marketplace. The transformation of health care into a competitive business industry has created many opportunities for nursing. The health care industry's incentives for efficiency along with the decreasing demand for inpatient hospital services will be the forces driving health care toward a competitive marketplace. The hospital's nursing department should be strategically positioned to become accountable for increasing market share and enhancing quality patient outcomes. The focus has shifted from the theoretical to the tactical, which is a step in the right direction, particularly for nursing. Nursing, if strategically positioned, will not only thrive but will also excel in this chaotic environment by capturing the opportunities and being innovative.

Measuring case-mix complexity of tertiary care hospitals using DRGs.

PubMed

Park, Hayoung; Shin, Youngsoo

2004-02-01

The objectives of the study were to develop a model that measures and evaluates case-mix complexity of tertiary care hospitals, and to examine the characteristics of such a model. Physician panels defined three classes of case complexity and assigned disease categories represented by Adjacent Diagnosis Related Groups (ADRGs) to one of three case complexity classes. Three types of scores, indicating proportions of inpatients in each case complexity class standardized by the proportions at the national level, were defined to measure the case-mix complexity of a hospital. Discharge information for about 10% of inpatient episodes at 85 hospitals with bed size larger than 400 and their input structure and research and education activity were used to evaluate the case-mix complexity model. Results show its power to predict hospitals with the expected functions of tertiary care hospitals, i.e. resource intensive care, expensive input structure, and high levels of research and education activities.

Can changes in population mixing and socio-economic deprivation in Cumbria, England explain changes in cancer incidence around Sellafield?

PubMed

McNally, Richard J Q; James, Peter W; Blakey, Karen; Basta, Nermine O; Norman, Paul D; Pearce, Mark S

2017-06-01

Previously excesses in incident cases of leukaemia and non-Hodgkin lymphoma have been observed amongst young people born or resident in Seascale, Cumbria. These excesses have not been seen more recently. It is postulated that the former apparent increased risk was related to 'unusual population mixing', which is not present in recent years. This study investigated changes in measures of population mixing from 1951-2001. Comparisons were made between three specified areas. Area-based measures were calculated (migration, commuting, deprivation, population density). All areas have become more affluent, although Seascale was consistently the most affluent. Seascale has become less densely populated, with less migration into the ward and less diversity with respect to migrants' origin. There have been marked changes in patterns of population mixing throughout Cumbria. Lesser population mixing has been observed in Seascale in recent decades. Changes in pattern and nature of population mixing may explain the lack of recent excesses. Copyright © 2017 Elsevier Ltd. All rights reserved.

Case mix of home health patients under capitated and fee-for-service payment.

PubMed Central

Shaughnessy, P W; Schlenker, R E; Hittle, D F

1995-01-01

OBJECTIVE. We compare case mix of Medicare home health patients under HMO and FFS payment. STUDY DESIGN. A pseudo-experimental design was employed to study case mix using three types of Medicare-certified home health agencies (HHAs): HMO-owned agencies, pure FFS agencies that admit few Medicare HMO patients (less than 5 percent of admissions are Medicare HMO patients), and mixed (or contractual) agencies that admit at least 15 Medicare FFS patients and 15 Medicare HMO patients per month. SAMPLES OF PROVIDERS AND PATIENTS. Random samples of Medicare-aged patients (> or = 65 years) were selected at admission between June 1989 and November 1991 from the 38 study HHAs. Sample sizes by agency type were: 308 patients from 9 HMO-owned agencies; 529 patients from 15 pure FFS agencies; and 381 HMO patients and 414 FFS patients from 14 contractual agencies. DATA. Primary longitudinal data were prospectively collected at admission for all patients on health status indicators, demographics, admission source, and home environment. MEASURES. The most important case-mix measures were functional and physiologic indicators of health status, including (instrumental) activities of daily living ([I]ADLs). Selected indicators of demographic variables, prior location, living situation, characteristics of informal caregivers, mental/behavioral factors, and resource needs were also used. PRINCIPAL FINDINGS. (a) The case mix of Medicare FFS patients compared with Medicare HMO patients was more intense in terms of impairments in ADLs, IADLs, and various physiologic conditions. Pressure ulcers as well as neurological and orthopedic impairments requiring rehabilitation care were also more prevalent among FFS patients. (b) Relative to HMO patients admitted to contractual agencies, HMO patients admitted to HMO-owned agencies were moderately more dependent in ADLs and IADLs. However, only 62 percent of HMO patients admitted to HMO-owned agencies, in contrast to 77 percent of HMO patients admitted to contractual agencies, had been hospitalized during the 30 days prior to home health admission. (c) In all, the case mix of patients receiving care from HMO-owned agencies is more heterogeneous than the case mix of HMO patients receiving care from contractual agencies. CONCLUSIONS. The case-mix (and selected utilization) findings indicate that HMOs use home health care differently than does the FFS sector. The greater diversity of case mix for HMO-owned agencies and the narrower or less diverse case mix that characterizes HMO patients receiving home care on a contractual basis point to the likelihood of cost differences among the two types of HMO patients and FFS patients, and raise the question of possible outcome differences. PMID:7721587

Frequency and topography of small cerebrovascular lesions in vascular and in mixed dementia: a post-mortem 7-tesla magnetic resonance imaging study with neuropathological correlates.

PubMed

De Reuck, Jacques; Auger, Florent; Durieux, Nicolas; Deramecourt, Vincent; Maurage, Claude-Alain; Cordonnier, Charlotte; Pasquier, Florence; Leys, Didier; Bordet, Regis

2017-01-01

Introduction: Mixed dementia (MixD) refers to a combination of definite Alzheimer's disease (AD) and vascular encephalopathy. The existence of a "pure" type of vascular dementia (VaD) is controversial. There is a need to find magnetic resonance imaging (MRI) characteristics allowing the distinction between VaD and MixD. The present post-mortem 7.0-tesla MRI compares the frequency or severity and the topography of the small cerebrovascular lesions in brains of patients with VaD and with MixD. Material and methods: Based on neuropathological criteria, 14 brains were classified as VaD, 24 as MixD and 11 as controls. Three coronal sections of a cerebral hemisphere and a horizontal section of a cerebellar hemisphere underwent T2 and T2* 7.0-tesla MRI examination. The mean values and topographic distribution of white matter changes (WMCs), lacunar infarcts (LIs), cortical microbleeds (CoMBs) and cortical microinfarcts (CoMIs) were determined and compared between the different groups. Results: Compared to the controls, both VaD and MixD brains had significantly more severe WMCs and increased numbers of CoMBs and CoMIs. Lacunar infarcts predominated only in the VaD cases. On mutual comparison of VaD and MixD brains, CoMBs and CoMIs predominated in the frontal lobe and the cerebellum of VaD, while were mainly present in the occipital lobe of MixD. White matter changes predominated in the temporal lobe of MixD cases. Lacunar infarcts were significantly increased in the corona radiata and putamen of VaD patients. Conclusions: The present post-mortem MRI study shows clear differences in the distribution and the types of cerebrovascular lesions on high-field MRI, confirming that VaD and MixD are different diseases. .

Discontinuous dual-primal mixed finite elements for elliptic problems

NASA Technical Reports Server (NTRS)

Bottasso, Carlo L.; Micheletti, Stefano; Sacco, Riccardo

2000-01-01

We propose a novel discontinuous mixed finite element formulation for the solution of second-order elliptic problems. Fully discontinuous piecewise polynomial finite element spaces are used for the trial and test functions. The discontinuous nature of the test functions at the element interfaces allows to introduce new boundary unknowns that, on the one hand enforce the weak continuity of the trial functions, and on the other avoid the need to define a priori algorithmic fluxes as in standard discontinuous Galerkin methods. Static condensation is performed at the element level, leading to a solution procedure based on the sole interface unknowns. The resulting family of discontinuous dual-primal mixed finite element methods is presented in the one and two-dimensional cases. In the one-dimensional case, we show the equivalence of the method with implicit Runge-Kutta schemes of the collocation type exhibiting optimal behavior. Numerical experiments in one and two dimensions demonstrate the order accuracy of the new method, confirming the results of the analysis.

A Direct Numerical Simulation of a Temporally Evolving Liquid-Gas Turbulent Mixing Layer

NASA Astrophysics Data System (ADS)

Vu, Lam Xuan; Chiodi, Robert; Desjardins, Olivier

2017-11-01

Air-blast atomization occurs when streams of co-flowing high speed gas and low speed liquid shear to form drops. Air-blast atomization has numerous industrial applications from combustion engines in jets to sprays used for medical coatings. The high Reynolds number and dynamic pressure ratio of a realistic air-blast atomization case requires large eddy simulation and the use of multiphase sub-grid scale (SGS) models. A direct numerical simulations (DNS) of a temporally evolving mixing layer is presented to be used as a base case from which future multiphase SGS models can be developed. To construct the liquid-gas mixing layer, half of a channel flow from Kim et al. (JFM, 1987) is placed on top of a static liquid layer that then evolves over time. The DNS is performed using a conservative finite volume incompressible multiphase flow solver where phase tracking is handled with a discretely conservative volume of fluid method. This study presents statistics on velocity and volume fraction at different Reynolds and Weber numbers.

Refining a case-mix measure for nursing homes: Resource Utilization Groups (RUG-III).

PubMed

Fries, B E; Schneider, D P; Foley, W J; Gavazzi, M; Burke, R; Cornelius, E

1994-07-01

A case-mix classification system for nursing home residents is developed, based on a sample of 7,658 residents in seven states. Data included a broad assessment of resident characteristics, corresponding to items of the Minimum Data Set, and detailed measurement of nursing staff care time over a 24-hour period and therapy staff time over a 1-week period. The Resource Utilization Groups, Version III (RUG-III) system, with 44 distinct groups, achieves 55.5% variance explanation of total (nursing and therapy) per diem cost and meets goals of clinical validity and payment incentives. The mean resource use (case-mix index) of groups spans a nine-fold range. The RUG-III system improves on an earlier version not only by increasing the variance explanation (from 43%), but, more importantly, by identifying residents with "high tech" procedures (e.g., ventilators, respirators, and parenteral feeding) and those with cognitive impairments; by using better multiple activities of daily living; and by providing explicit qualifications for the Medicare nursing home benefit. RUG-III is being implemented for nursing home payment in 11 states (six as part of a federal multistate demonstration) and can be used in management, staffing level determination, and quality assurance.

Applying Resource Utilization Groups (RUG-III) in Hong Kong nursing homes.

PubMed

Chou, Kee-Lee; Chi, Iris; Leung, Joe C B

2008-01-01

Resource Utilization Groups III (RUG-III) is a case-mix system developed in the United States for categorization of nursing home residents and the financing of residential care services. In Hong Kong, RUG-III is based on several board groups of residents. The aim of this study was to examine the reliability and validity of the RUG-III in Hong Kong nursing homes. A cross-sectional survey was conducted in seven residential facilities operated by one agency. Residents ( N = 1,127) were assessed by the Minimum Data Set (MDS) and nursing as well as auxiliary staff care times were recorded within 2 weeks before or after the completion of MDS assessment. Forty-five out 1,127 residents were re-interviewed by an independent assessor to assess the inter-rater reliability. The inter-rater reliability of MDS assessment was excellent (kappa = 0.76) and the original RUG-III accounted for about 30 per cent of nursing staff time. Results provide preliminary evidence to support that RUG-III is a reliable and valid case-mix system for Hong Kong nursing homes, but future studies must be explored to reduce the variance of resource use explained by this case-mix system.

Weatherization Beyond the Numbers: Case Studies of Fifteen High-performing Weatherization Agencies - Conducted May 2011 through July 2012

DOE Office of Scientific and Technical Information (OSTI.GOV)

Tonn, Bruce Edward; Rose, Erin M.; Hawkins, Beth A.

The report presents fifteen individual case studies of high-performing and unique local weatherization agencies. This research was one component of the retrospective evaluation of the U.S. Department of Energy s Weatherization Assistance Program. The agencies were chosen to represent a range of contexts and approaches to weatherization. For example, the set of agencies includes a mix of urban and rural agencies, those that mainly use in-house crews to weatherize homes versus those that use contractor crews, and a mix of locations, from very cold climates to moderate to hot humid and dry climates. The case studies were mainly based onmore » site visits to the agencies that encompassed interviews with program directors, weatherization crews, and recipients of weatherization. This information was supplemented by secondary materials. The cases document the diversity of contexts and challenges faced by the agencies and how they operate on a day-by-day basis. The cases also high common themes found throughout the agencies, such as their focus on mission and respect for their clients.« less

Population-based medical and disease management: an evaluation of cost and quality.

PubMed

Wise, Christopher G; Bahl, Vinita; Mitchell, Rita; West, Brady T; Carli, Thomas

2006-02-01

Reports by the Institute of Medicine and the Health Care Financing Administration have emphasized that the integration of medical care delivery, evidence-based medicine, and chronic care disease management may play a significant role in improving the quality of care and reducing medical care costs. The specific aim of this project is to assess the impact of an integrated set of care coordination tools and chronic disease management interventions on utilization, cost, and quality of care for a population of beneficiaries who have complementary health coverage through a plan designed to apply proactive medical and disease management processes. The utilization of health care services by the study population was compared to another population from the same geographic service area and covered by a traditional fee-for-service indemnity insurance plan that provided few medical or disease management services. Evaluation of the difference in utilization was based on the difference in the cost per-member-per-month (PMPM) in a 1-year measurement period, after adjusting for differences in fee schedules, case-mix and healthcare benefit design. After adjustments for both case-mix and benefit differences, the study group is $63 PMPM less costly than the comparison population for all members. Cost differences are largest in the 55-64 and 65 and above age groups. The study group is $115 PMPM lower than the comparison population for the age category of 65 years and older, after adjustments for case-mix and benefits. Health Plan Employer and Data Information Set (HEDIS)-based quality outcomes are near the 90th percentile for most indications. The cost outcomes of a population served by proactive, population-based disease management and complex care management, compared to an unmanaged population, demonstrates the potential of coordinated medical and disease management programs. Further studies utilizing appropriate methodologies would be beneficial.

WT1 immunoreactivity in breast carcinoma: selective expression in pure and mixed mucinous subtypes.

PubMed

Domfeh, Akosua B; Carley, AnnaMarie L; Striebel, Joan M; Karabakhtsian, Rouzan G; Florea, Anca V; McManus, Kim; Beriwal, Sushil; Bhargava, Rohit

2008-10-01

Current literature suggests that strong WT1 expression in a carcinoma of unknown origin virtually excludes a breast primary. Our previous pilot study on WT1 expression in breast carcinomas has shown WT1 expression in approximately 10% of carcinomas that show mixed micropapillary and mucinous morphology (Mod Pathol 2007;20(Suppl 2):38A). To definitively assess as to what subtype of breast carcinoma might express WT1 protein, we examined 153 cases of invasive breast carcinomas. These consisted of 63 consecutive carcinomas (contained 1 mucinous tumor), 20 cases with micropapillary morphology (12 pure and 8 mixed), 6 micropapillary 'mimics' (ductal no special type carcinomas with retraction artifacts), 33 pure mucinous carcinomas and 31 mixed mucinous carcinomas (mucinous mixed with other morphologic types). Overall, WT1 expression was identified in 33 carcinomas, that is, 22 of 34 (65%) pure mucinous carcinomas and in 11 of 33 (33%) mixed mucinous carcinomas. The non-mucinous component in these 11 mixed mucinous carcinomas was either a ductal no special type carcinoma (8 cases) or a micropapillary component (3 cases). WT1 expression level was similar in both the mucinous and the non-mucinous components. The degree of WT1 expression was generally weak to moderate (>90% cases) and rarely strong (<10% cases). None of the breast carcinoma subtype unassociated with mucinous component showed WT1 expression.

The "Nursing Home Compare" measure of urinary/fecal incontinence: cross-sectional variation, stability over time, and the impact of case mix.

PubMed

Li, Yue; Schnelle, John; Spector, William D; Glance, Laurent G; Mukamel, Dana B

2010-02-01

To assess the impact of facility case mix on cross-sectional variations and short-term stability of the "Nursing Home Compare" incontinence quality measure (QM) and to determine whether multivariate risk adjustment can minimize such impacts. Retrospective analyses of the 2005 national minimum data set (MDS) that included approximately 600,000 long-term care residents in over 10,000 facilities in each quarterly sample. Mixed logistic regression was used to construct the risk-adjusted QM (nonshrinkage estimator). Facility-level ordinary least-squares models and adjusted R(2) were used to estimate the impact of case mix on cross-sectional and short-term longitudinal variations of currently published and risk-adjusted QMs. At least 50 percent of the cross-sectional variation and 25 percent of the short-term longitudinal variation of the published QM are explained by facility case mix. In contrast, the cross-sectional and short-term longitudinal variations of the risk-adjusted QM are much less susceptible to case-mix variations (adjusted R(2)<0.10), even for facilities with more extreme or more unstable outcome. Current "Nursing Home Compare" incontinence QM reflects considerable case-mix variations across facilities and over time, and therefore it may be biased. This issue can be largely addressed by multivariate risk adjustment using risk factors available in the MDS.

Potential-based and non-potential-based cohesive zone formulations under mixed-mode separation and over-closure-Part II: Finite element applications

NASA Astrophysics Data System (ADS)

Máirtín, Éamonn Ó.; Parry, Guillaume; Beltz, Glenn E.; McGarry, J. Patrick

2014-02-01

This paper, the second of two parts, presents three novel finite element case studies to demonstrate the importance of normal-tangential coupling in cohesive zone models (CZMs) for the prediction of mixed-mode interface debonding. Specifically, four new CZMs proposed in Part I of this study are implemented, namely the potential-based MP model and the non-potential-based NP1, NP2 and SMC models. For comparison, simulations are also performed for the well established potential-based Xu-Needleman (XN) model and the non-potential-based model of van den Bosch, Schreurs and Geers (BSG model). Case study 1: Debonding and rebonding of a biological cell from a cyclically deforming silicone substrate is simulated when the mode II work of separation is higher than the mode I work of separation at the cell-substrate interface. An active formulation for the contractility and remodelling of the cell cytoskeleton is implemented. It is demonstrated that when the XN potential function is used at the cell-substrate interface repulsive normal tractions are computed, preventing rebonding of significant regions of the cell to the substrate. In contrast, the proposed MP potential function at the cell-substrate interface results in negligible repulsive normal tractions, allowing for the prediction of experimentally observed patterns of cell cytoskeletal remodelling. Case study 2: Buckling of a coating from the compressive surface of a stent is simulated. It is demonstrated that during expansion of the stent the coating is initially compressed into the stent surface, while simultaneously undergoing tangential (shear) tractions at the coating-stent interface. It is demonstrated that when either the proposed NP1 or NP2 model is implemented at the stent-coating interface mixed-mode over-closure is correctly penalised. Further expansion of the stent results in the prediction of significant buckling of the coating from the stent surface, as observed experimentally. In contrast, the BSG model does not correctly penalise mixed-mode over-closure at the stent-coating interface, significantly altering the stress state in the coating and preventing the prediction of buckling. Case study 3: Application of a displacement to the base of a bi-layered composite arch results in a symmetric sinusoidal distribution of normal and tangential traction at the arch interface. The traction defined mode mixity at the interface ranges from pure mode II at the base of the arch to pure mode I at the top of the arch. It is demonstrated that predicted debonding patterns are highly sensitive to normal-tangential coupling terms in a CZM. The NP2, XN, and BSG models exhibit a strong bias towards mode I separation at the top of the arch, while the NP1 model exhibits a bias towards mode II debonding at the base of the arch. Only the SMC model provides mode-independent behaviour in the early stages of debonding. This case study provides a practical example of the importance of the behaviour of CZMs under conditions of traction controlled mode mixity, following from the theoretical analysis presented in Part I of this study.

Medicare and Medicaid Programs; CY 2016 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements. Final rule.

PubMed

2015-11-05

This final rule will update Home Health Prospective Payment System (HH PPS) rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor under the Medicare prospective payment system for home health agencies (HHAs), effective for episodes ending on or after January 1, 2016. As required by the Affordable Care Act, this rule implements the 3rd year of the 4-year phase-in of the rebasing adjustments to the HH PPS payment rates. This rule updates the HH PPS case-mix weights using the most current, complete data available at the time of rulemaking and provides a clarification regarding the use of the "initial encounter'' seventh character applicable to certain ICD-10-CM code categories. This final rule will also finalize reductions to the national, standardized 60-day episode payment rate in CY 2016, CY 2017, and CY 2018 of 0.97 percent in each year to account for estimated case-mix growth unrelated to increases in patient acuity (nominal case-mix growth) between CY 2012 and CY 2014. In addition, this rule implements a HH value-based purchasing (HHVBP) model, beginning January 1, 2016, in which all Medicare-certified HHAs in selected states will be required to participate. Finally, this rule finalizes minor changes to the home health quality reporting program and minor technical regulations text changes.

[The mixed gonadal dysgenesis. Diagnostic criteria and surgical treatment].

PubMed

Blanco, J A; Martínez-Mora, J; Granada, M; Toran, N; Isnard, R M; Castellví, A; Casasa, J M

1997-01-01

The Mixed Gonadal Dysgenesis represents the 7.6% of all our patients with intersexual states. We report 14 patients who present Mixed Gonadal Dysgenesis. We have studied: diagnosis age; external genitalia description; sex assigned in birth and if has changed; the karyotype; sex chromatine; hormonal study; genitography; internal genitalia and internal Mullerians ducts structures; gonadal histologycal study; surgical treatment and hormonal treatment. The results show that 50% of the cases presents a 46XY karyotype and the other 50% mosaicisme 45XO/46XY. The histological study is very distinctive. A vulvovagynoplasty and clitoroplasty was made in all the cases. Four patients must follow an hormonal treatment after reaching puberal age. Summing up, with patients having ambiguous genitalia we can suspect it consists of a Mixed Gonadal Dysgenesis. The diagnosis must be precocious. And this diagnosis will be based in an ambiguous genitalia, with a karyotype 46XY or 45XO/46XY, the persistence of the internal Müllerian duct structures, and the histological study with a dysgenetic testis. These patients should be raised as females because they can obtain a good morphological and functional development like a normal female.

Thermal Conductivity of Polyimide/Carbon Nanofiller Blends

NASA Technical Reports Server (NTRS)

Delozier, D. M.; Watson, K. A.; Ghose, S.; Working, D. C.; Connell, J. W.; Smith, J. G.; Sun, Y. P.; Lin, Y.

2006-01-01

Ultem(TM) was mixed with three different carbon-based nanofillers in efforts to increase the thermal conductivity of the polymer. After initial mixing, the nanocomposites were extruded or processed via the Laboratory Mixing Molder (LMM) process. High resolution scanning electron microscopy (HRSEM) revealed significant alignment of the nanofillers in the extruded samples. Thermal conductivity measurements were made both in the direction and perpendicular to the direction of alignment of nanofillers as well as for unaligned samples. It was found that the largest improvement in thermal conductivity was achieved in the case of aligned samples when the measurement was performed in the direction of alignment. Unaligned samples also showed a significant improvement in thermal conductivity and may be useful in applications when it is not possible to align the nanofiller. However the improvements in thermal conductivity did not approach those expected based on a rule of mixtures. This is likely due to poor phonon transfer through the matrix.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chen Lin; Chen Yixin

We show that no universal quantum cloning machine exists that can broadcast an arbitrary mixed qubit with a constant fidelity. Based on this result, we investigate the dependent quantum cloner in the sense that some parameter of the input qubit {rho}{sub s}({theta},{omega},{lambda}) is regarded as constant in the fidelity. For the case of constant {omega}, we establish the 1{yields}2 optimal symmetric dependent cloner with a fidelity 1/2. It is also shown that the 1{yields}M optimal quantum cloning machine for pure qubits is also optimal for mixed qubits, when {lambda} is the unique parameter in the fidelity. For general N{yields}M broadcastingmore » of mixed qubits, the situation is very different.« less

System equivalent model mixing

NASA Astrophysics Data System (ADS)

Klaassen, Steven W. B.; van der Seijs, Maarten V.; de Klerk, Dennis

2018-05-01

This paper introduces SEMM: a method based on Frequency Based Substructuring (FBS) techniques that enables the construction of hybrid dynamic models. With System Equivalent Model Mixing (SEMM) frequency based models, either of numerical or experimental nature, can be mixed to form a hybrid model. This model follows the dynamic behaviour of a predefined weighted master model. A large variety of applications can be thought of, such as the DoF-space expansion of relatively small experimental models using numerical models, or the blending of different models in the frequency spectrum. SEMM is outlined, both mathematically and conceptually, based on a notation commonly used in FBS. A critical physical interpretation of the theory is provided next, along with a comparison to similar techniques; namely DoF expansion techniques. SEMM's concept is further illustrated by means of a numerical example. It will become apparent that the basic method of SEMM has some shortcomings which warrant a few extensions to the method. One of the main applications is tested in a practical case, performed on a validated benchmark structure; it will emphasize the practicality of the method.

RWPV bioreactor mass transport: earth-based and in microgravity

NASA Technical Reports Server (NTRS)

Begley, Cynthia M.; Kleis, Stanley J.

2002-01-01

Mass transport and mixing of perfused scalar quantities in the NASA Rotating Wall Perfused Vessel bioreactor are studied using numerical models of the flow field and scalar concentration field. Operating conditions typical of both microgravity and ground-based cell cultures are studied to determine the expected vessel performance for both flight and ground-based control experiments. Results are presented for the transport of oxygen with cell densities and consumption rates typical of colon cancer cells cultured in the RWPV. The transport and mixing characteristics are first investigated with a step change in the perfusion inlet concentration by computing the time histories of the time to exceed 10% inlet concentration. The effects of a uniform cell utilization rate are then investigated with time histories of the outlet concentration, volume average concentration, and volume fraction starved. It is found that the operating conditions used in microgravity produce results that are quite different then those for ground-based conditions. Mixing times for microgravity conditions are significantly shorter than those for ground-based operation. Increasing the differential rotation rates (microgravity) increases the mixing and transport, while increasing the mean rotation rate (ground-based) suppresses both. Increasing perfusion rates enhances mass transport for both microgravity and ground-based cases, however, for the present range of operating conditions, above 5-10 cc/min there are diminishing returns as much of the inlet fluid is transported directly to the perfusion exit. The results show that exit concentration is not a good indicator of the concentration distributions in the vessel. In microgravity conditions, the NASA RWPV bioreactor with the viscous pump has been shown to provide an environment that is well mixed. Even when operated near the theoretical minimum perfusion rates, only a small fraction of the volume provides less than the required oxygen levels. 2002 Wiley Periodicals, Inc.

RWPV bioreactor mass transport: earth-based and in microgravity.

PubMed

Begley, Cynthia M; Kleis, Stanley J

2002-11-20

Mass transport and mixing of perfused scalar quantities in the NASA Rotating Wall Perfused Vessel bioreactor are studied using numerical models of the flow field and scalar concentration field. Operating conditions typical of both microgravity and ground-based cell cultures are studied to determine the expected vessel performance for both flight and ground-based control experiments. Results are presented for the transport of oxygen with cell densities and consumption rates typical of colon cancer cells cultured in the RWPV. The transport and mixing characteristics are first investigated with a step change in the perfusion inlet concentration by computing the time histories of the time to exceed 10% inlet concentration. The effects of a uniform cell utilization rate are then investigated with time histories of the outlet concentration, volume average concentration, and volume fraction starved. It is found that the operating conditions used in microgravity produce results that are quite different then those for ground-based conditions. Mixing times for microgravity conditions are significantly shorter than those for ground-based operation. Increasing the differential rotation rates (microgravity) increases the mixing and transport, while increasing the mean rotation rate (ground-based) suppresses both. Increasing perfusion rates enhances mass transport for both microgravity and ground-based cases, however, for the present range of operating conditions, above 5-10 cc/min there are diminishing returns as much of the inlet fluid is transported directly to the perfusion exit. The results show that exit concentration is not a good indicator of the concentration distributions in the vessel. In microgravity conditions, the NASA RWPV bioreactor with the viscous pump has been shown to provide an environment that is well mixed. Even when operated near the theoretical minimum perfusion rates, only a small fraction of the volume provides less than the required oxygen levels. 2002 Wiley Periodicals, Inc.

Experimental comparison of conventional and nonlinear model-based control of a mixing tank

DOE Office of Scientific and Technical Information (OSTI.GOV)

Haeggblom, K.E.

1993-11-01

In this case study concerning control of a laboratory-scale mixing tank, conventional multiloop single-input single-output (SISO) control is compared with model-based'' control where the nonlinearity and multivariable characteristics of the process are explicitly taken into account. It is shown, especially if the operating range of the process is large, that the two outputs (level and temperature) cannot be adequately controlled by multiloop SISO control even if gain scheduling is used. By nonlinear multiple-input multiple-output (MIMO) control, on the other hand, very good control performance is obtained. The basic approach to nonlinear control used in this study is first to transformmore » the process into a globally linear and decoupled system, and then to design controllers for this system. Because of the properties of the resulting MIMO system, the controller design is very easy. Two nonlinear control system designs based on a steady-state and a dynamic model, respectively, are considered. In the dynamic case, both setpoint tracking and disturbance rejection can be addressed separately.« less

Renormalisation group corrections to neutrino mixing sum rules

NASA Astrophysics Data System (ADS)

Gehrlein, J.; Petcov, S. T.; Spinrath, M.; Titov, A. V.

2016-11-01

Neutrino mixing sum rules are common to a large class of models based on the (discrete) symmetry approach to lepton flavour. In this approach the neutrino mixing matrix U is assumed to have an underlying approximate symmetry form Ũν, which is dictated by, or associated with, the employed (discrete) symmetry. In such a setup the cosine of the Dirac CP-violating phase δ can be related to the three neutrino mixing angles in terms of a sum rule which depends on the symmetry form of Ũν. We consider five extensively discussed possible symmetry forms of Ũν: i) bimaximal (BM) and ii) tri-bimaximal (TBM) forms, the forms corresponding to iii) golden ratio type A (GRA) mixing, iv) golden ratio type B (GRB) mixing, and v) hexagonal (HG) mixing. For each of these forms we investigate the renormalisation group corrections to the sum rule predictions for δ in the cases of neutrino Majorana mass term generated by the Weinberg (dimension 5) operator added to i) the Standard Model, and ii) the minimal SUSY extension of the Standard Model.

Risk adjustment models for short-term outcomes after surgical resection for oesophagogastric cancer.

PubMed

Fischer, C; Lingsma, H; Hardwick, R; Cromwell, D A; Steyerberg, E; Groene, O

2016-01-01

Outcomes for oesophagogastric cancer surgery are compared with the aim of benchmarking quality of care. Adjusting for patient characteristics is crucial to avoid biased comparisons between providers. The study objective was to develop a case-mix adjustment model for comparing 30- and 90-day mortality and anastomotic leakage rates after oesophagogastric cancer resections. The study reviewed existing models, considered expert opinion and examined audit data in order to select predictors that were consequently used to develop a case-mix adjustment model for the National Oesophago-Gastric Cancer Audit, covering England and Wales. Models were developed on patients undergoing surgical resection between April 2011 and March 2013 using logistic regression. Model calibration and discrimination was quantified using a bootstrap procedure. Most existing risk models for oesophagogastric resections were methodologically weak, outdated or based on detailed laboratory data that are not generally available. In 4882 patients with oesophagogastric cancer used for model development, 30- and 90-day mortality rates were 2·3 and 4·4 per cent respectively, and 6·2 per cent of patients developed an anastomotic leak. The internally validated models, based on predictors selected from the literature, showed moderate discrimination (area under the receiver operating characteristic (ROC) curve 0·646 for 30-day mortality, 0·664 for 90-day mortality and 0·587 for anastomotic leakage) and good calibration. Based on available data, three case-mix adjustment models for postoperative outcomes in patients undergoing curative surgery for oesophagogastric cancer were developed. These models should be used for risk adjustment when assessing hospital performance in the National Health Service, and tested in other large health systems. © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd.

Theoretical investigation of mixing in warm clouds – Part 2: Homogeneous mixing

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pinsky, Mark; Khain, Alexander; Korolev, Alexei

Evolution of monodisperse and polydisperse droplet size distributions (DSD) during homogeneous mixing is analyzed. Time-dependent universal analytical expressions for supersaturation and liquid water content are derived. For an initial monodisperse DSD, these quantities are shown to depend on a sole non-dimensional parameter. The evolution of moments and moment-related functions in the course of homogeneous evaporation of polydisperse DSD is analyzed using a parcel model. It is shown that the classic conceptual scheme, according to which homogeneous mixing leads to a decrease in droplet mass at constant droplet concentration, is valid only in cases of monodisperse or initially very narrow polydispersemore » DSD. In cases of wide polydisperse DSD, mixing and successive evaporation lead to a decrease of both mass and concentration, so the characteristic droplet sizes remain nearly constant. As this feature is typically associated with inhomogeneous mixing, we conclude that in cases of an initially wide DSD at cloud top, homogeneous mixing is nearly indistinguishable from inhomogeneous mixing.« less

Theoretical investigation of mixing in warm clouds – Part 2: Homogeneous mixing

DOE PAGES

Pinsky, Mark; Khain, Alexander; Korolev, Alexei; ...

2016-07-28

Evolution of monodisperse and polydisperse droplet size distributions (DSD) during homogeneous mixing is analyzed. Time-dependent universal analytical expressions for supersaturation and liquid water content are derived. For an initial monodisperse DSD, these quantities are shown to depend on a sole non-dimensional parameter. The evolution of moments and moment-related functions in the course of homogeneous evaporation of polydisperse DSD is analyzed using a parcel model. It is shown that the classic conceptual scheme, according to which homogeneous mixing leads to a decrease in droplet mass at constant droplet concentration, is valid only in cases of monodisperse or initially very narrow polydispersemore » DSD. In cases of wide polydisperse DSD, mixing and successive evaporation lead to a decrease of both mass and concentration, so the characteristic droplet sizes remain nearly constant. As this feature is typically associated with inhomogeneous mixing, we conclude that in cases of an initially wide DSD at cloud top, homogeneous mixing is nearly indistinguishable from inhomogeneous mixing.« less

Understanding rapid changes in phase partitioning between cloud liquid and ice in an Arctic stratiform mixed-phase cloud

NASA Astrophysics Data System (ADS)

Kalesse, Heike; de Boer, Gijs; Solomon, Amy; Oue, Mariko; Ahlgrimm, Maike; Zhang, Damao; Shupe, Matthew; Luke, Edward; Protat, Alain

2016-04-01

In the Arctic, a region particularly sensitive to climate change, mixed-phase clouds occur as persistent single or multiple stratiform layers. For many climate models, the correct partitioning of hydrometeor phase (liquid vs. ice) remains a challenge. However, this phase partitioning plays an important role for precipitation processes and the radiation budget. To better understand the partitioning of phase in Arctic clouds, observations using a combination of surface-based remote sensors are useful. In this study, the focus is on a persistent low-level single-layer stratiform Arctic mixed-phase cloud observed during March 11-12, 2013 at the US Department of Energy's (DOE) Atmospheric Radiation Measurement (ARM) North Slope of Alaska (NSA) permanent site in Barrow, Alaska. This case is of particular interest due to two significant shifts in observed precipitation intensity over a 36 hour period. For the first 12 hours of this case, the observed liquid portion of the cloud cover featured a stable cloud top height with a gradually descending liquid cloud base and continuous ice precipitation. Then the ice precipitation intensity significantly decreased. A second decrease in ice precipitation intensity was observed a few hours later coinciding with the advection of a cirrus over the site. Through analysis of the data collected by extensive ground-based remote-sensing and in-situ observing systems as well as Nested Weather Research and Forecasting (WRF) simulations and ECMWF radiation scheme simulations, we try to shed light on the processes responsible for these rapid changes in precipitation rates. A variety of parameters such as the evolution of the internal dynamics and microphysics of the low-level mixed-phase cloud and the influence of the cirrus cloud are evaluated.

The economic implications of case-mix Medicaid reimbursement for nursing home care.

PubMed

Grabowski, David C

2002-01-01

In recent years, there has been large growth in the nursing home industry in the use of case-mix adjusted Medicaid payment systems that employ resident characteristics to predict the relative use of resources in setting payment levels. Little attention has been paid to the access and quality incentives that these systems provide in the presence of excess demand conditions due to certificate-of-need (CON) and construction moratoria. Using 1991 to 1998 panel data for all certified U.S. nursing homes, a fixed-effects model indicates that adoption of a case-mix payment system led to increased access for more dependent residents, but the effect was modified in excess demand markets. Quality remained relatively stable with the introduction of case-mix reimbursement, regardless of the presence of excess demand conditions. These results suggest that CON and construction moratoria are still important barriers within the nursing home market, and recent quality assurance activities related to the introduction of case-mix payment systems may have been effective.

A pilot study to determine whether combinations of objectively measured activity parameters can be used to differentiate between mixed states, mania, and bipolar depression.

PubMed

Scott, Jan; Vaaler, Arne E; Fasmer, Ole Bernt; Morken, Gunnar; Krane-Gartiser, Karoline

2017-12-01

Until recently, actigraphy studies in bipolar disorders focused on sleep rather than daytime activity in mania or depression, and have failed to analyse mixed episodes separately. Furthermore, even those studies that assessed activity parameters reported only mean levels rather than complexity or predictability of activity. We identified cases presenting in one of three acute phases of bipolar disorder and examined whether the application of non-linear dynamic models to the description of objectively measured activity can be used to predict case classification. The sample comprised 34 adults who were hospitalized with an acute episode of mania (n = 16), bipolar depression (n = 12), or a mixed state (n = 6), who agreed to wear an actiwatch for a continuous period of 24 h. Mean level, variability, regularity, entropy, and predictability of activity were recorded for a defined 64-min active morning and active evening period. Discriminant function analysis was used to determine the combination of variables that best classified cases based on phase of illness. The model identified two discriminant functions: the first was statistically significant and correlated with intra-individual fluctuation in activity and regularity of activity (sample entropy) in the active morning period; the second correlated with several measures of activity from the evening period (e.g. Fourier analysis, autocorrelation, sample entropy). A classification table generated from both functions correctly classified 79% of all cases based on phase of illness (χ 2  = 36.21; df 4; p = 0.001). However, 42% of bipolar depression cases were misclassified as being in manic phase. The findings should be treated with caution as this was a small-scale pilot study and we did not control for prescribed treatments, medication adherence, etc. However, the insights gained should encourage more widespread adoption of statistical approaches to the classification of cases alongside the application of more sophisticated modelling of activity patterns. The difficulty of accurately classifying cases of bipolar depression requires further research, as it is unclear whether the lower prediction rate reflects weaknesses in a model based only on actigraphy data, or if it reflects clinical reality i.e. the possibility that there may be more than one subtype of bipolar depression.

General practice performance in referral for suspected cancer: influence of number of cases and case-mix on publicly reported data.

PubMed

Murchie, P; Chowdhury, A; Smith, S; Campbell, N C; Lee, A J; Linden, D; Burton, C D

2015-05-26

Publicly available data show variation in GPs' use of urgent suspected cancer (USC) referral pathways. We investigated whether this could be due to small numbers of cancer cases and random case-mix, rather than due to true variation in performance. We analysed individual GP practice USC referral detection rates (proportion of the practice's cancer cases that are detected via USC) and conversion rates (proportion of the practice's USC referrals that prove to be cancer) in routinely collected data from GP practices in all of England (over 4 years) and northeast Scotland (over 7 years). We explored the effect of pooling data. We then modelled the effects of adding random case-mix to practice variation. Correlations between practice detection rate and conversion rate became less positive when data were aggregated over several years. Adding random case-mix to between-practice variation indicated that the median proportion of poorly performing practices correctly identified after 25 cancer cases were examined was 20% (IQR 17 to 24) and after 100 cases was 44% (IQR 40 to 47). Much apparent variation in GPs' use of suspected cancer referral pathways can be attributed to random case-mix. The methods currently used to assess the quality of GP-suspected cancer referral performance, and to compare individual practices, are misleading. These should no longer be used, and more appropriate and robust methods should be developed.

Application of case mix index in the allocation of nursing human resources.

PubMed

Han, Binru; Chen, Xi; Li, Qiuping

2018-02-23

To investigate the feasibility of the case mix index and compare the allocation of nursing human resources between two departments of a hospital with different case mix indexes in China. The case mix index is used to assess the resource allocation of all cases in two departments of a hospital. Its values can determine the resource allocation required to diagnose and treat the patients. Clinical data were obtained from 23 different departments in 2015 and analysed retrospectively from October to November, 2016. Factors influencing the allocation of registered nurses were identified, and balanced quantities of patients with different case mix indexes were chosen from two departments. Spearman correlation analysis was performed. The per capita nursing workload was significant (r = .669, p = .000). The length of hospital stay, quantity of nurses, and department case mix index were correlated with the nursing workload (t = 4.211, p = .000; t = 2.962, p = .008; t = 2.266, p = .035). Education levels (Z = -1.391, p = .164) and the professional titles (Z = -1.832, p = .067) of the nurses were not statistically significant, whereas the registered nurse level differed between two departments (Z = -2.125, p = .034). The case management index provides references for the efficient allocation of registered nurses in clinical practice. © 2018 John Wiley & Sons Ltd.

Literacy Instruction in the Mother Tongue: The Case of Pupils Using Mixed Vocabularies

ERIC Educational Resources Information Center

Sanchez, Alma Sonia Q.

2013-01-01

In the institutionalization of the mother tongue-based multilingual education (MTB-MLE) in the country, several trainings were conducted introducing its unique features such as the use of the two-track method in teaching reading based on the frequency of the sounds of the first language (L1). This study attempted to find out how the accuracy track…

Advancing Evaluation in Community Colleges: A Mixed Methods Case Study of Outcomes-Based Assessment Training in Student Affairs

ERIC Educational Resources Information Center

Russell, Tammy L.

2016-01-01

Many student affairs departments struggle to contribute to an institution's evidence base of student learning. In part, this results from student affairs personnel not having adequate training in how to assess learning outside the classroom. This is a particular challenge for small community colleges, in which individual units (e.g., admissions or…

a Framework for Distributed Mixed Language Scientific Applications

NASA Astrophysics Data System (ADS)

Quarrie, D. R.

The Object Management Group has defined an architecture (CORBA) for distributed object applications based on an Object Request Broker and Interface Definition Language. This project builds upon this architecture to establish a framework for the creation of mixed language scientific applications. A prototype compiler has been written that generates FORTRAN 90 or Eiffel stubs and skeletons and the required C++ glue code from an input IDL file that specifies object interfaces. This generated code can be used directly for non-distributed mixed language applications or in conjunction with the C++ code generated from a commercial IDL compiler for distributed applications. A feasibility study is presently underway to see whether a fully integrated software development environment for distributed, mixed-language applications can be created by modifying the back-end code generator of a commercial CASE tool to emit IDL.

Case-mix adjustment and the comparison of community health center performance on patient experience measures.

PubMed

Johnson, M Laura; Rodriguez, Hector P; Solorio, M Rosa

2010-06-01

To assess the effect of case-mix adjustment on community health center (CHC) performance on patient experience measures. A Medicaid-managed care plan in Washington State collected patient survey data from 33 CHCs over three fiscal quarters during 2007-2008. The survey included three composite patient experience measures (6-month reports) and two overall ratings of care. The analytic sample includes 2,247 adult patients and 2,859 adults reporting for child patients. We compared the relative importance of patient case-mix adjusters by calculating each adjuster's predictive power and variability across CHCs. We then evaluated the impact of case-mix adjustment on the relative ranking of CHCs. Important case-mix adjusters included adult self-reported health status or parent-reported child health status, adult age, and educational attainment. The effects of case-mix adjustment on patient reports and ratings were different in the adult and child samples. Adjusting for race/ethnicity and language had a greater impact on parent reports than adult reports, but it impacted ratings similarly across the samples. The impact of adjustment on composites and ratings was modest, but it affected the relative ranking of CHCs. To ensure equitable comparison of CHC performance on patient experience measures, reports and ratings should be adjusted for adult self-reported health status or parent-reported child health status, adult age, education, race/ethnicity, and survey language. Because of the differential impact of case-mix adjusters for child and adult surveys, initiatives should consider measuring and reporting adult and child scores separately.

Rating long-term care facilities on pressure ulcer development: importance of case-mix adjustment.

PubMed

Berlowitz, D R; Ash, A S; Brandeis, G H; Brand, H K; Halpern, J L; Moskowitz, M A

1996-03-15

To determine the importance of case-mix adjustment in interpreting differences in rates of pressure ulcer development in Department of Veterans Affairs long- term care facilities. A sample assembled from the Patient Assessment File, a Veterans Affairs administrative database, was used to derive predictors of pressure ulcer development; the resulting model was validated in a separate sample. Facility-level rates of pressure ulcer development, both unadjusted and adjusted for case mix using the predictive model, were compared. Department of Veterans Affairs long-term care facilities. The derivation sample consisted of 31 150 intermediate medicine and nursing home residents who were initially free of pressure ulcers and were institutionalized between October 1991 and April 1993. The validation sample consisted of 17 946 residents institutionalized from April 1993 to October 1993. Development of a stage 2 or greater pressure ulcer. 11 factors predicted pressure ulcer development. Validated performance properties of the resulting model were good. Model-predicted rates of pressure ulcer development at individual long-term care facilities varied from 1.9% to 6.3%, and observed rates ranged from 0% to 10.9%. Case-mix-adjusted rates and ranks of facilities differed considerably from unadjusted ratings. For example, among five facilities that were identified as high outliers on the basis of unadjusted rates, two remained as outliers after adjustment for case mix. Long-term care facilities differ in case mix. Adjustments for case mix result in different judgments about facility performance and should be used when facility incidence rates are compared.

Influence of Mixed Mode I-Mode II Loading on Fatigue Delamination Growth Characteristics of a Graphite Epoxy Tape Laminate

NASA Technical Reports Server (NTRS)

Ratcliffe, James G.; Johnston, William M., Jr.

2014-01-01

Mixed mode I-mode II interlaminar tests were conducted on IM7/8552 tape laminates using the mixed-mode bending test. Three mixed mode ratios, G(sub II)/G(sub T) = 0.2, 0.5, and 0.8, were considered. Tests were performed at all three mixed-mode ratios under quasi-static and cyclic loading conditions, where the former static tests were used to determine initial loading levels for the latter fatigue tests. Fatigue tests at each mixed-mode ratio were performed at four loading levels, Gmax, equal to 0.5G(sub c), 0.4G(sub c), 0.3G(sub c), and 0.2G(sub c), where G(sub c) is the interlaminar fracture toughness of the corresponding mixed-mode ratio at which a test was performed. All fatigue tests were performed using constant-amplitude load control and delamination growth was automatically documented using compliance solutions obtained from the corresponding quasi-static tests. Static fracture toughness data yielded a mixed-mode delamination criterion that exhibited monotonic increase in Gc with mixed-mode ratio, G(sub II)/G(sub T). Fatigue delamination onset parameters varied monotonically with G(sub II)/G(sub T), which was expected based on the fracture toughness data. Analysis of non-normalized data yielded a monotonic change in Paris law exponent with mode ratio. This was not the case when normalized data were analyzed. Fatigue data normalized by the static R-curve were most affected in specimens tested at G(sub II)/G(sub T)=0.2 (this process has little influence on the other data). In this case, the normalized data yielded a higher delamination growth rate compared to the raw data for a given loading level. Overall, fiber bridging appeared to be the dominant mechanism, affecting delamination growth rates in specimens tested at different load levels and differing mixed-mode ratios.

Effect of black carbon on dust property retrievals from satellite observations

NASA Astrophysics Data System (ADS)

Lin, Tang-Huang; Yang, Ping; Yi, Bingqi

2013-01-01

The effect of black carbon on the optical properties of polluted mineral dust is studied from a satellite remote-sensing perspective. By including the auxiliary data of surface reflectivity and aerosol mixing weight, the optical properties of mineral dust, or more specifically, the aerosol optical depth (AOD) and single-scattering albedo (SSA), can be retrieved with improved accuracy. Precomputed look-up tables based on the principle of the Deep Blue algorithm are utilized in the retrieval. The mean differences between the retrieved results and the corresponding ground-based measurements are smaller than 1% for both AOD and SSA in the case of pure dust. However, the retrievals can be underestimated by as much as 11.9% for AOD and overestimated by up to 4.1% for SSA in the case of polluted dust with an estimated 10% (in terms of the number-density mixing ratio) of soot aggregates if the black carbon effect on dust aerosols is neglected.

Evaluation of SYBR green I based visual loop-mediated isothermal amplification (LAMP) assay for genus and species-specific diagnosis of malaria in P. vivax and P. falciparum endemic regions.

PubMed

Singh, Ruchi; Singh, Dhirendra Pratap; Savargaonkar, Deepali; Singh, Om P; Bhatt, Rajendra M; Valecha, Neena

2017-01-01

Loop-mediated isothermal amplification (LAMP) is an emerging nucleic acid based diag- nostic approach that is easily adaptable to the field settings with limited technical resources. This study was aimed to evaluate the LAMP assay for the detection and identification of Plasmodium falciparum and P. vivax infection in malaria suspected cases using genus and species-specific assay. The 18S rRNA-based LAMP assay was evaluated for diagnosis of genus Plasmodium, and species- specific diagnosis of P. falciparum and P. vivax, infection employing 317 malaria suspected cases, and the results were compared with those obtained by 18S nested PCR (n-PCR). All the samples were confirmed by microscopy for the presence of Plasmodium parasite. The n-PCR was positive in all Plasmodium-infected cases (n=257; P. falciparum=133; P. vivax=124) and negative in microscopy negative cases (n=58) except for two cases which were positive for P. vivax, giving a sen- sitivity of 100% (95% CI: 97.04-100%) and a specificity of 100% (95% CI: 88.45-99.5%). Genus-specific LAMP assay missed 11 (3.2%) microscopy and n-PCR confirmed vivax malaria cases. Considering PCR results as a refer- ence, LAMP was 100% sensitive and specific for P. falciparum, whereas it exhibited 95.16% sensitivity and 96.7% specificity for P. vivax. The n-PCR assay detected 10 mixed infection cases while species-specific LAMP detected five mixed infection cases of P. vivax and P. falciparum, which were not detected by microscopy. Genus-specific LAMP assay displayed low sensitivity. Falciparum specific LAMP assay displayed high sensitivity whereas vivax specific LAMP assay displayed low sensitivity. Failed detection of vivax cases otherwise confirmed by the n-PCR assay indicates exploitation of new targets and improved detection methods to attain 100% results for P. vivax detection.

Response of mixed-phase boundary layer clouds with rapid and slow ice nucleation processes to cloud-top temperature trend

NASA Astrophysics Data System (ADS)

Fridlind, A. M.; Avramov, A.; Ackerman, A. S.; Alpert, P. A.; Knopf, D. A.; DeMott, P. J.; Brooks, S. D.; Glen, A.

2015-12-01

It has been argued on the basis of some laboratory data sets, observed mixed-phase cloud systems, and numerical modeling studies that weakly active or slowly consumed ice forming nuclei (IFN) may be important to natural cloud systems. It has also been argued on the basis of field measurements that ice nucleation under mixed-phase conditions appears to occur predominantly via a liquid-phase mechanism, requiring the presence of liquid droplets prior to substantial ice nucleation. Here we analyze the response of quasi-Lagrangian large-eddy simulations of mixed-phase cloud layers to IFN operating via a liquid-phase mode using assumptions that result in either slow or rapid depletion of IFN from the cloudy boundary layer. Using several generalized case studies that do not exhibit riming or drizzle, based loosely on field campaign data, we vary environmental conditions such that the cloud-top temperature trend varies. One objective of this work is to identify differing patterns in ice formation intensity that may be distinguishable from ground-based or satellite platforms.

Numerical analysis of mixing enhancement for micro-electroosmotic flow

NASA Astrophysics Data System (ADS)

Tang, G. H.; He, Y. L.; Tao, W. Q.

2010-05-01

Micro-electroosmotic flow is usually slow with negligible inertial effects and diffusion-based mixing can be problematic. To gain an improved understanding of electroosmotic mixing in microchannels, a numerical study has been carried out for channels patterned with wall blocks, and channels patterned with heterogeneous surfaces. The lattice Boltzmann method has been employed to obtain the external electric field, electric potential distribution in the electrolyte, the flow field, and the species concentration distribution within the same framework. The simulation results show that wall blocks and heterogeneous surfaces can significantly disturb the streamlines by fluid folding and stretching leading to apparently substantial improvements in mixing. However, the results show that the introduction of such features can substantially reduce the mass flow rate and thus effectively prolongs the available mixing time when the flow passes through the channel. This is a non-negligible factor on the effectiveness of the observed improvements in mixing efficiency. Compared with the heterogeneous surface distribution, the wall block cases can achieve more effective enhancement in the same mixing time. In addition, the field synergy theory is extended to analyze the mixing enhancement in electroosmotic flow. The distribution of the local synergy angle in the channel aids to evaluate the effectiveness of enhancement method.

Variation in fistula use across dialysis facilities: is it explained by case-mix?

PubMed

Tangri, Navdeep; Moorthi, Ranjani; Tighiouhart, Hocine; Meyer, Klemens B; Miskulin, Dana C

2010-02-01

Arteriovenous fistulas (AVFs) remain the preferred vascular access for hemodialysis patients. Dialysis facilities that fail to meet Centers for Medicare & Medicaid Services goals cite patient case-mix as a reason for low AVF prevalence. This study aimed to determine the magnitude of the variability in AVF usage across dialysis facilities and the extent to which patient case-mix explains it. The vascular access used in 10,112 patients dialyzed at 173 Dialysis Clinic Inc. facilities from October 1 to December 31, 2004, was evaluated. The access in use was considered to be an AVF if it was used for >70% of hemodialysis treatments. Mixed-effects models with a random intercept for dialysis facilities evaluated the effect of facilities on AVF usage. Sequentially adjusted multivariate models measured the extent to which patient factors (case-mix) explain variation across facilities in AVF rates. 3787 patients (38%) were dialyzed using AVFs. There was a significant facility effect: 7.6% of variation in AVF use was attributable to facility. This was reduced to 7.1% after case-mix adjustment. There were no identified specific facility-level factors that explained the interfacility variation. AVF usage varies across dialysis facilities, and patient case-mix did not reduce this variation. In this study, 92% of the total variation in AVF usage was due to patient factors, but most were not measurable. A combination of patient factors and process indicators should be considered in adjudicating facility performance for this quality indicator.

A survey of quantum Lyapunov control methods.

PubMed

Cong, Shuang; Meng, Fangfang

2013-01-01

The condition of a quantum Lyapunov-based control which can be well used in a closed quantum system is that the method can make the system convergent but not just stable. In the convergence study of the quantum Lyapunov control, two situations are classified: nondegenerate cases and degenerate cases. For these two situations, respectively, in this paper the target state is divided into four categories: the eigenstate, the mixed state which commutes with the internal Hamiltonian, the superposition state, and the mixed state which does not commute with the internal Hamiltonian. For these four categories, the quantum Lyapunov control methods for the closed quantum systems are summarized and analyzed. Particularly, the convergence of the control system to the different target states is reviewed, and how to make the convergence conditions be satisfied is summarized and analyzed.

A Bell-Curved Based Algorithm for Mixed Continuous and Discrete Structural Optimization

NASA Technical Reports Server (NTRS)

Kincaid, Rex K.; Weber, Michael; Sobieszczanski-Sobieski, Jaroslaw

2001-01-01

An evolutionary based strategy utilizing two normal distributions to generate children is developed to solve mixed integer nonlinear programming problems. This Bell-Curve Based (BCB) evolutionary algorithm is similar in spirit to (mu + mu) evolutionary strategies and evolutionary programs but with fewer parameters to adjust and no mechanism for self adaptation. First, a new version of BCB to solve purely discrete optimization problems is described and its performance tested against a tabu search code for an actuator placement problem. Next, the performance of a combined version of discrete and continuous BCB is tested on 2-dimensional shape problems and on a minimum weight hub design problem. In the latter case the discrete portion is the choice of the underlying beam shape (I, triangular, circular, rectangular, or U).

Success rates of a mixture of ciprofloxacin, metronidazole, and minocycline antibiotics used in the non-instrumentation endodontic treatment of mandibular primary molars with carious pulpal involvement.

PubMed

Trairatvorakul, Chutima; Detsomboonrat, Palinee

2012-05-01

To evaluate the clinical and radiographic success rates of three mixed antibiotics in the non-instrumentation endodontic treatment of primary mandibular molars at 24-27 months postoperatively. Eighty cariously involved lower primary molars from 58 children (ages 3-8 years) received a 3Mix medicament by non-instrumentation endodontic treatment and were then sealed with glass-ionomer cement and composite resin before permanent restoration with stainless steel crowns. The patients received a clinical and radiographic assessment every 6 months over a 2-year follow-up period with an intra-examiner reliability of 0.83-1.00 (κ value). In 60 cases at 24- to 27-month follow-up, the success rates as determined by clinical and radiographic evaluation were 75% and 36.7%, respectively; however, the overall success rate of 3Mix non-instrumentation endodontic treatment was 36.7% with 15.8% of cases demonstrating a pulpal response of internal resorption. Non-instrumentation endodontic treatment using 3Mix-MP showed good clinical success but had a low success rate based on radiographic evaluation at 2-year follow-up. Hence, 3Mix antibiotic treatment cannot replace a conventional root canal treatment agent as a long-term therapy. © 2011 The Authors. International Journal of Paediatric Dentistry © 2011 BSPD, IAPD and Blackwell Publishing Ltd.

Modeling the outcomes of nursing home care.

PubMed

Rohrer, J E; Hogan, A J

1987-01-01

In this exploratory analysis using data on 290 patients, we use regression analysis to model patient outcomes in two Veterans Administration nursing homes. We find resource use, as measured with minutes of nursing time, to be associated with outcomes when case mix is controlled. Our results suggest that, under case-based reimbursement systems, nursing homes could increase their revenues by withholding unskilled and psychosocial care and discouraging physicians' visits. Implications for nursing home policy are discussed.

A rare case report of mixed olfactory neuroblastoma: Carcinoma with review of literature

PubMed Central

Gandhoke, Charandeep S.; Dewan, Aditi; Gupta, Divya; Syal, Simran K.; Jagetia, Anita; Saran, Ravindra K.; Meher, Ravi; Srivastava, Arvind K.; Singh, Daljit

2017-01-01

Background: Olfactory neuroblastoma (ONB) is a rare malignant neuroectodermal tumor of the nasal cavity. Mixed olfactory neuroblastoma which contains areas of divergent differentiation is even rare. Till date, only 4 cases of mixed olfactory neuroblastomas have been reported. Case Description: We report the case of a 46-year-old male who presented with the chief complaints of nasal bleeding and nasal obstruction since 4 months. Radiological imaging was suggestive of a large heterogeneous mass in the left superior nasal cavity with extensions into bilateral maxillary, ethmoidal, and sphenoidal sinuses, as well as into the anterior cranial fossa. Bifrontal osteoplastic craniotomy and excision of the intracranial part of the tumor from above and transnasal endoscopic removal of the mass in the nasal cavities and paranasal sinuses from below was done. Postoperative radiological imaging was suggestive of gross complete excision of the mass. Histopathological diagnosis was “mixed olfactory neuroblastoma-carcinoma (squamous and glandular differentiation) Hyams grade IV.” On immunohistochemistry, the tumor cells were positive for neuron specific enolase (NSE), synaptophysin, chromogranin, and CD56 and peripherally for S100. Because of personal reasons, the patient did not take adjuvant radiotherapy. He presented again after 2 months with a full blown recurrence of esthesioneuroblastoma with similar extensions as before. The patient is now planned for salvage surgery followed by adjuvant chemoradiation. Conclusion: We report the 5th case in the world of mixed olfactory neuroblastoma-carcinoma with squamous and glandular differentiation. From an analysis of the findings in the 5 reported cases of mixed olfactory neuroblastomas, one might infer that a separate subcategory of ONB, i.e., mixed ONB, should be considered because mixed ONBs have an aggressive behavior, high rates of recurrence, and these tumors should be treated aggressively by multimodality treatment. PMID:28607817

Adjoint Sensitivity Analysis of Radiative Transfer Equation: Temperature and Gas Mixing Ratio Weighting Functions for Remote Sensing of Scattering Atmospheres in Thermal IR

NASA Technical Reports Server (NTRS)

Ustinov, E.

1999-01-01

Sensitivity analysis based on using of the adjoint equation of radiative transfer is applied to the case of atmospheric remote sensing in the thermal spectral region with non-negligeable atmospheric scattering.

Training Entrepreneurship at Universities: A Swedish Case.

ERIC Educational Resources Information Center

Klofsten, Magnus

2000-01-01

The Entrepreneurship and New Business Development Program trains Swedish individuals in the startup of technology- or knowledge-based enterprises. Built on the characteristics of entrepreneurial behavior, the program features a holistic outlook, a network of established entrepreneurs, mentoring, a mix of theory and practice, and focus on the…

Leaching from solid waste incineration ashes used in cement-treated base layers for pavements.

PubMed

Cai, Z; Bager, Dirch H; Christensen, T H

2004-01-01

Waste incineration bottom ash and treated flue gas cleaning products mixed with 2.5% of cement (50 kg/m3) were tested in the laboratory in terms of compressive strength and tank leaching tests over a 64-day period. Although the material displayed lower mechanical strength than a reference concrete, the strength still was sufficient for use as a base layer for roads. The metal content in the incineration-residue-based specimens was up to 100 times higher than in the reference concrete, suggesting that the mixed waste incineration residue should be used only for dedicated purposes. The leaching of Cl and Na was increased by a factor of 20-100 from the incineration-residue-based specimens as compared to the reference, while the leaching of K, Ca and SO4 was increased by a factor of 2-10. The leaching of heavy metals was also higher from the incineration-residue-based specimens than from the reference with respect to Cu (50 times), Cd, Pb and Zn (5 times), but not with respect to Cr and Ni. The leaching curves did only allow for a closer evaluation of the leaching process in a few cases. The physical retention of the constituents seemed to be the same in the reference as in the incineration-residue-based specimens. Heavy metal leaching was limited by enhanced chemical retention in the incineration-residue-specimens as compared to the reference. Since no quality criteria in terms of leaching from a monolithic material are currently available, the leaching issue must be evaluated case by case.

LIF measurements of scalar mixing in turbulent shear layers

NASA Technical Reports Server (NTRS)

Karasso, Paris S.; Mungal, M. G.

1993-01-01

The structure of shear layer flows at high Reynolds numbers remains a very interesting problem. Straight mixing layers have been studied and yielded information on the probability density function (pdf) of a passive scalar across the layer. Konrad and Koochesfahani & Dimotakis measured the pdf of the mixture fraction for mixing layers of moderate Reynolds numbers, each about 25,000 (Re based on velocity difference and visual thickness). Their measurements showed a 'non-marching' pdf (central hump which is invariant from edge to edge across the layer), a result which is linked to the visualizations of the spanwise Kelvin-Helmholtz (K-H) instability mode, which is the primary instability for plane shear layer flows. A secondary instability mode, the Taylor-Gortler (T-G) instability, which is associated with streamwise vortical structures, has also been observed in shear layers. Image reconstruction by Jimenez et al. and volume renderings by Karasso & Mungal at low Re numbers have demonstrated that the K-H and the T-G instability modes occur simultaneously in a non-mutually destructive way, evidence that supports the quasi two-dimensional aspect of these flows and the non-marching character of the pdf at low Reynolds numbers. At higher Re numbers though, the interaction of these two instability modes is still unclear and may affect the mixing process. In this study, we perform measurements of the concentration pdf of plane mixing layers for different operating conditions. At a speed ratio of r = U(sub 1)/U(sub 2) = 4:1, we examine three Reynolds number cases: Re = 14,000, Re = 31,000, and Re = 62,000. Some other Re number cases' results, not presented in detail, are invoked to explain the behavior of the pdf of the concentration field. A case of r = 2.6:1 at Re = 20,000 is also considered. The planar laser-induced fluorescence technique is used to yield quantitative measurements. The different Re are obtained by changing the velocity magnitudes of the two streams. The question of resolution of these measurements is addressed. In order to investigate the effects of the initial conditions on the development and the structure of the mixing layer, the boundary layer on the high-speed side of the splitter plate is tripped. The average concentration and the average mixed fluid concentration are also calculated to further understand the changes in the shear layer for the different cases examined.

Breast cancer risk factor associations differ for pure versus invasive carcinoma with an in situ component in case-control and case-case analyses

PubMed Central

Ruszczyk, Melanie; Zirpoli, Gary; Kumar, Shicha; Bandera, Elisa V.; Bovbjerg, Dana H.; Jandorf, Lina; Khoury, Thaer; Hwang, Helena; Ciupak, Gregory; Pawlish, Karen; Schedin, Pepper; Masso-Welch, Patricia; Ambrosone, Christine B.; Hong, Chi-Chen

2015-01-01

Purpose Invasive ductal carcinoma (IDC) is diagnosed with or without a ductal carcinoma in situ (DCIS) component. Previous analyses have found significant differences in tumor characteristics between pure IDC lacking DCIS and mixed IDC with DCIS. We will test our hypothesis that pure IDC represents a form of breast cancer with etiology and risk factors distinct from mixed IDC/DCIS. Methods We compared reproductive risk factors for breast cancer risk, as well as family and smoking history between 831 women with mixed IDC/DCIS (n=650) or pure IDC (n=181), and 1,620 controls, in the context of the Women's Circle of Health Study (WCHS), a case-control study of breast cancer in African-American and European-American women. Data on reproductive and lifestyle factors were collected during interviews, and tumor characteristics were abstracted from pathology reports. Case-control and case-case analyses were conducted using unconditional logistic regression. Results Most risk factors were similarly associated with pure IDC and mixed IDC/DCIS. However, among postmenopausal women, risk for pure IDC was lower in women with body mass index (BMI) 25 to <30 kg/m2 (Odds Ratio (OR)=0.66; 95% confidence interval (CI), 0.35-1.23) and BMI≥30 kg/m2 (OR=0.33; 95% CI, 0.18-0.67) compared to women with BMI<25 kg/m2, with no associations with mixed IDC/DCIS. In case-case analyses, women who breastfed up to 12 months (OR=0.55; 95% CI, 0.32-0.94) or longer (OR=0.47; 95% CI, 0.26-0.87) showed decreased odds of pure IDC than mixed IDC/DCIS compared to those who did not breastfeed. Conclusions Associations with some breast cancer risk factors differed between mixed IDC/DCIS and pure IDC, potentially suggesting differential developmental pathways. These findings, if confirmed in a larger study, will provide a better understanding of the development patterns of breast cancer and the influence of modifiable risk factors, which in turn could lead to better preventive measures for pure IDC, which have worse disease prognosis compared to mixed IDC/DCIS. PMID:26621543

[Development and practice evaluation of blood acid-base imbalance analysis software].

PubMed

Chen, Bo; Huang, Haiying; Zhou, Qiang; Peng, Shan; Jia, Hongyu; Ji, Tianxing

2014-11-01

To develop a blood gas, acid-base imbalance analysis computer software to diagnose systematically, rapidly, accurately and automatically determine acid-base imbalance type, and evaluate the clinical application. Using VBA programming language, a computer aided diagnostic software for the judgment of acid-base balance was developed. The clinical data of 220 patients admitted to the Second Affiliated Hospital of Guangzhou Medical University were retrospectively analyzed. The arterial blood gas [pH value, HCO(3)(-), arterial partial pressure of carbon dioxide (PaCO₂)] and electrolytes included data (Na⁺ and Cl⁻) were collected. Data were entered into the software for acid-base imbalances judgment. At the same time the data generation was calculated manually by H-H compensation formula for determining the type of acid-base imbalance. The consistency of judgment results from software and manual calculation was evaluated, and the judgment time of two methods was compared. The clinical diagnosis of the types of acid-base imbalance for the 220 patients: 65 cases were normal, 90 cases with simple type, mixed type in 41 cases, and triplex type in 24 cases. The accuracy of the judgment results of the normal and triplex types from computer software compared with which were calculated manually was 100%, the accuracy of the simple type judgment was 98.9% and 78.0% for the mixed type, and the total accuracy was 95.5%. The Kappa value of judgment result from software and manual judgment was 0.935, P=0.000. It was demonstrated that the consistency was very good. The time for software to determine acid-base imbalances was significantly shorter than the manual judgment (seconds:18.14 ± 3.80 vs. 43.79 ± 23.86, t=7.466, P=0.000), so the method of software was much faster than the manual method. Software judgment can replace manual judgment with the characteristics of rapid, accurate and convenient, can improve work efficiency and quality of clinical doctors and has great clinical application promotion value.

Adjusting for case mix and social class in examining variation in home visits between practices.

PubMed

Sullivan, Caoimhe O; Omar, Rumana Z; Forrest, Christopher B; Majeed, Azeem

2004-08-01

The purpose of this study was to investigate whether adjusting for clinical case mix and social class explains more of the variation in home visits between general practices than adjusting for age and sex alone. The setting was 60 general practices in England and Wales taking part in the 1 year Fourth National Morbidity Survey. The participants comprised 349 505 patients who were registered with one of the participating general practices for at least 180 days, and who had at least one consultation during the period. The outcome measure is whether or not a patient received a home visit in that year. A clinical case mix category (morbidity class) based on 1 year's diagnostic information was assigned to each patient using the Johns Hopkins Adjusted Clinical Groups (ACG) Case Mix System. The social class measure was derived from occupation and employment status and is similar to that of the 1991 UK census. Variations in home visits between practices were examined using multilevel logistic regression models. The variability between practices before and after adjusting for clinical case mix and social class was estimated using the intracluster correlation coefficient (ICC). The overall percentage of patients receiving a home visit over the 1 year study period was 17%, and this varied from 7 to 31% across the 60 practices. The percentage of the total variation in home visits attributable to differences between practices was 2.5% [95% confidence interval (CI) 1.4-3.2%] after adjusting for age and sex. This reduced to 1.6% (95% CI 1.1-2.4%) after taking into account morbidity class. The results were similar when social class was included instead of morbidity class. Morbidity and social class together reduced variation in home visits between practices to 1.5% (95% CI 1.1-2.2%). Age, sex, social class and clinical case mix are strong determinants of home visits in the UK. Adjusting for morbidity and social class results in a small improvement in explaining the variability in home visits between practices compared with adjusting for age and sex alone. There is far more variation between patients within practices; however, it is not straightforward to examine the factors influencing this variation. In addition to morbidity and social class, there could also be other unmeasured factors such as varying patient demand for home visits, disability or differences in GP home visiting practice style that could influence the large within-practice variability observed in this study.

Case Mix Complexity Differences between Teaching and Nonteaching Hospitals.

ERIC Educational Resources Information Center

Ament, Richard P.; And Others

1981-01-01

The differences between teaching and nonteaching hospitals in complexity and variety of cases seen are described. The results show that teaching hospitals could be expected to cost somewhat more per patient even if case mix were the only factor. (Author/MLW)

21 CFR 226.102 - Master-formula and batch-production records.

Code of Federal Regulations, 2010 CFR

2010-04-01

...(s) produced on a batch or continuous operation basis, including mixing steps and mixing times that have been determined to yield an adequately mixed Type A medicated article(s); and in the case of Type... batch size, or of appropriate size in the case of continuous systems to be produced from the master...

Center for the Built Environment: Research on Building Envelope Systems

Science.gov Websites

Studies Facade and Perimeter Zone Field Study Facades and Thermal Comfort Facade Symposium Mixed-Mode Research Adaptive Comfort Model Mixed-Mode Case Studies Operable Windows and Thermal Comfort Occupant thermal preferences in naturally ventilated as sealed buildings? Case Study Research of Mixed-Mode Office

Case-mix adjustment for diabetes indicators: a systematic review.

PubMed

Calsbeek, Hiske; Markhorst, Joekle G M; Voerman, Gerlienke E; Braspenning, Jozé C C

2016-02-01

Case-mix adjustment is generally considered indispensable for fair comparison of healthcare performance. Inaccurate results are also unfair to patients as they are ineffective for improving quality. However, little is known about what factors should be adjusted for. We reviewed case-mix factors included in adjustment models for key diabetes indicators, the rationale for their inclusion, and their impact on performance. Systematic review. This systematic review included studies published up to June 2013 addressing case-mix factors for 6 key diabetes indicators: 2 outcomes and 2 process indicators for glycated hemoglobin (A1C), low-density lipoprotein cholesterol, and blood pressure. Factors were categorized as demographic, diabetes-related, comorbidity, generic health, geographic, or care-seeking, and were evaluated on the rationale for inclusion in the adjustment models, as well as their impact on indicator scores and ranking. Thirteen studies were included, mainly addressing A1C value and measurement. Twenty-three different case-mix factors, mostly demographic and diabetes-related, were identified, and varied from 1 to 14 per adjustment model. Six studies provided selection motives for the inclusion of case-mix factors. Marital status and body mass index showed a significant impact on A1C value. For the other factors, either no or conflicting associations were reported, or too few studies (n ≤ 2) investigated this association. Scientific knowledge about the relative importance of case-mix factors for diabetes indicators is emerging, especially for demographic and diabetes-related factors and indicators on A1C, but is still limited. Because arbitrary adjustment potentially results in inaccurate quality information, meaningful stratification that demonstrates inequity in care might be a better guide, as it can be a driver for quality improvement.

Nursing home performance under case-mix reimbursement: responding to heavy-care incentives and market changes.

PubMed Central

Davis, M A; Freeman, J W; Kirby, E C

1998-01-01

OBJECTIVE: To examine the effect of case mix-adjusted reimbursement policy and market factors on nursing home performance. DATA SOURCES AND STUDY SETTING: Data from Medicaid certification inspection surveys, Medicaid cost reports, and the Kentucky State Center for Health Statistics for the years 1989 and 1991, to examine changes in nursing home performance stemming from the adoption of case mix-adjusted reimbursement in 1990. STUDY DESIGN: In addition to cross-sectional regressions, a first-difference approach to fixed-effects regression analyses was employed to control for facility differences that were essentially fixed during the survey years and to estimate the effects of time-varying predictors on changes in facility expenditures, efficiency, and profitability. PRINCIPAL FINDINGS: Facilities that increased the proportion of Medicaid residents and eliminated excess capacity experienced higher profitability gains during the beginning phase of case-mix reimbursement. Having a heavy-care resident population was positively related to expenditures prior to reimbursement reform, and it was negatively related to expenditures after the case-mix reimbursement policy was introduced. While facility-level changes in case mix had no reliable influence on costs or profits, nursing homes showing an increased prevalence of poor-quality nursing practices exhibited increases in efficiency and profitability. At the market level, reductions in excess or empty nursing home beds were accompanied by a significant growth in home health services. Moreover, nursing homes located in markets with expanding home health services exhibited higher increases in costs per case-mix unit. CONCLUSIONS: Characteristics of the reimbursement system appear to reward a cost minimization orientation with potentially detrimental effects on quality of care. These effects, exacerbated by a supply-constrained market, may be mitigated by policies that encourage the expansion of home health service availability. PMID:9776938

Productivity growth in outpatient child and adolescent mental health services: the impact of case-mix adjustment.

PubMed

Halsteinli, Vidar; Kittelsen, Sverre A; Magnussen, Jon

2010-02-01

The performance of health service providers may be monitored by measuring productivity. However, the policy value of such measures may depend crucially on the accuracy of input and output measures. In particular, an important question is how to adjust adequately for case-mix in the production of health care. In this study, we assess productivity growth in Norwegian outpatient child and adolescent mental health service units (CAMHS) over a period characterized by governmental utilization of simple productivity indices, a substantial increase in capacity and a concurrent change in case-mix. We analyze the sensitivity of the productivity growth estimates using different specifications of output to adjust for case-mix differences. Case-mix adjustment is achieved by distributing patients into eight groups depending on reason for referral, age and gender, as well as correcting for the number of consultations. We utilize the nonparametric Data Envelopment Analysis (DEA) method to implicitly calculate weights that maximize each unit's efficiency. Malmquist indices of technical productivity growth are estimated and bootstrap procedures are performed to calculate confidence intervals and to test alternative specifications of outputs. The dataset consist of an unbalanced panel of 48-60 CAMHS in the period 1998-2006. The mean productivity growth estimate from a simple unadjusted patient model (one single output) is 35%; adjusting for case-mix (eight outputs) reduces the growth estimate to 15%. Adding consultations increases the estimate to 28%. The latter reflects an increase in number of consultations per patient. We find that the governmental productivity indices strongly tend to overestimate productivity growth. Case-mix adjustment is of major importance and governmental utilization of performance indicators necessitates careful considerations of output specifications. Copyright 2009 Elsevier Ltd. All rights reserved.

Variability in case-mix adjusted in-hospital cardiac arrest rates.

PubMed

Merchant, Raina M; Yang, Lin; Becker, Lance B; Berg, Robert A; Nadkarni, Vinay; Nichol, Graham; Carr, Brendan G; Mitra, Nandita; Bradley, Steven M; Abella, Benjamin S; Groeneveld, Peter W

2012-02-01

It is unknown how in-hospital cardiac arrest (IHCA) rates vary across hospitals and predictors of variability. Measure variability in IHCA across hospitals and determine if hospital-level factors predict differences in case-mix adjusted event rates. Get with the Guidelines Resuscitation (GWTG-R) (n=433 hospitals) was used to identify IHCA events between 2003 and 2007. The American Hospital Association survey, Medicare, and US Census were used to obtain detailed information about GWTG-R hospitals. Adult patients with IHCA. Case-mix-adjusted predicted IHCA rates were calculated for each hospital and variability across hospitals was compared. A regression model was used to predict case-mix adjusted event rates using hospital measures of volume, nurse-to-bed ratio, percent intensive care unit beds, palliative care services, urban designation, volume of black patients, income, trauma designation, academic designation, cardiac surgery capability, and a patient risk score. We evaluated 103,117 adult IHCAs at 433 US hospitals. The case-mix adjusted IHCA event rate was highly variable across hospitals, median 1/1000 bed days (interquartile range: 0.7 to 1.3 events/1000 bed days). In a multivariable regression model, case-mix adjusted IHCA event rates were highest in urban hospitals [rate ratio (RR), 1.1; 95% confidence interval (CI), 1.0-1.3; P=0.03] and hospitals with higher proportions of black patients (RR, 1.2; 95% CI, 1.0-1.3; P=0.01) and lower in larger hospitals (RR, 0.54; 95% CI, 0.45-0.66; P<0.0001). Case-mix adjusted IHCA event rates varied considerably across hospitals. Several hospital factors associated with higher IHCA event rates were consistent with factors often linked with lower hospital quality of care.

Nursing home performance under case-mix reimbursement: responding to heavy-care incentives and market changes.

PubMed

Davis, M A; Freeman, J W; Kirby, E C

1998-10-01

To examine the effect of case mix-adjusted reimbursement policy and market factors on nursing home performance. Data from Medicaid certification inspection surveys, Medicaid cost reports, and the Kentucky State Center for Health Statistics for the years 1989 and 1991, to examine changes in nursing home performance stemming from the adoption of case mix-adjusted reimbursement in 1990. In addition to cross-sectional regressions, a first-difference approach to fixed-effects regression analyses was employed to control for facility differences that were essentially fixed during the survey years and to estimate the effects of time-varying predictors on changes in facility expenditures, efficiency, and profitability. Facilities that increased the proportion of Medicaid residents and eliminated excess capacity experienced higher profitability gains during the beginning phase of case-mix reimbursement. Having a heavy-care resident population was positively related to expenditures prior to reimbursement reform, and it was negatively related to expenditures after the case-mix reimbursement policy was introduced. While facility-level changes in case mix had no reliable influence on costs or profits, nursing homes showing an increased prevalence of poor-quality nursing practices exhibited increases in efficiency and profitability. At the market level, reductions in excess or empty nursing home beds were accompanied by a significant growth in home health services. Moreover, nursing homes located in markets with expanding home health services exhibited higher increases in costs per case-mix unit. Characteristics of the reimbursement system appear to reward a cost minimization orientation with potentially detrimental effects on quality of care. These effects, exacerbated by a supply-constrained market, may be mitigated by policies that encourage the expansion of home health service availability.

Expression of p16Ink4a in mixed squamous cell and glandular papilloma of the lung.

PubMed

Miyoshi, Ryo; Menju, Toshi; Yoshizawa, Akihiko; Date, Hiroshi

2017-06-01

Mixed squamous cell and glandular papilloma (mixed papilloma) of the lung is an extremely rare neoplasm, with only 21 cases reported in the English literature. Although the expression of p16 Ink4a has been analyzed in only two cases of mixed papilloma, they were negative for p16 Ink4a . Therefore, the significance of p16 Ink4a overexpression in mixed papilloma remains unclear. This is the first case of mixed papilloma with positive p16 Ink4a expression in a 72-year-old male smoker. The 20 mm sized tumor was histologically diagnosed as mixed papilloma following right upper lobectomy. Immunohistochemically, cytokeratin 5 and p40 positivity was predominant in basal cells of the glandular component and squamous cells, while thyroid transcription factor-1, p53, and Ki-67 were focally positive. Both glandular and squamous components were diffusely positive for p16 Ink4a . This finding could be important to clarify the pathogenesis and biology of mixed papilloma. © 2017 Japanese Society of Pathology and John Wiley & Sons Australia, Ltd.

Estimating the Numerical Diapycnal Mixing in the GO5.0 Ocean Model

NASA Astrophysics Data System (ADS)

Megann, A.; Nurser, G.

2014-12-01

Constant-depth (or "z-coordinate") ocean models such as MOM4 and NEMO have become the de facto workhorse in climate applications, and have attained a mature stage in their development and are well understood. A generic shortcoming of this model type, however, is a tendency for the advection scheme to produce unphysical numerical diapycnal mixing, which in some cases may exceed the explicitly parameterised mixing based on observed physical processes, and this is likely to have effects on the long-timescale evolution of the simulated climate system. Despite this, few quantitative estimations have been made of the magnitude of the effective diapycnal diffusivity due to numerical mixing in these models. GO5.0 is the latest ocean model configuration developed jointly by the UK Met Office and the National Oceanography Centre (Megann et al, 2014), and forms part of the GC1 and GC2 climate models. It uses version 3.4 of the NEMO model, on the ORCA025 ¼° global tripolar grid. We describe various approaches to quantifying the numerical diapycnal mixing in this model, and present results from analysis of the GO5.0 model based on the isopycnal watermass analysis of Lee et al (2002) that indicate that numerical mixing does indeed form a significant component of the watermass transformation in the ocean interior.

An in-depth assessment of a diagnosis-based risk adjustment model based on national health insurance claims: the application of the Johns Hopkins Adjusted Clinical Group case-mix system in Taiwan.

PubMed

Chang, Hsien-Yen; Weiner, Jonathan P

2010-01-18

Diagnosis-based risk adjustment is becoming an important issue globally as a result of its implications for payment, high-risk predictive modelling and provider performance assessment. The Taiwanese National Health Insurance (NHI) programme provides universal coverage and maintains a single national computerized claims database, which enables the application of diagnosis-based risk adjustment. However, research regarding risk adjustment is limited. This study aims to examine the performance of the Adjusted Clinical Group (ACG) case-mix system using claims-based diagnosis information from the Taiwanese NHI programme. A random sample of NHI enrollees was selected. Those continuously enrolled in 2002 were included for concurrent analyses (n = 173,234), while those in both 2002 and 2003 were included for prospective analyses (n = 164,562). Health status measures derived from 2002 diagnoses were used to explain the 2002 and 2003 health expenditure. A multivariate linear regression model was adopted after comparing the performance of seven different statistical models. Split-validation was performed in order to avoid overfitting. The performance measures were adjusted R2 and mean absolute prediction error of five types of expenditure at individual level, and predictive ratio of total expenditure at group level. The more comprehensive models performed better when used for explaining resource utilization. Adjusted R2 of total expenditure in concurrent/prospective analyses were 4.2%/4.4% in the demographic model, 15%/10% in the ACGs or ADGs (Aggregated Diagnosis Group) model, and 40%/22% in the models containing EDCs (Expanded Diagnosis Cluster). When predicting expenditure for groups based on expenditure quintiles, all models underpredicted the highest expenditure group and overpredicted the four other groups. For groups based on morbidity burden, the ACGs model had the best performance overall. Given the widespread availability of claims data and the superior explanatory power of claims-based risk adjustment models over demographics-only models, Taiwan's government should consider using claims-based models for policy-relevant applications. The performance of the ACG case-mix system in Taiwan was comparable to that found in other countries. This suggested that the ACG system could be applied to Taiwan's NHI even though it was originally developed in the USA. Many of the findings in this paper are likely to be relevant to other diagnosis-based risk adjustment methodologies.

[Case-mix index and length of hospitalization].

PubMed

D'Andrea, V; Catania, A; Di Matteo, F M; Savino, G; Greco, R; Di Marco, C; De Antoni, E

2010-05-01

The ACG (Adjusted Clinical Groups) case-mix system is a classification method of diseases of patients, focused on the person. Depending on the pattern of these morbid conditions, the ACG system assigns each patient to a single group (an ACG group), which allows to capture the effects of a group of diseases in estimates of resource use. Diseases are classified into a diagnostic group (ADG) according to 5 clinical dimensions: duration (acute, recurrent or chronic), severity (minor/major vs stable/unstable), diagnostic assessment (symptoms vs diseases), etiology (infectious, traumatic or other), specialty (medical, surgical, obstetric, ...). All diseases can be classified into these dimensions and into one of 32 groups. The ACG case-mix system uses an algorithm to classify each patient into one of 93 ACG categories. Each person is assigned to an ACG according to his ADG combination, his age and his gender. With the repayment system "case-mix", surgery has become central for all great hospitals in virtue of its great productive potential. The case-mix index is one of the factors which influence the duration of hospitalization. The case-mix system has emphasized the importance of the duration of hospitalization, encouraging the planning of programs in order to discharge patients early after surgical operations. It has also stimulated the surgical activity in operating units with "budget" forecasts in which resources are provided according to an expected level of specialist surgery.

A Case Study of Indoor Garden-Based Learning with Hydroponics and Aquaponics: Evaluating Pro-Environmental Knowledge, Perception, and Behavior Change

ERIC Educational Resources Information Center

Jon Schneller, Andrew; Schofield, Casey A.; Frank, Jenna; Hollister, Eliza; Mamuszka, Lauren

2015-01-01

This article reports on a mixed methods evaluation of an indoor garden-based learning curriculum for 5th and 6th graders which incorporated aquaponics and hydroponics technologies. This study provides a better understanding of the extent to which indoor gardening technologies can be used within the formal curriculum as an effective teaching tool.…

The mediating effect of context variation in mixed practice for transfer of basic science.

PubMed

Kulasegaram, Kulamakan; Min, Cynthia; Howey, Elizabeth; Neville, Alan; Woods, Nicole; Dore, Kelly; Norman, Geoffrey

2015-10-01

Applying a previously learned concept to a novel problem is an important but difficult process called transfer. Practicing multiple concepts together (mixed practice mode) has been shown superior to practicing concepts separately (blocked practice mode) for transfer. This study examined the effect of single and multiple practice contexts for both mixed and blocked practice modalities on transfer performance. We looked at performance on near transfer (familiar contexts) cases and far transfer (unfamiliar contexts) cases. First year psychology students (n = 42) learned three physiological concepts in a 2 × 2 factorial study (one or two practice contexts and blocked or mixed practice). Each concept was practiced with two clinical cases; practice context was defined as the number of organ systems used (one system per concept vs. two systems). In blocked practice, two practice cases followed each concept; in mixed practice, students learned all concepts before seeing six practice cases. Transfer testing consisted of correctly classifying and explaining 15 clinical cases involving near and far transfer. The outcome was ratings of quality of explanations on a 0-3 scale. The repeated measures analysis showed a significant near versus far by organ system interaction [F(1,38) = 3.4, p < 0.002] with practice with a single context showing lower far transfer scores than near transfer [0.58 (0.37)-0.83 (0.37)] compared to the two contexts which had similar far and near transfer scores [1.19 (0.50)-1.01 (0.38)]. Practicing with two organ contexts had a significant benefit for far transfer regardless of mixed or blocked practice; the single context mixed practice group had the lowest far transfer performance; this was a large effect size (Cohen's d = 0.81). Using only one practice context during practice significantly lowers performance even with the usually superior mixed practice mode. Novices should be exposed to multiple contexts and mixed practice to facilitate transfer.

High Static Stability in the Mixed Layer Above the Extratropical Tropopause

NASA Astrophysics Data System (ADS)

Kunz, A.; Konopka, P.; Müller, R.; Pan, L. L.; Schiller, C.

2009-04-01

A strong relationship between the static stability N2 in the tropopause inversion layer (TIL) and the intensity of mixing is evident from in-situ observations during SPURT. With a new simple measure of mixing intensity based on O3/CO tracer correlations, a very high mixing intensity connected to a high N2 is found in the extratropical mixing layer. Using radiative transfer calculations we simulate the influence of trace gases such as O3 and H2O on the temperature gradient and thus on the static stability above the tropopause in an idealized (L-shaped) non-mixed and reference mixed atmosphere. N2 enhances due to an intensifying mixing in the LS. At the same time the temperature decreases together with a development of an inversion and the TIL. Hereby H2O plays the dominant role in maintenance the temperature inversion and the TIL structure. In case of non mixed profiles the TIL vanishes. The results motivate a link between the mixing layer and the TIL. The mixing layer contains on the one hand older air masses, with high values of N2 due to radiative adjustment. This part of the mixing layer is spatial identically to the TIL. On the other hand, there are younger air masses with somehow lower N2 values within the mixing layer, because of fast intrusion processes from the troposphere due to the permeability or so-called mid-latitude-breaks associated with the jet.

Evaluating diagnosis-based case-mix measures: how well do they apply to the VA population?

PubMed

Rosen, A K; Loveland, S; Anderson, J J; Rothendler, J A; Hankin, C S; Rakovski, C C; Moskowitz, M A; Berlowitz, D R

2001-07-01

Diagnosis-based case-mix measures are increasingly used for provider profiling, resource allocation, and capitation rate setting. Measures developed in one setting may not adequately capture the disease burden in other settings. To examine the feasibility of adapting two such measures, Adjusted Clinical Groups (ACGs) and Diagnostic Cost Groups (DCGs), to the Department of Veterans Affairs (VA) population. A 60% random sample of veterans who used health care services during FY 1997 was obtained from VA inpatient and outpatient administrative databases. A split-sample technique was used to obtain a 40% sample (n = 1,046,803) for development and a 20% sample (n = 524,461) for validation. Concurrent ACG and DCG risk adjustment models, using 1997 diagnoses and demographics to predict FY 1997 utilization (ambulatory provider encounters, and service days-the sum of a patient's inpatient and outpatient visit days), were fitted and cross-validated. Patients were classified into groupings that indicated a population with multiple psychiatric and medical diseases. Model R-squares explained between 6% and 32% of the variation in service utilization. Although reparameterized models did better in predicting utilization than models with external weights, none of the models was adequate in characterizing the entire population. For predicting service days, DCGs were superior to ACGs in most categories, whereas ACGs did better at discriminating among veterans who had the lowest utilization. Although "off-the-shelf" case-mix measures perform moderately well when applied to another setting, modifications may be required to accurately characterize a population's disease burden with respect to the resource needs of all patients.

Medicare and Medicaid Programs; CY 2017 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements. Final rule.

PubMed

2016-11-03

This final rule updates the Home Health Prospective Payment System (HH PPS) payment rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor; effective for home health episodes of care ending on or after January 1, 2017. This rule also: Implements the last year of the 4-year phase-in of the rebasing adjustments to the HH PPS payment rates; updates the HH PPS case-mix weights using the most current, complete data available at the time of rulemaking; implements the 2nd-year of a 3-year phase-in of a reduction to the national, standardized 60-day episode payment to account for estimated case-mix growth unrelated to increases in patient acuity (that is, nominal case-mix growth) between CY 2012 and CY 2014; finalizes changes to the methodology used to calculate payments made under the HH PPS for high-cost "outlier" episodes of care; implements changes in payment for furnishing Negative Pressure Wound Therapy (NPWT) using a disposable device for patients under a home health plan of care; discusses our efforts to monitor the potential impacts of the rebasing adjustments; includes an update on subsequent research and analysis as a result of the findings from the home health study; and finalizes changes to the Home Health Value-Based Purchasing (HHVBP) Model, which was implemented on January 1, 2016; and updates to the Home Health Quality Reporting Program (HH QRP).

Complex sparse spatial filter for decoding mixed frequency and phase coded steady-state visually evoked potentials.

PubMed

Morikawa, Naoki; Tanaka, Toshihisa; Islam, Md Rabiul

2018-07-01

Mixed frequency and phase coding (FPC) can achieve the significant increase of the number of commands in steady-state visual evoked potential-based brain-computer interface (SSVEP-BCI). However, the inconsistent phases of the SSVEP over channels in a trial and the existence of non-contributing channels due to noise effects can decrease accurate detection of stimulus frequency. We propose a novel command detection method based on a complex sparse spatial filter (CSSF) by solving ℓ 1 - and ℓ 2,1 -regularization problems for a mixed-coded SSVEP-BCI. In particular, ℓ 2,1 -regularization (aka group sparsification) can lead to the rejection of electrodes that are not contributing to the SSVEP detection. A calibration data based canonical correlation analysis (CCA) and CSSF with ℓ 1 - and ℓ 2,1 -regularization cases were demonstrated for a 16-target stimuli with eleven subjects. The results of statistical test suggest that the proposed method with ℓ 1 - and ℓ 2,1 -regularization significantly achieved the highest ITR. The proposed approaches do not need any reference signals, automatically select prominent channels, and reduce the computational cost compared to the other mixed frequency-phase coding (FPC)-based BCIs. The experimental results suggested that the proposed method can be usable implementing BCI effectively with reduce visual fatigue. Copyright © 2018 Elsevier B.V. All rights reserved.

The Role of Nuclear Power in Reducing Risk of the Fossil Fuel Prices and Diversity of Electricity Generation in Tunisia: A Portfolio Approach

NASA Astrophysics Data System (ADS)

Abdelhamid, Mohamed Ben; Aloui, Chaker; Chaton, Corinne; Souissi, Jomâa

2010-04-01

This paper applies real options and mean-variance portfolio theories to analyze the electricity generation planning into presence of nuclear power plant for the Tunisian case. First, we analyze the choice between fossil fuel and nuclear production. A dynamic model is presented to illustrate the impact of fossil fuel cost uncertainty on the optimal timing to switch from gas to nuclear. Next, we use the portfolio theory to manage risk of the electricity generation portfolio and to determine the optimal fuel mix with the nuclear alternative. Based on portfolio theory, the results show that there is other optimal mix than the mix fixed for the Tunisian mix for the horizon 2010-2020, with lower cost for the same risk degree. In the presence of nuclear technology, we found that the optimal generating portfolio must include 13% of nuclear power technology share.

The Myth of Openness and Secrecy in Intimate Relationships: The Case of Spouses of Mixed-Orientation Marriage.

PubMed

Adler, Adir; Ben-Ari, Adital

2017-01-01

The phenomenon of mixed-orientation marriages, in which one of the partners is straight and the other is non-straight, is invisible, yet not insignificant. Focusing on gay and bisexual men who are married to straight women, this article was designed to explore one of the essential themes in their relationship: the dynamics between secrecy and openness regarding the men's sexual orientation and gay practices. Based on the phenomenological paradigm, 38 men and eight women of mixed-orientation marriages in Israel were interviewed and shared their subjective life reality. Six patterns of secrecy and openness were identified, including complete secrecy, conspiracy of silence, initiated concealment (of the husband and wife), disloyalty/violation of the agreement, selective sharing, and complete openness. The findings challenge the idea that secrecy is detrimental and openness is beneficial in the context of mixed-orientation marriages. Findings are discussed within the framework of the dialectical approach.

Multi-objective shape optimization of plate structure under stress criteria based on sub-structured mixed FEM and genetic algorithms

NASA Astrophysics Data System (ADS)

Garambois, Pierre; Besset, Sebastien; Jézéquel, Louis

2015-07-01

This paper presents a methodology for the multi-objective (MO) shape optimization of plate structure under stress criteria, based on a mixed Finite Element Model (FEM) enhanced with a sub-structuring method. The optimization is performed with a classical Genetic Algorithm (GA) method based on Pareto-optimal solutions and considers thickness distributions parameters and antagonist objectives among them stress criteria. We implement a displacement-stress Dynamic Mixed FEM (DM-FEM) for plate structure vibrations analysis. Such a model gives a privileged access to the stress within the plate structure compared to primal classical FEM, and features a linear dependence to the thickness parameters. A sub-structuring reduction method is also computed in order to reduce the size of the mixed FEM and split the given structure into smaller ones with their own thickness parameters. Those methods combined enable a fast and stress-wise efficient structure analysis, and improve the performance of the repetitive GA. A few cases of minimizing the mass and the maximum Von Mises stress within a plate structure under a dynamic load put forward the relevance of our method with promising results. It is able to satisfy multiple damage criteria with different thickness distributions, and use a smaller FEM.

Transport theory and the WKB approximation for interplanetary MHD fluctuations

NASA Technical Reports Server (NTRS)

Matthaeus, William H.; Zhou, YE; Zank, G. P.; Oughton, S.

1994-01-01

An alternative approach, based on a multiple scale analysis, is presented in order to reconcile the traditional Wentzel-Kramer-Brillouin (WKB) approach to the modeling of interplanetary fluctuations in a mildly inhomogeneous large-scale flow with a more recently developed transport theory. This enables us to compare directly, at a formal level, the inherent structure of the two models. In the case of noninteracting, incompressible (Alven) waves, the principle difference between the two models is the presence of leading-order couplings (called 'mixing effects') in the non-WKB turbulence model which are absent in a WKB development. Within the context of linearized MHD, two cases have been identified for which the leading order non-WJB 'mixing term' does not vanish at zero wavelength. For these cases the WKB expansion is divergent, whereas the multiple-scale theory is well behaved. We have thus established that the WKB results are contained within the multiple-scale theory, but leading order mixing effects, which are likely to have important observational consequences, can never be recovered in the WKB style expansion. Properties of the higher-order terms in each expansion are also discussed, leading to the conclusion that the non-WKB hierarchy may be applicable even when the scale separation parameter is not small.

Faculty and Community Collaboration in Sustained Community-University Engagement Partnerships

ERIC Educational Resources Information Center

Allen, Angela Danyell

2009-01-01

This dissertation is a qualitative case study of the factors of collaboration between faculty and community partners in sustained community-university engagement partnerships at a public research university in the Midwest. Based on secondary data from an annual, online, mixed-method survey of faculty-reported engagement activity, parallel yet…

The Leadership Gap: Preparing Leaders for Urban Schools

ERIC Educational Resources Information Center

Lee, Omaira Z.

2010-01-01

The purpose of this mixed-methods, purposive case study was to investigate the impact of participation in the Metropolitan ISD Principal Coaching Initiative (MPCI) on leadership practice. The MPCI is a district-wide executive leadership capacity building strategy, which combines the District's standards-based leadership curriculum with a…

Clustering "N" Objects into "K" Groups under Optimal Scaling of Variables.

ERIC Educational Resources Information Center

van Buuren, Stef; Heiser, Willem J.

1989-01-01

A method based on homogeneity analysis (multiple correspondence analysis or multiple scaling) is proposed to reduce many categorical variables to one variable with "k" categories. The method is a generalization of the sum of squared distances cluster analysis problem to the case of mixed measurement level variables. (SLD)

Digital Education: Opportunities for Social Collaboration. Digital Education and Learning

ERIC Educational Resources Information Center

Thomas, Michael, Ed.

2011-01-01

This timely collection of theoretical and applied studies examines the pedagogical potential and realities of digital technologies in a wide range of disciplinary contexts across the educational spectrum. By mixing content-based chapters with a theoretical perspective with case studies detailing actual teaching approaches utilizing digital…

Elementary Teachers' Perceptions of Elementary Principals' Effectiveness

ERIC Educational Resources Information Center

Fridenvalds, Kriss R.

2012-01-01

This dissertation examined the beliefs of elementary teachers to determine if their perceptions of effective principal leadership align to transformational leadership theory vis-a-vis the Educational Leadership Policy Standards (ELPS). A phenomenological, single-case study approach was utilized by means of a mixed-methodological, Web-based survey,…

Interactive Land-Use Optimization Using Laguerre Voronoi Diagram with Dynamic Generating Point Allocation

NASA Astrophysics Data System (ADS)

Chaidee, S.; Pakawanwong, P.; Suppakitpaisarn, V.; Teerasawat, P.

2017-09-01

In this work, we devise an efficient method for the land-use optimization problem based on Laguerre Voronoi diagram. Previous Voronoi diagram-based methods are more efficient and more suitable for interactive design than discrete optimization-based method, but, in many cases, their outputs do not satisfy area constraints. To cope with the problem, we propose a force-directed graph drawing algorithm, which automatically allocates generating points of Voronoi diagram to appropriate positions. Then, we construct a Laguerre Voronoi diagram based on these generating points, use linear programs to adjust each cell, and reconstruct the diagram based on the adjustment. We adopt the proposed method to the practical case study of Chiang Mai University's allocated land for a mixed-use complex. For this case study, compared to other Voronoi diagram-based method, we decrease the land allocation error by 62.557 %. Although our computation time is larger than the previous Voronoi-diagram-based method, it is still suitable for interactive design.

Patellar Tendinopathy

PubMed Central

Schwartz, Aaron; Watson, Jonathan N.; Hutchinson, Mark R.

2015-01-01

Context: Patellar tendinopathy is a common condition. There are a wide variety of treatment options available, the majority of which are nonoperative. No consensus exists on the optimal method of treatment. Evidence Acquisition: PubMed spanning 1962-2014. Study Design: Clinical review. Level of Evidence: Level 4. Results: The majority of cases resolve with nonoperative therapy: rest, physical therapy with eccentric exercises, cryotherapy, anti-inflammatories, corticosteroid injections, extracorporeal shockwave therapy, glyceryl trinitrate, platelet-rich plasma injections, and ultrasound-guided sclerosis. Refractory cases may require either open or arthroscopic debridement of the patellar tendon. Corticosteroid injections provide short-term pain relief but increase risk of tendon rupture. Anti-inflammatories and injectable agents have shown mixed results. Surgical treatment is effective in many refractory cases unresponsive to nonoperative modalities. Conclusion: Physical therapy with an eccentric exercise program is the mainstay of treatment for patellar tendinopathy. Platelet-rich plasma has demonstrated mixed results; evidence-based recommendations on its efficacy cannot be made. In the event that nonoperative treatment fails, surgical intervention has produced good to excellent outcomes in the majority of patients. PMID:26502416

[Possibilities and limitations for the representation of ENT medicine in the G-DRG reimbursement system. Results of the DRG evaluation project].

PubMed

Franz, D; Roeder, N; Hörmann, K; Alberty, J

2006-03-01

To improve the representation of ENT medicine in the German diagnosis related groups (G-DRG) reimbursement system, the German Association for ENT Medicine and the ENT Professional Medical Association, in cooperation with the DRG-Research Group of the University Hospital of Muenster, undertook a DRG evaluation project. A retrospective analysis was carried out of the DRG data records from 93,605 cases taken at 39 ENT institutions in 2003. A prospective collection of data from 25,666 cases, including defined expenditure data within a 4 month period in 2004, was also made. The number of cases per ENT institution ranged from 274 to 2,556. The mean case-mix was 792.0 and the mean case-mix index was 0.84. A total of 60.5% of the patients were male and 39.5% female, with an average age of 43.3 years. The mean patient clinical and complexity level (PCCL) was 0.72. Considerable adjustments have to be made, especially in oto-, rhino- and sinus-surgery. Allocation according to the complexity of the surgical procedure is mandatory and requires a revision of the German Catalogue of Medical Procedures. A DRG differentiation based on the PCCL should be implemented more frequently. Diagnostic endoscopies should be allocated via surgical partitioning. The adjustment proposals based on these results will gradually lead to an improved allocation of ENT medical procedures within the G-DRG system in 2006 and later.

In Search of a Time Efficient Approach to Crack and Delamination Growth Predictions in Composites

NASA Technical Reports Server (NTRS)

Krueger, Ronald; Carvalho, Nelson

2016-01-01

Analysis benchmarking was used to assess the accuracy and time efficiency of algorithms suitable for automated delamination growth analysis. First, the Floating Node Method (FNM) was introduced and its combination with a simple exponential growth law (Paris Law) and Virtual Crack Closure technique (VCCT) was discussed. Implementation of the method into a user element (UEL) in Abaqus/Standard(Registered TradeMark) was also presented. For the assessment of growth prediction capabilities, an existing benchmark case based on the Double Cantilever Beam (DCB) specimen was briefly summarized. Additionally, the development of new benchmark cases based on the Mixed-Mode Bending (MMB) specimen to assess the growth prediction capabilities under mixed-mode I/II conditions was discussed in detail. A comparison was presented, in which the benchmark cases were used to assess the existing low-cycle fatigue analysis tool in Abaqus/Standard(Registered TradeMark) in comparison to the FNM-VCCT fatigue growth analysis implementation. The low-cycle fatigue analysis tool in Abaqus/Standard(Registered TradeMark) was able to yield results that were in good agreement with the DCB benchmark example. Results for the MMB benchmark cases, however, only captured the trend correctly. The user element (FNM-VCCT) always yielded results that were in excellent agreement with all benchmark cases, at a fraction of the analysis time. The ability to assess the implementation of two methods in one finite element code illustrated the value of establishing benchmark solutions.

Determination of stress intensity factors for interface cracks under mixed-mode loading

NASA Technical Reports Server (NTRS)

Naik, Rajiv A.; Crews, John H., Jr.

1992-01-01

A simple technique was developed using conventional finite element analysis to determine stress intensity factors, K1 and K2, for interface cracks under mixed-mode loading. This technique involves the calculation of crack tip stresses using non-singular finite elements. These stresses are then combined and used in a linear regression procedure to calculate K1 and K2. The technique was demonstrated by calculating three different bimaterial combinations. For the normal loading case, the K's were within 2.6 percent of an exact solution. The normalized K's under shear loading were shown to be related to the normalized K's under normal loading. Based on these relations, a simple equation was derived for calculating K1 and K2 for mixed-mode loading from knowledge of the K's under normal loading. The equation was verified by computing the K's for a mixed-mode case with equal and normal shear loading. The correlation between exact and finite element solutions is within 3.7 percent. This study provides a simple procedure to compute K2/K1 ratio which has been used to characterize the stress state at the crack tip for various combinations of materials and loadings. Tests conducted over a range of K2/K1 ratios could be used to fully characterize interface fracture toughness.

Regression analysis of mixed recurrent-event and panel-count data

PubMed Central

Zhu, Liang; Tong, Xinwei; Sun, Jianguo; Chen, Manhua; Srivastava, Deo Kumar; Leisenring, Wendy; Robison, Leslie L.

2014-01-01

In event history studies concerning recurrent events, two types of data have been extensively discussed. One is recurrent-event data (Cook and Lawless, 2007. The Analysis of Recurrent Event Data. New York: Springer), and the other is panel-count data (Zhao and others, 2010. Nonparametric inference based on panel-count data. Test 20, 1–42). In the former case, all study subjects are monitored continuously; thus, complete information is available for the underlying recurrent-event processes of interest. In the latter case, study subjects are monitored periodically; thus, only incomplete information is available for the processes of interest. In reality, however, a third type of data could occur in which some study subjects are monitored continuously, but others are monitored periodically. When this occurs, we have mixed recurrent-event and panel-count data. This paper discusses regression analysis of such mixed data and presents two estimation procedures for the problem. One is a maximum likelihood estimation procedure, and the other is an estimating equation procedure. The asymptotic properties of both resulting estimators of regression parameters are established. Also, the methods are applied to a set of mixed recurrent-event and panel-count data that arose from a Childhood Cancer Survivor Study and motivated this investigation. PMID:24648408

Lagrangian particle statistics of numerically simulated shear waves

NASA Astrophysics Data System (ADS)

Kirby, J.; Briganti, R.; Brocchini, M.; Chen, Q. J.

2006-12-01

The properties of numerical solutions of various circulation models (Boussinesq-type and wave-averaged NLSWE) have been investigated on the basis of the induced horizontal flow mixing, for the case of shear waves. The mixing properties of the flow have been investigated using particle statistics, following the approach of LaCasce (2001) and Piattella et al. (2006). Both an idealized barred beach bathymetry and a test case taken from SANDYDUCK '97 have been considered. Random seeding patterns of passive tracer particles are used. The flow exhibits features similar to those discussed in literature. Differences are also evident due both to the physics (intense longshore shear shoreward of the bar) and the procedure used to obtain the statistics (lateral conditions limit the time/space window for the longshore flow). Within the Boussinesq framework, different formulations of Boussinesq type equations have been used and the results compared (Wei et al. 1995, Chen et al. (2003), Chen et al. (2006)). Analysis based on the Eulerian velocity fields suggests a close similarity between Wei et al. (1995) and Chen et. al (2006), while examination of particle displacements and implied mixing suggests a closer behaviour between Chen et al. (2003) and Chen et al. (2006). Two distinct stages of mixing are evident in all simulations: i) the first stage ends at t

Transient Ejector Analysis (TEA) code user's guide

NASA Technical Reports Server (NTRS)

Drummond, Colin K.

1993-01-01

A FORTRAN computer program for the semi analytic prediction of unsteady thrust augmenting ejector performance has been developed, based on a theoretical analysis for ejectors. That analysis blends classic self-similar turbulent jet descriptions with control-volume mixing region elements. Division of the ejector into an inlet, diffuser, and mixing region allowed flexibility in the modeling of the physics for each region. In particular, the inlet and diffuser analyses are simplified by a quasi-steady-analysis, justified by the assumption that pressure is the forcing function in those regions. Only the mixing region is assumed to be dominated by viscous effects. The present work provides an overview of the code structure, a description of the required input and output data file formats, and the results for a test case. Since there are limitations to the code for applications outside the bounds of the test case, the user should consider TEA as a research code (not as a production code), designed specifically as an implementation of the proposed ejector theory. Program error flags are discussed, and some diagnostic routines are presented.

Explaining resource consumption among non-normal neonates

PubMed Central

Schwartz, Rachel M.; Michelman, Thomas; Pezzullo, John; Phibbs, Ciaran S.

1991-01-01

The adoption by Medicare in 1983 of prospective payment using diagnosis-related groups (DRGs) has stimulated research to develop case-mix grouping schemes that more accurately predict resource consumption by patients. In this article, the authors explore a new method designed to improve case-mix classification for newborns through the use of birth weight in combination with DRGs to adjust the unexplained case-mix severity. Although the findings are developmental in nature, they reveal that the model significantly improves our ability to explain resource use. PMID:10122360

Integrating clinicians, knowledge and data: expert-based cooperative analysis in healthcare decision support

PubMed Central

2010-01-01

Background Decision support in health systems is a highly difficult task, due to the inherent complexity of the process and structures involved. Method This paper introduces a new hybrid methodology Expert-based Cooperative Analysis (EbCA), which incorporates explicit prior expert knowledge in data analysis methods, and elicits implicit or tacit expert knowledge (IK) to improve decision support in healthcare systems. EbCA has been applied to two different case studies, showing its usability and versatility: 1) Bench-marking of small mental health areas based on technical efficiency estimated by EbCA-Data Envelopment Analysis (EbCA-DEA), and 2) Case-mix of schizophrenia based on functional dependency using Clustering Based on Rules (ClBR). In both cases comparisons towards classical procedures using qualitative explicit prior knowledge were made. Bayesian predictive validity measures were used for comparison with expert panels results. Overall agreement was tested by Intraclass Correlation Coefficient in case "1" and kappa in both cases. Results EbCA is a new methodology composed by 6 steps:. 1) Data collection and data preparation; 2) acquisition of "Prior Expert Knowledge" (PEK) and design of the "Prior Knowledge Base" (PKB); 3) PKB-guided analysis; 4) support-interpretation tools to evaluate results and detect inconsistencies (here Implicit Knowledg -IK- might be elicited); 5) incorporation of elicited IK in PKB and repeat till a satisfactory solution; 6) post-processing results for decision support. EbCA has been useful for incorporating PEK in two different analysis methods (DEA and Clustering), applied respectively to assess technical efficiency of small mental health areas and for case-mix of schizophrenia based on functional dependency. Differences in results obtained with classical approaches were mainly related to the IK which could be elicited by using EbCA and had major implications for the decision making in both cases. Discussion This paper presents EbCA and shows the convenience of completing classical data analysis with PEK as a mean to extract relevant knowledge in complex health domains. One of the major benefits of EbCA is iterative elicitation of IK.. Both explicit and tacit or implicit expert knowledge are critical to guide the scientific analysis of very complex decisional problems as those found in health system research. PMID:20920289

Integrating clinicians, knowledge and data: expert-based cooperative analysis in healthcare decision support.

PubMed

Gibert, Karina; García-Alonso, Carlos; Salvador-Carulla, Luis

2010-09-30

Decision support in health systems is a highly difficult task, due to the inherent complexity of the process and structures involved. This paper introduces a new hybrid methodology Expert-based Cooperative Analysis (EbCA), which incorporates explicit prior expert knowledge in data analysis methods, and elicits implicit or tacit expert knowledge (IK) to improve decision support in healthcare systems. EbCA has been applied to two different case studies, showing its usability and versatility: 1) Bench-marking of small mental health areas based on technical efficiency estimated by EbCA-Data Envelopment Analysis (EbCA-DEA), and 2) Case-mix of schizophrenia based on functional dependency using Clustering Based on Rules (ClBR). In both cases comparisons towards classical procedures using qualitative explicit prior knowledge were made. Bayesian predictive validity measures were used for comparison with expert panels results. Overall agreement was tested by Intraclass Correlation Coefficient in case "1" and kappa in both cases. EbCA is a new methodology composed by 6 steps:. 1) Data collection and data preparation; 2) acquisition of "Prior Expert Knowledge" (PEK) and design of the "Prior Knowledge Base" (PKB); 3) PKB-guided analysis; 4) support-interpretation tools to evaluate results and detect inconsistencies (here Implicit Knowledg -IK- might be elicited); 5) incorporation of elicited IK in PKB and repeat till a satisfactory solution; 6) post-processing results for decision support. EbCA has been useful for incorporating PEK in two different analysis methods (DEA and Clustering), applied respectively to assess technical efficiency of small mental health areas and for case-mix of schizophrenia based on functional dependency. Differences in results obtained with classical approaches were mainly related to the IK which could be elicited by using EbCA and had major implications for the decision making in both cases. This paper presents EbCA and shows the convenience of completing classical data analysis with PEK as a mean to extract relevant knowledge in complex health domains. One of the major benefits of EbCA is iterative elicitation of IK.. Both explicit and tacit or implicit expert knowledge are critical to guide the scientific analysis of very complex decisional problems as those found in health system research.

Impact of Parameterized Lateral Mixing on the Circulation of the Southern Ocean

NASA Astrophysics Data System (ADS)

Ragen, S.; Gnanadesikan, A.

2016-02-01

The Antarctic Circumpolar Current (ACC) is the strongest ocean current in the world, transporting approximately 130 Sv Eastward around Antarctica. This current is often poorly simulated in climate models. It is not clear why this is the case as the Circumpolar Current is affected by both wind and buoyancy. Changes in wind and buoyancy are not independent of each other, however, so determining the effects of both separately has proved difficult. This study was undertaken in order to examine the impact of changing the lateral diffusion coefficient A­redi on ACC transport. A­redi is poorly known and its value ranges across an order of magnitude in the current generation of climate models. To explore these dynamics, a coarse resolution, fully coupled model suite was run with A­redi mixing coefficients of 400 m2/s, 800 m2/s, 1200 m2/s, and 2400 m2/s. Additionally, two models were run with two-dimensional representations of the mixing coefficient based on altimetry. Our initial results indicate that higher values of the lateral mixing coefficient result in the following changes. We see weaker winds over the Southern Ocean as a whole. The high mixing case results in an 8.7% decrease in peak wind stress. We see a 2% weaker transport in the Drake Passage in the highest mixing case compared to the lowest, but an 11% decrease in transport for a zonal average. The change of temperature and salinity with depth with different Redi parameters also shows a significant difference between the Southern Ocean as a whole and the Drake Passage. Our findings seem to suggest that the Drake Passage is not an adequate diagnostic for explaining the differences between different climate models, as processes distant from the passage may play an important role. Observed changes in overturning with an increase in lateral mixing include an increase in northward transport of Antarctic Bottom Water fed by a small diversion of northern deep water inflows. This diversion means that less of the deep water is converted into surface water, consistent with weaker wind stresses.

Bayesian quantile regression-based partially linear mixed-effects joint models for longitudinal data with multiple features.

PubMed

Zhang, Hanze; Huang, Yangxin; Wang, Wei; Chen, Henian; Langland-Orban, Barbara

2017-01-01

In longitudinal AIDS studies, it is of interest to investigate the relationship between HIV viral load and CD4 cell counts, as well as the complicated time effect. Most of common models to analyze such complex longitudinal data are based on mean-regression, which fails to provide efficient estimates due to outliers and/or heavy tails. Quantile regression-based partially linear mixed-effects models, a special case of semiparametric models enjoying benefits of both parametric and nonparametric models, have the flexibility to monitor the viral dynamics nonparametrically and detect the varying CD4 effects parametrically at different quantiles of viral load. Meanwhile, it is critical to consider various data features of repeated measurements, including left-censoring due to a limit of detection, covariate measurement error, and asymmetric distribution. In this research, we first establish a Bayesian joint models that accounts for all these data features simultaneously in the framework of quantile regression-based partially linear mixed-effects models. The proposed models are applied to analyze the Multicenter AIDS Cohort Study (MACS) data. Simulation studies are also conducted to assess the performance of the proposed methods under different scenarios.

High-Grade Mixed Adenoneuroendocrine Carcinoma in the Cecum: A Case Report

PubMed Central

Shin, Sang Ho; Jung, Sung Hee; Jang, Ji Woong; Kang, Min Seok; Kim, Sang Il; Kim, Ji Hye; Lee, Jun Ho

2017-01-01

Gastrointestinal neoplasms with an exocrine and a neuroendocrine component are rare. Such neoplasms are called “mixed adenoneuroendocrine carcinomas” (MANECs) according to the most recent World Health Organization classification of gastrointestinal tract neoplasms. MANECs have no specific findings that distinguish them from pure adenocarcinomas. In addition, the optimal management strategy of MANECs is largely unknown. We describe the case of a 32-year-old man with dizziness and abdominal bloating. A cecal mass was suspected based on an image study done at a local clinic. We evaluated the cecal mass by using colonoscopy, contrast enhanced computed tomography of the abdomen, positron emission tomography-computed tomography, and laboratory studies. The patient underwent a right hemicolectomy and adjuvant chemotherapy. The final histopathological diagnosis was a high-grade MANEC of the ascending colon, tumor stage T3N2M0. PMID:28289663

A Survey of Quantum Lyapunov Control Methods

PubMed Central

2013-01-01

The condition of a quantum Lyapunov-based control which can be well used in a closed quantum system is that the method can make the system convergent but not just stable. In the convergence study of the quantum Lyapunov control, two situations are classified: nondegenerate cases and degenerate cases. For these two situations, respectively, in this paper the target state is divided into four categories: the eigenstate, the mixed state which commutes with the internal Hamiltonian, the superposition state, and the mixed state which does not commute with the internal Hamiltonian. For these four categories, the quantum Lyapunov control methods for the closed quantum systems are summarized and analyzed. Particularly, the convergence of the control system to the different target states is reviewed, and how to make the convergence conditions be satisfied is summarized and analyzed. PMID:23766732

Importance of molecular typing in confirmation of the source of a national hepatitis A virus outbreak in Norway and the detection of a related cluster in Germany.

PubMed

Guzman-Herrador, Bernardo R; Panning, Marcus; Stene-Johansen, Kathrine; Borgen, Katrine; Einöder-Moreno, Margot; Huzly, Daniela; Jensvoll, Laila; Lange, Heidi; Maassen, Sigrid; Myking, Solveig; Myrmel, Mette; Neumann-Haefelin, Christoph; Nygård, Karin; Wenzel, Jürgen J; Øye, Ann Kristin; Vold, Line

2015-11-01

In March 2014, after an increase of notifications of domestically acquired hepatitis A virus infections, an outbreak investigation was launched in Norway. Sequenced-based typing results showed that these cases were associated with a strain that was identical to one causing an ongoing multinational outbreak in Europe linked to frozen mixed berries. Thirty-three confirmed cases with the outbreak strain were notified in Norway from November 2013 to June 2014. Epidemiological evidence and trace-back investigations linked the outbreak to the consumption of a berry mix cake. Identification of the hepatitis A virus outbreak strain in berries from one of the implicated cakes confirmed the cake to be the source. Subsequently, a cluster in Germany linked to the cake was also identified.

Corrosion-Fatigue Crack Growth in Plates: A Model Based on the Paris Law

PubMed Central

Toribio, Jesús; Matos, Juan-Carlos; González, Beatriz

2017-01-01

In this paper, a Paris law-based model is presented whereby crack propagation occurs under cyclic loading in air (fatigue) and in an aggressive environment (corrosion-fatigue) for the case of corner cracks (with a wide range of aspect ratios in the matter of the initial cracks) in finite-thickness plates of 316L austenitic stainless steel subjected to tension, bending, or combined (tension + bending) loading. Results show that the cracks tend during their growth towards a preferential propagation path, exhibiting aspect ratios slightly lower than unity only for the case of very shallow cracks, and diminishing as the crack grows (increasing the relative crack depth)—more intensely in the case of bending than in the case of tension (the mixed loading tension/bending representing an intermediate case). In addition, the crack aspect ratios during fatigue propagation evolution are lower in fatigue (in air) than in corrosion-fatigue (in aggressive environment). PMID:28772798

A unique approach to quantifying the changing workload and case mix in laparoscopic colorectal surgery.

PubMed

Shah, P R; Gupta, V; Haray, P N

2011-03-01

Laparoscopic colorectal surgery includes a range of operations with differing technical difficulty, and traditional parameters, such as conversion and complication rates, may not be sensitive enough to assess the complexity of these procedures. This study aims to define a reproducible and reliable tool for quantifying the total workload and the complexity of the case mix. This is a review of a single surgeon's 10-year experience. The intermediate equivalent value scoring system was used to code complexity of cases. To assess changes in the workload and case mix, the period has been divided into five phases. Three hundred and forty-nine laparoscopic operations were performed, of which there were 264 (75.6%) resections. The overall conversion rate was 17.8%, with progressive improvement over the phases. Complex major operation (CMO), as defined in the British United Provident Association (BUPA) schedule of procedures, accounted for 35% of the workload. In spite of similar numbers of cases in each phase, there was a steady increase in the workload score, correlating with the increasing complexity of the case mix. There was no significant difference in the conversion and complications rates between CMO and non-CMO. The paradoxical increase in the mean operating time with increasing experience corresponded to the progressive increase in the workload score, reflecting the increasing complexity of the case mix. This article establishes a reliable and reproducible tool for quantifying the total laparoscopic colorectal workload of an individual surgeon or of an entire department, while at the same time providing a measure of the complexity of the case mix. © 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.

Modelling rainfall amounts using mixed-gamma model for Kuantan district

NASA Astrophysics Data System (ADS)

Zakaria, Roslinazairimah; Moslim, Nor Hafizah

2017-05-01

An efficient design of flood mitigation and construction of crop growth models depend upon good understanding of the rainfall process and characteristics. Gamma distribution is usually used to model nonzero rainfall amounts. In this study, the mixed-gamma model is applied to accommodate both zero and nonzero rainfall amounts. The mixed-gamma model presented is for the independent case. The formulae of mean and variance are derived for the sum of two and three independent mixed-gamma variables, respectively. Firstly, the gamma distribution is used to model the nonzero rainfall amounts and the parameters of the distribution (shape and scale) are estimated using the maximum likelihood estimation method. Then, the mixed-gamma model is defined for both zero and nonzero rainfall amounts simultaneously. The formulae of mean and variance for the sum of two and three independent mixed-gamma variables derived are tested using the monthly rainfall amounts from rainfall stations within Kuantan district in Pahang Malaysia. Based on the Kolmogorov-Smirnov goodness of fit test, the results demonstrate that the descriptive statistics of the observed sum of rainfall amounts is not significantly different at 5% significance level from the generated sum of independent mixed-gamma variables. The methodology and formulae demonstrated can be applied to find the sum of more than three independent mixed-gamma variables.

77 FR 29644 - Agency Information Collection Activities: Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2012-05-18

... reliability and construct validity of survey items and composites. (c) Case mix adjustment analysis--Assess the variables that may be considered as case mix adjusters. These preliminary research activities are...

Case-mix fails to explain variation in mastectomy rates: management of screen-detected breast cancer in a UK region 1997–2003

PubMed Central

Caldon, L J M; Walters, S J; Reed, J A; Murphy, A; Worley, A; Reed, M W R

2004-01-01

Wide variation in the surgical management of breast cancer exists at hospital, regional, national and international level. To demonstrate whether variation in surgical practice observed at aggregate level between breast units persists following adjustment for case-mix, individual patient-level data from the Trent Breast Screening Programme Quality Assurance database (1997–2003) was analysed. Expected case-mix adjusted mastectomy rates were derived by logistic regression using the variables tumour size, site and grade, patient age and year of presentation, employing the region's overall case-mix adjusted practice as the reference population. The region's 11 breast screening units detected 5109 (3989 invasive) surgically managed primary breast cancers over the 6-year period. A total of 1828 mastectomies (Mx) were performed (Mx rate 35.8%, 95% confidence interval: 34.5–37.1%). Significant variation in mastectomy rates were observed between units (range 25–45%, P<0.0001), and persists following case-mix adjustment (P<0.0001). Two-fold variation in observed to expected unit mastectomy rate coefficient is demonstrated overall (range 0.66–1.36), increasing to almost four-fold variation in cancers less than 15 mm diameter (range 0.55–1.95). Significant variation in surgery for screen-detected primary breast cancer is not explained by case-mix. Further research is required to investigate potential patient and professional causative factors. PMID:15611797

Developing the DESCARTE Model: The Design of Case Study Research in Health Care.

PubMed

Carolan, Clare M; Forbat, Liz; Smith, Annetta

2016-04-01

Case study is a long-established research tradition which predates the recent surge in mixed-methods research. Although a myriad of nuanced definitions of case study exist, seminal case study authors agree that the use of multiple data sources typify this research approach. The expansive case study literature demonstrates a lack of clarity and guidance in designing and reporting this approach to research. Informed by two reviews of the current health care literature, we posit that methodological description in case studies principally focuses on description of case study typology, which impedes the construction of methodologically clear and rigorous case studies. We draw from the case study and mixed-methods literature to develop the DESCARTE model as an innovative approach to the design, conduct, and reporting of case studies in health care. We examine how case study fits within the overall enterprise of qualitatively driven mixed-methods research, and the potential strengths of the model are considered. © The Author(s) 2015.

Aerosol Indirect Effect on Warm Clouds over Eastern China Using Combined CALIOP and MODIS Observations

NASA Astrophysics Data System (ADS)

Guo, Jianping; Wang, Fu; Huang, Jingfeng; Li, Xiaowen

2015-04-01

Aerosol, one of key components of the climate system, is highly variable, both temporally and spatially. It often exerts great influences on the cloud-precipitation chain processes by serving as CCN/IN, altering cloud microphysics and its life cycle. Yet, the aerosol indirect effect on clouds remains largely unknown, because the initial changes in clouds due to aerosols may be enhanced or dampened by such feedback processes as modified cloud dynamics, or evaporation of the smaller droplets due to the competition for water vapor. In this study, we attempted to quantify the aerosol effects on warm cloud over eastern China, based on near-simultaneous retrievals from MODIS/AQUA, CALIOP/CALIPSO and CPR/CLOUDSAT during the period 2006 to 2010. The seasonality of aerosol from ground-based PM10 is quite different from that estimated from MODIS AOD. This result is corroborated by lower level profile of aerosol occurrence frequency from CALIOP, indicating the significant role CALIOP could play in aerosol-cloud interaction. The combined use of CALIOP and CPR facilitate the process to exactly determine the (vertical) position of warm cloud relative to aerosol, out of six scenarios in terms of aerosol-cloud mixing status in terms of aerosol-cloud mixing status, which shows as follows: AO (Aerosol only), CO (Cloud only), SASC (Single aerosol-single cloud), SADC (single aerosol-double cloud), DASC (double aerosol-single cloud), and others. Results shows that about 54% of all the cases belong to mixed status, among all the collocated aerosol-cloud cases. Under mixed condition, a boomerang shape is observed, i.e., reduced cloud droplet radius (CDR) is associated with increasing aerosol at moderate aerosol pollution (AOD<0.4), becoming saturated at AOD of 0.5, followed by an increase in CDR with aerosol. In contrast, there is no such boomerang shape found for (aerosol-cloud) separated cases. We categorize dataset into warm-season and cold-season subsets to figure out how the boomerang shape varies with season. For moderate aerosol loading (AOD<0.4), the effect on the droplet size for the "Mixed" cases is greater during cold season (denoted by a large slope), as compared with that during warm season. It is likely associated with an increase in the emission of light absorbing aerosol like smoke (black carbon), mainly caused by coal-fired heating during the cold season in China. As expected, the sensitivity of CDR to AOD is much weaker for "Separated" cases, irrespective of warm or cold seasons, indicating no real aerosol indirect effect occurring in this case. In contrast, for heavy aerosol loading (AOD>0.4), an increasing CDR with AOD can be seen in "Mixed" scenario during the warm season. Conversely, a closer look at the responses of CDR during the cold season shows that CDR decreases with AOD, although the strength is not much large. Therefore, we argue that cloud droplet size decreases with aerosol loading during cold season, irrespective of moderate or heavy atmospheric pollution. Finally, we discuss the possible factors that may influence the aerosol indirect effects on warm clouds investigated here. For instance, aerosol-cloud interaction conundrum might be affected by aerosol humidification, which is the case for MODIS AOD during warm seasons. But this issue can be partly overcome by categorizing dataset into warm-season and cold-season subsets, representing different ambient humidity condition in the atmosphere. The different boomerang shapes observed during various seasons, particularly after transition zone due to droplet saturation effect, have great implications for climate forcing by aerosol in eastern China.

Standardization of Type 2 Diabetes Outpatient Expenditure with Bundled Payment Method in China.

PubMed

Xu, Guo-Chao; Luo, Yun; Li, Qian; Wu, Meng-Fan; Zhou, Zi-Jun

2016-04-20

In recent years, the prevalence of type 2 diabetes among Chinese population has been increasing by years, directly leading to an average annual growth rate of 19.90% of medical expenditure. Therefore, it is urgent to work on strategies to control the growth of medical expenditure on type 2 diabetes on the basis of the reality of China. Therefore, in this study, we explored the feasibility of implementing bundled payment in China through analyzing bundled payment standards of type 2 diabetes outpatient services. This study analyzed the outpatient expenditure on type 2 diabetes with Beijing Urban Employee's Basic Medical Insurance from 2010 to 2012. Based on the analysis of outpatient expenditure and its influential factors, we adopted decision tree approach to conduct a case-mix analysis. In the end, we built a case-mix model to calculate the standard expenditure and the upper limit of each combination. We found that age, job status, and whether with complication were significant factors that influence outpatient expenditure for type 2 diabetes. Through the analysis of the decision tree, we used six variables (complication, age, diabetic foot, diabetic nephropathy, cardiac-cerebrovascular disease, and neuropathy) to group the cases, and obtained 11 case-mix groups. We argued that it is feasible to implement bundled payment on type 2 diabetes outpatient services. Bundled payment is effective to control the increase of outpatient expenditure. Further improvements are needed for the implementation of bundled payment reimbursement standards, together with relevant policies and measures.

Direct costs of emergency medical care: a diagnosis-based case-mix classification system.

PubMed

Baraff, L J; Cameron, J M; Sekhon, R

1991-01-01

To develop a diagnosis-based case mix classification system for emergency department patient visits based on direct costs of care designed for an outpatient setting. Prospective provider time study with collection of financial data from each hospital's accounts receivable system and medical information, including discharge diagnosis, from hospital medical records. Three community hospital EDs in Los Angeles County during selected times in 1984. Only direct costs of care were included: health care provider time, ED management and clerical personnel excluding registration, nonlabor ED expense including supplies, and ancillary hospital services. Indirect costs for hospitals and physicians, including depreciation and amortization, debt service, utilities, malpractice insurance, administration, billing, registration, and medical records were not included. Costs were derived by valuing provider time based on a formula using annual income or salary and fringe benefits, productivity and direct care factors, and using hospital direct cost to charge ratios. Physician costs were based on a national study of emergency physician income and excluded practice costs. Patients were classified into one of 216 emergency department groups (EDGs) on the basis of the discharge diagnosis, patient disposition, age, and the presence of a limited number of physician procedures. Total mean direct costs ranged from $23 for follow-up visit to $936 for trauma, admitted, with critical care procedure. The mean total direct costs for the 16,771 nonadmitted patients was $69. Of this, 34% was for ED costs, 45% was for ancillary service costs, and 21% was for physician costs. The mean total direct costs for the 1,955 admitted patients was $259. Of this, 23% was for ED costs, 63% was for ancillary service costs, and 14% was for physician costs. Laboratory and radiographic services accounted for approximately 85% of all ancillary service costs and 38% of total direct costs for nonadmitted patients versus 80% of ancillary service costs and 51% of total direct costs for admitted patients. We have developed a diagnosis-based case mix classification system for ED patient visits based on direct costs of care designed for an outpatient setting which, unlike diagnosis-related groups, includes the measurement of time-based cost for physician and nonphysician services. This classification system helps to define direct costs of hospital and physician emergency services by type of patient.

Clinical physiology grand rounds.

PubMed

Richards, Jeremy; Schwartzstein, Richard; Irish, Julie; Almeida, Jacqueline; Roberts, David

2013-04-01

Clinical Physiology Grand Rounds (CPGR) is an interactive, case-based conference for medical students designed to: (1) integrate preclinical and clinical learning; (2) promote inductive clinical reasoning; and (3) emphasise students as peer teachers. CPGR specifically encourages mixed learning level student interactions and emphasises the use of concept mapping. We describe the theoretical basis and logistical considerations for an interactive, integrative, mixed-learner environment such as CPGR. In addition, we report qualitative data regarding students' attitudes towards and perceptions of CPGR. Medical students from first to fourth year participate in a monthly, interactive conference. The CPGR was designed to bridge gaps and reinforce linkages between basic science and clinical concepts, and to incorporate interactive vertical integration between preclinical and clinical students. Medical education and content experts use Socratic, interactive teaching methods to develop real-time concept maps to emphasise the presence and importance of linkages across curricula. Student focus groups were held to assess attitudes towards and perceptions of the mixed-learner environment and concept maps in CPGR. Qualitative analyses of focus group transcripts were performed to develop themes and codes describing the students' impressions of CPGR. CPGR is a case-based, interactive conference designed to help students gain an increased appreciation of linkages between basic science and clinical medicine concepts, and an increased awareness of clinical reasoning thought processes. Success is dependent upon explicit attention being given to goals for students' integrated learning. © Blackwell Publishing Ltd 2013.

Nearly ideal binary communication in squeezed channels

NASA Astrophysics Data System (ADS)

Paris, Matteo G.

2001-07-01

We analyze the effect of squeezing the channel in binary communication based on Gaussian states. We show that for coding on pure states, squeezing increases the detection probability at fixed size of the strategy, actually saturating the optimal bound already for moderate signal energy. Using Neyman-Pearson lemma for fuzzy hypothesis testing we are able to analyze also the case of mixed states, and to find the optimal amount of squeezing that can be effectively employed. It results that optimally squeezed channels are robust against signal mixing, and largely improve the strategy power by comparison with coherent ones.

Lanthanide-based NMR: a tool to investigate component distribution in mixed-monolayer-protected nanoparticles.

PubMed

Guarino, Gaetano; Rastrelli, Federico; Scrimin, Paolo; Mancin, Fabrizio

2012-05-02

Gd(3+) ions, once bound to the monolayer of organic molecules coating the surface of gold nanoparticles, produce a paramagnetic relaxation enhancement (PRE) that broadens and eventually cancels the signals of the nuclear spins located nearby (within 1.6 nm distance). In the case of nanoparticles coated with mixed monolayers, the signals arising from the different coating molecules experience different PRE, depending on their distance from the binding site. As a consequence, observation of the signal broadening patterns provides direct information on the monolayer organization. © 2012 American Chemical Society

A rare case report of mixed olfactory neuroblastoma: Carcinoma with review of literature.

PubMed

Gandhoke, Charandeep S; Dewan, Aditi; Gupta, Divya; Syal, Simran K; Jagetia, Anita; Saran, Ravindra K; Meher, Ravi; Srivastava, Arvind K; Singh, Daljit

2017-01-01

Olfactory neuroblastoma (ONB) is a rare malignant neuroectodermal tumor of the nasal cavity. Mixed olfactory neuroblastoma which contains areas of divergent differentiation is even rare. Till date, only 4 cases of mixed olfactory neuroblastomas have been reported. We report the case of a 46-year-old male who presented with the chief complaints of nasal bleeding and nasal obstruction since 4 months. Radiological imaging was suggestive of a large heterogeneous mass in the left superior nasal cavity with extensions into bilateral maxillary, ethmoidal, and sphenoidal sinuses, as well as into the anterior cranial fossa. Bifrontal osteoplastic craniotomy and excision of the intracranial part of the tumor from above and transnasal endoscopic removal of the mass in the nasal cavities and paranasal sinuses from below was done. Postoperative radiological imaging was suggestive of gross complete excision of the mass. Histopathological diagnosis was "mixed olfactory neuroblastoma-carcinoma (squamous and glandular differentiation) Hyams grade IV." On immunohistochemistry, the tumor cells were positive for neuron specific enolase (NSE), synaptophysin, chromogranin, and CD56 and peripherally for S100. Because of personal reasons, the patient did not take adjuvant radiotherapy. He presented again after 2 months with a full blown recurrence of esthesioneuroblastoma with similar extensions as before. The patient is now planned for salvage surgery followed by adjuvant chemoradiation. We report the 5 th case in the world of mixed olfactory neuroblastoma-carcinoma with squamous and glandular differentiation. From an analysis of the findings in the 5 reported cases of mixed olfactory neuroblastomas, one might infer that a separate subcategory of ONB, i.e., mixed ONB, should be considered because mixed ONBs have an aggressive behavior, high rates of recurrence, and these tumors should be treated aggressively by multimodality treatment.

Semi-empirical correlation for binary interaction parameters of the Peng-Robinson equation of state with the van der Waals mixing rules for the prediction of high-pressure vapor-liquid equilibrium.

PubMed

Fateen, Seif-Eddeen K; Khalil, Menna M; Elnabawy, Ahmed O

2013-03-01

Peng-Robinson equation of state is widely used with the classical van der Waals mixing rules to predict vapor liquid equilibria for systems containing hydrocarbons and related compounds. This model requires good values of the binary interaction parameter kij . In this work, we developed a semi-empirical correlation for kij partly based on the Huron-Vidal mixing rules. We obtained values for the adjustable parameters of the developed formula for over 60 binary systems and over 10 categories of components. The predictions of the new equation system were slightly better than the constant-kij model in most cases, except for 10 systems whose predictions were considerably improved with the new correlation.

75 FR 54149 - Agency Information Collection Activities: Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2010-09-03

... current basic case-mix adjusted composite payment system and the methodologies for the reimbursement of... during the transition will be paid under the basic case-mix adjusted composite payment system. Form...

Mixed-phenotypic acute leukemia series from tertiary care center.

PubMed

Pawar, Ravikiran N; Banerjee, Sambhunath; Bramha, Subhajit; Krishnan, Shekhar; Bhattacharya, Arpita; Saha, Vaskar; Chakrapani, Anupam; Bhave, Saurabh; Chandy, Mammen; Nair, Reena; Parihar, Mayur; Arora, Neeraj; Mishra, D K

2017-01-01

Mixed-phenotype acute leukemias (MPALs) are a heterogeneous group of rare leukemias constituting approximately 2%-5% of all leukemias, in which assigning a single lineage of origin is not possible. They are diagnosed by either the presence of antigens of more than one lineage or by the presence of dual population of blasts belonging to two or more lineages. We highlight the clinicopathological, immunophenotype, and genetic data of a cohort (n = 14) of patients diagnosed and treated at our center. We retrospectively analyzed consecutive cases of MPAL diagnosed in our flow cytometry laboratory from May 2012 to August 2015. These cases were diagnosed based on immunophenotyping of peripheral blood/bone marrow aspirates and morphology/genetics wherever available as per the World Health Organization (WHO) 2008 guideline. Among 628 consecutive acute leukemia (AL) cases diagnosed and evaluated during this period, we identified 14 (2.2%) patients with MPAL fulfilling WHO 2008/EGIL criteria for immunological characterizing of AL criteria. Majority of these were males (n = 8, male:female ratio 1.3:1) and adults (n = 11, 78.5%). The median age of this cohort was 41 years (range 2-80). These cases were further classified as: B/myeloid (n = 9), T/myeloid (n = 4), and B/T MPAL (n = 1). Cytogenetics was available in 12 out of 14 cases, out of which, three cases had normal karyotype, three with t(9;22)(q34;q11), and two cases with complex karyotype. We also came across a rare case of B + T lymphoid MPAL who had mixed-lineage leukemia gene t(v; 11q23) rearrangement. MPAL is a complex entity with heterogeneous clinical, immunophenotypic, cytogenetic, and molecular features. Multiparametric flowcytometry by using comprehensive antibody panels is a valuable tool for diagnosis. Subsequent cytogenetic and molecular analysis for further prognostic stratification and treatment modalities are important.

Modeling Power Plant Cooling Water Requirements: A Regional Analysis of the Energy-Water Nexus Considering Renewable Sources within the Power Generation Mix

NASA Astrophysics Data System (ADS)

Peck, Jaron Joshua

Water is used in power generation for cooling processes in thermoelectric power. plants and currently withdraws more water than any other sector in the U.S. Reducing water. use from power generation will help to alleviate water stress in at risk areas, where droughts. have the potential to strain water resources. The amount of water used for power varies. depending on many climatic aspects as well as plant operation factors. This work presents. a model that quantifies the water use for power generation for two regions representing. different generation fuel portfolios, California and Utah. The analysis of the California Independent System Operator introduces the methods. of water energy modeling by creating an overall water use factor in volume of water per. unit of energy produced based on the fuel generation mix of the area. The idea of water. monitoring based on energy used by a building or region is explored based on live fuel mix. data. This is for the purposes of increasing public awareness of the water associated with. personal energy use and helping to promote greater energy efficiency. The Utah case study explores the effects more renewable, and less water-intensive, forms of energy will have on the overall water use from power generation for the state. Using a similar model to that of the California case study, total water savings are quantified. based on power reduction scenarios involving increased use of renewable energy. The. plausibility of implementing more renewable energy into Utah’s power grid is also. discussed. Data resolution, as well as dispatch methods, economics, and solar variability, introduces some uncertainty into the analysis.

Asymptotic behavior of the mixed mass in Rayleigh–Taylor and Richtmyer–Meshkov instability induced flows

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zhou, Ye; Cabot, William H.; Thornber, Ben

Rayleigh–Taylor instability (RTI) and Richtmyer–Meshkov instability (RMI) are serious practical issues in inertial confinement fusion research, and also have relevance to many cases of astrophysical fluid dynamics. So far, much of the attention has been paid to the late-time scaling of the mixed width, which is used as a surrogate to how well the fluids have been mixed. Yet, the actual amount of mixed mass could be viewed as a more direct indicator on the evolution of the mixing layers due to hydrodynamic instabilities. Despite its importance, there is no systematic study as yet on the scaling of the mixedmore » mass for either the RTI or the RMI induced flow. In this article, the normalized mixed mass (Ψ) is introduced for measuring the efficiency of the mixed mass. Six large numerical simulation databases have been employed: the RTI cases with heavy-to-light fluid density ratios of 1.5, 3, and 9; the single shock RMI cases with density ratios of 3 and 20; and a reshock RMI case with density ratio of 3. Using simulated flow fields, the normalized mixed mass Ψ is shown to be more sensitive in discriminating the variation with Atwood number for the RTI flows. Moreover, Ψ is demonstrated to provide more consistent results for both the RTI and RMI flows when compared with the traditional mixedness parameters, Ξ and Θ.« less

Cloud and boundary layer interactions over the Arctic sea-ice in late summer

NASA Astrophysics Data System (ADS)

Shupe, M. D.; Persson, P. O. G.; Brooks, I. M.; Tjernström, M.; Sedlar, J.; Mauritsen, T.; Sjogren, S.; Leck, C.

2013-05-01

Observations from the Arctic Summer Cloud Ocean Study (ASCOS), in the central Arctic sea-ice pack in late summer 2008, provide a detailed view of cloud-atmosphere-surface interactions and vertical mixing processes over the sea-ice environment. Measurements from a suite of ground-based remote sensors, near surface meteorological and aerosol instruments, and profiles from radiosondes and a helicopter are combined to characterize a week-long period dominated by low-level, mixed-phase, stratocumulus clouds. Detailed case studies and statistical analyses are used to develop a conceptual model for the cloud and atmosphere structure and their interactions in this environment. Clouds were persistent during the period of study, having qualities that suggest they were sustained through a combination of advective influences and in-cloud processes, with little contribution from the surface. Radiative cooling near cloud top produced buoyancy-driven, turbulent eddies that contributed to cloud formation and created a cloud-driven mixed layer. The depth of this mixed layer was related to the amount of turbulence and condensed cloud water. Coupling of this cloud-driven mixed layer to the surface boundary layer was primarily determined by proximity. For 75% of the period of study, the primary stratocumulus cloud-driven mixed layer was decoupled from the surface and typically at a warmer potential temperature. Since the near-surface temperature was constrained by the ocean-ice mixture, warm temperatures aloft suggest that these air masses had not significantly interacted with the sea-ice surface. Instead, back trajectory analyses suggest that these warm airmasses advected into the central Arctic Basin from lower latitudes. Moisture and aerosol particles likely accompanied these airmasses, providing necessary support for cloud formation. On the occasions when cloud-surface coupling did occur, back trajectories indicated that these air masses advected at low levels, while mixing processes kept the mixed layer in equilibrium with the near-surface environment. Rather than contributing buoyancy forcing for the mixed-layer dynamics, the surface instead simply appeared to respond to the mixed-layer processes aloft. Clouds in these cases often contained slightly higher condensed water amounts, potentially due to additional moisture sources from below.

Cloud and boundary layer interactions over the Arctic sea ice in late summer

NASA Astrophysics Data System (ADS)

Shupe, M. D.; Persson, P. O. G.; Brooks, I. M.; Tjernström, M.; Sedlar, J.; Mauritsen, T.; Sjogren, S.; Leck, C.

2013-09-01

Observations from the Arctic Summer Cloud Ocean Study (ASCOS), in the central Arctic sea-ice pack in late summer 2008, provide a detailed view of cloud-atmosphere-surface interactions and vertical mixing processes over the sea-ice environment. Measurements from a suite of ground-based remote sensors, near-surface meteorological and aerosol instruments, and profiles from radiosondes and a helicopter are combined to characterize a week-long period dominated by low-level, mixed-phase, stratocumulus clouds. Detailed case studies and statistical analyses are used to develop a conceptual model for the cloud and atmosphere structure and their interactions in this environment. Clouds were persistent during the period of study, having qualities that suggest they were sustained through a combination of advective influences and in-cloud processes, with little contribution from the surface. Radiative cooling near cloud top produced buoyancy-driven, turbulent eddies that contributed to cloud formation and created a cloud-driven mixed layer. The depth of this mixed layer was related to the amount of turbulence and condensed cloud water. Coupling of this cloud-driven mixed layer to the surface boundary layer was primarily determined by proximity. For 75% of the period of study, the primary stratocumulus cloud-driven mixed layer was decoupled from the surface and typically at a warmer potential temperature. Since the near-surface temperature was constrained by the ocean-ice mixture, warm temperatures aloft suggest that these air masses had not significantly interacted with the sea-ice surface. Instead, back-trajectory analyses suggest that these warm air masses advected into the central Arctic Basin from lower latitudes. Moisture and aerosol particles likely accompanied these air masses, providing necessary support for cloud formation. On the occasions when cloud-surface coupling did occur, back trajectories indicated that these air masses advected at low levels, while mixing processes kept the mixed layer in equilibrium with the near-surface environment. Rather than contributing buoyancy forcing for the mixed-layer dynamics, the surface instead simply appeared to respond to the mixed-layer processes aloft. Clouds in these cases often contained slightly higher condensed water amounts, potentially due to additional moisture sources from below.

The Rivalry between Simulation and Problem-Based Learning: A Study of Learning Transfer in Physician Assistant Students

ERIC Educational Resources Information Center

Meyer, Kimberly E.

2010-01-01

The purpose of this dissertation was to evaluate learning transfer achieved by physician assistant students comparing two instructional methods, human patient simulation and electronic clinical case studies. This prospective, randomized, mixed-methods study utilized first and second-year physician assistant student volunteers taking a pretest and…

Teacher Adoption of a Web-Based Instructional Planning System

ERIC Educational Resources Information Center

Saldivar, Manuel Gerardo

2012-01-01

Many policymakers, administrators, and other K-12 stakeholders have long advocated the use of computers and information technology in schools. Even in settings where such technologies have been introduced, however, evidence suggests that the impact on student outcomes has been mixed. In some cases, teachers simply do not adopt the new…

Evaluation of a Family-Centred Children's Weight Management Intervention

ERIC Educational Resources Information Center

Jinks, Annette; English, Sue; Coufopoulos, Anne

2013-01-01

Purpose: The purpose of this paper is to conduct an in-depth quantitative and qualitative evaluation of a family-based weight loss and healthy life style programme for clinically obese children in England. Design/methodology/approach: The mixed method case study evaluation used included obtaining pre and post measurements of anthropometry and a…

Interrelations between Policymakers' Intentions and School Agents' Interpretation of Accountability Policy in Israel

ERIC Educational Resources Information Center

Amdur, Lisa; Mero-Jaffe, Irit

2017-01-01

The study examined the interrelations between policymakers' intentions for test-based accountability policy and school agents' perceptions and actions with regard to this policy. Mixed methods were used and encompassed 24 policymakers, 80 school principals, 168 teachers and case studies of four schools. New institutional theory, including the…

Factors Affecting Student Retention at One Independent School in the Southwest

ERIC Educational Resources Information Center

Ahlstrom, Dan Roger

2013-01-01

This mixed-methods case study determined the factors and examined the issues associated with student retention at a faith-based independent day school in southwestern United States of America. The data included online surveys, personal interviews, collection of archival information, and the researcher's extensive field notes. Surveys (530) were…

What Makes Blogging Attractive to Bloggers: A Case of College-Level Constituency Users

ERIC Educational Resources Information Center

Huang, Y-H.; Lo, Y-F.

2012-01-01

This study presents a new perspective to facilitate learner-centred weblog evaluation, based on content attractiveness, blogging support, and the value-added service construct. A mixed method, combining fishbone diagram, fuzzy logic techniques, and the analytic hierarchy process, was conducted to identify further the criteria that attract bloggers…

Student Perceptions of Chemistry Experiments with Different Technological Interfaces: A Comparative Study

ERIC Educational Resources Information Center

Priest, Samuel J.; Pyke, Simon M.; Williamson, Natalie M.

2014-01-01

Microcomputer based laboratory activities have been suggested to have a number of benefits in science education. However, their implementation produces mixed results, and student perception data have in the past yielded responses that are negative regarding the technology. This work presents a case study of three first year undergraduate chemistry…

Mutual Adaptaion in Action

ERIC Educational Resources Information Center

Siskin, Leslie Santee

2016-01-01

Building on an expanded concept of mutual adaptation, this chapter explores a distinctive and successful aspect of International Baccalaureate's effort to scale up, as they moved to expand their programs and support services in Title I schools. Based on a three-year, mixed-methods study, it offers a case where we see not only local adaptations…

Organic Farming, Gender, and the Labor Process

ERIC Educational Resources Information Center

Hall, Alan; Mogyorody, Veronika

2007-01-01

This paper seeks to explain variations in gender participation in farm production and decision-making through an analysis of organic farm types, sizes, and orientations. Based on both survey and case study data, the analysis shows that female farmers on vegetable farms and mixed livestock/cash crop farms are more likely to be involved in farm…

Development of self-awareness after severe traumatic brain injury through participation in occupation-based rehabilitation: mixed-methods analysis of a case series.

PubMed

Doig, Emmah; Kuipers, Pim; Prescott, Sarah; Cornwell, Petrea; Fleming, Jennifer

2014-01-01

OBJECTIVE. We examined participation in goal planning and development of self-awareness for people with impaired self-awareness after traumatic brain injury. METHOD. We performed a mixed-methods study of 8 participants recently discharged from inpatient rehabilitation. Self-awareness was measured using discrepancy between self and significant other ratings on the Mayo-Portland Adaptability Index (MPAI-4) at four time points. We calculated effect size to evaluate the change in MPAI-4 discrepancy over time. RESULTS. Seven participants identified their own goals. We found a large reduction in mean MPAI-4 discrepancy (M = 8.57, SD = 6.59, N = 7, d = 1.08) in the first 6 wk and a further small reduction (M = 5.33, SD = 9.09, N = 6, d = 0.45) in the second 6 wk of intervention. Case data indicated that 7 participants demonstrated some growth in self-awareness. CONCLUSION. Engagement in occupation-based, goal-directed rehabilitation appeared to foster awareness of injury-related changes to varying extents. Copyright © 2014 by the American Occupational Therapy Association, Inc.

42 CFR 412.308 - Determining and updating the Federal rate.

Code of Federal Regulations, 2010 CFR

2010-10-01

..., changes in the case mix index, the effect of changes to DRG classification and relative weights, and... increase attributable to changes in case mix. (ii) Effective FY 1996. Effective FY 1996, the standard... under the Federal rate for outlier cases under subpart F of this part, determined as a proportion of...

A parallel metaheuristic for large mixed-integer dynamic optimization problems, with applications in computational biology

PubMed Central

Henriques, David; González, Patricia; Doallo, Ramón; Saez-Rodriguez, Julio; Banga, Julio R.

2017-01-01

Background We consider a general class of global optimization problems dealing with nonlinear dynamic models. Although this class is relevant to many areas of science and engineering, here we are interested in applying this framework to the reverse engineering problem in computational systems biology, which yields very large mixed-integer dynamic optimization (MIDO) problems. In particular, we consider the framework of logic-based ordinary differential equations (ODEs). Methods We present saCeSS2, a parallel method for the solution of this class of problems. This method is based on an parallel cooperative scatter search metaheuristic, with new mechanisms of self-adaptation and specific extensions to handle large mixed-integer problems. We have paid special attention to the avoidance of convergence stagnation using adaptive cooperation strategies tailored to this class of problems. Results We illustrate its performance with a set of three very challenging case studies from the domain of dynamic modelling of cell signaling. The simpler case study considers a synthetic signaling pathway and has 84 continuous and 34 binary decision variables. A second case study considers the dynamic modeling of signaling in liver cancer using high-throughput data, and has 135 continuous and 109 binaries decision variables. The third case study is an extremely difficult problem related with breast cancer, involving 690 continuous and 138 binary decision variables. We report computational results obtained in different infrastructures, including a local cluster, a large supercomputer and a public cloud platform. Interestingly, the results show how the cooperation of individual parallel searches modifies the systemic properties of the sequential algorithm, achieving superlinear speedups compared to an individual search (e.g. speedups of 15 with 10 cores), and significantly improving (above a 60%) the performance with respect to a non-cooperative parallel scheme. The scalability of the method is also good (tests were performed using up to 300 cores). Conclusions These results demonstrate that saCeSS2 can be used to successfully reverse engineer large dynamic models of complex biological pathways. Further, these results open up new possibilities for other MIDO-based large-scale applications in the life sciences such as metabolic engineering, synthetic biology, drug scheduling. PMID:28813442

A parallel metaheuristic for large mixed-integer dynamic optimization problems, with applications in computational biology.

PubMed

Penas, David R; Henriques, David; González, Patricia; Doallo, Ramón; Saez-Rodriguez, Julio; Banga, Julio R

2017-01-01

We consider a general class of global optimization problems dealing with nonlinear dynamic models. Although this class is relevant to many areas of science and engineering, here we are interested in applying this framework to the reverse engineering problem in computational systems biology, which yields very large mixed-integer dynamic optimization (MIDO) problems. In particular, we consider the framework of logic-based ordinary differential equations (ODEs). We present saCeSS2, a parallel method for the solution of this class of problems. This method is based on an parallel cooperative scatter search metaheuristic, with new mechanisms of self-adaptation and specific extensions to handle large mixed-integer problems. We have paid special attention to the avoidance of convergence stagnation using adaptive cooperation strategies tailored to this class of problems. We illustrate its performance with a set of three very challenging case studies from the domain of dynamic modelling of cell signaling. The simpler case study considers a synthetic signaling pathway and has 84 continuous and 34 binary decision variables. A second case study considers the dynamic modeling of signaling in liver cancer using high-throughput data, and has 135 continuous and 109 binaries decision variables. The third case study is an extremely difficult problem related with breast cancer, involving 690 continuous and 138 binary decision variables. We report computational results obtained in different infrastructures, including a local cluster, a large supercomputer and a public cloud platform. Interestingly, the results show how the cooperation of individual parallel searches modifies the systemic properties of the sequential algorithm, achieving superlinear speedups compared to an individual search (e.g. speedups of 15 with 10 cores), and significantly improving (above a 60%) the performance with respect to a non-cooperative parallel scheme. The scalability of the method is also good (tests were performed using up to 300 cores). These results demonstrate that saCeSS2 can be used to successfully reverse engineer large dynamic models of complex biological pathways. Further, these results open up new possibilities for other MIDO-based large-scale applications in the life sciences such as metabolic engineering, synthetic biology, drug scheduling.

The general surgery chief resident operative experience: 23 years of national ACGME case logs.

PubMed

Drake, Frederick Thurston; Horvath, Karen D; Goldin, Adam B; Gow, Kenneth W

2013-09-01

The chief resident (CR) year is a pivotal experience in surgical training. Changes in case volume and diversity may impact the educational quality of this important year. To evaluate changes in operative experience for general surgery CRs. Review of Accreditation Council for Graduate Medical Education case logs from 1989-1990 through 2011-2012 divided into 5 periods. Graduates in period 3 were the last to train with unrestricted work hours; those in period 4 were part of a transition period and trained under both systems; and those in period 5 trained fully under the 80-hour work week. Diversity of cases was assessed based on Accreditation Council for Graduate Medical Education defined categories. Total cases and defined categories were evaluated for changes over time. The average total CR case numbers have fallen (271 in period 1 vs 242 in period 5, P < .001). Total CR cases dropped to their lowest following implementation of the 80-hour work week (236 cases), but rebounded in period 5. The percentage of residents' 5-year operative experience performed as CRs has decreased (30% in period 1 vs 25.6% in period 5, P < .001). Regarding case mix: thoracic, trauma, and vascular cases declined steadily, while alimentary and intra-abdominal operations increased. Recent graduates averaged 80 alimentary and 78 intra-abdominal procedures during their CR years. Compared with period 1, in which these 2 categories represented 47.1% of CR experience, in period 5, they represented 65.2% (P < .001). Endocrine experience has been relatively unchanged. Total CR cases declined especially acutely following implementation of the 80-hour work week but have since rebounded. Chief resident cases contribute less to overall experience, although this proportion stabilized before the 80-hour work week. Case mix has narrowed, with significant increases in alimentary and intra-abdominal cases. Broad-based general surgery training may be jeopardized by reduced case diversity. Chief resident cases are crucial in surgical training and educators should consider these findings as surgical training evolves.

Effect of mix parameters on longevity of bituminous mixtures

NASA Astrophysics Data System (ADS)

Reichle, Clayton Matthew

This study was performed to evaluate the effects of varying aggregate sources, aggregate gradations on the stripping and rutting potential of bituminous based plant mixes specified by the Missouri Department of Transportation. The different aggregate combinations included two different aggregate sources (Potosi Dolomite and Jefferson City Dolomite) including two variations for the Jefferson City Dolomite mix to simulate a marginally in-specification mix and an out-of-specification but in-field tolerance mix. The "field" mix simulated the marginal mix where field tolerance of high dust and low binder content were maximized. All three mixes were evaluated for stripping susceptibility using the Tensile Strength Ratio (TSR) test and the Hamburg Wheel Tracking Device (HWTD). The mix characteristics (unit weight, effective binder content, and air voids) were used for a Level 3 analysis in the Mechanistic-Empirical Pavement Design Guide (MEPDG) to determine long term pavement distress conditions such as fatigue cracking, rutting, and IRI (smoothness). The Potosi mix exhibited the best resistance to rutting and stripping during both the TSR testing as well as the Hamburg testing. The Jefferson City In-Spec and Out-of-Spec mixes showed less resistance to rutting and stripping in order, respectively. This was expected for the Jefferson City mixes where the aggregate was of lower quality (higher Los Angeles Abrasion, Micro Deval loss, absorption, and deleterious materials). Also, in the case of the Jefferson City Out-of-Spec mix, the binder content was lower. Upon evaluating the mixes using the MEPDG software, it was shown that mix characteristics such as air voids, VMA, and VFA influenced the fatigue cracking, rutting, and IRI predictions to a minor degree.

A multidimensional approach to case mix for home health services

PubMed Central

Manton, Kenneth G.; Hausner, Tony

1987-01-01

Developing a case-mix methodology for home health services is more difficult than developing one for hospitalization and acute health services, because the determinants of need for home health care are more complex and because of the difficulty in defining episodes of care. To evaluate home health service case mix, a multivariate grouping methodology was applied to records from the 1982 National Long-Term Care Survey linked to Medicare records on home health reimbursements. Using this method, six distinct health and functional status dimensions were identified. These dimensions, combined with factors describing informal care resources and local market conditions, were used to explain significant proportions of the variance (r2 = .45) of individual differences in Medicare home health reimbursements and numbers of visits. Though the data were not collected for that purpose, the high level of prediction strongly suggests the feasibility of developing case-mix strategies for home health services. PMID:10312187

A multidimensional approach to case mix for home health services.

PubMed

Manton, K G; Hausner, T

1987-01-01

Developing a case-mix methodology for home health services is more difficult than developing one for hospitalization and acute health services, because the determinants of need for home health care are more complex and because of the difficulty in defining episodes of care. To evaluate home health service case mix, a multivariate grouping methodology was applied to records from the 1982 National Long-Term Care Survey linked to Medicare records on home health reimbursements. Using this method, six distinct health and functional status dimensions were identified. These dimensions, combined with factors describing informal care resources and local market conditions, were used to explain significant proportions of the variance (r2 = .45) of individual differences in Medicare home health reimbursements and numbers of visits. Though the data were not collected for that purpose, the high level of prediction strongly suggests the feasibility of developing case-mix strategies for home health services.

The use of the BDA Case Mix Model to assess the need for referral of patients to specialist dental services.

PubMed

AlKindi, N A; Nunn, J

2016-04-22

Access to health services is a right for every individual. However, there is evidence that people with disabilities face barriers in accessing dental health. One of the reasons associated with this is the unclear referral pathway existing in the Irish dental health service. The appropriate assignment of patients to relevant services is an important issue to ensure better access to healthcare. This is all the more pertinent because there are only a few trained dental practitioners to provide dental treatment for people with disabilities, as well as even fewer qualified specialists in special care dentistry. The aim of this part of the study was to assess the use of the BDA Case Mix Model to determine the need for referral of patients to specialist dental services, and to determine any association between patient complexity and the need for adjunct measures, such as sedation and general anaesthesia for the management of people with disabilities and complex needs. A retrospective analysis of dental records using the BDA Case Mix Model.Results The results showed that patients with different levels of complexities were being referred to the special care dentistry clinic at the Dublin Dental University Hospital. The results also showed that the need for supportive adjunct measures such as sedation and general anaesthesia was not necessarily the main reason for referring patients to specialist services. The assessment with the BDA Case Mix Model was comprehensive as it looked at many factors contributing to the cases' complexity. Not all categories in the Case Mix Model had significant association with the need for an adjunct.Conclusion The BDA Case Mix Model can be used to measure the need for supportive adjunct measures, such as sedation and general anaesthesia.

Estimating the numerical diapycnal mixing in an eddy-permitting ocean model

NASA Astrophysics Data System (ADS)

Megann, Alex

2018-01-01

Constant-depth (or "z-coordinate") ocean models such as MOM4 and NEMO have become the de facto workhorse in climate applications, having attained a mature stage in their development and are well understood. A generic shortcoming of this model type, however, is a tendency for the advection scheme to produce unphysical numerical diapycnal mixing, which in some cases may exceed the explicitly parameterised mixing based on observed physical processes, and this is likely to have effects on the long-timescale evolution of the simulated climate system. Despite this, few quantitative estimates have been made of the typical magnitude of the effective diapycnal diffusivity due to numerical mixing in these models. GO5.0 is a recent ocean model configuration developed jointly by the UK Met Office and the National Oceanography Centre. It forms the ocean component of the GC2 climate model, and is closely related to the ocean component of the UKESM1 Earth System Model, the UK's contribution to the CMIP6 model intercomparison. GO5.0 uses version 3.4 of the NEMO model, on the ORCA025 global tripolar grid. An approach to quantifying the numerical diapycnal mixing in this model, based on the isopycnal watermass analysis of Lee et al. (2002), is described, and the estimates thereby obtained of the effective diapycnal diffusivity in GO5.0 are compared with the values of the explicit diffusivity used by the model. It is shown that the effective mixing in this model configuration is up to an order of magnitude higher than the explicit mixing in much of the ocean interior, implying that mixing in the model below the mixed layer is largely dominated by numerical mixing. This is likely to have adverse consequences for the representation of heat uptake in climate models intended for decadal climate projections, and in particular is highly relevant to the interpretation of the CMIP6 class of climate models, many of which use constant-depth ocean models at ¼° resolution

[Assessment of geriatric patients' care needs based on sosia classification: the reality of the lombardy region in nursing home.

PubMed

Vanalli, Mariangela

2016-11-01

The increased demand to care that originates from demographic changes called in Italy a rapid development in Nursing Home with particular emergency the problem of programme the welfare response. It is essential the development of a classification system able to describe the stratification of the case mix on the basis of the care requirements, allowing a remuneration in function of the complexity care. Since 2003, the Lombardy region has introduced a case-mix reimbursement system for nursing homes based on the SOSIA form which classifies residents into eight classes of frailty. In the present study the agreement between SOSIA classification and other well documented instruments, including Barthel Index, Mini-Mental State Examination on the basis of three indicators (mobility, cognition, comorbidity) is evaluated in eight classes of frailty. However, it is not any research project was published in order to assess the agreement between SOSIA classification and other measuring instruments. Although various methods exist by which researchers have attempted to measure the need for nursing care, there is no nationally accepted system for determining the total amount of registered nursing resources required by residents in long-term care. The aim of this study was to evaluate the correlation between SOSIA and filing systems widely used, such as the degree of Barthel disability rating scale, the Mini-Mental State Examination to offer care appropriate for the case-mix. Only the higher complexity care has classified in the first two classes, while the remaining levels has categorized in the lowest paid. Misclassification therefore induces an underestimation of the real care needs and, consequently, inadequate remuneration.

Effect of prospective reimbursement on nursing home costs.

PubMed Central

Coburn, A F; Fortinsky, R; McGuire, C; McDonald, T P

1993-01-01

OBJECTIVE. This study evaluates the effect of Maine's Medicaid nursing home prospective payment system on nursing home costs and access to care for public patients. DATA SOURCES/STUDY SETTING. The implementation of a facility-specific prospective payment system for nursing homes provided the opportunity for longitudinal study of the effect of that system. Data sources included audited Medicaid nursing home cost reports, quality-of-care data from state facility survey and licensure files, and facility case-mix information from random, stratified samples of homes and residents. Data were obtained for six years (1979-1985) covering the three-year period before and after implementation of the prospective payment system. STUDY DESIGN. This study used a pre-post, longitudinal analytical design in which interrupted, time-series regression models were estimated to test the effects of prospective payment and other factors, e.g., facility characteristics, nursing home market factors, facility case mix, and quality of care, on nursing home costs. PRINCIPAL FINDINGS. Prospective payment contributed to an estimated $3.03 decrease in total variable costs in the third year from what would have been expected under the previous retrospective cost-based payment system. Responsiveness to payment system efficiency incentives declined over the study period, however, indicating a growing problem in achieving further cost reductions. Some evidence suggested that cost reductions might have reduced access for public patients. CONCLUSIONS. Study findings are consistent with the results of other studies that have demonstrated the effectiveness of prospective payment systems in restraining nursing home costs. Potential policy trade-offs among cost containment, access, and quality assurance deserve further consideration, particularly by researchers and policymakers designing the new generation of case mix-based and other nursing home payment systems. PMID:8463109

HEMS inter-facility transfer: a case-mix analysis.

PubMed

Di Rocco, Damien; Pasquier, Mathieu; Albrecht, Eric; Carron, Pierre-Nicolas; Dami, Fabrice

2018-05-16

Helicopter emergency medical services (HEMS) are popular rescue systems despite inconsistent evidence in the scientific literature to support their use for primary interventions, as well as for inter-facility transfer (IFT). There is little research about IFT by HEMS, hence questions remain about the appropriateness of this method of transport. The aim of this study was to describe a case-mix of operational and medical characteristics for IFT activity of a sole HEMS base, and identify indicators of over-triage. This is a retrospective study on HEMS IFT over 36 months, from January 1st 2013 to December 31st 2015. Medical and operational data from the database of the Emergency Department of Lausanne University Hospital, which provides the emergency physicians for this helicopter base, were reviewed. It included distance and time of flight transport, type of care during flight, and estimated distance of transport if conducted by ground. There were 2194 HEMS missions including 979 IFT (44.6%). Most transfers involved adults (> 17 years old; 799 patients, 81.6%). Forty patients (4.1%) were classified as having benefitted from resuscitation or life-saving measures performed in flight, 615 (62.8%) from emergency treatment and 324 (33.1%) from simple clinical examination. The median distance by air between hospitals was 35.4 km. The estimated median distance by road was 47.7 km. The median duration time from origin to destination by air was 12 min. This case-mix of IFTs by HEMS presents a high severity. There are many signs in favour of over-triage. We propose indicators to help choosing whether HEMS is the most appropriate mean of transport to perform the transfer regarding patient condition, geography, and medical competences available aboard ground ambulances; this may reduce over-triage.

Effect of prospective reimbursement on nursing home costs.

PubMed

Coburn, A F; Fortinsky, R; McGuire, C; McDonald, T P

1993-04-01

This study evaluates the effect of Maine's Medicaid nursing home prospective payment system on nursing home costs and access to care for public patients. The implementation of a facility-specific prospective payment system for nursing homes provided the opportunity for longitudinal study of the effect of that system. Data sources included audited Medicaid nursing home cost reports, quality-of-care data from state facility survey and licensure files, and facility case-mix information from random, stratified samples of homes and residents. Data were obtained for six years (1979-1985) covering the three-year period before and after implementation of the prospective payment system. This study used a pre-post, longitudinal analytical design in which interrupted, time-series regression models were estimated to test the effects of prospective payment and other factors, e.g., facility characteristics, nursing home market factors, facility case mix, and quality of care, on nursing home costs. Prospective payment contributed to an estimated $3.03 decrease in total variable costs in the third year from what would have been expected under the previous retrospective cost-based payment system. Responsiveness to payment system efficiency incentives declined over the study period, however, indicating a growing problem in achieving further cost reductions. Some evidence suggested that cost reductions might have reduced access for public patients. Study findings are consistent with the results of other studies that have demonstrated the effectiveness of prospective payment systems in restraining nursing home costs. Potential policy trade-offs among cost containment, access, and quality assurance deserve further consideration, particularly by researchers and policymakers designing the new generation of case mix-based and other nursing home payment systems.

Regional Differences in Case Mix and Peri-operative Outcome After Elective Abdominal Aortic Aneurysm Repair in the Vascunet Database.

PubMed

Mani, K; Venermo, M; Beiles, B; Menyhei, G; Altreuther, M; Loftus, I; Björck, M

2015-06-01

National differences exist in the outcome of elective abdominal aortic aneurysm (AAA) repair. The role of case mix variation was assessed based on an international vascular registry collaboration. All elective AAA repairs with aneurysm size data in the Vascunet database in the period 2005-09 were included. AAA size and peri-operative outcome (crude and age adjusted mortality) were analysed overall and in risk cohorts, as well as per country. Glasgow Aneurysm Score (GAS) was calculated as risk score, and patients were stratified in three equal sized risk cohorts based on GAS. Predictors of peri-operative mortality were analysed with multiple regression. Missing data were handled with multiple imputation. Patients from Australia, Finland, Hungary, Norway, Sweden and the UK (n = 5,895) were analysed; mean age was 72.7 years and 54% had endovascular repair (EVAR). There were significant variations in GAS (lowest = Finland [75.7], highest = UK [79.4], p for comparison of all regions < .001), proportion of AAA < 5.5 cm (lowest = UK [6.4%], highest = Hungary [29.0%]; p < .001), proportion undergoing EVAR (lowest = Finland [10.1%], highest = Australia [58.9%]; p < .001), crude mortality (lowest = Norway [2.0%], highest = Finland [5.0%]; p = .006), and age adjusted mortality (lowest = Norway [2.5%], highest = Finland [6.0%]; p = .048). Both aneurysm size and peri-operative mortality were highest among patients with a GAS >82. Of those with a GAS >82, 8.4% of men and 20.8% of women had an AAA <5.5 cm. Important regional differences exist in case selection for elective AAA repair, including variations in AAA size and patient risk profile. These differences partly explain the variations in peri-operative mortality. Further audit is warranted to assess the underlying reasons for the regional variation in case-mix. Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

On the existence and stability conditions for mixed-hybrid finite element solutions based on Reissner's variational principle

NASA Technical Reports Server (NTRS)

Karlovitz, L. A.; Atluri, S. N.; Xue, W.-M.

1985-01-01

The extensions of Reissner's two-field (stress and displacement) principle to the cases wherein the displacement field is discontinuous and/or the stress field results in unreciprocated tractions, at a finite number of surfaces ('interelement boundaries') in a domain (as, for instance, when the domain is discretized into finite elements), is considered. The conditions for the existence, uniqueness, and stability of mixed-hybrid finite element solutions based on such discontinuous fields, are summarized. The reduction of these global conditions to local ('element') level, and the attendant conditions on the ranks of element matrices, are discussed. Two examples of stable, invariant, least-order elements - a four-node square planar element and an eight-node cubic element - are discussed in detail.

Interhospital differences and case-mix in a nationwide prevalence survey.

PubMed

Kanerva, M; Ollgren, J; Lyytikäinen, O

2010-10-01

A prevalence survey is a time-saving and useful tool for obtaining an overview of healthcare-associated infection (HCAI) either in a single hospital or nationally. Direct comparison of prevalence rates is difficult. We evaluated the impact of case-mix adjustment on hospital-specific prevalences. All five tertiary care, all 15 secondary care and 10 (25% of 40) other acute care hospitals took part in the first national prevalence survey in Finland in 2005. US Centers for Disease Control and Prevention criteria served to define HCAI. The information collected included demographic characteristics, severity of the underlying disease, use of catheters and a respirator, and previous surgery. Patients with HCAI related to another hospital were excluded. Case-mix-adjusted HCAI prevalences were calculated by using a multivariate logistic regression model for HCAI risk and an indirect standardisation method. Altogether, 587 (7.2%) of 8118 adult patients had at least one infection; hospital-specific prevalences ranged between 1.9% and 12.6%. Risk factors for HCAI that were previously known or identified by univariate analysis (age, male gender, intensive care, high Charlson comorbidity and McCabe indices, respirator, central venous or urinary catheters, and surgery during stay) were included in the multivariate analysis for standardisation. Case-mix-adjusted prevalences varied between 2.6% and 17.0%, and ranked the hospitals differently from the observed rates. In 11 (38%) hospitals, the observed prevalence rank was lower than predicted by the case-mix-adjusted figure. Case-mix should be taken into consideration in the interhospital comparison of prevalence rates. Copyright 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.

Benchmarking antibiotic use in Finnish acute care hospitals using patient case-mix adjustment.

PubMed

Kanerva, Mari; Ollgren, Jukka; Lyytikäinen, Outi

2011-11-01

It is difficult to draw conclusions about the prudence of antibiotic use in different hospitals by directly comparing usage figures. We present a patient case-mix adjustment model of antibiotic use to rank hospitals while taking patient characteristics into account. Data on antibiotic use were collected during the national healthcare-associated infection (HAI) prevalence survey in 2005 in Finland in all 5 tertiary care, all 15 secondary care and 10 (25% of 40) other acute care hospitals. The use of antibiotics was measured using use-days/100 patient-days during a 7day period and the prevalence of patients receiving at least two antimicrobials during the study day. Case-mix-adjusted antibiotic use was calculated by using multivariate models and an indirect standardization method. Parameters in the model included age, sex, severity of underlying diseases, intensive care, haematology, preceding surgery, respirator, central venous and urinary catheters, community-associated infection, HAI and contact isolation due to methicillin-resistant Staphylococcus aureus. The ranking order changed one position in 12 (40%) hospitals and more than two positions in 13 (43%) hospitals when the case-mix-adjusted figures were compared with those observed. In 24 hospitals (80%), the antibiotic use density observed was lower than expected by the case-mix-adjusted use density. The patient case-mix adjustment of antibiotic use ranked the hospitals differently from the ranking according to observed use, and may be a useful tool for benchmarking hospital antibiotic use. However, the best set of easily and widely available parameters that would describe both patient material and hospital activities remains to be determined.

Multipartite entangled states in particle mixing

DOE Office of Scientific and Technical Information (OSTI.GOV)

Blasone, M.; INFN Sezione di Napoli, Gruppo collegato di Salerno, Baronissi; Dell'Anno, F.

2008-05-01

In the physics of flavor mixing, the flavor states are given by superpositions of mass eigenstates. By using the occupation number to define a multiqubit space, the flavor states can be interpreted as multipartite mode-entangled states. By exploiting a suitable global measure of entanglement, based on the entropies related to all possible bipartitions of the system, we analyze the correlation properties of such states in the instances of three- and four-flavor mixing. Depending on the mixing parameters, and, in particular, on the values taken by the free phases, responsible for the CP-violation, entanglement concentrates in certain bipartitions. We quantify inmore » detail the amount and the distribution of entanglement in the physically relevant cases of flavor mixing in quark and neutrino systems. By using the wave packet description for localized particles, we use the global measure of entanglement, suitably adapted for the instance of multipartite mixed states, to analyze the decoherence, induced by the free evolution dynamics, on the quantum correlations of stationary neutrino beams. We define a decoherence length as the distance associated with the vanishing of the coherent interference effects among massive neutrino states. We investigate the role of the CP-violating phase in the decoherence process.« less

Impact of case-mix on comparisons of patient-reported experience in NHS acute hospital trusts in England.

PubMed

Raleigh, Veena; Sizmur, Steve; Tian, Yang; Thompson, James

2015-04-01

To examine the impact of patient-mix on National Health Service (NHS) acute hospital trust scores in two national NHS patient surveys. Secondary analysis of 2012 patient survey data for 57,915 adult inpatients at 142 NHS acute hospital trusts and 45,263 adult emergency department attendees at 146 NHS acute hospital trusts in England. Changes in trust scores for selected questions, ranks, inter-trust variance and score-based performance bands were examined using three methods: no adjustment for case-mix; the current standardization method with weighting for age, sex and, for inpatients only, admission method; and a regression model adjusting in addition for ethnicity, presence of a long-term condition, proxy response (inpatients only) and previous emergency attendances (emergency department survey only). For both surveys, all the variables examined were associated with patients' responses and affected inter-trust variance in scores, although the direction and strength of impact differed between variables. Inter-trust variance was generally greatest for the unadjusted scores and lowest for scores derived from the full regression model. Although trust scores derived from the three methods were highly correlated (Kendall's tau coefficients 0.70-0.94), up to 14% of trusts had discordant ranks of when the standardization and regression methods were compared. Depending on the survey and question, up to 14 trusts changed performance bands when the regression model with its fuller case-mix adjustment was used rather than the current standardization method. More comprehensive case-mix adjustment of patient survey data than the current limited adjustment reduces performance variation between NHS acute hospital trusts and alters the comparative performance bands of some trusts. Given the use of these data for high-impact purposes such as performance assessment, regulation, commissioning, quality improvement and patient choice, a review of the long-standing method for analysing patient survey data would be timely, and could improve rigour and comparability across the NHS. Performance comparisons need to be perceived as fair and scientifically robust to maintain confidence in publicly reported data, and to support their use by both the public and the NHS. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

The General Surgery Chief Resident Operative Experience

PubMed Central

Drake, Frederick Thurston; Horvath, Karen D.; Goldin, Adam B.; Gow, Kenneth W.

2014-01-01

IMPORTANCE The chief resident (CR) year is a pivotal experience in surgical training. Changes in case volume and diversity may impact the educational quality of this important year. OBJECTIVE To evaluate changes in operative experience for general surgery CRs. DESIGN, SETTING, AND PARTICIPANTS Review of Accreditation Council for Graduate Medical Education case logs from 1989–1990 through 2011–2012 divided into 5 periods. Graduates in period 3 were the last to train with unrestricted work hours; those in period 4 were part of a transition period and trained under both systems; and those in period 5 trained fully under the 80-hour work week. Diversity of cases was assessed based on Accreditation Council for Graduate Medical Education defined categories. MAIN OUTCOMES AND MEASURES Total cases and defined categories were evaluated for changes over time. RESULTS The average total CR case numbers have fallen (271 in period 1 vs 242 in period 5, P < .001). Total CR cases dropped to their lowest following implementation of the 80-hour work week (236 cases), but rebounded in period 5. The percentage of residents’ 5-year operative experience performed as CRs has decreased (30% in period 1 vs 25.6% in period 5, P < .001). Regarding case mix: thoracic, trauma, and vascular cases declined steadily, while alimentary and intra-abdominal operations increased. Recent graduates averaged 80 alimentary and 78 intra-abdominal procedures during their CR years. Compared with period 1, in which these 2 categories represented 47.1% of CR experience, in period 5, they represented 65.2% (P < .001). Endocrine experience has been relatively unchanged. CONCLUSIONS AND RELEVANCE Total CR cases declined especially acutely following implementation of the 80-hour work week but have since rebounded. Chief resident cases contribute less to overall experience, although this proportion stabilized before the 80-hour work week. Case mix has narrowed, with significant increases in alimentary and intra-abdominal cases. Broad-based general surgery training may be jeopardized by reduced case diversity. Chief resident cases are crucial in surgical training and educators should consider these findings as surgical training evolves. PMID:23864049

Centaur Propellant Thermal Conditioning Study

NASA Technical Reports Server (NTRS)

Blatt, M. H.; Pleasant, R. L.; Erickson, R. C.

1976-01-01

A wicking investigation revealed that passive thermal conditioning was feasible and provided considerable weight advantage over active systems using throttled vent fluid in a Centaur D-1s launch vehicle. Experimental wicking correlations were obtained using empirical revisions to the analytical flow model. Thermal subcoolers were evaluated parametrically as a function of tank pressure and NPSP. Results showed that the RL10 category I engine was the best candidate for boost pump replacement and the option showing the lowest weight penalty employed passively cooled acquisition devices, thermal subcoolers, dry ducts between burns and pumping of subcooler coolant back into the tank. A mixing correlation was identified for sizing the thermodynamic vent system mixer. Worst case mixing requirements were determined by surveying Centaur D-1T, D-1S, IUS, and space tug vehicles. Vent system sizing was based upon worst case requirements. Thermodynamic vent system/mixer weights were determined for each vehicle.

Accuracy Enhancement of Raman Spectroscopy Using Complementary Laser-Induced Breakdown Spectroscopy (LIBS) with Geologically Mixed Samples.

PubMed

Choi, Soojin; Kim, Dongyoung; Yang, Junho; Yoh, Jack J

2017-04-01

Quantitative Raman analysis was carried out with geologically mixed samples that have various matrices. In order to compensate the matrix effect in Raman shift, laser-induced breakdown spectroscopy (LIBS) analysis was performed. Raman spectroscopy revealed the geological materials contained in the mixed samples. However, the analysis of a mixture containing different matrices was inaccurate due to the weak signal of the Raman shift, interference, and the strong matrix effect. On the other hand, the LIBS quantitative analysis of atomic carbon and calcium in mixed samples showed high accuracy. In the case of the calcite and gypsum mixture, the coefficient of determination of atomic carbon using LIBS was 0.99, while the signal using Raman was less than 0.9. Therefore, the geological composition of the mixed samples is first obtained using Raman and the LIBS-based quantitative analysis is then applied to the Raman outcome in order to construct highly accurate univariate calibration curves. The study also focuses on a method to overcome matrix effects through the two complementary spectroscopic techniques of Raman spectroscopy and LIBS.

Scale-up on basis of structured mixing models: A new concept.

PubMed

Mayr, B; Moser, A; Nagy, E; Horvat, P

1994-02-05

A new scale-up concept based upon mixing models for bioreactors equipped with Rushton turbines using the tanks-in-series concept is presented. The physical mixing model includes four adjustable parameters, i.e., radial and axial circulation time, number of ideally mixed elements in one cascade, and the volume of the ideally mixed turbine region. The values of the model parameters were adjusted with the application of a modified Monte-Carlo optimization method, which fitted the simulated response function to the experimental curve. The number of cascade elements turned out to be constant (N = 4). The model parameter radial circulation time is in good agreement with the one obtained by the pumping capacity. In case of remaining parameters a first or second order formal equation was developed, including four operational parameters (stirring and aeration intensity, scale, viscosity). This concept can be extended to several other types of bioreactors as well, and it seems to be a suitable tool to compare the bioprocess performance of different types of bioreactors. (c) 1994 John Wiley & Sons, Inc.

Heavy quarkonium hybrids: Spectrum, decay, and mixing

NASA Astrophysics Data System (ADS)

Oncala, Ruben; Soto, Joan

2017-07-01

We present a largely model-independent analysis of the lighter heavy quarkonium hybrids based on the strong coupling regime of potential nonrelativistic QCD. We calculate the spectrum at leading order, including the mixing of static hybrid states. We use potentials that fulfill the required short and long distance theoretical constraints and fit well the available lattice data. We argue that the decay width to the lower lying heavy quarkonia can be reliably estimated in some cases and provide results for a selected set of decays. We also consider the mixing with heavy quarkonium states. We establish the form of the mixing potential at O (1 /mQ) , mQ being the mass of the heavy quarks, and work out its short and long distance constraints. The weak coupling regime of potential nonrelativistic QCD and the effective string theory of QCD are used for that goal. We show that the mixing effects may indeed be important and produce large spin symmetry violations. Most of the isospin zero XYZ states fit well in our spectrum, either as a hybrid or standard quarkonium candidate.

High static stability in the mixing layer above the extratropical tropopause

NASA Astrophysics Data System (ADS)

Kunz, A.; Konopka, P.; Müller, R.; Pan, L. L.; Schiller, C.; Rohrer, F.

2009-08-01

The relationship between the static stability N2 and the mixing in the tropopause inversion layer (TIL) is investigated using in situ aircraft observations during SPURT (trace gas transport in the tropopause region). With a new simple measure of mixing degree based on O3-CO tracer correlations, high N2 related to an enhanced mixing in the extratropical mixing layer is found. This relation becomes even more pronounced if fresh mixing events are excluded, indicating that mixing within the TIL occurs on a larger than synoptic timescale. A temporal variance analysis of N2 suggests that processes responsible for the composition of the TIL take place on seasonal timescales. Using radiative transfer calculations, we simulate the influence of a change in O3 and H2O vertical gradients on the temperature gradient and thus on the static stability above the tropopause, which are contrasted in an idealized nonmixed atmosphere and in a reference mixed atmosphere. The results show that N2 increases with enhanced mixing degree near the tropopause. At the same time, the temperature above the tropopause decreases together with the development of an inversion and the TIL. In the idealized case of nonmixed profiles the TIL vanishes. Furthermore, the results suggest that H2O plays a major role in maintaining the temperature inversion and the TIL structure compared to O3. The results substantiate the link between the extratropical mixing layer and the TIL.

Identification and Correction of Sample Mix-Ups in Expression Genetic Data: A Case Study

PubMed Central

Broman, Karl W.; Keller, Mark P.; Broman, Aimee Teo; Kendziorski, Christina; Yandell, Brian S.; Sen, Śaunak; Attie, Alan D.

2015-01-01

In a mouse intercross with more than 500 animals and genome-wide gene expression data on six tissues, we identified a high proportion (18%) of sample mix-ups in the genotype data. Local expression quantitative trait loci (eQTL; genetic loci influencing gene expression) with extremely large effect were used to form a classifier to predict an individual’s eQTL genotype based on expression data alone. By considering multiple eQTL and their related transcripts, we identified numerous individuals whose predicted eQTL genotypes (based on their expression data) did not match their observed genotypes, and then went on to identify other individuals whose genotypes did match the predicted eQTL genotypes. The concordance of predictions across six tissues indicated that the problem was due to mix-ups in the genotypes (although we further identified a small number of sample mix-ups in each of the six panels of gene expression microarrays). Consideration of the plate positions of the DNA samples indicated a number of off-by-one and off-by-two errors, likely the result of pipetting errors. Such sample mix-ups can be a problem in any genetic study, but eQTL data allow us to identify, and even correct, such problems. Our methods have been implemented in an R package, R/lineup. PMID:26290572

Identification and Correction of Sample Mix-Ups in Expression Genetic Data: A Case Study.

PubMed

Broman, Karl W; Keller, Mark P; Broman, Aimee Teo; Kendziorski, Christina; Yandell, Brian S; Sen, Śaunak; Attie, Alan D

2015-08-19

In a mouse intercross with more than 500 animals and genome-wide gene expression data on six tissues, we identified a high proportion (18%) of sample mix-ups in the genotype data. Local expression quantitative trait loci (eQTL; genetic loci influencing gene expression) with extremely large effect were used to form a classifier to predict an individual's eQTL genotype based on expression data alone. By considering multiple eQTL and their related transcripts, we identified numerous individuals whose predicted eQTL genotypes (based on their expression data) did not match their observed genotypes, and then went on to identify other individuals whose genotypes did match the predicted eQTL genotypes. The concordance of predictions across six tissues indicated that the problem was due to mix-ups in the genotypes (although we further identified a small number of sample mix-ups in each of the six panels of gene expression microarrays). Consideration of the plate positions of the DNA samples indicated a number of off-by-one and off-by-two errors, likely the result of pipetting errors. Such sample mix-ups can be a problem in any genetic study, but eQTL data allow us to identify, and even correct, such problems. Our methods have been implemented in an R package, R/lineup. Copyright © 2015 Broman et al.

Rural and Urban Differences in Vocational Rehabilitation Case Mix, Delivery Practices, and Employment Outcomes

ERIC Educational Resources Information Center

Ipsen, Catherine; Swicegood, Grant

2015-01-01

Purpose: To examine rural and urban differences in Vocational Rehabilitation (VR) case mix, delivery practices, and employment outcomes. Methods: Rehabilitation Services Administration 911 (RSA-911) case data do not include location indicators that allow for rural analyses. We compiled RSA-911 data with county and ZIP code information from 47 VR…

Toward a general mixed quantum/classical method for the calculation of the vibronic ECD of a flexible dye molecule with different stable conformers: Revisiting the case of 2,2,2-trifluoro-anthrylethanol.

PubMed

Cerezo, Javier; Aranda, Daniel; Avila Ferrer, Francisco J; Prampolini, Giacomo; Mazzeo, Giuseppe; Longhi, Giovanna; Abbate, Sergio; Santoro, Fabrizio

2018-06-01

We extend a recently proposed mixed quantum/classical method for computing the vibronic electronic circular dichroism (ECD) spectrum of molecules with different conformers, to cases where more than one hindered rotation is present. The method generalizes the standard procedure, based on the simple Boltzmann average of the vibronic spectra of the stable conformers, and includes the contribution of structures that sample all the accessible conformational space. It is applied to the simulation of the ECD spectrum of (S)-2,2,2-trifluoroanthrylethanol, a molecule with easily interconvertible conformers, whose spectrum exhibits a pattern of alternating positive and negative vibronic peaks. Results are in very good agreement with experiment and show that spectra averaged over all the sampled conformational space can deviate significantly from the simple average of the contributions of the stable conformers. The present mixed quantum/classical method is able to capture the effect of the nonlinear dependence of the rotatory strength on the molecular structure and of the anharmonic couplings among the modes responsible for molecular flexibility. Despite its computational cost, the procedure is still affordable and promises to be useful in all cases where the ECD shape arises from a subtle balance between vibronic effects and conformational variety. © 2018 Wiley Periodicals, Inc.

[Home health resource utilization measures using a case-mix adjustor model].

PubMed

You, Sun-Ju; Chang, Hyun-Sook

2005-08-01

The purpose of this study was to measure home health resource utilization using a Case-Mix Adjustor Model developed in the U.S. The subjects of this study were 484 patients who had received home health care more than 4 visits during a 60-day episode at 31 home health care institutions. Data on the 484 patients had to be merged onto a 60-day payment segment. Based on the results, the researcher classified home health resource groups (HHRG). The subjects were classified into 34 HHRGs in Korea. Home health resource utilization according to clinical severity was in order of Minimum (C0) < 'Low (C1) < 'Moderate (C2) < 'High (C3), according to dependency in daily activities was in order of Minimum (F0) < 'High (F3) < 'Medium (F2) < 'Low (F1) < 'Maximum (F4). Resource utilization by HHRGs was the highest 564,735 won in group C0F0S2 (clinical severity minimum, dependency in daily activity minimum, service utilization moderate), and the lowest 97,000 won in group C2F3S1, so the former was 5.82 times higher than the latter. Resource utilization in home health care has become an issue of concern due to rising costs for home health care. The results suggest the need for more analytical attention on the utilization and expenditures for home care using a Case-Mix Adjustor Model.

Formation Dirac point and the topological surface states for HgCdTe-QW and mixed 3D HgCdTe TI

NASA Astrophysics Data System (ADS)

Marchewka, Michał

2017-01-01

In this paper the results of numerical calculations based on the finite difference method (FDM) for the 2D and 3D TI with and without uniaxial tensile strain for mixed Hg1-xCdxTe structures are presented. The numerical calculations were made using the 8×8 model for x from 0 up to 0.155 and for the wide range for the thickness from a few nm for 2D up to 150 nm for 3D TI as well as for different mismatch of the lattice constant and different barrier potential in the case of the QW. For the investigated region of the Cd composition (x value) the negative energy gap (Eg=Γ8-Γ6) in the Hg1-xCdxTe is smaller than in the case of pure HgTe which, as it turns out, has a significant influence on the topological surface states (TSS) and the position of the Dirac point for QW as well as for 3D TI. The results show that the strained gap and the position of the Dirac point against the Γ8 is a function of the x-Cd compounds in the case of the 3D TI as well as the critical width of the mixed Hg1-xCdxTe QW.

The cataract national data set electronic multi-centre audit of 55,567 operations: case-mix adjusted surgeon's outcomes for posterior capsule rupture.

PubMed

Sparrow, J M; Taylor, H; Qureshi, K; Smith, R; Johnston, R L

2011-08-01

To develop a methodology for case-mix adjustment of surgical outcomes for individual cataract surgeons using electronically collected multi-centre data conforming to the cataract national data set (CND). Routinely collected anonymised data were remotely extracted from electronic patient record (EPR) systems in 12 participating NHS Trusts undertaking cataract surgery. Following data checks and cleaning, analyses were carried out to risk adjust outcomes for posterior capsule rupture rates for individual surgeons, with stratification by surgical grade. A total of 406 surgeons from 12 NHS Trusts submitted data on 55,567 cataract operations between November 2001 and July 2006 (86% from January 2004). In all, 283 surgeons contributed data on >25 cases, providing 54,319 operations suitable for detailed analysis. Case-mix adjusted results of individual surgeons are presented as funnel plots for all surgeons together, and separately for three different grades of surgeon. Plots include 95 and 99.8% confidence limits around the case-mix adjusted outcomes for detection of surgical outliers. Routinely collected electronic data conforming to the CND provides sufficient detail for case-mix adjustment of cataract surgical outcomes. The validation of these risk indicators should be carried out using fresh data to confirm the validity of the risk model. Once validated this model should provide an equitable approach for peer-to-peer comparisons in the context of revalidation.

Modeling Bimolecular Reactive Transport With Mixing-Limitation: Theory and Application to Column Experiments

NASA Astrophysics Data System (ADS)

Ginn, T. R.

2018-01-01

The challenge of determining mixing extent of solutions undergoing advective-dispersive-diffusive transport is well known. In particular, reaction extent between displacing and displaced solutes depends on mixing at the pore scale, that is, generally smaller than continuum scale quantification that relies on dispersive fluxes. Here a novel mobile-mobile mass transfer approach is developed to distinguish diffusive mixing from dispersive spreading in one-dimensional transport involving small-scale velocity variations with some correlation, such as occurs in hydrodynamic dispersion, in which short-range ballistic transports give rise to dispersed but not mixed segregation zones, termed here ballisticules. When considering transport of a single solution, this approach distinguishes self-diffusive mixing from spreading, and in the case of displacement of one solution by another, each containing a participant reactant of an irreversible bimolecular reaction, this results in time-delayed diffusive mixing of reactants. The approach generates models for both kinetically controlled and equilibrium irreversible reaction cases, while honoring independently measured reaction rates and dispersivities. The mathematical solution for the equilibrium case is a simple analytical expression. The approach is applied to published experimental data on bimolecular reactions for homogeneous porous media under postasymptotic dispersive conditions with good results.

Occupational exposure to wood dust and risk of nasal and nasopharyngeal cancer: A case-control study among men in four nordic countries-With an emphasis on nasal adenocarcinoma.

PubMed

Siew, Sie Sie; Martinsen, Jan Ivar; Kjaerheim, Kristina; Sparén, Pär; Tryggvadottir, Laufey; Weiderpass, Elisabete; Pukkala, Eero

2017-12-15

The current study aims to provide stronger evidence to aid in our understanding of the role of cumulative occupational exposure to (softwood-dominated) mixed wood dust in aetiology of nasal cancer. We included broad exposure occurred in a range of wood-processing occupation across varied industries in four Nordic countries. A population-based case-control study was conducted on all male cases with nasal adenocarcinoma (393 cases), other types of nasal cancer (2,446) and nasopharyngeal cancer (1,747) diagnosed in Finland, Sweden, Norway and Iceland between 1961 and 2005. For each case, five male controls, who were alive at the time of diagnosis of the case (index date), were randomly selected, matched by birth-year and country. Cumulative exposures (CE)s to wood dust and formaldehyde before the index date were quantified based on a job-exposure matrix linked to occupational titles derived from population censuses. Hazard ratios (HRs) for the CE of wood dust were estimated by conditional logistic regression, adjusted for CE to formaldehyde and 95% confidence intervals (CIs) were calculated. There was an increasing risk of nasal adenocarcinoma related to wood dust exposure. The HR in the highest CE category of wood dust (≥ 28.82 mg/m 3 -years) was 16.5 (95% CI 5.05-54.1). Neither nonadenocarcinoma of the nose nor nasopharyngeal cancer could be linked to wood dust exposure. CE to softwood-dominated mixed wood dusts is strongly linked with elevated risk in nasal adenocarcinoma but not with other types of nasal or nasopharyngeal cancer. © 2017 UICC.

[Changes in 25-hydroxyvitamin D3 level in children with Henoch-Schönlein purpura].

PubMed

Zhang, Yuan-Da; Dong, Qing-Wei; Li, Rong-Min; Ji, Chao-Yu; Chu, Yong-Tao; Ma, Lei; Zhang, Yu

2017-03-01

To examine the changes in 25-hydroxyvitamin D 3 [25-(OH)D 3 ] level in children with Henoch-Schönlein purpura (HSP) and its clinical significance. A total of 92 HSP children were included in this study, and were divided into HSP nephritis (HSPN) group (31 cases) and HSP group (61 cases) based on the presence or absence of HSPN. Alternatively, the patients were divided into purpura alone group (22 cases), purpura with joint symptoms group (joint symptom group, 24 cases), purpura with gastrointestinal symptoms group (gastrointestinal symptom group, 20 cases), and purpura with joint and gastrointestinal symptoms (mixed group, 26 cases) based on their clinical symptoms. In addition, 42 healthy children were selected as healthy control group. The level of 25-(OH)D 3 in each group was measured using enzyme-linked immunoassay. The 25-(OH)D 3 level in the HSP and HSPN groups was significantly lower than that in the healthy control group (P<0.05), and the 25-(OH)D 3 level in the HSPN group was significantly lower than that in the HSP group (P<0.05). Although there was no significant difference in the 25-(OH)D 3 level between the joint symptom, gastrointestinal symptom, and mixed groups (P=0.22), the 25-(OH)D 3 level in the three groups was all significantly lower than that in the purpura alone group (P<0.05). The level of 25-(OH)D 3 is reduced in children with HSP, particularly those with HSPN or with joint and gastrointestinal symptoms. Therefore, the reduction in 25-(OH)D 3 level may serve as a predictor of whether HSP is associated with other impairments.

Regression analysis of mixed recurrent-event and panel-count data.

PubMed

Zhu, Liang; Tong, Xinwei; Sun, Jianguo; Chen, Manhua; Srivastava, Deo Kumar; Leisenring, Wendy; Robison, Leslie L

2014-07-01

In event history studies concerning recurrent events, two types of data have been extensively discussed. One is recurrent-event data (Cook and Lawless, 2007. The Analysis of Recurrent Event Data. New York: Springer), and the other is panel-count data (Zhao and others, 2010. Nonparametric inference based on panel-count data. Test 20: , 1-42). In the former case, all study subjects are monitored continuously; thus, complete information is available for the underlying recurrent-event processes of interest. In the latter case, study subjects are monitored periodically; thus, only incomplete information is available for the processes of interest. In reality, however, a third type of data could occur in which some study subjects are monitored continuously, but others are monitored periodically. When this occurs, we have mixed recurrent-event and panel-count data. This paper discusses regression analysis of such mixed data and presents two estimation procedures for the problem. One is a maximum likelihood estimation procedure, and the other is an estimating equation procedure. The asymptotic properties of both resulting estimators of regression parameters are established. Also, the methods are applied to a set of mixed recurrent-event and panel-count data that arose from a Childhood Cancer Survivor Study and motivated this investigation. © The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Educating resident physicians using virtual case-based simulation improves diabetes management: a randomized controlled trial.

PubMed

Sperl-Hillen, JoAnn; O'Connor, Patrick J; Ekstrom, Heidi L; Rush, William A; Asche, Stephen E; Fernandes, Omar D; Appana, Deepika; Amundson, Gerald H; Johnson, Paul E; Curran, Debra M

2014-12-01

To test a virtual case-based Simulated Diabetes Education intervention (SimDE) developed to teach primary care residents how to manage diabetes. Nineteen primary care residency programs, with 341 volunteer residents in all postgraduate years (PGY), were randomly assigned to a SimDE intervention group or control group (CG). The Web-based interactive educational intervention used computerized virtual patients who responded to provider actions through programmed simulation models. Eighteen distinct learning cases (L-cases) were assigned to SimDE residents over six months from 2010 to 2011. Impact was assessed using performance on four virtual assessment cases (A-cases), an objective knowledge test, and pre-post changes in self-assessed diabetes knowledge and confidence. Group comparisons were analyzed using generalized linear mixed models, controlling for clustering of residents within residency programs and differences in baseline knowledge. The percentages of residents appropriately achieving A-case composite clinical goals for glucose, blood pressure, and lipids were as follows: A-case 1: SimDE = 21.2%, CG = 1.8%, P = .002; A-case 2: SimDE = 15.7%, CG = 4.7%, P = .02; A-case 3: SimDE = 48.0%, CG = 10.4%, P < .001; and A-case 4: SimDE = 42.1%, CG = 18.7%, P = .004. The mean knowledge score and pre-post changes in self-assessed knowledge and confidence were significantly better for SimDE group than CG participants. A virtual case-based simulated diabetes education intervention improved diabetes management skills, knowledge, and confidence for primary care residents.

Does the average cost of home health care vary with case mix?

PubMed

Nyman, J A; Svetlik, M A

1989-01-01

The relationship between the average cost of home health care and the case mix of patients served by the home health agency is investigated using 1983 data from Wisconsin's home health care agencies. In contrast to previous work, case mix is shown to have a significant effect on the home health agency's average costs. The methods used in the previous work are evaluated, and differences between the earlier study and the present study are discussed to explain the divergent results. Also, average costs are shown to decrease with output, to increase with the proportion of private patients served by the agency, and to be higher if the home health agency is located in an urban area or if it has a proprietary charter. The implications of this research for the design of an appropriate home health reimbursement policy are discussed. Primarily, it is argued that, although future research might confirm the relationship between average costs and case mix for home health agencies, we cannot necessarily conclude that reimbursement rates must be adjusted to account for differences in case mix as many States are now doing for nursing home reimbursement. Policies must take into account the fundamental differences between home health agencies and nursing homes, and their respective markets, in order to be effective.

Does the average cost of home health care vary with case mix?

PubMed Central

Nyman, J A; Svetlik, M A

1989-01-01

The relationship between the average cost of home health care and the case mix of patients served by the home health agency is investigated using 1983 data from Wisconsin's home health care agencies. In contrast to previous work, case mix is shown to have a significant effect on the home health agency's average costs. The methods used in the previous work are evaluated, and differences between the earlier study and the present study are discussed to explain the divergent results. Also, average costs are shown to decrease with output, to increase with the proportion of private patients served by the agency, and to be higher if the home health agency is located in an urban area or if it has a proprietary charter. The implications of this research for the design of an appropriate home health reimbursement policy are discussed. Primarily, it is argued that, although future research might confirm the relationship between average costs and case mix for home health agencies, we cannot necessarily conclude that reimbursement rates must be adjusted to account for differences in case mix as many States are now doing for nursing home reimbursement. Policies must take into account the fundamental differences between home health agencies and nursing homes, and their respective markets, in order to be effective. PMID:2502804

Unlearning of Mixed States in the Hopfield Model —Extensive Loading Case—

NASA Astrophysics Data System (ADS)

Hayashi, Kao; Hashimoto, Chinami; Kimoto, Tomoyuki; Uezu, Tatsuya

2018-05-01

We study the unlearning of mixed states in the Hopfield model for the extensive loading case. Firstly, we focus on case I, where several embedded patterns are correlated with each other, whereas the rest are uncorrelated. Secondly, we study case II, where patterns are divided into clusters in such a way that patterns in any cluster are correlated but those in two different clusters are not correlated. By using the replica method, we derive the saddle point equations for order parameters under the ansatz of replica symmetry. The same equations are also derived by self-consistent signal-to-noise analysis in case I. In both cases I and II, we find that when the correlation between patterns is large, the network loses its ability to retrieve the embedded patterns and, depending on the parameters, a confused memory, which is a mixed state and/or spin glass state, emerges. By unlearning the mixed state, the network acquires the ability to retrieve the embedded patterns again in some parameter regions. We find that to delete the mixed state and to retrieve the embedded patterns, the coefficient of unlearning should be chosen appropriately. We perform Markov chain Monte Carlo simulations and find that the simulation and theoretical results agree reasonably well, except for the spin glass solution in a parameter region due to the replica symmetry breaking. Furthermore, we find that the existence of many correlated clusters reduces the stabilities of both embedded patterns and mixed states.

Medicaid payment rates, case-mix reimbursement, and nursing home staffing--1996-2004.

PubMed

Feng, Zhanlian; Grabowski, David C; Intrator, Orna; Zinn, Jacqueline; Mor, Vincent

2008-01-01

We examined the impact of state Medicaid payment rates and case-mix reimbursement on direct care staffing levels in US nursing homes. We used a recent time series of national nursing home data from the Online Survey Certification and Reporting system for 1996-2004, merged with annual state Medicaid payment rates and case-mix reimbursement information. A 5-category response measure of total staffing levels was defined according to expert recommended thresholds, and examined in a multinomial logistic regression model. Facility fixed-effects models were estimated separately for Registered Nurse (RN), Licensed Practical Nurse (LPN), and Certified Nurse Aide (CNA) staffing levels measured as average hours per resident day. Higher Medicaid payment rates were associated with increases in total staffing levels to meet a higher recommended threshold. However, these gains in overall staffing were accompanied by a reduction of RN staffing and an increase in both LPN and CNA staffing levels. Under case-mix reimbursement, the likelihood of nursing homes achieving higher recommended staffing thresholds decreased, as did levels of professional staffing. Independent of the effects of state, market, and facility characteristics, there was a significant downward trend in RN staffing and an upward trend in both LPN and CNA staffing. Although overall staffing may increase in response to more generous Medicaid reimbursement, it may not translate into improvements in the skill mix of staff. Adjusting for reimbursement levels and resident acuity, total staffing has not increased after the implementation of case-mix reimbursement.

A case study of the design, installation, and early performance of a nineteen-millimeter superpave mix.

DOT National Transportation Integrated Search

1999-07-01

An attempt was made to design and construct a coarse matrix high binder (CMHB) mix. When the design of the CMHB mix was unsuccessful a coarse 19.0-mm Superpave mix was substituted. This report describes the attempted design of the CMHB mix, as well a...

Quantification of mixing in vesicle suspensions using numerical simulations in two dimensions.

PubMed

Kabacaoğlu, G; Quaife, B; Biros, G

2017-02-01

We study mixing in Stokesian vesicle suspensions in two dimensions on a cylindrical Couette apparatus using numerical simulations. The vesicle flow simulation is done using a boundary integral method, and the advection-diffusion equation for the mixing of the solute is solved using a pseudo-spectral scheme. We study the effect of the area fraction, the viscosity contrast between the inside (the vesicles) and the outside (the bulk) fluid, the initial condition of the solute, and the mixing metric. We compare mixing in the suspension with mixing in the Couette apparatus without vesicles. On the one hand, the presence of vesicles in most cases slightly suppresses mixing. This is because the solute can be only diffused across the vesicle interface and not advected. On the other hand, there exist spatial distributions of the solute for which the unperturbed Couette flow completely fails to mix whereas the presence of vesicles enables mixing. We derive a simple condition that relates the velocity and solute and can be used to characterize the cases in which the presence of vesicles promotes mixing.

Quantification of mixing in vesicle suspensions using numerical simulations in two dimensions

PubMed Central

Quaife, B.; Biros, G.

2017-01-01

We study mixing in Stokesian vesicle suspensions in two dimensions on a cylindrical Couette apparatus using numerical simulations. The vesicle flow simulation is done using a boundary integral method, and the advection-diffusion equation for the mixing of the solute is solved using a pseudo-spectral scheme. We study the effect of the area fraction, the viscosity contrast between the inside (the vesicles) and the outside (the bulk) fluid, the initial condition of the solute, and the mixing metric. We compare mixing in the suspension with mixing in the Couette apparatus without vesicles. On the one hand, the presence of vesicles in most cases slightly suppresses mixing. This is because the solute can be only diffused across the vesicle interface and not advected. On the other hand, there exist spatial distributions of the solute for which the unperturbed Couette flow completely fails to mix whereas the presence of vesicles enables mixing. We derive a simple condition that relates the velocity and solute and can be used to characterize the cases in which the presence of vesicles promotes mixing. PMID:28344432

Long-Term Effects on Graphene Supercapacitors of Using a Zirconia Bowl and Zirconia Balls for Ball-Mill mixing of Active Materials

NASA Astrophysics Data System (ADS)

Song, Dae-Hoon; Kim, Jin-Young; Kahng, Yung Ho; Cho, Hoonsung; Kim, Eung-Sam

2018-04-01

Improving the energy storage performance of supercapacitor electrodes based on reduced graphene oxide (RGO) is one of the main subjects in this research field. However, when a zirconia bowl and zirconia balls were used for ball-mill mixing of the active materials for RGO supercapacitors, the energy storage performance deteriorated over time. Our study revealed that the source of the problem was the inclusion of zirconia bits from abrasion of the bowl and the balls during the ballmill mixing, which increased during a period of 1 year. We probed two solutions to this problem: 1) hydrofluoric (HF) acid treatment of the RGO supercapacitors and 2) use of a tempered steel bowl and tempered steel balls for the mixing. For both cases, the energy storage performance was restored to near the initial level, showing a specific capacitance ( C sp ) of 200 F/g. Our results should lead to progress in research on RGO supercapacitors.

Criticality Safety Analysis on the Mixed Be, Nat-U, and C (Graphite) Reflectors in 55-Gallon Waste Drums and Their Equivalents for HWM Applications

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chou, P

The objective of this analysis is to develop and establish the technical basis on the criticality safety controls for the storage of mixed beryllium (Be), natural uranium (Nat-U), and carbon (C)/graphite reflectors in 55-gallon waste containers and/or their equivalents in Hazardous Waste Management (HWM) facilities. Based on the criticality safety limits and controls outlined in Section 3.0, the operations involving the use of mixed-reflector drums satisfy the double-contingency principle as required by DOE Order 420.1 and are therefore criticality safe. The mixed-reflector mass limit is 120 grams for each 55-gallon drum or its equivalent. a reflector waiver of 50 gramsmore » is allowed for Be, Nat-U, or C/graphite combined. The waived reflectors may be excluded from the reflector mass calculations when determining if a drum is compliant. The mixed-reflector drums are allowed to mix with the typical 55-gallon one-reflector drums with a Pu mass limit of 120 grams. The fissile mass limit for the mixed-reflector container is 65 grams of Pu equivalent each. The corresponding reflector mass limits are 300 grams of Be, and/or 100 kilograms of Nat-U, and/or 110 kilograms of C/graphite for each container. All other unaffected control parameters for the one-reflector containers remain in effect for the mixed-reflector drums. For instance, Superior moderators, such as TrimSol, Superla white mineral oil No. 9, paraffin, and polyethylene, are allowed in unlimited quantities. Hydrogenous materials with a hydrogen density greater than 0.133 gram/cc are not allowed. Also, an isolation separation of no less than 76.2 cm (30-inch) is required between a mixed array and any other array. Waste containers in the action of being transported are exempted from this 76.2-cm (30-inch) separation requirement. All deviations from the CS controls and mass limits listed in Section 3.0 will require individual criticality safety analyses on a case-by-case basis for each of them to confirm their criticality safety prior to their deployment and implementation.« less

The Micropolitics of Implementing a School-Based Bonus Policy: The Case of New York City's Compensation Committees

ERIC Educational Resources Information Center

Marsh, Julie

2012-01-01

This article examines the micropolitics of implementing New York City's Schoolwide Performance Bonus Program and school governance bodies (Compensation Committees) that determined distribution of school-level rewards among personnel. Drawing on a two-year, mixed-methods study, the author finds that although most participants surveyed described a…

Examining Elementary Students' Development of Oral and Written Argumentation Practices through Argument-Based Inquiry

ERIC Educational Resources Information Center

Chen, Ying-Chih; Hand, Brian; Park, Soonhye

2016-01-01

Argumentation, and the production of scientific arguments are critical elements of inquiry that are necessary for helping students become scientifically literate through engaging them in constructing and critiquing ideas. This case study employed a mixed methods research design to examine the development in 5th grade students' practices of oral…

Exploring the Potential for Language Supportive Learning in English Medium Instruction: A Rwandan Case Study

ERIC Educational Resources Information Center

Milligan, Lizzi O.; Clegg, John; Tikly, Leon

2016-01-01

This article puts forward the argument for language supportive learning for learners in English medium instruction (EMI) classrooms based on the findings from a mixed methods study in Rwanda. The article first reviews the relevant literature and research which looks at the concept of language support, focusing on textbooks and pedagogy in…

Program Evaluation and Replications of School-Based Mental Health Services and Family-Community Interventions with Chronically Disruptive Students

ERIC Educational Resources Information Center

Carpenter-Aeby, Tracy; Aeby, Victor G.

2005-01-01

Although outcomes for alternative schools may be mixed, it is generally agreed that counseling, therapy, group work, case management, and family-community involvement have been credited in some effective programs. This study examined program evaluations from 1994-1999 for an alternative school for chronically disruptive students (599 students,…

Who Succeeds in Mathematics? Caribbean Perspectives on the Mix of Schools and Mathematics

ERIC Educational Resources Information Center

George, Patricia

2012-01-01

Within the Caribbean, there has been a perception that students are underachieving in mathematics. This assessment has seemingly been based amongst other things upon the proportion of students who are successful in mathematics compared to other subjects in external examinations. This notion was investigated in a case study of secondary schools in…

Charter School Autonomy: The Mismatch between Theory and Practice

ERIC Educational Resources Information Center

Finnigan, Kara S.

2007-01-01

In theory, the charter school concept is based on a trade-off or exchange: greater autonomy for increased accountability. Although charter schools have been operating for more than 10 years, little is known about charter school autonomy in practice. This mixed-methods study used survey and case study data to examine the degree of autonomy of…

Video-Based Intervention in Teaching Fraction Problem-Solving to Students with Autism Spectrum Disorder

ERIC Educational Resources Information Center

Yakubova, Gulnoza; Hughes, Elizabeth M.; Hornberger, Erin

2015-01-01

The purpose of this study was to determine the effectiveness of a point-of-view video modeling intervention to teach mathematics problem-solving when working on word problems involving subtracting mixed fractions with uncommon denominators. Using a multiple-probe across students design of single-case methodology, three high school students with…

Findings from a Pre-Kindergarten Classroom: Making the Case for STEM in Early Childhood Education

ERIC Educational Resources Information Center

Tippett, Christine D.; Milford, Todd M.

2017-01-01

Science, technology, engineering, and mathematics (STEM) in early childhood education is an area currently given little attention in the literature, which is unfortunate since young children are natural scientists and engineers. Here, we outline our mixed-methods design-based research investigation of a pre-kindergarten (Pre-K) classroom where two…

The Effect of Interactive Technology on Informal Learning and Performance in a Social Setting

ERIC Educational Resources Information Center

Boileau, Timothy

2011-01-01

This study is based on a qualitative multiple case study research design using a mixed methods approach to provide insight into the effect of interactive technology on informal learning and performance in a social business setting inhabited by knowledge workers. The central phenomenon examined is the variance in behavioral intention towards…

The Values-Based Infrastructure of Non-Formal Education: A Case Study of Personal Education in Israeli Schools

ERIC Educational Resources Information Center

Goldratt, Miri; Cohen, Eric H.

2016-01-01

This article explores encounters between formal, informal, and non-formal education and the role of mentor-educators in creating values education in which such encounters take place. Mixed-methods research was conducted in Israeli public schools participating in the Personal Education Model, which combines educational modes. Ethnographic and…

Student Perceptions of Effective Discussion in Online Forums: A Case Study of Pre-Service Teachers

ERIC Educational Resources Information Center

Ebrahimi, Alice; Faghih, Esmail; Dabir-Moghaddam, Mohammad

2017-01-01

This study reports on a mixed methods study which explored 32 Iranian pre-service teachers' perceptions of attending online asynchronous discussion forums during two seven-week online introductory courses in corpus linguistics. Data were collected through a questionnaire, discussion forum entries and online text-based semi-structured interviews.…

Using Primary Sources to Teach Civil War History: A Case Study in Pedagogical Decision Making

ERIC Educational Resources Information Center

Snook, David L.

2017-01-01

This exploratory study combined the process of modified analytic induction with a mixed methods approach to analyze various factors that affected or might have affected participating teachers' decisions to use or not use various primary source based teaching strategies to teach historical thinking skills. Four participating eighth and ninth grade…

Examining Transformative Faculty Development Factors to Advance Technology Adoption and Diffusion at a Campus-Based Institution

ERIC Educational Resources Information Center

McKissic, Stephanie Camille

2012-01-01

The purpose of this mixed-method research, in the context of a case study was to examine faculty concerns with integrating technologies and the influences and motivations that lead to technology adoption and diffusion in the classroom. Specifically, the study examined the conceptual frameworks of Rogers' Innovation Diffusion Theory (IDT) and…

Adult Learners' Use of Flexible Online Resources in a Blended Programme

ERIC Educational Resources Information Center

Cornelius, Sarah; Gordon, Carole

2009-01-01

This paper presents a case study of a blended programme for adults and discusses findings from a mixed-methods investigative study of learners' and tutors' experiences of the programme. The programme employs a set of flexible online resources, which are activity-based and designed to provide choice in study routes and modes of learning. Our…

Why so many "rigorous" evaluations fail to identify unintended consequences of development programs: How mixed methods can contribute.

PubMed

Bamberger, Michael; Tarsilla, Michele; Hesse-Biber, Sharlene

2016-04-01

Many widely-used impact evaluation designs, including randomized control trials (RCTs) and quasi-experimental designs (QEDs), frequently fail to detect what are often quite serious unintended consequences of development programs. This seems surprising as experienced planners and evaluators are well aware that unintended consequences frequently occur. Most evaluation designs are intended to determine whether there is credible evidence (statistical, theory-based or narrative) that programs have achieved their intended objectives and the logic of many evaluation designs, even those that are considered the most "rigorous," does not permit the identification of outcomes that were not specified in the program design. We take the example of RCTs as they are considered by many to be the most rigorous evaluation designs. We present a numbers of cases to illustrate how infusing RCTs with a mixed-methods approach (sometimes called an "RCT+" design) can strengthen the credibility of these designs and can also capture important unintended consequences. We provide a Mixed Methods Evaluation Framework that identifies 9 ways in which UCs can occur, and we apply this framework to two of the case studies. Copyright © 2016 Elsevier Ltd. All rights reserved.

Modelling the effect of environmental factors on resource allocation in mixed plants systems

NASA Astrophysics Data System (ADS)

Gayler, Sebastian; Priesack, Eckart

2010-05-01

In most cases, growth of plants is determined by competition against neighbours for the local resources light, water and nutrients and by defending against herbivores and pathogens. Consequently, it is important for a plant to grow fast without neglecting defence. However, plant internal substrates and energy required to support maintenance, growth and defence are limited and the total demand for these processes cannot be met in most cases. Therefore, allocation of carbohydrates to growth related primary metabolism or to defence related secondary metabolism can be seen as a trade-off between the demand of plants for being competitive against neighbours and for being more resistant against pathogens. A modelling approach is presented which can be used to simulate competition for light, water and nutrients between plant individuals in mixed canopies. The balance of resource allocation between growth processes and synthesis of secondary compounds is modelled by a concept originating from different plant defence hypothesis. The model is used to analyse the impact of environmental factors such as soil water and nitrogen availability, planting density and atmospheric concentration of CO2 on growth of plant individuals within mixed canopies and variations in concentration of carbon-based secondary metabolites in plant tissues.

Using Mixed Methods to Evaluate a Community Intervention for Sexual Assault Survivors: A Methodological Tale.

PubMed

Campbell, Rebecca; Patterson, Debra; Bybee, Deborah

2011-03-01

This article reviews current epistemological and design issues in the mixed methods literature and then examines the application of one specific design, a sequential explanatory mixed methods design, in an evaluation of a community-based intervention to improve postassault care for sexual assault survivors. Guided by a pragmatist epistemological framework, this study collected quantitative and qualitative data to understand how the implementation of a Sexual Assault Nurse Examiner (SANE) program affected prosecution rates of adult sexual assault cases in a large midwestern community. Quantitative results indicated that the program was successful in affecting legal systems change and the qualitative data revealed the mediating mechanisms of the intervention's effectiveness. Challenges of implementing this design are discussed, including epistemological and practical difficulties that developed from blending methodologies into a single project. © The Author(s) 2011.

The prediction of sea-surface temperature variations by means of an advective mixed-layer ocean model

NASA Technical Reports Server (NTRS)

Atlas, R. M.

1976-01-01

An advective mixed layer ocean model was developed by eliminating the assumption of horizontal homogeneity in an already existing mixed layer model, and then superimposing a mean and anomalous wind driven current field. This model is based on the principle of conservation of heat and mechanical energy and utilizes a box grid for the advective part of the calculation. Three phases of experiments were conducted: evaluation of the model's ability to account for climatological sea surface temperature (SST) variations in the cooling and heating seasons, sensitivity tests in which the effect of hypothetical anomalous winds was evaluated, and a thirty-day synoptic calculation using the model. For the case studied, the accuracy of the predictions was improved by the inclusion of advection, although nonadvective effects appear to have dominated.

Multi-sensor quantification of aerosol-induced variability in warm clouds over eastern China

NASA Astrophysics Data System (ADS)

Wang, Fu; Guo, Jianping; Zhang, Jiahua; Huang, Jingfeng; Min, Min; Chen, Tianmeng; Liu, Huan; Deng, Minjun; Li, Xiaowen

2015-07-01

Aerosol-cloud (AC) interactions remain uncharacterized due to difficulties in obtaining accurate aerosol and cloud observations. In this study, we quantified the aerosol indirect effects (AIE) on warm clouds over Eastern China based on near-simultaneous retrievals from MODIS/AQUA, CALIOP/CALIPSO, and CPR/CLOUDSAT between June 2006 and December 2010. The seasonality of aerosols from ground-based PM10 (aerosol particles with diameter of 10 μm or less) significantly differed from that estimated using MODIS aerosol optical depth (AOD). This result was supported by the lower level frequency profile of aerosol occurrence from CALIOP, indicative of the significant role of CALIOP in the AC interaction. To focus on warm clouds, cloud layers with base (top) altitudes above 7 (10) km were excluded. The combination of CALIOP and CPR was applied to determine the exact position of warm clouds relative to aerosols out of the following six scenarios in terms of AC mixing states: 1) aerosol only (AO); 2) cloud only (CO); 3) single aerosol layer-single cloud layer (SASC); 4) single aerosol layer-double cloud layers (SADC); 5) double aerosol layers - single cloud layer (DASC); and 6) others. The cases with vertical distance between aerosol and cloud layer less (more) than 100 m (700 m) were marked mixed (separated), and the rest as uncertain. Results showed that only 8.95% (7.53%) belonged to the mixed (separated and uncertain) state among all of the collocated AC overlapping cases, including SASC, SADC, and DASC. Under mixed conditions, the cloud droplet effective radius (CDR) decreased with increasing AOD at moderate aerosol loading (AOD<0.4), and then became saturated at an AOD of around 0.5, followed by an increase in CDR with increasing AOD, known as boomerang shape. Under separated conditions, no apparent changes in CDR with AOD were observed. We categorized the AC dataset into summer- and winter-season subsets to determine how the boomerang shape varied with season. The response of CDR to AOD in summer exhibited similar but much more deepened boomerang shape, as compared with the all year round case. In contrast, CDR in winter did not follow the boomerang shape for its continued decreasing with increasing AOD, even after the saturation zone (AOD around 0.5) of a cloud droplet.

Paediatric acid-base disorders: A case-based review of procedures and pitfalls

PubMed Central

Carmody, J Bryan; Norwood, Victoria F

2013-01-01

Acid-base disorders occur frequently in paediatric patients. Despite the perception that their analysis is complex and difficult, a straightforward set of rules is sufficient to interpret even the most complex disorders – provided certain pitfalls are avoided. Using a case-based approach, the present article reviews the fundamental concepts of acid-base analysis and highlights common mistakes and oversights. Specific topics include the proper identification of the primary disorder; distinguishing compensatory changes from additional primary disorders; use of the albumin-corrected anion gap to generate a differential diagnosis for patients with metabolic acidosis; screening for mixed disorders with the delta-delta formula; recognizing the limits of compensation; use of the anion gap to identify ‘hidden’ acidosis; and the importance of using information from the history and physical examination to identify the specific cause of a patient’s acid-base disturbance. PMID:24381489

Mixing properties of coaxial jets with large velocity ratios and large inverse density ratios

NASA Astrophysics Data System (ADS)

Alexander Schumaker, S.; Driscoll, James F.

2012-05-01

An experimental study was conducted to better understand the mixing properties of coaxial jets as several parameters were systematically varied, including the velocity ratio, density ratio, and the Reynolds number. Diameters of the inner and outer jet were also varied. Coaxial jets are commonly used to mix fluids due to the simplicity of their geometry and the rapid mixing that they provide. A measure of the overall mixing efficiency is the stoichiometric mixing length (Ls), which is the distance along the jet centerline where the two fluids have mixed to some desired concentration, which was selected to be the stoichiometric concentration for H2/O2 and CH4/O2 in this case. For 56 cases, the profiles of mean mixture fraction, rms mixture fraction fluctuations (unmixedness), and Ls were measured using acetone planar laser induced fluorescence diagnostics. Results were compared to three mixing models. The entrainment model of Villermaux and Rehab showed good agreement with the data, indicating that the proper non-dimensional scaling parameter is the momentum flux ratio M. The work extends the existing database of coaxial jet scalar mixing properties because it considers the specific regime of large values of both the velocity ratio and the inverse density ratio, which is the regime in which rocket injectors operate. Also the work focuses on the mixing up to Ls where previous work focused on the mixing up to the end of the inner core. The Reynolds numbers achieved for a number of cases were considerably larger than previous gas mixing studies, which insures that the jet exit boundary conditions are fully turbulent.

Standardization of Type 2 Diabetes Outpatient Expenditure with Bundled Payment Method in China

PubMed Central

Xu, Guo-Chao; Luo, Yun; Li, Qian; Wu, Meng-Fan; Zhou, Zi-Jun

2016-01-01

Background: In recent years, the prevalence of type 2 diabetes among Chinese population has been increasing by years, directly leading to an average annual growth rate of 19.90% of medical expenditure. Therefore, it is urgent to work on strategies to control the growth of medical expenditure on type 2 diabetes on the basis of the reality of China. Therefore, in this study, we explored the feasibility of implementing bundled payment in China through analyzing bundled payment standards of type 2 diabetes outpatient services. Methods: This study analyzed the outpatient expenditure on type 2 diabetes with Beijing Urban Employee's Basic Medical Insurance from 2010 to 2012. Based on the analysis of outpatient expenditure and its influential factors, we adopted decision tree approach to conduct a case-mix analysis. In the end, we built a case-mix model to calculate the standard expenditure and the upper limit of each combination. Results: We found that age, job status, and whether with complication were significant factors that influence outpatient expenditure for type 2 diabetes. Through the analysis of the decision tree, we used six variables (complication, age, diabetic foot, diabetic nephropathy, cardiac-cerebrovascular disease, and neuropathy) to group the cases, and obtained 11 case-mix groups. Conclusions: We argued that it is feasible to implement bundled payment on type 2 diabetes outpatient services. Bundled payment is effective to control the increase of outpatient expenditure. Further improvements are needed for the implementation of bundled payment reimbursement standards, together with relevant policies and measures. PMID:27064041

Invasion of cooperators in lattice populations: linear and non-linear public good games.

PubMed

Vásárhelyi, Zsóka; Scheuring, István

2013-08-01

A generalized version of the N-person volunteer's dilemma (NVD) Game has been suggested recently for illustrating the problem of N-person social dilemmas. Using standard replicator dynamics it can be shown that coexistence of cooperators and defectors is typical in this model. However, the question of how a rare mutant cooperator could invade a population of defectors is still open. Here we examined the dynamics of individual based stochastic models of the NVD. We analyze the dynamics in well-mixed and viscous populations. We show in both cases that coexistence between cooperators and defectors is possible; moreover, spatial aggregation of types in viscous populations can easily lead to pure cooperation. Furthermore we analyze the invasion of cooperators in populations consisting predominantly of defectors. In accordance with analytical results, in deterministic systems, we found the invasion of cooperators successful in the well-mixed case only if their initial concentration was higher than a critical threshold, defined by the replicator dynamics of the NVD. In the viscous case, however, not the initial concentration but the initial number determines the success of invasion. We show that even a single mutant cooperator can invade with a high probability, because the local density of aggregated cooperators exceeds the threshold defined by the game. Comparing the results to models using different benefit functions (linear or sigmoid), we show that the role of the benefit function is much more important in the well-mixed than in the viscous case. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Solution of non-steady-state substrate concentration in the action of biosensor response at mixed enzyme kinetics

NASA Astrophysics Data System (ADS)

Senthamarai, R.; Jana Ranjani, R.

2018-04-01

In this paper, a mathematical model of an amperometric biosensor at mixed enzyme kinetics and diffusion limitation in the case of substrate inhibition has been developed. The model is based on time dependent reaction diffusion equation containing a non -linear term related to non -Michaelis - Menten kinetics of the enzymatic reaction. Solution for the concentration of the substrate has been derived for all values of parameters using the homotopy perturbation method. All the approximate analytic expressions of substrate concentration are compared with simulation results using Scilab/Matlab program. Finally, we have given a satisfactory agreement between them.

A Modified Mixing Length Turbulence Model for Zero and Adverse Pressure Gradients. M.S. Thesis - Akron Univ., 1993

NASA Technical Reports Server (NTRS)

Conley, Julianne M.; Leonard, B. P.

1994-01-01

The modified mixing length (MML) turbulence model was installed in the Proteus Navier-Stokes code, then modified to make it applicable to a wider range of flows typical of aerospace propulsion applications. The modifications are based on experimental data for three flat-plate flows having zero, mild adverse, and strong adverse pressure gradients. Three transonic diffuser test cases were run with the new version of the model in order to evaluate its performance. All results are compared with experimental data and show improvements over calculations made using the Baldwin-Lomax turbulence model, the standard algebraic model in Proteus.

42 CFR 413.340 - Transition period.

Code of Federal Regulations, 2010 CFR

2010-10-01

... PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES Prospective Payment for Skilled Nursing... minus 1 percentage point. (c) SNFs participating in the Multistate Nursing Home Case-Mix and Quality Demonstration. SNFs that participated in the Multistate Nursing Home Case-Mix and Quality Demonstration in a...

42 CFR 413.340 - Transition period.

Code of Federal Regulations, 2013 CFR

2013-10-01

... PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES Prospective Payment for Skilled Nursing... minus 1 percentage point. (c) SNFs participating in the Multistate Nursing Home Case-Mix and Quality Demonstration. SNFs that participated in the Multistate Nursing Home Case-Mix and Quality Demonstration in a...

Theoretical and numerical studies of chaotic mixing

NASA Astrophysics Data System (ADS)

Kim, Ho Jun

Theoretical and numerical studies of chaotic mixing are performed to circumvent the difficulties of efficient mixing, which come from the lack of turbulence in microfluidic devices. In order to carry out efficient and accurate parametric studies and to identify a fully chaotic state, a spectral element algorithm for solution of the incompressible Navier-Stokes and species transport equations is developed. Using Taylor series expansions in time marching, the new algorithm employs an algebraic factorization scheme on multi-dimensional staggered spectral element grids, and extends classical conforming Galerkin formulations to nonconforming spectral elements. Lagrangian particle tracking methods are utilized to study particle dispersion in the mixing device using spectral element and fourth order Runge-Kutta discretizations in space and time, respectively. Comparative studies of five different techniques commonly employed to identify the chaotic strength and mixing efficiency in microfluidic systems are presented to demonstrate the competitive advantages and shortcomings of each method. These are the stirring index based on the box counting method, Poincare sections, finite time Lyapunov exponents, the probability density function of the stretching field, and mixing index inverse, based on the standard deviation of scalar species distribution. Series of numerical simulations are performed by varying the Peclet number (Pe) at fixed kinematic conditions. The mixing length (lm) is characterized as function of the Pe number, and lm ∝ ln(Pe) scaling is demonstrated for fully chaotic cases. Employing the aforementioned techniques, optimum kinematic conditions and the actuation frequency of the stirrer that result in the highest mixing/stirring efficiency are identified in a zeta potential patterned straight micro channel, where a continuous flow is generated by superposition of a steady pressure driven flow and time periodic electroosmotic flow induced by a stream-wise AC electric field. Finally, it is shown that the invariant manifold of hyperbolic periodic point determines the geometry of fast mixing zones in oscillatory flows in two-dimensional cavity.

Composition of gallbladder bile in healthy individuals and patients with gallstone disease from north and South India.

PubMed

Jayanthi, V; Sarika, S; Varghese, Joy; Vaithiswaran, V; Sharma, Malay; Reddy, Mettu Srinivas; Srinivasan, Vijaya; Reddy, G M M; Rela, Mohamed; Kalkura, S

2016-09-01

Gallstones (GS) in south India (SI) are predominantly pure pigment or mixed, while in North India (NI), these are either pure cholesterol or mixed. While cholesterol rich gallbladder (GB) bile predicts cholesterol GS, constituent of bile in primary pigment GS is not known. We compared the composition of GB bile from healthy liver donors and patients with GS from north and south India. Gallbladder bile from healthy liver donors from north (10) and south India (8) served as controls. Cases were patients from north (21) and south India (17) who underwent cholecystectomy for GS disease. Gallbladder bile from both cases and controls was analyzed for cholesterol, lecithin (phospholipid), and bile salts. Gallstones were classified as cholesterol, mixed, and pigment based on morphology and biochemical analysis. The median cholesterol concentration in control bile from north was significantly high compared to south (p<0.001) with no difference in lecithin and bile salts (p NS). Except for one sample each from north and south, the cholesterol solubility of controls was within the critical micellar zone. Mixed GS were most frequent in north India (61.9 %) while pigment GS dominated in south (61.9 %). The median cholesterol concentration in bile samples of cholecystectomy patients from north India was significantly high GS (p < 0.00001) with significant lowering of bile salts and lecithin (p < 0.00001). In south India, patients with mixed GS had high cholesterol content in bile compared to controls and patients with pigment GS; bile in latter had significantly higher concentration of bile salt compared to controls and mixed GS. The ternary plot confirmed the composition of GB bile from north and south India. Gallbladder bile in controls and patients with GS from north India had significantly high cholesterol concentration. In south India, patients with mixed GS had cholesterol rich bile while pigment GS had higher concentrations of bile salts.

Case mix adjusted variation in cesarean section rate in Sweden.

PubMed

Mesterton, Johan; Ladfors, Lars; Ekenberg Abreu, Anna; Lindgren, Peter; Saltvedt, Sissel; Weichselbraun, Marianne; Amer-Wåhlin, Isis

2017-05-01

Cesarean section (CS) rate is a well-established indicator of performance in maternity care and is also related to resource use. Case mix adjustment of CS rates when performing comparisons between hospitals is important. The objective of this study was to estimate case mix adjusted variation in CS rate between hospitals in Sweden. In total, 139 756 deliveries in 2011 and 2012 were identified in administrative systems in seven regions covering 67% of all deliveries in Sweden. Data were linked to the Medical birth register and population data. Twenty-three different sociodemographic and clinical characteristics were used for adjustment. Analyses were performed for the entire study population as well as for two subgroups. Logistic regression was used to analyze differences between hospitals. The overall CS rate was 16.9% (hospital minimum-maximum 12.1-22.6%). Significant variations in CS rate between hospitals were observed after case mix adjustment: hospital odds ratios for CS varied from 0.62 (95% CI 0.53-0.73) to 1.45 (95% CI 1.37-1.52). In nulliparous, cephalic, full-term, singletons the overall CS rate was 14.3% (hospital minimum-maximum: 9.0-19.0%), whereas it was 4.7% for multiparous, cephalic, full-term, singletons with no previous CS (hospital minimum-maximum: 3.2-6.7%). In both subgroups significant variations were observed in case mix adjusted CS rates. Significant differences in CS rate between Swedish hospitals were found after adjusting for differences in case mix. This indicates a potential for fewer interventions and lower resource use in Swedish childbirth care. Best practice sharing and continuous monitoring are important tools for improving childbirth care. © 2017 Nordic Federation of Societies of Obstetrics and Gynecology.

Audit, guidelines and standards: clinical governance for hip fracture care in Scotland.

PubMed

Currie, Colin T; Hutchison, James D

To report on experience of national-level audit, guidelines and standards for hip fracture care in Scotland. Scottish Hip Fracture Audit (from 1993) documents case-mix, process and outcomes of hip fracture care in Scotland. Evidence-based national guidelines on hip fracture care are available (1997, updated 2002). Hip fracture serves as a tracer condition by the health quality assurance authority for its work on older people, which reported in 2004. Audit data are used locally to document care and support and monitor service developments. Synergy between the guidelines and the audit provides a means of improving care locally and monitoring care nationally. External review by the quality assurance body shows to what extent guideline-based standards relating to A&E care, pre-operative delay, multidisciplinary care and audit participation are met. Three national-level initiatives on hip fracture care have delivered: Reliable and large-scale comparative information on case-mix, care and outcomes; evidence-based recommendations on care; and nationally accountable standards inspected and reported by the national health quality assurance authority. These developments are linked and synergistic, and enjoy both clinical and managerial support. They provide an evolving framework for clinical governance, with casemix-adjusted outcome assessment for hip fracture care as a next step.

Comparison of Mixing Calculations for Reacting and Non-Reacting Flows in a Cylindrical Duct

NASA Technical Reports Server (NTRS)

Oechsle, V. L.; Mongia, H. C.; Holdeman, J. D.

1994-01-01

A production 3-D elliptic flow code has been used to calculate non-reacting and reacting flow fields in an experimental mixing section relevant to a rich burn/quick mix/lean burn (RQL) combustion system. A number of test cases have been run to assess the effects of the variation in the number of orifices, mass flow ratio, and rich-zone equivalence ratio on the flow field and mixing rates. The calculated normalized temperature profiles for the non-reacting flow field agree qualitatively well with the normalized conserved variable isopleths for the reacting flow field indicating that non-reacting mixing experiments are appropriate for screening and ranking potential rapid mixing concepts. For a given set of jet momentum-flux ratio, mass flow ratio, and density ratio (J, MR, and DR), the reacting flow calculations show a reduced level of mixing compared to the non-reacting cases. In addition, the rich-zone equivalence ratio has noticeable effect on the mixing flow characteristics for reacting flows.

Mixed Streptococcus pneumoniae and Streptococcus pyogenes meningitis in an immunocompromised adult patient: a case report.

PubMed

Demerle, Clémence; Ivanov, Vadim; Mercier, Cédric; Costello, Régis; Drancourt, Michel

2015-11-29

Community-acquired meningitis is a monomicrobial infection caused by either viruses or bacteria in the vast majority of patients. We report here one exceptional case of a patient with mixed bacterial meningitis due to Streptococcus pneumoniae and Streptococcus pyogenes. We report the case of a 68-year-old immunocompromised Caucasian man suffering from otitis and then meningitis caused by Streptococcus pneumoniae and Streptococcus pyogenes. Bacteria were undistinguishable by direct microscopic examination of the cerebrospinal fluid. He responded well to treatment with cefotaxime and dexamethasone, with no sequelae observed at the 4-month follow-up. This first reported case of mixed S. pneumoniae and S. pyogenes meningitis illustrates the life-threatening consequences of barotrauma in immunocompromised patients suffering from otorhinolaryngeal infections.

Spatial variation of charge and sulfur oxidation state in a surface gradient affects plasma proteins adsorption

PubMed Central

Ding, Yong-Xue; Streitmatter, Seth; Wright, Bryon E.; Hlady, Vladimir

2010-01-01

A gradient of negative surface charge based on 1-D spatial variation from surface sulfhydryl to mixed sulfhydryl-sulfonate moities was prepared by controlled UV oxidation of 3-mercaptopropylsilane monolayer on fused silica. Adsorption of three human plasma proteins, albumin (HSA), immunoglobulin G (IgG), and fibrinogen (Fgn) onto such surface gradient was studied using spatially-resolved total internal reflection fluorescence (TIRF) and autoradiography. Adsorption was measured from dilute solutions equivalent to 1/100 (TIRF, autoradiography), and 1/500 and 1/1000 (autoradiography) of protein’s physiological concentrations in plasma. All three proteins adsorbed more to the non-oxidized sulfhydryl region than to the oxidized, mixed sulfhydryl-sulfonate region of the gradient. In the case of HSA the adsorption contrast along the gradient was largest when the adsorption took place from more dilute protein solutions. Increasing the concentration to 1/100 of protein plasma concentration eliminated the effect of the gradient on HSA adsorption and to the lesser extent on IgG adsorption. In the case of Fgn the greatest adsorption contrast was observed at the highest concentration used. Based on adsorption kinetics, the estimated binding affinity of HSA for the sulfhydryl region what twice the affinity for the mixed sulfhydryl-sulfonate region of the gradient. For IgG and Fgn the initial adsorption was transport-limited and the initial adsorption rates approached the computed flux of the protein to the surface. PMID:20568822

Housing Mix, School Mix: Barriers to Success

ERIC Educational Resources Information Center

Camina, M. M.; Iannone, P.

2014-01-01

Recent UK policy has emphasised both the development of socially mixed communities and the creation of balanced school intakes. In this paper, we use a case study of an area of mixed tenure in eastern England to explore policy in practice and the extent to which mechanisms of segregation impact on both the creation of socially mixed neighbourhoods…

Modification of Asian-dust particles transported by different routes - A case study

NASA Astrophysics Data System (ADS)

Zaizen, Yuji; Naoe, Hiroaki; Takahashi, Hiroshi; Okada, Kikuo

2014-11-01

Two separate Asian dust events occurred before and after the passage of a cold front over Japan on 21 March 2010. According to back trajectories and a model simulation, the two dusty air-masses originated from the same region in Mongoria or northern China and were transported over different routes to Japan. Samples of aerosol particles from both airmasses were collected at Tsukuba and Mt. Haruna and examined by single-particle analysis using a transmission electron microscope and an energy dispersive X-ray analyzer. The mixing properties of mineral aerosol were quite different in the two airmasses and size ranges. In the prefrontal airmass, which were associated with pollution, most of fine (<1 μm) mineral aerosol was internally mixed with sulfate. On the contrary, mineral aerosols in the postfront airmass, which were relatively natural, were mostly externally mixed. In the latter case, the internal mixing was associated with Ca, however in the former case, mixing processes not concerning mineralogy was suggested.

Case mix management in context.

PubMed

King, H

1988-02-01

The advent of DRGs has demanded that hospitals account for all costs and resources. A case mix management system must take into consideration every component of a total managerial accounting strategy. This article discusses the factors healthcare institutions need to address to achieve a completely interfaced accounting system.

Cancer patient experience, hospital performance and case mix: evidence from England.

PubMed

Abel, Gary A; Saunders, Catherine L; Lyratzopoulos, Georgios

2014-01-01

  This study aims to explore differences between crude and case mix-adjusted estimates of hospital performance with respect to the experience of cancer patients. This study analyzed the English 2011/2012 Cancer Patient Experience Survey covering all English National Health Service hospitals providing cancer treatment (n = 160). Logistic regression analysis was used to predict hospital performance for each of the 64 evaluative questions, adjusting for age, gender, ethnic group and cancer diagnosis. The degree of reclassification was explored across three categories (bottom 20%, middle 60% and top 20% of hospitals). There was high concordance between crude and adjusted ranks of hospitals (median Kendall's τ = 0.84; interquartile range: 0.82-0.88). Across all questions, a median of 5.0% (eight) of hospitals (interquartile range: 3.8-6.4%; six to ten hospitals) moved out of the extreme performance categories after case mix adjustment. In this context, patient case mix has only a small impact on measured hospital performance for cancer patient experience.

The Pediatric Home Care/Expenditure Classification Model (P/ECM): A Home Care Case-Mix Model for Children Facing Special Health Care Challenges.

PubMed

Phillips, Charles D

2015-01-01

Case-mix classification and payment systems help assure that persons with similar needs receive similar amounts of care resources, which is a major equity concern for consumers, providers, and programs. Although health service programs for adults regularly use case-mix payment systems, programs providing health services to children and youth rarely use such models. This research utilized Medicaid home care expenditures and assessment data on 2,578 children receiving home care in one large state in the USA. Using classification and regression tree analyses, a case-mix model for long-term pediatric home care was developed. The Pediatric Home Care/Expenditure Classification Model (P/ECM) grouped children and youth in the study sample into 24 groups, explaining 41% of the variance in annual home care expenditures. The P/ECM creates the possibility of a more equitable, and potentially more effective, allocation of home care resources among children and youth facing serious health care challenges.

The Pediatric Home Care/Expenditure Classification Model (P/ECM): A Home Care Case-Mix Model for Children Facing Special Health Care Challenges

PubMed Central

Phillips, Charles D.

2015-01-01

Case-mix classification and payment systems help assure that persons with similar needs receive similar amounts of care resources, which is a major equity concern for consumers, providers, and programs. Although health service programs for adults regularly use case-mix payment systems, programs providing health services to children and youth rarely use such models. This research utilized Medicaid home care expenditures and assessment data on 2,578 children receiving home care in one large state in the USA. Using classification and regression tree analyses, a case-mix model for long-term pediatric home care was developed. The Pediatric Home Care/Expenditure Classification Model (P/ECM) grouped children and youth in the study sample into 24 groups, explaining 41% of the variance in annual home care expenditures. The P/ECM creates the possibility of a more equitable, and potentially more effective, allocation of home care resources among children and youth facing serious health care challenges. PMID:26740744

Analyzing Association Mapping in Pedigree-Based GWAS Using a Penalized Multitrait Mixed Model

PubMed Central

Liu, Jin; Yang, Can; Shi, Xingjie; Li, Cong; Huang, Jian; Zhao, Hongyu; Ma, Shuangge

2017-01-01

Genome-wide association studies (GWAS) have led to the identification of many genetic variants associated with complex diseases in the past 10 years. Penalization methods, with significant numerical and statistical advantages, have been extensively adopted in analyzing GWAS. This study has been partly motivated by the analysis of Genetic Analysis Workshop (GAW) 18 data, which have two notable characteristics. First, the subjects are from a small number of pedigrees and hence related. Second, for each subject, multiple correlated traits have been measured. Most of the existing penalization methods assume independence between subjects and traits and can be suboptimal. There are a few methods in the literature based on mixed modeling that can accommodate correlations. However, they cannot fully accommodate the two types of correlations while conducting effective marker selection. In this study, we develop a penalized multitrait mixed modeling approach. It accommodates the two different types of correlations and includes several existing methods as special cases. Effective penalization is adopted for marker selection. Simulation demonstrates its satisfactory performance. The GAW 18 data are analyzed using the proposed method. PMID:27247027

[Clinical, pathological and imaging features of primary pelvic Ewing's sarcoma].

PubMed

Liu, J; Chen, Y; Ling, X L; Gong, Y; Ding, J P; Zhang, Z K; Wang, Y J

2016-07-19

To explore the clinical, pathological and imaging features of Ewing's sarcoma in pelvis and to improve knowledge and diagnosis of the disease. A retrospective analysis of the clinical, pathological and imaging data of pathologically confirmed 13 cases of Ewing's sarcoma in pelvis was carried out between May 2008 and March 2016 in the Affiliated Hospital of Hangzhou Normal University, the Third Hospital of Hebei Medical University and the Second Hospital of Hebei Medical University. The median age 13 cases of pelvic primary Ewing's sarcoma was 17 years old.The X-ray and CT imagings showed osteolytic and mixed bone destruction, CT showed mixed type in 10 cases, 8 cases of bone tumors as a flocculent, 10 cases of bone expansion failure, 10 cases of periosteal reaction, the layered 5 cases, radial in 5 cases.Thirteen cases showed soft tissue mass, soft tissue mass was equal or slightly lower density.Four cases showed heterogeneous contrast enhancement.The lesions showed low signal in T1WI and mixed high signal in T2WI of magnetic resonance imaging(MRI). The boundary of the lesions were obscure, and 5 cases had patchy necrosis area, and 9 cases had incomplete false capsule, surrounding soft tissue was violated.Four cases showed heterogeneous contrast enhancement after MRI enhancement scan. The age of onset of Ewing's sarcoma of the pelvis is more concentrated in about 15 years.The imaging feaures are mixed bone destruction and more bone is swelling and permeability damage, soft tissue mass is larger, bone tumor is cloudy or acicular, periosteal reaction in a layered and radial, most cases show that the false envelope is not complete.Combined with clinical and imaging examination, the diagnosis of the disease can be made.

SU-C-207A-05: Feature Based Water Equivalent Path Length (WEPL) Determination for Proton Radiography by the Technique of Time Resolved Dose Measurement

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zhang, R; Jee, K; Sharp, G

Purpose: Studies show that WEPL can be determined from modulated dose rate functions (DRF). However, the previous calibration method based on statistics of the DRF is sensitive to energy mixing of protons due to scattering through different materials (termed as range mixing here), causing inaccuracies in the determination of WEPL. This study intends to explore time-domain features of the DRF to reduce the effect of range mixing in proton radiography (pRG) by this technique. Methods: An amorphous silicon flat panel (PaxScan™ 4030CB, Varian Medical Systems, Inc., Palo Alto, CA) was placed behind phantoms to measure DRFs from a proton beammore » modulated by a specially designed modulator wheel. The performance of two methods, the previously used method based on the root mean square (RMS) and the new approach based on time-domain features of the DRF, are compared for retrieving WEPL and RSP from pRG of a Gammex phantom. Results: Calibration by T{sub 80} (the time point for 80% of the major peak) was more robust to range mixing and produced WEPL with improved accuracy. The error of RSP was reduced from 8.2% to 1.7% for lung equivalent material, with the mean error for all other materials reduced from 1.2% to 0.7%. The mean error of the full width at half maximum (FWHM) of retrieved inserts was decreased from 25.85% to 5.89% for the RMS and T{sub 80} method respectively. Monte Carlo simulations in simplified cases also demonstrated that the T{sub 80} method is less sensitive to range mixing than the RMS method. Conclusion: WEPL images have been retrieved based on single flat panel measured DRFs, with inaccuracies reduced by exploiting time-domain features as the calibration parameter. The T{sub 80} method is validated to be less sensitive to range mixing and can thus retrieve the WEPL values in proximity of interfaces with improved numerical and spatial accuracy for proton radiography.« less

Fine needle aspiration cytology of subcutaneous cysticercosis of the breast. Case report and pathogenic discussion.

PubMed

Vuong, P N

1989-01-01

A case of subcutaneous cysticercosis of the breast diagnosed by fine needle aspiration cytology is reported. The cytologic preparations showed the presence of many inflammatory cells mixed with spiked spherules resembling the rambutan tropical fruit. These spherules arose from the degenerated integument of the parasite found in the histologically excised cyst. They are suggestive of the presence of an encysted flat worm, but are not specific for cysticercosis, whose identification is based on the study of the cephalic extremity of the parasite.

Establishing treatment protocols for clinical mastitis.

PubMed

Roberson, Jerry R

2003-03-01

Each farm has a unique mix of mastitis pathogens and management procedures that have evolved over time. The herd veterinarian should work with the manager/owner to systematically develop treatment protocols that meet the needs and management of the farm. To establish a mastitis treatment protocol, it is necessary to develop a system to routinely identify clinical mastitis cases, develop a herd-specific severity level assessment system, manage the clinical mastitis cases based on severity level and culture result (when available), avoid antibiotic residues, and monitor the success of the system and alter the protocol as necessary.

Drug utilization review of potassium chloride injection formulations available in a private hospital in kuching, sarawak, malaysia.

PubMed

Melissa, Mohammad Hirman; Azmi, Sarriff

2013-07-01

The concentrated potassium chloride injection is a high-alert medication and replacing it with a pre-mixed formulation can reduce the risks associated with its use. The aim of this study was to determine the clinical characteristics of patients receiving different potassium chloride formulations available at a private institution. The study also assessed the effectiveness and safety of pre-mixed formulations in the correction of hypokalaemia. This was a retrospective observational study consisting of 296 cases using concentrated and pre-mixed potassium chloride injections in 2011 in a private hospital in Kuching, Sarawak, Malaysia. There were 135 (45.6%) cases that received concentrated potassium chloride, and 161 (54.4%) cases that received pre-mixed formulations. The patients' clinical characteristics that were significantly related to the utilization of the different formulations were diagnosis (P < 0.001), potassium serum blood concentration (P < 0.05), and fluid overload risk (P < 0.05). The difference observed for the cases that achieved or maintained normokalaemia was statistically insignificant (P = 0.172). Infusion-related adverse effects were seen more in pre-mixes compared to concentrated formulations (6.8% versus 2.2%, P < 0.05). This study provides insight into the utilization of potassium chloride injections at this specific institution. The results support current recommendations to use pre-mixed formulations whenever possible.

Simple removable appliances to correct anterior and posterior crossbite in mixed dentition: Case report

PubMed Central

Bindayel, Naif A.

2012-01-01

Different techniques have been used to correct anterior and posterior crossbites in mixed dentition. This case report illustrates the treatment of anterior and unilateral posterior crossbites during the mixed dentition. The patient was a 9-year-old boy with a crossbite of the maxillary right permanent central incisor and a unilateral right posterior crossbite, both expressed by a functional shift in the sagittal and transverse dimensions. Two upper acrylic removable appliances, each with an expansion jackscrew, were used to correct the crossbites. The total active treatment time was 4 months; the treatment outcomes were successfully maintained for the subsequent 4 months. General and pediatric dentists, as well as orthodontists, may find this technique useful in managing crossbite cases of the mixed dentition and utilizing the discussion and illustrations for further clinical guidance. PMID:23960537

Adaptive computations of multispecies mixing between scramjet nozzle flows and hypersonic freestream

NASA Technical Reports Server (NTRS)

Baysa, Oktay; Engelund, Walter C.; Eleshaky, Mohamed E.; Pittman, James L.

1989-01-01

The objective of this paper is to compute the expansion of a supersonic flow through an internal-external nozzle and its viscous mixing with the hypersonic flow of air. The supersonic jet may be that of a multispecies gas other than air. Calculations are performed for one case where both flows are those of air, and another case where a mixture of freon-12 and argon is discharged supersonically to mix with the hypersonic airflow. Comparisons are made between these two cases with respect to gas compositions, and fixed versus flow-adaptive grids. All the computational results are compared successfully with the wind-tunnel tests results.

Do case-mix adjusted nursing home reimbursements actually reflect costs? Minnesota's experience.

PubMed

Nyman, J A; Connor, R A

1994-07-01

Some states have adopted Medicaid reimbursement systems that pay nursing homes according to patient type. These case-mix adjusted reimbursements are intended in part to eliminate the incentive in prospective systems to exclude less profitable patients. This study estimates the marginal costs of different patient types under Minnesota's case-mix system and compares them to their corresponding reimbursements. We find that estimated costs do not match reimbursement rates, again making some patient types less profitable than others. Further, in confirmation of our estimates, we find that the percentage change in patient days between 1986 and 1990 is explained by our profitability estimates.

Mixed effects versus fixed effects modelling of binary data with inter-subject variability.

PubMed

Murphy, Valda; Dunne, Adrian

2005-04-01

The question of whether or not a mixed effects model is required when modelling binary data with inter-subject variability and within subject correlation was reported in this journal by Yano et al. (J. Pharmacokin. Pharmacodyn. 28:389-412 [2001]). That report used simulation experiments to demonstrate that, under certain circumstances, the use of a fixed effects model produced more accurate estimates of the fixed effect parameters than those produced by a mixed effects model. The Laplace approximation to the likelihood was used when fitting the mixed effects model. This paper repeats one of those simulation experiments, with two binary observations recorded for every subject, and uses both the Laplace and the adaptive Gaussian quadrature approximations to the likelihood when fitting the mixed effects model. The results show that the estimates produced using the Laplace approximation include a small number of extreme outliers. This was not the case when using the adaptive Gaussian quadrature approximation. Further examination of these outliers shows that they arise in situations in which the Laplace approximation seriously overestimates the likelihood in an extreme region of the parameter space. It is also demonstrated that when the number of observations per subject is increased from two to three, the estimates based on the Laplace approximation no longer include any extreme outliers. The root mean squared error is a combination of the bias and the variability of the estimates. Increasing the sample size is known to reduce the variability of an estimator with a consequent reduction in its root mean squared error. The estimates based on the fixed effects model are inherently biased and this bias acts as a lower bound for the root mean squared error of these estimates. Consequently, it might be expected that for data sets with a greater number of subjects the estimates based on the mixed effects model would be more accurate than those based on the fixed effects model. This is borne out by the results of a further simulation experiment with an increased number of subjects in each set of data. The difference in the interpretation of the parameters of the fixed and mixed effects models is discussed. It is demonstrated that the mixed effects model and parameter estimates can be used to estimate the parameters of the fixed effects model but not vice versa.

Parametric Study of a Mixer/Ejector Nozzle with Mixing Enhancement Devices

NASA Technical Reports Server (NTRS)

DalBello, T.; Steffen, C. J., Jr.

2001-01-01

A numerical study employing a simplified model of the High Speed Civil Transport mixer/ejector nozzle has been conducted to investigate the effect of tabs (vortex generators) on the mixing process. More complete mixing of the primary and secondary flows within the confined ejector lowers peak exit velocity resulting in reduced jet noise. Tabs were modeled as vortex pairs and inserted into the computational model. The location, size, and number of tabs were varied and its effect on the mixing process is presented here both quantitatively and qualitatively. A baseline case (no tabs) along with six other cases involving two different vortex strengths at three different orientations have been computed and analyzed. The case with the highest vorticity (six vortices representing large tabs) gives the best mixing. It is shown that the influence of the vorticity acts primarily in the forward or middle portions of the duct, significantly alters the flow structure, and promotes some mixing in the lateral direction. Unmixed pockets were found at the top and bottom of the lobe, and more clever placement of tabs improved mixing in the vertical direction. The technique of replacing tabs with vortices shows promise as an efficient tool for quickly optimizing tab placement in lobed mixers.

Heart Failure Virtual Consultation: bridging the gap of heart failure care in the community - A mixed-methods evaluation.

PubMed

Gallagher, Joseph; James, Stephanie; Keane, Ciara; Fitzgerald, Annie; Travers, Bronagh; Quigley, Etain; Hecht, Christina; Zhou, Shuaiwei; Watson, Chris; Ledwidge, Mark; McDonald, Kenneth

2017-08-01

We undertook a mixed-methods evaluation of a Web-based conferencing service (virtual consult) between general practitioners (GPs) and cardiologists in managing patients with heart failure in the community to determine its effect on use of specialist heart failure services and acceptability to GPs. All cases from June 2015 to October 2016 were recorded using a standardized recording template, which recorded patient demographics, medical history, medications, and outcome of the virtual consult for each case. Quantitative surveys and qualitative interviewing of 17 participating GPs were also undertaken. During this time, 142 cases were discussed-68 relating to a new diagnosis of heart failure, 53 relating to emerging deterioration in a known heart failure patient, and 21 relating to therapeutic issues. Only 17% required review in outpatient department following the virtual consultation. GPs reported increased confidence in heart failure management, a broadening of their knowledge base, and a perception of overall better patient outcomes. These data from an initial experience with Heart Failure Virtual Consultation present a very positive impact of this strategy on the provision of heart failure care in the community and acceptability to users. Further research on the implementation and expansion of this strategy is warranted. © 2017 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.

Omohyoid Muscle Syndrome in a Mixed Martial Arts Athlete: A Case Report.

PubMed

Lee, Alexander D; Yu, Alexander; Young, Shayne B; Battaglia, Patrick J; Ho, C John

2015-01-01

Omohyoid muscle syndrome is a rare cause of an X-shaped bulging lateral neck mass that occurs on swallowing. This is a diagnostic case report of a 22-year-old mixed martial arts athlete who acquired this condition. © 2014 The Author(s).

Assessing Discriminative Performance at External Validation of Clinical Prediction Models

PubMed Central

Nieboer, Daan; van der Ploeg, Tjeerd; Steyerberg, Ewout W.

2016-01-01

Introduction External validation studies are essential to study the generalizability of prediction models. Recently a permutation test, focusing on discrimination as quantified by the c-statistic, was proposed to judge whether a prediction model is transportable to a new setting. We aimed to evaluate this test and compare it to previously proposed procedures to judge any changes in c-statistic from development to external validation setting. Methods We compared the use of the permutation test to the use of benchmark values of the c-statistic following from a previously proposed framework to judge transportability of a prediction model. In a simulation study we developed a prediction model with logistic regression on a development set and validated them in the validation set. We concentrated on two scenarios: 1) the case-mix was more heterogeneous and predictor effects were weaker in the validation set compared to the development set, and 2) the case-mix was less heterogeneous in the validation set and predictor effects were identical in the validation and development set. Furthermore we illustrated the methods in a case study using 15 datasets of patients suffering from traumatic brain injury. Results The permutation test indicated that the validation and development set were homogenous in scenario 1 (in almost all simulated samples) and heterogeneous in scenario 2 (in 17%-39% of simulated samples). Previously proposed benchmark values of the c-statistic and the standard deviation of the linear predictors correctly pointed at the more heterogeneous case-mix in scenario 1 and the less heterogeneous case-mix in scenario 2. Conclusion The recently proposed permutation test may provide misleading results when externally validating prediction models in the presence of case-mix differences between the development and validation population. To correctly interpret the c-statistic found at external validation it is crucial to disentangle case-mix differences from incorrect regression coefficients. PMID:26881753

Assessing Discriminative Performance at External Validation of Clinical Prediction Models.

PubMed

Nieboer, Daan; van der Ploeg, Tjeerd; Steyerberg, Ewout W

2016-01-01

External validation studies are essential to study the generalizability of prediction models. Recently a permutation test, focusing on discrimination as quantified by the c-statistic, was proposed to judge whether a prediction model is transportable to a new setting. We aimed to evaluate this test and compare it to previously proposed procedures to judge any changes in c-statistic from development to external validation setting. We compared the use of the permutation test to the use of benchmark values of the c-statistic following from a previously proposed framework to judge transportability of a prediction model. In a simulation study we developed a prediction model with logistic regression on a development set and validated them in the validation set. We concentrated on two scenarios: 1) the case-mix was more heterogeneous and predictor effects were weaker in the validation set compared to the development set, and 2) the case-mix was less heterogeneous in the validation set and predictor effects were identical in the validation and development set. Furthermore we illustrated the methods in a case study using 15 datasets of patients suffering from traumatic brain injury. The permutation test indicated that the validation and development set were homogenous in scenario 1 (in almost all simulated samples) and heterogeneous in scenario 2 (in 17%-39% of simulated samples). Previously proposed benchmark values of the c-statistic and the standard deviation of the linear predictors correctly pointed at the more heterogeneous case-mix in scenario 1 and the less heterogeneous case-mix in scenario 2. The recently proposed permutation test may provide misleading results when externally validating prediction models in the presence of case-mix differences between the development and validation population. To correctly interpret the c-statistic found at external validation it is crucial to disentangle case-mix differences from incorrect regression coefficients.

Mixed Methods in Emerging Academic Subdisciplines: The Case of Sport Management

ERIC Educational Resources Information Center

van der Roest, Jan-Willem; Spaaij, Ramón; van Bottenburg, Maarten

2015-01-01

This article examines the prevalence and characteristics of mixed methods research in the relatively new subdiscipline of sport management. A mixed methods study is undertaken to evaluate the epistemological/philosophical, methodological, and technical levels of mixed methods design in sport management research. The results indicate that mixed…

On-orbit servicing system assessment and optimization methods based on lifecycle simulation under mixed aleatory and epistemic uncertainties

NASA Astrophysics Data System (ADS)

Yao, Wen; Chen, Xiaoqian; Huang, Yiyong; van Tooren, Michel

2013-06-01

To assess the on-orbit servicing (OOS) paradigm and optimize its utilities by taking advantage of its inherent flexibility and responsiveness, the OOS system assessment and optimization methods based on lifecycle simulation under uncertainties are studied. The uncertainty sources considered in this paper include both the aleatory (random launch/OOS operation failure and on-orbit component failure) and the epistemic (the unknown trend of the end-used market price) types. Firstly, the lifecycle simulation under uncertainties is discussed. The chronological flowchart is presented. The cost and benefit models are established, and the uncertainties thereof are modeled. The dynamic programming method to make optimal decision in face of the uncertain events is introduced. Secondly, the method to analyze the propagation effects of the uncertainties on the OOS utilities is studied. With combined probability and evidence theory, a Monte Carlo lifecycle Simulation based Unified Uncertainty Analysis (MCS-UUA) approach is proposed, based on which the OOS utility assessment tool under mixed uncertainties is developed. Thirdly, to further optimize the OOS system under mixed uncertainties, the reliability-based optimization (RBO) method is studied. To alleviate the computational burden of the traditional RBO method which involves nested optimum search and uncertainty analysis, the framework of Sequential Optimization and Mixed Uncertainty Analysis (SOMUA) is employed to integrate MCS-UUA, and the RBO algorithm SOMUA-MCS is developed. Fourthly, a case study on the OOS system for a hypothetical GEO commercial communication satellite is investigated with the proposed assessment tool. Furthermore, the OOS system is optimized with SOMUA-MCS. Lastly, some conclusions are given and future research prospects are highlighted.

Three-dimensional structure of the curved mixing layer using image reconstruction and volume rendering

NASA Astrophysics Data System (ADS)

Karasso, P. S.; Mungal, M. G.

1991-05-01

This study investigates the structure and mixing of the two-dimensional turbulent mixing layer when subjected to longitudinal streamwise curvature. The straight layer is now well known to be dominated by the primary Kelvin-Helmholtz (KH) instability as well as the secondary Taylor-Goertler (TG) instability. For equal density fluids, placing the high-speed fluid on the inside of a streamwise bend causes the TG instability to be enhanced (unstable case), while placing the low-speed fluid on the inside of the same bend leads to the suppression of the TG instability (stable case). The location of the mixing transition is correspondingly altered. Our goal is to study the changes to the mixing field and growth rate resulting from the competition between instabilities. Our studies are performed in a newly constructed blow-down water facility capable of high Reynolds numbers and excellent optical access. Maximum flow speeds are 2 and 0.25 m/sec for the high- and low-speed sides, respectively, leading to maximum Reynolds numbers of 80 000 based on velocity difference and the width of the layer. We are able to dye one stream with a fluorescent dye, thus providing several planar views of the flow under laser sheet illumination. These views are superior to conventional approaches as they are free of wall effects and are not spatially integrating. However, our most useful diagnostic of the structure of the flow is the ability to record high-speed images of the end view of the flow that are then reconstructed by computer using the volume rendering technique of Jiménez et al.1 This approach is especially useful as it allows us to compare the structural changes to the flow resulting from the competition between the KH and TG instabilities. Another advantage is the fact that several hundred frames, covering many characteristic times, are incorporated into the rendered image and thus capture considerably more flow physics than do still images. We currently have our rendering techniques fully operational,2 and are presently acquiring high quality high-speed movies of the various flow cases. Our findings to date, based on planar time-averaged and instantaneous views, show the following: (1) a 50% increase in growth rate from the stable to the unstable case resulting from mild curvature; (2) an enhancement of the TG vortices in the unstable case, but without major disruption of the KH instability which remains relatively intact; and (3) the occurrence of the KH instability at angles tilted with respect to the splitter plate tip, in agreement with the predictions of linear stability theory. This final observation has not been reported to date, primarily because sheet techniques have not been used at Reynolds numbers as high as the present study. The presentation will provide detailed views of the changes between the stable, straight, and unstable cases using our volume rendering approach, and will provide statistical measures such as changes to vortex spacing and size, to quantify such changes.

Mixed community-acquired pneumonia in hospitalised patients.

PubMed

de Roux, A; Ewig, S; García, E; Marcos, M A; Mensa, J; Lode, H; Torres, A

2006-04-01

The role of mixed community-acquired pneumonia (CAP) is controversial. The aim of the present study was to determine the incidence, principal microbial patterns, clinical predictors and course of mixed CAP. The current study included 1,511 consecutive hospitalised patients with CAP. Of these, 610 (40%) patients had an established aetiology. One pathogen was demonstrated in 528 patients and 82 (13%) patients had mixed pneumonia. Cases including CAP, by a pyogenic bacteria and a complete paired serology for "atypicals", revealed that 82 (13%) patients had definite single pyogenic pneumonia and 28 patients (5%) had mixed pyogenic pneumonia. In patients with mixed CAP, Streptococcus pneumoniae was the most prevalent microorganism (44 out of 82; 54%). The most frequent combination was S. pneumoniae with Haemophilus influenzae (17 out of 82; 21%). Influenza virus A and S. pneumoniae (five out of 28; 18%) was the most frequent association in the mixed pyogenic pneumonia group. No clinical predictors for mixed pneumonias could be identified. Patients with mixed pyogenic pneumonia more frequently developed shock when compared with patients with single pyogenic pneumonia (18 versus 4%). In conclusion, mixed pneumonia occurs in >10% of cases with community-acquired pneumonia requiring hospitalisation.

Directional nonlinear guided wave mixing: Case study of counter-propagating shear horizontal waves

NASA Astrophysics Data System (ADS)

Hasanian, Mostafa; Lissenden, Cliff J.

2018-04-01

While much nonlinear ultrasonics research has been conducted on higher harmonic generation, wave mixing provides the potential for sensitive measurements of incipient damage unencumbered by instrumentation nonlinearity. Studies of nonlinear ultrasonic wave mixing, both collinear and noncollinear, for bulk waves have shown the robust capability of wave mixing for early damage detection. One merit of bulk wave mixing lies in their non-dispersive nature, but guided waves enable inspection of otherwise inaccessible material and a variety of mixing options. Co-directional guided wave mixing was studied previously, but arbitrary direction guided wave mixing has not been addressed until recently. Wave vector analysis is applied to study variable mixing angles to find wave mode triplets (two primary waves and a secondary wave) resulting in the phase matching condition. As a case study, counter-propagating Shear Horizontal (SH) guided wave mixing is analyzed. SH wave interactions generate a secondary Lamb wave mode that is readily receivable. Reception of the secondary Lamb wave mode is compared for an angle beam transducer, an air coupled transducer, and a laser Doppler vibrometer (LDV). Results from the angle beam and air coupled transducers are quite consistent, while the LDV measurement is plagued by variability issues.

The Art of Empathy: A Mixed Methods Case Study of a Critical Place-Based Art Education Program

ERIC Educational Resources Information Center

Bertling, Joy G.

2015-01-01

Bowers (2001) described how our ecological crisis is marked by metaphors of difference and separation. By adopting an ecological paradigm, students have the opportunity to move past harmful distinctions that have characterized relations with the earth. Instead, students can move to a deep recognition of the interconnectedness of living things.…

Veterans Coming Home to the Community College: Linking Research to Practice

ERIC Educational Resources Information Center

Persky, Karen R.; Oliver, Diane E.

2011-01-01

Community colleges must prepare for change as increasing numbers of students who are veterans of the Iraq and Afghanistan Wars use their post-9/11 GI Bill benefits to join the colleges' diverse student bodies. Based on the findings of a mixed methods case study, needs of veterans at the community college are framed and discussed within five major…

Place Matters: A Mixed Methods Case Study of Institutional Place-Building in Higher Education

ERIC Educational Resources Information Center

Raykes, Jeffrey Stuart

2017-01-01

Colleges and universities are being increasingly recognized as key contributors to the well-being of the places in which they are located. However, in spite of the promise and potential of place-based engagement, there is little agreement about what place and place-building means or how these concepts can be operationalized in within the context…

A Design-Based Research Approach to Improving Professional Development and Teacher Knowledge: The Case of the Smithsonian Learning Lab

ERIC Educational Resources Information Center

Zinger, Doron; Naranjo, Ashley; Amador, Isabel; Gilbertson, Nicole; Warschauer, Mark

2017-01-01

Incorporating technology in classrooms to promote student learning is an ongoing instructional challenge. Teacher professional development (PD) is a central component of teacher education to support student use of technology and can improve student learning, but PD has had mixed results. In this study, researchers investigated a PD program…

The Effect of a Community College Promise Scholarship on Access and Success

ERIC Educational Resources Information Center

Pluhta, Elizabeth A.; Penny, G. Richard

2013-01-01

Based on a mixed methods case study design, the current study reports on a Promise Scholarship program offered by a community college and its affiliated foundation to graduating students at a nearby high school located in a low-income neighborhood of a large city and with a high proportion of African American and other students of color. Using a…

Credit BG. View looks west (286°) at the east facade. ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

Credit BG. View looks west (286°) at the east facade. This structure stands between two blast barricades, which protect surrounding structures from damage in case an explosion were to occur while propellants were being mixed in the 150 gallon Baker-Perkins mixer - Jet Propulsion Laboratory Edwards Facility, Mixer, Edwards Air Force Base, Boron, Kern County, CA