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.

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.

Optimizing ACS NSQIP modeling for evaluation of surgical quality and risk: patient risk adjustment, procedure mix adjustment, shrinkage adjustment, and surgical focus.

PubMed

Cohen, Mark E; Ko, Clifford Y; Bilimoria, Karl Y; Zhou, Lynn; Huffman, Kristopher; Wang, Xue; Liu, Yaoming; Kraemer, Kari; Meng, Xiangju; Merkow, Ryan; Chow, Warren; Matel, Brian; Richards, Karen; Hart, Amy J; Dimick, Justin B; Hall, Bruce L

2013-08-01

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) collects detailed clinical data from participating hospitals using standardized data definitions, analyzes these data, and provides participating hospitals with reports that permit risk-adjusted comparisons with a surgical quality standard. Since its inception, the ACS NSQIP has worked to refine surgical outcomes measurements and enhance statistical methods to improve the reliability and validity of this hospital profiling. From an original focus on controlling for between-hospital differences in patient risk factors with logistic regression, ACS NSQIP has added a variable to better adjust for the complexity and risk profile of surgical procedures (procedure mix adjustment) and stabilized estimates derived from small samples by using a hierarchical model with shrinkage adjustment. New models have been developed focusing on specific surgical procedures (eg, "Procedure Targeted" models), which provide opportunities to incorporate indication and other procedure-specific variables and outcomes to improve risk adjustment. In addition, comparative benchmark reports given to participating hospitals have been expanded considerably to allow more detailed evaluations of performance. Finally, procedures have been developed to estimate surgical risk for individual patients. This article describes the development of, and justification for, these new statistical methods and reporting strategies in ACS NSQIP. Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

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.

Iterative usage of fixed and random effect models for powerful and efficient genome-wide association studies

USDA-ARS?s Scientific Manuscript database

False positives in a Genome-Wide Association Study (GWAS) can be effectively controlled by a fixed effect and random effect Mixed Linear Model (MLM) that incorporates population structure and kinship among individuals to adjust association tests on markers; however, the adjustment also compromises t...

The Effect of Adding Comorbidities to Current Centers for Disease Control and Prevention Central-Line-Associated Bloodstream Infection Risk-Adjustment Methodology.

PubMed

Jackson, Sarah S; Leekha, Surbhi; Magder, Laurence S; Pineles, Lisa; Anderson, Deverick J; Trick, William E; Woeltje, Keith F; Kaye, Keith S; Stafford, Kristen; Thom, Kerri; Lowe, Timothy J; Harris, Anthony D

2017-09-01

BACKGROUND Risk adjustment is needed to fairly compare central-line-associated bloodstream infection (CLABSI) rates between hospitals. Until 2017, the Centers for Disease Control and Prevention (CDC) methodology adjusted CLABSI rates only by type of intensive care unit (ICU). The 2017 CDC models also adjust for hospital size and medical school affiliation. We hypothesized that risk adjustment would be improved by including patient demographics and comorbidities from electronically available hospital discharge codes. METHODS Using a cohort design across 22 hospitals, we analyzed data from ICU patients admitted between January 2012 and December 2013. Demographics and International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) discharge codes were obtained for each patient, and CLABSIs were identified by trained infection preventionists. Models adjusting only for ICU type and for ICU type plus patient case mix were built and compared using discrimination and standardized infection ratio (SIR). Hospitals were ranked by SIR for each model to examine and compare the changes in rank. RESULTS Overall, 85,849 ICU patients were analyzed and 162 (0.2%) developed CLABSI. The significant variables added to the ICU model were coagulopathy, paralysis, renal failure, malnutrition, and age. The C statistics were 0.55 (95% CI, 0.51-0.59) for the ICU-type model and 0.64 (95% CI, 0.60-0.69) for the ICU-type plus patient case-mix model. When the hospitals were ranked by adjusted SIRs, 10 hospitals (45%) changed rank when comorbidity was added to the ICU-type model. CONCLUSIONS Our risk-adjustment model for CLABSI using electronically available comorbidities demonstrated better discrimination than did the CDC model. The CDC should strongly consider comorbidity-based risk adjustment to more accurately compare CLABSI rates across hospitals. Infect Control Hosp Epidemiol 2017;38:1019-1024.

Coding response to a case-mix measurement system based on multiple diagnoses.

PubMed

Preyra, Colin

2004-08-01

To examine the hospital coding response to a payment model using a case-mix measurement system based on multiple diagnoses and the resulting impact on a hospital cost model. Financial, clinical, and supplementary data for all Ontario short stay hospitals from years 1997 to 2002. Disaggregated trends in hospital case-mix growth are examined for five years following the adoption of an inpatient classification system making extensive use of combinations of secondary diagnoses. Hospital case mix is decomposed into base and complexity components. The longitudinal effects of coding variation on a standard hospital payment model are examined in terms of payment accuracy and impact on adjustment factors. Introduction of the refined case-mix system provided incentives for hospitals to increase reporting of secondary diagnoses and resulted in growth in highest complexity cases that were not matched by increased resource use over time. Despite a pronounced coding response on the part of hospitals, the increase in measured complexity and case mix did not reduce the unexplained variation in hospital unit cost nor did it reduce the reliance on the teaching adjustment factor, a potential proxy for case mix. The main implication was changes in the size and distribution of predicted hospital operating costs. Jurisdictions introducing extensive refinements to standard diagnostic related group (DRG)-type payment systems should consider the effects of induced changes to hospital coding practices. Assessing model performance should include analysis of the robustness of classification systems to hospital-level variation in coding practices. Unanticipated coding effects imply that case-mix models hypothesized to perform well ex ante may not meet expectations ex post.

Coding Response to a Case-Mix Measurement System Based on Multiple Diagnoses

PubMed Central

Preyra, Colin

2004-01-01

Objective To examine the hospital coding response to a payment model using a case-mix measurement system based on multiple diagnoses and the resulting impact on a hospital cost model. Data Sources Financial, clinical, and supplementary data for all Ontario short stay hospitals from years 1997 to 2002. Study Design Disaggregated trends in hospital case-mix growth are examined for five years following the adoption of an inpatient classification system making extensive use of combinations of secondary diagnoses. Hospital case mix is decomposed into base and complexity components. The longitudinal effects of coding variation on a standard hospital payment model are examined in terms of payment accuracy and impact on adjustment factors. Principal Findings Introduction of the refined case-mix system provided incentives for hospitals to increase reporting of secondary diagnoses and resulted in growth in highest complexity cases that were not matched by increased resource use over time. Despite a pronounced coding response on the part of hospitals, the increase in measured complexity and case mix did not reduce the unexplained variation in hospital unit cost nor did it reduce the reliance on the teaching adjustment factor, a potential proxy for case mix. The main implication was changes in the size and distribution of predicted hospital operating costs. Conclusions Jurisdictions introducing extensive refinements to standard diagnostic related group (DRG)-type payment systems should consider the effects of induced changes to hospital coding practices. Assessing model performance should include analysis of the robustness of classification systems to hospital-level variation in coding practices. Unanticipated coding effects imply that case-mix models hypothesized to perform well ex ante may not meet expectations ex post. PMID:15230940

Application of a Mixed Consequential Ethical Model to a Problem Regarding Test Standards.

ERIC Educational Resources Information Center

Busch, John Christian

The work of the ethicist Charles Curran and the problem-solving strategy of the mixed consequentialist ethical model are applied to a traditional social science measurement problem--that of how to adjust a recommended standard in order to be fair to the test-taker and society. The focus is on criterion-referenced teacher certification tests.…

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.

How large are the consequences of covariate imbalance in cluster randomized trials: a simulation study with a continuous outcome and a binary covariate at the cluster level.

PubMed

Moerbeek, Mirjam; van Schie, Sander

2016-07-11

The number of clusters in a cluster randomized trial is often low. It is therefore likely random assignment of clusters to treatment conditions results in covariate imbalance. There are no studies that quantify the consequences of covariate imbalance in cluster randomized trials on parameter and standard error bias and on power to detect treatment effects. The consequences of covariance imbalance in unadjusted and adjusted linear mixed models are investigated by means of a simulation study. The factors in this study are the degree of imbalance, the covariate effect size, the cluster size and the intraclass correlation coefficient. The covariate is binary and measured at the cluster level; the outcome is continuous and measured at the individual level. The results show covariate imbalance results in negligible parameter bias and small standard error bias in adjusted linear mixed models. Ignoring the possibility of covariate imbalance while calculating the sample size at the cluster level may result in a loss in power of at most 25 % in the adjusted linear mixed model. The results are more severe for the unadjusted linear mixed model: parameter biases up to 100 % and standard error biases up to 200 % may be observed. Power levels based on the unadjusted linear mixed model are often too low. The consequences are most severe for large clusters and/or small intraclass correlation coefficients since then the required number of clusters to achieve a desired power level is smallest. The possibility of covariate imbalance should be taken into account while calculating the sample size of a cluster randomized trial. Otherwise more sophisticated methods to randomize clusters to treatments should be used, such as stratification or balance algorithms. All relevant covariates should be carefully identified, be actually measured and included in the statistical model to avoid severe levels of parameter and standard error bias and insufficient power levels.

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.

Racially Mixed People in America.

ERIC Educational Resources Information Center

Root, Maria P. P., Ed.

This book offers a comprehensive look at the social and psychological adjustment of multiracial people, models for identity development, contemporary immigration and marriage patterns, and methodological issues involved in conducting research with mixed-race people, all in the context of America's multiracial past and present. The following 26…

Access disparities to Magnet hospitals for patients undergoing neurosurgical operations

PubMed Central

Missios, Symeon; Bekelis, Kimon

2017-01-01

Background Centers of excellence focusing on quality improvement have demonstrated superior outcomes for a variety of surgical interventions. We investigated the presence of access disparities to hospitals recognized by the Magnet Recognition Program of the American Nurses Credentialing Center (ANCC) for patients undergoing neurosurgical operations. Methods We performed a cohort study of all neurosurgery patients who were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2009–2013. We examined the association of African-American race and lack of insurance with Magnet status hospitalization for neurosurgical procedures. A mixed effects propensity adjusted multivariable regression analysis was used to control for confounding. Results During the study period, 190,535 neurosurgical patients met the inclusion criteria. Using a multivariable logistic regression, we demonstrate that African-Americans had lower admission rates to Magnet institutions (OR 0.62; 95% CI, 0.58–0.67). This persisted in a mixed effects logistic regression model (OR 0.77; 95% CI, 0.70–0.83) to adjust for clustering at the patient county level, and a propensity score adjusted logistic regression model (OR 0.75; 95% CI, 0.69–0.82). Additionally, lack of insurance was associated with lower admission rates to Magnet institutions (OR 0.71; 95% CI, 0.68–0.73), in a multivariable logistic regression model. This persisted in a mixed effects logistic regression model (OR 0.72; 95% CI, 0.69–0.74), and a propensity score adjusted logistic regression model (OR 0.72; 95% CI, 0.69–0.75). Conclusions Using a comprehensive all-payer cohort of neurosurgery patients in New York State we identified an association of African-American race and lack of insurance with lower rates of admission to Magnet hospitals. PMID:28684152

A formulation of convection for stellar structure and evolution calculations without the mixing-length theory approximations. II - Application to Alpha Centauri A and B

NASA Technical Reports Server (NTRS)

Lydon, Thomas J.; Fox, Peter A.; Sofia, Sabatino

1993-01-01

We have constructed a series of models of Alpha Centauri A and Alpha Centauri B for the purposes of testing the effects of convection modeling both by means of the mixing-length theory (MLT), and by means of parameterization of energy fluxes based upon numerical simulations of turbulent compressible convection. We demonstrate that while MLT, through its adjustable parameter alpha, can be used to match any given values of luminosities and radii, our treatment of convection, which lacks any adjustable parameters, makes specific predictions of stellar radii. Since the predicted radii of the Alpha Centauri system fall within the errors of the observed radii, our treatment of convection is applicable to other stars in the H-R diagram in addition to the sun. A second set of models is constructed using MLT, adjusting alpha to yield not the 'measured' radii but, instead, the radii predictions of our revised treatment of convection. We conclude by assessing the appropriateness of using a single value of alpha to model a wide variety of stars.

Mixed-grade rejection and its association with overt aggression, relational aggression, anxious-withdrawal, and psychological maladjustment.

PubMed

Bowker, Julie C; Etkin, Rebecca G

2014-01-01

The authors examined the associations between mixed-grade rejection (rejection by peers in a different school grade), anxious-withdrawal, aggression, and psychological adjustment in a middle school setting. Participants were 181 seventh-grade and 180 eighth-grade students (M age = 13.20 years, SD = 0.68 years) who completed peer nomination and self-report measures in their classes. Analyses indicated that in general, same- and mixed-grade rejection were related to overt and relational aggression, but neither type was related to anxious-withdrawal. Mixed-grade rejection was associated uniquely and negatively with self-esteem for seventh-grade boys, while increasing the loneliness associated with anxious-withdrawal. The results suggest that school-wide models of peer relations may be promising for understanding the ways in which different peer contexts contribute to adjustment in middle school settings.

Response Monitoring and Adjustment: Differential Relations with Psychopathic Traits

PubMed Central

Bresin, Konrad; Finy, M. Sima; Sprague, Jenessa; Verona, Edelyn

2014-01-01

Studies on the relation between psychopathy and cognitive functioning often show mixed results, partially because different factors of psychopathy have not been considered fully. Based on previous research, we predicted divergent results based on a two-factor model of psychopathy (interpersonal-affective traits and impulsive-antisocial traits). Specifically, we predicted that the unique variance of interpersonal-affective traits would be related to increased monitoring (i.e., error-related negativity) and adjusting to errors (i.e., post-error slowing), whereas impulsive-antisocial traits would be related to reductions in these processes. Three studies using a diverse selection of assessment tools, samples, and methods are presented to identify response monitoring correlates of the two main factors of psychopathy. In Studies 1 (undergraduates), 2 (adolescents), and 3 (offenders), interpersonal-affective traits were related to increased adjustment following errors and, in Study 3, to enhanced monitoring of errors. Impulsive-antisocial traits were not consistently related to error adjustment across the studies, although these traits were related to a deficient monitoring of errors in Study 3. The results may help explain previous mixed findings and advance implications for etiological models of psychopathy. PMID:24933282

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.

Longitudinal Psychosocial Adjustment of Women to Human Papillomavirus Infection.

PubMed

Hsu, Yu-Yun; Wang, Wei-Ming; Fetzer, Susan Jane; Cheng, Ya-Min; Hsu, Keng-Fu

2018-05-29

The aim of this study was to examine the psychosocial adjustment trajectory, focusing on psychological distress, sexual relationships and health care information, as well as factors which have an impact on adjustment on receiving a positive diagnosis of human papillomavirus infection. Human papillomavirus is a common sexually transmitted infection in females. To date, knowledge of the longitudinal psychosocial response to the diagnosis of human papillomavirus is limited. A prospective longitudinal design was conducted with a convenience sample. Women aged 20-65 years old were followed at one, 6 and 12 months after a diagnosis of HPV. Participants completed measures of initial emotional distress and followed-up psychosocial adjustment. A mixed-effects model was applied to analyze the longitudinal changes in psychosocial adjustment. Seventy human papillomavirus positive women participated in the study with nearly 20% of the women reporting emotional distress during their first visit. Mixed-effects model analyses showed that a trajectory of psychosocial adjustment in health care orientation, sexual relationship and psychosocial distress occur from one to 6 months after HPV diagnosis. However, a declining trend from 6-12 months was significant in health care orientation. Initial emotional distress was associated with changes in psychological adjustment. Psychosocial adjustment to human papillomavirus was worse at one month compared with 6 and 12 months after diagnosis. Healthcare providers should offer health information and psychosocial support to women according to their disease progression. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

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.

A Water Model Study on Mixing Behavior of the Two-Layered Bath in Bottom Blown Copper Smelting Furnace

NASA Astrophysics Data System (ADS)

Shui, Lang; Cui, Zhixiang; Ma, Xiaodong; Jiang, Xu; Chen, Mao; Xiang, Yong; Zhao, Baojun

2018-05-01

The bottom-blown copper smelting furnace is a novel copper smelter developed in recent years. Many advantages of this furnace have been found, related to bath mixing behavior under its specific gas injection scheme. This study aims to use an oil-water double-phased laboratory-scale model to investigate the impact of industry-adjustable variables on bath mixing time, including lower layer thickness, gas flow rate, upper layer thickness and upper layer viscosity. Based on experimental results, an overall empirical relationship of mixing time in terms of these variables has been correlated, which provides the methodology for industry to optimize mass transfer in the furnace.

MIXOR: a computer program for mixed-effects ordinal regression analysis.

PubMed

Hedeker, D; Gibbons, R D

1996-03-01

MIXOR provides maximum marginal likelihood estimates for mixed-effects ordinal probit, logistic, and complementary log-log regression models. These models can be used for analysis of dichotomous and ordinal outcomes from either a clustered or longitudinal design. For clustered data, the mixed-effects model assumes that data within clusters are dependent. The degree of dependency is jointly estimated with the usual model parameters, thus adjusting for dependence resulting from clustering of the data. Similarly, for longitudinal data, the mixed-effects approach can allow for individual-varying intercepts and slopes across time, and can estimate the degree to which these time-related effects vary in the population of individuals. MIXOR uses marginal maximum likelihood estimation, utilizing a Fisher-scoring solution. For the scoring solution, the Cholesky factor of the random-effects variance-covariance matrix is estimated, along with the effects of model covariates. Examples illustrating usage and features of MIXOR are provided.

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.

Fuzzy Mixed Assembly Line Sequencing and Scheduling Optimization Model Using Multiobjective Dynamic Fuzzy GA

PubMed Central

Tahriri, Farzad; Dawal, Siti Zawiah Md; Taha, Zahari

2014-01-01

A new multiobjective dynamic fuzzy genetic algorithm is applied to solve a fuzzy mixed-model assembly line sequencing problem in which the primary goals are to minimize the total make-span and minimize the setup number simultaneously. Trapezoidal fuzzy numbers are implemented for variables such as operation and travelling time in order to generate results with higher accuracy and representative of real-case data. An improved genetic algorithm called fuzzy adaptive genetic algorithm (FAGA) is proposed in order to solve this optimization model. In establishing the FAGA, five dynamic fuzzy parameter controllers are devised in which fuzzy expert experience controller (FEEC) is integrated with automatic learning dynamic fuzzy controller (ALDFC) technique. The enhanced algorithm dynamically adjusts the population size, number of generations, tournament candidate, crossover rate, and mutation rate compared with using fixed control parameters. The main idea is to improve the performance and effectiveness of existing GAs by dynamic adjustment and control of the five parameters. Verification and validation of the dynamic fuzzy GA are carried out by developing test-beds and testing using a multiobjective fuzzy mixed production assembly line sequencing optimization problem. The simulation results highlight that the performance and efficacy of the proposed novel optimization algorithm are more efficient than the performance of the standard genetic algorithm in mixed assembly line sequencing model. PMID:24982962

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.

Permethrin Exposure Dosimetry: Biomarkers and Modifiable Factors

DTIC Science & Technology

2017-08-01

metabolite; (F = 16.16, p < 0.0001). This association holds after controlling for known confounders including sex , age, time that uniform was worn...and metabolite concentrations were examined via linear mixed modeling. All models were adjusted for creatinine, age, sex , days in BCT, number of

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

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

A D-vine copula-based model for repeated measurements extending linear mixed models with homogeneous correlation structure.

PubMed

Killiches, Matthias; Czado, Claudia

2018-03-22

We propose a model for unbalanced longitudinal data, where the univariate margins can be selected arbitrarily and the dependence structure is described with the help of a D-vine copula. We show that our approach is an extremely flexible extension of the widely used linear mixed model if the correlation is homogeneous over the considered individuals. As an alternative to joint maximum-likelihood a sequential estimation approach for the D-vine copula is provided and validated in a simulation study. The model can handle missing values without being forced to discard data. Since conditional distributions are known analytically, we easily make predictions for future events. For model selection, we adjust the Bayesian information criterion to our situation. In an application to heart surgery data our model performs clearly better than competing linear mixed models. © 2018, The International Biometric Society.

Time with Peers from Middle Childhood to Late Adolescence: Developmental Course and Adjustment Correlates

PubMed Central

Lam, Chun Bun; McHale, Susan M.; Crouter, Ann C.

2014-01-01

This study examined the developmental course and adjustment correlates of time with peers from age 8 to 18. On 7 occasions over 8 years, the two eldest siblings from 201 European American, working- and middle-class families provided questionnaire and/or phone diary data. Multilevel models revealed that girls’ time with mixed/opposite-sex peers increased beginning in middle childhood, but boys’ time increased beginning in early adolescence. For both girls and boys, time with same-sex peers peaked in mid-adolescence. At the within-person level, unsupervised time with mixed/opposite-sex peers longitudinally predicted problem behaviors and depressive symptoms, and supervised time with mixed/opposite-sex peers longitudinally predicted better school performance. Findings highlight the importance of social context in understanding peer involvement and its implications for youth development. PMID:24673293

Substantial shifts in ranking of California hospitals by hospital-associated methicillin-resistant Staphylococcus aureus infection following adjustment for hospital characteristics and case mix.

PubMed

Tehrani, David M; Phelan, Michael J; Cao, Chenghua; Billimek, John; Datta, Rupak; Nguyen, Hoanglong; Kwark, Homin; Huang, Susan S

2014-10-01

States have established public reporting of hospital-associated (HA) infections-including those of methicillin-resistant Staphylococcus aureus (MRSA)-but do not account for hospital case mix or postdischarge events. Identify facility-level characteristics associated with HA-MRSA infection admissions and create adjusted hospital rankings. A retrospective cohort study of 2009-2010 California acute care hospitals. We defined HA-MRSA admissions as involving MRSA pneumonia or septicemia events arising during hospitalization or within 30 days after discharge. We used mandatory hospitalization and US Census data sets to generate hospital population characteristics by summarizing across admissions. Facility-level factors associated with hospitals' proportions of HA-MRSA infection admissions were identified using generalized linear models. Using state methodology, hospitals were categorized into 3 tiers of HA-MRSA infection prevention performance, using raw and adjusted values. Among 323 hospitals, a median of 16 HA-MRSA infections (range, 0-102) per 10,000 admissions was found. Hospitals serving a greater proportion of patients who had serious comorbidities, were from low-education zip codes, and were discharged to locations other than home were associated with higher HA-MRSA infection risk. Total concordance between all raw and adjusted hospital rankings was 0.45 (95% confidence interval, 0.40-0.51). Among 53 community hospitals in the poor-performance category, more than 20% moved into the average-performance category after adjustment. Similarly, among 71 hospitals in the superior-performance category, half moved into the average-performance category after adjustment. When adjusting for nonmodifiable facility characteristics and case mix, hospital rankings based on HA-MRSA infections substantially changed. Quality indicators for hospitals require adequate adjustment for patient population characteristics for valid interhospital performance comparisons.

Ocean Turbulence. Paper 2; One-Point Closure Model Momentum, Heat and Salt Vertical Diffusivities in the Presence of Shear

NASA Technical Reports Server (NTRS)

Canuto, V. M.; Howard, A.; Cheng, Y.; Dubovikov, M. S.

1999-01-01

We develop and test a 1-point closure turbulence model with the following features: 1) we include the salinity field and derive the expression for the vertical turbulent diffusivities of momentum K(sub m) , heat K(sub h) and salt K(sub s) as a function of two stability parameters: the Richardson number R(sub i) (stratification vs. shear) and the Turner number R(sub rho) (salinity gradient vs. temperature gradient). 2) to describe turbulent mixing below the mixed layer (ML), all previous models have adopted three adjustable "background diffusivities" for momentum, heat and salt. We propose a model that avoids such adjustable diffusivities. We assume that below the ML, the three diffusivities have the same functional dependence on R( sub i) and R(sub rho) as derived from the turbulence model. However, in order to compute R(sub i) below the ML, we use data of vertical shear due to wave-breaking.measured by Gargett et al. The procedure frees the model from adjustable background diffusivities and indeed we employ the same model throughout the entire vertical extent of the ocean. 3) in the local model, the turbulent diffusivities K(sub m,h,s) are given as analytical functions of R(sub i) and R(sub rho). 5) the model is used in an O-GCM and several results are presented to exhibit the effect of double diffusion processes. 6) the code is available upon request.

Redesigning inpatient care: Testing the effectiveness of an accountable care team model.

PubMed

Kara, Areeba; Johnson, Cynthia S; Nicley, Amy; Niemeier, Michael R; Hui, Siu L

2015-12-01

US healthcare underperforms on quality and safety metrics. Inpatient care constitutes an immense opportunity to intervene to improve care. Describe a model of inpatient care and measure its impact. A quantitative assessment of the implementation of a new model of care. The graded implementation of the model allowed us to follow outcomes and measure their association with the dose of the implementation. Inpatient medical and surgical units in a large academic health center. Eight interventions rooted in improving interprofessional collaboration (IPC), enabling data-driven decisions, and providing leadership were implemented. Outcome data from August 2012 to December 2013 were analyzed using generalized linear mixed models for associations with the implementation of the model. Length of stay (LOS) index, case-mix index-adjusted variable direct costs (CMI-adjusted VDC), 30-day readmission rates, overall patient satisfaction scores, and provider satisfaction with the model were measured. The implementation of the model was associated with decreases in LOS index (P < 0.0001) and CMI-adjusted VDC (P = 0.0006). We did not detect improvements in readmission rates or patient satisfaction scores. Most providers (95.8%, n = 92) agreed that the model had improved the quality and safety of the care delivered. Creating an environment and framework in which IPC is fostered, performance data are transparently available, and leadership is provided may improve value on both medical and surgical units. These interventions appear to be well accepted by front-line staff. Readmission rates and patient satisfaction remain challenging. © 2015 Society of Hospital Medicine.

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.

Adjusting case mix payment amounts for inaccurately reported comorbidity data.

PubMed

Sutherland, Jason M; Hamm, Jeremy; Hatcher, Jeff

2010-03-01

Case mix methods such as diagnosis related groups have become a basis of payment for inpatient hospitalizations in many countries. Specifying cost weight values for case mix system payment has important consequences; recent evidence suggests case mix cost weight inaccuracies influence the supply of some hospital-based services. To begin to address the question of case mix cost weight accuracy, this paper is motivated by the objective of improving the accuracy of cost weight values due to inaccurate or incomplete comorbidity data. The methods are suitable to case mix methods that incorporate disease severity or comorbidity adjustments. The methods are based on the availability of detailed clinical and cost information linked at the patient level and leverage recent results from clinical data audits. A Bayesian framework is used to synthesize clinical data audit information regarding misclassification probabilities into cost weight value calculations. The models are implemented through Markov chain Monte Carlo methods. An example used to demonstrate the methods finds that inaccurate comorbidity data affects cost weight values by biasing cost weight values (and payments) downward. The implications for hospital payments are discussed and the generalizability of the approach is explored.

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.

Simulation Model for Scenario Optimization of the Ready-Mix Concrete Delivery Problem

NASA Astrophysics Data System (ADS)

Galić, Mario; Kraus, Ivan

2016-12-01

This paper introduces a discrete simulation model for solving routing and network material flow problems in construction projects. Before the description of the model a detailed literature review is provided. The model is verified using a case study of solving the ready-mix concrete network flow and routing problem in metropolitan area in Croatia. Within this study real-time input parameters were taken into account. Simulation model is structured in Enterprise Dynamics simulation software and Microsoft Excel linked with Google Maps. The model is dynamic, easily managed and adjustable, but also provides good estimation for minimization of costs and realization time in solving discrete routing and material network flow problems.

Explaining prescription drug use and expenditures using the adjusted clinical groups case-mix system in the population of British Columbia, Canada.

PubMed

Hanley, Gillian E; Morgan, Steve; Reid, Robert J

2010-05-01

Given that prescription drugs have become a major financial component of health care, there is an increased need to explain variations in the use of and expenditure on medicines. Case-mix systems built from existing administrative datasets may prove very useful for such prediction. We estimated the concurrent and prospective predictive validity of the adjusted clinical groups (ACG) system in pharmaceutical research and compared the ACG system with the Charlson index of comorbidity. We ran a generalized linear models to examine the predictive validity of the ACG system and the Charlson index and report the correlation between the predicted and observed expenditures. We reported mean predictive ratios across medical condition and cost-defined groups. When predicting use of medicines, we used C-statistics to summarize the area under the receiver operating characteristic curve. The 3,908,533 British Columbia residents who were registered for the universal health care plan for 275+ days in the calendar years 2004 and 2005. Outcomes were total pharmaceutical expenditures, use of any medicines, and use of medicines from 4+ different therapeutic categories. The ACG case mix system predicted drug expenditures better than the Charlson index. The mean predictive ratios for the ACG system models were all within 4% of the actual costs when examining medical condition group and the C-stats for the 2 dichotomous outcomes were between 0.82 and 0.89. ACG case-mix adjusters are a valuable predictor of pharmaceutical use and expenditures with much higher predictive power than age, sex, and the Charlson index of comorbidity.

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.

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.

Worldwide impact of economic cycles on suicide trends over 3 decades: differences according to level of development. A mixed effect model study

PubMed Central

Perez-Rodriguez, M Mercedes; Garcia-Nieto, Rebeca; Fernandez-Navarro, Pablo; Galfalvy, Hanga; de Leon, Jose; Baca-Garcia, Enrique

2012-01-01

Objectives To investigate the trends and correlations of gross domestic product (GDP) adjusted for purchasing power parity (PPP) per capita on suicide rates in 10 WHO regions during the past 30 years. Design Analyses of databases of PPP-adjusted GDP per capita and suicide rates. Countries were grouped according to the Global Burden of Disease regional classification system. Data sources World Bank's official website and WHO's mortality database. Statistical analyses After graphically displaying PPP-adjusted GDP per capita and suicide rates, mixed effect models were used for representing and analysing clustered data. Results Three different groups of countries, based on the correlation between the PPP-adjusted GDP per capita and suicide rates, are reported: (1) positive correlation: developing (lower middle and upper middle income) Latin-American and Caribbean countries, developing countries in the South East Asian Region including India, some countries in the Western Pacific Region (such as China and South Korea) and high-income Asian countries, including Japan; (2) negative correlation: high-income and developing European countries, Canada, Australia and New Zealand and (3) no correlation was found in an African country. Conclusions PPP-adjusted GDP per capita may offer a simple measure for designing the type of preventive interventions aimed at lowering suicide rates that can be used across countries. Public health interventions might be more suitable for developing countries. In high-income countries, however, preventive measures based on the medical model might prove more useful. PMID:22586285

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 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.

Models for extracting vertical crustal movements from leveling data

NASA Technical Reports Server (NTRS)

Holdahl, S. H.

1978-01-01

Various adjustment strategies are being used in North America to obtain vertical crustal movements from repeated leveling. The more successful models utilize polynomials or multiquadric analysis to describe elevation change with a velocity surface. Other features permit determination of nonlinear motions, motions associated with earthquakes or episodes, and vertical motions of blocks where boundaries are prespecified. The preferred models for estimating crustal motions permit the use of detached segments of releveling to govern the shape of a velocity surface and allow for input from nonleveling sources such as tide gages and paired lake gages. Some models for extracting vertical crustal movements from releveling data are also excellent for adjusting leveling networks, and permit mixing old and new data in areas exhibiting vertical motion. The new adjustment techniques are more general than older static models and will undoubtedly be used routinely in the future as the constitution of level networks becomes mainly relevelings.

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...

Vehicle height and posture control of the electronic air suspension system using the hybrid system approach

NASA Astrophysics Data System (ADS)

Sun, Xiaoqiang; Cai, Yingfeng; Chen, Long; Liu, Yanling; Wang, Shaohua

2016-03-01

The electronic air suspension (EAS) system can improve ride comfort, fuel economy and handling safety of vehicles by adjusting vehicle height. This paper describes the development of a novel controller using the hybrid system approach to adjust the vehicle height (height control) and to regulate the roll and pitch angles of the vehicle body during the height adjustment process (posture control). The vehicle height adjustment system of EAS poses challenging hybrid control problems, since it features different discrete modes of operation, where each mode has an associated linear continuous-time dynamic. In this paper, we propose a novel approach to the modelling and controller design problem for the vehicle height adjustment system of EAS. The system model is described firstly in the hybrid system description language (HYSDEL) to obtain a mixed logical dynamical (MLD) hybrid model. For the resulting model, a hybrid model predictive controller is tuned to improve the vehicle height and posture tracking accuracy and to achieve the on-off statuses direct control of solenoid valves. The effectiveness and performance of the proposed approach are demonstrated by simulations and actual vehicle tests.

Vertical Eddy Diffusivity as a Control Parameter in the Tropical Pacific Ocean

NASA Astrophysics Data System (ADS)

Martinez Avellaneda, N.; Cornuelle, B.; Mazloff, M. R.; Stammer, D.

2012-12-01

Ocean models suffer from errors in the treatment of turbulent sub-grid scale motions causing mixing and energy dissipation. Unrealistic small-scale features in models can have large-scale consequences, such as biases in the upper ocean temperature, a symptom of poorly-simulated upwelling, currents and air-sea interactions. This is of special importance in the tropical Pacific Ocean, which is home to energetic air-sea interactions that affect global climate. It has been shown in a number of studies that the simulated ENSO variability is highly dependent on the state of the ocean (e.g.: background mixing). Moreover, the magnitude of the vertical numerical diffusion is of primary importance in properly reproducing the Pacific equatorial thermocline. Yet, it is a common practice to use spatially uniform mixing parameters in ocean simulations. This work is part of a NASA-funded project to estimate the space-varying ocean mixing coefficients in an eddy-permitting model of the tropical Pacific. The usefulness of assimilation techniques in estimating mixing parameters has been previously explored (e.g.: Stammer, 2005, Ferreira et al., 2005). The authors also demonstrated that the spatial structure of the Equatorial Undercurrent (EUC) could be improved by adjusting wind-stress and surface buoyancy flux within their error bounds. In our work, we address the important question of whether adjusting mixing parameterizations can bring about similar improvements. To that end, an eddy-permitting state estimate for the tropical Pacific is developed using the MIT general circulation model and its adjoint where the vertical diffusivity is set as a control parameter. Complementary adjoint-based sensitivity results show strong sensitivities of the Tropical Pacific thermocline (thickness and location) and the EUC transport to the vertical diffusivity in the tropics. Argo, CTD, XBT and mooring in-situ data, as well as TMI SST and altimetry observations are assimilated in order to reduce the misfit between the model simulations and the ocean observations. Model domain topography of 1/3dgr of spatial resolution interpolated from ETOPO 2. The first and the last color levels represent regions shallower than 100m and deeper than 5000m, respectively

A mixed reality simulator for feline abdominal palpation training in veterinary medicine.

PubMed

Parkes, Rebecca; Forrest, Neil; Baillie, Sarah

2009-01-01

The opportunities for veterinary students to practice feline abdominal palpation are limited as cats have a low tolerance to being examined. Therefore, a mixed reality simulator was developed to complement clinical training. Two PHANToM premium haptic devices were positioned either side of a modified toy cat. Virtual models of the chest and some abdominal contents were superimposed on the physical model. The haptic properties of the virtual models were set by seven veterinarians; values were adjusted while the simulation was being palpated until the representation was satisfactory. Feedback from the veterinarians was encouraging suggesting that the simulator has a potential role in student training.

Analysis of mixed traffic flow with human-driving and autonomous cars based on car-following model

NASA Astrophysics Data System (ADS)

Zhu, Wen-Xing; Zhang, H. M.

2018-04-01

We investigated the mixed traffic flow with human-driving and autonomous cars. A new mathematical model with adjustable sensitivity and smooth factor was proposed to describe the autonomous car's moving behavior in which smooth factor is used to balance the front and back headway in a flow. A lemma and a theorem were proved to support the stability criteria in traffic flow. A series of simulations were carried out to analyze the mixed traffic flow. The fundamental diagrams were obtained from the numerical simulation results. The varying sensitivity and smooth factor of autonomous cars affect traffic flux, which exhibits opposite varying tendency with increasing parameters before and after the critical density. Moreover, the sensitivity of sensors and smooth factors play an important role in stabilizing the mixed traffic flow and suppressing the traffic jam.

Assessment of the value of repeated point-prevalence surveys for analyzing the trend in nosocomial infections.

PubMed

Sartor, Catherine; Delchambre, Anne; Pascal, Laurence; Drancourt, Michel; De Micco, Philippe; Sambuc, Roland

2005-04-01

To assess the value of repeated point-prevalence surveys in measuring the trend in nosocomial infections after adjustment for case mix. A 3,500-bed teaching facility composed of 4 acute care hospitals. From May 1992 to June 1996, eight point-prevalence surveys of nosocomial infections were performed in the hospitals using a sampling process. The trend of adjusted nosocomial infection rates was studied for the four surveys that collected data on indwelling catheters. Adjusted rates were calculated using a logistic regression model and a direct standardization method. From 1992 to 1996, a total of 20,238 patients were included in the 8 point-prevalence surveys. The nosocomial infection rate decreased from 8.6% in 1992 to 5% in 1996 (P < .001). The analysis of adjusted nosocomial infection rates included 9,600 patients. Four independent risk factors were identified: length of stay greater than 12 days, hospitalization in an intensive care unit, presence of an indwelling urinary catheter, and history of a surgical procedure. After adjustment for case mix, the nosocomial infection rate still showed a downward trend (from 7.2% in 1993 to 5.1% in 1996; P = .02). Adjusted prevalence rates of nosocomial infections showed a significant downward trend during the period of this study.

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.

Break-even analysis revisited: the need to adjust for profitability, the collection rate and autonomous income.

PubMed

Broyles, R W; Narine, L; Khaliq, A

2003-08-01

This paper modifies traditional break-even analysis and develops a model that reflects the influence of variation in payer mix, the collection rate, profitability and autonomous income on the desired volume alternative. The augmented model indicates that a failure to adjust for uncollectibles and the net surplus results in a systematic understatement of the desired volume alternative. Conversely, a failure to adjust for autonomous income derived from the operation of cafeterias, gift shops or an organization's investment in marketable securities produces an overstatement of the desired volume. In addition, this paper uses Microsoft Excel to develop a spreadsheet that constructs a pro forma income statement, expressed in terms of the contribution margin. The spreadsheet also relies on the percentage of sales or revenue approach to prepare a balance sheet from which indicators of fiscal performance are calculated. Hence, the analysis enables the organization to perform a sensitivity analysis of potential changes in the desired volume, the operating margin, the current ratio, the debt: equity ratio and the amount of cash derived from operations that are associated with expected variation in payer mix, the collection rate, grouped by payer, the net surplus and autonomous income.

The 2 x 2 Model of Perfectionism: A Comparison across Asian Canadians and European Canadians

ERIC Educational Resources Information Center

Franche, Veronique; Gaudreau, Patrick; Miranda, Dave

2012-01-01

The 2 x 2 model of perfectionism posits that the 4 within-person combinations of self-oriented and socially prescribed perfectionism (i.e., pure SOP, mixed perfectionism, pure SPP, and nonperfectionism) can be distinctively associated with psychological adjustment. This study examined whether the relationship between the 4 subtypes of…

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...

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.

Planning for Coupling Effects in Bitoric Mixed Astigmatism Ablative Treatments.

PubMed

Alpins, Noel; Ong, James K Y; Stamatelatos, George

2017-08-01

To demonstrate how to determine the historical coupling adjustments of bitoric mixed astigmatism ablative treatments and how to use these historical coupling adjustments to adjust future bitoric treatments. The individual coupling adjustments of the myopic and hyperopic cylindrical components of a bitoric treatment were derived empirically from a retrospective study where the theoretical combined treatment effect on spherical equivalent was compared to the actual change in refractive spherical equivalent. The coupling adjustments that provided the best fit in both mean and standard deviation were determined to be the historical coupling adjustments. Theoretical treatments that incorporated the historical coupling adjustments were then calculated. The actual distribution of postoperative spherical equivalent errors was compared to the theoretically adjusted distribution. The study group comprised 242 eyes and included 118 virgin right eyes and 124 virgin left eyes of 155 individuals. For the laser used, the myopic coupling adjustment was -0.02 and the hyperopic coupling adjustment was 0.30, as derived by global nonlinear optimization. This implies that almost no adjustment of the myopic component of the bitoric treatment is necessary, but that the hyperopic component of the bitoric treatment generates a large amount of unintended spherical shift. The theoretically adjusted treatments targeted zero mean spherical equivalent error, as intended, and the distribution of the theoretical spherical equivalent errors had the same spread as the distribution of actual postoperative spherical equivalent errors. Bitoric mixed astigmatism ablative treatments may display non-trivial coupling effects. Historical coupling adjustments should be taken into consideration when planning mixed astigmatism treatments to improve surgical outcomes. [J Refract Surg. 2017;33(8):545-551.]. Copyright 2017, SLACK Incorporated.

Fully-coupled analysis of jet mixing problems. Three-dimensional PNS model, SCIP3D

NASA Technical Reports Server (NTRS)

Wolf, D. E.; Sinha, N.; Dash, S. M.

1988-01-01

Numerical procedures formulated for the analysis of 3D jet mixing problems, as incorporated in the computer model, SCIP3D, are described. The overall methodology closely parallels that developed in the earlier 2D axisymmetric jet mixing model, SCIPVIS. SCIP3D integrates the 3D parabolized Navier-Stokes (PNS) jet mixing equations, cast in mapped cartesian or cylindrical coordinates, employing the explicit MacCormack Algorithm. A pressure split variant of this algorithm is employed in subsonic regions with a sublayer approximation utilized for treating the streamwise pressure component. SCIP3D contains both the ks and kW turbulence models, and employs a two component mixture approach to treat jet exhausts of arbitrary composition. Specialized grid procedures are used to adjust the grid growth in accordance with the growth of the jet, including a hybrid cartesian/cylindrical grid procedure for rectangular jets which moves the hybrid coordinate origin towards the flow origin as the jet transitions from a rectangular to circular shape. Numerous calculations are presented for rectangular mixing problems, as well as for a variety of basic unit problems exhibiting overall capabilities of SCIP3D.

Does the patient's inherent rating tendency influence reported satisfaction scores and affect division ranking?

PubMed

Francis, Patricia; Agoritsas, Thomas; Chopard, Pierre; Perneger, Thomas

2016-04-01

To determine the impact of adjusting for rating tendency (RT) on patient satisfaction scores in a large teaching hospital and to assess the impact of adjustment on the ranking of divisions. Cross-sectional survey. Large 2200-bed university teaching hospital. All adult patients hospitalized during a 1-month period in one of 20 medical divisions. None. Patient experience of care measured by the Picker Patient Experience questionnaire and RT scores. Problem scores were weakly but significantly associated with RT. Division ranking was slightly modified in RT adjusted models. Division ranking changed substantially in case-mix adjusted models. Adjusting patient self-reported problem scores for RT did impact ranking of divisions, although marginally. Further studies are needed to determine the impact of RT when comparing different institutions, particularly across inter-cultural settings, where the difference in RT may be more substantial. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.

The interactive role of subsynoptic scale jet sreak and planetary boundary layer adjustments in organizing an apparently isolated convective complex

NASA Technical Reports Server (NTRS)

Kaplan, M. L.; Zack, J. W.; Wong, V. C.; Tuccillo, J. J.; Coats, G. D.

1982-01-01

A mesoscale atmospheric simulation system is described that is being developed in order to improve the simulation of subsynoptic and mesoscale adjustments associated with cyclogenesis, severe storm development, and significant atmospheric transport processes. Present emphasis in model development is in the parameterization of physical processes, time-dependent boundary conditions, sophisticated initialization and analysis procedures, nested grid solutions, and applications software development. Basic characteristics of the system as of March 1982 are listed. In a case study, the Grand Island tornado outbreak of 3 June 1980 is considered in substantial detail. Results of simulations with a mesoscale atmospheric simulation system indicate that over the high plains subtle interactions between existing jet streaks and deep well mixed boundary layers can lead to well organized patterns of mesoscale divergence and pressure falls. The amplitude and positioning of these mesoscale features is a function of the subtle nonlinear interaction between the pre-existing jet-streak and deep well mixed boundary layers. Model results for the case study indicate that the model has the potential for forecasting the precursor mesoscale convective environment.

Developing a risk stratification tool for audit of outcome after surgery for head and neck squamous cell carcinoma.

PubMed

Tighe, David F; Thomas, Alan J; Sassoon, Isabel; Kinsman, Robin; McGurk, Mark

2017-07-01

Patients treated surgically for head and neck squamous cell carcinoma (HNSCC) represent a heterogeneous group. Adjusting for patient case mix and complexity of surgery is essential if reporting outcomes represent surgical performance and quality of care. A case note audit totaling 1075 patients receiving 1218 operations done for HNSCC in 4 cancer networks was completed. Logistic regression, decision tree analysis, an artificial neural network, and Naïve Bayes Classifier were used to adjust for patient case-mix using pertinent preoperative variables. Thirty-day complication rates varied widely (34%-51%; P < .015) between units. The predictive models allowed risk stratification. The artificial neural network demonstrated the best predictive performance (area under the curve [AUC] 0.85). Early postoperative complications are a measurable outcome that can be used to benchmark surgical performance and quality of care. Surgical outcome reporting in national clinical audits should be taking account of the patient case mix. © 2017 Wiley Periodicals, Inc.

Vertical profiles of nitrous acid in the nocturnal urban atmosphere of Houston, TX

NASA Astrophysics Data System (ADS)

Wong, K. W.; Oh, H.-J.; Lefer, B.; Rappenglück, B.; Stutz, J.

2010-12-01

Nitrous acid (HONO) often plays an important role in tropospheric photochemistry as a major precursor of the hydroxyl radical (OH) in early morning hours and potentially during the day. However, the processes leading to formation of HONO and its vertical distribution at night, which can have a considerable impact on daytime ozone formation, are currently poorly characterized by observations and models. Long-path differential optical absorption spectroscopy (LP-DOAS) measurements of HONO during the 2006 TexAQS II Radical and Aerosol Measurement Project (TRAMP), near downtown Houston, TX, show nocturnal vertical profiles of HONO, with mixing ratios of up to 2.2 ppb near the surface and below 100 ppt aloft. Three nighttime periods of HONO, NO2 and O3 observations during TRAMP were used to perform model simulations of vertical mixing ratio profiles. By adjusting vertical mixing and NOx emissions the modeled NO2 and O3 mixing ratios showed very good agreement with the observations. Using a simple conversion of NO2 to HONO on the ground, direct HONO emissions, as well as HONO loss at the ground and on aerosol, the observed HONO profiles were reproduced well by the model. The unobserved increase of HONO to NO2 ratio (HONO/NO2) with altitude that was simulated by the initial model runs was found to be due to HONO uptake being too small on aerosol and too large on the ground. Refined model runs, with adjusted HONO uptake coefficients, showed much better agreement of HONO and HONO/NO2 for two typical nights, except during morning rush hour, when other HONO formation pathways are most likely active. One of the nights analyzed showed increase of HONO mixing ratios together with decreasing NO2 mixing ratios that the model was unable to reproduce, most likely due to the impact of weak precipitation during this night. HONO formation and removal rates averaged over the lowest 300 m of the atmosphere showed that NO2 to HONO conversion on the ground was the dominant source of HONO, followed by traffic emission. Aerosol did not play an important role in HONO formation. Although ground deposition was also a major removal pathway of HONO, net HONO production at the ground was the main source of HONO in our model studies. Sensitivity studies showed that in the stable NBL, net HONO production at the ground tends to increase with faster vertical mixing and stronger emission. Vertical transport was found to be the dominant source of HONO aloft.

Adjusted adaptive Lasso for covariate model-building in nonlinear mixed-effect pharmacokinetic models.

PubMed

Haem, Elham; Harling, Kajsa; Ayatollahi, Seyyed Mohammad Taghi; Zare, Najaf; Karlsson, Mats O

2017-02-01

One important aim in population pharmacokinetics (PK) and pharmacodynamics is identification and quantification of the relationships between the parameters and covariates. Lasso has been suggested as a technique for simultaneous estimation and covariate selection. In linear regression, it has been shown that Lasso possesses no oracle properties, which means it asymptotically performs as though the true underlying model was given in advance. Adaptive Lasso (ALasso) with appropriate initial weights is claimed to possess oracle properties; however, it can lead to poor predictive performance when there is multicollinearity between covariates. This simulation study implemented a new version of ALasso, called adjusted ALasso (AALasso), to take into account the ratio of the standard error of the maximum likelihood (ML) estimator to the ML coefficient as the initial weight in ALasso to deal with multicollinearity in non-linear mixed-effect models. The performance of AALasso was compared with that of ALasso and Lasso. PK data was simulated in four set-ups from a one-compartment bolus input model. Covariates were created by sampling from a multivariate standard normal distribution with no, low (0.2), moderate (0.5) or high (0.7) correlation. The true covariates influenced only clearance at different magnitudes. AALasso, ALasso and Lasso were compared in terms of mean absolute prediction error and error of the estimated covariate coefficient. The results show that AALasso performed better in small data sets, even in those in which a high correlation existed between covariates. This makes AALasso a promising method for covariate selection in nonlinear mixed-effect models.

Primary care utilisation patterns among an urban immigrant population in the Spanish National Health System.

PubMed

Calderón-Larrañaga, Amaia; Gimeno-Feliu, Luis A; Macipe-Costa, Rosa; Poblador-Plou, Beatriz; Bordonaba-Bosque, Daniel; Prados-Torres, Alexandra

2011-06-06

There is evidence suggesting that the use of health services is lower among immigrants after adjusting for age and sex. This study takes a step forward to compare primary care (PC) utilisation patterns between immigrants and the native population with regard to their morbidity burden. This retrospective, observational study looked at 69,067 individuals representing the entire population assigned to three urban PC centres in the city of Zaragoza (Aragon, Spain). Poisson models were applied to determine the number of annual PC consultations per individual based on immigration status. All models were first adjusted for age and sex and then for age, sex and case mix (ACG System®). The age and sex adjusted mean number of total annual consultations was lower among the immigrant population (children: IRR = 0.79, p < 0.05; adults: IRR = 0.73, p < 0.05). After adjusting for morbidity burden, this difference decreased among children (IRR = 0.94, p < 0.05) and disappeared among adults (IRR = 1.00). Further analysis considering the PC health service and type of visit revealed higher usage of routine diagnostic tests among immigrant children (IRR = 1.77, p < 0.05) and a higher usage of emergency services among the immigrant adult population (IRR = 1.2, p < 0.05) after adjusting for age, sex and case mix. Although immigrants make lower use of PC services than the native population after adjusting the consultation rate for age and sex, these differences decrease significantly when considering their morbidity burden. These results reinforce the 'healthy migration effect' and discount the existence of differences in PC utilisation patterns between the immigrant and native populations in Spain.

Multi-Fluid Interpenetration Mixing in X-ray and Directly Laser driven ICF Capsule Implosions

NASA Astrophysics Data System (ADS)

Wilson, Douglas

2003-10-01

Mix between a surrounding shell and the fuel leads to degradation in ICF capsule performance. Both indirectly (X-ray) and directly laser driven implosions provide a wealth of data to test mix models. One model, the multi-fluid interpenetration mix model of Scannapieco and Cheng (Phys. Lett. A., 299, 49, 2002), was implemented in an ICF code and applied to a wide variety of experiments (e.g. J. D. Kilkenny et al., Proc. Conf Plasm. Phys. Contr. Nuc. Fus. Res. 3, 29(1988), P. Amendt, R. E. Turner, O. L. Landen, Phy. Rev. Lett., 89, 165001 (2002), or Li et al., Phy. Rev. Lett, 89, 165002 (2002)). With its single adjustable parameter fixed, it replicates well the yield degradation with increasing convergence ratio for both directly and indirectly driven capsules. Often, but not always the ion temperatures with mixing are calculated to be higher than in an unmixed implosion, agreeing with observations. Comparison with measured directly driven implosion yield rates ( from the neutron temporal diagnostic or NTD) shows mixing increases rapidly during the burn. The model also reproduces the decrease of the fuel "rho-r" with fill gas pressure, measured by observing escaping deuterons or secondary neutrons. The mix model assumes fully atomically mixed constituents, but when experiments with deuterated plastic layers and 3He fuel are modeled, less that full atomic mix is appropriate. Applying the mix model to the ablator - solid DT interface in indirectly driven ignition capsules for the NIF or LMJ suggests that the capsules will ignite, but that burn after ignition may be somewhat degraded. Situations in which the Scannapieco and Cheng model fails to agree with experiments can guide us to improvements or the development of other models. Some directly driven symmetric implosions suggest that in highly mixed situations, a higher value of the mix parameter may needed. Others show the model underestimating the fuel burn temperature. This work was performed by the Los Alamos National Laboratory under DOE contract number W-7405-Eng-36.

Model verification of mixed dynamic systems. [POGO problem in liquid propellant rockets

NASA Technical Reports Server (NTRS)

Chrostowski, J. D.; Evensen, D. A.; Hasselman, T. K.

1978-01-01

A parameter-estimation method is described for verifying the mathematical model of mixed (combined interactive components from various engineering fields) dynamic systems against pertinent experimental data. The model verification problem is divided into two separate parts: defining a proper model and evaluating the parameters of that model. The main idea is to use differences between measured and predicted behavior (response) to adjust automatically the key parameters of a model so as to minimize response differences. To achieve the goal of modeling flexibility, the method combines the convenience of automated matrix generation with the generality of direct matrix input. The equations of motion are treated in first-order form, allowing for nonsymmetric matrices, modeling of general networks, and complex-mode analysis. The effectiveness of the method is demonstrated for an example problem involving a complex hydraulic-mechanical system.

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...

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.

Synergistic effects of oleaginous yeast Rhodotorula glutinis and microalga Chlorella vulgaris for enhancement of biomass and lipid yields.

PubMed

Zhang, Zhiping; Ji, Hairui; Gong, Guiping; Zhang, Xu; Tan, Tianwei

2014-07-01

The optimal mixed culture model of oleaginous yeast Rhodotorula glutinis and microalga Chlorella vulgaris was confirmed to enhance lipid production. A double system bubble column photo-bioreactor was designed and used for demonstrating the relationship of yeast and alga in mixed culture. The results showed that using the log-phase cultures of yeast and alga as seeds for mixed culture, the improvements of biomass and lipid yields reached 17.3% and 70.9%, respectively, compared with those of monocultures. Growth curves of two species were confirmed in the double system bubble column photo-bioreactor, and the second growth of yeast was observed during 36-48 h of mixed culture. Synergistic effects of two species for cell growth and lipid accumulation were demonstrated on O2/CO2 balance, substance exchange, dissolved oxygen and pH adjustment in mixed culture. This study provided a theoretical basis and culture model for producing lipids by mixed culture in place of monoculture. Copyright © 2014 Elsevier Ltd. All rights reserved.

Monitoring risk-adjusted outcomes in congenital heart surgery: does the appropriateness of a risk model change with time?

PubMed

Tsang, Victor T; Brown, Katherine L; Synnergren, Mats Johanssen; Kang, Nicholas; de Leval, Marc R; Gallivan, Steve; Utley, Martin

2009-02-01

Risk adjustment of outcomes in pediatric congenital heart surgery is challenging due to the great diversity in diagnoses and procedures. We have previously shown that variable life-adjusted display (VLAD) charts provide an effective graphic display of risk-adjusted outcomes in this specialty. A question arises as to whether the risk model used remains appropriate over time. We used a recently developed graphic technique to evaluate the performance of an existing risk model among those patients at a single center during 2000 to 2003 originally used in model development. We then compared the distribution of predicted risk among these patients with that among patients in 2004 to 2006. Finally, we constructed a VLAD chart of risk-adjusted outcomes for the latter period. Among 1083 patients between April 2000 and March 2003, the risk model performed well at predicted risks above 3%, underestimated mortality at 2% to 3% predicted risk, and overestimated mortality below 2% predicted risk. There was little difference in the distribution of predicted risk among these patients and among 903 patients between June 2004 and October 2006. Outcomes for the more recent period were appreciably better than those expected according to the risk model. This finding cannot be explained by any apparent bias in the risk model combined with changes in case-mix. Risk models can, and hopefully do, become out of date. There is scope for complacency in the risk-adjusted audit if the risk model used is not regularly recalibrated to reflect changing standards and expectations.

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...

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.

Spirituality/religiosity's influence on college students' adjustment to bereavement: A systematic review.

PubMed

Hai, Audrey Hang; Currin-McCulloch, Jennifer; Franklin, Cynthia; Cole, Allan Hugh

2018-09-01

Bereavement is prevalent among college students and spirituality/religiosity may play an important role in their bereavement adjustment. This is the first systematic review to investigate the spirituality/religiosity's relationship with bereavement among college students. We searched 10 databases and screened 598 studies. Eight studies met the inclusion criteria. Findings suggested a favorable association of spirituality/religiosity with desirable bereavement adjustment outcomes (growth, spiritual wellbeing, and psychological wellbeing), but mixed association with undesirable bereavement outcomes (distress). We provided directions for future research to further investigate the complex relationship between spirituality/religiosity and bereavement and to refine the meaning-making coping model for the college student population.

The Design of the Trading Mechanism to Adapt the Development of Mixed Cooling Heating and Power

NASA Astrophysics Data System (ADS)

Liu, D. N.; Li, Z. H.; Zhou, H. M.; Zhao, Q.; Xu, X. F.

2017-08-01

The enterprise who has combined cooling heating and power system has both the customer group and the power generation resources. Therefore, it can be used as a power user, and can also be used as a power generation enterprise to participate in the direct purchase of electricity. This paper combines characteristics of mixed cooling heating and power, designs application business model of mixed cooling heating and power, and puts forward to the scene of cooling heating and power trading scheme, helping the enterprise according to the power supply and demand situation in the region adjust their positions and participate in the electricity market.

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.

Comparing statistical methods for analyzing skewed longitudinal count data with many zeros: an example of smoking cessation.

PubMed

Xie, Haiyi; Tao, Jill; McHugo, Gregory J; Drake, Robert E

2013-07-01

Count data with skewness and many zeros are common in substance abuse and addiction research. Zero-adjusting models, especially zero-inflated models, have become increasingly popular in analyzing this type of data. This paper reviews and compares five mixed-effects Poisson family models commonly used to analyze count data with a high proportion of zeros by analyzing a longitudinal outcome: number of smoking quit attempts from the New Hampshire Dual Disorders Study. The findings of our study indicated that count data with many zeros do not necessarily require zero-inflated or other zero-adjusting models. For rare event counts or count data with small means, a simpler model such as the negative binomial model may provide a better fit. Copyright © 2013 Elsevier Inc. All rights reserved.

Incorporation of habitat information in the development of indices of larval bluefin tuna (Thunnus thynnus) in the Western Mediterranean Sea (2001-2005 and 2012-2013)

NASA Astrophysics Data System (ADS)

Ingram, G. Walter; Alvarez-Berastegui, Diego; Reglero, Patricia; Balbín, Rosa; García, Alberto; Alemany, Francisco

2017-06-01

Fishery independent indices of bluefin tuna larvae in the Western Mediterranean Sea are presented utilizing ichthyoplankton survey data collected from 2001 through 2005 and 2012 through 2013. Indices were developed using larval catch rates collected using two different types of bongo sampling, by first standardizing catch rates by gear/fishing-style and then employing a delta-lognormal modeling approach. The delta-lognormal models were developed three ways: 1) a basic larval index including the following covariates: time of day, a systematic geographic area variable, month and year; 2) a standard environmental larval index including the following covariates: mean water temperature over the mixed layer depth, mean salinity over the mixed layer depth, geostrophic velocity, time of day, a systematic geographic area variable, month and year; and 3) a habitat-adjusted larval index including the following covariates: a potential habitat variable, time of day, a systematic geographic area variable, month and year. Results indicated that all three model-types had similar precision in index values. However, the habitat-adjusted larval index demonstrated a high correlation with estimates of spawning stock biomass from the previous stock assessment model, and, therefore, is recommended as a tuning index in future stock assessment models.

Linear mixed-effects models to describe individual tree crown width for China-fir in Fujian Province, southeast China.

PubMed

Hao, Xu; Yujun, Sun; Xinjie, Wang; Jin, Wang; Yao, Fu

2015-01-01

A multiple linear model was developed for individual tree crown width of Cunninghamia lanceolata (Lamb.) Hook in Fujian province, southeast China. Data were obtained from 55 sample plots of pure China-fir plantation stands. An Ordinary Linear Least Squares (OLS) regression was used to establish the crown width model. To adjust for correlations between observations from the same sample plots, we developed one level linear mixed-effects (LME) models based on the multiple linear model, which take into account the random effects of plots. The best random effects combinations for the LME models were determined by the Akaike's information criterion, the Bayesian information criterion and the -2logarithm likelihood. Heteroscedasticity was reduced by three residual variance functions: the power function, the exponential function and the constant plus power function. The spatial correlation was modeled by three correlation structures: the first-order autoregressive structure [AR(1)], a combination of first-order autoregressive and moving average structures [ARMA(1,1)], and the compound symmetry structure (CS). Then, the LME model was compared to the multiple linear model using the absolute mean residual (AMR), the root mean square error (RMSE), and the adjusted coefficient of determination (adj-R2). For individual tree crown width models, the one level LME model showed the best performance. An independent dataset was used to test the performance of the models and to demonstrate the advantage of calibrating LME models.

Comparative Robustness of Recent Methods for Analyzing Multivariate Repeated Measures Designs

ERIC Educational Resources Information Center

Seco, Guillermo Vallejo; Gras, Jaime Arnau; Garcia, Manuel Ato

2007-01-01

This study evaluated the robustness of two recent methods for analyzing multivariate repeated measures when the assumptions of covariance homogeneity and multivariate normality are violated. Specifically, the authors' work compares the performance of the modified Brown-Forsythe (MBF) procedure and the mixed-model procedure adjusted by the…

Identification of Hospital Outliers in Bleeding Complications After Percutaneous Coronary Intervention

PubMed Central

Hess, Connie N.; Rao, Sunil V.; McCoy, Lisa A.; Neely, Megan L.; Singh, Mandeep; Spertus, John A.; Krone, Ronald J.; Weaver, W. Douglas; Peterson, Eric D.

2014-01-01

Background Post-percutaneous coronary intervention (PCI) bleeding complications are an important quality metric. We sought to characterize site-level variation in post-PCI bleeding and explore the influence of patient and procedural factors on hospital bleeding performance. Methods and Results Hospital-level bleeding performance was compared pre- and post-adjustment using the newly-revised CathPCI Registry® bleeding risk model (c-index 0.77) among 1,292 NCDR® hospitals performing >50 PCIs from 7/2009–9/2012 (n=1,984,998 procedures). Using random effects models, outlier sites were identified based on 95% confidence intervals around the hospital’s random intercept. Bleeding 72 hours post-PCI was defined as: arterial access site, retroperitoneal, gastrointestinal, or genitourinary bleeding; intracranial hemorrhage; cardiac tamponade; non-bypass surgery-related blood transfusion with pre-procedure hemoglobin ≥8 g/dl; or absolute decrease in hemoglobin value ≥3g/dl with pre-procedure hemoglobin ≤16 g/dl. Overall, the median unadjusted post-PCI bleeding rate was 5.2% and varied among hospitals from 2.6%–10.4% (5th, 95th percentiles). Center-level bleeding variation persisted after case-mix adjustment (2.8%–9.5%; 5th, 95th percentiles). While hospitals’ observed and risk-adjusted bleeding ranks were correlated (Spearman’s rho 0.88), individual rankings shifted after risk-adjustment (median Δ rank order ± 91.5; IQR 37.0, 185.5). Outlier classification changed post-adjustment for 29.3%, 16.1%, and 26.5% of low-, non-, and high-outlier sites, respectively. Hospital use of bleeding avoidance strategies (bivalirudin, radial access, or vascular closure device) was associated with risk-adjusted bleeding rates. Conclusions Despite adjustment for patient case-mix, there is wide variation in rates of hospital PCI-related bleeding in the United States. Opportunities may exist for best performers to share practices with other sites. PMID:25424242

Comparing the behaviour of two ocean surface models in simulating dissolved O 2 concentration at O.W.S.P.

NASA Astrophysics Data System (ADS)

Thomas, F.; Minster, J. F.; Gaspar, P.; Gregoris, Y.

1993-02-01

We compare the simulation of the O 2 concentration in the mixed layer at Sta. P using two different mixed layer models with the same biological production-consumption function. One is the integral mixed layer model already used by THOMASet al. (Deep-Sea Research, 37, 463-491, 1990). The other is the eddy kinetic energy (EKE) model of GASPARet al. (Journal of Geophysical Research, 95, 16179-16194, 1990). The latter simulates better both the seasonal and the short time evolution of the oxygen concentration. The submixed layer summer supersaturation is also closer to observations, by about 25%, though a factor of 2 too high: this could be improved by adjustment of the production function. The net annual gas exchange flux with the atmosphere is always a degassing of the order of 10% of the total biological production. In general, the model values are smaller (within a factor of 3 for the EKE model) than the data. However, the latter may not be robust as 96 measurements per year are necessary to estimate this flux within a factor of 10.

Pulse Jet Mixing Tests With Noncohesive Solids

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

Meyer, Perry A.; Bamberger, Judith A.; Enderlin, Carl W.

2012-02-17

This report summarizes results from pulse jet mixing (PJM) tests with noncohesive solids in Newtonian liquid. The tests were conducted during FY 2007 and 2008 to support the design of mixing systems for the Hanford Waste Treatment and Immobilization Plant (WTP). Tests were conducted at three geometric scales using noncohesive simulants, and the test data were used to develop models predicting two measures of mixing performance for full-scale WTP vessels. The models predict the cloud height (the height to which solids will be lifted by the PJM action) and the critical suspension velocity (the minimum velocity needed to ensure allmore » solids are suspended off the floor, though not fully mixed). From the cloud height, the concentration of solids at the pump inlet can be estimated. The predicted critical suspension velocity for lifting all solids is not precisely the same as the mixing requirement for 'disturbing' a sufficient volume of solids, but the values will be similar and closely related. These predictive models were successfully benchmarked against larger scale tests and compared well with results from computational fluid dynamics simulations. The application of the models to assess mixing in WTP vessels is illustrated in examples for 13 distinct designs and selected operational conditions. The values selected for these examples are not final; thus, the estimates of performance should not be interpreted as final conclusions of design adequacy or inadequacy. However, this work does reveal that several vessels may require adjustments to design, operating features, or waste feed properties to ensure confidence in operation. The models described in this report will prove to be valuable engineering tools to evaluate options as designs are finalized for the WTP. Revision 1 refines data sets used for model development and summarizes models developed since the completion of Revision 0.« less

Iterative Usage of Fixed and Random Effect Models for Powerful and Efficient Genome-Wide Association Studies

PubMed Central

Liu, Xiaolei; Huang, Meng; Fan, Bin; Buckler, Edward S.; Zhang, Zhiwu

2016-01-01

False positives in a Genome-Wide Association Study (GWAS) can be effectively controlled by a fixed effect and random effect Mixed Linear Model (MLM) that incorporates population structure and kinship among individuals to adjust association tests on markers; however, the adjustment also compromises true positives. The modified MLM method, Multiple Loci Linear Mixed Model (MLMM), incorporates multiple markers simultaneously as covariates in a stepwise MLM to partially remove the confounding between testing markers and kinship. To completely eliminate the confounding, we divided MLMM into two parts: Fixed Effect Model (FEM) and a Random Effect Model (REM) and use them iteratively. FEM contains testing markers, one at a time, and multiple associated markers as covariates to control false positives. To avoid model over-fitting problem in FEM, the associated markers are estimated in REM by using them to define kinship. The P values of testing markers and the associated markers are unified at each iteration. We named the new method as Fixed and random model Circulating Probability Unification (FarmCPU). Both real and simulated data analyses demonstrated that FarmCPU improves statistical power compared to current methods. Additional benefits include an efficient computing time that is linear to both number of individuals and number of markers. Now, a dataset with half million individuals and half million markers can be analyzed within three days. PMID:26828793

A brief dataset on the model-based evaluation of the growth performance of Bacillus coagulans and l-lactic acid production in a lignin-supplemented medium.

PubMed

Glaser, Robert; Venus, Joachim

2017-04-01

The data presented in this article are related to the research article entitled "Model-based characterization of growth performance and l-lactic acid production with high optical purity by thermophilic Bacillus coagulans in a lignin-supplemented mixed substrate medium (R. Glaser and J. Venus, 2016) [1]". This data survey provides the information on characterization of three Bacillus coagulans strains. Information on cofermentation of lignocellulose-related sugars in lignin-containing media is given. Basic characterization data are supported by optical-density high-throughput screening and parameter adjustment to logistic growth models. Lab scale fermentation procedures are examined by model adjustment of a Monod kinetics-based growth model. Lignin consumption is analyzed using the data on decolorization of a lignin-supplemented minimal medium.

A High-Resolution Integrated Model of the National Ignition Campaign Cryogenic Layered Experiments

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

Jones, O. S.; Callahan, D. A.; Cerjan, C. J.

A detailed simulation-based model of the June 2011 National Ignition Campaign (NIC) cryogenic DT experiments is presented. The model is based on integrated hohlraum-capsule simulations that utilize the best available models for the hohlraum wall, ablator, and DT equations of state and opacities. The calculated radiation drive was adjusted by changing the input laser power to match the experimentally measured shock speeds, shock merger times, peak implosion velocity, and bangtime. The crossbeam energy transfer model was tuned to match the measured time-dependent symmetry. Mid-mode mix was included by directly modeling the ablator and ice surface perturbations up to mode 60.more » Simulated experimental values were extracted from the simulation and compared against the experiment. The model adjustments brought much of the simulated data into closer agreement with the experiment, with the notable exception of the measured yields, which were 15-40% of the calculated yields.« less

A High-Resolution Integrated Model of the National Ignition Campaign Cryogenic Layered Experiments

DOE PAGES

Jones, O. S.; Callahan, D. A.; Cerjan, C. J.; ...

2012-05-29

A detailed simulation-based model of the June 2011 National Ignition Campaign (NIC) cryogenic DT experiments is presented. The model is based on integrated hohlraum-capsule simulations that utilize the best available models for the hohlraum wall, ablator, and DT equations of state and opacities. The calculated radiation drive was adjusted by changing the input laser power to match the experimentally measured shock speeds, shock merger times, peak implosion velocity, and bangtime. The crossbeam energy transfer model was tuned to match the measured time-dependent symmetry. Mid-mode mix was included by directly modeling the ablator and ice surface perturbations up to mode 60.more » Simulated experimental values were extracted from the simulation and compared against the experiment. The model adjustments brought much of the simulated data into closer agreement with the experiment, with the notable exception of the measured yields, which were 15-40% of the calculated yields.« less

Towards an Integrated Model of the NIC Layered Implosions

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

Jones, O S; Callahan, D A; Cerjan, C J

A detailed simulation-based model of the June 2011 National Ignition Campaign (NIC) cryogenic DT experiments is presented. The model is based on integrated hohlraum-capsule simulations that utilize the best available models for the hohlraum wall, ablator, and DT equations of state and opacities. The calculated radiation drive was adjusted by changing the input laser power to match the experimentally measured shock speeds, shock merger times, peak implosion velocity, and bangtime. The crossbeam energy transfer model was tuned to match the measured time-dependent symmetry. Mid-mode mix was included by directly modeling the ablator and ice surface perturbations up to mode 60.more » Simulated experimental values were extracted from the simulation and compared against the experiment. The model adjustments brought much of the simulated data into closer agreement with the experiment, with the notable exception of the measured yields, which were 15-45% of the calculated yields.« less

Mixing Phenomena in a Bottom Blown Copper Smelter: A Water Model Study

NASA Astrophysics Data System (ADS)

Shui, Lang; Cui, Zhixiang; Ma, Xiaodong; Akbar Rhamdhani, M.; Nguyen, Anh; Zhao, Baojun

2015-03-01

The first commercial bottom blown oxygen copper smelting furnace has been installed and operated at Dongying Fangyuan Nonferrous Metals since 2008. Significant advantages have been demonstrated in this technology mainly due to its bottom blown oxygen-enriched gas. In this study, a scaled-down 1:12 model was set up to simulate the flow behavior for understanding the mixing phenomena in the furnace. A single lance was used in the present study for gas blowing to establish a reliable research technique and quantitative characterisation of the mixing behavior. Operating parameters such as horizontal distance from the blowing lance, detector depth, bath height, and gas flow rate were adjusted to investigate the mixing time under different conditions. It was found that when the horizontal distance between the lance and detector is within an effective stirring range, the mixing time decreases slightly with increasing the horizontal distance. Outside this range, the mixing time was found to increase with increasing the horizontal distance and it is more significant on the surface. The mixing time always decreases with increasing gas flow rate and bath height. An empirical relationship of mixing time as functions of gas flow rate and bath height has been established first time for the horizontal bottom blowing furnace.

Vertical profiles of nitrous acid in the nocturnal urban atmosphere of Houston, TX

NASA Astrophysics Data System (ADS)

Wong, K. W.; Oh, H.-J.; Lefer, B. L.; Rappenglück, B.; Stutz, J.

2011-04-01

Nitrous acid (HONO) often plays an important role in tropospheric photochemistry as a major precursor of the hydroxyl radical (OH) in early morning hours and potentially during the day. However, the processes leading to formation of HONO and its vertical distribution at night, which can have a considerable impact on daytime ozone formation, are currently poorly characterized by observations and models. Long-path differential optical absorption spectroscopy (LP-DOAS) measurements of HONO during the 2006 TexAQS II Radical and Aerosol Measurement Project (TRAMP), near downtown Houston, TX, show nocturnal vertical profiles of HONO, with mixing ratios of up to 2.2 ppb near the surface and below 100 ppt aloft. Three nighttime periods of HONO, NO2 and O3 observations during TRAMP were used to perform model simulations of vertical mixing ratio profiles. By adjusting vertical mixing and NOx emissions the modeled NO2 and O3 mixing ratios showed very good agreement with the observations. Using a simple conversion of NO2 to HONO on the ground, direct HONO emissions, as well as HONO loss at the ground and on aerosol, the observed HONO profiles were reproduced by the model for 1-2 and 7-8 September in the nocturnal boundary layer (NBL). The unobserved increase of HONO to NO2 ratio (HONO/NO2) with altitude that was simulated by the initial model runs was found to be due to HONO uptake being too small on aerosol and too large on the ground. Refined model runs, with adjusted HONO uptake coefficients, showed much better agreement of HONO and HONO/NO2 for two typical nights, except during morning rush hour, when other HONO formation pathways are most likely active. One of the nights analyzed showed an increase of HONO mixing ratios together with decreasing NO2 mixing ratios that the model was unable to reproduce, most likely due to the impact of weak precipitation during this night. HONO formation and removal rates averaged over the lowest 300 m of the atmosphere showed that NO2 to HONO conversion on the ground was the dominant source of HONO, followed by traffic emission. Aerosol did not play an important role in HONO formation. Although ground deposition was also a major removal pathway of HONO, net HONO production at the ground was the main source of HONO in our model studies. Sensitivity studies showed that in the stable NBL, net HONO production at the ground tends to increase with faster vertical mixing and stronger NOx emission. Vertical transport was found to be the dominant source of HONO aloft.

Nonideal mixing of phosphatidylserine and phosphatidylcholine in the fluid lamellar phase.

PubMed Central

Huang, J; Swanson, J E; Dibble, A R; Hinderliter, A K; Feigenson, G W

1993-01-01

The mixing of phosphatidylserine (PS) and phosphatidylcholine (PC) in fluid bilayer model membranes was studied by measuring binding of aqueous Ca2+ ions. The measured [Ca2+]aq was used to derive the activity coefficient for PS, gamma PS, in the lipid mixture. For (16:0, 18:1) PS in binary mixtures with either (16:0, 18:1)PC, (14:1, 14:1)PC, or (18:1, 18:1)PC, gamma PS > 1; i.e., mixing is nonideal, with PS and PC clustered rather than randomly distributed, despite the electrostatic repulsion between PS headgroups. To understand better this mixing behavior, Monte Carlo simulations of the PS/PC distributions were performed, using Kawasaki relaxation. The excess energy was divided into an electrostatic term Uel and one adjustable term including all other nonideal energy contributions, delta Em. Uel was calculated using a discrete charge theory. Kirkwood's coupling parameter method was used to calculate the excess free energy of mixing, delta GEmix, hence In gamma PS,calc. The values of In gamma PS,calc were equalized by adjusting delta Em in order to find the simulated PS/PC distribution that corresponded to the experimental results. We were thus able to compare the smeared charge calculation of [Ca2+]surf with a calculation ("masked evaluation method") that recognized clustering of the negatively charged PS: clustering was found to have a modest effect on [Ca2+]surf, relative to the smeared charge model. Even though both PS and PC tend to cluster, the long-range nature of the electrostatic repulsion reduces the extent of PS clustering at low PS mole fraction compared to PC clustering at an equivalent low PC mole fraction. PMID:8457667

Nonideal mixing of phosphatidylserine and phosphatidylcholine in the fluid lamellar phase.

PubMed

Huang, J; Swanson, J E; Dibble, A R; Hinderliter, A K; Feigenson, G W

1993-02-01

The mixing of phosphatidylserine (PS) and phosphatidylcholine (PC) in fluid bilayer model membranes was studied by measuring binding of aqueous Ca2+ ions. The measured [Ca2+]aq was used to derive the activity coefficient for PS, gamma PS, in the lipid mixture. For (16:0, 18:1) PS in binary mixtures with either (16:0, 18:1)PC, (14:1, 14:1)PC, or (18:1, 18:1)PC, gamma PS > 1; i.e., mixing is nonideal, with PS and PC clustered rather than randomly distributed, despite the electrostatic repulsion between PS headgroups. To understand better this mixing behavior, Monte Carlo simulations of the PS/PC distributions were performed, using Kawasaki relaxation. The excess energy was divided into an electrostatic term Uel and one adjustable term including all other nonideal energy contributions, delta Em. Uel was calculated using a discrete charge theory. Kirkwood's coupling parameter method was used to calculate the excess free energy of mixing, delta GEmix, hence In gamma PS,calc. The values of In gamma PS,calc were equalized by adjusting delta Em in order to find the simulated PS/PC distribution that corresponded to the experimental results. We were thus able to compare the smeared charge calculation of [Ca2+]surf with a calculation ("masked evaluation method") that recognized clustering of the negatively charged PS: clustering was found to have a modest effect on [Ca2+]surf, relative to the smeared charge model. Even though both PS and PC tend to cluster, the long-range nature of the electrostatic repulsion reduces the extent of PS clustering at low PS mole fraction compared to PC clustering at an equivalent low PC mole fraction.

The implementation of reverse Kessler warm rain scheme for radar reflectivity assimilation using a nudging approach in New Zealand

NASA Astrophysics Data System (ADS)

Zhang, Sijin; Austin, Geoff; Sutherland-Stacey, Luke

2014-05-01

Reverse Kessler warm rain processes were implemented within the Weather Research and Forecasting Model (WRF) and coupled with a Newtonian relaxation, or nudging technique designed to improve quantitative precipitation forecasting (QPF) in New Zealand by making use of observed radar reflectivity and modest computing facilities. One of the reasons for developing such a scheme, rather than using 4D-Var for example, is that radar VAR scheme in general, and 4D-Var in particular, requires computational resources beyond the capability of most university groups and indeed some national forecasting centres of small countries like New Zealand. The new scheme adjusts the model water vapor mixing ratio profiles based on observed reflectivity at each time step within an assimilation time window. The whole scheme can be divided into following steps: (i) The radar reflectivity is firstly converted to rain water, and (ii) then the rain water is used to derive cloud water content according to the reverse Kessler scheme; (iii) The cloud water content associated water vapor mixing ratio is then calculated based on the saturation adjustment processes; (iv) Finally the adjusted water vapor is nudged into the model and the model background is updated. 13 rainfall cases which occurred in the summer of 2011/2012 in New Zealand were used to evaluate the new scheme, different forecast scores were calculated and showed that the new scheme was able to improve precipitation forecasts on average up to around 7 hours ahead depending on different verification thresholds.

MIXREG: a computer program for mixed-effects regression analysis with autocorrelated errors.

PubMed

Hedeker, D; Gibbons, R D

1996-05-01

MIXREG is a program that provides estimates for a mixed-effects regression model (MRM) for normally-distributed response data including autocorrelated errors. This model can be used for analysis of unbalanced longitudinal data, where individuals may be measured at a different number of timepoints, or even at different timepoints. Autocorrelated errors of a general form or following an AR(1), MA(1), or ARMA(1,1) form are allowable. This model can also be used for analysis of clustered data, where the mixed-effects model assumes data within clusters are dependent. The degree of dependency is estimated jointly with estimates of the usual model parameters, thus adjusting for clustering. MIXREG uses maximum marginal likelihood estimation, utilizing both the EM algorithm and a Fisher-scoring solution. For the scoring solution, the covariance matrix of the random effects is expressed in its Gaussian decomposition, and the diagonal matrix reparameterized using the exponential transformation. Estimation of the individual random effects is accomplished using an empirical Bayes approach. Examples illustrating usage and features of MIXREG are provided.

The multivariate egg: quantifying within- and among-clutch correlations between maternally derived yolk immunoglobulins and yolk androgens using multivariate mixed models.

PubMed

Postma, Erik; Siitari, Heli; Schwabl, Hubert; Richner, Heinz; Tschirren, Barbara

2014-03-01

Egg components are important mediators of prenatal maternal effects in birds and other oviparous species. Because different egg components can have opposite effects on offspring phenotype, selection is expected to favour their mutual adjustment, resulting in a significant covariation between egg components within and/or among clutches. Here we tested for such correlations between maternally derived yolk immunoglobulins and yolk androgens in great tit (Parus major) eggs using a multivariate mixed-model approach. We found no association between yolk immunoglobulins and yolk androgens within clutches, indicating that within clutches the two egg components are deposited independently. Across clutches, however, there was a significant negative relationship between yolk immunoglobulins and yolk androgens, suggesting that selection has co-adjusted their deposition. Furthermore, an experimental manipulation of ectoparasite load affected patterns of covariance among egg components. Yolk immunoglobulins are known to play an important role in nestling immune defence shortly after hatching, whereas yolk androgens, although having growth-enhancing effects under many environmental conditions, can be immunosuppressive. We therefore speculate that variation in the risk of parasitism may play an important role in shaping optimal egg composition and may lead to the observed pattern of yolk immunoglobulin and yolk androgen deposition across clutches. More generally, our case study exemplifies how multivariate mixed-model methodology presents a flexible tool to not only quantify, but also test patterns of (co)variation across different organisational levels and environments, allowing for powerful hypothesis testing in ecophysiology.

Formation of well-mixed warm water column in central Bohai Sea during summer: Role of high-frequency atmospheric forcing

NASA Astrophysics Data System (ADS)

Ma, Weiwei; Wan, Xiuquan; Wang, Zhankun; Liu, Yulong; Wan, Kai

2017-12-01

The influence of high-frequency atmospheric forcing on the formation of a well-mixed summer warm water column in the central Bohai Sea is investigated comparing model simulations driven by daily surface forcing and those using monthly forcing data. In the absence of high-frequency atmospheric forcing, numerical simulations have repeatedly failed to reproduce this vertically uniform column of warm water measured over the past 35 years. However, high-frequency surface forcing is found to strongly influence the structure and distribution of the well-mixed warm water column, and simulations are in good agreement with observations. Results show that high frequency forcing enhances vertical mixing over the central bank, intensifies downward heat transport, and homogenizes the water column to form the Bohai central warm column. Evidence presented shows that high frequency forcing plays a dominant role in the formation of the well-mixed warm water column in summer, even without the effects of tidal and surface wave mixing. The present study thus provides a practical and rational way of further improving the performance of oceanic simulations in the Bohai Sea and can be used to adjust parameterization schemes of ocean models.

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.

General Education Pre-Service Teachers' Levels of Concern on Response to Intervention (RTI) Implementation

ERIC Educational Resources Information Center

Barrio, Brenda L.; Combes, Bertina H.

2015-01-01

Revisions to Individuals with Disabilities Education Improvement Act (IDEIA) proposed alternative models, such as Response to Intervention (RTI), as a preventive measure that supports students at risk. As teachers' roles evolve in response to RTI, teacher preparation programs must adjust their focus and curriculum accordingly. A mixed-methods…

Comparing observed and predicted mortality among ICUs using different prognostic systems: why do performance assessments differ?

PubMed

Kramer, Andrew A; Higgins, Thomas L; Zimmerman, Jack E

2015-02-01

To compare ICU performance using standardized mortality ratios generated by the Acute Physiology and Chronic Health Evaluation IVa and a National Quality Forum-endorsed methodology and examine potential reasons for model-based standardized mortality ratio differences. Retrospective analysis of day 1 hospital mortality predictions at the ICU level using Acute Physiology and Chronic Health Evaluation IVa and National Quality Forum models on the same patient cohort. Forty-seven ICUs at 36 U.S. hospitals from January 2008 to May 2013. Eighty-nine thousand three hundred fifty-three consecutive unselected ICU admissions. None. We assessed standardized mortality ratios for each ICU using data for patients eligible for Acute Physiology and Chronic Health Evaluation IVa and National Quality Forum predictions in order to compare unit-level model performance, differences in ICU rankings, and how case-mix adjustment might explain standardized mortality ratio differences. Hospital mortality was 11.5%. Overall standardized mortality ratio was 0.89 using Acute Physiology and Chronic Health Evaluation IVa and 1.07 using National Quality Forum, the latter having a widely dispersed and multimodal standardized mortality ratio distribution. Model exclusion criteria eliminated mortality predictions for 10.6% of patients for Acute Physiology and Chronic Health Evaluation IVa and 27.9% for National Quality Forum. The two models agreed on the significance and direction of standardized mortality ratio only 45% of the time. Four ICUs had standardized mortality ratios significantly less than 1.0 using Acute Physiology and Chronic Health Evaluation IVa, but significantly greater than 1.0 using National Quality Forum. Two ICUs had standardized mortality ratios exceeding 1.75 using National Quality Forum, but nonsignificant performance using Acute Physiology and Chronic Health Evaluation IVa. Stratification by patient and institutional characteristics indicated that units caring for more severely ill patients and those with a higher percentage of patients on mechanical ventilation had the most discordant standardized mortality ratios between the two predictive models. Acute Physiology and Chronic Health Evaluation IVa and National Quality Forum models yield different ICU performance assessments due to differences in case-mix adjustment. Given the growing role of outcomes in driving prospective payment patient referral and public reporting, performance should be assessed by models with fewer exclusions, superior accuracy, and better case-mix adjustment.

How age and gender predict illness course in a first-episode nonaffective psychosis cohort.

PubMed

Drake, Richard J; Addington, Jean; Viswanathan, Ananth C; Lewis, Shôn W; Cotter, Jack; Yung, Alison R; Abel, Kathryn M

2016-03-01

Male gender and young age at onset of schizophrenia are traditionally associated with poor treatment outcome and often used to determine prognosis. However, many studies use nonincident samples and fail to adjust for symptom severity at onset. We hypothesized that age and gender would influence severity of presentation but would not predict outcome after adjustment for symptoms at presentation. 628 people with first-episode ICD-9 and DSM-IV nonaffective psychosis from 2 historical cohorts recruited from sequential presentations in Canada and the United Kingdom (1996-1998) were assessed prospectively at presentation and over 12-18 months using the Positive and Negative Syndrome Scale (PANSS). Models of the age-at-onset distributions with 2 underlying modes at similar ages in women (ages 23 years and 47 years) and men (ages 22 years and 46 years) had relatively good fits compared to single-mode models (χ(2)1 better by 9.2 for females, 8.0 for males, both P < .05). At presentation, scores for negative symptoms were 1.84 points worse for males (95% CI, 1.05 to 2.58; P < .001) in a mixed effects model. Younger age also predicted higher negative scores at presentation (partial correlation r = -0.18, P < .01; P < .001 in the mixed effects model). Findings were similar for cognitive-disorganized symptoms. However, after controlling for baseline symptoms, age at onset and gender did not significantly predict subsequent symptom course in the mixed effects models. Gender and age at onset are independently associated with symptoms at presentation but not with medium-term course of schizophrenia. This finding reinforces the importance of early identification and prevention of severe negative symptoms at first episode, whatever an individual's age and gender. © Copyright 2016 Physicians Postgraduate Press, Inc.

Exploration of preterm birth rates associated with different models of antenatal midwifery care in Scotland: Unmatched retrospective cohort analysis.

PubMed

Symon, Andrew; Winter, Clare; Cochrane, Lynda

2015-06-01

preterm birth represents a significant personal, clinical, organisational and financial burden. Strategies to reduce the preterm birth rate have had limited success. Limited evidence indicates that certain antenatal care models may offer some protection, although the causal mechanism is not understood. We sought to compare preterm birth rates for mixed-risk pregnant women accessing antenatal care organised at a freestanding midwifery unit (FMU) and mixed-risk pregnant women attending an obstetric unit (OU) with related community-based antenatal care. unmatched retrospective 4-year Scottish cohort analysis (2008-2011) of mixed-risk pregnant women accessing (i) FMU antenatal care (n=1107); (ii) combined community-based and OU antenatal care (n=7567). Data were accessed via the Information and Statistics Division of the NHS in Scotland. Aggregates analysis and binary logistic regression were used to compare the cohorts׳ rates of preterm birth; and of spontaneous labour onset, use of pharmacological analgesia, unassisted vertex birth, and low birth weight. Odds ratios were adjusted for age, parity, deprivation score and smoking status in pregnancy. after adjustment the 'mixed risk' FMU cohort had a statistically significantly reduced risk of preterm birth (5.1% [n=57] versus 7.7% [n=583]; AOR 0.73 [95% CI 0.55-0.98]; p=0.034). Differences in these secondary outcome measures were also statistically significant: spontaneous labour onset (FMU 83.9% versus OU 74.6%; AOR 1.74 [95% CI 1.46-2.08]; p<0.001); minimal intrapartum analgesia (FMU 53.7% versus OU 34.4%; AOR 2.17 [95% CI 1.90-2.49]; p<0.001); spontaneous vertex delivery (FMU 71.9% versus OU 63.5%; AOR 1.46 [95% CI 1.32-1.78]; p<0.001). Incidence of low birth weight was not statistically significant after adjustment for other variables. There was no significant difference in the rate of perinatal or neonatal death. given this study׳s methodological limitations, we can only claim associations between the care model and or chosen outcomes. Although both cohorts were mixed risk, differences in risk levels could have contributed to these findings. Nevertheless, the significant difference in preterm birth rates in this study resonates with other research, including the recent Cochrane review of midwife-led continuity models. Because of the multiplicity of risk factors for preterm birth we need to explore the salient features of the FMU model which may be contributing to this apparent protective effect. Because a randomised controlled trial would necessarily restrict choice to pregnant women, we feel that this option is problematic in exploring this further. We therefore plan to conduct a prospective matched cohort analysis together with a survey of unit practices and experiences. Copyright © 2015 Elsevier Ltd. All rights reserved.

Stress Management in the Health Care Setting: Matching Interventions with Patient Coping Styles.

ERIC Educational Resources Information Center

Martelli, Michael F.; And Others

1987-01-01

Prospective preprosthetic oral surgery patients were presented with a problem-focused, emotion-focused, or mixed-focus stress management intervention. The mixed-focus intervention produced the best overall response to surgery; the emotion-focused intervention produced the lowest adjustment levels. Better adjustment and satisfaction and lower…

Modeled Health Economic Impact of a Hypothetical Certolizumab Pegol Risk-Sharing Scheme for Patients with Moderate-to-Severe Rheumatoid Arthritis in Finland.

PubMed

Soini, Erkki; Asseburg, Christian; Taiha, Maarit; Puolakka, Kari; Purcaru, Oana; Luosujärvi, Riitta

2017-10-01

To model the American College of Rheumatology (ACR) outcomes, cost-effectiveness, and budget impact of certolizumab pegol (CZP) (with and without a hypothetical risk-sharing scheme at treatment initiation for biologic-naïve patients) versus the current mix of reimbursed biologics for treatment of moderate-to-severe rheumatoid arthritis (RA) in Finland. A probabilistic model with 12-week cycles and a societal approach was developed for the years 2015-2019, accounting for differences in ACR responses (meta-analysis), mortality, and persistence. The risk-sharing scheme included a treatment switch and refund of the costs associated with CZP acquisition if patients failed to achieve ACR20 response at week 12. For the current treatment mix, ACR20 at week 24 determined treatment continuation. Quality-adjusted life years were derived on the basis of the Health Utilities Index. In the Finnish target population, CZP treatment with a risk-sharing scheme led to a estimated annual net expenditure decrease ranging from 1.7% in 2015 to 5.6% in 2019 compared with the current treatment mix. Per patient over the 5 years, CZP risk sharing was estimated to decrease the time without ACR response by 5%-units, decrease work absenteeism by 24 days, and increase the time with ACR20, ACR50, and ACR70 responses by 5%-, 6%-, and 1%-units, respectively, with a gain of 0.03 quality-adjusted life years. The modeled risk-sharing scheme showed reduced costs of €7866 per patient, with a more than 95% probability of cost-effectiveness when compared with the current treatment mix. The present analysis estimated that CZP, with or without the risk-sharing scheme, is a cost-effective alternative treatment for RA patients in Finland. The surplus provided by the CZP risk-sharing scheme could fund treatment for 6% more Finnish RA patients. UCB Pharma.

Patterns of Father Self Evaluations among Mexican and European American Men and Links to Adolescent Adjustment

PubMed Central

Perez-Brena, Norma J.; Cookston, Jeffrey T.; Fabricius, William V.; Saenz, Delia

2013-01-01

A mixed-method study identified profiles of fathers who mentioned key dimensions of their parenting and linked profile membership to adolescents’ adjustment using data from 337 European American, Mexican American and Mexican immigrant fathers and their early adolescent children. Father narratives about what fathers do well as parents were thematically coded for the presence of five fathering dimensions: emotional quality (how well father and child get along), involvement (amount of time spent together), provisioning (the amount of resources provided), discipline (the amount and success in parental control), and role modeling (teaching life lessons through example). Next, latent class analysis was used to identify three patterns of the likelihood of mentioning certain fathering dimensions: an emotionally-involved group mentioned emotional quality and involvement; an affective-control group mentioned emotional quality, involvement, discipline and role modeling; and an affective-model group mentioned emotional quality and role modeling. Profiles were significantly associated with subsequent adolescents’ reports of adjustment such that adolescents of affective-control fathers reported significantly more externalizing behaviors than adolescents of emotionally-involved fathers. PMID:24883049

New arrows in the quiver for targeting care management: high-risk versus high-opportunity case identification.

PubMed

Bernstein, Richard H

2007-01-01

"Care management" purposefully obscures the distinctions between disease and case management and stresses their common features: action in the present to prevent adverse future outcomes and costs. It includes identifying a high-need population by referrals, screening, or data analysis, assessing those likely to benefit from interventions, intervening, evaluating the intervention, and adjusting interventions when needed. High-risk individuals can be identified using at least 9 techniques, from referrals and questionnaires to retrospective claims analysis and predictive models. Other than referrals, software based on the risk-adjustment methodology that we have adapted can incorporate all these methodologies. Because the risk adjustment employs extensive case mix and severity adjustment, it provides care managers with 3 innovative ways to identify not only high-risk individuals but also high-opportunity cases.

A new framework to enhance the interpretation of external validation studies of clinical prediction models.

PubMed

Debray, Thomas P A; Vergouwe, Yvonne; Koffijberg, Hendrik; Nieboer, Daan; Steyerberg, Ewout W; Moons, Karel G M

2015-03-01

It is widely acknowledged that the performance of diagnostic and prognostic prediction models should be assessed in external validation studies with independent data from "different but related" samples as compared with that of the development sample. We developed a framework of methodological steps and statistical methods for analyzing and enhancing the interpretation of results from external validation studies of prediction models. We propose to quantify the degree of relatedness between development and validation samples on a scale ranging from reproducibility to transportability by evaluating their corresponding case-mix differences. We subsequently assess the models' performance in the validation sample and interpret the performance in view of the case-mix differences. Finally, we may adjust the model to the validation setting. We illustrate this three-step framework with a prediction model for diagnosing deep venous thrombosis using three validation samples with varying case mix. While one external validation sample merely assessed the model's reproducibility, two other samples rather assessed model transportability. The performance in all validation samples was adequate, and the model did not require extensive updating to correct for miscalibration or poor fit to the validation settings. The proposed framework enhances the interpretation of findings at external validation of prediction models. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.

Associations between Responsible Beverage Service Laws and Binge Drinking and Alcohol-Impaired Driving

ERIC Educational Resources Information Center

Linde, Ann C.; Toomey, Traci L.; Wolfson, Julian; Lenk, Kathleen M.; Jones-Webb, Rhonda; Erickson, Darin J.

2016-01-01

We explored potential associations between the strength of state Responsible Beverage Service (RBS) laws and self-reported binge drinking and alcohol-impaired driving in the U.S. A multi-level logistic mixed-effects model was used, adjusting for potential confounders. Analyses were conducted on the overall BRFSS sample and drinkers only. Seven…

The Pennsylvania Trauma Outcomes Study Risk-Adjusted Mortality Model: Results of a Statewide Benchmarking Program

PubMed Central

WIEBE, DOUGLAS J.; HOLENA, DANIEL N.; DELGADO, M. KIT; McWILLIAMS, NATHAN; ALTENBURG, JULIET; CARR, BRENDAN G.

2018-01-01

Trauma centers need objective feedback on performance to inform quality improvement efforts. The Trauma Quality Improvement Program recently published recommended methodology for case mix adjustment and benchmarking performance. We tested the feasibility of applying this methodology to develop risk-adjusted mortality models for a statewide trauma system. We performed a retrospective cohort study of patients ≥16 years old at Pennsylvania trauma centers from 2011 to 2013 (n = 100,278). Our main outcome measure was observed-to-expected mortality ratios (overall and within blunt, penetrating, multisystem, isolated head, and geriatric subgroups). Patient demographic variables, physiology, mechanism of injury, transfer status, injury severity, and pre-existing conditions were included as predictor variables. The statistical model had excellent discrimination (area under the curve = 0.94). Funnel plots of observed-to-expected identified five centers with lower than expected mortality and two centers with higher than expected mortality. No centers were outliers for management of penetrating trauma, but five centers had lower and three had higher than expected mortality for blunt trauma. It is feasible to use Trauma Quality Improvement Program methodology to develop risk-adjusted models for statewide trauma systems. Even with smaller numbers of trauma centers that are available in national datasets, it is possible to identify high and low outliers in performance. PMID:28541852

The Pennsylvania Trauma Outcomes Study Risk-Adjusted Mortality Model: Results of a Statewide Benchmarking Program.

PubMed

Wiebe, Douglas J; Holena, Daniel N; Delgado, M Kit; McWilliams, Nathan; Altenburg, Juliet; Carr, Brendan G

2017-05-01

Trauma centers need objective feedback on performance to inform quality improvement efforts. The Trauma Quality Improvement Program recently published recommended methodology for case mix adjustment and benchmarking performance. We tested the feasibility of applying this methodology to develop risk-adjusted mortality models for a statewide trauma system. We performed a retrospective cohort study of patients ≥16 years old at Pennsylvania trauma centers from 2011 to 2013 (n = 100,278). Our main outcome measure was observed-to-expected mortality ratios (overall and within blunt, penetrating, multisystem, isolated head, and geriatric subgroups). Patient demographic variables, physiology, mechanism of injury, transfer status, injury severity, and pre-existing conditions were included as predictor variables. The statistical model had excellent discrimination (area under the curve = 0.94). Funnel plots of observed-to-expected identified five centers with lower than expected mortality and two centers with higher than expected mortality. No centers were outliers for management of penetrating trauma, but five centers had lower and three had higher than expected mortality for blunt trauma. It is feasible to use Trauma Quality Improvement Program methodology to develop risk-adjusted models for statewide trauma systems. Even with smaller numbers of trauma centers that are available in national datasets, it is possible to identify high and low outliers in performance.

Crime Prevention Through Environmental Design (CPTED) Characteristics Associated With Violence and Safety in Middle Schools.

PubMed

Vagi, Kevin J; Stevens, Mark R; Simon, Thomas R; Basile, Kathleen C; Carter, Sherry P; Carter, Stanley L

2018-04-01

This study used a new Crime Prevention Through Environmental Design (CPTED) assessment tool to test the associations between physical attributes of schools and violence-related behaviors and perceptions of students. Data were collected from 4717 students from 50 middle schools. Student perceptions of risk and safety, and violence were assessed. Evaluators used the CPTED School Assessment (CSA) to quantify how well the physical elements of each school correspond to ideal CPTED principles. Generalized linear mixed models were used to adjust for school- and student-level characteristics. Higher CSA scores were generally associated with higher perceptions of safety and lower levels of violence perpetration and perceived risk in unadjusted models. Higher CSA scores were also associated with lower odds of missing school because of safety concerns in most adjusted models, with significant adjusted odds ratios (AORs) ranging from 0.32 to 0.63. CSA scores for parking and bus loading areas also remained associated with higher perceived safety (AORs = 1.28 and 1.32, respectively) and lower perceived risk (AORs = 0.73 and 0.66, respectively) in adjusted models. The CSA is useful for assessing school environments that are associated with violence-related behaviors and perceptions. The CSA might help guide school environmental modifications to reduce violence. © 2018, American School Health Association.

Neighborhood characteristics and sexual intimate partner violence against women among low-income, drug-involved New York City residents: results from the IMPACT Studies.

PubMed

Frye, Victoria; Blaney, Shannon; Cerdá, Magdalena; Vlahov, David; Galea, Sandro; Ompad, Danielle C

2014-07-01

We assessed relations among neighborhood characteristics and sexual intimate partner violence against women (SIPVAW), among low-income, drug-involved, women (n = 360) and men (n = 670) in New York City between 2005 and 2009. Six percent of women (n = 22) and 5% of men (n = 33) reported experiencing and perpetrating SIPVAW in the past year with a main partner. In adjusted mixed models among women, neighborhood ethnic heterogeneity was significantly negatively associated with SIPVAW victimization. In adjusted logistic models among men, neighborhood collective efficacy was significantly positively associated with SIPVAW perpetration. Novel theoretical frameworks are needed to guide research on neighborhoods and partner violence. © The Author(s) 2014.

Surgeon length of service and risk-adjusted outcomes: linked observational analysis of the UK National Adult Cardiac Surgery Audit Registry and General Medical Council Register.

PubMed

Hickey, Graeme L; Grant, Stuart W; Freemantle, Nick; Cunningham, David; Munsch, Christopher M; Livesey, Steven A; Roxburgh, James; Buchan, Iain; Bridgewater, Ben

2014-09-01

To explore the relationship between in-hospital mortality following adult cardiac surgery and the time since primary clinical qualification for the responsible consultant cardiac surgeon (a proxy for experience). Retrospective analysis of prospectively collected national registry data over a 10-year period using mixed-effects multiple logistic regression modelling. Surgeon experience was defined as the time between the date of surgery and award of primary clinical qualification. UK National Health Service hospitals performing cardiac surgery between January 2003 and December 2012. All patients undergoing coronary artery bypass grafts and/or valve surgery under the care of a consultant cardiac surgeon. All-cause in-hospital mortality. A total of 292,973 operations performed by 273 consultant surgeons (with lengths of service from 11.2 to 42.0 years) were included. Crude mortality increased approximately linearly until 33 years service, before decreasing. After adjusting for case-mix and year of surgery, there remained a statistically significant (p=0.002) association between length of service and in-hospital mortality (odds ratio 1.013; 95% CI 1.005-1.021 for each year of 'experience'). Consultant cardiac surgeons take on increasingly complex surgery as they gain experience. With this progression, the incidence of adverse outcomes is expected to increase, as is demonstrated in this study. After adjusting for case-mix using the EuroSCORE, we observed an increased risk of mortality in patients operated on by longer serving surgeons. This finding may reflect under-adjustment for risk, unmeasured confounding or a real association. Further research into outcomes over the time course of surgeon's careers is required. © The Royal Society of Medicine.

A genomic scan for age at onset of Alzheimer's disease in 437 families from the NIMH Genetic Initiative.

PubMed

Dickson, M Ryan; Li, Jian; Wiener, Howard W; Perry, Rodney T; Blacker, Deborah; Bassett, Susan S; Go, Rodney C P

2008-09-05

We performed linkage analysis for age at onset (AAO) in the total Alzheimer's disease (AD) NIMH sample (N = 437 families). Families were subset as late-onset (320 families, AAO > or = 65) and early/mixed (117 families, at least 1 member with 50 < AAO < 65). Treating AAO as a censored trait, we obtained the gender and APOE adjusted residuals in a parametric survival model and analyzed the residuals as the quantitative trait (QT) in variance-component linkage analysis. For comparison, AAO-age at exam (AAE) was analyzed as the QT adjusting for affection status, gender, and APOE. Heritabilities for residual and AAO-AAE outcomes were 66.3% and 74.0%, respectively for the total sample, 56.0% and 57.0% in the late-onset sample, and 33.0% for both models in the early/mixed sample. The residual model yielded the largest peaks on chromosome 1 with LOD = 2.0 at 190 cM in the total set, LOD = 1.7 at 116 cM on chromosome 3 in the early/mixed subset, and LOD = 1.4 at 71 and 86 cM, respectively, on chromosome 6 in the late-onset subset. For the AAO-AAE outcome model the largest peaks were identified on chromosome 1 at 137 cM (LOD = 2.8) and chromosome 6 at 69 cM (LOD = 2.3) and 86 cM (LOD = 2.2) all in the late-onset subset. Additional peaks with LOD > or = 1 were identified on chromosomes 1, 2, 3, 6, 8, 9, 10, and 12 for the total sample and each subset. Results replicate previous findings, but identify additional suggestive peaks indicating the genetics of AAO in AD is complex with many chromosomal regions potentially containing modifying genes. 2008 Wiley-Liss, Inc.

Cost and quality trends in direct contracting arrangements.

PubMed

Lyles, Alan; Weiner, Jonathan P; Shore, Andrew D; Christianson, Jon; Solberg, Leif I; Drury, Patricia

2002-01-01

This paper presents the first empirical analysis of a 1997 initiative of the Buyers Health Care Action Group (BHCAG) known as Choice Plus. This initiative entailed direct contracts with provider-controlled delivery systems; annual care system bidding; public reports of consumer satisfaction and quality; uniform benefits; and risk-adjusted payment. After case-mix adjustment, hospital costs decreased, ambulatory care costs rose modestly, and pharmacy costs increased substantially. Process-oriented quality indicators were stable or improved. The BHCAG employer-to-provider direct contracting and consumer choice model appeared to perform reasonably well in containing costs, without measurable adverse effects on quality.

Development and Validation of Perioperative Risk-Adjustment Models for Hip Fracture Repair, Total Hip Arthroplasty, and Total Knee Arthroplasty.

PubMed

Schilling, Peter L; Bozic, Kevin J

2016-01-06

Comparing outcomes across providers requires risk-adjustment models that account for differences in case mix. The burden of data collection from the clinical record can make risk-adjusted outcomes difficult to measure. The purpose of this study was to develop risk-adjustment models for hip fracture repair (HFR), total hip arthroplasty (THA), and total knee arthroplasty (TKA) that weigh adequacy of risk adjustment against data-collection burden. We used data from the American College of Surgeons National Surgical Quality Improvement Program to create derivation cohorts for HFR (n = 7000), THA (n = 17,336), and TKA (n = 28,661). We developed logistic regression models for each procedure using age, sex, American Society of Anesthesiologists (ASA) physical status classification, comorbidities, laboratory values, and vital signs-based comorbidities as covariates, and validated the models with use of data from 2012. The derivation models' C-statistics for mortality were 80%, 81%, 75%, and 92% and for adverse events were 68%, 68%, 60%, and 70% for HFR, THA, TKA, and combined procedure cohorts. Age, sex, and ASA classification accounted for a large share of the explained variation in mortality (50%, 58%, 70%, and 67%) and adverse events (43%, 45%, 46%, and 68%). For THA and TKA, these three variables were nearly as predictive as models utilizing all covariates. HFR model discrimination improved with the addition of comorbidities and laboratory values; among the important covariates were functional status, low albumin, high creatinine, disseminated cancer, dyspnea, and body mass index. Model performance was similar in validation cohorts. Risk-adjustment models using data from health records demonstrated good discrimination and calibration for HFR, THA, and TKA. It is possible to provide adequate risk adjustment using only the most predictive variables commonly available within the clinical record. This finding helps to inform the trade-off between model performance and data-collection burden as well as the need to define priorities for data capture from electronic health records. These models can be used to make fair comparisons of outcome measures intended to characterize provider quality of care for value-based-purchasing and registry initiatives. Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.

Adjusted hospital death rates: a potential screen for quality of medical care.

PubMed

Dubois, R W; Brook, R H; Rogers, W H

1987-09-01

Increased economic pressure on hospitals has accelerated the need to develop a screening tool for identifying hospitals that potentially provide poor quality care. Based upon data from 93 hospitals and 205,000 admissions, we used a multiple regression model to adjust the hospitals crude death rate. The adjustment process used age, origin of patient from the emergency department or nursing home, and a hospital case mix index based on DRGs (diagnostic related groups). Before adjustment, hospital death rates ranged from 0.3 to 5.8 per 100 admissions. After adjustment, hospital death ratios ranged from 0.36 to 1.36 per 100 (actual death rate divided by predicted death rate). Eleven hospitals (12 per cent) were identified where the actual death rate exceeded the predicted death rate by more than two standard deviations. In nine hospitals (10 per cent), the predicted death rate exceeded the actual death rate by a similar statistical margin. The 11 hospitals with higher than predicted death rates may provide inadequate quality of care or have uniquely ill patient populations. The adjusted death rate model needs to be validated and generalized before it can be used routinely to screen hospitals. However, the remaining large differences in observed versus predicted death rates lead us to believe that important differences in hospital performance may exist.

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.

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.

Ocean Turbulence. Paper 3; Two-Point Closure Model Momentum, Heat and Salt Vertical Diffusivities in the Presence of Shear

NASA Technical Reports Server (NTRS)

Canuto, V. M.; Dubovikov, M. S.; Howard, A.; Cheng, Y.

1999-01-01

In papers 1 and 2 we have presented the results of the most updated 1-point closure model for the turbulent vertical diffusivities of momentum, heat and salt, K(sub m,h,s). In this paper, we derive the analytic expressions for K(sub m,h,s) using a new 2-point closure model that has recently been developed and successfully tested against some approx. 80 turbulence statistics for different flows. The new model has no free parameters. The expressions for K(sub m, h. s) are analytical functions of two stability parameters: the Turner number R(sub rho) (salinity gradient/temperature gradient) and the Richardson number R(sub i) (temperature gradient/shear). The turbulent kinetic energy K and its rate of dissipation may be taken local or non-local (K-epsilon model). Contrary to all previous models that to describe turbulent mixing below the mixed layer (ML) have adopted three adjustable "background diffusivities" for momentum. heat and salt, we propose a model that avoids such adjustable diffusivities. We assume that below the ML, K(sub m,h,s) have the same functional dependence on R(sub i) and R(sub rho) derived from the turbulence model. However, in order to compute R(sub i) below the ML, we use data of vertical shear due to wave-breaking measured by Gargett et al. (1981). The procedure frees the model from adjustable background diffusivities and indeed we use the same model throughout the entire vertical extent of the ocean. Using the new K(sub m,h, s), we run an O-GCM and present a variety of results that we compare with Levitus and the KPP model. Since the traditional 1-point (used in papers 1 and 2) and the new 2-point closure models used here represent different modeling philosophies and procedures, testing them in an O-GCM is indispensable. The basic motivation is to show that the new 2-point closure model gives results that are overall superior to the 1-point closure in spite of the fact that the latter rely on several adjustable parameters while the new 2-point closure has none. After the extensive comparisons presented in papers 1 and 2, we conclude that the new model presented here is overall superior for it not only is parameter free but also 2 because is part of a more general turbulence model that has been previously successfully tested on a wide variety of other types of turbulent flows.

Crossover between structured and well-mixed networks in an evolutionary prisoner's dilemma game

NASA Astrophysics Data System (ADS)

Dai, Qionglin; Cheng, Hongyan; Li, Haihong; Li, Yuting; Zhang, Mei; Yang, Junzhong

2011-07-01

In a spatial evolutionary prisoner’s dilemma game (PDG), individuals interact with their neighbors and update their strategies according to some rules. As is well known, cooperators are destined to become extinct in a well-mixed population, whereas they could emerge and be sustained on a structured network. In this work, we introduce a simple model to investigate the crossover between a structured network and a well-mixed one in an evolutionary PDG. In the model, each link j is designated a rewiring parameter τj, which defines the time interval between two successive rewiring events for link j. By adjusting the rewiring parameter τ (the mean time interval for any link in the network), we could change a structured network into a well-mixed one. For the link rewiring events, three situations are considered: one synchronous situation and two asynchronous situations. Simulation results show that there are three regimes of τ: large τ where the density of cooperators ρc rises to ρc,∞ (the value of ρc for the case without link rewiring), small τ where the mean-field description for a well-mixed network is applicable, and moderate τ where the crossover between a structured network and a well-mixed one happens.

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.

State-Dependence of the Climate Sensitivity in Earth System Models of Intermediate Complexity

NASA Astrophysics Data System (ADS)

Pfister, Patrik L.; Stocker, Thomas F.

2017-10-01

Growing evidence from general circulation models (GCMs) indicates that the equilibrium climate sensitivity (ECS) depends on the magnitude of forcing, which is commonly referred to as state-dependence. We present a comprehensive assessment of ECS state-dependence in Earth system models of intermediate complexity (EMICs) by analyzing millennial simulations with sustained 2×CO2 and 4×CO2 forcings. We compare different extrapolation methods and show that ECS is smaller in the higher-forcing scenario in 12 out of 15 EMICs, in contrast to the opposite behavior reported from GCMs. In one such EMIC, the Bern3D-LPX model, this state-dependence is mainly due to the weakening sea ice-albedo feedback in the Southern Ocean, which depends on model configuration. Due to ocean-mixing adjustments, state-dependence is only detected hundreds of years after the abrupt forcing, highlighting the need for long model integrations. Adjustments to feedback parametrizations of EMICs may be necessary if GCM intercomparisons confirm an opposite state-dependence.

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

The volume-mortality relation for radical cystectomy in England: retrospective analysis of hospital episode statistics

PubMed Central

Bottle, Alex; Darzi, Ara W; Athanasiou, Thanos; Vale, Justin A

2010-01-01

Objectives To investigate the relation between volume and mortality after adjustment for case mix for radical cystectomy in the English healthcare setting using improved statistical methodology, taking into account the institutional and surgeon volume effects and institutional structural and process of care factors. Design Retrospective analysis of hospital episode statistics using multilevel modelling. Setting English hospitals carrying out radical cystectomy in the seven financial years 2000/1 to 2006/7. Participants Patients with a primary diagnosis of cancer undergoing an inpatient elective cystectomy. Main outcome measure Mortality within 30 days of cystectomy. Results Compared with low volume institutions, medium volume ones had a significantly higher odds of in-hospital and total mortality: odds ratio 1.72 (95% confidence interval 1.00 to 2.98, P=0.05) and 1.82 (1.08 to 3.06, P=0.02). This was only seen in the final model, which included adjustment for structural and processes of care factors. The surgeon volume-mortality relation showed weak evidence of reduced odds of in-hospital mortality (by 35%) for the high volume surgeons, although this did not reach statistical significance at the 5% level. Conclusions The relation between case volume and mortality after radical cystectomy for bladder cancer became evident only after adjustment for structural and process of care factors, including staffing levels of nurses and junior doctors, in addition to case mix. At least for this relatively uncommon procedure, adjusting for these confounders when examining the volume-outcome relation is critical before considering centralisation of care to a few specialist institutions. Outcomes other than mortality, such as functional morbidity and disease recurrence may ultimately influence towards centralising care. PMID:20305302

Growth and clinical variables in nitrogen-restricted piglets fed an adjusted essential amino acid mix: Effects using free amino acid-based diets

USDA-ARS?s Scientific Manuscript database

Excess protein intake in early life has been linked to obesity and metabolic syndrome in later life. Yet, protein, and in particular the essential amino acids (EAA), need to be present in adequate quantity to support growth. Using a piglet model restricted in dietary amino acids (AA), our objective...

Special Specification 3XXX, dense-graded hot-mix asphalt.

DOT National Transportation Integrated Search

2004-01-01

Construct a hot-mix asphalt (HMA) pavement layer composed of a compacted, dense-graded mixture of aggregate and asphalt binder mixed hot in a mixing plant. Pay adjustments will apply to HMA placed under this specification unless the HMA is deemed exe...

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 case-mix classification system for explaining healthcare costs using administrative data in Italy.

PubMed

Corti, Maria Chiara; Avossa, Francesco; Schievano, Elena; Gallina, Pietro; Ferroni, Eliana; Alba, Natalia; Dotto, Matilde; Basso, Cristina; Netti, Silvia Tiozzo; Fedeli, Ugo; Mantoan, Domenico

2018-03-04

The Italian National Health Service (NHS) provides universal coverage to all citizens, granting primary and hospital care with a copayment system for outpatient and drug services. Financing of Local Health Trusts (LHTs) is based on a capitation system adjusted only for age, gender and area of residence. We applied a risk-adjustment system (Johns Hopkins Adjusted Clinical Groups System, ACG® System) in order to explain health care costs using routinely collected administrative data in the Veneto Region (North-eastern Italy). All residents in the Veneto Region were included in the study. The ACG system was applied to classify the regional population based on the following information sources for the year 2015: Hospital Discharges, Emergency Room visits, Chronic disease registry for copayment exemptions, ambulatory visits, medications, the Home care database, and drug prescriptions. Simple linear regressions were used to contrast an age-gender model to models incorporating more comprehensive risk measures aimed at predicting health care costs. A simple age-gender model explained only 8% of the variance of 2015 total costs. Adding diagnoses-related variables provided a 23% increase, while pharmacy based variables provided an additional 17% increase in explained variance. The adjusted R-squared of the comprehensive model was 6 times that of the simple age-gender model. ACG System provides substantial improvement in predicting health care costs when compared to simple age-gender adjustments. Aging itself is not the main determinant of the increase of health care costs, which is better explained by the accumulation of chronic conditions and the resulting multimorbidity. Copyright © 2018. Published by Elsevier B.V.

On the multiple imputation variance estimator for control-based and delta-adjusted pattern mixture models.

PubMed

Tang, Yongqiang

2017-12-01

Control-based pattern mixture models (PMM) and delta-adjusted PMMs are commonly used as sensitivity analyses in clinical trials with non-ignorable dropout. These PMMs assume that the statistical behavior of outcomes varies by pattern in the experimental arm in the imputation procedure, but the imputed data are typically analyzed by a standard method such as the primary analysis model. In the multiple imputation (MI) inference, Rubin's variance estimator is generally biased when the imputation and analysis models are uncongenial. One objective of the article is to quantify the bias of Rubin's variance estimator in the control-based and delta-adjusted PMMs for longitudinal continuous outcomes. These PMMs assume the same observed data distribution as the mixed effects model for repeated measures (MMRM). We derive analytic expressions for the MI treatment effect estimator and the associated Rubin's variance in these PMMs and MMRM as functions of the maximum likelihood estimator from the MMRM analysis and the observed proportion of subjects in each dropout pattern when the number of imputations is infinite. The asymptotic bias is generally small or negligible in the delta-adjusted PMM, but can be sizable in the control-based PMM. This indicates that the inference based on Rubin's rule is approximately valid in the delta-adjusted PMM. A simple variance estimator is proposed to ensure asymptotically valid MI inferences in these PMMs, and compared with the bootstrap variance. The proposed method is illustrated by the analysis of an antidepressant trial, and its performance is further evaluated via a simulation study. © 2017, The International Biometric Society.

Spatio-temporal models to determine association between Campylobacter cases and environment

PubMed Central

Sanderson, Roy A; Maas, James A; Blain, Alasdair P; Gorton, Russell; Ward, Jessica; O’Brien, Sarah J; Hunter, Paul R; Rushton, Stephen P

2018-01-01

Abstract Background Campylobacteriosis is a major cause of gastroenteritis in the UK, and although 70% of cases are associated with food sources, the remainder are probably associated with wider environmental exposure. Methods In order to investigate wider environmental transmission, we conducted a spatio-temporal analysis of the association of human cases of Campylobacter in the Tyne catchment with weather, climate, hydrology and land use. A hydrological model was used to predict surface-water flow in the Tyne catchment over 5 years. We analysed associations between population-adjusted Campylobacter case rate and environmental factors hypothesized to be important in disease using a two-stage modelling framework. First, we investigated associations between temporal variation in case rate in relation to surface-water flow, temperature, evapotranspiration and rainfall, using linear mixed-effects models. Second, we used the random effects for the first model to quantify how spatial variation in static landscape features of soil and land use impacted on the likely differences between subcatchment associations of case rate with the temporal variables. Results Population-adjusted Campylobacter case rates were associated with periods of high predicted surface-water flow, and during above average temperatures. Subcatchments with cattle on stagnogley soils, and to a lesser extent sheep plus cattle grazing, had higher Campylobacter case rates. Conclusions Areas of stagnogley soils with mixed livestock grazing may be more vulnerable to both Campylobacter spread and exposure during periods of high rainfall, with resultant increased risk of human cases of the disease. PMID:29069406

Joint Machine Learning and Game Theory for Rate Control in High Efficiency Video Coding.

PubMed

Gao, Wei; Kwong, Sam; Jia, Yuheng

2017-08-25

In this paper, a joint machine learning and game theory modeling (MLGT) framework is proposed for inter frame coding tree unit (CTU) level bit allocation and rate control (RC) optimization in High Efficiency Video Coding (HEVC). First, a support vector machine (SVM) based multi-classification scheme is proposed to improve the prediction accuracy of CTU-level Rate-Distortion (R-D) model. The legacy "chicken-and-egg" dilemma in video coding is proposed to be overcome by the learning-based R-D model. Second, a mixed R-D model based cooperative bargaining game theory is proposed for bit allocation optimization, where the convexity of the mixed R-D model based utility function is proved, and Nash bargaining solution (NBS) is achieved by the proposed iterative solution search method. The minimum utility is adjusted by the reference coding distortion and frame-level Quantization parameter (QP) change. Lastly, intra frame QP and inter frame adaptive bit ratios are adjusted to make inter frames have more bit resources to maintain smooth quality and bit consumption in the bargaining game optimization. Experimental results demonstrate that the proposed MLGT based RC method can achieve much better R-D performances, quality smoothness, bit rate accuracy, buffer control results and subjective visual quality than the other state-of-the-art one-pass RC methods, and the achieved R-D performances are very close to the performance limits from the FixedQP method.

The relationship between effectiveness and costs measured by a risk-adjusted case-mix system: multicentre study of Catalonian population data bases.

PubMed

Sicras-Mainar, Antoni; Navarro-Artieda, Ruth; Blanca-Tamayo, Milagrosa; Velasco-Velasco, Soledad; Escribano-Herranz, Esperanza; Llopart-López, Josep Ramon; Violan-Fors, Concepción; Vilaseca-Llobet, Josep Maria; Sánchez-Fontcuberta, Encarna; Benavent-Areu, Jaume; Flor-Serra, Ferran; Aguado-Jodar, Alba; Rodríguez-López, Daniel; Prados-Torres, Alejandra; Estelrich-Bennasar, Jose

2009-06-25

The main objective of this study is to measure the relationship between morbidity, direct health care costs and the degree of clinical effectiveness (resolution) of health centres and health professionals by the retrospective application of Adjusted Clinical Groups in a Spanish population setting. The secondary objectives are to determine the factors determining inadequate correlations and the opinion of health professionals on these instruments. We will carry out a multi-centre, retrospective study using patient records from 15 primary health care centres and population data bases. The main measurements will be: general variables (age and sex, centre, service [family medicine, paediatrics], and medical unit), dependent variables (mean number of visits, episodes and direct costs), co-morbidity (Johns Hopkins University Adjusted Clinical Groups Case-Mix System) and effectiveness.The totality of centres/patients will be considered as the standard for comparison. The efficiency index for visits, tests (laboratory, radiology, others), referrals, pharmaceutical prescriptions and total will be calculated as the ratio: observed variables/variables expected by indirect standardization.The model of cost/patient/year will differentiate fixed/semi-fixed (visits) costs of the variables for each patient attended/year (N = 350,000 inhabitants). The mean relative weights of the cost of care will be obtained. The effectiveness will be measured using a set of 50 indicators of process, efficiency and/or health results, and an adjusted synthetic index will be constructed (method: percentile 50).The correlation between the efficiency (relative-weights) and synthetic (by centre and physician) indices will be established using the coefficient of determination. The opinion/degree of acceptance of physicians (N = 1,000) will be measured using a structured questionnaire including various dimensions. multiple regression analysis (procedure: enter), ANCOVA (method: Bonferroni's adjustment) and multilevel analysis will be carried out to correct models. The level of statistical significance will be p < 0.05.

An epidemiologic overview of 13 years of firearm hospitalizations in Pennsylvania.

PubMed

Gross, Brian W; Cook, Alan D; Rinehart, Cole D; Lynch, Caitlin A; Bradburn, Eric H; Bupp, Katherine A; Morrison, Chet A; Rogers, Frederick B

2017-04-01

Gun violence is a controversial public health issue plagued by a lack of recent research. We sought to provide a 13-y overview of firearm hospitalizations in Pennsylvania, analyzing trends in mode, intent, and outcome. We hypothesized that no adjusted change in mortality or functional status at discharge (FSD) would be observed for gunshot wound (GSW) victims over the study period. All admissions to the Pennsylvania Trauma Outcome Study database from 2003 to 2015 were queried. GSWs were identified by external cause-of-injury codes. Collected variables included patient demographics, firearm type, intent (assault and attempted suicide), FSD, and mortality. Multilevel mixed-effects logistic regression models and ordinal regression analyses using generalized linear mixed models assessed the impact of admission year (continuous) on adjusted mortality and FSD score, respectively. Significance was set at P < 0.05. Of the 462,081 patients presenting to Pennsylvania trauma centers from 2003 to 2015, 19,342 were GSWs (4.2%). Handguns were the most common weapon of injury (n = 7007; 86.7%) among cases with specified firearm type. Most GSWs were coded as assaults (n = 15,415; 79.7%), with suicide attempts accounting 1866 hospitalizations (9.2%). Suicide attempts were most prevalent among young and middle-aged white males, whereas assaults were more common in young black males. Rates of firearm hospitalizations decreased over time (test of trend P = 0.001); however, admission year was not associated with improved adjusted survival (adjusted odds ratio: 0.99, 95% confidence interval: 0.97-1.01; P = 0.353) or FSD (adjusted odds ratio: 0.99, 95% confidence interval: 0.98-1.00; P = 0.089) while controlling for demographic and injury severity covariates. Temporal trends in outcomes suggest rates of firearm hospitalizations are declining in Pennsylvania; however, outcomes remain unchanged. To combat this epidemic, a multidisciplinary, demographic-specific approach to prevention should be the focus of future scientific pursuits. Copyright © 2016 Elsevier Inc. All rights reserved.

The Occupational Mix Adjustment to the Medicare Hospital Wage Index: Why the Rural Impact Is Less than Expected

ERIC Educational Resources Information Center

Reiter, Kristin L.; Slifkin, Rebecca; Holmes, George M.

2008-01-01

Context: Rural hospitals are heavily dependent on Medicare for their long-term financial solvency. A recent change to Medicare prospective payment system reimbursement--the occupational mix adjustment (OMA) to the wage index--has attracted a great deal of attention in rural policy circles. Purpose: This paper explores variation in the OMA across…

Simulating mixed-phase Arctic stratus clouds: sensitivity to ice initiation mechanisms

NASA Astrophysics Data System (ADS)

Sednev, I.; Menon, S.; McFarquhar, G.

2008-06-01

The importance of Arctic mixed-phase clouds on radiation and the Arctic climate is well known. However, the development of mixed-phase cloud parameterization for use in large scale models is limited by lack of both related observations and numerical studies using multidimensional models with advanced microphysics that provide the basis for understanding the relative importance of different microphysical processes that take place in mixed-phase clouds. To improve the representation of mixed-phase cloud processes in the GISS GCM we use the GISS single-column model coupled to a bin resolved microphysics (BRM) scheme that was specially designed to simulate mixed-phase clouds and aerosol-cloud interactions. Using this model with the microphysical measurements obtained from the DOE ARM Mixed-Phase Arctic Cloud Experiment (MPACE) campaign in October 2004 at the North Slope of Alaska, we investigate the effect of ice initiation processes and Bergeron-Findeisen process (BFP) on glaciation time and longevity of single-layer stratiform mixed-phase clouds. We focus on observations taken during 9th-10th October, which indicated the presence of a single-layer mixed-phase clouds. We performed several sets of 12-h simulations to examine model sensitivity to different ice initiation mechanisms and evaluate model output (hydrometeors' concentrations, contents, effective radii, precipitation fluxes, and radar reflectivity) against measurements from the MPACE Intensive Observing Period. Overall, the model qualitatively simulates ice crystal concentration and hydrometeors content, but it fails to predict quantitatively the effective radii of ice particles and their vertical profiles. In particular, the ice effective radii are overestimated by at least 50%. However, using the same definition as used for observations, the effective radii simulated and that observed were more comparable. We find that for the single-layer stratiform mixed-phase clouds simulated, process of ice phase initiation due to freezing of supercooled water in both saturated and undersaturated (w.r.t. water) environments is as important as primary ice crystal origination from water vapor. We also find that the BFP is a process mainly responsible for the rates of glaciation of simulated clouds. These glaciation rates cannot be adequately represented by a water-ice saturation adjustment scheme that only depends on temperature and liquid and solid hydrometeors' contents as is widely used in bulk microphysics schemes and are better represented by processes that also account for supersaturation changes as the hydrometeors grow.

Simulating mixed-phase Arctic stratus clouds: sensitivity to ice initiation mechanisms

NASA Astrophysics Data System (ADS)

Sednev, I.; Menon, S.; McFarquhar, G.

2009-07-01

The importance of Arctic mixed-phase clouds on radiation and the Arctic climate is well known. However, the development of mixed-phase cloud parameterization for use in large scale models is limited by lack of both related observations and numerical studies using multidimensional models with advanced microphysics that provide the basis for understanding the relative importance of different microphysical processes that take place in mixed-phase clouds. To improve the representation of mixed-phase cloud processes in the GISS GCM we use the GISS single-column model coupled to a bin resolved microphysics (BRM) scheme that was specially designed to simulate mixed-phase clouds and aerosol-cloud interactions. Using this model with the microphysical measurements obtained from the DOE ARM Mixed-Phase Arctic Cloud Experiment (MPACE) campaign in October 2004 at the North Slope of Alaska, we investigate the effect of ice initiation processes and Bergeron-Findeisen process (BFP) on glaciation time and longevity of single-layer stratiform mixed-phase clouds. We focus on observations taken during 9-10 October, which indicated the presence of a single-layer mixed-phase clouds. We performed several sets of 12-h simulations to examine model sensitivity to different ice initiation mechanisms and evaluate model output (hydrometeors' concentrations, contents, effective radii, precipitation fluxes, and radar reflectivity) against measurements from the MPACE Intensive Observing Period. Overall, the model qualitatively simulates ice crystal concentration and hydrometeors content, but it fails to predict quantitatively the effective radii of ice particles and their vertical profiles. In particular, the ice effective radii are overestimated by at least 50%. However, using the same definition as used for observations, the effective radii simulated and that observed were more comparable. We find that for the single-layer stratiform mixed-phase clouds simulated, process of ice phase initiation due to freezing of supercooled water in both saturated and subsaturated (w.r.t. water) environments is as important as primary ice crystal origination from water vapor. We also find that the BFP is a process mainly responsible for the rates of glaciation of simulated clouds. These glaciation rates cannot be adequately represented by a water-ice saturation adjustment scheme that only depends on temperature and liquid and solid hydrometeors' contents as is widely used in bulk microphysics schemes and are better represented by processes that also account for supersaturation changes as the hydrometeors grow.

Risk adjustment in the American College of Surgeons National Surgical Quality Improvement Program: a comparison of logistic versus hierarchical modeling.

PubMed

Cohen, Mark E; Dimick, Justin B; Bilimoria, Karl Y; Ko, Clifford Y; Richards, Karen; Hall, Bruce Lee

2009-12-01

Although logistic regression has commonly been used to adjust for risk differences in patient and case mix to permit quality comparisons across hospitals, hierarchical modeling has been advocated as the preferred methodology, because it accounts for clustering of patients within hospitals. It is unclear whether hierarchical models would yield important differences in quality assessments compared with logistic models when applied to American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) data. Our objective was to evaluate differences in logistic versus hierarchical modeling for identifying hospitals with outlying outcomes in the ACS-NSQIP. Data from ACS-NSQIP patients who underwent colorectal operations in 2008 at hospitals that reported at least 100 operations were used to generate logistic and hierarchical prediction models for 30-day morbidity and mortality. Differences in risk-adjusted performance (ratio of observed-to-expected events) and outlier detections from the two models were compared. Logistic and hierarchical models identified the same 25 hospitals as morbidity outliers (14 low and 11 high outliers), but the hierarchical model identified 2 additional high outliers. Both models identified the same eight hospitals as mortality outliers (five low and three high outliers). The values of observed-to-expected events ratios and p values from the two models were highly correlated. Results were similar when data were permitted from hospitals providing < 100 patients. When applied to ACS-NSQIP data, logistic and hierarchical models provided nearly identical results with respect to identification of hospitals' observed-to-expected events ratio outliers. As hierarchical models are prone to implementation problems, logistic regression will remain an accurate and efficient method for performing risk adjustment of hospital quality comparisons.

Transported PDF Modeling of Nonpremixed Turbulent CO/H-2/N-2 Jet Flames

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

Zhao, xinyu; Haworth, D. C.; Huckaby, E. David

2012-01-01

Turbulent CO/H{sub 2}/N{sub 2} (“syngas”) flames are simulated using a transported composition probability density function (PDF) method. A consistent hybrid Lagrangian particle/Eulerian mesh algorithm is used to solve the modeled PDF transport equation. The model includes standard k–ϵ turbulence, gradient transport for scalars, and Euclidean minimum spanning tree (EMST) mixing. Sensitivities of model results to variations in the turbulence model, the treatment of radiation heat transfer, the choice of chemical mechanism, and the PDF mixing model are explored. A baseline model reproduces the measured mean and rms temperature, major species, and minor species profiles reasonably well, and captures the scalingmore » that is observed in the experiments. Both our results and the literature suggest that further improvements can be realized with adjustments in the turbulence model, the radiation heat transfer model, and the chemical mechanism. Although radiation effects are relatively small in these flames, consideration of radiation is important for accurate NO prediction. Chemical mechanisms that have been developed specifically for fuels with high concentrations of CO and H{sub 2} perform better than a methane mechanism that was not designed for this purpose. It is important to account explicitly for turbulence–chemistry interactions, although the details of the mixing model do not make a large difference in the results, within reasonable limits.« less

Identifying pleiotropic genes in genome-wide association studies from related subjects using the linear mixed model and Fisher combination function.

PubMed

Yang, James J; Williams, L Keoki; Buu, Anne

2017-08-24

A multivariate genome-wide association test is proposed for analyzing data on multivariate quantitative phenotypes collected from related subjects. The proposed method is a two-step approach. The first step models the association between the genotype and marginal phenotype using a linear mixed model. The second step uses the correlation between residuals of the linear mixed model to estimate the null distribution of the Fisher combination test statistic. The simulation results show that the proposed method controls the type I error rate and is more powerful than the marginal tests across different population structures (admixed or non-admixed) and relatedness (related or independent). The statistical analysis on the database of the Study of Addiction: Genetics and Environment (SAGE) demonstrates that applying the multivariate association test may facilitate identification of the pleiotropic genes contributing to the risk for alcohol dependence commonly expressed by four correlated phenotypes. This study proposes a multivariate method for identifying pleiotropic genes while adjusting for cryptic relatedness and population structure between subjects. The two-step approach is not only powerful but also computationally efficient even when the number of subjects and the number of phenotypes are both very large.

Modeled Urea Distribution Volume and Mortality in the HEMO Study

PubMed Central

Greene, Tom; Depner, Thomas A.; Levin, Nathan W.; Chertow, Glenn M.

2011-01-01

Summary Background and objectives In the Hemodialysis (HEMO) Study, observed small decreases in achieved equilibrated Kt/Vurea were noncausally associated with markedly increased mortality. Here we examine the association of mortality with modeled volume (Vm), the denominator of equilibrated Kt/Vurea. Design, setting, participants, & measurements Parameters derived from modeled urea kinetics (including Vm) and blood pressure (BP) were obtained monthly in 1846 patients. Case mix–adjusted time-dependent Cox regressions were used to relate the relative mortality hazard at each time point to Vm and to the change in Vm over the preceding 6 months. Mixed effects models were used to relate Vm to changes in intradialytic systolic BP and to other factors at each follow-up visit. Results Mortality was associated with Vm and change in Vm over the preceding 6 months. The association between change in Vm and mortality was independent of vascular access complications. In contrast, mortality was inversely associated with V calculated from anthropometric measurements (Vant). In case mix–adjusted analysis using Vm as a time-dependent covariate, the association of mortality with Vm strengthened after statistical adjustment for Vant. After adjustment for Vant, higher Vm was associated with slightly smaller reductions in intradialytic systolic BP and with risk factors for mortality including recent hospitalization and reductions in serum albumin concentration and body weight. Conclusions An increase in Vm is a marker for illness and mortality risk in hemodialysis patients. PMID:21511841

Overflow Simulations using MPAS-Ocean in Idealized and Realistic Domains

NASA Astrophysics Data System (ADS)

Reckinger, S.; Petersen, M. R.; Reckinger, S. J.

2016-02-01

MPAS-Ocean is used to simulate an idealized, density-driven overflow using the dynamics of overflow mixing and entrainment (DOME) setup. Numerical simulations are benchmarked against other models, including the MITgcm's z-coordinate model and HIM's isopycnal coordinate model. A full parameter study is presented that looks at how sensitive overflow simulations are to vertical grid type, resolution, and viscosity. Horizontal resolutions with 50 km grid cells are under-resolved and produce poor results, regardless of other parameter settings. Vertical grids ranging in thickness from 15 m to 120 m were tested. A horizontal resolution of 10 km and a vertical resolution of 60 m are sufficient to resolve the mesoscale dynamics of the DOME configuration, which mimics real-world overflow parameters. Mixing and final buoyancy are least sensitive to horizontal viscosity, but strongly sensitive to vertical viscosity. This suggests that vertical viscosity could be adjusted in overflow water formation regions to influence mixing and product water characteristics. Also, the study shows that sigma coordinates produce much less mixing than z-type coordinates, resulting in heavier plumes that go further down slope. Sigma coordinates are less sensitive to changes in resolution but as sensitive to vertical viscosity compared to z-coordinates. Additionally, preliminary measurements of overflow diagnostics on global simulations using a realistic oceanic domain are presented.

Clinical and genetic factors affecting tacrolimus trough levels and drug-related outcomes in Korean kidney transplant recipients.

PubMed

Kim, In-Wha; Moon, Yoo Jin; Ji, Eunhee; Kim, Kyung Im; Han, Nayoung; Kim, Sung Ju; Shin, Wan Gyoon; Ha, Jongwon; Yoon, Jeong-Hyun; Lee, Hye Suk; Oh, Jung Mi

2012-05-01

The purpose of this study was to characterize the effects of clinical and genetic variables on the pharmacokinetics and complications of tacrolimus during the first year after kidney transplantation. One hundred and thirty-two Korean kidney recipients who received tacrolimus were genotyped for ABCB1 (exons 12, 21, and 26) and CYP3A5 (intron 3). Tacrolimus trough levels, dose, or dose-adjusted trough levels and complications were compared among patients during the early stage (3, 7, 14, 30, and 90 days) and up to 1 year according to the genotypes. A donor source-adjusted linear mixed model with multilevel analysis adjusting for age, body weight, hematocrit, and serum creatinine showed that CYP3A5 genotype is associated with dose-adjusted level of tacrolimus (p < 0.001). The influence of ABCB1 polymorphisms on the pharmacokinetics or complications of tacrolimus was less certain in our study. The incidence of acute rejections was significantly higher in recipients of cadaveric donor kidney (p < 0.05). A generalized estimating equation model analysis showed that alopecia and hyperlipidemia were associated with dose-adjusted level of tacrolimus (p < 0.001). Genotype of CYP3A5 variants along with significant clinical covariates may be useful in individualizing tacrolimus therapy in kidney transplantation patients.

The adjusting factor method for weight-scaling truckloads of mixed hardwood sawlogs

Treesearch

Edward L. Adams

1976-01-01

A new method of weight-scaling truckloads of mixed hardwood sawlogs systematically adjusts for changes in the weight/volume ratio of logs coming into a sawmill. It uses a conversion factor based on the running average of weight/volume ratios of randomly selected sample loads. A test of the method indicated that over a period of time the weight-scaled volume should...

Recalibrating disease parameters for increasing realism in modeling epidemics in closed settings.

PubMed

Bioglio, Livio; Génois, Mathieu; Vestergaard, Christian L; Poletto, Chiara; Barrat, Alain; Colizza, Vittoria

2016-11-14

The homogeneous mixing assumption is widely adopted in epidemic modelling for its parsimony and represents the building block of more complex approaches, including very detailed agent-based models. The latter assume homogeneous mixing within schools, workplaces and households, mostly for the lack of detailed information on human contact behaviour within these settings. The recent data availability on high-resolution face-to-face interactions makes it now possible to assess the goodness of this simplified scheme in reproducing relevant aspects of the infection dynamics. We consider empirical contact networks gathered in different contexts, as well as synthetic data obtained through realistic models of contacts in structured populations. We perform stochastic spreading simulations on these contact networks and in populations of the same size under a homogeneous mixing hypothesis. We adjust the epidemiological parameters of the latter in order to fit the prevalence curve of the contact epidemic model. We quantify the agreement by comparing epidemic peak times, peak values, and epidemic sizes. Good approximations of the peak times and peak values are obtained with the homogeneous mixing approach, with a median relative difference smaller than 20 % in all cases investigated. Accuracy in reproducing the peak time depends on the setting under study, while for the peak value it is independent of the setting. Recalibration is found to be linear in the epidemic parameters used in the contact data simulations, showing changes across empirical settings but robustness across groups and population sizes. An adequate rescaling of the epidemiological parameters can yield a good agreement between the epidemic curves obtained with a real contact network and a homogeneous mixing approach in a population of the same size. The use of such recalibrated homogeneous mixing approximations would enhance the accuracy and realism of agent-based simulations and limit the intrinsic biases of the homogeneous mixing.

The impact of stroke unit care on outcome in a Scottish stroke population, taking into account case mix and selection bias.

PubMed

Turner, Melanie; Barber, Mark; Dodds, Hazel; Dennis, Martin; Langhorne, Peter; Macleod, Mary Joan

2015-03-01

Randomised trials indicate that stroke unit care reduces morbidity and mortality after stroke. Similar results have been seen in observational studies but many have not corrected for selection bias or independent predictors of outcome. We evaluated the effect of stroke unit compared with general ward care on outcomes after stroke in Scotland, adjusting for case mix by incorporating the six simple variables (SSV) model, also taking into account selection bias and stroke subtype. We used routine data from National Scottish datasets for acute stroke patients admitted between 2005 and 2011. Patients who died within 3 days of admission were excluded from analysis. The main outcome measures were survival and discharge home. Multivariable logistic regression was used to estimate the OR for survival, and adjustment was made for the effect of the SSV model and for early mortality. Cox proportional hazards model was used to estimate the hazard of death within 365 days. There were 41 692 index stroke events; 79% were admitted to a stroke unit at some point during their hospital stay and 21% were cared for in a general ward. Using the SSV model, we obtained a receiver operated curve of 0.82 (SE 0.002) for mortality at 6 months. The adjusted OR for survival at 7 days was 3.11 (95% CI 2.71 to 3.56) and at 1 year 1.43 (95% CI 1.34 to 1.54) while the adjusted OR for being discharged home was 1.19 (95% CI 1.11 to 1.28) for stroke unit care. In routine practice, stroke unit admission is associated with a greater likelihood of discharge home and with lower mortality up to 1 year, after correcting for known independent predictors of outcome, and excluding early non-modifiable mortality. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

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.

Factors associated with the course of symptoms in bipolar disorder during a 1-year follow-up: depression vs. sub-threshold mixed state.

PubMed

Mazza, Marianna; Mandelli, Laura; Zaninotto, Leonardo; Nicola, Marco Di; Martinotti, Giovanni; Harnic, Desiree; Bruschi, Angelo; Catalano, Valeria; Tedeschi, Daniela; Colombo, Roberto; Bria, Pietro; Serretti, Alessandro; Janiri, Luigi

2011-12-01

Mixed mood states, even in their sub-threshold forms, may significantly affect the course and outcome of bipolar disorder (BD). To compare two samples of BD patients presenting a major depressive episode and a sub-threshold mixed state in terms of global functioning, clinical outcome, social adjustment and quality of life during a 1-year follow-up. The sample was composed by 90 subjects (Group 1, D) clinically diagnosed with a major depressive episode and 41 patients (Group 2, Mx) for a sub-threshold mixed state. All patients were administered with a pharmacological treatment and evaluated for depressive, anxious and manic symptoms by common rating scales. Further evaluations included a global assessment of severity and functioning, social adjustment and quality of life. All evaluations were performed at baseline and after 1, 3, 6 and 12 months of treatment. The two groups were no different for baseline as well as improvement in global severity and functioning. Though clearly different for symptoms severity, the amount of change of depressive and anxiety symptoms was also no different. Manic symptoms showed instead a trend to persist over time in group 2, whereas a slight increase of manic symptoms was observed in group 1, especially after 6 months of treatment. Moreover, in group 1, some manic symptoms were also detected at the Young Mania Rating Scale (n = 24, 26.6%). Finally, improvement in quality of life and social adjustment was similar in the two groups, though a small trend toward a faster improvement in social adjustment in group 1. Sub-threshold mixed states have a substantial impact on global functioning, social adjustment and subjective well-being, similarly to that of acute phases, or at least major depression. In particular, mixed features, even in their sub-threshold forms, tend to be persistent over time. Finally, manic symptoms may be still often underestimated in depressive episodes, even in patients for BD.

Fund allocation within Australian dental care: an innovative approach to output based funding.

PubMed

Tennant, M; Carrello, C; Kruger, E

2005-12-01

Over the last 15 years in Australia the process of funding government health care has changed significantly. The development of dental funding models that transparently meet both the service delivery needs for data at the treatment level and policy makers' need for health condition data is critical to the continued integration of dentistry into the wider health system. This paper presents a model of fund allocation that provides a communication construct that addresses the needs of both policy makers and service providers. In this model, dental treatments (dental item numbers) have been grouped into eight broad dental health conditions. Within each dental health condition, a weighted average price is determined using the Department of Veterans Affairs' (DVA) fee schedule as the benchmark, adjusted for the mix of care. The model also adjusts for the efficiency differences between sectors providing government funded dental care. In summary, the price to be applied to a dental health condition category is determined by the weighted average DVA price adjusted by the sector efficiency. This model allows governments and dental service providers to develop funding agreements that both quantify and justify the treatment to be provided. Such a process facilitates the continued integration of dental care into the wider health system.

Numerical experiments with a wind- and buoyancy-driven two-and-a-half-layer upper ocean model

NASA Astrophysics Data System (ADS)

Cherniawsky, J. Y.; Yuen, C. W.; Lin, C. A.; Mysak, L. A.

1990-09-01

We describe numerical experiments with a limited domain (15°-67°N, 65° west to east) coarse-resolution two-and-a-half-layer upper ocean model. The model consists of two active variable density layers: a Niiler and Kraus (1977) type mixed layer and a pycnocline layer, which overlays a semipassive deep ocean. The mixed layer is forced with a cosine wind stress and Haney type heat and precipitation-evaporation fluxes, which were derived from zonally averaged climatological (Levitus, 1982) surface temperatures and salinities for the North Atlantic. The second layer is forced from below with (1) Newtonian cooling to climatological temperatures and salinities at the lower boundary, (2) convective adjustment, which occurs whenever the density of the second layer is unstable with respect to climatology, and (3) mass entrainment in areas of strong upwelling, when the deep ocean ventilates through the bottom surface. The sensitivity of this model to changes in its internal (mixed layer) and external (e.g., a Newtonian coupling coefficient) parameters is investigated and compared to the results from a control experiment. We find that the model is not overly sensitive to changes in most of the parameters that were tested, albeit these results may depend to some extent on the choice of the control experiment.

A high-resolution integrated model of the National Ignition Campaign cryogenic layered experiments

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

Jones, O. S.; Cerjan, C. J.; Marinak, M. M.

A detailed simulation-based model of the June 2011 National Ignition Campaign cryogenic DT experiments is presented. The model is based on integrated hohlraum-capsule simulations that utilize the best available models for the hohlraum wall, ablator, and DT equations of state and opacities. The calculated radiation drive was adjusted by changing the input laser power to match the experimentally measured shock speeds, shock merger times, peak implosion velocity, and bangtime. The crossbeam energy transfer model was tuned to match the measured time-dependent symmetry. Mid-mode mix was included by directly modeling the ablator and ice surface perturbations up to mode 60. Simulatedmore » experimental values were extracted from the simulation and compared against the experiment. Although by design the model is able to reproduce the 1D in-flight implosion parameters and low-mode asymmetries, it is not able to accurately predict the measured and inferred stagnation properties and levels of mix. In particular, the measured yields were 15%-40% of the calculated yields, and the inferred stagnation pressure is about 3 times lower than simulated.« less

Affordable Care Act risk adjustment: overview, context, and challenges.

PubMed

Kautter, John; Pope, Gregory C; Keenan, Patricia

2014-01-01

Beginning in 2014, individuals and small businesses will be able to purchase private health insurance through competitive marketplaces. The Affordable Care Act (ACA) provides for a program of risk adjustment in the individual and small group markets in 2014 as Marketplaces are implemented and new market reforms take effect. The purpose of risk adjustment is to lessen or eliminate the influence of risk selection on the premiums that plans charge and the incentive for plans to avoid sicker enrollees. This article--the first of three in the Medicare & Medicaid Research Review--describes the key program goal and issues in the Department of Health and Human Services (HHS) developed risk adjustment methodology, and identifies key choices in how the methodology responds to these issues. The goal of the HHS risk adjustment methodology is to compensate health insurance plans for differences in enrollee health mix so that plan premiums reflect differences in scope of coverage and other plan factors, but not differences in health status. The methodology includes a risk adjustment model and a risk transfer formula that together address this program goal as well as three issues specific to ACA risk adjustment: 1) new population; 2) cost and rating factors; and 3) balanced transfers within state/market. The risk adjustment model, described in the second article, estimates differences in health risks taking into account the new population and scope of coverage (actuarial value level). The transfer formula, described in the third article, calculates balanced transfers that are intended to account for health risk differences while preserving permissible premium differences.

Investigating Summer Thermal Stratification in Lake Ontario

NASA Astrophysics Data System (ADS)

James, S. C.; Arifin, R. R.; Craig, P. M.; Hamlet, A. F.

2017-12-01

Seasonal temperature variations establish strong vertical density gradients (thermoclines) between the epilimnion and hypolimnion. Accurate simulation of vertical mixing and seasonal stratification of large lakes is a crucial element of the thermodynamic coupling between lakes and the atmosphere in integrated models. Time-varying thermal stratification patterns can be accurately simulated with the versatile Environmental Fluid Dynamics Code (EFDC). Lake Ontario bathymetry was interpolated onto a 2-km-resolution curvilinear grid with vertical layering using a new approach in EFDC+, the so-called "sigma-zed" coordinate system which allows the number of vertical layers to be varied based on water depth. Inflow from the Niagara River and outflow to the St. Lawrence River in conjunction with hourly meteorological data from seven local weather stations plus three-hourly data from the North American Regional Reanalysis govern the hydrodynamic and thermodynamic responses of the Lake. EFDC+'s evaporation algorithm was updated to more accurately simulate net surface heat fluxes. A new vertical mixing scheme from Vinçon-Leite that implements different eddy diffusivity formulations above and below the thermocline was compared to results from the original Mellor-Yamada vertical mixing scheme. The model was calibrated by adjusting solar-radiation absorption coefficients in addition to background horizontal and vertical mixing parameters. Model skill was evaluated by comparing measured and simulated vertical temperature profiles at shallow (20 m) and deep (180 m) locations on the Lake. These model improvements, especially the new sigma-zed vertical discretization, accurately capture thermal-stratification patterns with low root-mean-squared errors when using the Vinçon-Leite vertical mixing scheme.

Cognitive ability and risk of post-traumatic stress disorder after military deployment: an observational cohort study

PubMed Central

Karstoft, Karen-Inge; Vedtofte, Mia S.; Nielsen, Anni B.S.; Osler, Merete; Mortensen, Erik L.; Christensen, Gunhild T.; Andersen, Søren B.

2017-01-01

Background Studies of the association between pre-deployment cognitive ability and post-deployment post-traumatic stress disorder (PTSD) have shown mixed results. Aims To study the influence of pre-deployment cognitive ability on PTSD symptoms 6–8 months post-deployment in a large population while controlling for pre-deployment education and deployment-related variables. Method Study linking prospective pre-deployment conscription board data with post-deployment self-reported data in 9695 Danish Army personnel deployed to different war zones in 1997–2013. The association between pre-deployment cognitive ability and post-deployment PTSD was investigated using repeated-measure logistic regression models. Two models with cognitive ability score as the main exposure variable were created (model 1 and model 2). Model 1 was only adjusted for pre-deployment variables, while model 2 was adjusted for both pre-deployment and deployment-related variables. Results When including only variables recorded pre-deployment (cognitive ability score and educational level) and gender (model 1), all variables predicted post-deployment PTSD. When deployment-related variables were added (model 2), this was no longer the case for cognitive ability score. However, when educational level was removed from the model adjusted for deployment-related variables, the association between cognitive ability and post-deployment PTSD became significant. Conclusions Pre-deployment lower cognitive ability did not predict post-deployment PTSD independently of educational level after adjustment for deployment-related variables. Declaration of interest None. Copyright and usage © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license. PMID:29163983

Mixing and unmixedness in plasma jets 1: Near-field analysis

NASA Technical Reports Server (NTRS)

Ilegbusi, Olusegun J.

1993-01-01

The flow characteristics in the near-field of a plasma jet are simulated with a two-fluid model. This model accounts for both gradient-diffusion mixing and uni-directional sifting motion resulting from pressure-gradient-body-force imbalance. This latter mechanism is believed to be responsible for the umixedness observed in plasma jets. The unmixedness is considered to be essentially a Rayleigh-Taylor kind instability. Transport equations are solved for the individual plasma and ambient gas velocities, temperatures and volume fractions. Empirical relations are employed for the interface transfers of mass, momentum and heat. The empirical coefficients are first established by comparison of predictions with available experimental data for shear flows. The model is then applied to an Argon plasma jet ejecting into stagnant air. The predicted results show the significant build-up of unmixed air within the plasma gas, even relatively far downstream of the torch. By adjusting the inlet condition, the model adequately reproduces the experimental data.

Incidence and Variation of Discrepancies in Recording Chronic Conditions in Australian Hospital Administrative Data

PubMed Central

Assareh, Hassan; Achat, Helen M.; Stubbs, Joanne M.; Guevarra, Veth M.; Hill, Kim

2016-01-01

Diagnostic data routinely collected for hospital admitted patients and used for case-mix adjustment in care provider comparisons and reimbursement are prone to biases. We aim to measure discrepancies, variations and associated factors in recorded chronic morbidities for hospital admitted patients in New South Wales (NSW), Australia. Of all admissions between July 2010 and June 2014 in all NSW public and private acute hospitals, admissions with over 24 hours stay and one or more of the chronic conditions of diabetes, smoking, hepatitis, HIV, and hypertension were included. The incidence of a non-recorded chronic condition in an admission occurring after the first admission with a recorded chronic condition (index admission) was considered as a discrepancy. Poisson models were employed to (i) derive adjusted discrepancy incidence rates (IR) and rate ratios (IRR) accounting for patient, admission, comorbidity and hospital characteristics and (ii) quantify variation in rates among hospitals. The discrepancy incidence rate was highest for hypertension (51% of 262,664 admissions), followed by hepatitis (37% of 12,107), smoking (33% of 548,965), HIV (27% of 1500) and diabetes (19% of 228,687). Adjusted rates for all conditions declined over the four-year period; with the sharpest drop of over 80% for diabetes (47.7% in 2010 vs. 7.3% in 2014), and 20% to 55% for the other conditions. Discrepancies were more common in private hospitals and smaller public hospitals. Inter-hospital differences were responsible for 1% (HIV) to 9.4% (smoking) of variation in adjusted discrepancy incidences, with an increasing trend for diabetes and HIV. Chronic conditions are recorded inconsistently in hospital administrative datasets, and hospitals contribute to the discrepancies. Adjustment for patterns and stratification in risk adjustments; and furthermore longitudinal accumulation of clinical data at patient level, refinement of clinical coding systems and standardisation of comorbidity recording across hospitals would enhance accuracy of datasets and validity of case-mix adjustment. PMID:26808428

Model simulations of dense bottom currents in the Western Baltic Sea

NASA Astrophysics Data System (ADS)

Burchard, Hans; Janssen, Frank; Bolding, Karsten; Umlauf, Lars; Rennau, Hannes

2009-01-01

Only recently, medium intensity inflow events into the Baltic Sea have gained more awareness because of their potential to ventilate intermediate layers in the Southern Baltic Sea basins. With the present high-resolution model study of the Western Baltic Sea a first attempt is made to obtain model based realistic estimates of turbulent mixing in this area where dense bottom currents resulting from medium intensity inflow events are weakened by turbulent entrainment. The numerical model simulation which is carried out using the General Estuarine Transport Model (GETM) during nine months in 2003 and 2004 is first validated by means of three automatic stations at the Drogden and Darss Sills and in the Arkona Sea. In order to obtain good agreement between observations and model results, the 0.5×0.5 nautical mile bathymetry had to be adjusted in order to account for the fact that even at that scale many relevant topographic features are not resolved. Current velocity, salinity and turbulence observations during a medium intensity inflow event through the Øresund are then compared to the model results. Given the general problems of point to point comparisons between observations and model simulations, the agreement is fairly good with the characteristic features of the inflow event well represented by the model simulations. Two different bulk measures for mixing activity are then introduced, the vertically integrated decay of salinity variance, which is equal to the production of micro-scale salinity variance, and the vertically integrated turbulent salt flux, which is related to an increase of potential energy due to vertical mixing of stably stratified flow. Both measures give qualitatively similar results and identify the Drogden and Darss Sills as well as the Bornholm Channel as mixing hot spots. Further regions of strong mixing are the dense bottom current pathways from these sills into the Arkona Sea, areas around Kriegers Flak (a shoal in the western Arkona Sea) and north-west of the island of Rügen.

Real medical benefit assessed by indirect comparison.

PubMed

Falissard, Bruno; Zylberman, Myriam; Cucherat, Michel; Izard, Valérie; Meyer, François

2009-01-01

Frequently, in data packages submitted for Marketing Approval to the CHMP, there is a lack of relevant head-to-head comparisons of medicinal products that could enable national authorities responsible for the approval of reimbursement to assess the Added Therapeutic Value (ASMR) of new clinical entities or line extensions of existing therapies.Indirect or mixed treatment comparisons (MTC) are methods stemming from the field of meta-analysis that have been designed to tackle this problem. Adjusted indirect comparisons, meta-regressions, mixed models, Bayesian network analyses pool results of randomised controlled trials (RCTs), enabling a quantitative synthesis.The REAL procedure, recently developed by the HAS (French National Authority for Health), is a mixture of an MTC and effect model based on expert opinions. It is intended to translate the efficacy observed in the trials into effectiveness expected in day-to-day clinical practice in France.

Ethnicity and sexual risk in heterosexual people attending sexual health clinics in England: a cross-sectional, self-administered questionnaire study.

PubMed

Coyle, Rachel Margaret; Miltz, Ada Rose; Lampe, Fiona C; Sewell, Janey; Phillips, Andrew N; Speakman, Andrew; Dhar, Jyoti; Sherr, Lorraine; Sadiq, S Tariq; Taylor, Stephen; Ivens, Daniel R; Collins, Simon; Elford, Jonathan; Anderson, Jane; Rodger, Alison

2018-03-08

In the UK, people of black ethnicity experience a disproportionate burden of HIV and STI. We aimed to assess the association of ethnicity with sexual behaviour and sexual health among women and heterosexual men attending genitourinary medicine (GUM) clinics in England. The Attitudes to and Understanding of Risk of Acquisition of HIV is a cross-sectional, self-administered questionnaire study of HIV negative people recruited from 20 GUM clinics in England, 2013-2014. Modified Poisson regression with robust SEs was used to calculate adjusted prevalence ratios (aPR) for the association between ethnicity and various sexual risk behaviours, adjusted for age, study region, education and relationship status. Questionnaires were completed by 1146 individuals, 676 women and 470 heterosexual men. Ethnicity was recorded for 1131 (98.8%) participants: 550 (48.6%) black/mixed African, 168 (14.9%) black/mixed Caribbean, 308 (27.2%) white ethnic groups, 105 (9.3%) other ethnicity. Compared with women from white ethnic groups, black/mixed African women were less likely to report condomless sex with a non-regular partner (aPR (95% CI) 0.67 (0.51 to 0.88)), black/mixed African and black/mixed Caribbean women were less likely to report two or more new partners (0.42 (0.32 to 0.55) and 0.44 (0.29 to 0.65), respectively), and black/mixed Caribbean women were more likely to report an STI diagnosis (1.56 (1.00 to 2.42)). Compared with men from white ethnic groups, black/mixed Caribbean men were more likely to report an STI diagnosis (1.91 (1.20 to 3.04)), but did not report risk behaviours more frequently. Men and women of black/mixed Caribbean ethnicity remained more likely to report STI history after adjustment for sexual risk behaviours. Risk behaviours were reported less frequently by women of black ethnicity; however, history of STI was more prevalent among black/mixed Caribbean women. In black/mixed Caribbean men, higher STI history was not explained by ethnic variation in reported risk behaviours. The association between STI and black/mixed Caribbean ethnicity remained after adjustment for risk behaviours. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Nature and Stability of the Martian Seasonal Water Cycle

NASA Astrophysics Data System (ADS)

Richardson, M. I.; Wilson, R. J.

2001-12-01

Which components control the contemporary water cycle and what is the nature of the control mechanisms? These questions are at the heart of understanding how the Martian exchangeable water budget adjusts to perturbations and changes in the climate system. Analysis of a water cycle model embedded in the GFDL Mars GCM provides a paradigm for the water cycle as a feedback system, providing information on the important control points and response times. Much information on this system derives from monitoring the evolution towards steady state--one that resembles the observed water vapour and ice cloud distributions. The most important exchange balance in the system is that between the northern polar atmosphere and the rest of the planet. As the major net source for water, the northern residual water ice cap is active during summer, in the window of time between the sublimation and recondensation of the seasonal CO2 cap. At this time, water is exported from the northern polar atmosphere at a rate determined by the mixing capacity of the atmosphere and the amount of water held in the polar atmosphere. The latter is determined by the cap surface temperature. During the remainder of the year, water is returned to the pole. This return flux is determined by the atmospheric mixing capacity and the amount of water vapour held in the tropical and winter extratropical atmosphere. Steady-state is achieved when these fluxes balance. For a given climate state (and a roughly repeatable annual cycle of mixing), the outflux and influx of polar water are controlled by separate variables. Holding the cap temperature constant, the outflux will remain constant. Any perturbation to the global water budget will result in a change in the return flux that tends to oppose the sense of the perturbation--the perturbation will be damped. In the same way, a change in cap temperature (e.g. associated with a change in albedo) will result in changed water outflow. Again, this will tend to change the non-polar water vapour budget and hence the polar water influx so as to develop a new steady-state. It is important to note that only in this case is the steady-state global humidity changed: a given cap temperature and seasonal cycle of mixing capacity specifies a bulk steady-state atmospheric humidity. In all cases, the regolith acts as a damper on the system and adjusts to the global water distribution dictated ultimately by the northern cap. The model also suggests fast adjustment times, on order decades. A number of factors can affect atmospheric mixing capacity. As climate forcing factors change (associated with obliquity or greenhouse gas loading) the mixing capacity will change--an area for future study. The current mixing capacity of the atmosphere is also different from one that would obtain without atmospheric water condensation and sedimentation. Model clouds play important roles in returning water to the residual ice cap in northern summer, and significantly altering interhemispheric transport from that which would occur without clouds. As with previous studies, the southern polar cap acts as a permanent sink for water. The model and resulting paradigm for the water cycle can be used in very preliminary studies of past climate states. Forcing the model with an obliquity of 45 deg., the seasonal water ice caps become significantly more extended, reaching into the summer hemisphere. In fact, the seasonal caps "overlap" in the northern tropics, generating a year-round surface ice belt. Much work remains to be done in understanding water ice transport and exchange processes before models of paleoclimate can be of widespread utility--of which analysis of data from MGS and future missions will be key.

Determination of community structure through deconvolution of PLFA-FAME signature of mixed population.

PubMed

Dey, Dipesh K; Guha, Saumyen

2007-02-15

Phospholipid fatty acids (PLFAs) as biomarkers are well established in the literature. A general method based on least square approximation (LSA) was developed for the estimation of community structure from the PLFA signature of a mixed population where biomarker PLFA signatures of the component species were known. Fatty acid methyl ester (FAME) standards were used as species analogs and mixture of the standards as representative of the mixed population. The PLFA/FAME signatures were analyzed by gas chromatographic separation, followed by detection in flame ionization detector (GC-FID). The PLFAs in the signature were quantified as relative weight percent of the total PLFA. The PLFA signatures were analyzed by the models to predict community structure of the mixture. The LSA model results were compared with the existing "functional group" approach. Both successfully predicted community structure of mixed population containing completely unrelated species with uncommon PLFAs. For slightest intersection in PLFA signatures of component species, the LSA model produced better results. This was mainly due to inability of the "functional group" approach to distinguish the relative amounts of the common PLFA coming from more than one species. The performance of the LSA model was influenced by errors in the chromatographic analyses. Suppression (or enhancement) of a component's PLFA signature in chromatographic analysis of the mixture, led to underestimation (or overestimation) of the component's proportion in the mixture by the model. In mixtures of closely related species with common PLFAs, the errors in the common components were adjusted across the species by the model.

Tutorial on Biostatistics: Linear Regression Analysis of Continuous Correlated Eye Data.

PubMed

Ying, Gui-Shuang; Maguire, Maureen G; Glynn, Robert; Rosner, Bernard

2017-04-01

To describe and demonstrate appropriate linear regression methods for analyzing correlated continuous eye data. We describe several approaches to regression analysis involving both eyes, including mixed effects and marginal models under various covariance structures to account for inter-eye correlation. We demonstrate, with SAS statistical software, applications in a study comparing baseline refractive error between one eye with choroidal neovascularization (CNV) and the unaffected fellow eye, and in a study determining factors associated with visual field in the elderly. When refractive error from both eyes were analyzed with standard linear regression without accounting for inter-eye correlation (adjusting for demographic and ocular covariates), the difference between eyes with CNV and fellow eyes was 0.15 diopters (D; 95% confidence interval, CI -0.03 to 0.32D, p = 0.10). Using a mixed effects model or a marginal model, the estimated difference was the same but with narrower 95% CI (0.01 to 0.28D, p = 0.03). Standard regression for visual field data from both eyes provided biased estimates of standard error (generally underestimated) and smaller p-values, while analysis of the worse eye provided larger p-values than mixed effects models and marginal models. In research involving both eyes, ignoring inter-eye correlation can lead to invalid inferences. Analysis using only right or left eyes is valid, but decreases power. Worse-eye analysis can provide less power and biased estimates of effect. Mixed effects or marginal models using the eye as the unit of analysis should be used to appropriately account for inter-eye correlation and maximize power and precision.

Correlation of hospital magnet status with the quality of physicians performing neurosurgical procedures in New York State.

PubMed

Bekelis, Kimon; Missios, Symeon; MacKenzie, Todd A

2018-01-24

The quality of physicians practicing in hospitals recognized for nursing excellence by the American Nurses Credentialing Center has not been studied before. We investigated whether Magnet hospital recognition is associated with higher quality of physicians performing neurosurgical procedures. We performed a cohort study of patients undergoing neurosurgical procedures from 2009-2013, who were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Propensity score adjusted multivariable regression models were used to adjust for known confounders, with mixed effects methods to control for clustering at the facility level. An instrumental variable analysis was used to control for unmeasured confounding and simulate the effect of a randomized trial. During the study period, 185,277 patients underwent neurosurgical procedures, and met the inclusion criteria. Of these, 66,607 (35.6%) were hospitalized in Magnet hospitals, and 118,670 (64.4%) in non-Magnet institutions. Instrumental variable analysis demonstrated that undergoing neurosurgical operations in Magnet hospitals was associated with a 13.6% higher chance of being treated by a physician with superior performance in terms of mortality (95% CI, 13.2% to 14.1%), and a 4.3% higher chance of being treated by a physician with superior performance in terms of length-of-stay (LOS) (95% CI, 3.8% to 4.7%) in comparison to non-Magnet institutions. The same associations were present in propensity score adjusted mixed effects models. Using a comprehensive all-payer cohort of neurosurgical patients in New York State we identified an association of Magnet hospital recognition with superior physician performance.

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).

Association of patient case-mix adjustment, hospital process performance rankings, and eligibility for financial incentives.

PubMed

Mehta, Rajendra H; Liang, Li; Karve, Amrita M; Hernandez, Adrian F; Rumsfeld, John S; Fonarow, Gregg C; Peterson, Eric D

2008-10-22

While most comparisons of hospital outcomes adjust for patient characteristics, process performance comparisons typically do not. To evaluate the degree to which hospital process performance ratings and eligibility for financial incentives are altered after accounting for hospitals' patient demographics, clinical characteristics, and mix of treatment opportunities. Using data from the American Heart Association's Get With the Guidelines program between January 2, 2000, and March 28, 2008, we analyzed hospital process performance based on the Centers for Medicare & Medicaid Services' defined core measures for acute myocardial infarction. Hospitals were initially ranked based on crude composite process performance and then ranked again after accounting for hospitals' patient demographics, clinical characteristics, and eligibility for measures using a hierarchical model. We then compared differences in hospital performance rankings and pay-for-performance financial incentive categories (top 20%, middle 60%, and bottom 20% institutions). Hospital process performance ranking and pay-for-performance financial incentive categories. A total of 148,472 acute myocardial infarction patients met the study criteria from 449 centers. Hospitals for which crude composite acute myocardial infarction performance was in the bottom quintile (n = 89) were smaller nonacademic institutions that treated a higher percentage of patients from racial or ethnic minority groups and also patients with greater comorbidities than hospitals ranked in the top quintile (n = 90). Although there was overall agreement on hospital rankings based on observed vs adjusted composite scores (weighted kappa, 0.74), individual hospital ranking changed with adjustment (median, 22 ranks; range, 0-214; interquartile range, 9-40). Additionally, 16.5% of institutions (n = 74) changed pay-for-performance financial status categories after accounting for patient and treatment opportunity mix. Our findings suggest that accounting for hospital differences in patient characteristics and treatment opportunities is associated with modest changes in hospital performance rankings and eligibility for financial benefits in pay-for-performance programs for treatment of myocardial infarction.

Assessment of simulated aerosol effective radiative forcings in the terrestrial spectrum

NASA Astrophysics Data System (ADS)

Heyn, Irene; Block, Karoline; Mülmenstädt, Johannes; Gryspeerdt, Edward; Kühne, Philipp; Salzmann, Marc; Quaas, Johannes

2017-01-01

In its fifth assessment report (AR5), the Intergovernmental Panel on Climate Change provides a best estimate of the effective radiative forcing (ERF) due to anthropogenic aerosol at -0.9 W m-2. This value is considerably weaker than the estimate of -1.2 W m-2 in AR4. A part of the difference can be explained by an offset of +0.2 W m-2 which AR5 added to all published estimates that only considered the solar spectrum, in order to account for adjustments in the terrestrial spectrum. We find that, in the CMIP5 multimodel median, the ERF in the terrestrial spectrum is small, unless microphysical effects on ice- and mixed-phase clouds are parameterized. In the latter case it is large but accompanied by a very strong ERF in the solar spectrum. The total adjustments can be separated into microphysical adjustments (aerosol "effects") and thermodynamic adjustments. Using a kernel technique, we quantify the latter and find that the rapid thermodynamic adjustments of water vapor and temperature profiles are small. Observation-based constraints on these model results are urgently needed.

Anogenital distance: A longitudinal evaluation of its variants and indices in boys and girls of Sonora, Mexico.

PubMed

Loreto-Gómez, Carmen; Farías, Paulina; Moreno-Macías, Hortensia; Romano-Riquer, S P; Riojas-Rodríguez, Horacio

2017-10-01

There is no consensus on which anogenital distance (AGD) variant to use and how to adjust it by body size in humans. This study quantitatively evaluated AGD variants and body size adjustments to determine which would be the best choice. AGD variants, height, and weight were measured on five occasions during the first year of life of 307 infants. The ratio of anoscrotal distance (ASD) in boys and anofourchette distance (AFD) in girls increased from 1.9 at birth to 2.3 at 12 months of age. Each AGD variant was divided by each body size variable to generate different indices. Such indices were standardized to make them comparable when analyzing their performance through mixed models. ASD and AFD adjusted by height generated precise (p<0.05) AGD indices: 0.4-0.5 and 0.2, respectively. Results suggest that the best body size adjustment for all AGD variants in the first year of life is height. Copyright © 2017 Elsevier Inc. All rights reserved.

The impact of psychomotor subtypes and duration of delirium on 6-month mortality in hip-fractured elderly patients.

PubMed

Bellelli, Giuseppe; Carnevali, Lucio; Corsi, Maurizio; Morandi, Alessandro; Zambon, Antonella; Mazzola, Paolo; Galeazzi, Marianna; Bonfanti, Alessandra; Massariello, Francesca; Szabo, Hajnalka; Oliveri, Giulia; Haas, Justin; d'Oro, Luca Cavalieri; Annoni, Giorgio

2018-05-31

Studies exploring the incidence and impact of the psychomotor subtypes of postoperative delirium (POD) on the survival of hip fracture patients are few, and results are inconsistent. We sought to assess the incidence of POD subtypes and their impact, in addition to delirium duration, on 6-month mortality in older patients after hip-fracture surgery. This is a prospective study involving 571 individuals admitted to an Orthogeriatric Unit within a 5-year period with a diagnosis of hip fracture. Survival status was assessed 6 months after posthip fracture surgery. Postoperative delirium was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders. Postoperative delirium subtypes were classified according to Lipowski's criteria. Cox regressions were used to evaluate the associations between POD subtypes, POD duration, and 6-month mortality, adjusting for covariates. The incidence of psychomotor POD subtypes was hypoactive 57 (10.0%), hyperactive 84 (14.7%), and mixed 79 (13.8%). Six-month mortality rates were 8.3%, 10.7%, 36.8%, and 29.1% in the no-delirium, hyperactive, hypoactive, and mixed-delirium subgroups, respectively. In adjusted models, the hypoactive subgroup (Hazard Ratio, HR = 3.14, 95% Confidence Intervals, CI, 1.63-6.04) and mixed subgroup (HR = 2.89, 95% CI, 1.49-5.62) showed high mortality rates and a significantly increased risk of mortality associated with POD duration as well. Hyperactive delirium was the most common POD psychomotor subtype, but hypoactive and mixed POD were associated with 6-month mortality risk. Moreover, the risk of death 6 months after surgery increased for both subgroups (hypoactive and mixed) with increasing duration of POD. Copyright © 2018 John Wiley & Sons, Ltd.

Time variation of effective climate sensitivity in GCMs

NASA Astrophysics Data System (ADS)

Williams, K. D.; Ingram, W. J.; Gregory, J. M.

2009-04-01

Effective climate sensitivity is often assumed to be constant (if uncertain), but some previous studies of General Circulation Model (GCM) simulations have found it varying as the simulation progresses. This complicates the fitting of simple models to such simulations, as well as having implications for the estimation of climate sensitivity from observations. This study examines the evolution of the feedbacks determining the climate sensitivity in GCMs submitted to the Coupled Model Intercomparison Project. Apparent centennial-timescale variations of effective climate sensitivity during stabilisation to a forcing can be considered an artefact of using conventional forcings which only allow for instantaneous effects and stratospheric adjustment. If the forcing is adjusted for processes occurring on timescales which are short compared to the climate stabilisation timescale then there is little centennial timescale evolution of effective climate sensitivity in any of the GCMs. We suggest that much of the apparent variation in effective climate sensitivity identified in previous studies is actually due to the comparatively fast forcing adjustment. Persistent differences are found in the strength of the feedbacks between the coupled atmosphere - ocean (AO) versions and their atmosphere - mixed-layer ocean (AML) counterparts, (the latter are often assumed to give the equilibrium climate sensitivity of the AOGCM). The AML model can typically only estimate the equilibrium climate sensitivity of the parallel AO version to within about 0.5K. The adjustment to the forcing to account for comparatively fast processes varies in magnitude and sign between GCMs, as well as differing between AO and AML versions of the same model. There is evidence from one AOGCM that the forcing adjustment may take a couple of decades, with implications for observationally based estimates of equilibrium climate sensitivity. We suggest that at least some of the spread in 21st century global temperature predictions between GCMs is due to differing adjustment processes, hence work to understand these differences should be a priority.

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.

Influence of mixed electrolytes and pH on adsorption of bovine serum albumin in hydrophobic interaction chromatography.

PubMed

Hackemann, Eva; Hasse, Hans

2017-10-27

Using salt mixtures instead of single salts can be beneficial for hydrophobic interaction chromatography (HIC). The effect of electrolytes on the adsorption of proteins, however, depends on the pH. Little is known on that dependence for mixed electrolytes. Therefore, the effect of the pH on protein adsorption from aqueous solutions containing mixed salts is systematically studied in the present work for a model system: the adsorption of bovine serum albumin (BSA) on the mildly hydrophobic resin Toyopearl PPG-600M. The pH is adjusted to 4.0, 4.7 or 7.0 using 25mM sodium phosphate or sodium citrate buffer. Binary and ternary salt mixtures of sodium chloride, ammonium chloride, sodium sulfate and ammonium sulfate as well as the pure salts are used at overall ionic strengths between 1500 and 4200mM. The temperature is always 25°C. The influence of the mixed electrolytes on the adsorption behavior of BSA changes completely with varying pH. Positive as well as negative cooperative effects of the mixed electrolytes are observed. The results are analyzed using a mathematical model which was recently introduced by our group. In that model the influence of the electrolytes is described by a Taylor series expansion in the individual ion molarities. After suitable parametrization using a subset of the data determined in the present work, the model successfully predicts the influence of mixed electrolytes on the protein adsorption. Furthermore, results for BSA from the present study are compared to literature data for lysozyme, which are available for the same adsorbent, temperature and salts. By calculating the ratio of the loading of the adsorbent for both proteins particularly favorable separation conditions can be selected. Hence, a model-based optimization of solvents for protein separation is possible. Copyright © 2017 Elsevier B.V. All rights reserved.

Characterization and Modeling of Atmospheric Flow Within and Above Plant Canopies

NASA Astrophysics Data System (ADS)

Souza Freire Grion, Livia

The turbulent flow within and above plant canopies is responsible for the exchange of momentum, heat, gases and particles between vegetation and the atmosphere. Turbulence is also responsible for the mixing of air inside the canopy, playing an important role in chemical and biophysical processes occurring in the plants' environment. In the last fifty years, research has significantly advanced the understanding of and ability to model the flow field within and above the canopy, but important issues remain unsolved. In this work, we focus on (i) the estimation of turbulent mixing timescales within the canopy from field data; and (ii) the development of new computationally efficient modeling approaches for the coupled canopy-atmosphere flow field. The turbulent mixing timescale represents how quickly turbulence creates a well-mixed environment within the canopy. When the mixing timescale is much smaller than the timescale of other relevant processes (e.g. chemical reactions, deposition), the system can be assumed to be well-mixed and detailed modeling of turbulence is not critical to predict the system evolution. Conversely, if the mixing timescale is comparable or larger than the other timescales, turbulence becomes a controlling factor for the concentration of the variables involved; hence, turbulence needs to be taken into account when studying and modeling such processes. In this work, we used a combination of ozone concentration and high-frequency velocity data measured within and above the canopy in the Amazon rainforest to characterize turbulent mixing. The eddy diffusivity parameter (used as a proxy for mixing efficiency) was applied in a simple theoretical model of one-dimensional diffusion, providing an estimate of turbulent mixing timescales as a function of height within the canopy and time-of-day. Results showed that, during the day, the Amazon rainforest is characterized by well-mixed conditions with mixing timescales smaller than thirty minutes in the upper-half of the canopy, and partially mixed conditions in the lower half of the canopy. During the night, most of the canopy (except for the upper 20%) is either partially or poorly mixed, resulting in mixing timescales of up to several hours. For the specific case of ozone, the mixing timescales observed during the day are much lower than the chemical and deposition timescales, whereas chemical processes and turbulence have comparable timescales during the night. In addition, the high day-to-day variability in mixing conditions and the fast increase in mixing during the morning transition period indicate that turbulence within the canopy needs to be properly investigated and modeled in many studies involving plant-atmosphere interactions. Motivated by the findings described above, this work proposes and tests a new approach for modeling canopy flows. Typically, vertical profiles of flow statistics are needed to represent canopy-atmosphere exchanges in chemical and biophysical processes happening within the canopy. Current single-column models provide only steady-state (equilibrium) profiles, and rely on closure assumptions that do not represent the dominant non-local turbulent fluxes present in canopy flows. We overcome these issues by adapting the one-dimensional turbulent (ODT) model to represent atmospheric flows from the ground up to the top of the atmospheric boundary layer (ABL). The ODT model numerically resolves the one-dimensional diffusion equation along a vertical line (representing a horizontally homogeneous ABL column), and the presence of three-dimensional turbulence is added through the effect of stochastic eddies. Simulations of ABL without canopy were performed for different atmospheric stabilities and a diurnal cycle, to test the capabilities of this modeling approach in representing unsteady flows with strong non-local transport. In addition, four different types of canopies were simulated, one of them including the transport of scalar with a point source located inside the canopy. The comparison of all simulations with theory and field data provided satisfactory results. The main advantages of using ODT compared to typical 1D canopy-flow models are the ability to represent the coupled canopy-ABL flow with one single modeling approach, the presence of non-local turbulent fluxes, the ability to simulate transient conditions, the straightforward representation of multiple scalar fields, and the presence of only one adjustable parameter (as opposed to the several adjustable constants and boundary conditions needed for other modeling approaches). The results obtained with ODT as a stand-alone model motivated its use as a surface parameterization for Large-Eddy Simulation (LES). In this two-way coupling between LES and ODT, the former is used to simulate the ABL in a case where a canopy is present but cannot be resolved by the LES (i.e., the LES first vertical grid point is above the canopy). ODT is used to represent the flow field between the ground and the first LES grid point, including the region within and just above the canopy. In this work, we tested the ODT-LES model for three different types of canopies and obtained promising results. Although more work is needed in order to improve first and second-order statistics within the canopy (i.e. in the ODT domain), the results obtained for the flow statistics in the LES domain and for the third order statistics in the ODT domain demonstrate that the ODT-LES model is capable of capturing some important features of the canopy-atmosphere interaction. This new surface superparameterization approach using ODT provides a new alternative for simulations that require complex interactions between the flow field and near-surface processes (e.g. sand and snow drift, waves over water surfaces) and can potentially be extended to other large-scale models, such as mesoscale and global circulation models.

Development and Evaluation of an Automated Machine Learning Algorithm for In-Hospital Mortality Risk Adjustment Among Critical Care Patients.

PubMed

Delahanty, Ryan J; Kaufman, David; Jones, Spencer S

2018-06-01

Risk adjustment algorithms for ICU mortality are necessary for measuring and improving ICU performance. Existing risk adjustment algorithms are not widely adopted. Key barriers to adoption include licensing and implementation costs as well as labor costs associated with human-intensive data collection. Widespread adoption of electronic health records makes automated risk adjustment feasible. Using modern machine learning methods and open source tools, we developed and evaluated a retrospective risk adjustment algorithm for in-hospital mortality among ICU patients. The Risk of Inpatient Death score can be fully automated and is reliant upon data elements that are generated in the course of usual hospital processes. One hundred thirty-one ICUs in 53 hospitals operated by Tenet Healthcare. A cohort of 237,173 ICU patients discharged between January 2014 and December 2016. The data were randomly split into training (36 hospitals), and validation (17 hospitals) data sets. Feature selection and model training were carried out using the training set while the discrimination, calibration, and accuracy of the model were assessed in the validation data set. Model discrimination was evaluated based on the area under receiver operating characteristic curve; accuracy and calibration were assessed via adjusted Brier scores and visual analysis of calibration curves. Seventeen features, including a mix of clinical and administrative data elements, were retained in the final model. The Risk of Inpatient Death score demonstrated excellent discrimination (area under receiver operating characteristic curve = 0.94) and calibration (adjusted Brier score = 52.8%) in the validation dataset; these results compare favorably to the published performance statistics for the most commonly used mortality risk adjustment algorithms. Low adoption of ICU mortality risk adjustment algorithms impedes progress toward increasing the value of the healthcare delivered in ICUs. The Risk of Inpatient Death score has many attractive attributes that address the key barriers to adoption of ICU risk adjustment algorithms and performs comparably to existing human-intensive algorithms. Automated risk adjustment algorithms have the potential to obviate known barriers to adoption such as cost-prohibitive licensing fees and significant direct labor costs. Further evaluation is needed to ensure that the level of performance observed in this study could be achieved at independent sites.

ADJUSTABLE DOUBLE PULSE GENERATOR

DOEpatents

Gratian, J.W.; Gratian, A.C.

1961-08-01

>A modulator pulse source having adjustable pulse width and adjustable pulse spacing is described. The generator consists of a cross coupled multivibrator having adjustable time constant circuitry in each leg, an adjustable differentiating circuit in the output of each leg, a mixing and rectifying circuit for combining the differentiated pulses and generating in its output a resultant sequence of negative pulses, and a final amplifying circuit for inverting and square-topping the pulses. (AEC)

Playing Active Video Games may not develop movement skills: An intervention trial.

PubMed

Barnett, Lisa M; Ridgers, Nicola D; Reynolds, John; Hanna, Lisa; Salmon, Jo

2015-01-01

To investigate the impact of playing sports Active Video Games on children's actual and perceived object control skills. Intervention children played Active Video Games for 6 weeks (1 h/week) in 2012. The Test of Gross Motor Development-2 assessed object control skill. The Pictorial Scale of Perceived Movement Skill Competence assessed perceived object control skill. Repeated measurements of object control and perceived object control were analysed for the whole sample, using linear mixed models, which included fixed effects for group (intervention or control) and time (pre and post) and their interaction. The first model adjusted for sex only and the second model also adjusted for age, and prior ball sports experience (yes/no). Seven mixed-gender focus discussions were conducted with intervention children after programme completion. Ninety-five Australian children (55% girls; 43% intervention group) aged 4 to 8 years (M 6.2, SD 0.95) participated. Object control skill improved over time (p = 0.006) but there was no significant difference (p = 0.913) between groups in improvement (predicted means: control 31.80 to 33.53, SED = 0.748; intervention 30.33 to 31.83, SED = 0.835). A similar result held for the second model. Similarly the intervention did not change perceived object control in Model 1 (predicted means: control: 19.08 to 18.68, SED = 0.362; intervention 18.67 to 18.88, SED = 0.406) or Model 2. Children found the intervention enjoyable, but most did not perceive direct equivalence between Active Video Games and 'real life' activities. Whilst Active Video Game play may help introduce children to sport, this amount of time playing is unlikely to build skill.

Playing Active Video Games may not develop movement skills: An intervention trial

PubMed Central

Barnett, Lisa M.; Ridgers, Nicola D.; Reynolds, John; Hanna, Lisa; Salmon, Jo

2015-01-01

Background: To investigate the impact of playing sports Active Video Games on children's actual and perceived object control skills. Methods: Intervention children played Active Video Games for 6 weeks (1 h/week) in 2012. The Test of Gross Motor Development-2 assessed object control skill. The Pictorial Scale of Perceived Movement Skill Competence assessed perceived object control skill. Repeated measurements of object control and perceived object control were analysed for the whole sample, using linear mixed models, which included fixed effects for group (intervention or control) and time (pre and post) and their interaction. The first model adjusted for sex only and the second model also adjusted for age, and prior ball sports experience (yes/no). Seven mixed-gender focus discussions were conducted with intervention children after programme completion. Results: Ninety-five Australian children (55% girls; 43% intervention group) aged 4 to 8 years (M 6.2, SD 0.95) participated. Object control skill improved over time (p = 0.006) but there was no significant difference (p = 0.913) between groups in improvement (predicted means: control 31.80 to 33.53, SED = 0.748; intervention 30.33 to 31.83, SED = 0.835). A similar result held for the second model. Similarly the intervention did not change perceived object control in Model 1 (predicted means: control: 19.08 to 18.68, SED = 0.362; intervention 18.67 to 18.88, SED = 0.406) or Model 2. Children found the intervention enjoyable, but most did not perceive direct equivalence between Active Video Games and ‘real life’ activities. Conclusions: Whilst Active Video Game play may help introduce children to sport, this amount of time playing is unlikely to build skill. PMID:26844136

Social mixing in Fiji: Who-eats-with-whom contact patterns and the implications of age and ethnic heterogeneity for disease dynamics in the Pacific Islands.

PubMed

Watson, Conall H; Coriakula, Jeremaia; Ngoc, Dung Tran Thi; Flasche, Stefan; Kucharski, Adam J; Lau, Colleen L; Thieu, Nga Tran Vu; le Polain de Waroux, Olivier; Rawalai, Kitione; Van, Tan Trinh; Taufa, Mere; Baker, Stephen; Nilles, Eric J; Kama, Mike; Edmunds, W John

2017-01-01

Empirical data on contact patterns can inform dynamic models of infectious disease transmission. Such information has not been widely reported from Pacific islands, nor strongly multi-ethnic settings, and few attempts have been made to quantify contact patterns relevant for the spread of gastrointestinal infections. As part of enteric fever investigations, we conducted a cross-sectional survey of the general public in Fiji, finding that within the 9,650 mealtime contacts reported by 1,814 participants, there was strong like-with-like mixing by age and ethnicity, with higher contact rates amongst iTaukei than non-iTaukei Fijians. Extra-domiciliary lunchtime contacts follow these mixing patterns, indicating the overall data do not simply reflect household structures. Inter-ethnic mixing was most common amongst school-age children. Serological responses indicative of recent Salmonella Typhi infection were found to be associated, after adjusting for age, with increased contact rates between meal-sharing iTaukei, with no association observed for other contact groups. Animal ownership and travel within the geographical division were common. These are novel data that identify ethnicity as an important social mixing variable, and use retrospective mealtime contacts as a socially acceptable metric of relevance to enteric, contact and respiratory diseases that can be collected in a single visit to participants. Application of these data to other island settings will enable communicable disease models to incorporate locally relevant mixing patterns in parameterisation.

Social mixing in Fiji: Who-eats-with-whom contact patterns and the implications of age and ethnic heterogeneity for disease dynamics in the Pacific Islands

PubMed Central

Coriakula, Jeremaia; Ngoc, Dung Tran Thi; Flasche, Stefan; Kucharski, Adam J.; Lau, Colleen L.; Thieu, Nga Tran Vu; le Polain de Waroux, Olivier; Rawalai, Kitione; Van, Tan Trinh; Taufa, Mere; Baker, Stephen; Nilles, Eric J.; Kama, Mike; Edmunds, W. John

2017-01-01

Empirical data on contact patterns can inform dynamic models of infectious disease transmission. Such information has not been widely reported from Pacific islands, nor strongly multi-ethnic settings, and few attempts have been made to quantify contact patterns relevant for the spread of gastrointestinal infections. As part of enteric fever investigations, we conducted a cross-sectional survey of the general public in Fiji, finding that within the 9,650 mealtime contacts reported by 1,814 participants, there was strong like-with-like mixing by age and ethnicity, with higher contact rates amongst iTaukei than non-iTaukei Fijians. Extra-domiciliary lunchtime contacts follow these mixing patterns, indicating the overall data do not simply reflect household structures. Inter-ethnic mixing was most common amongst school-age children. Serological responses indicative of recent Salmonella Typhi infection were found to be associated, after adjusting for age, with increased contact rates between meal-sharing iTaukei, with no association observed for other contact groups. Animal ownership and travel within the geographical division were common. These are novel data that identify ethnicity as an important social mixing variable, and use retrospective mealtime contacts as a socially acceptable metric of relevance to enteric, contact and respiratory diseases that can be collected in a single visit to participants. Application of these data to other island settings will enable communicable disease models to incorporate locally relevant mixing patterns in parameterisation. PMID:29211731

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.

Research on Bifurcation and Chaos in a Dynamic Mixed Game System with Oligopolies Under Carbon Emission Constraint

NASA Astrophysics Data System (ADS)

Ma, Junhai; Yang, Wenhui; Lou, Wandong

This paper establishes an oligopolistic game model under the carbon emission reduction constraint and investigates its complex characteristics like bifurcation and chaos. Two oligopolistic manufacturers comprise three mixed game models, aiming to explore the variation in the status of operating system as per the upgrading of benchmark reward-penalty mechanism. Firstly, we set up these basic models that are respectively distinguished with carbon emission quantity and study these models using different game methods. Then, we concentrate on one typical game model to further study the dynamic complexity of variations in the system status, through 2D bifurcation diagrams and 4D parameter adjustment features based on the bounded rationality scheme for price, and the adaptive scheme for carbon emission. The results show that the carbon emission constraint has significant influence on the status variation of two-oligopolistic game operating systems no matter whether it is stable or chaotic. Besides, the new carbon emission regulation meets government supervision target and achieves the goal of being environment friendly by motivating the system to operate with lower carbon emission.

Efficacy of Sibling Preparation Classes.

PubMed

Beyers-Carlson, Emma E A; Volling, Brenda L

To examine the effectiveness of sibling preparation classes to facilitate the adjustment of a firstborn child to the birth of a sibling. Longitudinal study with five measurement occasions: third trimester of the mother's pregnancy and 1, 4, 8, and 12 months after the sibling's birth. Communities in southeastern Michigan. A total of 241 families, including mothers, fathers, and firstborn children. Mothers and fathers completed questionnaires to assess changes in children's adjustment. Parents were also asked about their children's attendance at a sibling preparation class focused specifically on preparation for the newborn. Effects of attendance were tested using linear mixed models. Other than avoidance of the infant, children who attended sibling preparation classes did not differ from children who did not attend. Sibling preparation classes for adjustment after the birth of an infant sibling had few effects on participants. Copyright © 2017 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.

75 FR 49029 - Medicare Program; End-Stage Renal Disease Prospective Payment System

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-12

...This final rule implements a case-mix adjusted bundled prospective payment system (PPS) for Medicare outpatient end-stage renal disease (ESRD) dialysis facilities beginning January 1, 2011 (ESRD PPS), in compliance with the statutory requirement of the Medicare Improvements for Patients and Providers Act (MIPPA), enacted July 15, 2008. This ESRD PPS also replaces the current basic case-mix adjusted composite payment system and the methodologies for the reimbursement of separately billable outpatient ESRD services.

Preparation of hydrophilic interaction/ion-exchange mixed-mode chromatographic stationary phase with adjustable selectivity by controlling different ratios of the co-monomers.

PubMed

Bo, Chunmiao; Wang, Xiaomeng; Wang, Chaozhan; Wei, Yinmao

2017-03-03

Development of mixed-mode chromatography (MMC) stationary phase with adjustable selectivity is beneficial to meet the needs of complex samples. In this work, surface-initiated atom transfer radical polymerization (SI-ATRP) using the mixture of two functional monomers was proposed as a new preparation strategy for MMC stationary phase with adjustable selectivity. The mixture of sodium 4-styrenesulfonate (NASS) and dimethylaminoethyl methacrylate (DMAEMA) underwent SI-ATRP to bond poly(NASS-co-DMAEMA) on the surface of silica to prepare hydrophilic interaction/ion-exchange mixed-mode stationary phase. Various analytes (neutral, acidic, basic analytes and strong polar nucleosides) were employed to investigate the retention behaviors. The influences of water content and pH of the mobile phase on the retention validated the mixed-mode retention mechanisms of HILIC and ion-exchange. The charge and polarity of stationary phase as well as the separation selectivity were conveniently manipulated by the ratio of NASS to DMAEMA monomer, and the use of DMAEMA in the mixture additionally endowed the column with the temperature-responsive characteristics. Moreover, the application of the developed column was demonstrated by the successful separation of nucleosides, β-agonists and safflower injection. In a word, the proposed strategy can be potentially applied in the controllable preparation of MMC stationary phase with adjustable selectivity. Copyright © 2017 Elsevier B.V. All rights reserved.

Net returns, fiscal risks, and the optimal patient mix for a profit-maximizing hospital.

PubMed

Ozatalay, S; Broyles, R

1987-10-01

As is well recognized, the provisions of PL98-21 not only transfer financial risks from the Medicare program to the hospital but also induce institutions to adjust the diagnostic mix of Medicare beneficiaries so as to maximize net income or minimize the net loss. This paper employs variation in the set of net returns as the sole measure of financial risk and develops a model that identifies the mix of beneficiaries that maximizes net income, subject to a given level of risk. The results indicate that the provisions of PL98-21 induce the institution to deny admission to elderly patients presenting conditions for which the net return is relatively low and the variance in the cost per case is large. Further, the paper suggests that the treatment of beneficiaries at a level commensurate with previous periods or the preferences of physicians may jeopardize the viability and solvency of Medicare-dependent hospitals.

Model predictive control of an air suspension system with damping multi-mode switching damper based on hybrid model

NASA Astrophysics Data System (ADS)

Sun, Xiaoqiang; Yuan, Chaochun; Cai, Yingfeng; Wang, Shaohua; Chen, Long

2017-09-01

This paper presents the hybrid modeling and the model predictive control of an air suspension system with damping multi-mode switching damper. Unlike traditional damper with continuously adjustable damping, in this study, a new damper with four discrete damping modes is applied to vehicle semi-active air suspension. The new damper can achieve different damping modes by just controlling the on-off statuses of two solenoid valves, which makes its damping adjustment more efficient and more reliable. However, since the damping mode switching induces different modes of operation, the air suspension system with the new damper poses challenging hybrid control problem. To model both the continuous/discrete dynamics and the switching between different damping modes, the framework of mixed logical dynamical (MLD) systems is used to establish the system hybrid model. Based on the resulting hybrid dynamical model, the system control problem is recast as a model predictive control (MPC) problem, which allows us to optimize the switching sequences of the damping modes by taking into account the suspension performance requirements. Numerical simulations results demonstrate the efficacy of the proposed control method finally.

High Static Stability in the Mixed Layer Above the Extratropical Tropopause

NASA Astrophysics Data System (ADS)

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

2008-12-01

A strong relationship between the static stability N2 and the strength of mixing in the mixed layer above the extratropical tropopause is evident from in-situ data observed during the SPURT aircraft campaigns. We present a method for quantifying the strength of mixing from O3/CO tracer correlations and we find that N2 is positively correlated with the strength of mixing. Age of air simulations with the CLaMS model reveal two different types of mixed regions. One type consisting of older airmasses with higher values of N2 which are created by radiative adjustment after a mixing event. These airmasses are within the TIL (Tropopause Inversion Layer), considering the TIL as part of the mixing layer. The second type comprises younger airmasses with somehow lower stratospheric N2 values within the mixing layer, because of recent intrusion processes due to the permeability or so-called mid-latitude-breaks associated with the jet stream. With the help of 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 the idealized case of non-mixing (L-shape) O3 and H2O profiles and in the reference case of mixed profiles. Within the altitude range of the SPURT campaigns the mean vertical SPURT profiles are used as reference, which are fitted to the HALOE climatological profiles above the UT/LS.

Outcome differences in adolescent blunt severe polytrauma patients managed at pediatric versus adult trauma centers.

PubMed

Rogers, Amelia T; Gross, Brian W; Cook, Alan D; Rinehart, Cole D; Lynch, Caitlin A; Bradburn, Eric H; Heinle, Colin C; Jammula, Shreya; Rogers, Frederick B

2017-12-01

Previous research suggests adolescent trauma patients can be managed equally effectively at pediatric and adult trauma centers. We sought to determine whether this association would be upheld for adolescent severe polytrauma patients. We hypothesized that no difference in adjusted outcomes would be observed between pediatric trauma centers (PTCs) and adult trauma centers (ATCs) for this population. All severely injured adolescent (aged 12-17 years) polytrauma patients were extracted from the Pennsylvania Trauma Outcomes Study database from 2003 to 2015. Polytrauma was defined as an Abbreviated Injury Scale (AIS) score ≥3 for two or more AIS-defined body regions. Dead on arrival, transfer, and penetrating trauma patients were excluded from analysis. ATC were defined as adult-only centers, whereas standalone pediatric hospitals and adult centers with pediatric affiliation were considered PTC. Multilevel mixed-effects logistic regression models assessed the adjusted impact of center type on mortality and total complications while controlling for age, shock index, Injury Severity Score, Glasgow Coma Scale motor score, trauma center level, case volume, and injury year. A generalized linear mixed model characterized functional status at discharge (FSD) while controlling for the same variables. A total of 1,606 patients met inclusion criteria (PTC: 868 [54.1%]; ATC: 738 [45.9%]), 139 (8.66%) of which died in-hospital. No significant difference in mortality (adjusted odds ratio [AOR]: 1.10, 95% CI 0.54-2.24; p = 0.794; area under the receiver operating characteristic: 0.89) was observed between designations in adjusted analysis; however, FSD (AOR: 0.38, 95% CI 0.15-0.97; p = 0.043) was found to be lower and total complication trends higher (AOR: 1.78, 95% CI 0.98-3.32; p = 0.058) at PTC for adolescent polytrauma patients. Contrary to existing literature on adolescent trauma patients, our results suggest patients aged 12-17 presenting with polytrauma may experience improved overall outcomes when managed at adult compared to pediatric trauma centers. Epidemiologic study, level III.

Adjusting to Random Demands of Patient Care: A Predictive Model for Nursing Staff Scheduling at Naval Medical Center San Diego

DTIC Science & Technology

2008-09-01

rich mix of medical services that range from simple ambulatory visits to plastic surgery , neuro- surgery , general surgery , bariatric , ophthalmology...CENTER SAN DIEGO NMCSD is a 266-bed tertiary care facility providing patient services ranging from same day surgery to brain surgery . The hospital...orthopedics, cardiology, thoracic surgery , vascular surgery , transient ischemic attack/cerebro vascular accident (TIA/CVA), OB/GYN, urology, non

Development of a test to measure the tendency for a hot-mix asphalt to segregate

DOT National Transportation Integrated Search

2000-02-01

Hot Mix Asphalt tends to segregate during handling and placement. The use of a test to determine the tendency to segregate would assist the user in determining when a mix gradation needs adjustment to avoid construction of a segregated pavement or wh...

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.

An Earth longwave radiation climate model

NASA Technical Reports Server (NTRS)

Yang, S. K.

1984-01-01

An Earth outgoing longwave radiation (OLWR) climate model was constructed for radiation budget study. Required information is provided by on empirical 100mb water vapor mixing ratio equation of the mixing ratio interpolation scheme. Cloud top temperature is adjusted so that the calculation would agree with NOAA scanning radiometer measurements. Both clear sky and cloudy sky cases are calculated and discussed for global average, zonal average and world-wide distributed cases. The results agree well with the satellite observations. The clear sky case shows that the OLWR field is highly modulated by water vapor, especially in the tropics. The strongest longitudinal variation occurs in the tropics. This variation can be mostly explained by the strong water vapor gradient. Although in the zonal average case the tropics have a minimum in OLWR, the minimum is essentially contributed by a few very low flux regions, such as the Amazon, Indonesian and the Congo.

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.

Missing continuous outcomes under covariate dependent missingness in cluster randomised trials

PubMed Central

Diaz-Ordaz, Karla; Bartlett, Jonathan W

2016-01-01

Attrition is a common occurrence in cluster randomised trials which leads to missing outcome data. Two approaches for analysing such trials are cluster-level analysis and individual-level analysis. This paper compares the performance of unadjusted cluster-level analysis, baseline covariate adjusted cluster-level analysis and linear mixed model analysis, under baseline covariate dependent missingness in continuous outcomes, in terms of bias, average estimated standard error and coverage probability. The methods of complete records analysis and multiple imputation are used to handle the missing outcome data. We considered four scenarios, with the missingness mechanism and baseline covariate effect on outcome either the same or different between intervention groups. We show that both unadjusted cluster-level analysis and baseline covariate adjusted cluster-level analysis give unbiased estimates of the intervention effect only if both intervention groups have the same missingness mechanisms and there is no interaction between baseline covariate and intervention group. Linear mixed model and multiple imputation give unbiased estimates under all four considered scenarios, provided that an interaction of intervention and baseline covariate is included in the model when appropriate. Cluster mean imputation has been proposed as a valid approach for handling missing outcomes in cluster randomised trials. We show that cluster mean imputation only gives unbiased estimates when missingness mechanism is the same between the intervention groups and there is no interaction between baseline covariate and intervention group. Multiple imputation shows overcoverage for small number of clusters in each intervention group. PMID:27177885

Missing continuous outcomes under covariate dependent missingness in cluster randomised trials.

PubMed

Hossain, Anower; Diaz-Ordaz, Karla; Bartlett, Jonathan W

2017-06-01

Attrition is a common occurrence in cluster randomised trials which leads to missing outcome data. Two approaches for analysing such trials are cluster-level analysis and individual-level analysis. This paper compares the performance of unadjusted cluster-level analysis, baseline covariate adjusted cluster-level analysis and linear mixed model analysis, under baseline covariate dependent missingness in continuous outcomes, in terms of bias, average estimated standard error and coverage probability. The methods of complete records analysis and multiple imputation are used to handle the missing outcome data. We considered four scenarios, with the missingness mechanism and baseline covariate effect on outcome either the same or different between intervention groups. We show that both unadjusted cluster-level analysis and baseline covariate adjusted cluster-level analysis give unbiased estimates of the intervention effect only if both intervention groups have the same missingness mechanisms and there is no interaction between baseline covariate and intervention group. Linear mixed model and multiple imputation give unbiased estimates under all four considered scenarios, provided that an interaction of intervention and baseline covariate is included in the model when appropriate. Cluster mean imputation has been proposed as a valid approach for handling missing outcomes in cluster randomised trials. We show that cluster mean imputation only gives unbiased estimates when missingness mechanism is the same between the intervention groups and there is no interaction between baseline covariate and intervention group. Multiple imputation shows overcoverage for small number of clusters in each intervention group.

NGA-West2 Empirical Fourier Model for Active Crustal Regions to Generate Regionally Adjustable Response Spectra

NASA Astrophysics Data System (ADS)

Bora, S. S.; Cotton, F.; Scherbaum, F.; Kuehn, N. M.

2016-12-01

Adjustment of median ground motion prediction equations (GMPEs) from data-rich (host) regions to data-poor regions (target) is one of major challenges that remains with the current practice of engineering seismology and seismic hazard analysis. Fourier spectral representation of ground motion provides a solution to address the problem of adjustment that is physically transparent and consistent with the concepts of linear system theory. Also, it provides a direct interface to appreciate the physically expected behavior of seismological parameters on ground motion. In the present study, we derive an empirical Fourier model for computing regionally adjustable response spectral ordinates based on random vibration theory (RVT) from shallow crustal earthquakes in active tectonic regions, following the approach of Bora et al. (2014, 2015). , For this purpose, we use an expanded NGA-West2 database with M 3.2—7.9 earthquakes at distances ranging from 0 to 300 km. A mixed-effects regression technique is employed to further explore various components of variability. The NGA-West2 database expanded over a wide magnitude range provides a better understanding (and constraint) of source scaling of ground motion. The large global volume of the database also allows investigating regional patterns in distance-dependent attenuation (i.e., geometrical spreading and inelastic attenuation) of ground motion as well as in the source parameters (e.g., magnitude and stress drop). Furthermore, event-wise variability and its correlation with stress parameter are investigated. Finally, application of the derived Fourier model in generating adjustable response spectra will be shown.

Development of a risk-adjustment model for antimicrobial utilization data in 21 public hospitals in Queensland, Australia (2006-11).

PubMed

Rajmokan, M; Morton, A; Marquess, J; Playford, E G; Jones, M

2013-10-01

Making valid comparisons of antimicrobial utilization between hospitals requires risk adjustment for each hospital's case mix. Data on individual patients may be unavailable or difficult to process. Therefore, risk adjustment for antimicrobial usage frequently needs to be based on a hospital's services. This study evaluated such a strategy for hospital antimicrobial utilization. Data were obtained on five broad subclasses of antibiotics [carbapenems, β-lactam/β-lactamase inhibitor combinations (BLBLIs), fluoroquinolones, glycopeptides and third-generation cephalosporins] from the Queensland pharmacy database (MedTrx) for 21 acute public hospitals (2006-11). Eleven clinical services and a variable for hospitals from the tropical region were employed for risk adjustment. Multivariable regression models were used to identify risk and protective services for these antibiotics. Funnel plots were used to display hospitals' antimicrobial utilization. Total inpatient antibiotic utilization for these antibiotics increased from 130.6 defined daily doses (DDDs)/1000 patient-days in 2006 to 155.8 DDDs/1000 patient-days in 2011 (P < 0.0001). Except for third-generation cephalosporins, the average utilization rate was higher for intensive care, renal/nephrology, cardiac, burns/plastic surgery, neurosurgery, transplant and acute spinal services than for the respective reference group (no service). In addition, oncology, high-activity infectious disease and coronary care services were associated with higher utilization of carbapenems, BLBLIs and glycopeptides. Our model predicted antimicrobial utilization rates by hospital services. The funnel plots displayed hospital utilization data after adjustment for variation among the hospitals. However, the methodology needs to be validated in other populations, ideally using a larger group of hospitals.

Validating a benchmarking tool for audit of early outcomes after operations for head and neck cancer.

PubMed

Tighe, D; Sassoon, I; McGurk, M

2017-04-01

INTRODUCTION In 2013 all UK surgical specialties, with the exception of head and neck surgery, published outcome data adjusted for case mix for indicator operations. This paper reports a pilot study to validate a previously published risk adjustment score on patients from separate UK cancer centres. METHODS A case note audit was performed of 1,075 patients undergoing 1,218 operations for head and neck squamous cell carcinoma under general anaesthesia in 4 surgical centres. A logistic regression equation predicting for all complications, previously validated internally at sites A-C, was tested on a fourth external validation sample (site D, 172 operations) using receiver operating characteristic curves, Hosmer-Lemeshow goodness of fit analysis and Brier scores. RESULTS Thirty-day complication rates varied widely (34-51%) between the centres. The predictive score allowed imperfect risk adjustment (area under the curve: 0.70), with Hosmer-Lemeshow analysis suggesting good calibration. The Brier score changed from 0.19 for sites A-C to 0.23 when site D was also included, suggesting poor accuracy overall. CONCLUSIONS Marked differences in operative risk and patient case mix captured by the risk adjustment score do not explain all the differences in observed outcomes. Further investigation with different methods is recommended to improve modelling of risk. Morbidity is common, and usually has a major impact on patient recovery, ward occupancy, hospital finances and patient perception of quality of care. We hope comparative audit will highlight good performance and challenge underperformance where it exists.

Validating a benchmarking tool for audit of early outcomes after operations for head and neck cancer

PubMed Central

Sassoon, I; McGurk, M

2017-01-01

INTRODUCTION In 2013 all UK surgical specialties, with the exception of head and neck surgery, published outcome data adjusted for case mix for indicator operations. This paper reports a pilot study to validate a previously published risk adjustment score on patients from separate UK cancer centres. METHODS A case note audit was performed of 1,075 patients undergoing 1,218 operations for head and neck squamous cell carcinoma under general anaesthesia in 4 surgical centres. A logistic regression equation predicting for all complications, previously validated internally at sites A–C, was tested on a fourth external validation sample (site D, 172 operations) using receiver operating characteristic curves, Hosmer–Lemeshow goodness of fit analysis and Brier scores. RESULTS Thirty-day complication rates varied widely (34–51%) between the centres. The predictive score allowed imperfect risk adjustment (area under the curve: 0.70), with Hosmer–Lemeshow analysis suggesting good calibration. The Brier score changed from 0.19 for sites A–C to 0.23 when site D was also included, suggesting poor accuracy overall. CONCLUSIONS Marked differences in operative risk and patient case mix captured by the risk adjustment score do not explain all the differences in observed outcomes. Further investigation with different methods is recommended to improve modelling of risk. Morbidity is common, and usually has a major impact on patient recovery, ward occupancy, hospital finances and patient perception of quality of care. We hope comparative audit will highlight good performance and challenge underperformance where it exists. PMID:27917662

Assessment of hospital performance with a case-mix standardized mortality model using an existing administrative database in Japan.

PubMed

Miyata, Hiroaki; Hashimoto, Hideki; Horiguchi, Hiromasa; Fushimi, Kiyohide; Matsuda, Shinya

2010-05-19

Few studies have examined whether risk adjustment is evenly applicable to hospitals with various characteristics and case-mix. In this study, we applied a generic prediction model to nationwide discharge data from hospitals with various characteristics. We used standardized data of 1,878,767 discharged patients provided by 469 hospitals from July 1 to October 31, 2006. We generated and validated a case-mix in-hospital mortality prediction model using 50/50 split sample validation. We classified hospitals into two groups based on c-index value (hospitals with c-index > or = 0.8; hospitals with c-index < 0.8) and examined differences in their characteristics. The model demonstrated excellent discrimination as indicated by the high average c-index and small standard deviation (c-index = 0.88 +/- 0.04). Expected mortality rate of each hospital was highly correlated with observed mortality rate (r = 0.693, p < 0.001). Among the studied hospitals, 446 (95%) had a c-index of >/=0.8 and were classified as the higher c-index group. A significantly higher proportion of hospitals in the lower c-index group were specialized hospitals and hospitals with convalescent wards. The model fits well to a group of hospitals with a wide variety of acute care events, though model fit is less satisfactory for specialized hospitals and those with convalescent wards. Further sophistication of the generic prediction model would be recommended to obtain optimal indices to region specific conditions.

Impact of socioeconomic adjustment on physicians' relative cost of care.

PubMed

Timbie, Justin W; Hussey, Peter S; Adams, John L; Ruder, Teague W; Mehrotra, Ateev

2013-05-01

Ongoing efforts to profile physicians on their relative cost of care have been criticized because they do not account for differences in patients' socioeconomic status (SES). The importance of SES adjustment has not been explored in cost-profiling applications that measure costs using an episode of care framework. We assessed the relationship between SES and episode costs and the impact of adjusting for SES on physicians' relative cost rankings. We analyzed claims submitted to 3 Massachusetts commercial health plans during calendar years 2004 and 2005. We grouped patients' care into episodes, attributed episodes to individual physicians, and standardized costs for price differences across plans. We accounted for differences in physicians' case mix using indicators for episode type and a patient's severity of illness. A patient's SES was measured using an index of 6 indicators based on the zip code in which the patient lived. We estimated each physician's case mix-adjusted average episode cost and percentile rankings with and without adjustment for SES. Patients in the lowest SES quintile had $80 higher unadjusted episode costs, on average, than patients in the highest quintile. Nearly 70% of the variation in a physician's average episode cost was explained by case mix of their patients, whereas the contribution of SES was negligible. After adjustment for SES, only 1.1% of physicians changed relative cost rankings >2 percentiles. Accounting for patients' SES has little impact on physicians' relative cost rankings within an episode cost framework.

Tutorial on Biostatistics: Linear Regression Analysis of Continuous Correlated Eye Data

PubMed Central

Ying, Gui-shuang; Maguire, Maureen G; Glynn, Robert; Rosner, Bernard

2017-01-01

Purpose To describe and demonstrate appropriate linear regression methods for analyzing correlated continuous eye data. Methods We describe several approaches to regression analysis involving both eyes, including mixed effects and marginal models under various covariance structures to account for inter-eye correlation. We demonstrate, with SAS statistical software, applications in a study comparing baseline refractive error between one eye with choroidal neovascularization (CNV) and the unaffected fellow eye, and in a study determining factors associated with visual field data in the elderly. Results When refractive error from both eyes were analyzed with standard linear regression without accounting for inter-eye correlation (adjusting for demographic and ocular covariates), the difference between eyes with CNV and fellow eyes was 0.15 diopters (D; 95% confidence interval, CI −0.03 to 0.32D, P=0.10). Using a mixed effects model or a marginal model, the estimated difference was the same but with narrower 95% CI (0.01 to 0.28D, P=0.03). Standard regression for visual field data from both eyes provided biased estimates of standard error (generally underestimated) and smaller P-values, while analysis of the worse eye provided larger P-values than mixed effects models and marginal models. Conclusion In research involving both eyes, ignoring inter-eye correlation can lead to invalid inferences. Analysis using only right or left eyes is valid, but decreases power. Worse-eye analysis can provide less power and biased estimates of effect. Mixed effects or marginal models using the eye as the unit of analysis should be used to appropriately account for inter-eye correlation and maximize power and precision. PMID:28102741

An Adjustable Gas-Mixing Device to Increase Feasibility of In Vitro Culture of Plasmodium falciparum Parasites in the Field

PubMed Central

Volkman, Sarah K.; Ahouidi, Ambroise D.; Ndiaye, Daouda; Mboup, Souleymane; Wirth, Dyann F.

2014-01-01

A challenge to conducting high-impact and reproducible studies of the mechanisms of P. falciparum drug resistance, invasion, virulence, and immunity is the lack of robust and sustainable in vitro culture in the field. While the technology exists and is routinely utilized in developed countries, various factors–from cost, to supply, to quality–make it hard to implement in malaria endemic countries. Here, we design and rigorously evaluate an adjustable gas-mixing device for the in vitro culture of P. falciparum parasites in the field to circumvent this challenge. The device accurately replicates the gas concentrations needed to culture laboratory isolates, short-term adapted field isolates, cryopreserved previously non-adapted isolates, as well as to adapt ex vivo isolates to in vitro culture in the field. We also show an advantage over existing alternatives both in cost and in supply. Furthermore, the adjustable nature of the device makes it an ideal tool for many applications in which varied gas concentrations could be critical to culture success. This adjustable gas-mixing device will dramatically improve the feasibility of in vitro culture of Plasmodium falciparum parasites in malaria endemic countries given its numerous advantages. PMID:24603696

Survival advantage in black versus white men with CKD: effect of estimated GFR and case mix.

PubMed

Kovesdy, Csaba P; Quarles, L Darryl; Lott, Evan H; Lu, Jun Ling; Ma, Jennie Z; Molnar, Miklos Z; Kalantar-Zadeh, Kamyar

2013-08-01

Black dialysis patients have significantly lower mortality compared with white patients, in contradistinction to the higher mortality seen in blacks in the general population. It is unclear whether a similar paradox exists in patients with non-dialysis-dependent chronic kidney disease (CKD), and if it does, what its underlying reasons are. Historical cohort. 518,406 white and 52,402 black male US veterans with non-dialysis-dependent CKD stages 3-5. Black race. We examined overall and CKD stage-specific all-cause mortality using parametric survival models. The effect of sociodemographic characteristics, comorbid conditions, and laboratory characteristics on the observed differences was explored in multivariable models. During a median follow-up of 4.7 years, 172,093 patients died (mortality rate, 71.0 [95% CI, 70.6-71.3] per 1,000 patient-years). Black race was associated with significantly lower crude mortality (HR, 0.95; 95% CI, 0.94-0.97; P < 0.001). The survival advantage was attenuated after adjustment for age (HR, 1.14; 95% CI, 1.12-1.16), but was magnified after full multivariable adjustment (HR, 0.72; 95% CI, 0.70-0.73; P < 0.001). The unadjusted survival advantage of blacks was more prominent in those with more advanced stages of CKD, but CKD stage-specific differences were attenuated by multivariable adjustment. Exclusively male patients. Black patients with CKD have lower mortality compared with white patients. The survival advantage seen in blacks is accentuated in patients with more advanced stages of CKD, which may be explained by changes in case-mix and laboratory characteristics occurring during the course of kidney disease. Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc.

Survival Advantage in Black Versus White Men With CKD: Effect of Estimated GFR and Case Mix

PubMed Central

Kovesdy, Csaba P.; Quarles, L. Darryl; Lott, Evan H.; Lu, Jun Ling; Ma, Jennie Z.; Molnar, Miklos Z.; Kalantar-Zadeh, Kamyar

2013-01-01

Background Black dialysis patients have significantly lower mortality compared to white patients, in contradistinction to the higher mortality seen in blacks in the general population. It is unclear if a similar paradox exists in non–dialysis-dependent CKD, and if it does, what its underlying reasons are. Study Design Historical cohort. Setting & Participants 518,406 white and 52,402 black male US veterans with non-dialysis dependent CKD stages 3–5. Predictor Black race. Outcomes & Measurements We examined overall and CKD stage-specific all-cause mortality using parametric survival models. The effect of sociodemographic characteristics, comorbidities and laboratory characteristics on the observed differences was explored in multivariable models. Results Over a median follow-up of 4.7 years 172,093 patients died (mortality rate, 71.0 [95% CI, 70.6–71.3] per 1000 patient-years). Black race was associated with significantly lower crude mortality (HR, 0.95; 95% CI, 0.94–0.97; p<0.001). The survival advantage was attenuated after adjustment for age (HR, 1.14; 95% CI, 1.12–1.16), but was even magnified after full multivariable adjustment (HR, 0.72; 95% CI, 0.70–0.73; p<0.001). The unadjusted survival advantage of blacks was more prominent in those with more advanced stages of CKD, but CKD stage-specific differences were attenuated by multivariable adjustment. Limitations Exclusively male patients. Conclusions Black patients with CKD have lower mortality compared to white patients. The survival advantage seen in blacks is accentuated in patients with more advanced stages of CKD, which may be explained by changes in case mix and laboratory characteristics occurring during the course of kidney disease. PMID:23369826

Frequency and Determinants of a Short-Interval Follow-up Recommendation After an Abnormal Screening Mammogram.

PubMed

Pelletier, Eric; Daigle, Jean-Marc; Defay, Fannie; Major, Diane; Guertin, Marie-Hélène; Brisson, Jacques

2016-11-01

After imaging assessment of an abnormal screening mammogram, a follow-up examination 6 months later is recommended to some women. Our aim was to identify which characteristics of lesions, women, and physicians are associated to such short-interval follow-up recommendation in the Quebec Breast Cancer Screening Program. Between 1998 and 2008, 1,839,396 screening mammograms were performed and a total of 114,781 abnormal screens were assessed by imaging only. Multivariate analysis was done with multilevel Poisson regression models with robust variance and generalized linear mixed models. A short-interval follow-up was recommended in 26.7% of assessments with imaging only, representing 2.3% of all screens. Case-mix adjusted proportion of short-interval follow-up recommendations varied substantially across physicians (range: 4%-64%). Radiologists with high recall rates (≥15%) had a high proportion of short-interval follow-up recommendation (risk ratio: 1.82; 95% confidence interval: 1.35-2.45) compared to radiologists with low recall rates (<5%). The adjusted proportion of short-interval follow-up was high (22.8%) even when a previous mammogram was usually available. Short-interval follow-up recommendation at assessment is frequent in this Canadian screening program, even when a previous mammogram is available. Characteristics related to radiologists appear to be key determinants of short-interval follow-up recommendation, rather than characteristics of lesions or patient mix. Given that it can cause anxiety to women and adds pressure on the health system, it appears important to record and report short-interval follow-up and to identify ways to reduce its frequency. Short-interval follow-up recommendations should be considered when assessing the burden of mammography screening. Copyright © 2016 Canadian Association of Radiologists. Published by Elsevier Inc. All rights reserved.

Comparisons of body size, composition, and whole body bone mass between North American and South African children.

PubMed

Micklesfield, Lisa K; Norris, Shane A; Nelson, Dorothy A; Lambert, Estelle V; van der Merwe, Lize; Pettifor, John M

2007-12-01

We compared whole body BMC of 811 black, white, and mixed ancestral origin children from Detroit, MI; Johannesburg, South Africa; and Cape Town, South Africa. Our findings support the role of genetic and environmental influences in the determination of bone mass in prepubertal children. Higher bone mass and lower fracture rates have been shown in black compared with white children and adults in North America. We compared whole body BMC (WBBMC), whole body fat mass (WBFM), and whole body fat free soft tissue (WBFFST) data between three ethnic groups of children from Detroit, MI (n = 181 white, USW; n = 230 black, USB), Johannesburg, South Africa (n = 73 white, SAW; n = 263 black, SAB), and Cape Town, South Africa (n = 64 mixed ancestral origin, SAM). SAB and SAW groups were slightly older than USW and USB groups (9.5 +/- 0.3 versus 9.3 +/- 0.1 yr); however, USB and USW boys were significantly taller, were heavier, and had a higher BMI than SAM and SAB boys. USB girls were significantly taller than SAB girls and heavier than SAB and SAM girls. In South Africa and the United States, black children had a significantly higher WBBMC than white children, after adjusting for selected best predictors. After adjusting for age, weight, and height, WBBMC was significantly higher in the SAB and SAW boys than in USW and USB and in the SAM group compared with the USW and USB groups. WBFFST and WBFM made significant contributions to a best linear model for log(WBBMC), together with age, height, and ethnicity. The best model accounted for 79% of the WBBMC variance. When included separately in the model, the model containing WBFFST accounted for 76%, and the model containing WBFM accounted for 70%, of the variance in WBBMC. WBBMC is lower in children of European ancestry compared with African ancestry, irrespective of geographical location; however, South African children have significantly higher WBBMC compared with USB and USW groups, thereby acknowledging the possible contribution of environmental factors. Reasons for the significantly higher WBBMC in the children of mixed ancestral origin compared with the other groups need to be studied further.

Gender differences in the causal direction between workplace harassment and drinking.

PubMed

Freels, Sally A; Richman, Judith A; Rospenda, Kathleen M

2005-08-01

Data from a longitudinal study of university employees across four waves is used to determine the extent to which workplace harassment predicts drinking or conversely the extent to which drinking predicts workplace harassment, and to address gender differences in these relationships. Mixed effects regression models are used to test the effects of 1) harassment at the previous wave on drinking at the current wave, adjusting for drinking at the previous wave, and 2) drinking at the previous wave on harassment at the current wave, adjusting for harassment at the previous wave. For males, drinking at the previous wave predicts sexual harassment at the current wave, whereas for females, sexual harassment at the previous wave predicts drinking at the current wave.

Effect of Hospital Case Mix on the Hospital Consumer Assessment of Healthcare Providers and Systems Star Scores: Are All Stars the Same?

PubMed

Thiels, Cornelius A; Hanson, Kristine T; Yost, Kathleen J; Zielinski, Martin D; Habermann, Elizabeth B; Cima, Robert R

2016-10-01

We aimed to evaluate variations in patient experience measures across different surgical specialties and to assess the impact of further case-mix adjustment. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a publicly reported survey of patients' hospital experiences that directly influence Medicare reimbursement. All adult surgical inpatients meeting criteria for HCAHPS sampling from 2013 to 2014 at a single academic center were identified. HCAHPS measures were analyzed according to published top-box and Star-rating methodologies, and were dichotomized ("high" vs "low"). Multivariable logistic regression was used to identify independent associations of high patient scores on various HCAHPS measures with specialty, diagnosis-related group complexity, cancer diagnosis, sex, and emergency admission after adjusting for HCAHPS case-mix adjusters (education, overall health status, language, and age). We identified 36,551 eligible patients, of which 30.8% (n = 11,273) completed HCAHPS. Women [odds ratio (OR) 0.78, 95% confidence interval (CI) 0.72-0.85, P < 0.001], complex cases (OR 0.90, 95% CI 0.82-0.99, P = 0.02), and emergency admissions (OR 0.67, 95% CI 0.55-0.82, P < 0.001) had lesser Star scores on adjusted analysis, whereas patients with a cancer diagnosis had greater Star scores (OR 1.15, 95% CI 1.03-1.29, P = 0.01). Using general surgery as the reference, the Star scores varied significantly across 12 specialties (range OR 0.65 for plastics to 1.29 for transplant surgery). Patient responses to individual composite scores (pain, care transition, physician, and nurse) varied by specialty. HCAHPS case-mix adjustment does not include adjustment for specialty or diagnosis, which may result in artificially lower scores for centers that provide a high level of complex care. Further research is needed to ensure that the HCAHPS is an unbiased comparison tool.

Geographic Model and Biomarker-Derived Measures of Pesticide Exposure and Parkinson’s Disease

PubMed Central

RITZ, BEATE; COSTELLO, SADIE

2013-01-01

For more than two decades, reports have suggested that pesticides and herbicides may be an etiologic factor in idiopathic Parkinson’s disease (PD). To date, no clear associations with any specific pesticide have been demonstrated from epidemiological studies perhaps, in part, because methods of reliably estimating exposures are lacking. We tested the validity of a Geographic Information Systems (GIS)-based exposure assessment model that estimates potential environmental exposures at residences from pesticide applications to agricultural crops based on California Pesticide Use Reports (PUR). Using lipid-adjusted dichlorodiphenyldichloroethylene (DDE) serum levels as the “gold standard” for pesticide exposure, we conducted a validation study in a sample taken from an ongoing, population-based case–control study of PD in Central California. Residential, occupational, and other risk factor data were collected for 22 cases and 24 controls from Kern county, California. Environmental GIS–PUR-based organochlorine (OC) estimates were derived for each subject and compared to lipid-adjusted DDE serum levels. Relying on a linear regression model, we predicted log-transformed lipid-adjusted DDE serum levels. GIS–PUR-derived OC measure, body mass index, age, gender, mixing and loading pesticides by hand, and using pesticides in the home, together explained 47% of the DDE serum level variance (adjusted r2 = 0.47). The specificity of using our environmental GIS–PUR-derived OC measures to identify those with high-serum DDE levels was reasonably good (87%). Our environmental GIS–PUR-based approach appears to provide a valid model for assessing residential exposures to agricultural pesticides. PMID:17119217

Academic status does not affect outcome following complex hepato-pancreato-biliary procedures.

PubMed

Altieri, Maria S; Yang, Jie; Groves, Donald; Yin, Donglei; Cagino, Kristen; Talamini, Mark; Pryor, Aurora

2018-05-01

There is a growing debate regarding outcomes following complex hepato-pancreato-biliary (HPB) procedures. The purpose of our study is to examine if facility type has any impact on complications, readmission rates, emergency department (ED) visit rates, and length of stay (LOS) for patients undergoing HPB surgery. The SPARCS administrative database was used to identify patients undergoing complex HPB procedures between 2012 and 2014 in New York. Univariate generalized linear mixed models were fit to estimate the marginal association between outcomes such as overall/severe complication rates, 30-day and 1-year readmission rates, 30-day and 1-year ED-visit rates, and potential risk factors. Univariate linear mixed models were used to estimate the marginal association between possible risk factors and LOS. Facility type, as well as any variables found to be significant in our univariate analysis (p = 0.05), was further included in the multivariable regression models. There were 4122 complex HPB procedures performed. Academic facilities were more likely to have a higher hospital volume (p < 0001). Surgery at academic facilities were less likely to have coexisting comorbidities; however, they were more likely to have metastatic cancer and/or liver disease (p = 0.0114, < 0. 0001, and = 0.0299, respectively). Postoperatively, patients at non-academic facilities experienced higher overall complication rates, and higher severe complication rates, when compared to those at academic facilities (p < 0.0001 and = 0.0018, respectively). Further analysis via adjustment for possible confounding factors, however, revealed no significant difference in the risk of severe complications between the two facility types. Such adjustment also demonstrated higher 30-day readmission risk in patients who underwent their surgery at an academic facility. No significant difference was found when comparing the outcomes of academic and non-academic facilities, after adjusting for age, gender, race, region, insurance, and hospital volume. Patients from academic facilities were more likely to be readmitted within the first 30-days after surgery.

Youth and young adult physical activity and body composition of young adult women: findings from the dietary intervention study in children.

PubMed

Hodge, Melissa G; Hovinga, Mary; Shepherd, John A; Egleston, Brian; Gabriel, Kelley; Van Horn, Linda; Robson, Alan; Snetselaar, Linda; Stevens, Victor K; Jung, Seungyoun; Dorgan, Joanne

2015-02-01

This study prospectively investigates associations between youth moderate-to-vigorous-intensity physical activity (MVPA) and body composition in young adult women using data from the Dietary Intervention Study in Children (DISC) and the DISC06 Follow-Up Study. MVPA was assessed by questionnaire on 5 occasions between the ages 8 and 18 years and at age 25-29 years in 215 DISC female participants. Using whole body dual-energy x-ray absorptiometry (DXA), overall adiposity and body fat distribution were assessed at age 25-29 years by percent body fat (%fat) and android-to-gynoid (A:G) fat ratio, respectively. Linear mixed effects models and generalized linear latent and mixed models were used to assess associations of youth MVPA with both outcomes. Young adult MVPA, adjusted for other young adult characteristics, was significantly inversely associated with young adult %fat (%fat decreased from 37.4% in the lowest MVPA quartile to 32.8% in the highest (p-trend = 0.02)). Adjusted for youth and young adult characteristics including young adult MVPA, youth MVPA also was significantly inversely associated with young adult %fat (β=-0.40 per 10 MET-hrs/wk, p = .02) . No significant associations between MVPA and A:G fat ratio were observed. Results suggest that youth and young adult MVPA are important independent predictors of adiposity in young women.

Studies of Opinion Stability for Small Dynamic Networks with Opportunistic Agents

NASA Astrophysics Data System (ADS)

Sobkowicz, Pawel

There are numerous examples of societies with extremely stable mix of contrasting opinions. We argue that this stability is a result of an interplay between society network topology adjustment and opinion changing processes. To support this position we present a computer model of opinion formation based on some novel assumptions, designed to bring the model closer to social reality. In our model, the agents, in addition to changing their opinions due to influence of the rest of society and external propaganda, have the ability to modify their social network, forming links with agents sharing the same opinions and cutting the links with those they disagree with. To improve the model further we divide the agents into "fanatics" and "opportunists," depending on how easy it is to change their opinions. The simulations show significant differences compared to traditional models, where network links are static. In particular, for the dynamical model where inter-agent links are adjustable, the final network structure and opinion distribution is shown to resemble real world observations, such as social structures and persistence of minority groups even when most of the society is against them and the propaganda is strong.

Estimating the variance for heterogeneity in arm-based network meta-analysis.

PubMed

Piepho, Hans-Peter; Madden, Laurence V; Roger, James; Payne, Roger; Williams, Emlyn R

2018-04-19

Network meta-analysis can be implemented by using arm-based or contrast-based models. Here we focus on arm-based models and fit them using generalized linear mixed model procedures. Full maximum likelihood (ML) estimation leads to biased trial-by-treatment interaction variance estimates for heterogeneity. Thus, our objective is to investigate alternative approaches to variance estimation that reduce bias compared with full ML. Specifically, we use penalized quasi-likelihood/pseudo-likelihood and hierarchical (h) likelihood approaches. In addition, we consider a novel model modification that yields estimators akin to the residual maximum likelihood estimator for linear mixed models. The proposed methods are compared by simulation, and 2 real datasets are used for illustration. Simulations show that penalized quasi-likelihood/pseudo-likelihood and h-likelihood reduce bias and yield satisfactory coverage rates. Sum-to-zero restriction and baseline contrasts for random trial-by-treatment interaction effects, as well as a residual ML-like adjustment, also reduce bias compared with an unconstrained model when ML is used, but coverage rates are not quite as good. Penalized quasi-likelihood/pseudo-likelihood and h-likelihood are therefore recommended. Copyright © 2018 John Wiley & Sons, Ltd.

Ensemble of trees approaches to risk adjustment for evaluating a hospital's performance.

PubMed

Liu, Yang; Traskin, Mikhail; Lorch, Scott A; George, Edward I; Small, Dylan

2015-03-01

A commonly used method for evaluating a hospital's performance on an outcome is to compare the hospital's observed outcome rate to the hospital's expected outcome rate given its patient (case) mix and service. The process of calculating the hospital's expected outcome rate given its patient mix and service is called risk adjustment (Iezzoni 1997). Risk adjustment is critical for accurately evaluating and comparing hospitals' performances since we would not want to unfairly penalize a hospital just because it treats sicker patients. The key to risk adjustment is accurately estimating the probability of an Outcome given patient characteristics. For cases with binary outcomes, the method that is commonly used in risk adjustment is logistic regression. In this paper, we consider ensemble of trees methods as alternatives for risk adjustment, including random forests and Bayesian additive regression trees (BART). Both random forests and BART are modern machine learning methods that have been shown recently to have excellent performance for prediction of outcomes in many settings. We apply these methods to carry out risk adjustment for the performance of neonatal intensive care units (NICU). We show that these ensemble of trees methods outperform logistic regression in predicting mortality among babies treated in NICU, and provide a superior method of risk adjustment compared to logistic regression.

Modifying mixing and instability growth through the adjustment of initial conditions in a high-energy-density counter-propagating shear experiment on OMEGA

DOE PAGES

Merritt, E. C.; Doss, F. W.; Loomis, E. N.; ...

2015-06-24

Counter-propagating shear experiments conducted at the OMEGA Laser Facility have been evaluating the effect of target initial conditions, specifically the characteristics of a tracer foil located at the shear boundary, on Kelvin-Helmholtz instability evolution and experiment transition toward nonlinearity and turbulence in the high-energy-density (HED) regime. Experiments are focused on both identifying and uncoupling the dependence of the model initial turbulent length scale in variable-density turbulence models of k-ϵ type on competing physical instability seed lengths as well as developing a path toward fully developed turbulent HED experiments. We present results from a series of experiments controllably and independently varyingmore » two initial types of scale lengths in the experiment: the thickness and surface roughness (surface perturbation scale spectrum) of a tracer layer at the shear interface. We show that decreasing the layer thickness and increasing the surface roughness both have the ability to increase the relative mixing in the system, and thus theoretically decrease the time required to begin transitioning to turbulence in the system. In addition, we also show that we can connect a change in observed mix width growth due to increased foil surface roughness to an analytically predicted change in model initial turbulent scale lengths.« less

Outcomes for youth residential treatment programs using administrative data from the child welfare system: a risk-adjustment application.

PubMed

McMillen, J Curtis; Lee, Bethany R; Jonson-Reid, Melissa

2008-05-01

This study assessed whether administrative data from the public child welfare system could be used to develop risk-adjusted performance reports for residential mental health programs for adolescents. Regression methods were used with 3,759 residential treatment spells for 2,784 children and youth to determine which outcomes could be adequately risk adjusted for case mix. Expected outcomes were created for each residential program given its case mix; then, expected and achieved outcomes were compared. For most programs, achieved results did not differ significantly from expected results for individual outcomes. Overall, outcomes achieved were not impressive. Only one quarter of spells resulted in a youth being maintained in a single less restrictive setting in the year following discharge. Methodological implications of this study suggest further refinements are needed for child welfare administrative data in order to develop risk-adjusted report cards of program performance.

Method for producing a compressed body of mix-powder for ceramic

NASA Technical Reports Server (NTRS)

Okawa, K.

1983-01-01

Under the invented method, a compressed body of mix powder for ceramic is produced by mixing and stirring several raw powder materials with mixing liquid such as water, and, in the process of sending the resulted viscous material pressurized at 5 kg/cm to 7 kg/cm, using 1.5 to 2 times the pressure to filter and dehydrate, adjusting the water content to 10 to 20%.

Developing quality indicators and auditing protocols from formal guideline models: knowledge representation and transformations.

PubMed

Advani, Aneel; Goldstein, Mary; Shahar, Yuval; Musen, Mark A

2003-01-01

Automated quality assessment of clinician actions and patient outcomes is a central problem in guideline- or standards-based medical care. In this paper we describe a model representation and algorithm for deriving structured quality indicators and auditing protocols from formalized specifications of guidelines used in decision support systems. We apply the model and algorithm to the assessment of physician concordance with a guideline knowledge model for hypertension used in a decision-support system. The properties of our solution include the ability to derive automatically context-specific and case-mix-adjusted quality indicators that can model global or local levels of detail about the guideline parameterized by defining the reliability of each indicator or element of the guideline.

A study of overflow simulations using MPAS-Ocean: Vertical grids, resolution, and viscosity

NASA Astrophysics Data System (ADS)

Reckinger, Shanon M.; Petersen, Mark R.; Reckinger, Scott J.

2015-12-01

MPAS-Ocean is used to simulate an idealized, density-driven overflow using the dynamics of overflow mixing and entrainment (DOME) setup. Numerical simulations are carried out using three of the vertical coordinate types available in MPAS-Ocean, including z-star with partial bottom cells, z-star with full cells, and sigma coordinates. The results are first benchmarked against other models, including the MITgcm's z-coordinate model and HIM's isopycnal coordinate model, which are used to set the base case used for this work. A full parameter study is presented that looks at how sensitive overflow simulations are to vertical grid type, resolution, and viscosity. Horizontal resolutions with 50 km grid cells are under-resolved and produce poor results, regardless of other parameter settings. Vertical grids ranging in thickness from 15 m to 120 m were tested. A horizontal resolution of 10 km and a vertical resolution of 60 m are sufficient to resolve the mesoscale dynamics of the DOME configuration, which mimics real-world overflow parameters. Mixing and final buoyancy are least sensitive to horizontal viscosity, but strongly sensitive to vertical viscosity. This suggests that vertical viscosity could be adjusted in overflow water formation regions to influence mixing and product water characteristics. Lastly, the study shows that sigma coordinates produce much less mixing than z-type coordinates, resulting in heavier plumes that go further down slope. Sigma coordinates are less sensitive to changes in resolution but as sensitive to vertical viscosity compared to z-coordinates.

A multistream model of visual word recognition.

PubMed

Allen, Philip A; Smith, Albert F; Lien, Mei-Ching; Kaut, Kevin P; Canfield, Angie

2009-02-01

Four experiments are reported that test a multistream model of visual word recognition, which associates letter-level and word-level processing channels with three known visual processing streams isolated in macaque monkeys: the magno-dominated (MD) stream, the interblob-dominated (ID) stream, and the blob-dominated (BD) stream (Van Essen & Anderson, 1995). We show that mixing the color of adjacent letters of words does not result in facilitation of response times or error rates when the spatial-frequency pattern of a whole word is familiar. However, facilitation does occur when the spatial-frequency pattern of a whole word is not familiar. This pattern of results is not due to different luminance levels across the different-colored stimuli and the background because isoluminant displays were used. Also, the mixed-case, mixed-hue facilitation occurred when different display distances were used (Experiments 2 and 3), so this suggests that image normalization can adjust independently of object size differences. Finally, we show that this effect persists in both spaced and unspaced conditions (Experiment 4)--suggesting that inappropriate letter grouping by hue cannot account for these results. These data support a model of visual word recognition in which lower spatial frequencies are processed first in the more rapid MD stream. The slower ID and BD streams may process some lower spatial frequency information in addition to processing higher spatial frequency information, but these channels tend to lose the processing race to recognition unless the letter string is unfamiliar to the MD stream--as with mixed-case presentation.

Use of cumulative mortality data in patients with acute myocardial infarction for early detection of variation in clinical practice: observational study.

PubMed

Lawrance, R A; Dorsch, M F; Sapsford, R J; Mackintosh, A F; Greenwood, D C; Jackson, B M; Morrell, C; Robinson, M B; Hall, A S

2001-08-11

Use of cumulative mortality adjusted for case mix in patients with acute myocardial infarction for early detection of variation in clinical practice. Observational study. 20 hospitals across the former Yorkshire region. All 2153 consecutive patients with confirmed acute myocardial infarction identified during three months. Variable life-adjusted displays showing cumulative differences between observed and expected mortality of patients; expected mortality calculated from risk model based on admission characteristics of age, heart rate, and systolic blood pressure. The performance of two individual hospitals over three months was examined as an example. One, the smallest district hospital in the region, had a series of 30 consecutive patients but had five more deaths than predicted. The variable life-adjusted display showed minimal variation from that predicted for the first 15 patients followed by a run of unexpectedly high mortality. The second example was the main tertiary referral centre for the region, which admitted 188 consecutive patients. The display showed a period of apparently poor performance followed by substantial improvement, where the plot rose steadily from a cumulative net lives saved of -4 to 7. These variations in patient outcome are unlikely to have been revealed during conventional audit practice. Variable life-adjusted display has been integrated into surgical care as a graphical display of risk-adjusted survival for individual surgeons or centres. In combination with a simple risk model, it may have a role in monitoring performance and outcome in patients with acute myocardial infarction.

Breast Radiotherapy with Mixed Energy Photons; a Model for Optimal Beam Weighting.

PubMed

Birgani, Mohammadjavad Tahmasebi; Fatahiasl, Jafar; Hosseini, Seyed Mohammad; Bagheri, Ali; Behrooz, Mohammad Ali; Zabiehzadeh, Mansour; Meskani, Reza; Gomari, Maryam Talaei

2015-01-01

Utilization of high energy photons (>10 MV) with an optimal weight using a mixed energy technique is a practical way to generate a homogenous dose distribution while maintaining adequate target coverage in intact breast radiotherapy. This study represents a model for estimation of this optimal weight for day to day clinical usage. For this purpose, treatment planning computed tomography scans of thirty-three consecutive early stage breast cancer patients following breast conservation surgery were analyzed. After delineation of the breast clinical target volume (CTV) and placing opposed wedge paired isocenteric tangential portals, dosimeteric calculations were conducted and dose volume histograms (DVHs) were generated, first with pure 6 MV photons and then these calculations were repeated ten times with incorporating 18 MV photons (ten percent increase in weight per step) in each individual patient. For each calculation two indexes including maximum dose in the breast CTV (Dmax) and the volume of CTV which covered with 95% Isodose line (VCTV, 95%IDL) were measured according to the DVH data and then normalized values were plotted in a graph. The optimal weight of 18 MV photons was defined as the intersection point of Dmax and VCTV, 95%IDL graphs. For creating a model to predict this optimal weight multiple linear regression analysis was used based on some of the breast and tangential field parameters. The best fitting model for prediction of 18 MV photons optimal weight in breast radiotherapy using mixed energy technique, incorporated chest wall separation plus central lung distance (Adjusted R2=0.776). In conclusion, this study represents a model for the estimation of optimal beam weighting in breast radiotherapy using mixed photon energy technique for routine day to day clinical usage.

Endotoxin and gender modify lung function recovery after occupational organic dust exposure: a 30-year study.

PubMed

Lai, Peggy S; Hang, Jing-Qing; Valeri, Linda; Zhang, Feng-Ying; Zheng, Bu-Yong; Mehta, Amar J; Shi, Jing; Su, Li; Brown, Dan; Eisen, Ellen A; Christiani, David C

2015-08-01

The purpose of this study is to determine the trajectory of lung function change after exposure cessation to occupational organic dust exposure, and to identify factors that modify improvement. The Shanghai Textile Worker Study is a longitudinal study of 447 cotton workers exposed to endotoxin-containing dust and 472 silk workers exposed to non-endotoxin-containing dust. Spirometry was performed at 5-year intervals. Air sampling was performed to estimate individual cumulative exposures. The effect of work cessation on forced expiratory volume in 1 s (FEV1) was modelled using generalised additive mixed effects models to identify the trajectory of FEV1 recovery. Linear mixed effects models incorporating interaction terms were used to identify modifiers of FEV1 recovery. Loss to follow-up was accounted for with inverse probability of censoring weights. 74.2% of the original cohort still alive participated in 2011. Generalised additive mixed models identified a non-linear improvement in FEV1 for all workers after exposure cessation, with no plateau noted 25 years after retirement. Linear mixed effects models incorporating interaction terms identified prior endotoxin exposure (p=0.01) and male gender (p=0.002) as risk factors for impaired FEV1 improvement after exposure cessation. After adjusting for gender, smoking delayed the onset of FEV1 gain but did not affect the overall magnitude of change. Lung function improvement after cessation of exposure to organic dust is sustained. Endotoxin exposure and male gender are risk factors for less FEV1 improvement. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

The importance of work organization on workload and musculoskeletal health--Grocery store work as a model.

PubMed

Balogh, I; Ohlsson, K; Nordander, C; Björk, J; Hansson, G-Å

2016-03-01

We have evaluated the consequences of work organization on musculoskeletal health. Using a postal questionnaire, answered by 1600 female grocery store workers, their main work tasks were identified and four work groups were defined (cashier, picking, and delicatessen work, and a mixed group, who performed a mix of these tasks). The crude odds ratios (ORs) for neck/shoulder complaints were 1.5 (95% CI 1.0-2.2), 1.1 (0.7-1.5) and 1.6 (1.1-2.3), respectively, compared to mixed work. Adjusting for individual and psychosocial factors had no effect on these ORs. For elbows/hands, no significant differences were found. Technical measurements of the workload showed large differences between the work groups. Picking work was the most strenuous, while cashier work showed low loads. Quantitative measures of variation revealed for mixed work high between minutes variation and the highest between/within minutes variation. Combining work tasks with different physical exposure levels increases the variation and may reduce the risk of musculoskeletal complaints. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.

Analysis of mixed model in gear transmission based on ADAMS

NASA Astrophysics Data System (ADS)

Li, Xiufeng; Wang, Yabin

2012-09-01

The traditional method of mechanical gear driving simulation includes gear pair method and solid to solid contact method. The former has higher solving efficiency but lower results accuracy; the latter usually obtains higher precision of results while the calculation process is complex, also it is not easy to converge. Currently, most of the researches are focused on the description of geometric models and the definition of boundary conditions. However, none of them can solve the problems fundamentally. To improve the simulation efficiency while ensure the results with high accuracy, a mixed model method which uses gear tooth profiles to take the place of the solid gear to simulate gear movement is presented under these circumstances. In the process of modeling, build the solid models of the mechanism in the SolidWorks firstly; Then collect the point coordinates of outline curves of the gear using SolidWorks API and create fit curves in Adams based on the point coordinates; Next, adjust the position of those fitting curves according to the position of the contact area; Finally, define the loading conditions, boundary conditions and simulation parameters. The method provides gear shape information by tooth profile curves; simulates the mesh process through tooth profile curve to curve contact and offer mass as well as inertia data via solid gear models. This simulation process combines the two models to complete the gear driving analysis. In order to verify the validity of the method presented, both theoretical derivation and numerical simulation on a runaway escapement are conducted. The results show that the computational efficiency of the mixed model method is 1.4 times over the traditional method which contains solid to solid contact. Meanwhile, the simulation results are more closely to theoretical calculations. Consequently, mixed model method has a high application value regarding to the study of the dynamics of gear mechanism.

A multiobjective optimization model and an orthogonal design-based hybrid heuristic algorithm for regional urban mining management problems.

PubMed

Wu, Hao; Wan, Zhong

2018-02-01

In this paper, a multiobjective mixed-integer piecewise nonlinear programming model (MOMIPNLP) is built to formulate the management problem of urban mining system, where the decision variables are associated with buy-back pricing, choices of sites, transportation planning, and adjustment of production capacity. Different from the existing approaches, the social negative effect, generated from structural optimization of the recycling system, is minimized in our model, as well as the total recycling profit and utility from environmental improvement are jointly maximized. For solving the problem, the MOMIPNLP model is first transformed into an ordinary mixed-integer nonlinear programming model by variable substitution such that the piecewise feature of the model is removed. Then, based on technique of orthogonal design, a hybrid heuristic algorithm is developed to find an approximate Pareto-optimal solution, where genetic algorithm is used to optimize the structure of search neighborhood, and both local branching algorithm and relaxation-induced neighborhood search algorithm are employed to cut the searching branches and reduce the number of variables in each branch. Numerical experiments indicate that this algorithm spends less CPU (central processing unit) time in solving large-scale regional urban mining management problems, especially in comparison with the similar ones available in literature. By case study and sensitivity analysis, a number of practical managerial implications are revealed from the model. Since the metal stocks in society are reliable overground mineral sources, urban mining has been paid great attention as emerging strategic resources in an era of resource shortage. By mathematical modeling and development of efficient algorithms, this paper provides decision makers with useful suggestions on the optimal design of recycling system in urban mining. For example, this paper can answer how to encourage enterprises to join the recycling activities by government's support and subsidies, whether the existing recycling system can meet the developmental requirements or not, and what is a reasonable adjustment of production capacity.

The Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model: Part 1—Statistical Methodology

PubMed Central

O’Brien, Sean M.; Jacobs, Jeffrey P.; Pasquali, Sara K.; Gaynor, J. William; Karamlou, Tara; Welke, Karl F.; Filardo, Giovanni; Han, Jane M.; Kim, Sunghee; Shahian, David M.; Jacobs, Marshall L.

2016-01-01

Background This study’s objective was to develop a risk model incorporating procedure type and patient factors to be used for case-mix adjustment in the analysis of hospital-specific operative mortality rates after congenital cardiac operations. Methods Included were patients of all ages undergoing cardiac operations, with or without cardiopulmonary bypass, at centers participating in The Society of Thoracic Surgeons Congenital Heart Surgery Database during January 1, 2010, to December 31, 2013. Excluded were isolated patent ductus arteriosus closures in patients weighing less than or equal to 2.5 kg, centers with more than 10% missing data, and patients with missing data for key variables. Data from the first 3.5 years were used for model development, and data from the last 0.5 year were used for assessing model discrimination and calibration. Potential risk factors were proposed based on expert consensus and selected after empirically comparing a variety of modeling options. Results The study cohort included 52,224 patients from 86 centers with 1,931 deaths (3.7%). Covariates included in the model were primary procedure, age, weight, and 11 additional patient factors reflecting acuity status and comorbidities. The C statistic in the validation sample was 0.858. Plots of observed-vs-expected mortality rates revealed good calibration overall and within subgroups, except for a slight overestimation of risk in the highest decile of predicted risk. Removing patient preoperative factors from the model reduced the C statistic to 0.831 and affected the performance classification for 12 of 86 hospitals. Conclusions The risk model is well suited to adjust for case mix in the analysis and reporting of hospital-specific mortality for congenital heart operations. Inclusion of patient factors added useful discriminatory power and reduced bias in the calculation of hospital-specific mortality metrics. PMID:26245502

Evaluating targeted interventions via meta-population models with multi-level mixing.

PubMed

Feng, Zhilan; Hill, Andrew N; Curns, Aaron T; Glasser, John W

2017-05-01

Among the several means by which heterogeneity can be modeled, Levins' (1969) meta-population approach preserves the most analytical tractability, a virtue to the extent that generality is desirable. When model populations are stratified, contacts among their respective sub-populations must be described. Using a simple meta-population model, Feng et al. (2015) showed that mixing among sub-populations, as well as heterogeneity in characteristics affecting sub-population reproduction numbers, must be considered when evaluating public health interventions to prevent or control infectious disease outbreaks. They employed the convex combination of preferential within- and proportional among-group contacts first described by Nold (1980) and subsequently generalized by Jacquez et al. (1988). As the utility of meta-population modeling depends on more realistic mixing functions, the authors added preferential contacts between parents and children and among co-workers (Glasser et al., 2012). Here they further generalize this function by including preferential contacts between grandparents and grandchildren, but omit workplace contacts. They also describe a general multi-level mixing scheme, provide three two-level examples, and apply two of them. In their first application, the authors describe age- and gender-specific patterns in face-to-face conversations (Mossong et al., 2008), proxies for contacts by which respiratory pathogens might be transmitted, that are consistent with everyday experience. This suggests that meta-population models with inter-generational mixing could be employed to evaluate prolonged school-closures, a proposed pandemic mitigation measure that could expose grandparents, and other elderly surrogate caregivers for working parents, to infectious children. In their second application, the authors use a meta-population SEIR model stratified by 7 age groups and 50 states plus the District of Columbia, to compare actual with optimal vaccination during the 2009-2010 influenza pandemic in the United States. They also show that vaccination efforts could have been adjusted month-to-month during the fall of 2009 to ensure maximum impact. Such applications inspire confidence in the reliability of meta-population modeling in support of public health policymaking. Published by Elsevier Inc.

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.

Dialysate Sodium Concentration and the Association with Interdialytic Weight Gain, Hospitalization, and Mortality

PubMed Central

Hecking, Manfred; Karaboyas, Angelo; Saran, Rajiv; Sen, Ananda; Inaba, Masaaki; Rayner, Hugh; Hörl, Walter H.; Pisoni, Ronald L.; Robinson, Bruce M.; Sunder-Plassmann, Gere; Port, Friedrich K.

2012-01-01

Summary Background and objectives Recommendations to decrease the dialysate sodium (DNa) prescription demand analyses of patient outcomes. We analyzed morbidity and mortality at various levels of DNa, simultaneously accounting for interdialytic weight gain (IDWG) and for the mortality risk associated with lower predialysis serum sodium (SNa) levels. Design, setting, participants, & measurements We used multiply-adjusted linear mixed models to evaluate the magnitude of IDWG and Cox proportional hazards models to assess hospitalizations and deaths in 29,593 patients from the Dialysis Outcomes and Practice Patterns Study with baseline DNa and SNa as predictors, categorized according to lowest to highest levels. Results IDWG increased with higher DNa across all SNa categories, by 0.17% of body weight per 2 mEq/L higher DNa; however, higher DNa was not associated with higher mortality in a fully adjusted model (also adjusted for SNa; hazard ratio [HR]=0.98 per 2 mEq/L higher DNa, 95% confidence interval [CI] 0.95–1.02). Instead, higher DNa was associated with lower hospitalization risk (HR=0.97 per 2 mEq/L higher DNa, 95% CI 0.95–1.00, P=0.04). Additional adjustments for IDWG did not change these results. In sensitivity analyses restricted to study facilities, in which 90%–100% of patients have the same DNa (56%), the adjusted HR for mortality was 0.88 per 2 mEq/L higher DNa (95% CI 0.83–0.94). These analyses represented a pseudo-randomized experiment in which the association between DNa and mortality is unlikely to have been confounded by indication. Conclusions In the absence of randomized prospective studies, the benefit of reducing IDWG by decreasing DNa prescriptions should be carefully weighed against an increased risk for adverse outcomes. PMID:22052942

Flexible Fusion Structure-Based Performance Optimization Learning for Multisensor Target Tracking

PubMed Central

Ge, Quanbo; Wei, Zhongliang; Cheng, Tianfa; Chen, Shaodong; Wang, Xiangfeng

2017-01-01

Compared with the fixed fusion structure, the flexible fusion structure with mixed fusion methods has better adjustment performance for the complex air task network systems, and it can effectively help the system to achieve the goal under the given constraints. Because of the time-varying situation of the task network system induced by moving nodes and non-cooperative target, and limitations such as communication bandwidth and measurement distance, it is necessary to dynamically adjust the system fusion structure including sensors and fusion methods in a given adjustment period. Aiming at this, this paper studies the design of a flexible fusion algorithm by using an optimization learning technology. The purpose is to dynamically determine the sensors’ numbers and the associated sensors to take part in the centralized and distributed fusion processes, respectively, herein termed sensor subsets selection. Firstly, two system performance indexes are introduced. Especially, the survivability index is presented and defined. Secondly, based on the two indexes and considering other conditions such as communication bandwidth and measurement distance, optimization models for both single target tracking and multi-target tracking are established. Correspondingly, solution steps are given for the two optimization models in detail. Simulation examples are demonstrated to validate the proposed algorithms. PMID:28481243

Detailed high-resolution three-dimensional simulations of OMEGA separated reactants inertial confinement fusion experiments

DOE PAGES

Haines, Brian Michael; Grim, Gary P.; Fincke, James R.; ...

2016-07-29

Here, we present results from the comparison of high-resolution three-dimensional (3D) simulations with data from the implosions of inertial confinement fusion capsules with separated reactants performed on the OMEGA laser facility. Each capsule, referred to as a “CD Mixcap,” is filled with tritium and has a polystyrene (CH) shell with a deuterated polystyrene (CD) layer whose burial depth is varied. In these implosions, fusion reactions between deuterium and tritium ions can occur only in the presence of atomic mix between the gas fill and shell material. The simulations feature accurate models for all known experimental asymmetries and do not employmore » any adjustable parameters to improve agreement with experimental data. Simulations are performed with the RAGE radiation-hydrodynamics code using an Implicit Large Eddy Simulation (ILES) strategy for the hydrodynamics. We obtain good agreement with the experimental data, including the DT/TT neutron yield ratios used to diagnose mix, for all burial depths of the deuterated shell layer. Additionally, simulations demonstrate good agreement with converged simulations employing explicit models for plasma diffusion and viscosity, suggesting that the implicit sub-grid model used in ILES is sufficient to model these processes in these experiments. In our simulations, mixing is driven by short-wavelength asymmetries and longer-wavelength features are responsible for developing flows that transport mixed material towards the center of the hot spot. Mix material transported by this process is responsible for most of the mix (DT) yield even for the capsule with a CD layer adjacent to the tritium fuel. Consistent with our previous results, mix does not play a significant role in TT neutron yield degradation; instead, this is dominated by the displacement of fuel from the center of the implosion due to the development of turbulent instabilities seeded by long-wavelength asymmetries. Through these processes, the long-wavelength asymmetries degrade TT yield more than the DT yield and thus bring DT/TT neutron yield ratios into agreement with experiment. Finally, we present a detailed comparison of the flows in 2D and 3D simulations.« less

Detailed high-resolution three-dimensional simulations of OMEGA separated reactants inertial confinement fusion experiments

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

Haines, Brian M., E-mail: bmhaines@lanl.gov; Fincke, James R.; Shah, Rahul C.

We present results from the comparison of high-resolution three-dimensional (3D) simulations with data from the implosions of inertial confinement fusion capsules with separated reactants performed on the OMEGA laser facility. Each capsule, referred to as a “CD Mixcap,” is filled with tritium and has a polystyrene (CH) shell with a deuterated polystyrene (CD) layer whose burial depth is varied. In these implosions, fusion reactions between deuterium and tritium ions can occur only in the presence of atomic mix between the gas fill and shell material. The simulations feature accurate models for all known experimental asymmetries and do not employ anymore » adjustable parameters to improve agreement with experimental data. Simulations are performed with the RAGE radiation-hydrodynamics code using an Implicit Large Eddy Simulation (ILES) strategy for the hydrodynamics. We obtain good agreement with the experimental data, including the DT/TT neutron yield ratios used to diagnose mix, for all burial depths of the deuterated shell layer. Additionally, simulations demonstrate good agreement with converged simulations employing explicit models for plasma diffusion and viscosity, suggesting that the implicit sub-grid model used in ILES is sufficient to model these processes in these experiments. In our simulations, mixing is driven by short-wavelength asymmetries and longer-wavelength features are responsible for developing flows that transport mixed material towards the center of the hot spot. Mix material transported by this process is responsible for most of the mix (DT) yield even for the capsule with a CD layer adjacent to the tritium fuel. Consistent with our previous results, mix does not play a significant role in TT neutron yield degradation; instead, this is dominated by the displacement of fuel from the center of the implosion due to the development of turbulent instabilities seeded by long-wavelength asymmetries. Through these processes, the long-wavelength asymmetries degrade TT yield more than the DT yield and thus bring DT/TT neutron yield ratios into agreement with experiment. Finally, we present a detailed comparison of the flows in 2D and 3D simulations.« less

Detailed high-resolution three-dimensional simulations of OMEGA separated reactants inertial confinement fusion experiments

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

Haines, Brian Michael; Grim, Gary P.; Fincke, James R.

Here, we present results from the comparison of high-resolution three-dimensional (3D) simulations with data from the implosions of inertial confinement fusion capsules with separated reactants performed on the OMEGA laser facility. Each capsule, referred to as a “CD Mixcap,” is filled with tritium and has a polystyrene (CH) shell with a deuterated polystyrene (CD) layer whose burial depth is varied. In these implosions, fusion reactions between deuterium and tritium ions can occur only in the presence of atomic mix between the gas fill and shell material. The simulations feature accurate models for all known experimental asymmetries and do not employmore » any adjustable parameters to improve agreement with experimental data. Simulations are performed with the RAGE radiation-hydrodynamics code using an Implicit Large Eddy Simulation (ILES) strategy for the hydrodynamics. We obtain good agreement with the experimental data, including the DT/TT neutron yield ratios used to diagnose mix, for all burial depths of the deuterated shell layer. Additionally, simulations demonstrate good agreement with converged simulations employing explicit models for plasma diffusion and viscosity, suggesting that the implicit sub-grid model used in ILES is sufficient to model these processes in these experiments. In our simulations, mixing is driven by short-wavelength asymmetries and longer-wavelength features are responsible for developing flows that transport mixed material towards the center of the hot spot. Mix material transported by this process is responsible for most of the mix (DT) yield even for the capsule with a CD layer adjacent to the tritium fuel. Consistent with our previous results, mix does not play a significant role in TT neutron yield degradation; instead, this is dominated by the displacement of fuel from the center of the implosion due to the development of turbulent instabilities seeded by long-wavelength asymmetries. Through these processes, the long-wavelength asymmetries degrade TT yield more than the DT yield and thus bring DT/TT neutron yield ratios into agreement with experiment. Finally, we present a detailed comparison of the flows in 2D and 3D simulations.« less

Detailed high-resolution three-dimensional simulations of OMEGA separated reactants inertial confinement fusion experiments

NASA Astrophysics Data System (ADS)

Haines, Brian M.; Grim, Gary P.; Fincke, James R.; Shah, Rahul C.; Forrest, Chad J.; Silverstein, Kevin; Marshall, Frederic J.; Boswell, Melissa; Fowler, Malcolm M.; Gore, Robert A.; Hayes-Sterbenz, Anna C.; Jungman, Gerard; Klein, Andreas; Rundberg, Robert S.; Steinkamp, Michael J.; Wilhelmy, Jerry B.

2016-07-01

We present results from the comparison of high-resolution three-dimensional (3D) simulations with data from the implosions of inertial confinement fusion capsules with separated reactants performed on the OMEGA laser facility. Each capsule, referred to as a "CD Mixcap," is filled with tritium and has a polystyrene (CH) shell with a deuterated polystyrene (CD) layer whose burial depth is varied. In these implosions, fusion reactions between deuterium and tritium ions can occur only in the presence of atomic mix between the gas fill and shell material. The simulations feature accurate models for all known experimental asymmetries and do not employ any adjustable parameters to improve agreement with experimental data. Simulations are performed with the RAGE radiation-hydrodynamics code using an Implicit Large Eddy Simulation (ILES) strategy for the hydrodynamics. We obtain good agreement with the experimental data, including the DT/TT neutron yield ratios used to diagnose mix, for all burial depths of the deuterated shell layer. Additionally, simulations demonstrate good agreement with converged simulations employing explicit models for plasma diffusion and viscosity, suggesting that the implicit sub-grid model used in ILES is sufficient to model these processes in these experiments. In our simulations, mixing is driven by short-wavelength asymmetries and longer-wavelength features are responsible for developing flows that transport mixed material towards the center of the hot spot. Mix material transported by this process is responsible for most of the mix (DT) yield even for the capsule with a CD layer adjacent to the tritium fuel. Consistent with our previous results, mix does not play a significant role in TT neutron yield degradation; instead, this is dominated by the displacement of fuel from the center of the implosion due to the development of turbulent instabilities seeded by long-wavelength asymmetries. Through these processes, the long-wavelength asymmetries degrade TT yield more than the DT yield and thus bring DT/TT neutron yield ratios into agreement with experiment. Finally, we present a detailed comparison of the flows in 2D and 3D simulations.

A novel approach to mixing qualitative and quantitative methods in HIV and STI prevention research.

PubMed

Penman-Aguilar, Ana; Macaluso, Maurizio; Peacock, Nadine; Snead, M Christine; Posner, Samuel F

2014-04-01

Mixed-method designs are increasingly used in sexually transmitted infection (STI) and HIV prevention research. The authors designed a mixedmethod approach and applied it to estimate and evaluate a predictor of continued female condom use (6+ uses, among those who used it at least once) in a 6-month prospective cohort study. The analysis included 402 women who received an intervention promoting use of female and male condoms for STI prevention and completed monthly quantitative surveys; 33 also completed a semistructured qualitative interview. The authors identified a qualitative theme (couples' female condom enjoyment [CFCE]), applied discriminant analysis techniques to estimate CFCE for all participants, and added CFCE to a multivariable logistic regression model of continued female condom use. CFCE related to comfort, naturalness, pleasure, feeling protected, playfulness, ease of use, intimacy, and feeling in control of protection. CFCE was associated with continued female condom use (adjusted odds ratio: 2.8, 95% confidence interval: 1.4-5.6) and significantly improved model fit (p < .001). CFCE predicted continued female condom use. Mixed-method approaches for "scaling up" qualitative findings from small samples to larger numbers of participants can benefit HIV and STI prevention research.

Dysglycemia, Glycemic Variability, and Outcome After Cardiac Arrest and Temperature Management at 33°C and 36°C.

PubMed

Borgquist, Ola; Wise, Matt P; Nielsen, Niklas; Al-Subaie, Nawaf; Cranshaw, Julius; Cronberg, Tobias; Glover, Guy; Hassager, Christian; Kjaergaard, Jesper; Kuiper, Michael; Smid, Ondrej; Walden, Andrew; Friberg, Hans

2017-08-01

Dysglycemia and glycemic variability are associated with poor outcomes in critically ill patients. Targeted temperature management alters blood glucose homeostasis. We investigated the association between blood glucose concentrations and glycemic variability and the neurologic outcomes of patients randomized to targeted temperature management at 33°C or 36°C after cardiac arrest. Post hoc analysis of the multicenter TTM-trial. Primary outcome of this analysis was neurologic outcome after 6 months, referred to as "Cerebral Performance Category." Thirty-six sites in Europe and Australia. All 939 patients with out-of-hospital cardiac arrest of presumed cardiac cause that had been included in the TTM-trial. Targeted temperature management at 33°C or 36°C. Nonparametric tests as well as multiple logistic regression and mixed effects logistic regression models were used. Median glucose concentrations on hospital admission differed significantly between Cerebral Performance Category outcomes (p < 0.0001). Hyper- and hypoglycemia were associated with poor neurologic outcome (p = 0.001 and p = 0.054). In the multiple logistic regression models, the median glycemic level was an independent predictor of poor Cerebral Performance Category (Cerebral Performance Category, 3-5) with an odds ratio (OR) of 1.13 in the adjusted model (p = 0.008; 95% CI, 1.03-1.24). It was also a predictor in the mixed model, which served as a sensitivity analysis to adjust for the multiple time points. The proportion of hyperglycemia was higher in the 33°C group compared with the 36°C group. Higher blood glucose levels at admission and during the first 36 hours, and higher glycemic variability, were associated with poor neurologic outcome and death. More patients in the 33°C treatment arm had hyperglycemia.

Bidirectional influence: A longitudinal analysis of size of drug network and depression among inner-city residents in Baltimore, Maryland

PubMed Central

Yang, Jingyan; Latkin, Carl A.; Davey-Rothwell, Melissa

2015-01-01

BACKGROUND The prevalence of depression among drug users is high. It has been recognized that drug use behaviors can be influenced and spread through social networks. OBJECTIVES We investigated the directional relationship between social network factors and depressive symptoms among a sample of inner-city residents in Baltimore, MD. METHODS We performed a longitudinal study of four-wave data collected from a network-based HIV/STI prevention intervention for women and network members, consisting of both men and women. Our primary outcome and exposure were depression using CESD scale and social network characteristics, respectively. Linear mixed model with clustering adjustment was used to account for both repeated measurement and network design. RESULTS Of the 746 participants, those who had high levels of depression tended to be female, less educated, homeless, smokers, and did not have a main partner. In the univariate longitudinal model, larger size of drug network was significantly associated with depression (OR=1.38, p<0.001). This relationship held after controlling for age, gender, homeless in the past six months, college education, having a main partner, cigarette smoking, perceived health, and social support network (aOR=1.19, p=0.001). In the univariate mixed model using depression to predict size of drug network, the data suggested that depression was associated with larger size of drug network (coef.=1.23, p<0.001) and the same relation held in multivariate model (adjusted coef.=1.08, p=0.001). CONCLUSIONS The results suggest that larger size of drug network is a risk factor for depression, and vice versa. Further intervention strategies to reduce depression should address social networks factors. PMID:26584046

CERAMIC: Case-Control Association Testing in Samples with Related Individuals, Based on Retrospective Mixed Model Analysis with Adjustment for Covariates

PubMed Central

Zhong, Sheng; McPeek, Mary Sara

2016-01-01

We consider the problem of genetic association testing of a binary trait in a sample that contains related individuals, where we adjust for relevant covariates and allow for missing data. We propose CERAMIC, an estimating equation approach that can be viewed as a hybrid of logistic regression and linear mixed-effects model (LMM) approaches. CERAMIC extends the recently proposed CARAT method to allow samples with related individuals and to incorporate partially missing data. In simulations, we show that CERAMIC outperforms existing LMM and generalized LMM approaches, maintaining high power and correct type 1 error across a wider range of scenarios. CERAMIC results in a particularly large power increase over existing methods when the sample includes related individuals with some missing data (e.g., when some individuals with phenotype and covariate information have missing genotype), because CERAMIC is able to make use of the relationship information to incorporate partially missing data in the analysis while correcting for dependence. Because CERAMIC is based on a retrospective analysis, it is robust to misspecification of the phenotype model, resulting in better control of type 1 error and higher power than that of prospective methods, such as GMMAT, when the phenotype model is misspecified. CERAMIC is computationally efficient for genomewide analysis in samples of related individuals of almost any configuration, including small families, unrelated individuals and even large, complex pedigrees. We apply CERAMIC to data on type 2 diabetes (T2D) from the Framingham Heart Study. In a genome scan, 9 of the 10 smallest CERAMIC p-values occur in or near either known T2D susceptibility loci or plausible candidates, verifying that CERAMIC is able to home in on the important loci in a genome scan. PMID:27695091

Patterns of Unit and Item Nonresponse in the CAHPS® Hospital Survey

PubMed Central

Elliott, Marc N; Edwards, Carol; Angeles, January; Hambarsoomians, Katrin; Hays, Ron D

2005-01-01

Objective To examine the predictors of unit and item nonresponse, the magnitude of nonresponse bias, and the need for nonresponse weights in the Consumer Assessment of Health Care Providers and Systems (CAHPS®) Hospital Survey. Methods A common set of 11 administrative variables (41 degrees of freedom) was used to predict unit nonresponse and the rate of item nonresponse in multivariate models. Descriptive statistics were used to examine the impact of nonresponse on CAHPS Hospital Survey ratings and reports. Results Unit nonresponse was highest for younger patients and patients other than non-Hispanic whites (p<.001); item nonresponse increased steadily with age (p<.001). Fourteen of 20 reports of ratings of care had significant (p<.05) but small negative correlations with nonresponse weights (median −0.06; maximum −0.09). Nonresponse weights do not improve overall precision below sample sizes of 300–1,000, and are unlikely to improve the precision of hospital comparisons. In some contexts, case-mix adjustment eliminates most observed nonresponse bias. Conclusions Nonresponse weights should not be used for between-hospital comparisons of the CAHPS Hospital Survey, but may make small contributions to overall estimates or demographic comparisons, especially in the absence of case-mix adjustment. PMID:16316440

Separation of pedogenic and lithogenic components of magnetic susceptibility in the Chinese loess/palaeosol sequence as determined by the CBD procedure and a mixing analysis

NASA Astrophysics Data System (ADS)

Vidic, Nataša. J.; TenPas, Jeff D.; Verosub, Kenneth L.; Singer, Michael J.

2000-08-01

Magnetic susceptibility variations in the Chinese loess/palaeosol sequences have been used extensively for palaeoclimatic interpretations. The magnetic signal of these sequences must be divided into lithogenic and pedogenic components because the palaeoclimatic record is primarily reflected in the pedogenic component. In this paper we compare two methods for separating the pedogenic and lithogenic components of the magnetic susceptibility signal: the citrate-bicarbonate-dithionite (CBD) extraction procedure, and a mixing analysis. Both methods yield good estimates of the pedogenic component, especially for the palaeosols. The CBD procedure underestimates the lithogenic component and overestimates the pedogenic component. The magnitude of this effect is moderately high in loess layers but almost negligible in palaeosols. The mixing model overestimates the lithogenic component and underestimates the pedogenic component. Both methods can be adjusted to yield better estimates of both components. The lithogenic susceptibility, as determined by either method, suggests that palaeoclimatic interpretations based only on total susceptibility will be in error and that a single estimate of the average lithogenic susceptibility is not an accurate basis for adjusting the total susceptibility. A long-term decline in lithogenic susceptibility with depth in the section suggests more intense or prolonged periods of weathering associated with the formation of the older palaeosols. The CBD procedure provides the most comprehensive information on the magnitude of the components and magnetic mineralogy of loess and palaeosols. However, the mixing analysis provides a sensitive, rapid, and easily applied alternative to the CBD procedure. A combination of the two approaches provides the most powerful and perhaps the most accurate way of separating the magnetic susceptibility components.

The consumption of alcohol mixed with energy drinks: prevalence and key correlates among Canadian high school students.

PubMed

Azagba, Sunday; Langille, Don; Asbridge, Mark

2013-01-01

An emerging body of research has reported high consumption of alcohol mixed with energy drinks among young adults, particularly college students. However, little is known about adolescents' consumption of these drinks. The purpose of this study was to determine the prevalence of consumption of alcohol mixed with energy drinks and to examine its correlates among Canadian high school students. We used a nationally representative sample of 36 155 Canadian students in grades 7 to 12 who participated in the 2010/2011 Youth Smoking Survey. About 20% of Canadian high school students reported consuming alcohol mixed with energy drinks in the last year, with considerable variation across provinces. Multivariate logistic regression analyses showed that the odds of consumption of these drinks were higher among students in lower grades (grades 7 and 8) and among students who identified their ethnicity as black or "other." Consumption of alcohol mixed with energy drinks was positively associated with substance use (current smoking [adjusted odds ratio (OR) 1.52, 95% confidence interval (CI) 1.19-1.95], past-year heavy drinking [adjusted OR 3.41, 95% CI 2.84-4.09] and marijuana use [adjusted OR 2.29, 95% CI 1.90-2.76]), absence from school, participation in school team sports and having more weekly spending money. Students who felt more connected to school and had an academic average of 70% or higher were less likely to consume alcohol mixed with energy drinks. The consumption of alcohol mixed with energy drinks is an emerging public health concern. Consumption of these drinks is substantial among Canadian high school students and can lead to many potential harms, both acute (e.g., injury) and long term (e.g., increased alcohol dependence). Our findings highlight the need for further research into the long-term effects of consumption of alcohol mixed with energy drinks among young people, as well as the development of interventions aimed at reducing consumption of these drinks.

Using a case-mix-adjusted pressure sore incidence study in a surgical directorate to improve patient outcomes in pressure ulcer prevention.

PubMed

Watret, L

1999-10-01

The Glasgow Acute Clinical Audit Sub-Committee on Pressure Sores has previously carried out studies of incidence of pressure ulcers in the medical directorates and case-mix-adjusted the figures for length of hospital stay and risk assessment score. Case-mix classification is 'classification of people or treatment placed into groups using characteristics associated with condition, treatment or outcome that can be used to predict need, resource, use of outcomes'. In this instance, crude pressure ulcer incidence figures may be adjusted for length of hospital stay and pressure sore risk assessment score, and stratified into groups, which allows like to be compared with like. The value in case-mix-adjusted figures lies in repeating the exercise, thus determining the trend for individual areas and assessing whether improvement in the quality of care is being achieved. This is more positive than creation of 'league tables' comparing simultaneous studies in a number of areas. The figures showed that there was no statistically significant difference between surgical directorates in trusts with regard to risk assessment scores and length of hospital stay. Gathering data on the incidence of pressure ulcer development allows us to identify where new sores are occurring, but does not critically analyse the nursing intervention taken in individual cases, which identifies preventive strategies. The Glasgow group's primary aim was to gather data on case-mix-adjusted incidence of pressure damage; the secondary objectives were to scrutinize the data to gather more general information on intrinsic and extrinsic factors which may predispose to pressure ulcer development. The study was carried out in the surgical directorate. Findings showed that incidence was low (1.1%), with the majority of sores being superficial. There was a correlation between pressure ulcer development and incontinence, evidence of under-utilization of moving and handling aids for prevention of pressure ulcers, and a need for greater collaboration between nursing staff and dietitians. All patients had access to pressure-reducing surfaces, with cut-foam pressure-reducing mattresses with vapour-permeable covers on all beds. Dynamic systems were available if the primary nurse identified a need for them.

Hospital-Level Factors Associated with Pediatric Emergency Department Return Visits.

PubMed

Pittsenbarger, Zachary; Thurm, Cary; Neuman, Mark; Spencer, Sandra; Simon, Harold; Gosdin, Craig; Shah, Samir; McClead, Richard; Stack, Anne; Alpern, Elizabeth

2017-07-01

Return visits (RVs) and RVs with admission (RVAs) are commonly used emergency department quality measures. Visit- and patient-level factors, including several social determinants of health, have been associated with RV rates, but hospital-specific factors have not been studied. To identify what hospital-level factors correspond with high RV and RVA rates. Multicenter mixed-methods study of hospital characteristics associated with RV and RVA rates. Pediatric Health Information System with survey of emergency department directors. Adjusted return rates were calculated with generalized linear mixed-effects models. Hospitals were categorized by adjusted RV and RVA rates for analysis. Twenty-four hospitals accounted for 1,456,377 patient visits with an overall adjusted RV rate of 3.7% and RVA rate of 0.7%. Hospitals with the highest RV rates served populations that were more likely to have government insurance and lower median household incomes and less likely to carry commercial insurance. Hospitals in the highest RV rate outlier group had lower pediatric emergency medicine specialist staffing, calculated as full-time equivalents per 10,000 patient visits: median (interquartile range) of 1.9 (1.5-2.1) versus 2.9 (2.2-3.6). There were no differences in hospital population characteristics or staffing by RVA groups. RV rates were associated with population social determinants of health and inversely related to staffing. Hospital-level variation may indicate population-level economic factors outside the control of the hospital and unrelated to quality of care. © 2017 Society of Hospital Medicine

Subpixel target detection and enhancement in hyperspectral images

NASA Astrophysics Data System (ADS)

Tiwari, K. C.; Arora, M.; Singh, D.

2011-06-01

Hyperspectral data due to its higher information content afforded by higher spectral resolution is increasingly being used for various remote sensing applications including information extraction at subpixel level. There is however usually a lack of matching fine spatial resolution data particularly for target detection applications. Thus, there always exists a tradeoff between the spectral and spatial resolutions due to considerations of type of application, its cost and other associated analytical and computational complexities. Typically whenever an object, either manmade, natural or any ground cover class (called target, endmembers, components or class) gets spectrally resolved but not spatially, mixed pixels in the image result. Thus, numerous manmade and/or natural disparate substances may occur inside such mixed pixels giving rise to mixed pixel classification or subpixel target detection problems. Various spectral unmixing models such as Linear Mixture Modeling (LMM) are in vogue to recover components of a mixed pixel. Spectral unmixing outputs both the endmember spectrum and their corresponding abundance fractions inside the pixel. It, however, does not provide spatial distribution of these abundance fractions within a pixel. This limits the applicability of hyperspectral data for subpixel target detection. In this paper, a new inverse Euclidean distance based super-resolution mapping method has been presented that achieves subpixel target detection in hyperspectral images by adjusting spatial distribution of abundance fraction within a pixel. Results obtained at different resolutions indicate that super-resolution mapping may effectively aid subpixel target detection.

Evidence for competition and cooperation among climbing plants.

PubMed

Biernaskie, Jay M

2011-07-07

A plant's best strategy for acquiring resources may often depend on the identity of neighbours. Here, I ask whether plants adjust their strategy to local relatedness: individuals may cooperate (reduce competitiveness) with kin but compete relatively intensely with non-kin. In a greenhouse experiment with Ipomoea hederacea, neighbouring siblings from the same inbred line were relatively uniform in height; groups of mixed lines, however, were increasingly variable as their mean height increased. The reproductive yield of mixed and sibling groups was similar overall, but when adjusted to a common mean height and height inequality, the yield of mixed groups was significantly less. Where this difference in yield was most pronounced (among groups that varied most in height), mixed groups tended to allocate more mass to roots than comparable sibling groups, and overall, mixed groups produced significantly fewer seeds per unit mass of roots. These results suggest that, from the group perspective, non-kin may have wasted resources in below-ground competition at the expense of reproduction; kin groups, on the other hand, displayed the relative efficiency that is expected of reduced competitiveness.

Controlled differential pressure system for an enhanced fluid blending apparatus

DOEpatents

Hallman, Jr., Russell Louis

2009-02-24

A system and method for producing a controlled blend of two or more fluids. Thermally-induced permeation through a permeable tube is used to mix a first fluid from outside the tube with a second fluid flowing through the tube. Mixture ratios may be controlled by adjusting the temperature of the first fluid or by adjusting the pressure drop through the permeable tube. The combination of a back pressure control valve and a differential regulator is used to control the output pressure of the blended fluid. The combination of the back pressure control valve and differential regulator provides superior flow control of the second dry gas. A valve manifold system may be used to mix multiple fluids, and to adjust the volume of blended fluid produced, and to further modify the mixture ratio.

Methodology of mixed load customized bus lines and adjustment based on time windows

PubMed Central

Song, Rui

2018-01-01

Custom bus routes need to be optimized to meet the needs of a customized bus for personalized trips of different passengers. This paper introduced a customized bus routing problem in which trips for each depot are given, and each bus stop has a fixed time window within which trips should be completed. Treating a trip as a virtual stop was the first consideration in solving the school bus routing problem (SBRP). Then, the mixed load custom bus routing model was established with a time window that satisfies its requirement and the result were solved by Cplex software. Finally, a simple network diagram with three depots, four pickup stops, and five delivery stops was structured to verify the correctness of the model, and based on the actual example, the result is that all the buses ran 124.42 kilometers, the sum of kilometers was 10.35 kilometers less than before. The paths and departure times of the different busses that were provided by the model were evaluated to meet the needs of the given conditions, thus providing valuable information for actual work. PMID:29320505

Mapping eQTL Networks with Mixed Graphical Markov Models

PubMed Central

Tur, Inma; Roverato, Alberto; Castelo, Robert

2014-01-01

Expression quantitative trait loci (eQTL) mapping constitutes a challenging problem due to, among other reasons, the high-dimensional multivariate nature of gene-expression traits. Next to the expression heterogeneity produced by confounding factors and other sources of unwanted variation, indirect effects spread throughout genes as a result of genetic, molecular, and environmental perturbations. From a multivariate perspective one would like to adjust for the effect of all of these factors to end up with a network of direct associations connecting the path from genotype to phenotype. In this article we approach this challenge with mixed graphical Markov models, higher-order conditional independences, and q-order correlation graphs. These models show that additive genetic effects propagate through the network as function of gene–gene correlations. Our estimation of the eQTL network underlying a well-studied yeast data set leads to a sparse structure with more direct genetic and regulatory associations that enable a straightforward comparison of the genetic control of gene expression across chromosomes. Interestingly, it also reveals that eQTLs explain most of the expression variability of network hub genes. PMID:25271303

Quasi-Chemical PC-SAFT: An Extended Perturbed Chain-Statistical Associating Fluid Theory for Lattice-Fluid Mixtures.

PubMed

Parvaneh, Khalil; Shariati, Alireza

2017-09-07

In this study, a new modification of the perturbed chain-statistical associating fluid theory (PC-SAFT) has been proposed by incorporating the lattice fluid theory of Guggenheim as an additional term to the original PC-SAFT terms. As the proposed model has one more term than the PC-SAFT, a new mixing rule has been developed especially for the new additional term, while for the conventional terms of the PC-SAFT, the one-fluid mixing rule is used. In order to evaluate the proposed model, the vapor-liquid equilibria were estimated for binary CO 2 mixtures with 16 different ionic liquids (ILs) of the 1-alkyl-3-methylimidazolium family with various anions consisting of bis(trifluoromethylsulfonyl) imide, hexafluorophosphate, tetrafluoroborate, and trifluoromethanesulfonate. For a comprehensive comparison, three different modes (different adjustable parameters) of the proposed model were compared with the conventional PC-SAFT. Results indicate that the proposed modification of the PC-SAFT EoS is generally more reliable with respect to the conventional PC-SAFT in all the three proposed modes of vapor-liquid equilibria, giving good agreement with literature data.

On the interatomic potentials for noble gas mixtures

NASA Astrophysics Data System (ADS)

Watanabe, Kyoko; Allnatt, A. R.; Meath, William J.

1982-07-01

Recently, a relatively simple scheme for the construction of isotropic intermolecular potentials has been proposed and tested for the like species interactions involving He, Ne, Ar, Kr and H 2. The model potential has an adjustable parameter which controls the balance between its exchange and Coulomb energy components. The representation of the Coulomb energy contains a damped multipolar dispersion energy series (which is truncated through O( R-10) and provides additional flexibility through adjustment of the dispersion energy coefficients, particularly C8 and C10, within conservative error estimates. In this paper the scheme is tested further by application to interactions involving unlike noble gas atoms where the parameters in the potential model are determined by fitting mixed second virial coefficient data as a function of temperature. Generally the approach leads to potential of accuracy comparable to the best available literature potentials which are usually determined using a large base of experimental and theoretical input data. Our results also strongly indicate the need of high quality virial data.

Developing Quality Indicators and Auditing Protocols from Formal Guideline Models: Knowledge Representation and Transformations

PubMed Central

Advani, Aneel; Goldstein, Mary; Shahar, Yuval; Musen, Mark A.

2003-01-01

Automated quality assessment of clinician actions and patient outcomes is a central problem in guideline- or standards-based medical care. In this paper we describe a model representation and algorithm for deriving structured quality indicators and auditing protocols from formalized specifications of guidelines used in decision support systems. We apply the model and algorithm to the assessment of physician concordance with a guideline knowledge model for hypertension used in a decision-support system. The properties of our solution include the ability to derive automatically (1) context-specific and (2) case-mix-adjusted quality indicators that (3) can model global or local levels of detail about the guideline (4) parameterized by defining the reliability of each indicator or element of the guideline. PMID:14728124

Simulation analysis of an integrated model for dynamic cellular manufacturing system

NASA Astrophysics Data System (ADS)

Hao, Chunfeng; Luan, Shichao; Kong, Jili

2017-05-01

Application of dynamic cellular manufacturing system (DCMS) is a well-known strategy to improve manufacturing efficiency in the production environment with high variety and low volume of production. Often, neither the trade-off of inter and intra-cell material movements nor the trade-off of hiring and firing of operators are examined in details. This paper presents simulation results of an integrated mixed-integer model including sensitivity analysis for several numerical examples. The comprehensive model includes cell formation, inter and intracellular materials handling, inventory and backorder holding, operator assignment (including resource adjustment) and flexible production routing. The model considers multi-production planning with flexible resources (machines and operators) where each period has different demands. The results verify the validity and sensitivity of the proposed model using a genetic algorithm.

2009–2010 Seasonal Influenza Vaccination Coverage Among College Students From 8 Universities in North Carolina

PubMed Central

Poehling, Katherine A.; Blocker, Jill; Ip, Edward H.; Peters, Timothy R.; Wolfson, Mark

2012-01-01

Objective We sought to describe the 2009–2010 seasonal influenza vaccine coverage of college students. Participants 4090 college students from eight North Carolina universities participated in a confidential, web-based survey in October-November 2009. Methods Associations between self-reported 2009–2010 seasonal influenza vaccination and demographic characteristics, campus activities, parental education, and email usage were assessed by bivariate analyses and by a mixed-effects model adjusting for clustering by university. Results Overall, 20% of students (range 14%–30% by university) reported receiving 2009–2010 seasonal influenza vaccine. Being a freshman, attending a private university, having a college-educated parent, and participating in academic clubs/honor societies predicted receipt of influenza vaccine in the mixed-effects model. Conclusions The self-reported 2009–2010 influenza vaccine coverage was one-quarter of the 2020 Healthy People goal (80%) for healthy persons 18–64 years of age. College campuses have the opportunity to enhance influenza vaccine coverage among its diverse student populations. PMID:23157195

2009-2010 seasonal influenza vaccination coverage among college students from 8 universities in North Carolina.

PubMed

Poehling, Katherine A; Blocker, Jill; Ip, Edward H; Peters, Timothy R; Wolfson, Mark

2012-01-01

The authors sought to describe the 2009-2010 seasonal influenza vaccine coverage of college students. A total of 4,090 college students from 8 North Carolina universities participated in a confidential, Web-based survey in October-November 2009. Associations between self-reported 2009-2010 seasonal influenza vaccination and demographic characteristics, campus activities, parental education, and e-mail usage were assessed by bivariate analyses and by a mixed-effects model adjusting for clustering by university. Overall, 20% of students (range 14%-30% by university) reported receiving 2009-2010 seasonal influenza vaccine. Being a freshman, attending a private university, having a college-educated parent, and participating in academic clubs/honor societies predicted receipt of influenza vaccine in the mixed-effects model. The self-reported 2009-2010 influenza vaccine coverage was one-quarter of the 2020 Healthy People goal (80%) for healthy persons 18 to 64 years of age. College campuses have the opportunity to enhance influenza vaccine coverage among its diverse student populations.

Semi-idealized modeling of lightning initiation related to vertical air motion and cloud microphysics

NASA Astrophysics Data System (ADS)

Wang, Fei; Zhang, Yijun; Zheng, Dong; Xu, Liangtao; Zhang, Wenjuan; Meng, Qing

2017-10-01

A three-dimensional charge-discharge numerical model is used, in a semi-idealized mode, to simulate a thunder-storm cell. Characteristics of the graupel microphysics and vertical air motion associated with the lightning initiation are revealed, which could be useful in retrieving charge strength during lightning when no charge-discharge model is available. The results show that the vertical air motion at the lightning initiation sites ( W ini) has a cubic polynomial correlation with the maximum updraft of the storm cell ( W cell-max), with the adjusted regression coefficient R 2 of approximately 0.97. Meanwhile, the graupel mixing ratio at the lightning initiation sites ( q g-ini) has a linear correlation with the maximum graupel mixing ratio of the storm cell ( q g-cell-max) and the initiation height ( z ini), with the coefficients being 0.86 and 0.85, respectively. These linear correlations are more significant during the middle and late stages of lightning activity. A zero-charge zone, namely, the area with very low net charge density between the main positive and negative charge layers, appears above the area of q g-cell-max and below the upper edge of the graupel region, and is found to be an important area for lightning initiation. Inside the zero-charge zone, large electric intensity forms, and the ratio of q ice (ice crystal mixing ratio) to q g (graupel mixing ratio) illustrates an exponential relationship to q g-ini. These relationships provide valuable clues to more accurately locating the high-risk area of lightning initiation in thunderstorms when only dual-polarization radar data or outputs from numerical models without charging/discharging schemes are available. The results can also help understand the environmental conditions at lightning initiation sites.

The Influence of Midlatitude Ocean-Atmosphere Coupling on the Low-Frequency Variability of a GCM. Part I: No Tropical SST Forcing*.

NASA Astrophysics Data System (ADS)

Bladé, Ileana

1997-08-01

This study examines the extent to which the thermodynamic interactions between the midlatitude atmosphere and the underlying oceanic mixed layer contribute to the low-frequency atmospheric variability. A general circulation model, run under perpetual northern winter conditions, is coupled to a motionless constant-depth mixed layer in midlatitudes, while elsewhere the sea surface temperature (SST) is kept fixed; interannual tropical SST forcing is not included. It is found that coupling does not modify the spatial organization of the variability. The influence of coupling is manifested as a slight reddening of the spectrum of 500-mb geopotential height and a significant enhancement of the lower-tropospheric thermal variance over the oceans at very low frequencies by virtue of the mixed-layer adjustment to surface air temperature variations that occurs on those timescales. This adjustment effectively reduces the thermal damping of the atmosphere associated with surface heat fluxes (or negative oceanic feedback), thus increasing the thermal variance and the persistence of circulation anomalies.In studying the covariability between ocean and atmosphere it is found that the dominant mode of natural atmospheric variability is coupled to the leading mode of SST in each ocean, with the atmosphere leading the ocean by about one month. The cross-correlation function between oceanic and atmospheric anomalies is strongly asymmetric about zero lag. The SST structures are consistent with direct forcing by the anomalous heat fluxes implied by the concurrent surface air temperature and wind fluctuations. Additionally, composites based on large amplitude SST anomaly events contain no evidence of direct driving of atmospheric perturbations by these SST anomalies. Thus, in terms of the spatial organization of the covariability and the evolution of the coupled system from one regime to another, large-scale air-sea interaction in the model is characterized by one-way atmospheric forcing of the mixed layer.These results are qualitatively consistent with those from an earlier idealized study. They imply a subtle but fundamental role for the midlatitude oceans as stabilizing rather than directly generating atmospheric anomalies. It is argued that this scenario is relevant to the dynamics of extratropical atmosphere-ocean coupling on intraseasonal timescales at least: the model is able to qualitatively reproduce the temporal and spatial characteristics of the observed dominant patterns of interaction on these timescales, particularly over the Atlantic.

Misconceptions about case-mix payments for nursing homes.

PubMed

Grimaldi, P L

1987-04-01

Despite the increasing use of case-mix payment systems for skilled and intermediate nursing home care (at least 10 state Medicaid programs have adopted or are considering adopting such a system), misconceptions about such systems still exist. Unless these inaccurate perceptions are corrected, a state may adopt a system that fails to realize its goals. Some of these misconceptions include the beliefs that case-mix payment systems: Apply to all nursing homes costs; Will benefit hospital-based facilities; Will resolve the access problems of heavy care public patients; Will result in higher statewide payment rates because patient characteristics are factored directly into the calculations. In fact, case-mix adjustments are applied only to costs that can be traced directly to patients' impairments. Nursing services and some ancillary services are dependent on case mix, while administrative and support services are largely independent of case mix. Capital costs usually can be ignored in formulating the case-mix adjustment. Although hospital-based facilities frequently have sicker patients than freestanding facilities, studies show that only a portion of the cost differential is explained by case-mix differences. In the case of heavy-care patients, some believe that case-mix payment systems will resolve access problems by paying higher rates in response to the higher treatment costs. Access may not improve, however, if the new rates are lower than those paid by comparable private patients. Perhaps a loosening in the certificate-of-need process will also be needed to resolve the access problem.(ABSTRACT TRUNCATED AT 250 WORDS)

Abrasive slurry jet cutting model based on fuzzy relations

NASA Astrophysics Data System (ADS)

Qiang, C. H.; Guo, C. W.

2017-12-01

The cutting process of pre-mixed abrasive slurry or suspension jet (ASJ) is a complex process affected by many factors, and there is a highly nonlinear relationship between the cutting parameters and cutting quality. In this paper, guided by fuzzy theory, the fuzzy cutting model of ASJ was developed. In the modeling of surface roughness, the upper surface roughness prediction model and the lower surface roughness prediction model were established respectively. The adaptive fuzzy inference system combines the learning mechanism of neural networks and the linguistic reasoning ability of the fuzzy system, membership functions, and fuzzy rules are obtained by adaptive adjustment. Therefore, the modeling process is fast and effective. In this paper, the ANFIS module of MATLAB fuzzy logic toolbox was used to establish the fuzzy cutting model of ASJ, which is found to be quite instrumental to ASJ cutting applications.

Axial static mixer

DOEpatents

Sandrock, H.E.

1982-05-06

Static axial mixing apparatus includes a plurality of channels, forming flow paths of different dimensions. The axial mixer includes a flow adjusting device for adjustable selective control of flow resistance of various flow paths in order to provide substantially identical flows through the various channels, thereby reducing nonuniform coating of interior surfaces of the channels. The flow adjusting device may include diaphragm valves, and may further include a pressure regulating system therefor.

Is the distinction between adjustment disorder with depressed mood and adjustment disorder with mixed anxious and depressed mood valid?

PubMed

Zimmerman, Mark; Martinez, Jennifer H; Dalrymple, Kristy; Martinez, Jennifer H; Chelminski, Iwona; Young, Diane

2013-11-01

In the DSM-IV, adjustment disorder is subtyped according to the predominant presenting feature. The different diagnostic code numbers assigned to each subtype suggest their significance in DSM-IV. However, little research has examined the validity of these subtypes. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the demographic and clinical profiles of patients diagnosed with adjustment disorder subtypes to determine whether there was enough empirical evidence supporting the retention of multiple adjustment disorder subtypes in future versions of the DSM. A total of 3,400 psychiatric patients presenting to the Rhode Island Hospital outpatient practice were evaluated with semistructured diagnostic interviews for DSM-IV Axis I and Axis II disorders and measures of psychosocial morbidity. Approximately 7% (224 of 3,400) of patients were diagnosed with current adjustment disorder. Adjustment disorder with depressed mood and with mixed anxious and depressed mood were the most common subtypes, accounting for 80% of the patients diagnosed with adjustment disorder. There was no significant difference between these 2 groups with regard to demographic variables, current comorbid Axis I or Axis II disorders, lifetime history of major depressive disorder or anxiety disorders, psychosocial morbidity, or family history of psychiatric disorders. The only difference between the groups was lifetime history of drug use, which was significantly higher in the patients diagnosed with adjustment disorder with depressed mood. There is no evidence supporting the retention of both of these adjustment disorder subtypes, and DSM-IV previously set a precedent for eliminating adjustment disorder subtypes in the absence of any data. Therefore, in the spirit of nosologic parsimony, consideration should be given to collapsing the 2 disorders into 1: adjustment disorder with depressed mood.

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

[Risk-adjusted assessment: late-onset infection in neonates].

PubMed

Gmyrek, Dieter; Koch, Rainer; Vogtmann, Christoph; Kaiser, Annette; Friedrich, Annette

2011-01-01

The weak point of the countrywide perinatal/neonatal quality surveillance is the ignorance of interhospital differences in the case mix of patients. As a result, this approach does not produce reliable benchmarking. The objective of this study was to adjust the result of the late-onset infection incidence of different hospitals according to their risk profile of patients by multivariate analysis. The perinatal/neonatal database of 41,055 newborns of the Saxonian quality surveillance from 1998 to 2004 was analysed. Based on 18 possible risk factors, a logistic regression model was used to develop a specific risk predictor for the quality indicator "late-onset infection". The developed risk predictor for the incidence of late-onset infection could be described by 4 of the 18 analysed risk factors, namely gestational age, admission from home, hypoxic ischemic encephalopathy and B-streptococcal infection. The AUC(ROC) value of this quality indicator was 83.3%, which demonstrates its reliability. The hospital ranking based on the adjusted risk assessment was very different from hospital rankings before this adjustment. The average correction of ranking position was 4.96 for 35 clinics. The application of the risk adjustment method proposed here allows for a more objective comparison of the incidence of the quality indicator "late onset infection" among different hospitals. Copyright © 2011. Published by Elsevier GmbH.

Longitudinal Links between Older Sibling Features and Younger Siblings’ Academic Adjustment during Early Adolescence

PubMed Central

Bouchey, Heather A.; Shoulberg, Erin K.; Jodl, Kathleen M.; Eccles, Jacquelynne S.

2010-01-01

This study investigated prospective relations between (1) older siblings’ support and academic engagement and (2) younger siblings’ academic adjustment from 7th to 8th grade. The study was unique in that it incorporated a sample of both African American and European American adolescents. Also investigated was the extent to which the gender constellation (same-sex vs. mixed-sex) of sibling dyads moderated prospective associations. Findings revealed that, in mixed-sex dyads only, younger siblings’ perceptions of support received from the older sibling and their positive image of the older sibling predicted declines in the younger sibling’s academic self-perceptions and performance over time, even after controlling for younger siblings’ background characteristics and support from parents. Older siblings’ reported support to younger siblings also predicted declines in younger siblings’ academic adjustment, whereas the older siblings’ own level of academic engagement predicted an increase in younger siblings’ academic adjustment over time. Overall, findings did not differ substantially for African and European American adolescents. PMID:20376283

The role of gender in a smoking cessation intervention: a cluster randomized clinical trial.

PubMed

Puente, Diana; Cabezas, Carmen; Rodriguez-Blanco, Teresa; Fernández-Alonso, Carmen; Cebrian, Tránsito; Torrecilla, Miguel; Clemente, Lourdes; Martín, Carlos

2011-05-23

The prevalence of smoking in Spain is high in both men and women. The aim of our study was to evaluate the role of gender in the effectiveness of a specific smoking cessation intervention conducted in Spain. This study was a secondary analysis of a cluster randomized clinical trial in which the randomization unit was the Basic Care Unit (family physician and nurse who care for the same group of patients). The intervention consisted of a six-month period of implementing the recommendations of a Clinical Practice Guideline. A total of 2,937 current smokers at 82 Primary Care Centers in 13 different regions of Spain were included (2003-2005). The success rate was measured by a six-month continued abstinence rate at the one-year follow-up. A logistic mixed-effects regression model, taking Basic Care Units as random-effect parameter, was performed in order to analyze gender as a predictor of smoking cessation. At the one-year follow-up, the six-month continuous abstinence quit rate was 9.4% in men and 8.5% in women (p = 0.400). The logistic mixed-effects regression model showed that women did not have a higher odds of being an ex-smoker than men after the analysis was adjusted for confounders (OR adjusted = 0.9, 95% CI = 0.7-1.2). Gender does not appear to be a predictor of smoking cessation at the one-year follow-up in individuals presenting at Primary Care Centers. CLINICALTRIALS.GOV IDENTIFIER: NCT00125905.

[Relationship between finger dermatoglyphics and body size indicators in adulthood among Chinese twin population from Qingdao and Lishui cities].

PubMed

Sun, Luanluan; Yu, Canqing; Lyu, Jun; Cao, Weihua; Pang, Zengchang; Chen, Weijian; Wang, Shaojie; Chen, Rongfu; Gao, Wenjing; Li, Liming

2014-01-01

To study the correlation between fingerprints and body size indicators in adulthood. Samples were composed of twins from two sub-registries of Chinese National Twin Registry (CNTR), including 405 twin pairs in Lishui and 427 twin pairs in Qingdao. All participants were asked to complete the field survey, consisting of questionnaire, physical examination and blood collection. From the 832 twin pairs, those with complete and clear demographic prints were selected as the target population. Information of Fingerprints pixel on the demographic characteristics of these 100 twin pairs and their related adulthood body type indicators were finally chosen to form this research. Descriptive statistics and mixed linear model were used for data analyses. In the mixed linear models adjusted for age and sex, data showed that the body fat percentage of those who had arches was higher than those who did not have the arches (P = 0.002), and those who had radial loops would have higher body fat percentage when compared with ones who did not (P = 0.041). After adjusted for age, there appeared no statistically significant correlation between radial loops and systolic pressure, but the correlations of arches (P = 0.031)and radial loops (P = 0.022) to diastolic pressure still remained statistically significant. Statistically significant correlations were found between fingerprint types and body size indicators, and the fingerprint types showed a useful tool to explore the effects of uterine environment on health status in one's adulthood.

Spiking and bursting patterns of fractional-order Izhikevich model

NASA Astrophysics Data System (ADS)

Teka, Wondimu W.; Upadhyay, Ranjit Kumar; Mondal, Argha

2018-03-01

Bursting and spiking oscillations play major roles in processing and transmitting information in the brain through cortical neurons that respond differently to the same signal. These oscillations display complex dynamics that might be produced by using neuronal models and varying many model parameters. Recent studies have shown that models with fractional order can produce several types of history-dependent neuronal activities without the adjustment of several parameters. We studied the fractional-order Izhikevich model and analyzed different kinds of oscillations that emerge from the fractional dynamics. The model produces a wide range of neuronal spike responses, including regular spiking, fast spiking, intrinsic bursting, mixed mode oscillations, regular bursting and chattering, by adjusting only the fractional order. Both the active and silent phase of the burst increase when the fractional-order model further deviates from the classical model. For smaller fractional order, the model produces memory dependent spiking activity after the pulse signal turned off. This special spiking activity and other properties of the fractional-order model are caused by the memory trace that emerges from the fractional-order dynamics and integrates all the past activities of the neuron. On the network level, the response of the neuronal network shifts from random to scale-free spiking. Our results suggest that the complex dynamics of spiking and bursting can be the result of the long-term dependence and interaction of intracellular and extracellular ionic currents.

Continuous production of ethanol from hexoses and pentoses using immobilized mixed cultures of Escherichia coli strains

PubMed Central

Unrean, Pornkamol; Srienc, Friedrich

2010-01-01

We have developed highly efficient ethanologenic E. coli strains that selectively consume pentoses and/or hexoses. Mixed cultures of these strains can be used to selectively adjust the sugar utilization kinetics in ethanol fermentations. Based on the kinetics of sugar utilization, we have designed and implemented an immobilized cell system for the optimized continuous conversion of sugars into ethanol. The results confirm that immobilized mixed cultures support a simultaneous conversion of hexoses and pentoses into ethanol at high yield and at a faster rate than immobilized homogenous cells. Continuous ethanol production has been maintained for several weeks at high productivity with near complete sugar utilization. The control of sugar utilization using immobilized mixed cultures can be adapted to any composition of hexoses and pentoses by adjusting the strain distribution of immobilized cells. The approach, therefore, holds promise for ethanol fermentation from lignocellulosic hydrolysates where the feedstock varies in sugar composition. PMID:20699108

Hospital costs by cost center of inpatient hospitalization for medicare patients undergoing major abdominal surgery.

PubMed

Stey, Anne M; Brook, Robert H; Needleman, Jack; Hall, Bruce L; Zingmond, David S; Lawson, Elise H; Ko, Clifford Y

2015-02-01

This study aims to describe the magnitude of hospital costs among patients undergoing elective colectomy, cholecystectomy, and pancreatectomy, determine whether these costs relate as expected to duration of care, patient case-mix severity and comorbidities, and whether risk-adjusted costs vary significantly by hospital. Correctly estimating the cost of production of surgical care may help decision makers design mechanisms to improve the efficiency of surgical care. Patient data from 202 hospitals in the ACS-NSQIP were linked to Medicare inpatient claims. Patient charges were mapped to cost center cost-to-charge ratios in the Medicare cost reports to estimate costs. The association of patient case-mix severity and comorbidities with cost was analyzed using mixed effects multivariate regression. Cost variation among hospitals was quantified by estimating risk-adjusted hospital cost ratios and 95% confidence intervals from the mixed effects multivariate regression. There were 21,923 patients from 202 hospitals who underwent an elective colectomy (n = 13,945), cholecystectomy (n = 5,569), or pancreatectomy (n = 2,409). Median cost was lowest for cholecystectomy ($15,651) and highest for pancreatectomy ($37,745). Room and board costs accounted for the largest proportion (49%) of costs and were correlated with length of stay, R = 0.89, p < 0.001. The patient case-mix severity and comorbidity variables most associated with cost were American Society of Anesthesiologists (ASA) class IV (estimate 1.72, 95% CI 1.57 to 1.87) and fully dependent functional status (estimate 1.63, 95% CI 1.53 to 1.74). After risk-adjustment, 66 hospitals had significantly lower costs than the average hospital and 57 hospitals had significantly higher costs. The hospital costs estimates appear to be consistent with clinical expectations of hospital resource use and differ significantly among 202 hospitals after risk-adjustment for preoperative patient characteristics and procedure type. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Group Prenatal Care: A Financial Perspective.

PubMed

Rowley, Rebecca A; Phillips, Lindsay E; O'Dell, Lisa; Husseini, Racha El; Carpino, Sarah; Hartman, Scott

2016-01-01

Multiple studies have demonstrated improved perinatal outcomes for group prenatal care (GPC) when compared to traditional prenatal care. Benefits of GPC include lower rates of prematurity and low birth weight, fewer cesarean deliveries, improved breastfeeding outcomes and improved maternal satisfaction with care. However, the outpatient financial costs of running a GPC program are not well established. This study involved the creation of a financial model that forecasted costs and revenues for prenatal care groups with various numbers of participants based on numerous variables, including patient population, payor mix, patient show rates, staffing mix, supply usage and overhead costs. The model was developed for use in an urban underserved practice. Adjusted revenue per pregnancy in this model was found to be $989.93 for traditional care and $1080.69 for GPC. Cost neutrality for GPC was achieved when each group enrolled an average of 10.652 women with an enriched staffing model or 4.801 women when groups were staffed by a single nurse and single clinician. Mathematical cost-benefit modeling in an urban underserved practice demonstrated that GPC can be not only financially sustainable but possibly a net income generator for the outpatient clinic. Use of this model could offer maternity care practices an important tool for demonstrating the financial practicality of GPC.

On the repeated measures designs and sample sizes for randomized controlled trials.

PubMed

Tango, Toshiro

2016-04-01

For the analysis of longitudinal or repeated measures data, generalized linear mixed-effects models provide a flexible and powerful tool to deal with heterogeneity among subject response profiles. However, the typical statistical design adopted in usual randomized controlled trials is an analysis of covariance type analysis using a pre-defined pair of "pre-post" data, in which pre-(baseline) data are used as a covariate for adjustment together with other covariates. Then, the major design issue is to calculate the sample size or the number of subjects allocated to each treatment group. In this paper, we propose a new repeated measures design and sample size calculations combined with generalized linear mixed-effects models that depend not only on the number of subjects but on the number of repeated measures before and after randomization per subject used for the analysis. The main advantages of the proposed design combined with the generalized linear mixed-effects models are (1) it can easily handle missing data by applying the likelihood-based ignorable analyses under the missing at random assumption and (2) it may lead to a reduction in sample size, compared with the simple pre-post design. The proposed designs and the sample size calculations are illustrated with real data arising from randomized controlled trials. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Evaluation of the Community Multiscale Air Quality Model for Simulating Winter Ozone Formation in the Uinta Basin

NASA Astrophysics Data System (ADS)

Matichuk, Rebecca; Tonnesen, Gail; Luecken, Deborah; Gilliam, Rob; Napelenok, Sergey L.; Baker, Kirk R.; Schwede, Donna; Murphy, Ben; Helmig, Detlev; Lyman, Seth N.; Roselle, Shawn

2017-12-01

The Weather Research and Forecasting (WRF) and Community Multiscale Air Quality (CMAQ) models were used to simulate a 10 day high-ozone episode observed during the 2013 Uinta Basin Winter Ozone Study (UBWOS). The baseline model had a large negative bias when compared to ozone (O3) and volatile organic compound (VOC) measurements across the basin. Contrary to other wintertime Uinta Basin studies, predicted nitrogen oxides (NOx) were typically low compared to measurements. Increases to oil and gas VOC emissions resulted in O3 predictions closer to observations, and nighttime O3 improved when reducing the deposition velocity for all chemical species. Vertical structures of these pollutants were similar to observations on multiple days. However, the predicted surface layer VOC mixing ratios were generally found to be underestimated during the day and overestimated at night. While temperature profiles compared well to observations, WRF was found to have a warm temperature bias and too low nighttime mixing heights. Analyses of more realistic snow heat capacity in WRF to account for the warm bias and vertical mixing resulted in improved temperature profiles, although the improved temperature profiles seldom resulted in improved O3 profiles. While additional work is needed to investigate meteorological impacts, results suggest that the uncertainty in the oil and gas emissions contributes more to the underestimation of O3. Further, model adjustments based on a single site may not be suitable across all sites within the basin.

Return to work from long-term sick leave: a six-year prospective study of the importance of adjustment latitudes at work and home.

PubMed

Dellve, Lotta; Fallman, Sara L; Ahlstrom, Linda

2016-01-01

The aim was to investigate the long-term importance of adjustment latitude for increased work ability and return to work among female human service workers on long-term sick leave. A cohort of female human service workers on long-term sick leave (>60 days) was given a questionnaire four times (0, 6, 12, 60 months). Linear mixed models were used for longitudinal analysis of the repeated measurements of work ability and return to work. Having a higher level of adjustment latitude was associated with both increased work ability and return to work. Adjustments related to work pace were strongly associated with increased work ability, as were adjustments to the work place. Having individual opportunities for taking short breaks and a general acceptance of taking short breaks were associated with increased work ability. At home, a higher level of responsibility for household work was related to increased work ability and return to work. Individuals with possibilities for adjustment latitude, especially pace and place at work, and an acceptance of taking breaks had greater increased work ability over time and a greater work ability compared with individuals who did not have such opportunities. This study highlights the importance of opportunities for adjustment latitude at work to increase work ability and return to work among female human service workers who have been on long-term sick leave. The results support push and pull theories for individual decision-making on return to work.

Anti-methanogenic effects of monensin in dairy and beef cattle: a meta-analysis.

PubMed

Appuhamy, J A D Ranga Niroshan; Strathe, A B; Jayasundara, S; Wagner-Riddle, C; Dijkstra, J; France, J; Kebreab, E

2013-08-01

Monensin is a widely used feed additive with the potential to minimize methane (CH4) emissions from cattle. Several studies have investigated the effects of monensin on CH4, but findings have been inconsistent. The objective of the present study was to conduct meta-analyses to quantitatively summarize the effect of monensin on CH4 production (g/d) and the percentage of dietary gross energy lost as CH4 (Ym) in dairy cows and beef steers. Data from 22 controlled studies were used. Heterogeneity of the monensin effects were estimated using random effect models. Due to significant heterogeneity (>68%) in both dairy and beef studies, the random effect models were then extended to mixed effect models by including fixed effects of DMI, dietary nutrient contents, monensin dose, and length of monensin treatment period. Monensin reduced Ym from 5.97 to 5.43% and diets with greater neutral detergent fiber contents (g/kg of dry matter) tended to enhance the monensin effect on CH4 in beef steers. When adjusted for the neutral detergent fiber effect, monensin supplementation [average 32 mg/kg of dry matter intake (DMI)] reduced CH4 emissions from beef steers by 19±4 g/d. Dietary ether extract content and DMI had a positive and a negative effect on monensin in dairy cows, respectively. When adjusted for these 2 effects in the final mixed-effect model, monensin feeding (average 21 mg/kg of DMI) was associated with a 6±3 g/d reduction in CH4 emissions in dairy cows. When analyzed across dairy and beef cattle studies, DMI or monensin dose (mg/kg of DMI) tended to decrease or increase the effect of monensin in reducing methane emissions, respectively. Methane mitigation effects of monensin in dairy cows (-12±6 g/d) and beef steers (-14±6 g/d) became similar when adjusted for the monensin dose differences between dairy cow and beef steer studies. When adjusted for DMI differences, monensin reduced Ym in dairy cows (-0.23±0.14) and beef steers (-0.33±0.16). Monensin treatment period length did not significantly modify the monensin effects in dairy cow or beef steer studies. Overall, monensin had stronger antimethanogenic effects in beef steers than dairy cows, but the effects in dairy cows could potentially be improved by dietary composition modifications and increasing the monensin dose. Copyright © 2013 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.

Performance evaluation of inpatient service in Beijing: a horizontal comparison with risk adjustment based on Diagnosis Related Groups.

PubMed

Jian, Weiyan; Huang, Yinmin; Hu, Mu; Zhang, Xiumei

2009-04-30

The medical performance evaluation, which provides a basis for rational decision-making, is an important part of medical service research. Current progress with health services reform in China is far from satisfactory, without sufficient regulation. To achieve better progress, an effective tool for evaluating medical performance needs to be established. In view of this, this study attempted to develop such a tool appropriate for the Chinese context. Data was collected from the front pages of medical records (FPMR) of all large general public hospitals (21 hospitals) in the third and fourth quarter of 2007. Locally developed Diagnosis Related Groups (DRGs) were introduced as a tool for risk adjustment and performance evaluation indicators were established: Charge Efficiency Index (CEI), Time Efficiency Index (TEI) and inpatient mortality of low-risk group cases (IMLRG), to reflect respectively work efficiency and medical service quality. Using these indicators, the inpatient services' performance was horizontally compared among hospitals. Case-mix Index (CMI) was used to adjust efficiency indices and then produce adjusted CEI (aCEI) and adjusted TEI (aTEI). Poisson distribution analysis was used to test the statistical significance of the IMLRG differences between different hospitals. Using the aCEI, aTEI and IMLRG scores for the 21 hospitals, Hospital A and C had relatively good overall performance because their medical charges were lower, LOS shorter and IMLRG smaller. The performance of Hospital P and Q was the worst due to their relatively high charge level, long LOS and high IMLRG. Various performance problems also existed in the other hospitals. It is possible to develop an accurate and easy to run performance evaluation system using Case-Mix as the tool for risk adjustment, choosing indicators close to consumers and managers, and utilizing routine report forms as the basic information source. To keep such a system running effectively, it is necessary to improve the reliability of clinical information and the risk-adjustment ability of Case-Mix.

Analysis of genetic effects of nuclear-cytoplasmic interaction on quantitative traits: genetic model for diploid plants.

PubMed

Han, Lide; Yang, Jian; Zhu, Jun

2007-06-01

A genetic model was proposed for simultaneously analyzing genetic effects of nuclear, cytoplasm, and nuclear-cytoplasmic interaction (NCI) as well as their genotype by environment (GE) interaction for quantitative traits of diploid plants. In the model, the NCI effects were further partitioned into additive and dominance nuclear-cytoplasmic interaction components. Mixed linear model approaches were used for statistical analysis. On the basis of diallel cross designs, Monte Carlo simulations showed that the genetic model was robust for estimating variance components under several situations without specific effects. Random genetic effects were predicted by an adjusted unbiased prediction (AUP) method. Data on four quantitative traits (boll number, lint percentage, fiber length, and micronaire) in Upland cotton (Gossypium hirsutum L.) were analyzed as a worked example to show the effectiveness of the model.

Can statistic adjustment of OR minimize the potential confounding bias for meta-analysis of case-control study? A secondary data analysis.

PubMed

Liu, Tianyi; Nie, Xiaolu; Wu, Zehao; Zhang, Ying; Feng, Guoshuang; Cai, Siyu; Lv, Yaqi; Peng, Xiaoxia

2017-12-29

Different confounder adjustment strategies were used to estimate odds ratios (ORs) in case-control study, i.e. how many confounders original studies adjusted and what the variables are. This secondary data analysis is aimed to detect whether there are potential biases caused by difference of confounding factor adjustment strategies in case-control study, and whether such bias would impact the summary effect size of meta-analysis. We included all meta-analyses that focused on the association between breast cancer and passive smoking among non-smoking women, as well as each original case-control studies included in these meta-analyses. The relative deviations (RDs) of each original study were calculated to detect how magnitude the adjustment would impact the estimation of ORs, compared with crude ORs. At the same time, a scatter diagram was sketched to describe the distribution of adjusted ORs with different number of adjusted confounders. Substantial inconsistency existed in meta-analysis of case-control studies, which would influence the precision of the summary effect size. First, mixed unadjusted and adjusted ORs were used to combine individual OR in majority of meta-analysis. Second, original studies with different adjustment strategies of confounders were combined, i.e. the number of adjusted confounders and different factors being adjusted in each original study. Third, adjustment did not make the effect size of original studies trend to constringency, which suggested that model fitting might have failed to correct the systematic error caused by confounding. The heterogeneity of confounder adjustment strategies in case-control studies may lead to further bias for summary effect size in meta-analyses, especially for weak or medium associations so that the direction of causal inference would be even reversed. Therefore, further methodological researches are needed, referring to the assessment of confounder adjustment strategies, as well as how to take this kind of bias into consideration when drawing conclusion based on summary estimation of meta-analyses.

Effect of flow and peristaltic mixing on bacterial growth in a gut-like channel

PubMed Central

Cremer, Jonas; Segota, Igor; Yang, Chih-yu; Arnoldini, Markus; Sauls, John T.; Zhang, Zhongge; Gutierrez, Edgar; Groisman, Alex; Hwa, Terence

2016-01-01

The ecology of microbes in the gut has been shown to play important roles in the health of the host. To better understand microbial growth and population dynamics in the proximal colon, the primary region of bacterial growth in the gut, we built and applied a fluidic channel that we call the “minigut.” This is a channel with an array of membrane valves along its length, which allows mimicking active contractions of the colonic wall. Repeated contraction is shown to be crucial in maintaining a steady-state bacterial population in the device despite strong flow along the channel that would otherwise cause bacterial washout. Depending on the flow rate and the frequency of contractions, the bacterial density profile exhibits varying spatial dependencies. For a synthetic cross-feeding community, the species abundance ratio is also strongly affected by mixing and flow along the length of the device. Complex mixing dynamics due to contractions is described well by an effective diffusion term. Bacterial dynamics is captured by a simple reaction–diffusion model without adjustable parameters. Our results suggest that flow and mixing play a major role in shaping the microbiota of the colon. PMID:27681630

Modeling indoor particulate exposures in inner city school classrooms

PubMed Central

Gaffin, Jonathan M.; Petty, Carter R.; Hauptman, Marissa; Kang, Choong-Min; Wolfson, Jack M.; Awad, Yara Abu; Di, Qian; Lai, Peggy S.; Sheehan, William J.; Baxi, Sachin; Coull, Brent A.; Schwartz, Joel D.; Gold, Diane R.; Koutrakis, Petros; Phipatanakul, Wanda

2016-01-01

Outdoor air pollution penetrates buildings and contributes to total indoor exposures. We investigated the relationship of indoor to outdoor particulate matter in inner-city school classrooms. The School Inner City Asthma Study investigates the effect of classroom-based environmental exposures on students with asthma in the northeast United States. Mixed-effects linear models were used to determine the relationships between indoor PM2.5 and BC and their corresponding outdoor concentrations, and to develop a model for predicting exposures to these pollutants. The indoor-outdoor sulfur ratio was used as an infiltration factor of outdoor fine particles. Weeklong concentrations of PM2.5 and BC in 199 samples from 136 classrooms (30 school buildings) were compared to those measured at a central monitoring site averaged over the same timeframe. Mixed effects regression models found significant random intercept and slope effects, which indicate that: 1) there are important PM2.5 sources in classrooms; 2) the penetration of outdoor PM2.5 particles varies by school, and 3) the site-specific outside PM2.5 levels (inferred by the models) differ from those observed at the central monitor site. Similar results were found for BC except for lack of indoor sources. The fitted predictions from the sulfur-adjusted models were moderately predictive of observed indoor pollutant levels (Out of sample correlations: PM2.5: r2 = 0.68, BC; r2 = 0.61). Our results suggest that PM2.5 has important classroom sources, which vary by school. Furthermore, using these mixed effects models, classroom exposures can be accurately predicted for dates when central site measures are available but indoor measures are not available. PMID:27599884

Mixed QM/MM molecular electrostatic potentials.

PubMed

Hernández, B; Luque, F J; Orozco, M

2000-05-01

A new method is presented for the calculation of the Molecular Electrostatic Potential (MEP) in large systems. Based on the mixed Quantum Mechanics/Molecular Mechanics (QM/MM) approach, the method assumes both a quantum and classical description for the molecule, and the calculation of the MEP in the space surrounding the molecule is made using this dual treatment. The MEP at points close to the molecule is computed using a full QM formalism, while a pure classical evaluation of the MEP is used for points located at large distances from the molecule. The algorithm allows the user to select the desired level of accuracy in the MEP, so that the definition of the regions where the MEP is computed at the classical or QM levels is adjusted automatically. The potential use of this QM/MM MEP in molecular modeling studies is discussed.

A Comparative Theoretical and Computational Study on Robust Counterpart Optimization: I. Robust Linear Optimization and Robust Mixed Integer Linear Optimization

PubMed Central

Li, Zukui; Ding, Ran; Floudas, Christodoulos A.

2011-01-01

Robust counterpart optimization techniques for linear optimization and mixed integer linear optimization problems are studied in this paper. Different uncertainty sets, including those studied in literature (i.e., interval set; combined interval and ellipsoidal set; combined interval and polyhedral set) and new ones (i.e., adjustable box; pure ellipsoidal; pure polyhedral; combined interval, ellipsoidal, and polyhedral set) are studied in this work and their geometric relationship is discussed. For uncertainty in the left hand side, right hand side, and objective function of the optimization problems, robust counterpart optimization formulations induced by those different uncertainty sets are derived. Numerical studies are performed to compare the solutions of the robust counterpart optimization models and applications in refinery production planning and batch process scheduling problem are presented. PMID:21935263

Do Mixed-Flora Preoperative Urine Cultures Matter?

PubMed

Polin, Michael R; Kawasaki, Amie; Amundsen, Cindy L; Weidner, Alison C; Siddiqui, Nazema Y

2017-06-01

To determine whether mixed-flora preoperative urine cultures, as compared with no-growth preoperative urine cultures, are associated with a higher prevalence of postoperative urinary tract infections (UTIs). This was a retrospective cohort study. Women who underwent urogynecologic surgery were included if their preoperative clean-catch urine culture result was mixed flora or no growth. Women were excluded if they received postoperative antibiotics for reasons other than treatment of a UTI. Women were divided into two cohorts based on preoperative urine culture results-mixed flora or no growth; the prevalence of postoperative UTI was compared between cohorts. Baseline characteristics were compared using χ 2 or Student t tests. A logistic regression analysis then was performed. We included 282 women who were predominantly postmenopausal, white, and overweight. There were many concomitant procedures; 46% underwent a midurethral sling procedure and 68% underwent pelvic organ prolapse surgery. Preoperative urine cultures resulted as mixed flora in 192 (68%) and no growth in 90 (32%) patients. Overall, 14% were treated for a UTI postoperatively. There was no difference in the proportion of patients treated for a postoperative UTI between the two cohorts (25 mixed flora vs 13 no growth, P = 0.77). These results remained when controlling for potentially confounding variables in a logistic regression model (adjusted odds ratio 0.92, 95% confidence interval 0.43-1.96). In women with mixed-flora compared with no-growth preoperative urine cultures, there were no differences in the prevalence of postoperative UTI. The clinical practice of interpreting mixed-flora cultures as negative is appropriate.

Developing a stroke severity index based on administrative data was feasible using data mining techniques.

PubMed

Sung, Sheng-Feng; Hsieh, Cheng-Yang; Kao Yang, Yea-Huei; Lin, Huey-Juan; Chen, Chih-Hung; Chen, Yu-Wei; Hu, Ya-Han

2015-11-01

Case-mix adjustment is difficult for stroke outcome studies using administrative data. However, relevant prescription, laboratory, procedure, and service claims might be surrogates for stroke severity. This study proposes a method for developing a stroke severity index (SSI) by using administrative data. We identified 3,577 patients with acute ischemic stroke from a hospital-based registry and analyzed claims data with plenty of features. Stroke severity was measured using the National Institutes of Health Stroke Scale (NIHSS). We used two data mining methods and conventional multiple linear regression (MLR) to develop prediction models, comparing the model performance according to the Pearson correlation coefficient between the SSI and the NIHSS. We validated these models in four independent cohorts by using hospital-based registry data linked to a nationwide administrative database. We identified seven predictive features and developed three models. The k-nearest neighbor model (correlation coefficient, 0.743; 95% confidence interval: 0.737, 0.749) performed slightly better than the MLR model (0.742; 0.736, 0.747), followed by the regression tree model (0.737; 0.731, 0.742). In the validation cohorts, the correlation coefficients were between 0.677 and 0.725 for all three models. The claims-based SSI enables adjusting for disease severity in stroke studies using administrative data. Copyright © 2015 Elsevier Inc. All rights reserved.

Factors associated with degree of atopy in Latino children in a nationwide pediatric sample: The GALA II Study

PubMed Central

Kumar, Rajesh; Nguyen, Elizabeth A; Roth, Lindsey A; Oh, Sam S; Gignoux, Christopher R.; Huntsman, Scott; Eng, Celeste; Moreno-Estrada, Andres; Sandoval, Karla; Peñaloza-Espinosa, Rosenda; López-López, Marisol; Avila, Pedro C.; Farber, Harold J.; Tcheurekdjian, Haig; Rodriguez-Cintron, William; Rodriguez-Santana, Jose R; Serebrisky, Denise; Thyne, Shannon M.; Williams, L. Keoki; Winkler, Cheryl; Bustamante, Carlos D.; Pérez-Stable, Eliseo J.; Borrell, Luisa N.; Burchard, Esteban G

2013-01-01

Background Atopy varies by ethnicity even within Latino groups. This variation may be due to environmental, socio-cultural or genetic factors. Objective To examine risk factors for atopy within a nationwide study of U.S. Latino children with and without asthma. Methods Aeroallergen skin test repsonse was analyzed in 1830 US latino subjects. Key determinants of atopy included: country / region of origin, generation in the U.S., acculturation, genetic ancestry and site to which individuals migrated. Serial multivariate zero inflated negative binomial regressions, stratified by asthma status, examined the association of each key determinant variable with the number of positive skin tests. In addition, the independent effect of each key variable was determined by including all key variables in the final models. Results In baseline analyses, African ancestry was associated with 3 times as many positive skin tests in participants with asthma (95% CI:1.62–5.57) and 3.26 times as many positive skin tests in control participants (95% CI: 1.02–10.39). Generation and recruitment site were also associated with atopy in crude models. In final models adjusted for key variables, Puerto Rican [exp(β) (95%CI): 1.31(1.02–1.69)] and mixed ethnicity [exp(β) (95%CI):1.27(1.03–1.56)] asthmatics had a greater probability of positive skin tests compared to Mexican asthmatics. Ancestry associations were abrogated by recruitment site, but not region of origin. Conclusions Puerto Rican ethnicity and mixed origin were associated with degree of atopy within U.S. Latino children with asthma. African ancestry was not associated with degree of atopy after adjusting for recruitment site. Local environment variation, represented by site, was associated with degree of sensitization. PMID:23684070

Cognitive decline and survival in Alzheimer's disease according to education level.

PubMed

Bruandet, A; Richard, F; Bombois, S; Maurage, C A; Masse, I; Amouyel, P; Pasquier, F

2008-01-01

We tested the hypothesis that a higher education level is associated with faster cognitive decline and lower survival in a cohort of 670 Alzheimer's disease patients, followed for 3.5 years at the Lille-Bailleul memory centre. The patients were categorized in 3 groups according to educational levels: low (12 years). Cognitive function was measured with the Mini Mental State Examination (MMSE) and the Mattis Dementia Rating Scale (DRS). Survival was analyzed with a Cox model. Analyses were adjusted for age, sex, cholinesterase inhibitor treatment, diabetes, hypertension, visible vascular lesions on MRI, baseline DRS and MMSE. The adjusted mixed random model showed that MMSE declined faster for patients with high and intermediate educational levels compared with those with a low educational level (p < 0.0001). The mean annually adjusted DRS decline was highest for the groups with the most education (p = 0.05). The mortality risk was not higher in the better-educated groups (high vs. low: RR = 0.84; 95% CI = 0.35-1.99, intermediate vs. low: RR = 0.82; 95% CI = 0.41-1.63). In our cohort, highly educated patients had a faster cognitive decline than less educated patients but similar mortality rates. Our findings support the cognitive reserve hypothesis. (c) 2007 S. Karger AG, Basel.

A Coupled Surface Nudging Scheme for use in Retrospective ...

EPA Pesticide Factsheets

A surface analysis nudging scheme coupling atmospheric and land surface thermodynamic parameters has been implemented into WRF v3.8 (latest version) for use with retrospective weather and climate simulations, as well as for applications in air quality, hydrology, and ecosystem modeling. This scheme is known as the flux-adjusting surface data assimilation system (FASDAS) developed by Alapaty et al. (2008). This scheme provides continuous adjustments for soil moisture and temperature (via indirect nudging) and for surface air temperature and water vapor mixing ratio (via direct nudging). The simultaneous application of indirect and direct nudging maintains greater consistency between the soil temperature–moisture and the atmospheric surface layer mass-field variables. The new method, FASDAS, consistently improved the accuracy of the model simulations at weather prediction scales for different horizontal grid resolutions, as well as for high resolution regional climate predictions. This new capability has been released in WRF Version 3.8 as option grid_sfdda = 2. This new capability increased the accuracy of atmospheric inputs for use air quality, hydrology, and ecosystem modeling research to improve the accuracy of respective end-point research outcome. IMPACT: A new method, FASDAS, was implemented into the WRF model to consistently improve the accuracy of the model simulations at weather prediction scales for different horizontal grid resolutions, as wel

Determinants of captan air and dermal exposures among orchard pesticide applicators in the Agricultural Health Study.

PubMed

Hines, Cynthia J; Deddens, James A; Coble, Joseph; Kamel, Freya; Alavanja, Michael C R

2011-07-01

To identify and quantify determinants of captan exposure among 74 private orchard pesticide applicators in the Agricultural Health Study (AHS). To adjust an algorithm used for estimating pesticide exposure intensity in the AHS based on these determinants and to compare the correlation of the adjusted and unadjusted algorithms with urinary captan metabolite levels. External exposure metrics included personal air, hand rinse, and dermal patch samples collected from each applicator on 2 days in 2002-2003. A 24-h urine sample was also collected. Exposure determinants were identified for each external metric using multiple linear regression models via the NLMIXED procedure in SAS. The AHS algorithm was adjusted, consistent with the identified determinants. Mixed-effect models were used to evaluate the correlation between the adjusted and unadjusted algorithm and urinary captan metabolite levels. Consistent determinants of captan exposure were a measure of application size (kilogram of captan sprayed or application method), wearing chemical-resistant (CR) gloves and/or a coverall/suit, repairing spray equipment, and product formulation. Application by airblast was associated with a 4- to 5-fold increase in exposure as compared to hand spray. Exposure reduction to the hands, right thigh, and left forearm from wearing CR gloves averaged ∼80%, to the right and left thighs and right forearm from wearing a coverall/suit by ∼70%. Applicators using wettable powder formulations had significantly higher air, thigh, and forearm exposures than those using liquid formulations. Application method weights in the AHS algorithm were adjusted to nine for airblast and two for hand spray; protective equipment reduction factors were adjusted to 0.2 (CR gloves), 0.3 (coverall/suit), and 0.1 (both). Adjustment of application method, CR glove, and coverall weights in the AHS algorithm based on our exposure determinant findings substantially improved the correlation between the AHS algorithm and urinary metabolite levels.

Determinants of Captan Air and Dermal Exposures among Orchard Pesticide Applicators in the Agricultural Health Study

PubMed Central

Hines, Cynthia J.; Deddens, James A.; Coble, Joseph; Kamel, Freya; Alavanja, Michael C. R.

2011-01-01

Objectives: To identify and quantify determinants of captan exposure among 74 private orchard pesticide applicators in the Agricultural Health Study (AHS). To adjust an algorithm used for estimating pesticide exposure intensity in the AHS based on these determinants and to compare the correlation of the adjusted and unadjusted algorithms with urinary captan metabolite levels. Methods: External exposure metrics included personal air, hand rinse, and dermal patch samples collected from each applicator on 2 days in 2002–2003. A 24-h urine sample was also collected. Exposure determinants were identified for each external metric using multiple linear regression models via the NLMIXED procedure in SAS. The AHS algorithm was adjusted, consistent with the identified determinants. Mixed-effect models were used to evaluate the correlation between the adjusted and unadjusted algorithm and urinary captan metabolite levels. Results: Consistent determinants of captan exposure were a measure of application size (kilogram of captan sprayed or application method), wearing chemical-resistant (CR) gloves and/or a coverall/suit, repairing spray equipment, and product formulation. Application by airblast was associated with a 4- to 5-fold increase in exposure as compared to hand spray. Exposure reduction to the hands, right thigh, and left forearm from wearing CR gloves averaged ∼80%, to the right and left thighs and right forearm from wearing a coverall/suit by ∼70%. Applicators using wettable powder formulations had significantly higher air, thigh, and forearm exposures than those using liquid formulations. Application method weights in the AHS algorithm were adjusted to nine for airblast and two for hand spray; protective equipment reduction factors were adjusted to 0.2 (CR gloves), 0.3 (coverall/suit), and 0.1 (both). Conclusions: Adjustment of application method, CR glove, and coverall weights in the AHS algorithm based on our exposure determinant findings substantially improved the correlation between the AHS algorithm and urinary metabolite levels. PMID:21427168

Spatiotemporal Dynamics of Bumblebees Foraging under Predation Risk

NASA Astrophysics Data System (ADS)

Lenz, Friedrich; Ings, Thomas C.; Chittka, Lars; Chechkin, Aleksei V.; Klages, Rainer

2012-03-01

We analyze 3D flight paths of bumblebees searching for nectar in a laboratory experiment with and without predation risk from artificial spiders. For the flight velocities we find mixed probability distributions reflecting the access to the food sources while the threat posed by the spiders shows up only in the velocity correlations. The bumblebees thus adjust their flight patterns spatially to the environment and temporally to predation risk. Key information on response to environmental changes is contained in temporal correlation functions, as we explain by a simple emergent model.

Study of the Formation and Evolution of Precipitation Induced Sea Surface Salinity Minima in the Tropical Pacific Using HYCOM

NASA Astrophysics Data System (ADS)

Gallagher, R. L.

2016-02-01

During heavy rain events in the tropics, areas of relatively low salinity water collect on the ocean surface. Rainfall events increase the buoyancy of the ocean surface and impact upper ocean salinity and temperature profiles. This resists downward mixing and as a result can persist (SPURS II planning group, 2012; Oceanography 28(1) 150-159). Salinity at the surface adjusts through advective and diffusive mixing processes (Scott, J. et al, 2013; AGU Fall meeting abstracts). This project investigates the upper ocean salinity response in both advection and diffusion dominated regions. The changes in ocean surface salinity are tracked before, during, and after rainfall events. Data from a standard oceanographic model, HYCOM, are used to identify areas where each surface process is significant. Rainfall events are identified using a TRMM dataset. It provides a tropical rainfall analysis which uses amalgamated satellite data to develop detailed global precipitation grids between 50 o north and south latitude. TRMM is useful due its high temporal and spatial resolutions. The salinity response in HYCOM is tested against simple theoretical advective and diffusive mixing models. The magnitude of sea surface salinity minima, their persistence and the precision by which HYCOM can resolve these phenomena are of interest.

Decompression Surgery Alone Versus Decompression Plus Fusion in Symptomatic Lumbar Spinal Stenosis: A Swiss Prospective Multicenter Cohort Study With 3 Years of Follow-up.

PubMed

Ulrich, Nils H; Burgstaller, Jakob M; Pichierri, Giuseppe; Wertli, Maria M; Farshad, Mazda; Porchet, François; Steurer, Johann; Held, Ulrike

2017-09-15

Retrospective analysis of a prospective, multicenter cohort study. To estimate the added effect of surgical fusion as compared to decompression surgery alone in symptomatic lumbar spinal stenosis patients with spondylolisthesis. The optimal surgical management of lumbar spinal stenosis patients with spondylolisthesis remains controversial. Patients of the Lumbar Stenosis Outcome Study with confirmed DLSS and spondylolisthesis were enrolled in this study. The outcomes of this study were Spinal Stenosis Measure (SSM) symptoms (score range 1-5, best-worst) and function (1-4) over time, measured at baseline, 6, 12, 24, and 36 months follow-up. In order to quantify the effect of fusion surgery as compared to decompression alone and number of decompressed levels, we used mixed effects models and accounted for the repeated observations in main outcomes (SSM symptoms and SSM function) over time. In addition to individual patients' random effects, we also fitted random slopes for follow-up time points and compared these two approaches with Akaike's Information Criterion and the chi-square test. Confounders were adjusted with fixed effects for age, sex, body mass index, diabetes, Cumulative Illness Rating Scale musculoskeletal disorders, and duration of symptoms. One hundred thirty-one patients undergoing decompression surgery alone (n = 85) or decompression with fusion surgery (n = 46) were included in this study. In the multiple mixed effects model the adjusted effect of fusion compared with decompression alone surgery on SSM symptoms was 0.06 (95% confidence interval: -0.16-0.27) and -0.07 (95% confidence interval: -0.25-0.10) on SSM function, respectively. Among the patients with degenerative lumbar spinal stenosis and spondylolisthesis our study confirms that in the two groups, decompression alone and decompression with fusion, patients distinctively benefited from surgical treatment. When adjusted for confounders, fusion surgery was not associated with a more favorable outcome in both SSM scores as compared to decompression alone surgery. 3.

Reductions in Medication-Related Hospitalizations in Older Adults with Medication Management by Hospital and Community Pharmacists: A Quasi-Experimental Study.

PubMed

Pellegrin, Karen L; Krenk, Les; Oakes, Sheena Jolson; Ciarleglio, Anita; Lynn, Joanne; McInnis, Terry; Bairos, Alistair W; Gomez, Lara; McCrary, Mercedes Benitez; Hanlon, Alexandra L; Miyamura, Jill

2017-01-01

To evaluate the association between a system of medication management services provided by specially trained hospital and community pharmacists (Pharm2Pharm) and rates and costs of medication-related hospitalization in older adults. Quasi-experimental interrupted time series design comparing intervention and nonintervention hospitals using a mixed-effects analysis that modeled the intervention as a time-dependent variable. Sequential implementation of Pharm2Pharm at six general nonfederal acute care hospitals in Hawaii with more than 50 beds in 2013 and 2014. All five other such hospitals served as a contemporaneous comparison group. Adult inpatients who met criteria for being at risk for medication problems (N = 2,083), 62% of whom were aged 65 or older. A state-wide system of medication management services provided by specially trained hospital and community pharmacists serving high-risk individuals from hospitalization through transition to home and for up to 1 year after discharge. Medication-related hospitalization rate per 1,000 admissions of individuals aged 65 and older, adjusted for case mix; estimate of costs of hospitalizations and actual costs of pharmacist services. The predicted, case mix-adjusted medication-related hospitalization rate of individuals aged 65 and older was 36.5% lower in the Pharm2Pharm hospitals after implementation than in the nonintervention hospitals (P = .01). The estimated annualized cost of avoided admissions was $6.6 million. The annual cost of the pharmacist services for all Pharm2Pharm participants was $1.8 million. The Pharm2Pharm model was associated with an estimated 36% reduction in the medication-related hospitalization rate for older adults and a 2.6:1 return on investment, highlighting the value of pharmacists as drug therapy experts in geriatric care. © 2016 The Authors. The Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society.

The consumption of alcohol mixed with energy drinks: prevalence and key correlates among Canadian high school students

PubMed Central

Azagba, Sunday; Langille, Don

2013-01-01

Background An emerging body of research has reported high consumption of alcohol mixed with energy drinks among young adults, particularly college students. However, little is known about adolescents’ consumption of these drinks. The purpose of this study was to determine the prevalence of consumption of alcohol mixed with energy drinks and to examine its correlates among Canadian high school students. Methods We used a nationally representative sample of 36 155 Canadian students in grades 7 to 12 who participated in the 2010/2011 Youth Smoking Survey. Results About 20% of Canadian high school students reported consuming alcohol mixed with energy drinks in the last year, with considerable variation across provinces. Multivariate logistic regression analyses showed that the odds of consumption of these drinks were higher among students in lower grades (grades 7 and 8) and among students who identified their ethnicity as black or “other.” Consumption of alcohol mixed with energy drinks was positively associated with substance use (current smoking [adjusted odds ratio (OR) 1.52, 95% confidence interval (CI) 1.19–1.95], past-year heavy drinking [adjusted OR 3.41, 95% CI 2.84–4.09] and marijuana use [adjusted OR 2.29, 95% CI 1.90–2.76]), absence from school, participation in school team sports and having more weekly spending money. Students who felt more connected to school and had an academic average of 70% or higher were less likely to consume alcohol mixed with energy drinks. Interpretation The consumption of alcohol mixed with energy drinks is an emerging public health concern. Consumption of these drinks is substantial among Canadian high school students and can lead to many potential harms, both acute (e.g., injury) and long term (e.g., increased alcohol dependence). Our findings highlight the need for further research into the long-term effects of consumption of alcohol mixed with energy drinks among young people, as well as the development of interventions aimed at reducing consumption of these drinks. PMID:25077098

Do effects of common case-mix adjusters on patient experiences vary across patient groups?

PubMed

de Boer, Dolf; van der Hoek, Lucas; Rademakers, Jany; Delnoij, Diana; van den Berg, Michael

2017-11-22

Many survey studies in health care adjust for demographic characteristics such as age, gender, educational attainment and general health when performing statistical analyses. Whether the effects of these demographic characteristics are consistent between patient groups remains to be determined. This is important as the rationale for adjustment is often that demographic sub-groups differ in their so-called 'response tendency'. This rationale may be less convincing if the effects of response tendencies vary across patient groups. The present paper examines whether the impact of these characteristics on patients' global rating of care varies across patient groups. Secondary analyses using multi-level regression models were performed on a dataset including 32 different patient groups and 145,578 observations. For each demographic variable, the 95% expected range of case-mix coefficients across patient groups is presented. In addition, we report whether the variance of coefficients for demographic variables across patient groups is significant. Overall, men, elderly, lower educated people and people in good health tend to give higher global ratings. However, these effects varied significantly across patient groups and included the possibility of no effect or an opposite effect in some patient groups. The response tendency attributed to demographic characteristics - such as older respondents being milder, or higher educated respondents being more critical - is not general or universal. As such, the mechanism linking demographic characteristics to survey results on patient experiences with quality of care is more complicated than a general response tendency. It is possible that the response tendency interacts with patient group, but it is also possible that other mechanisms are at play.

Prevalence, patterns, and correlates of HIV disclosure among TB-HIV patients initiating antiretroviral therapy in Lesotho.

PubMed

Hayes-Larson, Eleanor; Hirsch-Moverman, Yael; Saito, Suzue; Frederix, Koen; Pitt, Blanche; Maama, Bridget Llang; Howard, Andrea A

2017-08-01

Disclosure of HIV-positive status has important implications for patient outcomes and preventing HIV transmission, but has been understudied in TB-HIV patients. We assessed disclosure patterns and correlates of non-disclosure among adult TB-HIV patients initiating ART enrolled in the START Study, a mixed-methods cluster-randomized trial conducted in Lesotho, which evaluated a combination intervention package (CIP) versus standard of care. Interviewer-administered questionnaire data were analyzed to describe patterns of disclosure. Patient-related factors were assessed for association with non-disclosure to anyone other than a health-care provider and primary partners using generalized linear mixed models. Among 371 participants, 95% had disclosed their HIV diagnosis to someone other than a health-care provider, most commonly a spouse/primary partner (76%). Age, TB knowledge, not planning to disclose TB status, greater perceived TB stigma, and CIP were associated with non-disclosure in unadjusted models (p < .1). In adjusted models, all point estimates were similar and greater TB knowledge (adjusted odds ratio [aOR] 0.59, 95% confidence interval [CI] 0.39-0.90) and CIP (aOR 0.20, 95% CI 0.05-0.79) remained statistically significant. Among 220 participants with a primary partner, 76% had disclosed to that partner. Significant correlates of partner non-disclosure (p < .1) in unadjusted analyses included being female, married/cohabitating, electricity at home, not knowing if partner was HIV-positive, and TB knowledge. Adjusted point estimates were largely similar, and being married/cohabitating (aOR 0.03, 95% CI 0.01-0.12), having electricity at home (aOR 0.38, 95% CI 0.17-0.85) and greater TB knowledge (aOR 0.76, 95% CI 0.59-0.98) remained significant. In conclusion, although nearly all participants reported disclosing their HIV status to someone other than a health-care provider at ART initiation, nearly a quarter of participants with a primary partner had not disclosed to their partner. Additional efforts to support HIV disclosure (e.g., counseling) may be needed for TB-HIV patients, particularly for women and those unaware of their partners' status.

Seeded hot dark matter models with inflation

NASA Technical Reports Server (NTRS)

Gratsias, John; Scherrer, Robert J.; Steigman, Gary; Villumsen, Jens V.

1993-01-01

We examine massive neutrino (hot dark matter) models for large-scale structure in which the density perturbations are produced by randomly distributed relic seeds and by inflation. Power spectra, streaming velocities, and the Sachs-Wolfe quadrupole fluctuation are derived for this model. We find that the pure seeded hot dark matter model without inflation produces Sachs-Wolfe fluctuations far smaller than those seen by COBE. With the addition of inflationary perturbations, fluctuations consistent with COBE can be produced. The COBE results set the normalization of the inflationary component, which determines the large-scale (about 50/h Mpc) streaming velocities. The normalization of the seed power spectrum is a free parameter, which can be adjusted to obtain the desired fluctuations on small scales. The power spectra produced are very similar to those seen in mixed hot and cold dark matter models.

[Study on the multilevel and longitudinal association between red meat consumption and changes in body mass index, body weight and risk of incident overweight among Chinese adults].

PubMed

Wang, Zhi-hong; Zhang, Bing; Wang, Hui-jun; Zhang, Ji-guo; DU, Wen-wen; Su, Chang; Zhang, Ji; Zhai, Feng-ying

2013-07-01

To examine the longitudinal association between red meat consumption and changes in body mass index(BMI), body weight and overweight risk in Chinese adults. Data from the open, prospective cohort study 'China Health and Nutrition Survey' (CHNS), 18 006 adults(47.5% males)were chosen as the study subjects who participated in at least one wave of survey between 1991 and 2009. Three-level(community-individual-measure occasion) mixed effect modeling was performed to investigate the effect of red meat consumption on BMI, body weight changes and risk of overweight. The average daily red meat intake was assessed using consecutive 3 d 24 h recalls. In general, participants with higher red meat intake appeared to be those with younger age, higher personal income and higher education level, lower physical activities, higher total energy intake, smokers and alcohol drinkers. 3-level mixed-effects linear regression models showed that red meat intake was positively associated with changes in BMI and body weight. Compared to those who consumed no red meat, men and women in the highest quartile of red meat intake showed an increase of 0.17(95% CI:0.08-0.26, P < 0.0001)and 0.12 kg/m(2) (95%CI:0.02-0.22, P < 0.05) on BMI and increase of 596 g (95%CI:329-864, P < 0.0001) and 400 g (95%CI:164-636, P < 0.0001) on body weight, respectively, after adjustment for potential confounders (age, income, education, smoking, alcohol, physical activity level, community urbanization index and total energy intake). After adjustment for above confounders and baseline BMI, results from the 3-level mixed effect logistic model indicated that the odds ratios of being overweight in males and females who had the highest quartile of red meat intake were 1.21 (95%CI:1.01-1.46, P < 0.05)and 1.18(95% CI:1.01-1.37, P < 0.05) in comparison with non-consumers of red meat, respectively. Higher red meat intake was associated with increased BMI and body weight, as well as increased overweight risk.

Prenatal Methamphetamine Exposure and Inhibitory Control among Young School-Age Children

PubMed Central

Derauf, Chris; LaGasse, Linda L.; Smith, Lynne M.; Newman, Elana; Shah, Rizwan; Neal, Charles; Arria, Amelia; Huestis, Marilyn A.; Grotta, Sheri Della; Dansereau, Lynne M.; Lin, Hai; Lester, Barry M.

2012-01-01

Objective To examine the association between prenatal methamphetamine exposure and inhibitory control in 66 month old children followed since birth in the multicenter, longitudinal Infant Development, Environment and Lifestyle Study. Study design The sample included 137 children with prenatal methamphetamine exposure and 130 comparison children, matched for race, birth weight, maternal education and type of insurance. Inhibitory control, an executive function related to emotional and cognitive control, was assessed using a computerized Stroop-like task developed for young children. Hierarchical linear modeling tested the relationship between the extent (heavy, some and no use) of prenatal methamphetamine exposure and accuracy and reaction time outcomes, adjusting for prenatal exposure to alcohol, tobacco and marijuana, age, sex, socioeconomic status, caregiver IQ and psychological symptoms, child protective services report of physical or sexual abuse, and site. Results In adjusted analyses, heavy prenatal methamphetamine exposure was related to reduced accuracy in both the incongruent and mixed conditions on the Stroop task. Caregiver psychological symptoms and Child Protective Services (CPS) report of physical or sexual abuse were associated with reduced accuracy in the incongruent and mixed, and incongruent conditions, respectively. Conclusions Heavy prenatal methamphetamine exposure, along with caregiver psychological distress and child maltreatment, is related to subtle deficits in inhibitory control during the early school-aged years. PMID:22424953

Variability in Proactive and Reactive Cognitive Control Processes Across the Adult Lifespan

PubMed Central

Karayanidis, Frini; Whitson, Lisa Rebecca; Heathcote, Andrew; Michie, Patricia T.

2011-01-01

Task-switching paradigms produce a highly consistent age-related increase in mixing cost [longer response time (RT) on repeat trials in mixed-task than single-task blocks] but a less consistent age effect on switch cost (longer RT on switch than repeat trials in mixed-task blocks). We use two approaches to examine the adult lifespan trajectory of control processes contributing to mixing cost and switch cost: latent variables derived from an evidence accumulation model of choice, and event-related potentials (ERP) that temporally differentiate proactive (cue-driven) and reactive (target-driven) control processes. Under highly practiced and prepared task conditions, aging was associated with increasing RT mixing cost but reducing RT switch cost. Both effects were largely due to the same cause: an age effect for mixed-repeat trials. In terms of latent variables, increasing age was associated with slower non-decision processes, slower rate of evidence accumulation about the target, and higher response criterion. Age effects on mixing costs were evident only on response criterion, the amount of evidence required to trigger a decision, whereas age effects on switch cost were present for all three latent variables. ERPs showed age-related increases in preparation for mixed-repeat trials, anticipatory attention, and post-target interference. Cue-locked ERPs that are linked to proactive control were associated with early emergence of age differences in response criterion. These results are consistent with age effects on strategic processes controlling decision caution. Consistent with an age-related decline in cognitive flexibility, younger adults flexibly adjusted response criterion from trial-to-trial on mixed-task blocks, whereas older adults maintained a high criterion for all trials. PMID:22073037

Using structural equation modeling for network meta-analysis.

PubMed

Tu, Yu-Kang; Wu, Yun-Chun

2017-07-14

Network meta-analysis overcomes the limitations of traditional pair-wise meta-analysis by incorporating all available evidence into a general statistical framework for simultaneous comparisons of several treatments. Currently, network meta-analyses are undertaken either within the Bayesian hierarchical linear models or frequentist generalized linear mixed models. Structural equation modeling (SEM) is a statistical method originally developed for modeling causal relations among observed and latent variables. As random effect is explicitly modeled as a latent variable in SEM, it is very flexible for analysts to specify complex random effect structure and to make linear and nonlinear constraints on parameters. The aim of this article is to show how to undertake a network meta-analysis within the statistical framework of SEM. We used an example dataset to demonstrate the standard fixed and random effect network meta-analysis models can be easily implemented in SEM. It contains results of 26 studies that directly compared three treatment groups A, B and C for prevention of first bleeding in patients with liver cirrhosis. We also showed that a new approach to network meta-analysis based on the technique of unrestricted weighted least squares (UWLS) method can also be undertaken using SEM. For both the fixed and random effect network meta-analysis, SEM yielded similar coefficients and confidence intervals to those reported in the previous literature. The point estimates of two UWLS models were identical to those in the fixed effect model but the confidence intervals were greater. This is consistent with results from the traditional pairwise meta-analyses. Comparing to UWLS model with common variance adjusted factor, UWLS model with unique variance adjusted factor has greater confidence intervals when the heterogeneity was larger in the pairwise comparison. The UWLS model with unique variance adjusted factor reflects the difference in heterogeneity within each comparison. SEM provides a very flexible framework for univariate and multivariate meta-analysis, and its potential as a powerful tool for advanced meta-analysis is still to be explored.

Wavelet-based functional linear mixed models: an application to measurement error-corrected distributed lag models.

PubMed

Malloy, Elizabeth J; Morris, Jeffrey S; Adar, Sara D; Suh, Helen; Gold, Diane R; Coull, Brent A

2010-07-01

Frequently, exposure data are measured over time on a grid of discrete values that collectively define a functional observation. In many applications, researchers are interested in using these measurements as covariates to predict a scalar response in a regression setting, with interest focusing on the most biologically relevant time window of exposure. One example is in panel studies of the health effects of particulate matter (PM), where particle levels are measured over time. In such studies, there are many more values of the functional data than observations in the data set so that regularization of the corresponding functional regression coefficient is necessary for estimation. Additional issues in this setting are the possibility of exposure measurement error and the need to incorporate additional potential confounders, such as meteorological or co-pollutant measures, that themselves may have effects that vary over time. To accommodate all these features, we develop wavelet-based linear mixed distributed lag models that incorporate repeated measures of functional data as covariates into a linear mixed model. A Bayesian approach to model fitting uses wavelet shrinkage to regularize functional coefficients. We show that, as long as the exposure error induces fine-scale variability in the functional exposure profile and the distributed lag function representing the exposure effect varies smoothly in time, the model corrects for the exposure measurement error without further adjustment. Both these conditions are likely to hold in the environmental applications we consider. We examine properties of the method using simulations and apply the method to data from a study examining the association between PM, measured as hourly averages for 1-7 days, and markers of acute systemic inflammation. We use the method to fully control for the effects of confounding by other time-varying predictors, such as temperature and co-pollutants.

Native American ancestry, lung function, and COPD in Costa Ricans.

PubMed

Chen, Wei; Brehm, John M; Boutaoui, Nadia; Soto-Quiros, Manuel; Avila, Lydiana; Celli, Bartolome R; Bruse, Shannon; Tesfaigzi, Yohannes; Celedón, Juan C

2014-04-01

Whether Native American ancestry (NAA) is associated with COPD or lung function in a racially admixed Hispanic population is unknown. We recruited 578 Costa Ricans with and without COPD into a hybrid case-control/family-based cohort, including 316 members of families of index case subjects. All participants completed questionnaires and spirometry and gave a blood sample for DNA extraction. Genome-wide genotyping was conducted with the Illumina Human610-Quad and HumanOmniExpress BeadChip kits (Illumina Inc), and individual ancestral proportions were estimated from these genotypic data and reference panels. For unrelated individuals, linear or logistic regression was used for the analysis of NAA and COPD (GOLD [Global Initiative for Chronic Obstructive Lung Disease] stage II or greater) or lung function. For extended families, linear mixed models and generalized estimating equations were used for the analysis. All models were adjusted for age, sex, educational level, and smoking behavior; models for FEV1 were also adjusted for height. The average proportion of European, Native American, and African ancestry among participants was 62%, 35%, and 3%, respectively. After adjustment for current smoking and other covariates, NAA was inversely associated with COPD (OR per 10% increment, 0.55; 95% CI, 0.41-0.75) but positively associated with FEV1, FVC, and FEV1/FVC. After additional adjustment for pack-years of smoking, the association between NAA and COPD or lung function measures was slightly attenuated. We found that about 31% of the estimated effect of NAA on COPD is mediated by pack-years of smoking. NAA is inversely associated with COPD but positively associated with FEV1 or FVC in Costa Ricans. Ancestral effects on smoking behavior partly explain the findings for COPD but not for FEV1 or FVC.

Native American Ancestry, Lung Function, and COPD in Costa Ricans

PubMed Central

Chen, Wei; Brehm, John M.; Boutaoui, Nadia; Soto-Quiros, Manuel; Avila, Lydiana; Celli, Bartolome R.; Bruse, Shannon; Tesfaigzi, Yohannes

2014-01-01

Background: Whether Native American ancestry (NAA) is associated with COPD or lung function in a racially admixed Hispanic population is unknown. Methods: We recruited 578 Costa Ricans with and without COPD into a hybrid case-control/family-based cohort, including 316 members of families of index case subjects. All participants completed questionnaires and spirometry and gave a blood sample for DNA extraction. Genome-wide genotyping was conducted with the Illumina Human610-Quad and HumanOmniExpress BeadChip kits (Illumina Inc), and individual ancestral proportions were estimated from these genotypic data and reference panels. For unrelated individuals, linear or logistic regression was used for the analysis of NAA and COPD (GOLD [Global Initiative for Chronic Obstructive Lung Disease] stage II or greater) or lung function. For extended families, linear mixed models and generalized estimating equations were used for the analysis. All models were adjusted for age, sex, educational level, and smoking behavior; models for FEV1 were also adjusted for height. Results: The average proportion of European, Native American, and African ancestry among participants was 62%, 35%, and 3%, respectively. After adjustment for current smoking and other covariates, NAA was inversely associated with COPD (OR per 10% increment, 0.55; 95% CI, 0.41-0.75) but positively associated with FEV1, FVC, and FEV1/FVC. After additional adjustment for pack-years of smoking, the association between NAA and COPD or lung function measures was slightly attenuated. We found that about 31% of the estimated effect of NAA on COPD is mediated by pack-years of smoking. Conclusions: NAA is inversely associated with COPD but positively associated with FEV1 or FVC in Costa Ricans. Ancestral effects on smoking behavior partly explain the findings for COPD but not for FEV1 or FVC. PMID:24306962

Antidepressant Medication Use and Its Association With Cardiovascular Disease and All-Cause Mortality in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study.

PubMed

Hansen, Richard A; Khodneva, Yulia; Glasser, Stephen P; Qian, Jingjing; Redmond, Nicole; Safford, Monika M

2016-04-01

Mixed evidence suggests that second-generation antidepressants may increase the risk of cardiovascular and cerebrovascular events. To assess whether antidepressant use is associated with acute coronary heart disease (CHD), stroke, cardiovascular disease (CVD) death, and all-cause mortality. Secondary analyses of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) longitudinal cohort study were conducted. Use of selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, bupropion, nefazodone, and trazodone was measured during the baseline (2003-2007) in-home visit. Outcomes of CHD, stroke, CVD death, and all-cause mortality were assessed every 6 months and adjudicated by medical record review. Cox proportional hazards time-to-event analysis followed patients until their first event on or before December 31, 2011, iteratively adjusting for covariates. Among 29 616 participants, 3458 (11.7%) used an antidepressant of interest. Intermediate models adjusting for everything but physical and mental health found an increased risk of acute CHD (hazard ratio [HR] = 1.21; 95% CI = 1.04-1.41), stroke (HR = 1.28; 95% CI = 1.02-1.60), CVD death (HR = 1.29; 95% CI = 1.09-1.53), and all-cause mortality (HR = 1.27; 95% CI = 1.15-1.41) for antidepressant users. Risk estimates trended in this direction for all outcomes in the fully adjusted model but only remained statistically associated with increased risk of all-cause mortality (HR = 1.12; 95% CI = 1.01-1.24). This risk was attenuated in sensitivity analyses censoring follow-up time at 2 years (HR = 1.37; 95% CI = 1.11-1.68). In fully adjusted models, antidepressant use was associated with a small increase in all-cause mortality. © The Author(s) 2016.

Association between Arsenic Exposure from Drinking Water and Longitudinal Change in Blood Pressure among HEALS Cohort Participants.

PubMed

Jiang, Jieying; Liu, Mengling; Parvez, Faruque; Wang, Binhuan; Wu, Fen; Eunus, Mahbub; Bangalore, Sripal; Newman, Jonathan D; Ahmed, Alauddin; Islam, Tariqul; Rakibuz-Zaman, Muhammad; Hasan, Rabiul; Sarwar, Golam; Levy, Diane; Slavkovich, Vesna; Argos, Maria; Scannell Bryan, Molly; Farzan, Shohreh F; Hayes, Richard B; Graziano, Joseph H; Ahsan, Habibul; Chen, Yu

2015-08-01

Cross-sectional studies have shown associations between arsenic exposure and prevalence of high blood pressure; however, studies examining the relationship of arsenic exposure with longitudinal changes in blood pressure are lacking. We evaluated associations of arsenic exposure in relation to longitudinal change in blood pressure in 10,853 participants in the Health Effects of Arsenic Longitudinal Study (HEALS). Arsenic was measured in well water and in urine samples at baseline and in urine samples every 2 years after baseline. Mixed-effect models were used to estimate the association of baseline well and urinary creatinine-adjusted arsenic with annual change in blood pressure during follow-up (median, 6.7 years). In the HEALS population, the median water arsenic concentration at baseline was 62 μg/L. Individuals in the highest quartile of baseline water arsenic or urinary creatinine-adjusted arsenic had a greater annual increase in systolic blood pressure compared with those in the reference group (β = 0.48 mmHg/year; 95% CI: 0.35, 0.61, and β = 0.43 mmHg/year; 95% CI: 0.29, 0.56 for water arsenic and urinary creatinine-adjusted arsenic, respectively) in fully adjusted models. Likewise, individuals in the highest quartile of baseline arsenic exposure had a greater annual increase in diastolic blood pressure for water arsenic and urinary creatinine-adjusted arsenic, (β = 0.39 mmHg/year; 95% CI: 0.30, 0.49, and β = 0.45 mmHg/year; 95% CI: 0.36, 0.55, respectively) compared with those in the lowest quartile. Our findings suggest that long-term arsenic exposure may accelerate age-related increases in blood pressure. These findings may help explain associations between arsenic exposure and cardiovascular disease.

Severity-Adjusted Mortality in Trauma Patients Transported by Police

PubMed Central

Band, Roger A.; Salhi, Rama A.; Holena, Daniel N.; Powell, Elizabeth; Branas, Charles C.; Carr, Brendan G.

2018-01-01

Study objective Two decades ago, Philadelphia began allowing police transport of patients with penetrating trauma. We conduct a large, multiyear, citywide analysis of this policy. We examine the association between mode of out-of-hospital transport (police department versus emergency medical services [EMS]) and mortality among patients with penetrating trauma in Philadelphia. Methods This is a retrospective cohort study of trauma registry data. Patients who sustained any proximal penetrating trauma and presented to any Level I or II trauma center in Philadelphia between January 1, 2003, and December 31, 2007, were included. Analyses were conducted with logistic regression models and were adjusted for injury severity with the Trauma and Injury Severity Score and for case mix with a modified Charlson index. Results Four thousand one hundred twenty-two subjects were identified. Overall mortality was 27.4%. In unadjusted analyses, patients transported by police were more likely to die than patients transported by ambulance (29.8% versus 26.5%; OR 1.18; 95% confidence interval [CI] 1.00 to 1.39). In adjusted models, no significant difference was observed in overall mortality between the police department and EMS groups (odds ratio [OR] 0.78; 95% CI 0.61 to 1.01). In subgroup analysis, patients with severe injury (Injury Severity Score >15) (OR 0.73; 95% CI 0.59 to 0.90), patients with gunshot wounds (OR 0.70; 95% CI 0.53 to 0.94), and patients with stab wounds (OR 0.19; 95% CI 0.08 to 0.45) were more likely to survive if transported by police. Conclusion We found no significant overall difference in adjusted mortality between patients transported by the police department compared with EMS but found increased adjusted survival among 3 key subgroups of patients transported by police. This practice may augment traditional care. PMID:24387925

Classroom Age Composition and Rates of Change in School Readiness for Children Enrolled in Head Start

ERIC Educational Resources Information Center

Bell, Elizabeth R.; Greenfield, Daryl B.; Bulotsky-Shearer, Rebecca J.

2013-01-01

Despite policy and theoretical support for mixed-age classrooms in early childhood, research examining associations between age-mixing and children's outcomes is inconclusive and warrants further investigation, particularly in preschools serving children who are at risk for poor adjustment to formal schooling. One recent study conducted in…

Use of a double chip seal to correct a flushing hot mix asphalt pavement in Washington state - final report.

DOT National Transportation Integrated Search

2016-09-01

A double chip seal was applied to an existing hot mix asphalt (HMA) pavement to mitigate severe flushing that existed throughout the project. Special care was taken to adjust the amount of binder used to account for the degree of flushing in the exis...

In-field experiment of electro-hydraulic tillage depth draft-position mixed control on tractor

NASA Astrophysics Data System (ADS)

Han, Jiangyi; Xia, Changgao; Shang, Gaogao; Gao, Xiang

2017-12-01

The soil condition and condition of the plow affect the tillage resistance and the maximum traction of tractor. In order to improve the adaptability of tractor tillage depth control, a multi-parameter control strategy is proposed that included tillage depth target, draft force aim and draft-position mixed ratio. In the strategy, the resistance coefficient was used to adjust the draft force target. Then, based on a JINMA1204 tractor, the electro-hydraulic hitch prototype is constructed that could set control parameters.. The fuzzy controller of draft-position mixed control is designed. After that, in-field experiments of position control was carried on, and the result of experiment shows the error of tillage depth was less than ±20mm. The experiment of draft-position control shown that the draft force and the tillage depth could be adjust by multi-parameter such as tillage depth, resistance coefficient and draft-position mixed coefficient. So that, the multi-parameter control strategy could improve the adaptability of tillage depth control in various soils and plow condition.

The Importance of Submesoscale Versus Basin-scale Processes in Driving the Subpolar Spring Phytoplankton Bloom.

NASA Astrophysics Data System (ADS)

Brody, S.; Mahadevan, A.; Lozier, M. S.

2014-12-01

The subpolar spring phytoplankton bloom has important consequences for marine ecosystems and the carbon cycle. The timing of the bloom has been conceived of as a basin-scale event: as the ocean warms, the seasonal mixed layer shoals, restricting phytoplankton to shallower depths and increasing available light to a level at which the bloom can begin. Recent studies have highlighted the importance of localized phenomena in driving the bloom initiation. Specifically, the role of lateral density gradients in generating <10km instabilities in the upper ocean, which then stratify the mixed layer before surface heating begins, has been explored with a process study model and fine-scale observations from a field program to study the North Atlantic spring bloom [1]. However, an alternative hypothesis has recently been validated at both the small scale, using the same observational data [2], and at the basin scale, using remote sensing data [3]. According to this hypothesis, blooms begin when surface heat fluxes weaken, mixing shifts from primarily convectively-driven to primarily wind-driven, and the depth of active mixing in the upper ocean consequently decreases. Here, we compare the importance of the barriers to mixing presented by submesoscale instabilities with the decreases in mixing depth caused by changes in surface forcing in driving the initiation of the spring bloom prior to the onset of surface heating. To make this comparison, we use a Lagrangian framework to track the light history of particles seeded in a high-resolution numerical model that we initialize with various surface forcing scenarios, and with and without lateral density gradients. Because the model parameterizes convection with convective adjustment, we present two methodologies to account for turbulent mixing processes that utilize observations of turbulent vertical mixing from a Lagrangian float. We present conclusions on whether and how submesoscale processes affect bloom initiation under varied surface forcing conditions in the context of whether the timing of the subpolar phytoplankton bloom can be thought of as a basin-scale or submesoscale phenomenon. [1] A. Mahadevan et al.. Science 337, 6090 (2012). [2] Brody, S.R. and Lozier, M.S. (under review, ICES J. Mar. Sci) [3] Brody, S.R. and Lozier, M.S. Geophys. Res. Lett. 41, (2014).

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.

Internal pilots for a class of linear mixed models with Gaussian and compound symmetric data

PubMed Central

Gurka, Matthew J.; Coffey, Christopher S.; Muller, Keith E.

2015-01-01

SUMMARY An internal pilot design uses interim sample size analysis, without interim data analysis, to adjust the final number of observations. The approach helps to choose a sample size sufficiently large (to achieve the statistical power desired), but not too large (which would waste money and time). We report on recent research in cerebral vascular tortuosity (curvature in three dimensions) which would benefit greatly from internal pilots due to uncertainty in the parameters of the covariance matrix used for study planning. Unfortunately, observations correlated across the four regions of the brain and small sample sizes preclude using existing methods. However, as in a wide range of medical imaging studies, tortuosity data have no missing or mistimed data, a factorial within-subject design, the same between-subject design for all responses, and a Gaussian distribution with compound symmetry. For such restricted models, we extend exact, small sample univariate methods for internal pilots to linear mixed models with any between-subject design (not just two groups). Planning a new tortuosity study illustrates how the new methods help to avoid sample sizes that are too small or too large while still controlling the type I error rate. PMID:17318914

Aging effect on step adjustments and stability control in visually perturbed gait initiation.

PubMed

Sun, Ruopeng; Cui, Chuyi; Shea, John B

2017-10-01

Gait adaptability is essential for fall avoidance during locomotion. It requires the ability to rapidly inhibit original motor planning, select and execute alternative motor commands, while also maintaining the stability of locomotion. This study investigated the aging effect on gait adaptability and dynamic stability control during a visually perturbed gait initiation task. A novel approach was used such that the anticipatory postural adjustment (APA) during gait initiation were used to trigger the unpredictable relocation of a foot-size stepping target. Participants (10 young adults and 10 older adults) completed visually perturbed gait initiation in three adjustment timing conditions (early, intermediate, late; all extracted from the stereotypical APA pattern) and two adjustment direction conditions (medial, lateral). Stepping accuracy, foot rotation at landing, and Margin of Dynamic Stability (MDS) were analyzed and compared across test conditions and groups using a linear mixed model. Stepping accuracy decreased as a function of adjustment timing as well as stepping direction, with older subjects exhibited a significantly greater undershoot in foot placement to late lateral stepping. Late adjustment also elicited a reaching-like movement (i.e. foot rotation prior to landing in order to step on the target), regardless of stepping direction. MDS measures in the medial-lateral and anterior-posterior direction revealed both young and older adults exhibited reduced stability in the adjustment step and subsequent steps. However, young adults returned to stable gait faster than older adults. These findings could be useful for future study of screening deficits in gait adaptability and preventing falls. Copyright © 2017 Elsevier B.V. All rights reserved.

[Control strategies of nitrogen removal process in a pilot test of the southern WWTP based on the nitrogen balance].

PubMed

Jiang, Ying-He; Liu, Pei-Ju; Wang, Lei; Tian, Zhong-Kai; Liu, Xiao-Ying

2014-04-01

By building the mass balance of nitrogen in A2/O process, the nitrogen model which raised some strategies on how to control sludge return ratio and mixed liquid return ratio to make the effluent nitrogen achieve the national standard A under different influent total nitrogen (TN) , was set up. And the presumed parameters were verified by the pilot test of the Wuhan's Longwangzui WWTP. The result showed that when the temperature and the TN were over 15 degrees C and below 30 mg x L(-1) respectively, the mixed liquid return ratio was 0. When the temperature was between 10 degrees C and 15 degrees C and TN was over 30 mg x L(-1), higher MLSS and DO elevated N removal. When the temperature was far below 10 degrees C, the mixed liquid return ratio was also at a higher level. Based on the Wuhan's Longwangzui WWTP influent water quality, measures of adjusting the return ratio were well adapted to obtain acceptable nitrogen effluent.

Controlled morphology and size of curcumin using ultrasound in supercritical CO2 antisolvent.

PubMed

Jia, Jingfu; Wang, Wucong; Gao, Yahui; Zhao, Yaping

2015-11-01

Controllable morphology and size of crystal materials prepared by using a supercritical antisolvent (SAS) technique is still challenge. In this study, ultrasound was introduced into the SAS process to produce the particles of curcumin, a model compound. The effects of ultrasound power on the particle morphology and size were investigated in the range of 0 and 240 W at three different pressures. The observation of jet flow indicated ultrasound could accelerate the mixing speed between the liquid solution and the CO2, and thus reduced the gaseous region and the local saturation gradient. Mixed polymorphic and uniform particles of the curcumin were produced at a low and high mixing speed, respectively, confirmed by scanning electron microscopy. The needle- or rod-like particle, irregular lumpy particle and nano spherical particle were generated with the increase of the ultrasound power, attributed to the changes of the degree of supersaturation. Therefore, the ultrasound can be potentially applied to adjust the morphology and size of the crystal materials in supercritical CO2 antisolvent. Copyright © 2015 Elsevier B.V. All rights reserved.

Direct simulations of chemically reacting turbulent mixing layers

NASA Technical Reports Server (NTRS)

Riley, J. J.; Metcalfe, R. W.

1984-01-01

The report presents the results of direct numerical simulations of chemically reacting turbulent mixing layers. The work consists of two parts: (1) the development and testing of a spectral numerical computer code that treats the diffusion reaction equations; and (2) the simulation of a series of cases of chemical reactions occurring on mixing layers. The reaction considered is a binary, irreversible reaction with no heat release. The reacting species are nonpremixed. The results of the numerical tests indicate that the high accuracy of the spectral methods observed for rigid body rotation are also obtained when diffusion, reaction, and more complex flows are considered. In the simulations, the effects of vortex rollup and smaller scale turbulence on the overall reaction rates are investigated. The simulation results are found to be in approximate agreement with similarity theory. Comparisons of simulation results with certain modeling hypotheses indicate limitations in these hypotheses. The nondimensional product thickness computed from the simulations is compared with laboratory values and is found to be in reasonable agreement, especially since there are no adjustable constants in the method.

Dark matter detection in supersymmetric models with non-universal gaugino masses

NASA Astrophysics Data System (ADS)

Park, Eun-Kyung

SUSY is one of the most promising new physics ideas, and will soon be tested at high energy accelerators like the CERN LHC. Moreover SUSY provides a good candidate for cold dark matter (CDM). In this dissertation, we investigated phenomenology of SUSY models with non-universal gaugino masses (NUGM) at colliding experiments using event generators such as ISAJET and examined direct and indirect detection rates of relic neutralino CDM in the universe. The motivation of these models is that in most of mSUGRA parameter space, the relic density WZ1˜ h2 is considerably larger than the WMAP measurement, and it is well known that if non-universal gaugino masses are allowed, then qualitatively new possibilities arise that are not realized in the mSUGRA model. Our first NUGM attempt is to allow a mixed wino-bino lightest SUSY particle (LSP) by lowering SU(2) gaugino mass M2 at the weak scale from its mSUGRA value while keeping the hypercharge gaugino mass M1 fixed (Mixed Wino Dark Matter). In this model, wino-like Z˜1 with sufficiently low M2 compared to M1 enhances Z˜1Z˜ 1 → W+1W-1 annihilations to reach the WMAP measured relic density. The second attempt is study on the NUGM model with different signs of M 1 and M2 (Bino-Wino Co-Annihilation Scenario). In this case, there is little mixing, so that Z˜1 remains nearly a pure bino or a pure wino. By increasing M1 ≃ M 2, enhanced bino-wino co-annihilation can achieve the relic neutralino abundance. The final attempt of NUGM models is lowering the SU(3) gaugino mass to diminish the effect of the large top quark Yukawa coupling in the running of the higgs mass, so that the value of superpotential mu parameter gets efficiently low to give rise to mixed higgsino dark matter (Mixed Higgsino Dark Matter). Consequences of these NUGM model studies show us that relaxing universality of gaugino masses in SUSY models leads to enhanced direct and indirect dark matter detection rates and reduced mZ2˜-m Z1˜ mass gap so that the LHC and ILC can distinguish each NUGM model from others. Finally, we found that models with well-tempered neutralinos, where the composition of the neutralino is adjusted to give observed relic density, yield target cross sections which are detectable at proposed experiments.

Does the presence and mix of destinations influence walking and physical activity?

PubMed

King, Tania Louise; Bentley, Rebecca Jodie; Thornton, Lukar Ezra; Kavanagh, Anne Marie

2015-09-17

Local destinations have previously been shown to be associated with higher levels of both physical activity and walking, but little is known about how specific destinations are related to activity. This study examined associations between types and mix of destinations and both walking frequency and physical activity. The sample consisted of 2349 residents of 50 urban areas in metropolitan Melbourne, Australia. Using geographic information systems, seven types of destinations were examined within three network buffers (400 meters (m), 800 m and 1200 m) of respondents' homes. Multilevel logistic regression was used to estimate effects of each destination type separately, as well as destination mix (variety) on: 1) likelihood of walking for at least 10 min ≥ 4/week; 2) likelihood of being sufficiently physically active. All models were adjusted for potential confounders. All destination types were positively associated with walking frequency, and physical activity sufficiency at 1200 m. For the 800 m buffer: all destinations except transport stops and sports facilities were significantly associated with physical activity, while all except sports facilities were associated with walking frequency; at 400 m, café/takeaway food stores and transport stops were associated with walking frequency and physical activity sufficiency, and sports facilities were also associated with walking frequency. Strongest associations for both outcomes were observed for community resources and small food stores at both 800 m and 1200 m. For all buffer distances: greater mix was associated with greater walking frequency. Inclusion of walking in physical activity models led to attenuation of associations. The results of this analysis indicate that there is an association between destinations and both walking frequency and physical activity sufficiency, and that this relationship varies by destination type. It is also clear that greater mix of destinations positively predicts walking frequency and physical activity sufficiency.

Explaining variation in hospice visit intensity for routine home care.

PubMed

Stearns, Sally C; Sheingold, Steven; Zuckerman, Rachael B

2014-01-01

Medicare pays a flat per diem rate by level of hospice service without case-mix adjustment, although previous research shows that visit intensity varies considerably over the course of hospice episodes. Concerns pertain to the inherent financial incentives for routine home care, the most frequently used level, and whether payment efficiency can be improved using case-mix adjustment. The aim of this study was to assess variation in hospice visit intensity during hospice episodes by patient, hospice, and episode characteristics to inform policy discussions regarding hospice payment methods. This observational study used Medicare claims for hospice episodes in 2010. Multiple observations were constructed per episode phase (eg, days 1-14, 15-30, etc.). Episode phase and observed characteristics were regressed on average routine home care visit intensity per day; patient and hospice fixed effects controlled for unobserved characteristics. Visit intensity was constructed using national wages to weight visits by provider type. Observed patient characteristics included age, sex, race, diagnoses, venue of care, use of other hospice levels of care, and discharge status; hospice characteristics included ownership, affiliation, size, and urban/state location. Visit intensity varied substantially by episode phase. This pattern was largely invariant to observed patient and hospice characteristics, which explained <4% of variation in visit intensity per day after adjusting for episode phase. Unobserved patient characteristics explained approximately 85% of remaining variation. These results show that case-mix adjustment based on commonly observed factors would only minimally improve hospice payment methodology.

Investigations of cloud microphysical response to mixing using digital holography

NASA Astrophysics Data System (ADS)

Beals, Matthew Jacob

Cloud edge mixing plays an important role in the life cycle and development of clouds. Entrainment of subsaturated air affects the cloud at the microscale, altering the number density and size distribution of its droplets. The resulting effect is determined by two timescales: the time required for the mixing event to complete, and the time required for the droplets to adjust to their new environment. If mixing is rapid, evaporation of droplets is uniform and said to be homogeneous in nature. In contrast, slow mixing (compared to the adjustment timescale) results in the droplets adjusting to the transient state of the mixture, producing an inhomogeneous result. Studying this process in real clouds involves the use of airborne optical instruments capable of measuring clouds at the 'single particle' level. Single particle resolution allows for direct measurement of the droplet size distribution. This is in contrast to other 'bulk' methods (i.e. hot-wire probes, lidar, radar) which measure a higher order moment of the distribution and require assumptions about the distribution shape to compute a size distribution. The sampling strategy of current optical instruments requires them to integrate over a path tens to hundreds of meters to form a single size distribution. This is much larger than typical mixing scales (which can extend down to the order of centimeters), resulting in difficulties resolving mixing signatures. The Holodec is an optical particle instrument that uses digital holography to record discrete, local volumes of droplets. This method allows for statistically significant size distributions to be calculated for centimeter scale volumes, allowing for full resolution at the scales important to the mixing process. The hologram also records the three dimensional position of all particles within the volume, allowing for the spatial structure of the cloud volume to be studied. Both of these features represent a new and unique view into the mixing problem. In this dissertation, holographic data recorded during two different field projects is analyzed to study the mixing structure of cumulus clouds. Using Holodec data, it is shown that mixing at cloud top can produce regions of clear but humid air that can subside down along the edge of the cloud as a narrow shell, or advect down shear as a 'humid halo'. This air is then entrained into the cloud at lower levels, producing mixing that appears to be very inhomogeneous. This inhomogeneous-like mixing is shown to be well correlated with regions containing elevated concentrations of large droplets. This is used to argue in favor of the hypothesis that dilution can lead to enhanced droplet growth rates. I also make observations on the microscale spatial structure of observed cloud volumes recorded by the Holodec.

The role of gender in a smoking cessation intervention: a cluster randomized clinical trial

PubMed Central

2011-01-01

Background The prevalence of smoking in Spain is high in both men and women. The aim of our study was to evaluate the role of gender in the effectiveness of a specific smoking cessation intervention conducted in Spain. Methods This study was a secondary analysis of a cluster randomized clinical trial in which the randomization unit was the Basic Care Unit (family physician and nurse who care for the same group of patients). The intervention consisted of a six-month period of implementing the recommendations of a Clinical Practice Guideline. A total of 2,937 current smokers at 82 Primary Care Centers in 13 different regions of Spain were included (2003-2005). The success rate was measured by a six-month continued abstinence rate at the one-year follow-up. A logistic mixed-effects regression model, taking Basic Care Units as random-effect parameter, was performed in order to analyze gender as a predictor of smoking cessation. Results At the one-year follow-up, the six-month continuous abstinence quit rate was 9.4% in men and 8.5% in women (p = 0.400). The logistic mixed-effects regression model showed that women did not have a higher odds of being an ex-smoker than men after the analysis was adjusted for confounders (OR adjusted = 0.9, 95% CI = 0.7-1.2). Conclusions Gender does not appear to be a predictor of smoking cessation at the one-year follow-up in individuals presenting at Primary Care Centers. ClinicalTrials.gov Identifier NCT00125905. PMID:21605389

Mixing and segregation of microspheres in microchannel flows of mono- and bidispersed suspensions

NASA Astrophysics Data System (ADS)

Gao, C.; Xu, B.; Gilchrist, J. F.

2009-03-01

We investigate the mixing and segregation of mono- and bidispersed microsphere suspensions in microchannel flows. These flows are common in biological microelectromechanical systems (BioMEMS) applications handling blood or suspensions of DNA. Suspension transport in pressure driven flows is significantly hindered by shear-induced migration, where particles migrate away from the walls and are focused in the center due to multibody hydrodynamic interactions. The microchannels used in this study have geometries that induce chaotic advection in Newtonian fluids. Our results show that mixing in straight, herringbone and staggered herringbone channels depends strongly on volume fraction. Due to this complex interplay of advection and shear-induced migration, a staggered herringbone channel that typically results in chaotic mixing is not always effective for dispersing particles. The maximum degree of segregation is observed in a straight channel once the maximum packing fraction is reached at channel center. We modify a one-dimensional suspension balance model [R. Miller and J. Morris, J. Non-Newtonian Fluid Mech. 135, 149 (2006)] to describe the behavior at the center of the straight channel. The degree of mixing is then calculated as a function of bulk volume fraction, predicting the volume fraction that results in the maximum degree of segregation. In bidispersed suspension flow, it is shown that mixing of the larger species is enhanced in straight and staggered herringbone channels while segregation is enhanced at moderate volume fractions in herringbone channels. This suggests mixing and separations can be tailored by adjusting both the suspension properties and the channel geometry.

Mixing a sol and a precipitate of block copolymers with different block ratios leads to an injectable hydrogel.

PubMed

Yu, Lin; Zhang, Zheng; Zhang, Huan; Ding, Jiandong

2009-06-08

A facile method to obtain a thermoreversible physical hydrogel was found by simply mixing an aqueous sol of a block copolymer with a precipitate of a similar copolymer but with a different block ratio. Two ABA-type triblock copolymers poly(D,L-lactic acid-co-glycolic acid)-B-poly(ethylene glycol)-B-poly(D,L-lactic acid-co-glycolic acid) (PLGA-PEG-PLGA) were synthesized. One sample in water was a sol in a broad temperature region, while the other in water was just a precipitate. The mixture of these two samples with a certain mix ratio underwent, however, a sol-to-gel-to-precipitate transition upon an increase of temperature. A dramatic tuning of the sol-gel transition temperature was conveniently achieved by merely varying mix ratio, even in the case of a similar molecular weight. Our study indicates that the balance of hydrophobicity and hydrophilicity within this sort of amphiphilic copolymers is critical to the inverse thermal gelation in water resulting from aggregation of micelles. The availability of encapsulation and sustained release of lysozyme, a model protein by the thermogelling systems was confirmed. This "mix" method provides a very convenient approach to design injectable thermogelling biomaterials with a broad adjustable window, and the novel copolymer mixture platform is potentially used in drug delivery and other biomedical applications.

Observation of Terahertz Radiation via the Two-Color Laser Scheme with Uncommon Frequency Ratios

NASA Astrophysics Data System (ADS)

Zhang, Liang-Liang; Wang, Wei-Min; Wu, Tong; Zhang, Rui; Zhang, Shi-Jing; Zhang, Cun-Lin; Zhang, Yan; Sheng, Zheng-Ming; Zhang, Xi-Cheng

2017-12-01

In the widely studied two-color laser scheme for terahertz (THz) radiation from a gas, the frequency ratio of the two lasers is usually fixed at ω2/ω1=1 :2 . We investigate THz generation with uncommon frequency ratios. Our experiments show, for the first time, efficient THz generation with new ratios of ω2/ω1=1 :4 and 2 ∶3 . We observe that the THz polarization can be adjusted by rotating the longer-wavelength laser polarization and the polarization adjustment becomes inefficient by rotating the other laser polarization; the THz energy shows similar scaling laws with different frequency ratios. These observations are inconsistent with multiwave mixing theory, but support the gas-ionization or plasma-current model. This study pushes the development of the two-color scheme and provides a new dimension to explore the long-standing problem of the THz generation mechanism.

Observation of Terahertz Radiation via the Two-Color Laser Scheme with Uncommon Frequency Ratios.

PubMed

Zhang, Liang-Liang; Wang, Wei-Min; Wu, Tong; Zhang, Rui; Zhang, Shi-Jing; Zhang, Cun-Lin; Zhang, Yan; Sheng, Zheng-Ming; Zhang, Xi-Cheng

2017-12-08

In the widely studied two-color laser scheme for terahertz (THz) radiation from a gas, the frequency ratio of the two lasers is usually fixed at ω_{2}/ω_{1}=1:2. We investigate THz generation with uncommon frequency ratios. Our experiments show, for the first time, efficient THz generation with new ratios of ω_{2}/ω_{1}=1:4 and 2∶3. We observe that the THz polarization can be adjusted by rotating the longer-wavelength laser polarization and the polarization adjustment becomes inefficient by rotating the other laser polarization; the THz energy shows similar scaling laws with different frequency ratios. These observations are inconsistent with multiwave mixing theory, but support the gas-ionization or plasma-current model. This study pushes the development of the two-color scheme and provides a new dimension to explore the long-standing problem of the THz generation mechanism.

A simulated annealing approach for redesigning a warehouse network problem

NASA Astrophysics Data System (ADS)

Khairuddin, Rozieana; Marlizawati Zainuddin, Zaitul; Jiun, Gan Jia

2017-09-01

Now a day, several companies consider downsizing their distribution networks in ways that involve consolidation or phase-out of some of their current warehousing facilities due to the increasing competition, mounting cost pressure and taking advantage on the economies of scale. Consequently, the changes on economic situation after a certain period of time require an adjustment on the network model in order to get the optimal cost under the current economic conditions. This paper aimed to develop a mixed-integer linear programming model for a two-echelon warehouse network redesign problem with capacitated plant and uncapacitated warehouses. The main contribution of this study is considering capacity constraint for existing warehouses. A Simulated Annealing algorithm is proposed to tackle with the proposed model. The numerical solution showed the model and method of solution proposed was practical.

Decubitus ulcers in patients undergoing vascular operations do not influence mortality but affect resource utilization.

PubMed

Mehaffey, J Hunter; Politano, Amani D; Bhamidipati, Castigliano M; Tracci, Margaret C; Cherry, Kenneth J; Kern, John A; Kron, Irving L; Upchurch, Gilbert R

2017-06-01

While it is anticipated that decubitus ulcers are detrimental to outcomes after vascular operations, the contemporary influence of perioperative decubitus ulcers in vascular surgery remains unknown. Using the National Impatient Survey, all adult patients who underwent vascular operation were selected. Patients were stratified by the presence or absence (non-decubitus ulcers) of decubitus ulcer. Case-mix adjusted hierarchical mixed-models examined in-hospital mortality, the occurrence of any complication, and discharge disposition. A total of 538,808 cases were analyzed. Decubitus ulcers were most prevalent among Caucasian male Medicare beneficiaries (P < .001). Decubitus ulcer patients also underwent more nonelective vascular operations (P < .001). Wound, infectious, and procedural complications were more common in patients with decubitus ulcers (P < .001). Failure to rescue, defined as mortality after any complication, was more than doubled in decubitus ulcers (non-decubitus ulcers: 1.5%, decubitus ulcers: 3.2%, P < .001). Similarly, unadjusted mortality was also doubled in patients undergoing vascular operation with decubitus ulcers (non-decubitus ulcers: 3%, decubitus ulcers: 6%, P < .001). After risk adjustment among all patients, neither the presence of a decubitus ulcer nor specific ulcer staging increased the adjusted odds of death. Having a decubitus ulcer increased the adjusted odds of discharge to an intermediate care facility (odds ratio 2.9, P < .001). These patients also had 1.6 times the total charges compared to their non-decubitus ulcer cohort (non-decubitus ulcers: $49,460 ± $281 vs decubitus ulcers: $81,149 ± $5,855, P < .001). Contrary to common perception, perioperative decubitus ulcer does not adversely affect mortality after vascular operation in patients proceeding to operative intervention. Patients with decubitus ulcers are, however, at higher risk for complications and incur sizeable additional charges. Copyright © 2017 Elsevier Inc. All rights reserved.

A comparison of patient characteristics and survival in two trauma centres located in different countries.

PubMed

Templeton, J; Oakley, P A; MacKenzie, G; Cook, A L; Brand, D; Mullins, R J; Trunkey, D D

2000-09-01

The aim of the study was to compare patient characteristics and mortality in severely injured patients in two trauma centres located in different countries, allowing for differences in case-mix. It represents a direct bench-marking exercise between the trauma centres at the North Staffordshire Hospital (NSH), Stoke-on-Trent, UK and the Oregon Health Sciences University (OHSU) Hospital, Portland, Oregon, USA. Patients of all ages admitted to the two hospitals during 1995 and 1996 with an Injury Severity Score >15 were included, except for those who died in the emergency departments. Twenty-three factors were studied, including the Injury Severity Score, Glasgow Coma Score, mechanism of injury and anatomical site of injury. Outcome analysis was based on mortality at discharge. The pattern of trauma differed significantly between Stoke and Portland. Patients from Stoke tended to be older, presented with a lower conscious level and a lower systolic blood pressure and were intubated less frequently before arriving at hospital. Mortality depended on similar factors in both centres, especially age, highest AIS score, systolic blood pressure and Glasgow Coma Score.The crude analysis of mortality showed a highly significant odds-ratio of 1.64 in Stoke compared with Portland. Single-factor adjustments were made for the above four factors, which had a similar influence on mortality in both centres. Adjusting for the first three factors individually did not alter the odds-ratio, which stayed in the range 1.53-1.59 and remained highly significant. Adjusting for the Glasgow Coma Score reduced the odds-ratio to 0.82 and rendered it non-significant. In a multi-factor logistic regression model incorporating all of the factors shown to influence mortality in either centre, the odds-ratio was 1.7 but was not significant. The analysis illustrates the limitations and pitfalls of making crude outcome comparisons between centres. Highly significant differences in crude mortality were rendered non-significant by case-mix adjustments, supporting the null hypothesis that the two centres were equally effective in terms of this short-term indicator of outcome. To achieve a meaningful comparison between centres, adjustments must be made for the factors which affect mortality.

Cardiovascular Disease Risk Varies by Birth Month in Canines.

PubMed

Boland, Mary Regina; Kraus, Marc S; Dziuk, Eddie; Gelzer, Anna R

2018-05-17

The canine heart is a robust physiological model for the human heart. Recently, birth month associations have been reported and replicated in humans using clinical health records. While animals respond readily to their environment in the wild, a systematic investigation of birth season dependencies among pets and specifically canines remains lacking. We obtained data from the Orthopedic Foundation of Animals on 129,778 canines representing 253 distinct breeds. Among canines that were not predisposed to cardiovascular disease, a clear birth season relationship is observed with peak risk occurring in June-August. Our findings indicate that acquired cardiovascular disease among canines, especially those that are not predisposed to cardiovascular disease, appears birth season dependent. The relative risk of cardiovascular disease for canines not predisposed to cardiovascular disease was as high as 1.47 among July pups. The overall adjusted odds ratio, when mixed breeds were excluded, for the birth season effect was 1.02 (95% CI: 1.002, 1.047, p = 0.032) after adjusting for breed and genetic cardiovascular predisposition effects. Studying birth season effects in model organisms can help to elucidate potential mechanisms behind the reported associations.

Eating behaviors and weight over time in a prospective study: the Healthy Twin Study.

PubMed

Song, Yun-Mi; Lee, Kayoung; Sung, Joohon

2014-01-01

We examined the relationships of combined initial restrained and external/emotional eating with initial BMI and change in weight and these subscales over time. BMI and the Dutch Eating Behavior Questionnaire were twicemeasured in 1361 Korean twins and families (482 men, 879 women) over a period of 2.7±0.9 years. Subjects were classified by combination of initial sex-specific restrained and external (or emotional) eating tertiles. Linear mixed models were performed after adjusting for confounders at baseline (household, sibling relations, sex, age, education level, smoking, alcohol use, energy intake, physical activity, and medical history). In adjusted models, initial BMI increased with increasing tertiles of initial restrained eating across initial external/emotional eating tertiles. Weight was less likely to increase over time with increasing tertiles of initial restrained eating in the lowest external eating tertile and middle tertile of emotional eating at baseline. Subscale scores decreased over time with increasing tertiles of corresponding subscales at baseline. These findings suggest that high dietary restraint and external/emotional eating may indicate concurrent high BMI and attenuated weight gain and decreases in corresponding subscales over time.

A Model Based Approach to Sample Size Estimation in Recent Onset Type 1 Diabetes

PubMed Central

Bundy, Brian; Krischer, Jeffrey P.

2016-01-01

The area under the curve C-peptide following a 2-hour mixed meal tolerance test from 481 individuals enrolled on 5 prior TrialNet studies of recent onset type 1 diabetes from baseline to 12 months after enrollment were modelled to produce estimates of its rate of loss and variance. Age at diagnosis and baseline C-peptide were found to be significant predictors and adjusting for these in an ANCOVA resulted in estimates with lower variance. Using these results as planning parameters for new studies results in a nearly 50% reduction in the target sample size. The modelling also produces an expected C-peptide that can be used in Observed vs. Expected calculations to estimate the presumption of benefit in ongoing trials. PMID:26991448

Sigma meson in vacuum and nuclear matter

NASA Astrophysics Data System (ADS)

Menchaca-Maciel, M. C.; Morones-Ibarra, J. R.

2013-04-01

We have obtained the value of the interaction constant g σππ that adjusts the values obtained in the E791 Collaboration at Fermilab and BES Collaboration at the Beijing Electron Positron Collider experiments. To get this we have used the concept of critical width to make compatible the parameters obtained from the Breit-Wigner formula and those obtained from the density function. Also, the total width and effective mass modification of the sigma meson in nuclear matter has been studied in the Walecka model, assuming that the sigma couples to a pair of nucleon-antinucleon states and to particle-hole states, including the in-medium effect of sigma-omega mixing. We have considered, for completeness, the coupling of sigma to two virtual pions. We have found that the sigma meson mass decreases with respect to its value in vacuum and that the contribution of the sigma-omega mixing effect on the mass shift is relevant.

Subjective Social Status and Self-Reported Health Among US-born and Immigrant Latinos.

PubMed

Garza, Jeremiah R; Glenn, Beth A; Mistry, Rashmita S; Ponce, Ninez A; Zimmerman, Frederick J

2017-02-01

Subjective social status is associated with a range of health outcomes. Few studies have tested the relevance of subjective social status among Latinos in the U.S.; those that have yielded mixed results. Data come from the Latino subsample of the 2003 National Latino and Asian American Study (N = 2554). Regression models adjusted for socioeconomic and demographic factors. Stratified analyses tested whether nativity status modifies the effect of subjective social status on health. Subjective social status was associated with better health. Income and education mattered more for health than subjective social status among U.S.-born Latinos. However, the picture was mixed among immigrant Latinos, with subjective social status more strongly predictive than income but less so than education. Subjective social status may tap into stressful immigrant experiences that affect one's perceived self-worth and capture psychosocial consequences and social disadvantage left out by conventional socioeconomic measures.

Modeling the relative contributions of secondary ice formation processes to ice crystal number concentrations within mixed-phase clouds

NASA Astrophysics Data System (ADS)

Sullivan, Sylvia; Hoose, Corinna; Nenes, Athanasios

2016-04-01

Measurements of in-cloud ice crystal number concentrations can be three or four orders of magnitude greater than the in-cloud ice nuclei number concentrations. This discrepancy can be explained by various secondary ice formation processes, which occur after initial ice nucleation, but the relative importance of these processes, and even the exact physics of each, is still unclear. A simple bin microphysics model (2IM) is constructed to investigate these knowledge gaps. 2IM extends the time-lag collision parameterization of Yano and Phillips, 2011 to include rime splintering, ice-ice aggregation, and droplet shattering and to incorporate the aspect ratio evolution as in Jensen and Harrington, 2015. The relative contribution of the secondary processes under various conditions are shown. In particular, temperature-dependent efficiencies are adjusted for ice-ice aggregation versus collision around -15°C, when rime splintering is no longer active, and the effect of aspect ratio on the process weighting is explored. The resulting simulations are intended to guide secondary ice formation parameterizations in larger-scale mixed-phase cloud schemes.

Growth in bone and body size among Asian and white girls in the Female Adolescent Maturation (FAM) study.

PubMed

Novotny, Rachel; Davis, James

2015-01-01

This study intends to identify differences in growth of Asian and White girls. Asian girls gained bone at similar rates to White girls. Physical activity was important to bone growth. Ethnic differences remained after adjusting for physical activity, demographics, and diet. Physical activity can improve bone gain. The purpose of this study is to examine differences in body size and bone growth of Asian, White, and Asian-White Mixed girls. Three prospective examinations of 99 Asian, 73 White, and 63 Mixed Asian and White girls, with a mean age of 11.0 years at enrollment were performed. Calcaneal bone mass, skeletal breadths, and body fat were measured. Physical activity, diet, and birth size were reported. The analyses examined the extent that body dimensions and bone size changed over time by demographic, diet, physical activity, body, and bone size parameters. White children were the most physically active yet had lower calcaneal ultrasound values for speed of sound (SOS). Based on regression models, bone mass, and subscapular skinfold thickness were greater in Asian girls compared to White and Asian-White Mixed girls at age 10 years. Asian-White Mixed girls had greater BMI compared to Asian or White girls. Asian girls gained body size more slowly than White girls, but changes in bone parameters did not differ significantly; Asian-White Mixed girls gained abdomen, hip, and weight more slowly than White girls. Among all girls, SOS and broadband ultrasound attenuation (BUA) increased significantly by level of physical activity before 12 years, but not after. Asian girls had more upper body (subscapular) fat at age 10 years and gained height and hip and abdomen circumferences more slowly than Asian-White and White girls. Asian girls had greater bone SOS and BUA at age 10 years but gained bone at similar rates to White girls. Physical activity was especially important to bone growth before age 12 years. However, ethnic differences remained after adjusting for physical activity, demographic, and dietary factors.

Longitudinal Modeling of Depressive Trajectories Among HIV-Infected Men Using Cocaine.

PubMed

Mukerji, Shibani; Haghighat, Roxanna; Misra, Vikas; Lorenz, David R; Holman, Alex; Dutta, Anupriya; Gabuzda, Dana

2017-07-01

Cocaine use is prevalent among HIV-infected individuals. While cross-sectional studies suggest that cocaine users may be at increased risk for depression, long-term effects of cocaine on depressive symptoms remain unclear. This is a longitudinal study of 341 HIV-infected and uninfected men (135 cocaine users and 206 controls) ages 30-60 enrolled in the Multicenter AIDS Cohort Study during 1996-2009. The median baseline age was 41; 73% were African-American. In mixed-effects models over a median of 4.8 years of observation, cocaine use was associated with higher depressive symptoms independent of age, education level, and smoking (n = 288; p = 0.02); HIV infection modified this association (p = 0.03). Latent class mixed models were used to empirically identify distinct depressive trajectories (n = 160). In adjusted models, cocaine use was associated with threefold increased odds of membership in the class with persistent high depressive symptoms (95% confidence interval (CI) 1.38-6.69) and eightfold increased odds (95% CI (2.73-25.83) when tested among HIV-infected subjects only. Cocaine use is a risk factor for chronic depressive symptoms, particularly among HIV-infected men, highlighting the importance of integrating mental health and substance use treatments to address barriers to well-being and successful HIV-care.

Modelling growth-competition relationships in trembling aspen and white spruce mixed boreal forests of Western Canada.

PubMed

Huang, Jian-Guo; Stadt, Kenneth J; Dawson, Andria; Comeau, Philip G

2013-01-01

We examined the effect of competition on stem growth of Picea glauca and Populus tremuloides in boreal mixedwood stands during the stem exclusion stage. We combined traditional approaches of collecting competition data with dendrochronology to provide retrospective measurements of stem diameter growth. Several competition indices including stand basal area (BA), the sum of stem diameter at breast height (SDBH), and density (N) for the broadleaf and coniferous species, as well as similar indices considering only trees with diameters greater than each subject (BAGR, SDBHGR, and NGR), were evaluated. We used a nonlinear mixed model to characterize the basal area increment over the past 5, 10, 15, 20, 25, 30, and 35 years as a function of growth of nearby dominant trees, the size of the subject trees, deciduous and coniferous competition indices, and ecoregions. SDBHGR and BAGR were better predictors for spruce, and SDBHGR and NGR were better for aspen, respectively, than other indices. Results showed strongest correlations with long-term stem growth, as the best models integrated growth for 10-25 years for aspen and ≥ 25 for spruce. Our model demonstrated a remarkable capability (adjusted R(2)>0.67) to represent this complex variation in growth as a function of site, size and competition.

Modelling Growth-Competition Relationships in Trembling Aspen and White Spruce Mixed Boreal Forests of Western Canada

PubMed Central

Huang, Jian-Guo; Stadt, Kenneth J.; Dawson, Andria; Comeau, Philip G.

2013-01-01

We examined the effect of competition on stem growth of Picea glauca and Populus tremuloides in boreal mixedwood stands during the stem exclusion stage. We combined traditional approaches of collecting competition data with dendrochronology to provide retrospective measurements of stem diameter growth. Several competition indices including stand basal area (BA), the sum of stem diameter at breast height (SDBH), and density (N) for the broadleaf and coniferous species, as well as similar indices considering only trees with diameters greater than each subject (BAGR, SDBHGR, and NGR), were evaluated. We used a nonlinear mixed model to characterize the basal area increment over the past 5, 10, 15, 20, 25, 30, and 35 years as a function of growth of nearby dominant trees, the size of the subject trees, deciduous and coniferous competition indices, and ecoregions. SDBHGR and BAGR were better predictors for spruce, and SDBHGR and NGR were better for aspen, respectively, than other indices. Results showed strongest correlations with long-term stem growth, as the best models integrated growth for 10–25 years for aspen and ≥25 for spruce. Our model demonstrated a remarkable capability (adjusted R2>0.67) to represent this complex variation in growth as a function of site, size and competition. PMID:24204891

Modelling the Progression of Competitive Performance of an Academy's Soccer Teams.

PubMed

Malcata, Rita M; Hopkins, Will G; Richardson, Scott

2012-01-01

Progression of a team's performance is a key issue in competitive sport, but there appears to have been no published research on team progression for periods longer than a season. In this study we report the game-score progression of three teams of a youth talent-development academy over five seasons using a novel analytic approach based on generalised mixed modelling. The teams consisted of players born in 1991, 1992 and 1993; they played totals of 115, 107 and 122 games in Asia and Europe between 2005 and 2010 against teams differing in age by up to 3 years. Game scores predicted by the mixed model were assumed to have an over-dispersed Poisson distribution. The fixed effects in the model estimated an annual linear pro-gression for Aspire and for the other teams (grouped as a single opponent) with adjustment for home-ground advantage and for a linear effect of age difference between competing teams. A random effect allowed for different mean scores for Aspire and opposition teams. All effects were estimated as factors via log-transformation and presented as percent differences in scores. Inferences were based on the span of 90% confidence intervals in relation to thresholds for small factor effects of x/÷1.10 (+10%/-9%). Most effects were clear only when data for the three teams were combined. Older teams showed a small 27% increase in goals scored per year of age difference (90% confidence interval 13 to 42%). Aspire experienced a small home-ground advantage of 16% (-5 to 41%), whereas opposition teams experienced 31% (7 to 60%) on their own ground. After adjustment for these effects, the Aspire teams scored on average 1.5 goals per match, with little change in the five years of their existence, whereas their opponents' scores fell from 1.4 in their first year to 1.0 in their last. The difference in progression was trivial over one year (7%, -4 to 20%), small over two years (15%, -8 to 44%), but unclear over >2 years. In conclusion, the generalized mixed model has marginal utility for estimating progression of soccer scores, owing to the uncertainty arising from low game scores. The estimates are likely to be more precise and useful in sports with higher game scores. Key pointsA generalized linear mixed model is the approach for tracking game scores, key performance indicators or other measures of performance based on counts in sports where changes within and/or between games/seasons have to be considered.Game scores in soccer could be useful to track performance progression of teams, but hundreds of games are needed.Fewer games will be needed for tracking performance represented by counts with high scores, such as game scores in rugby or key performance indicators based on frequent events or player actions in any team sport.

Modelling the Progression of Competitive Performance of an Academy’s Soccer Teams

PubMed Central

Malcata, Rita M.; Hopkins, Will G; Richardson, Scott

2012-01-01

Progression of a team’s performance is a key issue in competitive sport, but there appears to have been no published research on team progression for periods longer than a season. In this study we report the game-score progression of three teams of a youth talent-development academy over five seasons using a novel analytic approach based on generalised mixed modelling. The teams consisted of players born in 1991, 1992 and 1993; they played totals of 115, 107 and 122 games in Asia and Europe between 2005 and 2010 against teams differing in age by up to 3 years. Game scores predicted by the mixed model were assumed to have an over-dispersed Poisson distribution. The fixed effects in the model estimated an annual linear pro-gression for Aspire and for the other teams (grouped as a single opponent) with adjustment for home-ground advantage and for a linear effect of age difference between competing teams. A random effect allowed for different mean scores for Aspire and opposition teams. All effects were estimated as factors via log-transformation and presented as percent differences in scores. Inferences were based on the span of 90% confidence intervals in relation to thresholds for small factor effects of x/÷1.10 (+10%/-9%). Most effects were clear only when data for the three teams were combined. Older teams showed a small 27% increase in goals scored per year of age difference (90% confidence interval 13 to 42%). Aspire experienced a small home-ground advantage of 16% (-5 to 41%), whereas opposition teams experienced 31% (7 to 60%) on their own ground. After adjustment for these effects, the Aspire teams scored on average 1.5 goals per match, with little change in the five years of their existence, whereas their opponents’ scores fell from 1.4 in their first year to 1.0 in their last. The difference in progression was trivial over one year (7%, -4 to 20%), small over two years (15%, -8 to 44%), but unclear over >2 years. In conclusion, the generalized mixed model has marginal utility for estimating progression of soccer scores, owing to the uncertainty arising from low game scores. The estimates are likely to be more precise and useful in sports with higher game scores. Key pointsA generalized linear mixed model is the approach for tracking game scores, key performance indicators or other measures of performance based on counts in sports where changes within and/or between games/seasons have to be considered.Game scores in soccer could be useful to track performance progression of teams, but hundreds of games are needed.Fewer games will be needed for tracking performance represented by counts with high scores, such as game scores in rugby or key performance indicators based on frequent events or player actions in any team sport. PMID:24149364

Performance evaluation of inpatient service in Beijing: a horizontal comparison with risk adjustment based on Diagnosis Related Groups

PubMed Central

Jian, Weiyan; Huang, Yinmin; Hu, Mu; Zhang, Xiumei

2009-01-01

Background The medical performance evaluation, which provides a basis for rational decision-making, is an important part of medical service research. Current progress with health services reform in China is far from satisfactory, without sufficient regulation. To achieve better progress, an effective tool for evaluating medical performance needs to be established. In view of this, this study attempted to develop such a tool appropriate for the Chinese context. Methods Data was collected from the front pages of medical records (FPMR) of all large general public hospitals (21 hospitals) in the third and fourth quarter of 2007. Locally developed Diagnosis Related Groups (DRGs) were introduced as a tool for risk adjustment and performance evaluation indicators were established: Charge Efficiency Index (CEI), Time Efficiency Index (TEI) and inpatient mortality of low-risk group cases (IMLRG), to reflect respectively work efficiency and medical service quality. Using these indicators, the inpatient services' performance was horizontally compared among hospitals. Case-mix Index (CMI) was used to adjust efficiency indices and then produce adjusted CEI (aCEI) and adjusted TEI (aTEI). Poisson distribution analysis was used to test the statistical significance of the IMLRG differences between different hospitals. Results Using the aCEI, aTEI and IMLRG scores for the 21 hospitals, Hospital A and C had relatively good overall performance because their medical charges were lower, LOS shorter and IMLRG smaller. The performance of Hospital P and Q was the worst due to their relatively high charge level, long LOS and high IMLRG. Various performance problems also existed in the other hospitals. Conclusion It is possible to develop an accurate and easy to run performance evaluation system using Case-Mix as the tool for risk adjustment, choosing indicators close to consumers and managers, and utilizing routine report forms as the basic information source. To keep such a system running effectively, it is necessary to improve the reliability of clinical information and the risk-adjustment ability of Case-Mix. PMID:19402913

Hospital Standardized Mortality Ratios: Sensitivity Analyses on the Impact of Coding

PubMed Central

Bottle, Alex; Jarman, Brian; Aylin, Paul

2011-01-01

Introduction Hospital standardized mortality ratios (HSMRs) are derived from administrative databases and cover 80 percent of in-hospital deaths with adjustment for available case mix variables. They have been criticized for being sensitive to issues such as clinical coding but on the basis of limited quantitative evidence. Methods In a set of sensitivity analyses, we compared regular HSMRs with HSMRs resulting from a variety of changes, such as a patient-based measure, not adjusting for comorbidity, not adjusting for palliative care, excluding unplanned zero-day stays ending in live discharge, and using more or fewer diagnoses. Results Overall, regular and variant HSMRs were highly correlated (ρ > 0.8), but differences of up to 10 points were common. Two hospitals were particularly affected when palliative care was excluded from the risk models. Excluding unplanned stays ending in same-day live discharge had the least impact despite their high frequency. The largest impacts were seen when capturing postdischarge deaths and using just five high-mortality diagnosis groups. Conclusions HSMRs in most hospitals changed by only small amounts from the various adjustment methods tried here, though small-to-medium changes were not uncommon. However, the position relative to funnel plot control limits could move in a significant minority even with modest changes in the HSMR. PMID:21790587

On the geometric analysis and adjustment of optical satellite observations. M.S. Thesis

NASA Technical Reports Server (NTRS)

Tsimis, E.

1972-01-01

Satellite geodesy methods were catagorized into three divisions: geometric, dynamic, and mixed. These catagories furnish the basis for distinction between geometric and dynamic satellite geodesy. The dual adjustment, geometric analysis, and Cartesian coodinate determination are examined for two observing stations. Similar illustrations are given when more than two observing stations are used.

Assessing Advanced Airway Management Performance in a National Cohort of Emergency Medical Services Agencies.

PubMed

Wang, Henry E; Donnelly, John P; Barton, Dustin; Jarvis, Jeffrey L

2018-05-01

Although often the focus of quality improvement efforts, emergency medical services (EMS) advanced airway management performance has few national comparisons, nor are there many assessments with benchmarks accounting for differences in agency volume or patient mix. We seek to assess variations in advanced airway management and conventional intubation performance in a national cohort of EMS agencies. We used EMS data from ESO Solutions, a national EMS electronic health record system. We identified EMS emergency responses with attempted advanced airway management (conventional intubation, rapid sequence intubation, sedation-assisted intubation, supraglottic airway insertion, and cricothyroidotomy). We also separately examined cases with initial conventional intubation. We determined EMS agency risk-standardized advanced airway management and initial conventional intubation success rates by using mixed-effects regression models, fitting agency as a random intercept, adjusting for patient age, sex, race, cardiac arrest, or trauma status, and use of rapid sequence or sedation-assisted intubation, and accounting for reliability variations from EMS agency airway volume. We assessed changes in agency advanced airway management and initial conventional intubation performance rank after risk and reliability adjustment. We also identified high and low performers (reliability-adjusted and risk-standardized success confidence intervals falling outside the mean). During 2011 to 2015, 550 EMS agencies performed 57,209 advanced airway management procedures. Among 401 EMS agencies with greater than or equal to 10 advanced airway management procedures, there were a total of 56,636 procedures. Median reliability-adjusted and risk-standardized EMS agency advanced airway management success was 92.9% (interquartile range 90.1% to 94.8%; minimum 58.2%; maximum 99.0%). There were 56 advanced airway management low-performing and 38 high-performing EMS agencies. Among 342 agencies with greater than or equal to 10 initial conventional intubations, there were a total of 37,360 initial conventional intubations. Median reliability-adjusted and risk-standardized EMS agency initial conventional intubation success was 77.3% (interquartile range 70.9% to 83.6%; minimum 47.1%; maximum 95.8%). There were 64 initial conventional intubation low-performing and 45 high-performing EMS agencies. In this national series, EMS advanced airway management and initial conventional intubation performance varied widely. Reliability adjustment and risk standardization may influence EMS airway management performance assessments. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

The barriers to and enablers of providing reasonably adjusted health services to people with intellectual disabilities in acute hospitals: evidence from a mixed-methods study

PubMed Central

Tuffrey-Wijne, Irene; Goulding, Lucy; Giatras, Nikoletta; Abraham, Elisabeth; Gillard, Steve; White, Sarah; Edwards, Christine; Hollins, Sheila

2014-01-01

Objective To identify the factors that promote and compromise the implementation of reasonably adjusted healthcare services for patients with intellectual disabilities in acute National Health Service (NHS) hospitals. Design A mixed-methods study involving interviews, questionnaires and participant observation (July 2011–March 2013). Setting Six acute NHS hospital trusts in England. Methods Reasonable adjustments for people with intellectual disabilities were identified through the literature. Data were collected on implementation and staff understanding of these adjustments. Results Data collected included staff questionnaires (n=990), staff interviews (n=68), interviews with adults with intellectual disabilities (n=33), questionnaires (n=88) and interviews (n=37) with carers of patients with intellectual disabilities, and expert panel discussions (n=42). Hospital strategies that supported implementation of reasonable adjustments did not reliably translate into consistent provision of such adjustments. Good practice often depended on the knowledge, understanding and flexibility of individual staff and teams, leading to the delivery of reasonable adjustments being haphazard throughout the organisation. Major barriers included: lack of effective systems for identifying and flagging patients with intellectual disabilities, lack of staff understanding of the reasonable adjustments that may be needed, lack of clear lines of responsibility and accountability for implementing reasonable adjustments, and lack of allocation of additional funding and resources. Key enablers were the Intellectual Disability Liaison Nurse and the ward manager. Conclusions The evidence suggests that ward culture, staff attitudes and staff knowledge are crucial in ensuring that hospital services are accessible to vulnerable patients. The authors suggest that flagging the need for specific reasonable adjustments, rather than the vulnerable condition itself, may address some of the barriers. Further research is recommended that describes and quantifies the most frequently needed reasonable adjustments within the hospital pathways of vulnerable patient groups, and the most effective organisational infrastructure required to guarantee their use, together with resource implications. PMID:24740978

Teachers' Achievement Goals: A Mixed Method

ERIC Educational Resources Information Center

Demirtas, Zeynep; Arslan, Nihan

2018-01-01

In this study, the first aim of the research is to adjust the scale of teachers' achievement goals to the Turkish culture. The second aim of the research is to get point of view about their achievement goals within the qualitative questions prepared by base on scale items. The mixed method has been used in the survey. The qualitative and…

Simulation of air-droplet mixed phase flow in icing wind-tunnel

NASA Astrophysics Data System (ADS)

Mengyao, Leng; Shinan, Chang; Menglong, Wu; Yunhang, Li

2013-07-01

Icing wind-tunnel is the main ground facility for the research of aircraft icing, which is different from normal wind-tunnel for its refrigeration system and spraying system. In stable section of icing wind-tunnel, the original parameters of droplets and air are different, for example, to keep the nozzles from freezing, the droplets are heated while the temperature of air is low. It means that complex mass and heat transfer as well as dynamic interactive force would happen between droplets and air, and the parameters of droplet will acutely change along the passageway. Therefore, the prediction of droplet-air mixed phase flow is necessary in the evaluation of icing researching wind-tunnel. In this paper, a simplified droplet-air mixed phase flow model based on Lagrangian method was built. The variation of temperature, diameter and velocity of droplet, as well as the air flow field, during the flow process were obtained under different condition. With calculating three-dimensional air flow field by FLUENT, the droplet could be traced and the droplet distribution could also be achieved. Furthermore, the patterns about how initial parameters affect the parameters in test section were achieved. The numerical simulation solving the flow and heat and mass transfer characteristics in the mixing process is valuable for the optimization of experimental parameters design and equipment adjustment.

Cycling Empirical Antibiotic Therapy in Hospitals: Meta-Analysis and Models

PubMed Central

Abel, Sören; Viechtbauer, Wolfgang; Bonhoeffer, Sebastian

2014-01-01

The rise of resistance together with the shortage of new broad-spectrum antibiotics underlines the urgency of optimizing the use of available drugs to minimize disease burden. Theoretical studies suggest that coordinating empirical usage of antibiotics in a hospital ward can contain the spread of resistance. However, theoretical and clinical studies came to different conclusions regarding the usefulness of rotating first-line therapy (cycling). Here, we performed a quantitative pathogen-specific meta-analysis of clinical studies comparing cycling to standard practice. We searched PubMed and Google Scholar and identified 46 clinical studies addressing the effect of cycling on nosocomial infections, of which 11 met our selection criteria. We employed a method for multivariate meta-analysis using incidence rates as endpoints and find that cycling reduced the incidence rate/1000 patient days of both total infections by 4.95 [9.43–0.48] and resistant infections by 7.2 [14.00–0.44]. This positive effect was observed in most pathogens despite a large variance between individual species. Our findings remain robust in uni- and multivariate metaregressions. We used theoretical models that reflect various infections and hospital settings to compare cycling to random assignment to different drugs (mixing). We make the realistic assumption that therapy is changed when first line treatment is ineffective, which we call “adjustable cycling/mixing”. In concordance with earlier theoretical studies, we find that in strict regimens, cycling is detrimental. However, in adjustable regimens single resistance is suppressed and cycling is successful in most settings. Both a meta-regression and our theoretical model indicate that “adjustable cycling” is especially useful to suppress emergence of multiple resistance. While our model predicts that cycling periods of one month perform well, we expect that too long cycling periods are detrimental. Our results suggest that “adjustable cycling” suppresses multiple resistance and warrants further investigations that allow comparing various diseases and hospital settings. PMID:24968123

Medicare Advantage and Fee-for-Service Performance on Clinical Quality and Patient Experience Measures: Comparisons from Three Large States.

PubMed

Timbie, Justin W; Bogart, Andy; Damberg, Cheryl L; Elliott, Marc N; Haas, Ann; Gaillot, Sarah J; Goldstein, Elizabeth H; Paddock, Susan M

2017-12-01

To compare performance between Medicare Advantage (MA) and Fee-for-Service (FFS) Medicare during a time of policy changes affecting both programs. Performance data for 16 clinical quality measures and 6 patient experience measures for 9.9 million beneficiaries living in California, New York, and Florida. We compared MA and FFS performance overall, by plan type, and within service areas associated with contracts between CMS and MA organizations. Case mix-adjusted analyses (for measures not typically adjusted) were used to explore the effect of case mix on MA/FFS differences. Performance measures were submitted by MA organizations, obtained from the nationwide fielding of the Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) Survey, or derived from claims. Overall, MA outperformed FFS on all 16 clinical quality measures. Differences were large for HEDIS measures and small for Part D measures and remained after case mix adjustment. MA enrollees reported better experiences overall, but FFS beneficiaries reported better access to care. Relative to FFS, performance gaps were much wider for HMOs than PPOs. Excluding HEDIS measures, MA/FFS differences were much smaller in contract-level comparisons. Medicare Advantage/Fee-for-Service differences are often large but vary in important ways across types of measures and contracts. © Health Research and Educational Trust.

Effects of Mesoscale Eddies in the Active Mixed Layer: Test of the Parametrisation in Eddy Resolving Simulations

NASA Technical Reports Server (NTRS)

Luneva, M. V.; Clayson, C. A.; Dubovikov, Mikhail

2015-01-01

In eddy resolving simulations, we test a mixed layer mesoscale parametrisation, developed recently by Canuto and Dubovikov [Ocean Model., 2011, 39, 200-207]. With no adjustable parameters, the parametrisation yields the horizontal and vertical mesoscale fluxes in terms of coarse-resolution fields and eddy kinetic energy (EKE). We compare terms of the parametrisation diagnosed from coarse-grained fields with the eddy mesoscale fluxes diagnosed directly from the high resolution model. An expression for the EKE in terms of mean fields has also been found to get a closed parametrisation in terms of the mean fields only. In 40 numerical experiments we simulated two types of flows: idealised flows driven by baroclinic instabilities only, and more realistic flows, driven by wind and surface fluxes as well as by inflow-outflow. The diagnosed quasi-instantaneous horizontal and vertical mesoscale buoyancy fluxes (averaged over 1-2 degrees and 10 days) demonstrate a strong scatter typical for turbulent flows, however, the fluxes are positively correlated with the parametrisation with higher (0.5-0.74) correlations at the experiments with larger baroclinic radius Rossby. After being averaged over 3-4 months, diffusivities diagnosed from the eddy resolving simulations are consistent with the parametrisation for a broad range of parameters. Diagnosed vertical mesoscale fluxes restratify mixed layer and are in a good agreement with the parametrisation unless vertical turbulent mixing in the upper layer becomes strong enough in comparison with mesoscale advection. In the latter case, numerical simulations demonstrate that the deviation of the fluxes from the parametrisation is controlled by dimensionless parameter estimating the ratio of vertical turbulent mixing term to mesoscale advection. An analysis using a modified omega-equation reveals that the effects of the vertical mixing of vorticity is responsible for the two-three fold amplification of vertical mesoscale flux. Possible physical mechanisms, responsible for the amplification of vertical mesoscale flux are discussed.

Selective Optical Addressing of Nuclear Spins through Superhyperfine Interaction in Rare-Earth Doped Solids.

PubMed

Car, B; Veissier, L; Louchet-Chauvet, A; Le Gouët, J-L; Chanelière, T

2018-05-11

In Er^{3+}:Y_{2}SiO_{5}, we demonstrate the selective optical addressing of the ^{89}Y^{3+} nuclear spins through their superhyperfine coupling with the Er^{3+} electronic spins possessing large Landé g factors. We experimentally probe the electron-nuclear spin mixing with photon echo techniques and validate our model. The site-selective optical addressing of the Y^{3+} nuclear spins is designed by adjusting the magnetic field strength and orientation. This constitutes an important step towards the realization of long-lived solid-state qubits optically addressed by telecom photons.

Selective Optical Addressing of Nuclear Spins through Superhyperfine Interaction in Rare-Earth Doped Solids

NASA Astrophysics Data System (ADS)

Car, B.; Veissier, L.; Louchet-Chauvet, A.; Le Gouët, J.-L.; Chanelière, T.

2018-05-01

In Er3 +:Y2SiO5 , we demonstrate the selective optical addressing of the Y89 3 + nuclear spins through their superhyperfine coupling with the Er3 + electronic spins possessing large Landé g factors. We experimentally probe the electron-nuclear spin mixing with photon echo techniques and validate our model. The site-selective optical addressing of the Y3 + nuclear spins is designed by adjusting the magnetic field strength and orientation. This constitutes an important step towards the realization of long-lived solid-state qubits optically addressed by telecom photons.

Impact of Hospital Population Case-Mix, Including Poverty, on Hospital All-Cause and Infection-Related 30-Day Readmission Rates.

PubMed

Gohil, Shruti K; Datta, Rupak; Cao, Chenghua; Phelan, Michael J; Nguyen, Vinh; Rowther, Armaan A; Huang, Susan S

2015-10-15

Reducing hospital readmissions, including preventable healthcare-associated infections, is a national priority. The proportion of readmissions due to infections is not well-understood. Better understanding of hospital risk factors for readmissions and infection-related readmissions may help optimize interventions to prevent readmissions. Retrospective cohort study of California acute care hospitals and their patient populations discharged between 2009 and 2011. Demographics, comorbidities, and socioeconomic status were entered into a hierarchical generalized linear mixed model predicting all-cause and infection-related readmissions. Crude verses adjusted hospital rankings were compared using Cohen's kappa. We assessed 30-day readmission rates from 323 hospitals, accounting for 213 879 194 post-discharge person-days of follow-up. Infection-related readmissions represented 28% of all readmissions and were associated with discharging a high proportion of patients to skilled nursing facilities. Hospitals serving populations with high proportions of males, comorbidities, prolonged length of stay, and populations living in a federal poverty area, had higher all-cause and infection-related readmission rates. Academic hospitals had higher all-cause and infection-related readmission rates (odds ratio 1.24 and 1.15, respectively). When comparing adjusted vs crude hospital rankings for infection-related readmission rates, adjustment revealed 31% of hospitals changed performance category for infection-related readmissions. Infection-related readmissions accounted for nearly 30% of all-cause readmissions. High hospital infection-related readmissions were associated with serving a high proportion of patients with comorbidities, long lengths of stay, discharge to skilled nursing facility, and those living in federal poverty areas. Preventability of these infections needs to be assessed. © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

Hospital volume of throughput and periprocedural and medium‐term adverse events after percutaneous coronary intervention: retrospective cohort study of all 17 417 procedures undertaken in Scotland, 1997–2003

PubMed Central

Burton, K R; Slack, R; Oldroyd, K G; Pell, A C H; Flapan, A D; Starkey, I R; Eteiba, H; Jennings, K P; Northcote, R J; Hillis, W Stewart; Pell, J P

2006-01-01

Objective To determine whether percutaneous coronary intervention (PCI) hospital volume of throughput is associated with periprocedural and medium‐term events, and whether any associations are independent of differences in case mix. Design Retrospective cohort study of all PCIs undertaken in Scottish National Health Service hospitals over a six‐year period. Methods All PCIs in Scotland during 1997–2003 were examined. Linkage to administrative databases identified events over two years' follow up. The risk of events by hospital volume at 30 days and two years was compared by using logistic regression and Cox proportional hazards models. Results Of the 17 417 PCIs, 4900 (28%) were in low‐volume hospitals and 3242 (19%) in high‐volume hospitals. After adjustment for case mix, there were no significant differences in risk of death or myocardial infarction. Patients treated in high‐volume hospitals were less likely to require emergency surgery (adjusted odds ratio 0.18, 95% confidence interval (CI) 0.07 to 0.54, p  =  0.002). Over two years, patients in high‐volume hospitals were less likely to undergo surgery (adjusted hazard ratio 0.52, 95% CI 0.35 to 0.75, p  =  0.001), but this was offset by an increased likelihood of further PCI. There was no net difference in coronary revascularisation or in overall events. Conclusion Death and myocardial infarction were infrequent complications of PCI and did not differ significantly by volume. Emergency surgery was less common in high‐volume hospitals. Over two years, patients treated in high‐volume centres were as likely to undergo some form of revascularisation but less likely to undergo surgery. PMID:16709693

Hospital volume of throughput and periprocedural and medium-term adverse events after percutaneous coronary intervention: retrospective cohort study of all 17,417 procedures undertaken in Scotland, 1997-2003.

PubMed

Burton, K R; Slack, R; Oldroyd, K G; Pell, A C H; Flapan, A D; Starkey, I R; Eteiba, H; Jennings, K P; Northcote, R J; Hillis, W Stewart; Pell, J P

2006-11-01

To determine whether percutaneous coronary intervention (PCI) hospital volume of throughput is associated with periprocedural and medium-term events, and whether any associations are independent of differences in case mix. Retrospective cohort study of all PCIs undertaken in Scottish National Health Service hospitals over a six-year period. All PCIs in Scotland during 1997-2003 were examined. Linkage to administrative databases identified events over two years' follow up. The risk of events by hospital volume at 30 days and two years was compared by using logistic regression and Cox proportional hazards models. Of the 17,417 PCIs, 4900 (28%) were in low-volume hospitals and 3242 (19%) in high-volume hospitals. After adjustment for case mix, there were no significant differences in risk of death or myocardial infarction. Patients treated in high-volume hospitals were less likely to require emergency surgery (adjusted odds ratio 0.18, 95% confidence interval (CI) 0.07 to 0.54, p = 0.002). Over two years, patients in high-volume hospitals were less likely to undergo surgery (adjusted hazard ratio 0.52, 95% CI 0.35 to 0.75, p = 0.001), but this was offset by an increased likelihood of further PCI. There was no net difference in coronary revascularisation or in overall events. Death and myocardial infarction were infrequent complications of PCI and did not differ significantly by volume. Emergency surgery was less common in high-volume hospitals. Over two years, patients treated in high-volume centres were as likely to undergo some form of revascularisation but less likely to undergo surgery.

Variation in cervical and breast cancer screening coverage in England: a cross-sectional analysis to characterise districts with atypical behaviour

PubMed Central

Massat, Nathalie J; Douglas, Elaine; Waller, Jo; Wardle, Jane; Duffy, Stephen W

2015-01-01

Objectives Reducing cancer screening inequalities in England is a major focus of the 2011 Department of Health cancer outcome strategy. Screening coverage requires regular monitoring in order to implement targeted interventions where coverage is low. This study aimed to characterise districts with atypical coverage levels for cervical or breast screening. Design Observational study of district-level coverage in the English Cervical and Breast screening programmes in 2012. Setting England, UK. Participants All English women invited to participate in the cervical (age group 25–49 and 50–64) and breast (age group 50–64) screening programmes. Outcomes Risk adjustment models for coverage were developed based on district-level characteristics. Funnel plots of adjusted coverage were constructed, and atypical districts examined by correlation analysis. Results Variability in coverage was primarily explained by population factors, whereas general practice characteristics had little independent effect. Deprivation and ethnicity other than white, Asian, black or mixed were independently associated with poorer coverage in both screening programmes, with ethnicity having the strongest effect; by comparison, the influence of Asian, black or mixed ethnic minority was limited. Deprivation, ethnicity and urbanisation largely accounted for the lower cervical screening coverage in London. However, for breast screening, being located in London remained a strong negative predictor. A subset of districts was identified as having atypical coverage across programmes. Correlates of deprivation in districts with relatively low adjusted coverage were substantially different from overall correlates of deprivation. Discussion These results inform the continuing drive to reduce avoidable cancer deaths in England, and encourage implementation of targeted interventions in communities residing in districts identified as having atypically low coverage. Sequential implementation to monitor the impact of local interventions would help accrue evidence on ‘what works’. PMID:26209119

Variation in ventilation time after coronary artery bypass grafting: an analysis from the society of thoracic surgeons adult cardiac surgery database.

PubMed

Jacobs, Jeffrey P; He, Xia; O'Brien, Sean M; Welke, Karl F; Filardo, Giovanni; Han, Jane M; Ferraris, Victor A; Prager, Richard L; Shahian, David M

2013-09-01

Short postoperative ventilation times are accepted as a marker of quality. This analysis assesses center level variation in postoperative ventilation time in a subset of patients undergoing isolated coronary artery bypass grafting (CABG). In 2009 and 2010, 325,129 patients in the STS Adult Cardiac Surgery Database underwent isolated CABG. Patients were excluded if they were intubated before entering the operating room, required ventilation for greater than 24 hours, or had missing data on key covariates. The final study cohort was 274,231 isolated CABG patients from 1,008 centers. Bayesian hierarchical models were used to assess between-center variation in ventilation time and to explore the effect of center-level covariates. Analyses were performed with and without adjusting for case mix. After adjusting for case mix, the ratio of median ventilator time at the 90th percentile of the center-level distribution compared with the tenth percentile was 9.0:5.0=1.8 (95% credible interval: 1.79 to 1.85). This ratio illustrates the scale of between-center differences: centers above the 90th percentile have a ventilation time of at least 1.8 times that of centers below the tenth percentile. Smaller hospital volume, presence of a residency program, and some census regions were associated with longer ventilation times. After adjustment for severity of illness, substantial inter-center variation exists in postoperative ventilation time in this subset of patients undergoing isolated CABG. This finding represents an opportunity for multi-institutional quality improvement initiatives designed to limit variations in ventilator management and achieve the shortest possible ventilation times for all patients, thus benefiting both clinical outcomes and resource utilization. Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Extended residence time centrifugal contactor design modification and centrifugal contactor vane plate valving apparatus for extending mixing zone residence time

DOEpatents

Wardle, Kent E.

2017-06-06

The present invention provides an annular centrifugal contactor, having a housing adapted to receive a plurality of flowing liquids; a rotor on the interior of the housing; an annular mixing zone, wherein the annular mixing zone has a plurality of fluid retention reservoirs with ingress apertures near the bottom of the annular mixing zone and egress apertures located above the ingress apertures of the annular mixing zone; and an adjustable vane plate stem, wherein the stem can be raised to restrict the flow of a liquid into the rotor or lowered to increase the flow of the liquid into the rotor.

Pregnancy in polymyositis or dermatomyositis: retrospective results from a tertiary centre in China.

PubMed

Zhong, Zhiqiang; Lin, Fuan; Yang, Jing; Zhang, Fengchun; Zeng, Xiaofeng; You, Xin

2017-08-01

To examine if patients with PM/DM are at higher risk of complicated pregnancies. In a retrospective cohort in a large tertiary centre in North China, the outcomes of 144 pregnancies were evaluated in 62 women with PM/DM. Generalized linear mixed effect models were fitted to assess the effect of pregnancy occurring after disease on pregnancy outcomes including preterm birth (PTB), abortion (spontaneous or induced) and normal delivery. Adjustment for confounding factors including parity, maternal age and pregnancy-disease interval were achieved with a multivariable model. For women who became pregnant after disease onset, there was significantly higher risk of either PTB or spontaneous abortion (adjusted odds ratio, OR = 9.36, 95% CI: 1.10, 79.88; P = 0.041). The odds increase was more prominent if PM/DM was also active during pregnancy (adjusted OR = 435.35, 95% CI: 5.32, 35628.18; P = 0.007). Disease flare upon conception was observed in 4 of 22 post-PM/DM pregnancies (P = 0.125), and responded well to steroids and IVIG but resulted in PTB or spontaneous abortion. PM/DM, especially those less well controlled, might contribute to an increased risk of complicated pregnancy. © The Author 2017. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com

Primary and embedded steel imports to the U.S.: implications for the design of border tax adjustments.

PubMed

Izard, Catherine F; Weber, Christopher L; Matthews, H Scott

2010-09-01

Carbon Border Tax Adjustments (BTAs) are a politically popular strategy for avoiding competitive disadvantage problems when a country implements a unilateral climate change policy. A BTA taxes carbon embodied in imported goods in order to protect domestic industry and motivate other countries to implement climate change policy. To estimate the effectiveness of a BTA, is it is necessary to know which products are covered, where they were originally produced and ultimately exported from, and how the covered amount compares to total production in foreign countries. Using a scrap-adjusted, mixed-unit input-output model in conjunction with a multiregional input-output model, this analysis evaluates the effectiveness of BTAs for the case study of U.S. steel imports. Most imported steel by mass is embedded in finished products (60%), and 30% of that steel is produced in a different country than the one from which the final good is exported. Given the magnitudes involved and complexities of global supply chains, a BTA that protects domestic industry will be a challenge to implement. We propose a logistically feasible BTA structure that minimizes the information burden while still accounting for these complexities. However, the amount of steel imported to the U.S. is negligible (5%) compared to foreign production in BTA-eligible countries and is unlikely to motivate affected countries to impose an emissions reduction policy.

Direct vs. Expressed Breast Milk Feeding: Relation to Duration of Breastfeeding.

PubMed

Pang, Wei Wei; Bernard, Jonathan Y; Thavamani, Geetha; Chan, Yiong Huak; Fok, Doris; Soh, Shu-E; Chua, Mei Chien; Lim, Sok Bee; Shek, Lynette P; Yap, Fabian; Tan, Kok Hian; Gluckman, Peter D; Godfrey, Keith M; van Dam, Rob M; Kramer, Michael S; Chong, Yap-Seng

2017-05-27

Studies examining direct vs. expressed breast milk feeding are scarce. We explored the predictors of mode of breastfeeding and its association with breastfeeding duration in a multi-ethnic Asian population. We included 541 breastfeeding mother-infant pairs from the Growing Up in Singapore Toward healthy Outcomes cohort. Mode of breastfeeding (feeding directly at the breast, expressed breast milk (EBM) feeding only, or mixed feeding (a combination of the former 2 modes)) was ascertained at three months postpartum. Ordinal logistic regression analyses identified predictors of breast milk expression. Cox regression models examined the association between mode of breastfeeding and duration of any and of full breastfeeding. Maternal factors independently associated with a greater likelihood of breast milk expression instead of direct breastfeeding were Chinese (vs. Indian) ethnicity, (adjusted odds ratio, 95% CI; 3.41, 1.97-5.91), tertiary education (vs. secondary education or lower) (2.22, 1.22-4.04), primiparity (1.54, 1.04-2.26) and employment during pregnancy (2.53, 1.60-4.02). Relative to those who fed their infants directly at the breast, mothers who fed their infants EBM only had a higher likelihood of early weaning among all mothers who were breastfeeding (adjusted hazard ratio, 95% CI; 2.20, 1.61-3.02), and among those who were fully breastfeeding (2.39, 1.05-5.41). Mothers who practiced mixed feeding, however, were not at higher risk of earlier termination of any or of full breastfeeding. Mothers who fed their infants EBM exclusively, but not those who practiced mixed feeding, were at a higher risk of terminating breastfeeding earlier than those who fed their infants directly at the breast. More education and support are required for women who feed their infants EBM only.

Hospital variation and the impact of postoperative complications on the use of perioperative chemo(radio)therapy in resectable gastric cancer. Results from the Dutch Upper GI Cancer Audit.

PubMed

Schouwenburg, M G; Busweiler, L A D; Beck, N; Henneman, D; Amodio, S; van Berge Henegouwen, M I; Cats, A; van Hillegersberg, R; van Sandick, J W; Wijnhoven, B P L; Wouters, M W J; Nieuwenhuijzen, G A P

2018-04-01

Dutch national guidelines on the diagnosis and treatment of gastric cancer recommend the use of perioperative chemotherapy in patients with resectable gastric cancer. However, adjuvant chemotherapy is often not administered. The aim of this study was to evaluate hospital variation on the probability to receive adjuvant chemotherapy and to identify associated factors with special attention to postoperative complications. All patients who received neoadjuvant chemotherapy and underwent an elective surgical resection for stage IB-IVa (M0) gastric adenocarcinoma between 2011 and 2015 were identified from a national database (Dutch Upper GI Cancer Audit). A multivariable linear mixed model was used to evaluate case-mix adjusted hospital variation and to identify factors associated with adjuvant therapy. Of all surgically treated gastric cancer patients who received neoadjuvant chemotherapy (n = 882), 68% received adjuvant chemo(radio)therapy. After adjusting for case-mix and random variation, a large hospital variation in the administration rates for adjuvant was observed (OR range 0.31-7.1). In multivariable analysis, weight loss, a poor health status and failure of neoadjuvant chemotherapy completion were strongly associated with an increased likelihood of adjuvant therapy omission. Patients with severe postoperative complications had a threefold increased likelihood of adjuvant therapy omission (OR 3.07 95% CI 2.04-4.65). Despite national guidelines, considerable hospital variation was observed in the probability of receiving adjuvant chemo(radio)therapy. Postoperative complications were strongly associated with adjuvant chemo(radio)therapy omission, underlining the need to further reduce perioperative morbidity in gastric cancer surgery. Copyright © 2018 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

A Simple Insightful Approach to Investigating a Hospital Standardised Mortality Ratio: An Illustrative Case-Study

PubMed Central

Mohammed, Mohammed A.; Stevens, Andrew J.

2013-01-01

Background Despite methodological concerns Hospital Standardised Mortality Ratios (HSMRs) are promoted as measures of performance. Hospitals that experience an increase in their HSMR are presented with a serious challenge but with little guidance on how to investigate this complex phenomenon. We illustrate a simple penetrating approach. Methods Retrospective analysis of routinely collected hospital admissions data comparing observed and expected deaths predicted by the Dr Foster Unit case mix adjustment method over three years (n = 74,860 admissions) in Shropshire and Telford NHS Trust Hospital (SaTH) constituting PRH (Princess Royal Hospital) and RSH (Royal Shrewsbury Hospital); whose HSMR increased from 99 in the year 2008/09 to 118 in the year 2009/10. Results The step up in HSMR was primarily located in PRH (109 to 130 vs. 105 to 118 RSH). Disentangling the HSMR by plotting run charts of observed and expected deaths showed that observed deaths were stable in RSH and PRH but expected deaths, especially at PRH, had fallen. The fall in expected deaths has two possible explanations–genuinely lower risk admissions or that the case-mix adjustment model is underestimating the risk of admissions perhaps because of inadequate clinical coding. There was no evidence that the case-mix profile of admissions had changed but there was considerable evidence that clinical coding process at PRH was producing a lower depth of coding resulting in lower expected mortality. Conclusion Knowing whether the change (increase/decrease) in HSMR is driven by the numerator or the denominator is a crucial pivotal first step in understanding a given HSMR and so such information should be an integral part of the HSMR reporting methodology. PMID:23472111

A commentary on the Atlantic meridional overturning circulation stability in climate models

NASA Astrophysics Data System (ADS)

Gent, Peter R.

2018-02-01

The stability of the Atlantic meridional overturning circulation (AMOC) in ocean models depends quite strongly on the model formulation, especially the vertical mixing, and whether it is coupled to an atmosphere model. A hysteresis loop in AMOC strength with respect to freshwater forcing has been found in several intermediate complexity climate models and in one fully coupled climate model that has very coarse resolution. Over 40% of modern climate models are in a bistable AMOC state according to the very frequently used simple stability criterion which is based solely on the sign of the AMOC freshwater transport across 33° S. In a recent freshwater hosing experiment in a climate model with an eddy-permitting ocean component, the change in the gyre freshwater transport across 33° S is larger than the AMOC freshwater transport change. This casts very strong doubt on the usefulness of this simple AMOC stability criterion. If a climate model uses large surface flux adjustments, then these adjustments can interfere with the atmosphere-ocean feedbacks, and strongly change the AMOC stability properties. AMOC can be shut off for many hundreds of years in modern fully coupled climate models if the hosing or carbon dioxide forcing is strong enough. However, in one climate model the AMOC recovers after between 1000 and 1400 years. Recent 1% increasing carbon dioxide runs and RCP8.5 future scenario runs have shown that the AMOC reduction is smaller using an eddy-resolving ocean component than in the comparable standard 1° ocean climate models.

Determinants of treatment plan implementation in multidisciplinary team meetings for patients with chronic diseases: a mixed-methods study

PubMed Central

Raine, Rosalind; Xanthopoulou, Penny; Wallace, Isla; Nic a’ Bháird, Caoimhe; Lanceley, Anne; Clarke, Alex; Livingston, Gill; Prentice, Archie; Ardron, Dave; Harris, Miriam; King, Michael; Michie, Susan; Blazeby, Jane M; Austin-Parsons, Natalie; Gibbs, Simon; Barber, Julie

2014-01-01

Objective Multidisciplinary team (MDT) meetings are assumed to produce better decisions and are extensively used to manage chronic disease in the National Health Service (NHS). However, evidence for their effectiveness is mixed. Our objective was to investigate determinants of MDT effectiveness by examining factors influencing the implementation of MDT treatment plans. This is a proxy measure of effectiveness, because it lies on the pathway to improvements in health, and reflects team decision making which has taken account of clinical and non-clinical information. Additionally, this measure can be compared across MDTs for different conditions. Methods We undertook a prospective mixed-methods study of 12 MDTs in London and North Thames. Data were collected by observation of 370 MDT meetings, interviews with 53 MDT members, and from 2654 patient medical records. We examined the influence of patient-related factors (disease, age, sex, deprivation, whether their preferences and other clinical/health behaviours were mentioned) and MDT features (as measured using the ‘Team Climate Inventory’ and skill mix) on the implementation of MDT treatment plans. Results The adjusted odds (or likelihood) of implementation was reduced by 25% for each additional professional group represented at the MDT meeting. Implementation was more likely in MDTs with clear goals and processes and a good ‘Team Climate’ (adjusted OR 1.96; 95% CI 1.15 to 3.31 for a unit increase in Team Climate Inventory (TCI) score). Implementation varied by disease category, with the lowest adjusted odds of implementation in mental health teams. Implementation was also lower for patients living in more deprived areas (adjusted odds of implementation for patients in the most compared with least deprived areas was 0.60, 95% CI 0.39 to 0.91). Conclusions Greater multidisciplinarity is not necessarily associated with more effective decision making. Explicit goals and procedures are also crucial. Decision implementation should be routinely monitored to ensure the equitable provision of care. PMID:24915539

Direct-drive DT implosions with Knudsen number variations

DOE PAGES

Kim, Yong Ho; Herrmann, Hans W.; Hoffman, Nelson M.; ...

2016-05-26

Direct-drive implosions of DT-filled plastic-shells have been conducted at the Omega laser facility, measuring nuclear yields while varying Knudsen numbers (i.e., the ratio of mean free path of fusing ions to the length of fuel region) by adjusting both shell thickness (e.g., 7.5, 15, 20, 30 μm) and fill pressure (e.g., 2, 5, 15 atm). In addition, the fusion reactivity reduction model showed a stronger effect on yield as the Knudsen number increases (or the shell thickness decreases). The Reduced-Ion-Kinetic (RIK) simulation which includes both fusion reactivity reduction and mix model was necessary to provide a better match between themore » observed neutron yields and those simulated.« less

Analysis of free turbulent shear flows by numerical methods

NASA Technical Reports Server (NTRS)

Korst, H. H.; Chow, W. L.; Hurt, R. F.; White, R. A.; Addy, A. L.

1973-01-01

Studies are described in which the effort was essentially directed to classes of problems where the phenomenologically interpreted effective transport coefficients could be absorbed by, and subsequently extracted from (by comparison with experimental data), appropriate coordinate transformations. The transformed system of differential equations could then be solved without further specifications or assumptions by numerical integration procedures. An attempt was made to delineate different regimes for which specific eddy viscosity models could be formulated. In particular, this would account for the carryover of turbulence from attached boundary layers, the transitory adjustment, and the asymptotic behavior of initially disturbed mixing regions. Such models were subsequently used in seeking solutions for the prescribed two-dimensional test cases, yielding a better insight into overall aspects of the exchange mechanisms.

Restructuring in response to case mix reimbursement in nursing homes: A contingency approach

PubMed Central

Zinn, Jacqueline; Feng, Zhanlian; Mor, Vincent; Intrator, Orna; Grabowski, David

2013-01-01

Background Resident-based case mix reimbursement has become the dominant mechanism for publicly funded nursing home care. In 1998 skilled nursing facility reimbursement changed from cost-based to case mix adjusted payments under the Medicare Prospective Payment System for the costs of all skilled nursing facility care provided to Medicare recipients. In addition, as of 2004, 35 state Medicaid programs had implemented some form of case mix reimbursement. Purpose The purpose of the study is to determine if the implementation of Medicare and Medicaid case mix reimbursement increased the administrative burden on nursing homes, as evidenced by increased levels of nurses in administrative functions. Methodology/Approach The primary data for this study come from the Centers for Medicare and Medicaid Services Online Survey Certification and Reporting database from 1997 through 2004, a national nursing home database containing aggregated facility-level information, including staffing, organizational characteristics and resident conditions, on all Medicare/Medicaid certified nursing facilities in the country. We conducted multivariate regression analyses using a facility fixed-effects model to examine the effects of the implementation of Medicaid case mix reimbursement and Medicare Prospective Payment System on changes in the level of total administrative nurse staffing in nursing homes. Findings Both Medicaid case mix reimbursement and Medicare Prospective Payment System increased the level of administrative nurse staffing, on average by 5.5% and 4.0% respectively. However, lack of evidence for a substitution effect suggests that any decline in direct care staffing after the introduction of case mix reimbursement is not attributable to a shift from clinical nursing resources to administrative functions. Practice Implications Our findings indicate that the administrative burden posed by case mix reimbursement has resource implications for all freestanding facilities. At the margin, the increased administrative burden imposed by case mix may become a factor influencing a range of decisions, including resident admission and staff hiring. PMID:18360162

Restructuring in response to case mix reimbursement in nursing homes: a contingency approach.

PubMed

Zinn, Jacqueline; Feng, Zhanlian; Mor, Vincent; Intrator, Orna; Grabowski, David

2008-01-01

Resident-based case mix reimbursement has become the dominant mechanism for publicly funded nursing home care. In 1998 skilled nursing facility reimbursement changed from cost-based to case mix adjusted payments under the Medicare Prospective Payment System for the costs of all skilled nursing facility care provided to Medicare recipients. In addition, as of 2004, 35 state Medicaid programs had implemented some form of case mix reimbursement. The purpose of the study is to determine if the implementation of Medicare and Medicaid case mix reimbursement increased the administrative burden on nursing homes, as evidenced by increased levels of nurses in administrative functions. The primary data for this study come from the Centers for Medicare and Medicaid Services Online Survey Certification and Reporting database from 1997 through 2004, a national nursing home database containing aggregated facility-level information, including staffing, organizational characteristics and resident conditions, on all Medicare/Medicaid certified nursing facilities in the country. We conducted multivariate regression analyses using a facility fixed-effects model to examine the effects of the implementation of Medicaid case mix reimbursement and Medicare Prospective Payment System on changes in the level of total administrative nurse staffing in nursing homes. Both Medicaid case mix reimbursement and Medicare Prospective Payment System increased the level of administrative nurse staffing, on average by 5.5% and 4.0% respectively. However, lack of evidence for a substitution effect suggests that any decline in direct care staffing after the introduction of case mix reimbursement is not attributable to a shift from clinical nursing resources to administrative functions. Our findings indicate that the administrative burden posed by case mix reimbursement has resource implications for all freestanding facilities. At the margin, the increased administrative burden imposed by case mix may become a factor influencing a range of decisions, including resident admission and staff hiring.

Early return visits by primary care patients: a retail nurse practitioner clinic versus standard medical office care.

PubMed

Rohrer, James E; Angstman, Kurt B; Garrison, Gregory

2012-08-01

The purpose of this study was to compare return visits made by patients within 2 weeks after using retail nurse practitioner clinics to return visits made by similar patients after using standard medical office clinics. Retail medicine clinics have become widely available. However, their impact on return visit rates compared to standard medical office visits for similar patients has not been extensively studied. Electronic medical records of adult primary care patients seen in a large group practice in Minnesota in 2009 were analyzed for this study. Patients who were treated for sinusitis were selected. Two groups of patients were studied: those who used one of 2 retail walk-in clinics staffed by nurse practitioners and a comparison group who used one of 4 regular office clinics. The dependent variable was a return office visit to any site within 2 weeks. Multiple logistic regression analysis was used to adjust for case-mix differences between groups. Unadjusted odds of return visits were lower for retail clinic patients than for standard office care patients. After adjustment for case mix, patients with more outpatient visits in the previous 6 months had higher odds of return visits within 2 weeks (2-6 prior visits: odds ratio [OR]=1.99, P=0.00; 6 or more prior visits: OR=6.80, P=0.00). The odds of a return visit within 2 weeks were not different by clinic type after adjusting for propensity to use services (OR=1.17, P=0.28). After adjusting for case mix differences, return visit rates did not differ by clinic type.

Influence of alluvial cover and lithology on the adjustment characteristics of semi-alluvial bedrock channels

NASA Astrophysics Data System (ADS)

Ferguson, Sean P.; Rennie, Colin D.

2017-05-01

A growing body of research has focused on evaluating the adjustment characteristics of semi-alluvial channels containing proximate bedrock, mixed, and alluvial sections. Active orogens have been the focus of most empirical field-based studies with comparatively less focus on semi-alluvial bedrock channels located in other regions. In this study, we present an inventory of channel geometry data collected from semi-alluvial bedrock channels in Ontario and Québec, Canada, which are not subject to tectonic uplift. Data were sourced from a variety of physiographic settings, permitting evaluation of the influence of alluvial cover, lithology, and gradient on cross-sectional channel form. Our results show no substantial difference in channel width or scaling behaviour amongst bedrock, mixed, and alluvial channels included in our study, except for sedimentary bedrock channels virtually bare of alluvial cover that represent a uniquely wide, distinct subgroup. Channel gradient does not appear to exhibit any observable control on channel width amongst our study rivers, suggesting that sedimentary bedrock channels form a distinct subgroup because of lithology. Comparatively, the widths of our bedrock channels formed in igneous/metamorphic bedrock are comparable to the widths of mixed channels and alluvial channels for a given discharge and drainage area. Our findings also suggest that cross-sectional adjustment of sedimentary bedrock channels is achieved through lateral erosion of the channel banks and downward erosion of the channel bed, whereas cross-sectional adjustment of igneous/metamorphic bedrock is primarily achieved through downward erosion of the bed with limited lateral erosion of the banks.

Validity of Monod kinetics at different sludge ages--peptone biodegradation under aerobic conditions.

PubMed

Orhon, Derin; Cokgor, Emine Ubay; Insel, Guclu; Karahan, Ozlem; Katipoglu, Tugce

2009-12-01

The study presented an evaluation of the effect of culture history (sludge age) on the growth kinetics of a mixed culture grown under aerobic conditions. It involved an experimental setup where a lab-scale sequencing batch reactor was operated at steady-state at two different sludge ages (theta(X)) of 2 and 10 days. The system sustained a mixed culture fed with a synthetic substrate mainly consisting of peptone. The initial concentration of substrate COD was selected around 500 mg COD/L. Polyhydroxyalkanoate (PHA) storage occurred to a limited extent, around 30 mg COD/L for theta(X)=10 days and 15 mg COD/L for theta(X)=2 days. Evaluation of the experimental data based on calibration of two different models provided consistent and reliable evidence for a variable Monod kinetics where the maximum specific growth rate, was assessed as 6.1/day for theta(X)=2 days and 4.1/day for theta(X)=10 days. A similar variability was also applicable for the hydrolysis and storage kinetics. The rate of storage was significantly lower than the levels reported in the literature, exhibiting the ability of the microorganisms to regulate their metabolic mechanisms for adjusting the rate of microbial growth and storage competing for the same substrate. This adjustment evidently resulted in case-specific, variable kinetics both for microbial growth and substrate storage.

Growth and clinical variables in nitrogen-restricted piglets fed an adjusted essential amino acid mix: Effects using partially intact protein-based diets

USDA-ARS?s Scientific Manuscript database

Current recommendations for protein levels in infant formula ensure that growth matches or exceeds growth of breast-fed infants, but may provide a surplus of amino acids (AA). Recent studies in infants using AA-based formulas support specific adjustment of the essential AA (EAA) composition allowing...

Examining the Experiences and Adjustment Challenges of Saudi Arabian Students in the California State University System

ERIC Educational Resources Information Center

Caldwell, Jeremy Dean

2013-01-01

The purpose of this study was to examine the experiences and adjustment challenges of Saudi Arabian students in the California State University (CSU) system. Specifically, the study was conducted to better understand and serve the Saudi Arabian students studying in the system. The design for this mixed method study integrated both quantitative and…

Profiles of dyadic adjustment for advanced prostate cancer to inform couple-based intervention.

PubMed

Elliott, Kate-Ellen J; Scott, Jennifer L; Monsour, Michael; Nuwayhid, Fadi

2015-01-01

The purpose of the study is to describe from a relational perspective, partners' psychological adjustment, coping and support needs for advanced prostate cancer. A mixed methods design was adopted, employing triangulation of qualitative and quantitative data, to produce dyadic profiles of adjustment for six couples recruited from the urology clinics of local hospitals in Tasmania, Australia. Dyads completed a video-taped communication task, semi-structured interview and standardised self-report questionnaires. Themes identified were associated with the dyadic challenges of the disease experience (e.g. relationship intimacy, disease progression and carer burden). Couples with poor psychological adjustment profiles had both clinical and global locus of distress, treatment side-effects, carer burden and poor general health. Resilient couples demonstrated relationship closeness and adaptive cognitive and behavioural coping strategies. The themes informed the adaption of an effective program for couples coping with women's cancers (CanCOPE, to create a program for couples facing advanced prostate cancer (ProCOPE-Adv). Mixed method results inform the development of psychological therapy components for couples coping with advanced prostate cancer. The concomitance of co-morbid health problems may have implications for access and engagement for older adult populations in face-to-face intervention.

Novel Associations between Common Breast Cancer Susceptibility Variants and Risk-Predicting Mammographic Density Measures

PubMed Central

Stone, Jennifer; Thompson, Deborah J.; dos-Santos-Silva, Isabel; Scott, Christopher; Tamimi, Rulla M.; Lindstrom, Sara; Kraft, Peter; Hazra, Aditi; Li, Jingmei; Eriksson, Louise; Czene, Kamila; Hall, Per; Jensen, Matt; Cunningham, Julie; Olson, Janet E.; Purrington, Kristen; Couch, Fergus J.; Brown, Judith; Leyland, Jean; Warren, Ruth M. L.; Luben, Robert N.; Khaw, Kay-Tee; Smith, Paula; Wareham, Nicholas J.; Jud, Sebastian M.; Heusinger, Katharina; Beckmann, Matthias W.; Douglas, Julie A.; Shah, Kaanan P.; Chan, Heang-Ping; Helvie, Mark A.; Le Marchand, Loic; Kolonel, Laurence N.; Woolcott, Christy; Maskarinec, Gertraud; Haiman, Christopher; Giles, Graham G.; Baglietto, Laura; Krishnan, Kavitha; Southey, Melissa C.; Apicella, Carmel; Andrulis, Irene L.; Knight, Julia A.; Ursin, Giske; Grenaker Alnaes, Grethe I.; Kristensen, Vessela N.; Borresen-Dale, Anne-Lise; Gram, Inger Torhild; Bolla, Manjeet K.; Wang, Qin; Michailidou, Kyriaki; Dennis, Joe; Simard, Jacques; Paroah, Paul; Dunning, Alison M.; Easton, Douglas F.; Fasching, Peter A.; Pankratz, V. Shane; Hopper, John; Vachon, Celine M.

2015-01-01

Mammographic density measures adjusted for age and body mass index (BMI) are heritable predictors of breast cancer risk but few mammographic density-associated genetic variants have been identified. Using data for 10,727 women from two international consortia, we estimated associations between 77 common breast cancer susceptibility variants and absolute dense area, percent dense area and absolute non-dense area adjusted for study, age and BMI using mixed linear modeling. We found strong support for established associations between rs10995190 (in the region of ZNF365), rs2046210 (ESR1) and rs3817198 (LSP1) and adjusted absolute and percent dense areas (all p <10−5). Of 41 recently discovered breast cancer susceptibility variants, associations were found between rs1432679 (EBF1), rs17817449 (MIR1972-2: FTO), rs12710696 (2p24.1), and rs3757318 (ESR1) and adjusted absolute and percent dense areas, respectively. There were associations between rs6001930 (MKL1) and both adjusted absolute dense and non-dense areas, and between rs17356907 (NTN4) and adjusted absolute non-dense area. Trends in all but two associations were consistent with those for breast cancer risk. Results suggested that 18% of breast cancer susceptibility variants were associated with at least one mammographic density measure. Genetic variants at multiple loci were associated with both breast cancer risk and the mammographic density measures. Further understanding of the underlying mechanisms at these loci could help identify etiological pathways implicated in how mammographic density predicts breast cancer risk. PMID:25862352

Improved prediction of heat of mixing and segregation in metallic alloys using tunable mixing rule for embedded atom method

NASA Astrophysics Data System (ADS)

Divi, Srikanth; Agrahari, Gargi; Ranjan Kadulkar, Sanket; Kumar, Sanjeet; Chatterjee, Abhijit

2017-12-01

Capturing segregation behavior in metal alloy nanoparticles accurately using computer simulations is contingent upon the availability of high-fidelity interatomic potentials. The embedded atom method (EAM) potential is a widely trusted interatomic potential form used with pure metals and their alloys. When limited experimental data is available, the A-B EAM cross-interaction potential for metal alloys AxB 1-x are often constructed from pure metal A and B potentials by employing a pre-defined ‘mixing rule’ without any adjustable parameters. While this approach is convenient, we show that for AuPt, NiPt, AgAu, AgPd, AuNi, NiPd, PtPd and AuPd such mixing rules may not even yield the correct alloy properties, e.g., heats of mixing, that are closely related to the segregation behavior. A general theoretical formulation based on scaling invariance arguments is introduced that addresses this issue by tuning the mixing rule to better describe alloy properties. Starting with an existing pure metal EAM potential that is used extensively in literature, we find that the mixing rule fitted to heats of mixing for metal solutions usually provides good estimates of segregation energies, lattice parameters and cohesive energy, as well as equilibrium distribution of metals within a nanoparticle using Monte Carlo simulations. While the tunable mixing rule generally performs better than non-adjustable mixing rules, the use of the tunable mixing rule may still require some caution. For e.g., in Pt-Ni system we find that the segregation behavior can deviate from the experimentally observed one at Ni-rich compositions. Despite this the overall results suggest that the same approach may be useful for developing improved cross-potentials with other existing pure metal EAM potentials as well. As a further test of our approach, mixing rule estimated from binary data is used to calculate heat of mixing in AuPdPt, AuNiPd, AuPtNi, AgAuPd and NiPtPd. Excellent agreement with experiments is observed for AuPdPt.

Using Case-Mix Adjustment Methods To Measure the Effectiveness of Substance Abuse Treatment: Three Examples Using Client Employment Outcomes.

ERIC Educational Resources Information Center

Koenig, Lane; Fields, Errol L.; Dall, Timothy M.; Ameen, Ansari Z.; Harwood, Henrick J.

This report demonstrates three applications of case-mix methods using regression analysis. The results are used to assess the relative effectiveness of substance abuse treatment providers. The report also examines the ability of providers to improve client employment outcomes, an outcome domain relatively unexamined in the assessment of provider…

The use of a non-nuclear density gauge for monitoring the compaction process of asphalt pavement

NASA Astrophysics Data System (ADS)

Van den bergh, Wim; Vuye, Cedric; Kara, Patricia; Couscheir, Karolien; Blom, Johan; Van Bouwel, Philippe

2017-09-01

The mechanical performance of an asphalt pavement affects its durability - thus carbon footprint. Many parameters contribute to the success of a durable asphalt mix, e.g. material selection, an accurate mix and even the road design in which the asphalt mix quality is quantified. The quality of the asphalt mix, by its mechanical properties, is also related to the compaction degree. However, and specifically for high volume rates, the laying process at the construction site needs an effective method to monitor and adjust immediately the compaction quality before cooling and without damaging the layer, which is now absent. In this paper the use of a non-nuclear density gauge (PQI - Pavement Quality Indicator) is evaluated, based on a site at Brussels Airport. Considering the outcome of the present research, this PQI is advised as a unique tool for continuous density measurements and allow immediate adjustments during compaction, and decreases the number of core drilling for quality control, and as a posteriori asphalt pavement density test where cores are prohibited. The use of PQI could be recommended to be a part of the standard quality control process in the Flemish region.

Eating in groups: Do multiple social influences affect intake in a fast-food restaurant?

PubMed

Brindal, Emily; Wilson, Carlene; Mohr, Philip; Wittert, Gary

2015-05-01

This study investigated multiple social influences to determine whether they affect amount eaten at a fast-food environment. Using observational methods, data on meal duration, foods eaten and personal characteristics were collected for 157 McDonald's patrons. Analysis of covariance revealed that female diners ate less kilojoules when eating in mixed- versus same-sex groups (adjusted difference = 967 kJ, p < .05), while male diners eating in mixed-sex company ate more in groups compared to pairs (adjusted difference = 1067 kJ, p = .019). Influences to increase and restrict the amount eaten can operate simultaneously in an eating environment with gender a critical factor for consideration. © The Author(s) 2015.

Effect of Medicaid Payment on Rehabilitation Care for Nursing Home Residents

PubMed Central

Wodchis, Walter P.; Hirth, Richard A.; Fries, Brant E.

2007-01-01

There is considerable interest in examining how Medicaid payment affects nursing home care. This study examines the effect of Medicaid payment methods and reimbursement rates on the delivery of rehabilitation therapy to Medicaid nursing home residents in six States from 1992-1995. In States that changed payment from prospective facility-specific to prospective case-mix adjusted payment methods, Medicaid residents received more rehabilitation therapy after the change. While residents in States using case-mix adjusted payment rates for Medicaid payment were more likely to receive rehabilitation than residents in States using prospective facility-specific Medicaid payment, the differences were general and not specific to Medicaid residents. Retrospective payment for Medicaid resident care was associated with greater use of therapy for Medicaid residents. PMID:17645160

Effect of Medicaid payment on rehabilitation care for nursing home residents.

PubMed

Wodchis, Walter P; Hirth, Richard A; Fries, Brant E

2007-01-01

There is considerable interest in examining how Medicaid payment affects nursing home care. This study examines the effect of Medicaid payment methods and reimbursement rates on the delivery of rehabilitation therapy to Medicaid nursing home residents in six States from 1992-1995. In States that changed payment from prospective facility-specific to prospective case-mix adjusted payment methods, Medicaid residents received more rehabilitation therapy after the change. While residents in States using case-mix adjusted payment rates for Medicaid payment were more likely to receive rehabilitation than residents in States using prospective facility-specific Medicaid payment, the differences were general and not specific to Medicaid residents. Retrospective payment for Medicaid resident care was associated with greater use of therapy for Medicaid residents.

Resolution-Adapted All-Atomic and Coarse-Grained Model for Biomolecular Simulations.

PubMed

Shen, Lin; Hu, Hao

2014-06-10

We develop here an adaptive multiresolution method for the simulation of complex heterogeneous systems such as the protein molecules. The target molecular system is described with the atomistic structure while maintaining concurrently a mapping to the coarse-grained models. The theoretical model, or force field, used to describe the interactions between two sites is automatically adjusted in the simulation processes according to the interaction distance/strength. Therefore, all-atomic, coarse-grained, or mixed all-atomic and coarse-grained models would be used together to describe the interactions between a group of atoms and its surroundings. Because the choice of theory is made on the force field level while the sampling is always carried out in the atomic space, the new adaptive method preserves naturally the atomic structure and thermodynamic properties of the entire system throughout the simulation processes. The new method will be very useful in many biomolecular simulations where atomistic details are critically needed.

Chemical supply chain modeling for analysis of homeland security events

DOE PAGES

Ehlen, Mark A.; Sun, Amy C.; Pepple, Mark A.; ...

2013-09-06

The potential impacts of man-made and natural disasters on chemical plants, complexes, and supply chains are of great importance to homeland security. To be able to estimate these impacts, we developed an agent-based chemical supply chain model that includes: chemical plants with enterprise operations such as purchasing, production scheduling, and inventories; merchant chemical markets, and multi-modal chemical shipments. Large-scale simulations of chemical-plant activities and supply chain interactions, running on desktop computers, are used to estimate the scope and duration of disruptive-event impacts, and overall system resilience, based on the extent to which individual chemical plants can adjust their internal operationsmore » (e.g., production mixes and levels) versus their external interactions (market sales and purchases, and transportation routes and modes). As a result, to illustrate how the model estimates the impacts of a hurricane disruption, a simple example model centered on 1,4-butanediol is presented.« less

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

Zuidema, P; Chiu, C; Fairall, CW

Southern Africa is the world’s largest emitter of biomass-burning (BB) aerosols. Their westward transport over the remote southeast Atlantic Ocean colocates some of the largest atmospheric loadings of absorbing aerosol with the least examined of the Earth’s major subtropical stratocumulus decks. Global aerosol model results highlight that the largest positive top-of-atmosphere forcing in the world occurs in the southeast Atlantic, but this region exhibits large differences in magnitude and sign between reputable models, in part because of high variability in the underlying model cloud distributions. Many uncertainties contribute to the highly variable model radiation fields: the aging of shortwave-absorbing aerosolmore » during transport, how much of the aerosol mixes into the cloudy boundary layer, and how the low clouds adjust to smoke-radiation and smoke-cloud interactions. In addition, the ability of the BB aerosol to absorb shortwave radiation is known to vary seasonally as the fuel type on land changes.« less

Estimating relative risks in multicenter studies with a small number of centers - which methods to use? A simulation study.

PubMed

Pedroza, Claudia; Truong, Van Thi Thanh

2017-11-02

Analyses of multicenter studies often need to account for center clustering to ensure valid inference. For binary outcomes, it is particularly challenging to properly adjust for center when the number of centers or total sample size is small, or when there are few events per center. Our objective was to evaluate the performance of generalized estimating equation (GEE) log-binomial and Poisson models, generalized linear mixed models (GLMMs) assuming binomial and Poisson distributions, and a Bayesian binomial GLMM to account for center effect in these scenarios. We conducted a simulation study with few centers (≤30) and 50 or fewer subjects per center, using both a randomized controlled trial and an observational study design to estimate relative risk. We compared the GEE and GLMM models with a log-binomial model without adjustment for clustering in terms of bias, root mean square error (RMSE), and coverage. For the Bayesian GLMM, we used informative neutral priors that are skeptical of large treatment effects that are almost never observed in studies of medical interventions. All frequentist methods exhibited little bias, and the RMSE was very similar across the models. The binomial GLMM had poor convergence rates, ranging from 27% to 85%, but performed well otherwise. The results show that both GEE models need to use small sample corrections for robust SEs to achieve proper coverage of 95% CIs. The Bayesian GLMM had similar convergence rates but resulted in slightly more biased estimates for the smallest sample sizes. However, it had the smallest RMSE and good coverage across all scenarios. These results were very similar for both study designs. For the analyses of multicenter studies with a binary outcome and few centers, we recommend adjustment for center with either a GEE log-binomial or Poisson model with appropriate small sample corrections or a Bayesian binomial GLMM with informative priors.

A model-based approach to sample size estimation in recent onset type 1 diabetes.

PubMed

Bundy, Brian N; Krischer, Jeffrey P

2016-11-01

The area under the curve C-peptide following a 2-h mixed meal tolerance test from 498 individuals enrolled on five prior TrialNet studies of recent onset type 1 diabetes from baseline to 12 months after enrolment were modelled to produce estimates of its rate of loss and variance. Age at diagnosis and baseline C-peptide were found to be significant predictors, and adjusting for these in an ANCOVA resulted in estimates with lower variance. Using these results as planning parameters for new studies results in a nearly 50% reduction in the target sample size. The modelling also produces an expected C-peptide that can be used in observed versus expected calculations to estimate the presumption of benefit in ongoing trials. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

Complexity study on the Cournot-Bertrand mixed duopoly game model with market share preference

NASA Astrophysics Data System (ADS)

Ma, Junhai; Sun, Lijian; Hou, Shunqi; Zhan, Xueli

2018-02-01

In this paper, a Cournot-Bertrand duopoly model with market share preference is established. Assume that there is a degree of product difference between the two firms, where one firm takes the price as a decision variable and the other takes the quantity. Both firms are bounded rational, with linear cost functions and demand functions. The stability of the equilibrium points is analyzed, and the effects of some parameters (α, β, d and v1) on the model stability are studied. Basins of attraction are investigated and the evolution process is shown with the increase in the output adjustment speed. The simulation results show that instability will lead to the increase in the average utility of the firm that determines the quantity and reduce the average utility of the firm that determines price.

The Martian atmospheric planetary boundary layer stability, fluxes, spectra, and similarity

NASA Technical Reports Server (NTRS)

Tillman, James E.

1994-01-01

This is the first analysis of the high frequency data from the Viking lander and spectra of wind, in the Martian atmospheric surface layer, along with the diurnal variation of the height of the mixed surface layer, are calculated for the first time for Mars. Heat and momentum fluxes, stability, and z(sub O) are estimated for early spring, from a surface temperature model and from Viking Lander 2 temperatures and winds at 44 deg N, using Monin-Obukhov similarity theory. The afternoon maximum height of the mixed layer for these seasons and conditions is estimated to lie between 3.6 and 9.2 km. Estimations of this height is of primary importance to all models of the boundary layer and Martian General Circulation Models (GCM's). Model spectra for two measuring heights and three surface roughnesses are calculated using the depth of the mixed layer, and the surface layer parameters and flow distortion by the lander is also taken into account. These experiments indicate that z(sub O), probably lies between 1.0 and 3.0 cm, and most likely is closer to 1.0 cm. The spectra are adjusted to simulate aliasing and high frequency rolloff, the latter caused both by the sensor response and the large Kolmogorov length on Mars. Since the spectral models depend on the surface parameters, including the estimated surface temperature, their agreement with the calculated spectra indicates that the surface layer estimates are self consistent. This agreement is especially noteworthy in that the inertial subrange is virtually absent in the Martian atmosphere at this height, due to the large Kolmogorov length scale. These analyses extend the range of applicability of terrestrial results and demonstrate that it is possible to estimate the effects of severe aliasing of wind measurements, to produce a models which agree well with the measured spectra. The results show that similarity theory developed for Earth applies to Mars, and that the spectral models are universal.

Influence of Gestational Age and Body Weight on the Pharmacokinetics of Labetalol in Pregnancy

PubMed Central

Fischer, James H.; Sarto, Gloria E.; Hardman, Jennifer; Endres, Loraine; Jenkins, Thomas M.; Kilpatrick, Sarah J.; Jeong, Hyunyoung; Geller, Stacie; Deyo, Kelly; Fischer, Patricia A.; Rodvold, Keith A.

2015-01-01

Background and Objectives Labetalol is frequently prescribed for treatment of hypertension during pregnancy. However, the influence of pregnancy on labetalol pharmacokinetics is uncertain, with inconsistent findings reported by previous studies. This study examined the population pharmacokinetics of oral labetalol during and after pregnancy in women receiving labetalol for hypertension. Methods Data were collected from 57 women receiving the drug for hypertension from the 12th week of pregnancy through 12 weeks postpartum using a prospective, longitudinal design. A sparse sampling strategy guided collection of plasma samples. Samples were assayed for labetalol by high performance liquid chromatography. Estimation of population pharmacokinetic parameters and covariate effects was performed by nonlinear mixed effects modeling using NONMEM. Final population model was validated by bootstrap analysis and visual predictive check. Simulations were performed with the final model to evaluate the appropriate body weight to guide labetalol dosing. Results Lean body weight (LBW) and gestational age, i.e., weeks of pregnancy, were identified as significantly influencing oral clearance (CL/F) of labetalol, with CL/F ranging from 1.4-fold greater than postpartum values at 12 weeks gestational age to 1.6-fold greater at 40 weeks. Doses adjusted for LBW provide more consistent drug exposure than doses adjusted for total body weight. The apparent volumes of distribution for the central compartment and at steady-state were 1.9-fold higher during pregnancy. Conclusions Gestational age and LBW impact the pharmacokinetics of labetalol during pregnancy and have clinical implications for adjusting labetalol doses in these women. PMID:24297680

Is gender policy related to the gender gap in external cause and circulatory disease mortality? A mixed effects model of 22 OECD countries 1973-2008.

PubMed

Backhans, Mona; Burström, Bo; de Leon, Antonio Ponce; Marklund, Staffan

2012-11-12

Gender differences in mortality vary widely between countries and over time, but few studies have examined predictors of these variations, apart from smoking. The aim of this study is to investigate the link between gender policy and the gender gap in cause-specific mortality, adjusted for economic factors and health behaviours. 22 OECD countries were followed 1973-2008 and the outcomes were gender gaps in external cause and circulatory disease mortality. A previously found country cluster solution was used, which includes indicators on taxes, parental leave, pensions, social insurances and social services in kind. Male breadwinner countries were made reference group and compared to earner-carer, compensatory breadwinner, and universal citizen countries. Specific policies were also analysed. Mixed effect models were used, where years were the level 1-units, and countries were the level 2-units. Both the earner-carer cluster (ns after adjustment for GDP) and policies characteristic of that cluster are associated with smaller gender differences in external causes, particularly due to an association with increased female mortality. Cluster differences in the gender gap in circulatory disease mortality are the result of a larger relative decrease of male mortality in the compensatory breadwinner cluster and the earner-carer cluster. Policies characteristic of those clusters were however generally related to increased mortality. Results for external cause mortality are in concordance with the hypothesis that women become more exposed to risks of accident and violence when they are economically more active. For circulatory disease mortality, results differ depending on approach--cluster or indicator. Whether cluster differences not explained by specific policies reflect other welfare policies or unrelated societal trends is an open question. Recommendations for further studies are made.

Automatic adjustment of astrochronologic correlations

NASA Astrophysics Data System (ADS)

Zeeden, Christian; Kaboth, Stefanie; Hilgen, Frederik; Laskar, Jacques

2017-04-01

Here we present an algorithm for the automated adjustment and optimisation of correlations between proxy data and an orbital tuning target (or similar datasets as e.g. ice models) for the R environment (R Development Core Team 2008), building on the 'astrochron' package (Meyers et al.2014). The basis of this approach is an initial tuning on orbital (precession, obliquity, eccentricity) scale. We use filters of orbital frequency ranges related to e.g. precession, obliquity or eccentricity of data and compare these filters to an ensemble of target data, which may consist of e.g. different combinations of obliquity and precession, different phases of precession and obliquity, a mix of orbital and other data (e.g. ice models), or different orbital solutions. This approach allows for the identification of an ideal mix of precession and obliquity to be used as tuning target. In addition, the uncertainty related to different tuning tie points (and also precession- and obliquity contributions of the tuning target) can easily be assessed. Our message is to suggest an initial tuning and then obtain a reproducible tuned time scale, avoiding arbitrary chosen tie points and replacing these by automatically chosen ones, representing filter maxima (or minima). We present and discuss the above outlined approach and apply it to artificial and geological data. Artificial data are assessed to find optimal filter settings; real datasets are used to demonstrate the possibilities of such an approach. References: Meyers, S.R. (2014). Astrochron: An R Package for Astrochronology. http://cran.r-project.org/package=astrochron R Development Core Team (2008). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. ISBN 3-900051-07-0, URL http://www.R-project.org.

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.

Caregiver responses to early cleft palate care: A mixed method approach.

PubMed

Sischo, Lacey; Clouston, Sean A P; Phillips, Ceib; Broder, Hillary L

2016-05-01

This study sought to understand caregivers' (CGs') responses to early cleft lip/palate care for their infants. A prospective, mixed methods multicenter longitudinal study was conducted among CGs (N = 118) seeking treatment for their infants' cleft lip and palate or cleft lip only at 1 of 6 cleft treatment centers in the United States. Participants were in 1 of 2 treatment groups: traditional care only or nasoalveolar molding (NAM) plus traditional care. The CGs completed semistructured interviews and standardized questionnaires assessing psychosocial well-being and family impact at 3 time points: the beginning of treatment (∼1 month of age), prelip surgery (∼3-5 months of age), and postpalate surgery (∼12-13 months of age). Multilevel modeling was used to longitudinally assess CGs' psychosocial outcomes. Although the first year was demanding for all CGs, NAM onset and the child's lip surgery were particularly stressful times. CGs used optimism, problem-solving behavior, and social support to cope with this stress. Qualitatively, CGs' ability to balance cleft treatment demands with their psychosocial resources and coping strategies influenced family adaptation. Qualitative and quantitative results indicated CGs of NAM-treated infants experienced more rapid declines in anxiety and depressive symptoms and better coping skills over time than CGs whose infants had traditional care. CGs of NAM-treated infants experienced more positive psychosocial outcomes than CGs whose infants had traditional care. Results from the mixed model support the family adjustment and adaptation response model as used in pediatric chronic condition research. (c) 2016 APA, all rights reserved).

Cost-Utility Analysis of Bariatric Surgery in Italy: Results of Decision-Analytic Modelling

PubMed Central

Lucchese, Marcello; Borisenko, Oleg; Mantovani, Lorenzo Giovanni; Cortesi, Paolo Angelo; Cesana, Giancarlo; Adam, Daniel; Burdukova, Elisabeth; Lukyanov, Vasily; Di Lorenzo, Nicola

2017-01-01

Objective To evaluate the cost-effectiveness of bariatric surgery in Italy from a third-party payer perspective over a medium-term (10 years) and a long-term (lifetime) horizon. Methods A state-transition Markov model was developed, in which patients may experience surgery, post-surgery complications, diabetes mellitus type 2, cardiovascular diseases or die. Transition probabilities, costs, and utilities were obtained from the Italian and international literature. Three types of surgeries were considered: gastric bypass, sleeve gastrectomy, and adjustable gastric banding. A base-case analysis was performed for the population, the characteristics of which were obtained from surgery candidates in Italy. Results In the base-case analysis, over 10 years, bariatric surgery led to cost increment of EUR 2,661 and generated additional 1.1 quality-adjusted life years (QALYs). Over a lifetime, surgery led to savings of EUR 8,649, additional 0.5 life years and 3.2 QALYs. Bariatric surgery was cost-effective at 10 years with an incremental cost-effectiveness ratio of EUR 2,412/QALY and dominant over conservative management over a lifetime. Conclusion In a comprehensive decision analytic model, a current mix of surgical methods for bariatric surgery was cost-effective at 10 years and cost-saving over the lifetime of the Italian patient cohort considered in this analysis. PMID:28601866

State estimation and prediction using clustered particle filters.

PubMed

Lee, Yoonsang; Majda, Andrew J

2016-12-20

Particle filtering is an essential tool to improve uncertain model predictions by incorporating noisy observational data from complex systems including non-Gaussian features. A class of particle filters, clustered particle filters, is introduced for high-dimensional nonlinear systems, which uses relatively few particles compared with the standard particle filter. The clustered particle filter captures non-Gaussian features of the true signal, which are typical in complex nonlinear dynamical systems such as geophysical systems. The method is also robust in the difficult regime of high-quality sparse and infrequent observations. The key features of the clustered particle filtering are coarse-grained localization through the clustering of the state variables and particle adjustment to stabilize the method; each observation affects only neighbor state variables through clustering and particles are adjusted to prevent particle collapse due to high-quality observations. The clustered particle filter is tested for the 40-dimensional Lorenz 96 model with several dynamical regimes including strongly non-Gaussian statistics. The clustered particle filter shows robust skill in both achieving accurate filter results and capturing non-Gaussian statistics of the true signal. It is further extended to multiscale data assimilation, which provides the large-scale estimation by combining a cheap reduced-order forecast model and mixed observations of the large- and small-scale variables. This approach enables the use of a larger number of particles due to the computational savings in the forecast model. The multiscale clustered particle filter is tested for one-dimensional dispersive wave turbulence using a forecast model with model errors.

State estimation and prediction using clustered particle filters

PubMed Central

Lee, Yoonsang; Majda, Andrew J.

2016-01-01

Particle filtering is an essential tool to improve uncertain model predictions by incorporating noisy observational data from complex systems including non-Gaussian features. A class of particle filters, clustered particle filters, is introduced for high-dimensional nonlinear systems, which uses relatively few particles compared with the standard particle filter. The clustered particle filter captures non-Gaussian features of the true signal, which are typical in complex nonlinear dynamical systems such as geophysical systems. The method is also robust in the difficult regime of high-quality sparse and infrequent observations. The key features of the clustered particle filtering are coarse-grained localization through the clustering of the state variables and particle adjustment to stabilize the method; each observation affects only neighbor state variables through clustering and particles are adjusted to prevent particle collapse due to high-quality observations. The clustered particle filter is tested for the 40-dimensional Lorenz 96 model with several dynamical regimes including strongly non-Gaussian statistics. The clustered particle filter shows robust skill in both achieving accurate filter results and capturing non-Gaussian statistics of the true signal. It is further extended to multiscale data assimilation, which provides the large-scale estimation by combining a cheap reduced-order forecast model and mixed observations of the large- and small-scale variables. This approach enables the use of a larger number of particles due to the computational savings in the forecast model. The multiscale clustered particle filter is tested for one-dimensional dispersive wave turbulence using a forecast model with model errors. PMID:27930332

Increased morbidity and mortality in domestic animals eating dropped and bitten fruit in Bangladeshi villages: Implications for zoonotic disease transmission

PubMed Central

Openshaw, John J.; Hegde, Sonia; Sazzad, Hossain M. S.; Khan, Salah Uddin; Hossain, M. Jahangir; Epstein, Jonathan H.; Daszak, Peter; Gurley, Emily S.; Luby, Stephen P.

2016-01-01

We used data on feeding practices and domestic animal health gathered from 207 Bangladeshi villages to identify any association between grazing dropped fruit found on the ground or owners directly feeding bat or bird-bitten fruit and animal health. We compared mortality and morbidity in domestic animals using a mixed effects model controlling for village clustering, herd size, and proxy measures of household wealth. Thirty percent of household heads reported that their animals grazed on dropped fruit and 20% reported that they actively fed bitten fruit to their domestic herds. Household heads allowing their cattle to graze on dropped fruit were more likely to report an illness within their herd (adjusted prevalence ratio 1.17, 95% CI 1.02-1.31). Household heads directly feeding goats bitten fruit were more likely to report illness (adjusted prevalence ratio 1.35, 95% CI 1.16-1.57) and deaths (adjusted prevalence ratio 1.64, 95% CI 1.13-2.4). Reporting of illnesses and deaths among goats rose as the frequency of feeding bitten fruit increased. One possible explanation for this finding is the transmission of bat pathogens to domestic animals via bitten fruit consumption. PMID:26668032

Increased Morbidity and Mortality in Domestic Animals Eating Dropped and Bitten Fruit in Bangladeshi Villages: Implications for Zoonotic Disease Transmission.

PubMed

Openshaw, John J; Hegde, Sonia; Sazzad, Hossain M S; Khan, Salah Uddin; Hossain, M Jahangir; Epstein, Jonathan H; Daszak, Peter; Gurley, Emily S; Luby, Stephen P

2016-03-01

We used data on feeding practices and domestic animal health gathered from 207 Bangladeshi villages to identify any association between grazing dropped fruit found on the ground or owners directly feeding bat- or bird-bitten fruit and animal health. We compared mortality and morbidity in domestic animals using a mixed effects model controlling for village clustering, herd size, and proxy measures of household wealth. Thirty percent of household heads reported that their animals grazed on dropped fruit and 20% reported that they actively fed bitten fruit to their domestic herds. Household heads allowing their cattle to graze on dropped fruit were more likely to report an illness within their herd (adjusted prevalence ratio 1.17, 95% CI 1.02-1.31). Household heads directly feeding goats bitten fruit were more likely to report illness (adjusted prevalence ratio 1.35, 95% CI 1.16-1.57) and deaths (adjusted prevalence ratio 1.64, 95% CI 1.13-2.4). Reporting of illnesses and deaths among goats rose as the frequency of feeding bitten fruit increased. One possible explanation for this finding is the transmission of bat pathogens to domestic animals via bitten fruit consumption.

Quantifying immediate radiative forcing by black carbon and organic matter with the Specific Forcing Pulse

NASA Astrophysics Data System (ADS)

Bond, T. C.; Zarzycki, C.; Flanner, M. G.; Koch, D. M.

2010-06-01

We propose a measure to quantify climate warming or cooling by pollutants with atmospheric lifetimes of less than one year: the Specific Forcing Pulse (SFP). SFP is the amount of energy added to the Earth system per mass of pollutant emitted. Global average SFP for black carbon, including atmosphere and cryosphere, is 1.12 GJ g-1 and that for organic matter is -0.061 GJ g-1. We provide regional values for black carbon (BC) and organic matter (OM) emitted from 23 source-region combinations, divided between atmosphere and cryosphere impacts and identifying forcing by latitude. Regional SFP varies by about 40% for black carbon. This variation is relatively small because of compensating effects; particles from regions that affect ice albedo typically have shorter atmospheric lifetimes because of lower convection. The ratio between BC and OM SFP implies that, for direct forcing, an OM:BC mass ratio of 15 has a neutral effect on top-of-atmosphere direct forcing for any region, and any lower ratio induces direct warming. However, important processes, particularly cloud changes that tend toward cooling, have not been included here. We demonstrate ensemble adjustment, in which we produce a "best estimate" by combining a suite of diverse but simple models and enhanced models of greater complexity. Adjustments for black carbon internal mixing and for regional variability are discussed; regions with convection are implicated in greater model diversity. SFP expresses scientific uncertainty and separates it from policy uncertainty; the latter is caused by disagreements about the relevant time horizon, impact, or spatial scale of interest. However, metrics used in policy discussions, such as global warming potentials, are easily derived from SFP. Global-average SFP for biofuel and fossil fuel emissions translates to a 100-year GWP of about 760 for black carbon and -40 for organic matter when snow forcing is included. Ensemble-adjusted estimates of atmospheric radiative impact by black and organic matter using year 2000 emissions are +0.46 W m-2 and -0.17 W m-2, respectively; anthropogenic forcing is +0.38 W m-2 and -0.12 W m-2. The black carbon value is only 11% higher than that of the Intergovernmental Panel on Climate Change (IPCC), although this value includes enhanced absorption due to internal mixing.

Rural hospital wages

PubMed Central

Hendricks, Ann M.

1989-01-01

Average fiscal year 1982 wages from 2,302 rural American hospitals were used to test for a gradient descending from hospitals in counties adjacent to metropolitan areas to those not adjacent. Considerable variation in the ratios of adjacent to nonadjacent averages existed. No statistically significant difference was found, however. Of greater importance in explaining relative wages within States were occupational mix, mix of part-time and full-time workers, case mix, presence of medical residencies, and location in a high-rent county within the State. Medicare already adjusts payments for only two of these variables. PMID:10313454

Paramagnetic particles and mixing in micro-scale flows.

PubMed

Calhoun, R; Yadav, A; Phelan, P; Vuppu, A; Garcia, A; Hayes, M

2006-02-01

Mixing in microscale flows with rotating chains of paramagnetic particles can be enhanced by adjusting the ratio of viscous to magnetic forces so that chains dynamically break and reform. Lattice Boltzmann (LB) simulations were used to calculate the interaction between the fluid and suspended paramagnetic particles under the influence of a rotating magnetic field. Fluid velocities obtained from the LB simulations are used to solve the advection diffusion equation for massless tracer particles. At relatively high Mason numbers, small chains result in low edge velocities, and hence mixing is slower than at other Mason numbers. At low Mason numbers, long, stable chains form and produce little mixing toward the center of the chains. A peak in mixing rate is observed when chains break and reform. The uniformity of mixing is greater at higher Mason numbers because more small chains result in a larger number of small mixing areas.

Serum uric acid, protein intake and mortality in hemodialysis patients.

PubMed

Park, Christina; Obi, Yoshitsugu; Streja, Elani; Rhee, Connie M; Catabay, Christina J; Vaziri, Nosratola D; Kovesdy, Csaba P; Kalantar-Zadeh, Kamyar

2017-10-01

The association between serum uric acid (SUA) and mortality has been conflicting among studies using hemodialysis (HD) patients. Given the close link between purine and protein in foods, we hypothesized that normalized protein catabolic rate (nPCR), a dietary protein intake surrogate, modifies the SUA-mortality association in the HD population. We identified 4298 patients who initiated HD and had one or more SUA measurement in a contemporary cohort of HD patients over 5 years (1 January 2007-31 December 2011), and examined survival probability according to the first uric acid measurement, adjusting for dialysis vintage, case-mix and malnutrition-inflammation complex-related variables. Mean SUA concentration was 6.6 ± 1.8 mg/dL. There was a consistent association of higher SUA with better nutritional status and lower all-cause mortality irrespective of adjusted models (Ptrend < 0.001). In the case-mix adjusted model, the highest SUA category (≥8.0 mg/dL) compared with the reference group (>6.0-7.0 mg/dL) showed no significant mortality risk [hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.72-1.13], while the lowest category (<5.0 mg/dL) was associated with higher mortality (HR 1.42, 95% CI 1.16-1.72). The hypouricemia-mortality association was significantly modified by nPCR (Pinteraction = 0.001). Mortality risk of low SUA (<5.0 mg/dL) persisted among patients with low nPCR (<0.9 g/kg/day; HR 1.73, 95% CI 1.42-2.10) but not with high nPCR (≥0.9 g/kg/day; HR 0.99, 95% CI 0.74-1.33). SUA may be a nutritional marker in HD patients. Contrary to the general population, low but not high SUA is associated with higher all-cause mortality in HD patients, especially in those with low protein intake. Nutritional features of SUA warrant additional studies. © The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

Polygenic risk scores in familial Alzheimer disease

PubMed Central

Tosto, Giuseppe; Bird, Thomas D.; Tsuang, Debby; Bennett, David A.; Boeve, Bradley F.; Cruchaga, Carlos; Faber, Kelley; Foroud, Tatiana M.; Farlow, Martin; Goate, Alison M.; Bertlesen, Sarah; Graff-Radford, Neill R.; Medrano, Martin; Lantigua, Rafael; Manly, Jennifer; Ottman, Ruth; Rosenberg, Roger; Schaid, Daniel J.; Schupf, Nicole; Stern, Yaakov; Sweet, Robert A.

2017-01-01

Objective: To investigate the association between a genetic risk score (GRS) and familial late-onset Alzheimer disease (LOAD) and its predictive value in families multiply affected by the disease. Methods: Using data from the National Institute on Aging Genetics Initiative for Late-Onset Alzheimer Disease (National Institute on Aging–Late-Onset Alzheimer's Disease Family Study), mixed regression models tested the association of familial LOAD with a GRS based on single nucleotide polymorphisms (SNPs) previously associated with LOAD. We modeled associations using unweighted and weighted scores with estimates derived from the literature. In secondary models, we adjusted subsequent models for presence of the APOE ε4 allele and further tested the interaction between APOE ε4 and the GRS. We constructed a similar GRS in a cohort of Caribbean Hispanic families multiply affected by LOAD by selecting the SNP with the strongest p value within the same regions. Results: In the NIA-LOAD families, the GRS was significantly associated with LOAD (odds ratio [OR] 1.29; 95% confidence interval 1.21–1.37). The results did not change after adjusting for APOE ε4. In Caribbean Hispanic families, the GRS also significantly predicted LOAD (OR 1.73; 1.57–1.93). Higher scores were associated with lower age at onset in both cohorts. Conclusions: High GRS increases the risk of familial LOAD and lowers the age at onset, regardless of ethnic group. PMID:28213371

Polygenic risk scores in familial Alzheimer disease.

PubMed

Tosto, Giuseppe; Bird, Thomas D; Tsuang, Debby; Bennett, David A; Boeve, Bradley F; Cruchaga, Carlos; Faber, Kelley; Foroud, Tatiana M; Farlow, Martin; Goate, Alison M; Bertlesen, Sarah; Graff-Radford, Neill R; Medrano, Martin; Lantigua, Rafael; Manly, Jennifer; Ottman, Ruth; Rosenberg, Roger; Schaid, Daniel J; Schupf, Nicole; Stern, Yaakov; Sweet, Robert A; Mayeux, Richard

2017-03-21

To investigate the association between a genetic risk score (GRS) and familial late-onset Alzheimer disease (LOAD) and its predictive value in families multiply affected by the disease. Using data from the National Institute on Aging Genetics Initiative for Late-Onset Alzheimer Disease (National Institute on Aging-Late-Onset Alzheimer's Disease Family Study), mixed regression models tested the association of familial LOAD with a GRS based on single nucleotide polymorphisms (SNPs) previously associated with LOAD. We modeled associations using unweighted and weighted scores with estimates derived from the literature. In secondary models, we adjusted subsequent models for presence of the APOE ε4 allele and further tested the interaction between APOE ε4 and the GRS. We constructed a similar GRS in a cohort of Caribbean Hispanic families multiply affected by LOAD by selecting the SNP with the strongest p value within the same regions. In the NIA-LOAD families, the GRS was significantly associated with LOAD (odds ratio [OR] 1.29; 95% confidence interval 1.21-1.37). The results did not change after adjusting for APOE ε4. In Caribbean Hispanic families, the GRS also significantly predicted LOAD (OR 1.73; 1.57-1.93). Higher scores were associated with lower age at onset in both cohorts. High GRS increases the risk of familial LOAD and lowers the age at onset, regardless of ethnic group. © 2017 American Academy of Neurology.

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.

A monitoring tool for performance improvement in plastic surgery at the individual level.

PubMed

Maruthappu, Mahiben; Duclos, Antoine; Orgill, Dennis; Carty, Matthew J

2013-05-01

The assessment of performance in surgery is expanding significantly. Application of relevant frameworks to plastic surgery, however, has been limited. In this article, the authors present two robust graphic tools commonly used in other industries that may serve to monitor individual surgeon operative time while factoring in patient- and surgeon-specific elements. The authors reviewed performance data from all bilateral reduction mammaplasties performed at their institution by eight surgeons between 1995 and 2010. Operative time was used as a proxy for performance. Cumulative sum charts and exponentially weighted moving average charts were generated using a train-test analytic approach, and used to monitor surgical performance. Charts mapped crude, patient case-mix-adjusted, and case-mix and surgical-experience-adjusted performance. Operative time was found to decline from 182 minutes to 118 minutes with surgical experience (p < 0.001). Cumulative sum and exponentially weighted moving average charts were generated using 1995 to 2007 data (1053 procedures) and tested on 2008 to 2010 data (246 procedures). The sensitivity and accuracy of these charts were significantly improved by adjustment for case mix and surgeon experience. The consideration of patient- and surgeon-specific factors is essential for correct interpretation of performance in plastic surgery at the individual surgeon level. Cumulative sum and exponentially weighted moving average charts represent accurate methods of monitoring operative time to control and potentially improve surgeon performance over the course of a career.

Retrospective Binary-Trait Association Test Elucidates Genetic Architecture of Crohn Disease

PubMed Central

Jiang, Duo; Zhong, Sheng; McPeek, Mary Sara

2016-01-01

In genetic association testing, failure to properly control for population structure can lead to severely inflated type 1 error and power loss. Meanwhile, adjustment for relevant covariates is often desirable and sometimes necessary to protect against spurious association and to improve power. Many recent methods to account for population structure and covariates are based on linear mixed models (LMMs), which are primarily designed for quantitative traits. For binary traits, however, LMM is a misspecified model and can lead to deteriorated performance. We propose CARAT, a binary-trait association testing approach based on a mixed-effects quasi-likelihood framework, which exploits the dichotomous nature of the trait and achieves computational efficiency through estimating equations. We show in simulation studies that CARAT consistently outperforms existing methods and maintains high power in a wide range of population structure settings and trait models. Furthermore, CARAT is based on a retrospective approach, which is robust to misspecification of the phenotype model. We apply our approach to a genome-wide analysis of Crohn disease, in which we replicate association with 17 previously identified regions. Moreover, our analysis on 5p13.1, an extensively reported region of association, shows evidence for the presence of multiple independent association signals in the region. This example shows how CARAT can leverage known disease risk factors to shed light on the genetic architecture of complex traits. PMID:26833331

The 2 × 2 model of perfectionism: a comparison across Asian Canadians and European Canadians.

PubMed

Franche, Véronique; Gaudreau, Patrick; Miranda, Dave

2012-10-01

The 2 × 2 model of perfectionism posits that the 4 within-person combinations of self-oriented and socially prescribed perfectionism (i.e., pure SOP, mixed perfectionism, pure SPP, and nonperfectionism) can be distinctively associated with psychological adjustment. This study examined whether the relationship between the 4 subtypes of perfectionism proposed in the 2 × 2 model (Gaudreau & Thompson, 2010) and academic outcomes (i.e., academic satisfaction and grade-point average [GPA]) differed across 2 sociocultural groups: Asian Canadians and European Canadians. A sample of 697 undergraduate students (23% Asian Canadians) completed self-report measures of dispositional perfectionism, academic satisfaction, and GPA. Results replicated most of the 2 × 2 model's hypotheses on ratings of GPA, thus supporting that nonperfectionism was associated with lower GPA than pure SOP (Hypothesis 1a) but with higher GPA than pure SPP (Hypothesis 2). Results also showed that mixed perfectionism was related to higher GPA than pure SPP (Hypothesis 3) but to similar levels as pure SOP, thus disproving Hypothesis 4. Furthermore, results provided evidence for cross-cultural differences in academic satisfaction. While all 4 hypotheses were supported among European Canadians, only Hypotheses 1a and 3 were supported among Asian Canadians. Future lines of research are discussed in light of the importance of acknowledging the role of culture when studying the influence of dispositional perfectionism on academic outcomes. (c) 2012 APA, all rights reserved.

A modified method for measuring antibiotic use in healthcare settings: implications for antibiotic stewardship and benchmarking.

PubMed

Aldeyab, Mamoon A; McElnay, James C; Scott, Michael G; Lattyak, William J; Darwish Elhajji, Feras W; Aldiab, Motasem A; Magee, Fidelma A; Conlon, Geraldine; Kearney, Mary P

2014-04-01

To determine whether adjusting the denominator of the common hospital antibiotic use measurement unit (defined daily doses/100 bed-days) by including age-adjusted comorbidity score (100 bed-days/age-adjusted comorbidity score) would result in more accurate and meaningful assessment of hospital antibiotic use. The association between the monthly sum of age-adjusted comorbidity and monthly antibiotic use was measured using time-series analysis (January 2008 to June 2012). For the purposes of conducting internal benchmarking, two antibiotic usage datasets were constructed, i.e. 2004-07 (first study period) and 2008-11 (second study period). Monthly antibiotic use was normalized per 100 bed-days and per 100 bed-days/age-adjusted comorbidity score. Results showed that antibiotic use had significant positive relationships with the sum of age-adjusted comorbidity score (P = 0.0004). The results also showed that there was a negative relationship between antibiotic use and (i) alcohol-based hand rub use (P = 0.0370) and (ii) clinical pharmacist activity (P = 0.0031). Normalizing antibiotic use per 100 bed-days contributed to a comparative usage rate of 1.31, i.e. the average antibiotic use during the second period was 31% higher than during the first period. However, normalizing antibiotic use per 100 bed-days per age-adjusted comorbidity score resulted in a comparative usage rate of 0.98, i.e. the average antibiotic use was 2% lower in the second study period. Importantly, the latter comparative usage rate is independent of differences in patient density and case mix characteristics between the two studied populations. The proposed modified antibiotic measure provides an innovative approach to compare variations in antibiotic prescribing while taking account of patient case mix effects.

APOL1 genetic variants are not associated with longitudinal blood pressure in young black adults.

PubMed

Chen, Teresa K; Estrella, Michelle M; Vittinghoff, Eric; Lin, Feng; Gutierrez, Orlando M; Kramer, Holly; Lewis, Cora E; Kopp, Jeffrey B; Allen, Norrina B; Winkler, Cheryl A; Bibbins-Domingo, Kirsten B; Peralta, Carmen A

2017-10-01

Whether APOL1 polymorphisms contribute to the excess risk of hypertension among blacks is unknown. To assess this we evaluated whether self-reported race and, in blacks, APOL1 risk variants (high-risk [2 risk alleles] versus low-risk [0-1 risk allele]) were associated with longitudinal blood pressure. Blood pressure trajectories were determined using linear mixed-effects (slope) and latent class models (5 distinct groups) during 25 years of follow-up in the Coronary Artery Risk Development in Young Adults Study. Associations of race and APOL1 genotypes with blood pressure change, separately, using linear mixed-effects and multinomial logistic regression models, adjusting for demographic, socioeconomic, and traditional hypertension risk factors, anti-hypertensive medication use, and kidney function were evaluated. Among 1700 whites and 1330 blacks (13% APOL1 high-risk, mean age 25 years; 46% male) mean mid-, ([systolic + diastolic blood pressure]/2), systolic, and diastolic blood pressures were 89, 110, and 69 mm Hg, respectively. One percent of participants used anti-hypertensive medications at baseline. Compared to whites, blacks, regardless of APOL1 genotype, had significantly greater increases in mid-blood pressure and were more likely to experience significantly increasing mid-blood pressure trajectories with adjusted relative risk ratios of 5.21 and 7.27 for moderate-increasing and elevated-increasing versus low-stable blood pressure, respectively. Among blacks, longitudinal mid-blood pressure changes and mid-blood pressure trajectory classification were similar by APOL1 risk status. Modeling systolic and diastolic blood pressure as outcomes yielded similar findings. From young adulthood to mid-life, blacks have greater blood pressure increases versus whites that are not fully explained by traditional risk factors. Thus APOL1 variants are not associated with longitudinal blood pressure in blacks. Copyright © 2017 International Society of Nephrology. All rights reserved.

Neighborhood income and major depressive disorder in a large Dutch population: results from the LifeLines Cohort study.

PubMed

Klijs, Bart; Kibele, Eva U B; Ellwardt, Lea; Zuidersma, Marij; Stolk, Ronald P; Wittek, Rafael P M; Mendes de Leon, Carlos M; Smidt, Nynke

2016-08-11

Previous studies are inconclusive on whether poor socioeconomic conditions in the neighborhood are associated with major depressive disorder. Furthermore, conceptual models that relate neighborhood conditions to depressive disorder have not been evaluated using empirical data. In this study, we investigated whether neighborhood income is associated with major depressive episodes. We evaluated three conceptual models. Conceptual model 1: The association between neighborhood income and major depressive episodes is explained by diseases, lifestyle factors, stress and social participation. Conceptual model 2: A low individual income relative to the mean income in the neighborhood is associated with major depressive episodes. Conceptual model 3: A high income of the neighborhood buffers the effect of a low individual income on major depressive disorder. We used adult baseline data from the LifeLines Cohort Study (N = 71,058) linked with data on the participants' neighborhoods from Statistics Netherlands. The current presence of a major depressive episode was assessed using the MINI neuropsychiatric interview. The association between neighborhood income and major depressive episodes was assessed using a mixed effect logistic regression model adjusted for age, sex, marital status, education and individual (equalized) income. This regression model was sequentially adjusted for lifestyle factors, chronic diseases, stress, and social participation to evaluate conceptual model 1. To evaluate conceptual models 2 and 3, an interaction term for neighborhood income*individual income was included. Multivariate regression analysis showed that a low neighborhood income is associated with major depressive episodes (OR (95 % CI): 0.82 (0.73;0.93)). Adjustment for diseases, lifestyle factors, stress, and social participation attenuated this association (ORs (95 % CI): 0.90 (0.79;1.01)). Low individual income was also associated with major depressive episodes (OR (95 % CI): 0.72 (0.68;0.76)). The interaction of individual income*neighborhood income on major depressive episodes was not significant (p = 0.173). Living in a low-income neighborhood is associated with major depressive episodes. Our results suggest that this association is partly explained by chronic diseases, lifestyle factors, stress and poor social participation, and thereby partly confirm conceptual model 1. Our results do not support conceptual model 2 and 3.

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

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.

Increased genomic prediction accuracy in wheat breeding through spatial adjustment of field trial data.

PubMed

Lado, Bettina; Matus, Ivan; Rodríguez, Alejandra; Inostroza, Luis; Poland, Jesse; Belzile, François; del Pozo, Alejandro; Quincke, Martín; Castro, Marina; von Zitzewitz, Jarislav

2013-12-09

In crop breeding, the interest of predicting the performance of candidate cultivars in the field has increased due to recent advances in molecular breeding technologies. However, the complexity of the wheat genome presents some challenges for applying new technologies in molecular marker identification with next-generation sequencing. We applied genotyping-by-sequencing, a recently developed method to identify single-nucleotide polymorphisms, in the genomes of 384 wheat (Triticum aestivum) genotypes that were field tested under three different water regimes in Mediterranean climatic conditions: rain-fed only, mild water stress, and fully irrigated. We identified 102,324 single-nucleotide polymorphisms in these genotypes, and the phenotypic data were used to train and test genomic selection models intended to predict yield, thousand-kernel weight, number of kernels per spike, and heading date. Phenotypic data showed marked spatial variation. Therefore, different models were tested to correct the trends observed in the field. A mixed-model using moving-means as a covariate was found to best fit the data. When we applied the genomic selection models, the accuracy of predicted traits increased with spatial adjustment. Multiple genomic selection models were tested, and a Gaussian kernel model was determined to give the highest accuracy. The best predictions between environments were obtained when data from different years were used to train the model. Our results confirm that genotyping-by-sequencing is an effective tool to obtain genome-wide information for crops with complex genomes, that these data are efficient for predicting traits, and that correction of spatial variation is a crucial ingredient to increase prediction accuracy in genomic selection models.

Symptoms of attention-deficit/hyperactivity disorder and social and school adjustment: the moderating roles of age and parenting.

PubMed

Kawabata, Yoshito; Tseng, Wan-Ling; Gau, Susan Shur-Fen

2012-02-01

This study examined the associations between symptoms of attention-deficit/hyperactivity disorder (ADHD) and social and school adjustment (academic performance, peer relationships, school social problems) and the moderating roles of children's age and maternal parenting (affection and overprotection) in these associations. The sample consisted of 2,463 students who were in the first to ninth grade in northern Taiwan. Results from the linear mixed models demonstrated that ADHD symptoms were inversely associated with academic performance and positively associated with social adjustment problems. Further, children's age and maternal parenting moderated the associations between ADHD symptoms and school and social adjustment. For example, maternal overprotection moderated the relation between hyperactivity and negative peer relationships (i.e., difficulty forming and maintaining friendships), such that this relation was stronger for children who experienced higher levels of overprotection than children who did not. Moreover, children's age moderated the association between attention problems and decreased academic performance, such that this association was stronger for older children and adolescents than for younger children. Furthermore, children's age and maternal affection interacted to influence the association between attention problems and school social problems (i.e., bullying, aggression, and peer rejection) with maternal affection acting as a buffer for older children (grades 4-6) only. These findings are discussed from a developmental psychopathology perspective.

Social patterning of cardiovascular and metabolic risk in Colombian adults.

PubMed

Lucumi, Diego I; LeBrón, Alana M W; Schulz, Amy J; Mentz, Graciela

2017-08-01

To test for differences in cardiovascular and metabolic risk (CMR) by educational attainment and physical capital. To compare CMR among black, indigenous, and mixed populations, accounting for socioeconomic status (SES). We conducted multivariate analyses using cross-sectional data from a national survey of Colombian adults (n = 10,814) to examine the social patterning of CMR. In sex/gender-stratified models, a CMR index was regressed on educational attainment, physical capital, ethnicity/race, and age. Women with a primary education (OR = 1.64, 95% CI: 1.25, 2.15) had higher age- and ethnicity/race-adjusted odds of CMR than women with more than secondary education. Men with a primary education (OR = 0.67, 95% CI: 0.48, 0.92) had significantly lower adjusted odds of CMR than men with more than secondary education; these associations did not remain significant after adjustments for physical capital. Men in the first (OR = 0.45, 95% CI: 0.36, 0.57) and second (OR = 0.72, 95% CI: 0.57, 0.91) physical capital tertiles had significantly lower adjusted odds of CMR than those in the highest tertile. There was not a significant patterning of CMR by ethnicity/race for women or men, or by physical capital for women. Findings suggest that for Colombian adults CMR is patterned by SES; these associations differ by sex/gender.

Unemployment in chronic airflow obstruction around the world: results from the BOLD study.

PubMed

Grønseth, Rune; Erdal, Marta; Tan, Wan C; Obaseki, Daniel O; Amaral, Andre F S; Gislason, Thorarinn; Juvekar, Sanjay K; Koul, Parvaiz A; Studnicka, Michael; Salvi, Sundeep; Burney, Peter; Buist, A Sonia; Vollmer, William M; Johannessen, Ane

2017-09-01

We aimed to examine associations between chronic airflow obstruction (CAO) and unemployment across the world.Cross-sectional data from 26 sites in the Burden of Obstructive Lung Disease (BOLD) study were used to analyse effects of CAO on unemployment. Odds ratios for unemployment in subjects aged 40-65 years were estimated using a multilevel mixed-effects generalised linear model with study site as random effect. Site-by-site heterogeneity was assessed using individual participant data meta-analyses.Out of 18 710 participants, 11.3% had CAO. The ratio of unemployed subjects with CAO divided by subjects without CAO showed large site discrepancies, although these were no longer significant after adjusting for age, sex, smoking and education. The site-adjusted odds ratio (95% CI) for unemployment was 1.79 (1.41-2.27) for CAO cases, decreasing to 1.43 (1.14-1.79) after adjusting for sociodemographic factors, comorbidities and forced vital capacity. Of other covariates that were associated with unemployment, age and education were important risk factors in high-income sites (4.02 (3.53-4.57) and 3.86 (2.80-5.30), respectively), while female sex was important in low- to middle-income sites (3.23 (2.66-3.91)).In the global BOLD study, CAO was associated with increased levels of unemployment, even after adjusting for sociodemographic factors, comorbidities and lung function. Copyright ©ERS 2017.

A Two-Step Approach for Analysis of Nonignorable Missing Outcomes in Longitudinal Regression: an Application to Upstate KIDS Study.

PubMed

Liu, Danping; Yeung, Edwina H; McLain, Alexander C; Xie, Yunlong; Buck Louis, Germaine M; Sundaram, Rajeshwari

2017-09-01

Imperfect follow-up in longitudinal studies commonly leads to missing outcome data that can potentially bias the inference when the missingness is nonignorable; that is, the propensity of missingness depends on missing values in the data. In the Upstate KIDS Study, we seek to determine if the missingness of child development outcomes is nonignorable, and how a simple model assuming ignorable missingness would compare with more complicated models for a nonignorable mechanism. To correct for nonignorable missingness, the shared random effects model (SREM) jointly models the outcome and the missing mechanism. However, the computational complexity and lack of software packages has limited its practical applications. This paper proposes a novel two-step approach to handle nonignorable missing outcomes in generalized linear mixed models. We first analyse the missing mechanism with a generalized linear mixed model and predict values of the random effects; then, the outcome model is fitted adjusting for the predicted random effects to account for heterogeneity in the missingness propensity. Extensive simulation studies suggest that the proposed method is a reliable approximation to SREM, with a much faster computation. The nonignorability of missing data in the Upstate KIDS Study is estimated to be mild to moderate, and the analyses using the two-step approach or SREM are similar to the model assuming ignorable missingness. The two-step approach is a computationally straightforward method that can be conducted as sensitivity analyses in longitudinal studies to examine violations to the ignorable missingness assumption and the implications relative to health outcomes. © 2017 John Wiley & Sons Ltd.

Causal Inference for fMRI Time Series Data with Systematic Errors of Measurement in a Balanced On/Off Study of Social Evaluative Threat.

PubMed

Sobel, Michael E; Lindquist, Martin A

2014-07-01

Functional magnetic resonance imaging (fMRI) has facilitated major advances in understanding human brain function. Neuroscientists are interested in using fMRI to study the effects of external stimuli on brain activity and causal relationships among brain regions, but have not stated what is meant by causation or defined the effects they purport to estimate. Building on Rubin's causal model, we construct a framework for causal inference using blood oxygenation level dependent (BOLD) fMRI time series data. In the usual statistical literature on causal inference, potential outcomes, assumed to be measured without systematic error, are used to define unit and average causal effects. However, in general the potential BOLD responses are measured with stimulus dependent systematic error. Thus we define unit and average causal effects that are free of systematic error. In contrast to the usual case of a randomized experiment where adjustment for intermediate outcomes leads to biased estimates of treatment effects (Rosenbaum, 1984), here the failure to adjust for task dependent systematic error leads to biased estimates. We therefore adjust for systematic error using measured "noise covariates" , using a linear mixed model to estimate the effects and the systematic error. Our results are important for neuroscientists, who typically do not adjust for systematic error. They should also prove useful to researchers in other areas where responses are measured with error and in fields where large amounts of data are collected on relatively few subjects. To illustrate our approach, we re-analyze data from a social evaluative threat task, comparing the findings with results that ignore systematic error.

Methodological approaches in analysing observational data: A practical example on how to address clustering and selection bias.

PubMed

Trutschel, Diana; Palm, Rebecca; Holle, Bernhard; Simon, Michael

2017-11-01

Because not every scientific question on effectiveness can be answered with randomised controlled trials, research methods that minimise bias in observational studies are required. Two major concerns influence the internal validity of effect estimates: selection bias and clustering. Hence, to reduce the bias of the effect estimates, more sophisticated statistical methods are needed. To introduce statistical approaches such as propensity score matching and mixed models into representative real-world analysis and to conduct the implementation in statistical software R to reproduce the results. Additionally, the implementation in R is presented to allow the results to be reproduced. We perform a two-level analytic strategy to address the problems of bias and clustering: (i) generalised models with different abilities to adjust for dependencies are used to analyse binary data and (ii) the genetic matching and covariate adjustment methods are used to adjust for selection bias. Hence, we analyse the data from two population samples, the sample produced by the matching method and the full sample. The different analysis methods in this article present different results but still point in the same direction. In our example, the estimate of the probability of receiving a case conference is higher in the treatment group than in the control group. Both strategies, genetic matching and covariate adjustment, have their limitations but complement each other to provide the whole picture. The statistical approaches were feasible for reducing bias but were nevertheless limited by the sample used. For each study and obtained sample, the pros and cons of the different methods have to be weighted. Copyright © 2017 The Author(s). Published by Elsevier Ltd.. All rights reserved.

Do pregnancy characteristics contribute to rising childhood cancer incidence rates in the United States?

PubMed

Kehm, Rebecca D; Osypuk, Theresa L; Poynter, Jenny N; Vock, David M; Spector, Logan G

2018-03-01

Since 1975, childhood cancer incidence rates have gradually increased in the United States; however, few studies have conducted analyses across time to unpack this temporal rise. The aim of this study was to test the hypothesis that increasing cancer incidence rates are due to secular trends in pregnancy characteristics that are established risk factors for childhood cancer incidence including older maternal age, higher birthweight, and lower birth order. We also considered temporal trends in sociodemographic characteristics including race/ethnicity and poverty. We conducted a time series county-level ecologic analysis using linked population-based data from Surveillance, Epidemiology, and End Results cancer registries (1975-2013), birth data from the National Center for Health Statistics (1970-2013), and sociodemographic data from the US Census (1970-2010). We estimated unadjusted and adjusted average annual percent changes (AAPCs) in incidence of combined (all diagnoses) and individual types of cancer among children, ages 0-4 years, from Poisson mixed models. There was a statistically significant unadjusted temporal rise in incidence of combined childhood cancers (AAPC = 0.71%; 95% CI = 0.55-0.86), acute lymphoblastic leukemia (0.78%; 0.49-1.07), acute myeloid leukemia (1.86%; 1.13-2.59), central nervous system tumors (1.31%; 0.94-1.67), and hepatoblastoma (2.70%; 1.68-3.72). Adjustment for county-level maternal age reduced estimated AAPCs between 8% (hepatoblastoma) and 55% (combined). However, adjustment for other county characteristics did not attenuate AAPCs, and AAPCs remained significantly above 0% in models fully adjusted for county-level characteristics. Although rising maternal age may account for some of the increase in childhood cancer incidence over time, other factors, not considered in this analysis, may also contribute to temporal trends. © 2017 Wiley Periodicals, Inc.

Hospital-level Variation in Utilization of Surgery for Clinical Stage I-II Pancreatic Adenocarcinoma.

PubMed

Swords, Douglas S; Mulvihill, Sean J; Skarda, David E; Finlayson, Samuel R G; Stoddard, Gregory J; Ott, Mark J; Firpo, Matthew A; Scaife, Courtney L

2017-07-11

To (1) evaluate rates of surgery for clinical stage I-II pancreatic ductal adenocarcinoma (PDAC), (2) identify predictors of not undergoing surgery, (3) quantify the degree to which patient- and hospital-level factors explain differences in hospital surgery rates, and (4) evaluate the association between adjusted hospital-specific surgery rates and overall survival (OS) of patients treated at different hospitals. Curative-intent surgery for potentially resectable PDAC is underutilized in the United States. Retrospective cohort study of patients ≤85 years with clinical stage I-II PDAC in the 2004 to 2014 National Cancer Database. Mixed effects multivariable models were used to characterize hospital-level variation across quintiles of hospital surgery rates. Multivariable Cox proportional hazards models were used to estimate the effect of adjusted hospital surgery rates on OS. Of 58,553 patients without contraindications or refusal of surgery, 63.8% underwent surgery, and the rate decreased from 2299/3528 (65.2%) in 2004 to 4412/7092 (62.2%) in 2014 (P < 0.001). Adjusted hospital rates of surgery varied 6-fold (11.4%-70.9%). Patients treated at hospitals with higher rates of surgery had better unadjusted OS (median OS 10.2, 13.3, 14.2, 16.5, and 18.4 months in quintiles 1-5, respectively, P < 0.001, log-rank). Treatment at hospitals in lower surgery rate quintiles 1-3 was independently associated with mortality [Hazard ratio (HR) 1.10 (1.01, 1.21), HR 1.08 (1.02, 1.15), and HR 1.09 (1.04, 1.14) for quintiles 1-3, respectively, compared with quintile 5] after adjusting for patient factors, hospital type, and hospital volume. Quality improvement efforts are needed to help hospitals with low rates of surgery ensure that their patients have access to appropriate surgery.

Price Elasticity of Alcohol Demand in India.

PubMed

Kumar, Santosh

2017-05-01

Using a household survey conducted in 2014, this study estimates price elasticity of demand (PED) for beer, country liquor and spirits in India. Ordinary least-square models were used to estimate the responsiveness in alcohol demand due to price change. A large number of control variables were included to adjust for potential confounding in the model. Inter-district variation in alcohol consumption is adjusted for by including district fixed effects. Alcohol prices are negatively associated with demand for alcoholic beverages. The PED ranged from -0.14 for spirits to -0.46 for country liquor. Low level of education was positively associated with spirits consumption. The magnitude of elasticity varied by rural-urban, education and gender. Results indicate that a policy mix of price controls and awareness campaigns would be most effective in tackling the adverse effects of harmful drinking in India. The demand for beer, country liquor and spirits is negatively associated with its own price. The elasticity estimates ranged from -0.14 for spirits to -0.44 for country liquor. The elasticity estimates varied by rural-urban, gender and by education levels of the drinkers. © The Author 2017. Medical Council on Alcohol and Oxford University Press. All rights reserved

Do Differential Response Rates to Patient Surveys Between Organizations Lead to Unfair Performance Comparisons?: Evidence From the English Cancer Patient Experience Survey.

PubMed

Saunders, Catherine L; Elliott, Marc N; Lyratzopoulos, Georgios; Abel, Gary A

2016-01-01

Patient surveys typically have variable response rates between organizations, leading to concerns that such differences may affect the validity of performance comparisons. To explore the size and likely sources of associations between hospital-level survey response rates and patient experience. Cross-sectional mail survey including 60 patient experience items sent to 101,771 cancer survivors recently treated by 158 English NHS hospitals. Age, sex, race/ethnicity, socioeconomic status, clinical diagnosis, hospital type, and region were available for respondents and nonrespondents. The overall response rate was 67% (range, 39% to 77% between hospitals). Hospitals with higher response rates had higher scores for all items (Spearman correlation range, 0.03-0.44), particularly questions regarding hospital-level administrative processes, for example, procedure cancellations or medical note availability.From multivariable analysis, associations between individual patient experience and hospital-level response rates were statistically significant (P<0.05) for 53/59 analyzed questions, decreasing to 37/59 after adjusting for case-mix, and 25/59 after further adjusting for hospital-level characteristics.Predicting responses of nonrespondents, and re-estimating hypothetical hospital scores assuming a 100% response rate, we found that currently low performing hospitals would have attained even lower scores. Overall nationwide attainment would have decreased slightly to that currently observed. Higher response rate hospitals have more positive experience scores, and this is only partly explained by patient case-mix. High response rates may be a marker of efficient hospital administration, and higher quality that should not, therefore, be adjusted away in public reporting. Although nonresponse may result in slightly overestimating overall national levels of performance, it does not appear to meaningfully bias comparisons of case-mix-adjusted hospital results.

Efficacy of different fibres and flour mixes in South-Asian flatbreads for reducing post-prandial glucose responses in healthy adults.

PubMed

Boers, Hanny M; MacAulay, Katrina; Murray, Peter; Seijen Ten Hoorn, Jack; Hoogenraad, Anne-Roos; Peters, Harry P F; Vente-Spreeuwenberg, Maria A M; Mela, David J

2017-09-01

Type 2 diabetes (T2DM) is increasing, particularly in South-East Asia. Intake of high-glycaemic foods has been positively associated with T2DM, and feasible routes to reduce the glycaemic response to carbohydrate-rich staple foods are needed. The research question was whether different fibre and legume flour mixes in flatbreads lower postprandial glucose (PPG) responses. Using a balanced incomplete block design, we tested the inclusion of guar gum (GG), konjac mannan (KM) and chickpea flour (CPF) in 10 combinations (2/4/6 g GG; 2/4 g KM; 15 g CPF, and 10 or 15 g CPF plus 2 or 4 g GG) in 100 g total of a control commercial high-fibre flatbread flour mix ("atta") on PPG in 38 normal-weight adults. Self-reported appetite was an additional exploratory outcome. An in vitro digestion assay was adapted for flatbreads and assessed for prediction of in vivo PPG. Flatbreads with 6 g GG, 4 g KM, and 15 g CPF plus 2 or 4 g GG reduced PPG ≥30 % (p < 0.01), while no other combinations differed significantly from the control. A statistical model with four in vitro parameters (rate of digestion, %RDS, AUC, carbohydrate level) was highly predictive of PPG results (adjusted R 2  = 0.89). Test products were similar to the control for appetite-related measures. The results confirm the efficacy of specific additions to flatbread flour mixes for reducing PPG and the value of the in vitro model as a predictive tool with these ingredients and product format. This trial is registered at ClinicalTrials.gov with identifier NCT02671214.

Characterization of Urinary Phthalate Metabolites Among Custodians

PubMed Central

Cavallari, Jennifer M.; Simcox, Nancy J.; Wakai, Sara; Lu, Chensheng; Garza, Jennifer L.; Cherniack, Martin

2015-01-01

Phthalates, a ubiquitous class of chemicals found in consumer, personal care, and cleaning products, have been linked to adverse health effects. Our goal was to characterize urinary phthalate metabolite concentrations and to identify work and nonwork sources among custodians using traditional cleaning chemicals and ‘green’ or environmentally preferable products (EPP). Sixty-eight custodians provided four urine samples on a workday (first void, before shift, end of shift, and before bedtime) and trained observers recorded cleaning tasks and types of products used (traditional, EPP, or disinfectant) hourly over the work shifts. Questionnaires were used to assess personal care product use. Four different phthalate metabolites [monoethyl phthalate (MEP), monomethyl phthalate (MMP), mono (2-ethylhexyl) phthalate (MEHP), and monobenzyl phthalate (MBzP)] were quantified using liquid chromatography mass spectrometry. Geometric means (GM) and 95% confidence intervals (95% CI) were calculated for creatinine-adjusted urinary phthalate concentrations. Mixed effects univariate and multivariate modeling, using a random intercept for each individual, was performed to identify predictors of phthalate metabolites including demographics, workplace factors, and personal care product use. Creatinine-adjusted urinary concentrations [GM (95% CI)] of MEP, MMP, MEHP, and MBzP were 107 (91.0–126), 2.69 (2.18–3.30), 6.93 (6.00–7.99), 8.79 (7.84–9.86) µg g−1, respectively. An increasing trend in phthalate concentrations from before to after shift was not observed. Creatinine-adjusted urinary MEP was significantly associated with frequency of traditional cleaning chemical intensity in the multivariate model after adjusting for potential confounding by demographics, workplace factors, and personal care product use. While numerous demographics, workplace factors, and personal care products were statistically significant univariate predictors of MMP, MEHP, and MBzP, few associations persisted in multivariate models. In summary, among this population of custodians, we identified both occupational and nonoccupational predictors of phthalate exposures. Identification of phthalates as ingredients in cleaning chemicals and consumer products would allow workers and consumers to avoid phthalate exposure. PMID:26240196

Antidepressant Medication Use and its Association with Cardiovascular Disease and All-Cause Mortality in the Reasons for Geographic and Ethnic Differences in Stroke (REGARDS) Study

PubMed Central

Hansen, Richard A.; Khodneva, Yulia; Glasser, Stephen P.; Qian, Jingjing; Redmond, Nicole; Safford, Monika M.

2018-01-01

Background Mixed evidence suggests second-generation antidepressants may increase risk of cardiovascular and cerebrovascular events. Objective Assess whether antidepressant use is associated with acute coronary heart disease, stroke, cardiovascular disease death, and all-cause mortality. Methods Secondary analyses of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) longitudinal cohort study were conducted. Use of selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, bupropion, nefazodone, and trazodone was measured during the baseline (2003-2007) in-home visit. Outcomes of coronary heart disease, stroke, cardiovascular disease death, and all-cause mortality were assessed every 6 months and adjudicated by medical record review. Cox proportional hazards time-to-event analysis followed patients until their first event on or before December 31, 2011, iteratively adjusting for covariates. Results Among 29,616 participants, 3,458 (11.7%) used an antidepressant of interest. Intermediate models adjusting for everything but physical and mental health found an increased risk of acute coronary heart disease (Hazard Ratio=1.21; 95% CI 1.04-1.41), stroke (Hazard Ratio=1.28; 95% CI 1.02-1.60), cardiovascular disease death (Hazard Ratio =1.29; 95% CI 1.09-1.53), and all-cause mortality (Hazard Ratio=1.27; 95% CI 1.15-1.41) for antidepressant users. Risk estimates trended in this direction for all outcomes in the fully adjusted model, but only remained statistically associated with increased risk of all-cause mortality (Hazard Ratio=1.12; 95% CI 1.01-1.24). This risk was attenuated in sensitivity analyses censoring follow-up time at 2-years (Hazard Ratio=1.37; 95% CI 1.11-1.68). Conclusions In fully adjusted models antidepressant use was associated with a small increase in all-cause mortality. PMID:26783360

Residential green space and birth outcomes in a coastal setting.

PubMed

Glazer, Kimberly B; Eliot, Melissa N; Danilack, Valery A; Carlson, Lynn; Phipps, Maureen G; Dadvand, Payam; Savitz, David A; Wellenius, Gregory A

2018-05-01

Residential green space may improve birth outcomes, with prior studies reporting higher birthweight among infants of women living in greener areas. However, results from studies evaluating associations between green space and preterm birth have been mixed. Further, the potential influence of residential proximity to water, or 'blue space', on health has not previously been evaluated. To evaluate associations between green and blue space and birth outcomes in a coastal area of the northeastern United States. Using residential surrounding greenness (measured by Normalized Difference Vegetation Index [NDVI]) and proximity to recreational facilities, coastline, and freshwater as measures of green and blue space, we examined associations with preterm birth (PTB), term birthweight, and term small for gestational age (SGA) among 61,640 births in Rhode Island. We evaluated incremental adjustment for socioeconomic and environmental metrics. In models adjusted for individual - and neighborhood-level markers of socioeconomic status (SES), an interquartile range (IQR) increase in NDVI was associated with a 12% higher (95% CI: 4, 20%) odds of PTB and, conversely, living within 500 m of a recreational facility was associated with a 7% lower (95% CI: 1, 13%) odds of PTB. These associations were eliminated after further adjustment for town of residence. NDVI was associated with higher birthweight (7.4 g, 95% CI: 0.4-14.4 g) and lower odds of SGA (OR = 0.92, 95% CI: 0.87-0.98) when adjusted for individual-level markers of SES, but not when further adjusted for neighborhood SES or town. Living within 500 m of a freshwater body was associated with a higher birthweight of 10.1 g (95% CI: 2.0, 18.2) in fully adjusted models. Findings from this study do not support the hypothesis that residential green space is associated with reduced risk of preterm birth or higher birthweight after adjustment for individual and contextual socioeconomic factors, but variation in results with incremental adjustment raises questions about the optimal degree of control for confounding by markers of SES. We found that living near a freshwater body was associated with higher birthweight. This result is novel and bears further investigation in other settings and populations. Copyright © 2018 Elsevier Inc. All rights reserved.

Trace element levels in drinking water and cognitive function among elderly Chinese.

PubMed

Emsley, C L; Gao, S; Li, Y; Liang, C; Ji, R; Hall, K S; Cao, J; Ma, F; Wu, Y; Ying, P; Zhang, Y; Sun, S; Unverzagt, F W; Slemenda, C W; Hendrie, H C

2000-05-01

The relation between trace element levels in drinking water and cognitive function was investigated in a population-based study of elderly residents (n = 1,016) in rural China in 1996-1997. Cognitive function was measured using a Chinese translation of the Community Screening Interview for Dementia. A mixed effects model was used to evaluate the effect of each of the elements on cognitive function while adjusting for age, sex, and educational level. Several of the elements examined had a significant effect on cognitive function when they were assessed in a univariate context. However, after adjustment for other elements, many of these results were not significant. There was a significant quadratic effect for calcium and a significant zinc-cadmium interaction. Cognitive function increased with calcium level up to a certain point and then decreased as calcium continued to increase. Zinc showed a positive relation with cognitive function at low cadmium levels but a negative relation at high levels.

Transforce lingual appliances pre-adjusted invisible appliances simplify treatment.

PubMed

Clark, William John

2011-01-01

Transforce lingual appliances are designed to be used in conjunction with conventional fixed appliances. Lingual arch development is normally followed by bonded fixed appliances to detail the occlusion. Alternatively Transforce appliance treatment is an efficient method of preparing complex malocclusions prior to a finishing stage with invisible appliances. This approach is ideal for adult treatment, using light continuous forces for arch development with appliances that are comfortable to wear. Sagittal and Transverse appliances are designed for arch development in a range of sizes for contracted arches. They can be used to treat all classes of malocclusion and are pre-adjusted fixed/removable devices for non-compliance treatment. Force modules with nickel titanium coil springs enclosed in a tube deliver a gentle, biocompatible continuous force with a long range of action. They are excellent for mixed dentition and ideal for adult arch development. There are multiple sizes for upper and lower arch development and a sizing chart may be placed over a study model for correct selection, eliminating the need for laboratory work.

Canopy-wake dynamics: the failure of the constant flux layer

NASA Astrophysics Data System (ADS)

Stefan, H. G.; Markfort, C. D.; Porte-Agel, F.

2013-12-01

The atmospheric boundary layer adjustment at the abrupt transition from a canopy (forest) to a flat surface (land or water) was investigated in a wind tunnel experiment. Detailed measurements examining the effect of canopy turbulence on flow separation, reduced surface shear stress and wake recovery are compared to data for the classical case of a solid backward-facing step. Results provide new insights into the data interpretation for flux estimation by eddy-covariance and flux gradient methods and for the assessment of surface boundary conditions in turbulence models of the atmospheric boundary layer in complex landscapes and over water bodies affected by canopy wakes. The wind tunnel results indicate that the wake of a forest canopy strongly affects surface momentum flux within a distance of 35 - 100 times the step or canopy height, and mean turbulence quantities require distances of at least 100 times the canopy height to adjust to the new surface. The near-surface mixing length in the wake exhibits characteristic length scales of canopy flows at the canopy edge, of the flow separation in the near wake and adjusts to surface layer scaling in the far wake. Components of the momentum budget are examined individually to determine the impact of the wake. The results demonstrate why a constant flux layer does not form until far downwind in the wake. An empirical model for surface shear stress distribution from a forest to a clearing or lake is proposed.

Higgs-portal assisted Higgs inflation with a sizeable tensor-to-scalar ratio

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

Kim, Jinsu; Ko, Pyungwon; Park, Wan-Il, E-mail: kimjinsu@kias.re.kr, E-mail: pko@kias.re.kr, E-mail: Wanil.Park@uv.es

We show that the Higgs portal interactions involving extra dark Higgs field can save generically the original Higgs inflation of the standard model (SM) from the problem of a deep non-SM vacuum in the SM Higgs potential. Specifically, we show that such interactions disconnect the top quark pole mass from inflationary observables and allow multi-dimensional parameter space to save the Higgs inflation, thanks to the additional parameters (the dark Higgs boson mass m {sub φ}, the mixing angle α between the SM Higgs H and dark Higgs Φ, and the mixed quartic coupling) affecting RG-running of the Higgs quartic coupling.more » The effect of Higgs portal interactions may lead to a larger tensor-to-scalar ratio, 0.08 ∼< r ∼< 0.1, by adjusting relevant parameters in wide ranges of α and m {sub φ}, some region of which can be probed at future colliders. Performing a numerical analysis we find an allowed region of parameters, matching the latest Planck data.« less

A Vignette (User's Guide) for “An R Package for Statistical ...

EPA Pesticide Factsheets

StatCharrms is a graphical user front-end for ease of use in analyzing data generated from OCSPP 890.2200, Medaka Extended One Generation Reproduction Test (MEOGRT) and OCSPP 890.2300, Larval Amphibian Gonad Development Assay (LAGDA). The analyses StatCharrms is capable of performing are: Rao-Scott adjusted Cochran-Armitage test for trend By Slices (RSCABS), a Standard Cochran-Armitage test for trend By Slices (SCABS), mixed effects Cox proportional model, Jonckheere-Terpstra step down trend test, Dunn test, one way ANOVA, weighted ANOVA, mixed effects ANOVA, repeated measures ANOVA, and Dunnett test. This document provides a User’s Manual (termed a Vignette by the Comprehensive R Archive Network (CRAN)) for the previously created R-code tool called StatCharrms (Statistical analysis of Chemistry, Histopathology, and Reproduction endpoints using Repeated measures and Multi-generation Studies). The StatCharrms R-code has been publically available directly from EPA staff since the approval of OCSPP 890.2200 and 890.2300, and now is available publically available at the CRAN.

Intellectual and Emotional Development and School Adjustment in Preterm Children at 6 and 7 Years of Age. Continuation of a Follow-Up Study.

ERIC Educational Resources Information Center

Grigoroiu-Serbanescu, Maria

1984-01-01

Continues a previous five-year follow-up of preterm and full-term children by studying the continuity in their intellectual and emotional development. Prematurity was predictive for school adjustment at ages six and seven only when regression was performed on the preterm group, but failed to be predictive when mixed groups of preterm and full-term…

A comparison of the emotional and behavioral problems of children of patients with cancer or a mental disorder and their association with parental quality of life.

PubMed

Krattenmacher, Thomas; Kühne, Franziska; Halverscheid, Susanne; Wiegand-Grefe, Silke; Bergelt, Corinna; Romer, Georg; Möller, Birgit

2014-03-01

To compare the emotional and behavioral problems of children of patients suffering from cancer or a mental disorder and their association with parental quality of life. A total of 223 children from 136 families and their 160 parents were investigated from multiple perspectives in a cross-sectional study. The consistency of different adjustment reports between family members was examined. Through mixed models, the differences between parental HRQoL and the children's symptomatology were studied with regard to the type of parental illness. The prediction of children's adjustment through parental HRQoL was further examined. Additionally, gender and age of the children were considered. Half of the children exhibited psychosocial problems. Gender and age differences were independent of the type of parental disease. In families with parental cancer, the reports of children's adjustment were more consistent between family members than in families where a parental mental disorder was present. We found differences in HRQoL between families with mentally ill parents and those with parental cancer patients. Specifically, the healthy partners of mentally ill parents showed worse HRQoL compared with healthy partners of cancer patients. Healthy parents' reduced HRQoL was associated with worse adjustment in their children, regardless of the type of parental illness, but this result was not found for ill parents. Family members confronted with parental cancer or mental disorders are more burdened compared with those from the "normal" population, independently of the type of disease. Our results indicate that the type of a parental disease has no direct effect on children's adjustment. However, there are disease-specific effects on parental HRQoL, which are associated with children's adjustment. Copyright © 2013 Elsevier Inc. All rights reserved.

Effects of autistic traits on social and school adjustment in children and adolescents: the moderating roles of age and gender.

PubMed

Hsiao, Mei-Ni; Tseng, Wan-Ling; Huang, Hui-Yi; Gau, Susan Shur-Fen

2013-01-01

This study examined the associations between children's and adolescents' autistic-like social deficits and school and social adjustment as well as the moderating roles of age and gender in these associations. The sample consisted of 1321 students (48.7% boys) in Grade 1 to Grade 8 from northern Taiwan. Children's and adolescents' autistic-like social deficits were assessed using the Social Responsiveness Scale (SRS), and their school and social adjustment (i.e., academic performance, negative attitudes toward schoolwork/teachers/classmates, behavioral problems at schools, negative peer relationships, and problems with peers) were assessed using the Social Adjustment Inventory for Children and Adolescents (SAICA). Both measures were completed by the mothers of the participants. Results from the linear mixed models demonstrated that autistic-like social deficits were associated with poor academic performance, negative attitudes toward schoolwork, teachers, and classmates, behavioral problems at schools, negative peer relationships, and problematic peer interactions. Moreover, gender and/or age moderated the associations between autistic-like social deficits and school and social adjustment problems. For example, autistic-like social deficits were more strongly related to negative school attitude, school social problems, and negative peer relationships in boys than in girls. Further, autistic-like social deficits were more strongly related to problems with peers in older girls than in older boys or younger children (regardless of gender). In conclusion, the present study suggests that autistic-like social deficits may place children and adolescents at increased risk for social and school maladjustment and that the extent of maladjustment may vary with the child's age and gender and the domains of adjustment under discussion. Copyright © 2012 Elsevier Ltd. All rights reserved.

Common Breast Cancer Susceptibility Variants in LSP1 and RAD51L1 Are Associated with Mammographic Density Measures that Predict Breast Cancer Risk

PubMed Central

Vachon, Celine M.; Scott, Christopher G.; Fasching, Peter A.; Hall, Per; Tamimi, Rulla M.; Li, Jingmei; Stone, Jennifer; Apicella, Carmel; Odefrey, Fabrice; Gierach, Gretchen L.; Jud, Sebastian M.; Heusinger, Katharina; Beckmann, Matthias W.; Pollan, Marina; Fernández-Navarro, Pablo; González-Neira, Anna; Benítez, Javier; van Gils, Carla H.; Lokate, Mariëtte; Onland-Moret, N. Charlotte; Peeters, Petra H.M.; Brown, Judith; Leyland, Jean; Varghese, Jajini S.; Easton, Douglas F.; Thompson, Deborah J.; Luben, Robert N.; Warren, Ruth ML; Wareham, Nicholas J.; Loos, Ruth JF; Khaw, Kay-Tee; Ursin, Giske; Lee, Eunjung; Gayther, Simon A.; Ramus, Susan J.; Eeles, Rosalind A.; Leach, Martin O.; Kwan-Lim, Gek; Couch, Fergus J.; Giles, Graham G.; Baglietto, Laura; Krishnan, Kavitha; Southey, Melissa C.; Le Marchand, Loic; Kolonel, Laurence N.; Woolcott, Christy; Maskarinec, Gertraud; Haiman, Christopher A; Walker, Kate; Johnson, Nichola; McCormack, Valerie A.; Biong, Margarethe; Alnæs, Grethe I.G.; Gram, Inger Torhild; Kristensen, Vessela N.; Børresen-Dale, Anne-Lise; Lindström, Sara; Hankinson, Susan E.; Hunter, David J.; Andrulis, Irene L.; Knight, Julia A.; Boyd, Norman F.; Figueroa, Jonine D.; Lissowska, Jolanta; Wesolowska, Ewa; Peplonska, Beata; Bukowska, Agnieszka; Reszka, Edyta; Liu, JianJun; Eriksson, Louise; Czene, Kamila; Audley, Tina; Wu, Anna H.; Pankratz, V. Shane; Hopper, John L.; dos-Santos-Silva, Isabel

2013-01-01

Background Mammographic density adjusted for age and body mass index (BMI) is a heritable marker of breast cancer susceptibility. Little is known about the biological mechanisms underlying the association between mammographic density and breast cancer risk. We examined whether common low-penetrance breast cancer susceptibility variants contribute to inter-individual differences in mammographic density measures. Methods We established an international consortium (DENSNP) of 19 studies from 10 countries, comprising 16,895 Caucasian women, to conduct a pooled cross-sectional analysis of common breast cancer susceptibility variants in 14 independent loci and mammographic density measures. Dense and non-dense areas, and percent density, were measured using interactive-thresholding techniques. Mixed linear models were used to assess the association between genetic variants and the square roots of mammographic density measures adjusted for study, age, case status, body mass index (BMI) and menopausal status. Results Consistent with their breast cancer associations, the C-allele of rs3817198 in LSP1 was positively associated with both adjusted dense area (p=0.00005) and adjusted percent density (p=0.001) whereas the A-allele of rs10483813 in RAD51L1 was inversely associated with adjusted percent density (p=0.003), but not with adjusted dense area (p=0.07). Conclusion We identified two common breast cancer susceptibility variants associated with mammographic measures of radio-dense tissue in the breast gland. Impact We examined the association of 14 established breast cancer susceptibility loci with mammographic density phenotypes within a large genetic consortium and identified two breast cancer susceptibility variants, LSP1-rs3817198 and RAD51L1-rs10483813, associated with mammographic measures and in the same direction as the breast cancer association. PMID:22454379

The effect of marital status on the presentation and outcomes of elderly male veterans hospitalized for pneumonia.

PubMed

Metersky, Mark L; Fine, Michael J; Mortensen, Eric M

2012-10-01

Although marital status has been shown to affect the outcomes of many conditions, there are limited data on the relationships between marital status and the presentation and outcomes of pneumonia. We used Veterans Affairs administrative databases to identify a retrospective cohort of male veterans age ≥ 65 years hospitalized for pneumonia between 2002 and 2007. We assessed unadjusted and adjusted associations between marital status and mortality, hospital length of stay, and readmission to the hospital using generalized linear mixed-effect models with admitting hospital as a random effect and adjusted for baseline patient characteristics. There were 48,635 patients (26,558 married and 22,077 unmarried) in the study. Married men had a slightly higher Charlson comorbidity score (3.0 vs 2.8, P < .0001) but were less likely to require ICU admission, ventilator support, and vasopressor treatment during the first 48 h of hospitalization. Married patients had significantly lower crude and adjusted in-hospital mortality (9.4% vs 10.6%; adjusted OR, 0.87; 95% CI, 0.81-0.93) and mortality during the 90 days after hospital discharge (14.7% vs 16.0%; adjusted OR, 0.92; 95% CI, 0.88-0.98). Their adjusted incidence rate ratio length of stay was also lower (0.92; 95% CI, 0.91-0.92). Unmarried elderly men admitted to the hospital with pneumonia have a higher risk of in-hospital and postdischarge mortality, despite having a lower degree of comorbidity. Although marital status may be a surrogate marker for other predictors, it is an easily identifiable one. These results should be considered by those responsible for care-transition decisions for patients hospitalized with pneumonia.

Trends in Hospitalization Rates and Outcomes of Endocarditis among Medicare Beneficiaries

PubMed Central

Bikdeli, Behnood; Wang, Yun; Kim, Nancy; Desai, Mayur M.; Quagliarello, Vincent; Krumholz, Harlan M.

2015-01-01

Objectives To determine the hospitalization rates and outcomes of endocarditis among older adults. Background Endocarditis is the most serious cardiovascular infection and is especially common among older adults. Little is known about recent trends for endocarditis hospitalizations and outcomes. Methods Using Medicare inpatient Standard Analytic Files, we identified all Fee-For-Service beneficiaries aged ≥65 years with a principal or secondary diagnosis of endocarditis from 1999-2010. We used Medicare Denominator Files to report hospitalizations per 100,000 person-years. Rates of 30-day and 1-year mortality were calculated using Vital Status Files. We used mixed-effects models to calculate adjusted rates of hospitalization and mortality and to compare the results before and after 2007, when the American Heart Association revised recommendations for endocarditis prophylaxis. Results Overall, 262,658 beneficiaries were hospitalized with endocarditis. The adjusted hospitalization rate increased from 1999-2005, reaching 83.5 per 100,000 person-years in 2005, and declined during 2006-2007. After 2007, the decline continued, reaching 70.6 per 100,000 person-years in 2010. Adjusted 30-day and 1-year mortality rates ranged from 14.2% to 16.5% and from 32.6% to 36.2%, respectively. There were no consistent changes in adjusted rates of 30-day and 1-year mortality after 2007. Trends in rates of hospitalization and outcomes were consistent across demographic subgroups. Adjusted rates of hospitalization and mortality declined consistently in the subgroup with principal diagnosis of endocarditis. Conclusions Our study highlights the high burden of endocarditis among older adults. We did not observe an increase in adjusted rates of hospitalization or mortality associated with endocarditis after publication of the 2007 guidelines. PMID:23994421

Different as night and day: Patterns of isolated seizures, clusters, and status epilepticus.

PubMed

Goldenholz, Daniel M; Rakesh, Kshitiz; Kapur, Kush; Gaínza-Lein, Marina; Hodgeman, Ryan; Moss, Robert; Theodore, William H; Loddenkemper, Tobias

2018-05-01

Using approximations based on presumed U.S. time zones, we characterized day and nighttime seizure patterns in a patient-reported database, Seizure Tracker. A total of 632 995 seizures (9698 patients) were classified into 4 categories: isolated seizure event (ISE), cluster without status epilepticus (CWOS), cluster including status epilepticus (CIS), and status epilepticus (SE). We used a multinomial mixed-effects logistic regression model to calculate odds ratios (ORs) to determine night/day ratios for the difference between seizure patterns: ISE versus SE, ISE versus CWOS, ISE versus CIS, and CWOS versus CIS. Ranges of OR values were reported across cluster definitions. In adults, ISE was more likely at night compared to CWOS (OR = 1.49, 95% adjusted confidence interval [CI] = 1.36-1.63) and to CIS (OR = 1.61, 95% adjusted CI = 1.34-1.88). The ORs for ISE versus SE and CWOS versus SE were not significantly different regardless of cluster definition. In children, ISE was less likely at night compared to SE (OR = 0.85, 95% adjusted CI = 0.79-0.91). ISE was more likely at night compared to CWOS (OR = 1.35, 95% adjusted CI = 1.26-1.44) and CIS (OR = 1.65, 95% adjusted CI = 1.44-1.86). CWOS was more likely during the night compared to CIS (OR = 1.22, 95% adjusted CI = 1.05-1.39). With the exception of SE in children, our data suggest that more severe patterns favor daytime. This suggests distinct day/night preferences for different seizure patterns in children and adults. Wiley Periodicals, Inc. © 2018 International League Against Epilepsy.

Trends in hospitalization rates and outcomes of endocarditis among Medicare beneficiaries.

PubMed

Bikdeli, Behnood; Wang, Yun; Kim, Nancy; Desai, Mayur M; Quagliarello, Vincent; Krumholz, Harlan M

2013-12-10

The aim of this study was to determine the hospitalization rates and outcomes of endocarditis among older adults. Endocarditis is the most serious cardiovascular infection and is especially common among older adults. Little is known about recent trends for endocarditis hospitalizations and outcomes. Using Medicare inpatient Standard Analytic Files, we identified all fee-for-service beneficiaries age ≥65 years with a principal or secondary diagnosis of endocarditis from 1999 to 2010. We used Medicare Denominator Files to report hospitalizations per 100,000 person-years. Rates of 30-day and 1-year mortality were calculated using Vital Status Files. We used mixed-effects models to calculate adjusted rates of hospitalization and mortality and to compare the results before and after 2007, when the American Heart Association revised their recommendations for endocarditis prophylaxis. Overall, 262,658 beneficiaries were hospitalized with endocarditis. The adjusted hospitalization rate increased from 1999 to 2005, reaching 83.5 per 100,000 person-years in 2005, and declined during 2006 to 2007. After 2007, the decline continued, reaching 70.6 per 100,000 person-years in 2010. Adjusted 30-day and 1-year mortality rates ranged from 14.2% to 16.5% and from 32.6% to 36.2%, respectively. There were no consistent changes in adjusted rates of 30-day and 1-year mortality after 2007. Trends in rates of hospitalization and outcomes were consistent across demographic subgroups. Adjusted rates of hospitalization and mortality declined consistently in the subgroup with a principal diagnosis of endocarditis. Our study highlights the high burden of endocarditis among older adults. We did not observe an increase in adjusted rates of hospitalization or mortality associated with endocarditis after publication of the 2007 guidelines. Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Ground-level falls: 9-year cumulative experience in a regionalized trauma system

PubMed Central

Cade, Angela; King, Brad; Berne, John; Fernandez, Luis; Norwood, Scott

2012-01-01

Ground-level falls (GLFs) are the leading cause of nonfatal hospitalized injuries in the US. We hypothesized that risk-adjusted mortality would not vary between levels of trauma center verification if regional triage functioned appropriately. Data were collected from our regional trauma registry for the years 2001 through 2009. A multilevel mixed-effects logistic regression model was developed to compare risk-adjusted mortality rates by trauma center level and by year. GLF patients numbered 8202 over 9 years with 2.1% mortality. Mean age was 74.5 years and mean probability of death was 0.021 (95% confidence interval [CI], 0.020–0.021). The level I center–treated patients had the highest probability of death (0.033) compared to levels II and III/IV patients (0.023 and 0.018, respectively; P < 0.001), with the highest mortality (6.0%, 3.1%, and 1.1% for levels I, II, and III/IV; P < 0.001). The adjusted odds ratio of mortality was lowest at the level I center (0.71; 95% CI, 0.56–0.91), while no difference existed between level II (1.17; 95% CI, 0.90–1.51) and level III/IV centers (1.22; 95% CI, 0.90–1.66). The 95% CIs for risk-adjusted mortality by year overlapped the 1.0 reference line for each year from 2002 to 2009. In conclusion, regional risk-adjusted mortality for GLF has varied little since 2002. More study is warranted to understand the lower risk-adjusted GLF mortality at the level I center for this growing patient population. PMID:22275774

Task-related and person-related variables influence the effect of low back pain on anticipatory postural adjustments.

PubMed

Jacobs, Jesse V; Lyman, Courtney A; Hitt, Juvena R; Henry, Sharon M

2017-08-01

People with low back pain exhibit altered postural coordination that has been suggested as a target for treatment, but heterogeneous presentation has rendered it difficult to identify appropriate candidates and protocols for such treatments. This study evaluated the associations of task-related and person-related factors with the effect of low back pain on anticipatory postural adjustments. Thirteen subjects with and 13 without low back pain performed seated, rapid arm flexion in self-initiated and cued conditions. Mixed-model ANOVA were used to evaluate group and condition effects on APA onset latencies of trunk muscles, arm-raise velocity, and pre-movement cortical potentials. These measures were evaluated for correlation with pain ratings, Fear Avoidance Beliefs Questionnaire scores, and Modified Oswestry Questionnaire scores. Delayed postural adjustments of subjects with low back pain were greater in the cued condition than in the self-initiated condition. The group with low back pain exhibited larger-amplitude cortical potentials than the group without pain, but also significantly slower arm-raise velocities. With arm-raise velocity as a covariate, the effect of low back pain remained significant for the latencies of postural adjustments but not for cortical potentials. Latencies of the postural adjustments significantly correlated with Oswestry and Fear Avoidance Beliefs scores. Delayed postural adjustments with low back pain appear to be influenced by cueing of movement, pain-related disability and fear of activity. These results highlight the importance of subject characteristics, task condition, and task performance when comparing across studies or when developing treatment of people with low back pain. Copyright © 2017 Elsevier B.V. All rights reserved.

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.

A Mixed Methods Case Study: Understanding the Experience of Nebraska 4-H Participants Relative to Their Transition and Adaptation to College

ERIC Educational Resources Information Center

Walahoski, Jill

2013-01-01

This mixed methods case study was designed to assess the preparedness of former Nebraska 4-H participants to successfully transition and adjust to college. The study also sought to understand the way that students' experiences in Nebraska 4-H may have influenced their readiness to transition to college. The initial quantitative stage of this case…

Long-term vigorous training in young adulthood and later physical activity as predictors of hypertension in middle-aged and older men.

PubMed

Hernelahti, M; Kujala, U M; Kaprio, J; Sarna, S

2002-04-01

500 and 69 male former elite athletes and 319 male controls completed a health questionnaire in 1985 and in 1995. Register data on the subjects were also collected. Subjects were aged 65 years or less and had no history of hypertension in 1985, and they had been healthy at the age of 20 years. The athletes were grouped into endurance and mixed sports (n = 386), and power sports (n = 183). The cumulative 10-year incidence of hypertension up to 1995 was significantly lower in the endurance and mixed sports group (23.6 %) compared to the power sports group (33.3 %) or the control group (32.0 %). The difference between the endurance and mixed sports group and the two other groups was still significant after adjustment for age, but not after further adjustment for body mass index, alcohol consumption, and later physical activity. However, the trend of reduced risk remained. In conclusion, a history of being an elite athlete in endurance or mixed sports predicts a lower risk of hypertension in working age men, while a history of being an elite athlete in power sports appears to confer no benefit. Later physical activity was also associated with lower risk.

On-demand generation and mixing of liquid-in-gas slugs with digitally-programmable composition and size

PubMed Central

Chen, Yi-Chun; Liu, Kan; Shen, Clifton Kwang-Fu; van Dam, R. Michael

2017-01-01

Microscopic droplets or slugs of mixed reagents provide a convenient platform for performing large numbers of isolated biochemical or chemical reactions for many screening and optimization applications. Myriad microfluidic approaches have emerged for creating droplets or slugs with controllable size and composition, generally using an immiscible carrier fluid to assist with the formation or merging processes. We report a novel device for generation of liquid slugs in air when the use of a carrier liquid is not compatible with the application. The slug generator contains two adjacent chambers, each of which has a volume that can be digitally adjusted by closing selected microvalves. Reagents are filled into the two chambers, merged together into a contiguous liquid slug, ejected at the desired time from the device using gas pressure, and mixed by flowing in a downstream channel. Programmable size and composition of slugs is achieved by dynamically adjusting the volume of each chamber prior to filling. Slug formation in this fashion is independent of fluid properties and can easily be scaled to mix larger numbers of reagents. This device has already been used to screen monomer ratios in supramolecular nanoparticle assembly and radiolabeling conditions of engineered antibodies, and here we provide a detailed description of the underlying device. PMID:29167603

Stepwise multiple regression method of greenhouse gas emission modeling in the energy sector in Poland.

PubMed

Kolasa-Wiecek, Alicja

2015-04-01

The energy sector in Poland is the source of 81% of greenhouse gas (GHG) emissions. Poland, among other European Union countries, occupies a leading position with regard to coal consumption. Polish energy sector actively participates in efforts to reduce GHG emissions to the atmosphere, through a gradual decrease of the share of coal in the fuel mix and development of renewable energy sources. All evidence which completes the knowledge about issues related to GHG emissions is a valuable source of information. The article presents the results of modeling of GHG emissions which are generated by the energy sector in Poland. For a better understanding of the quantitative relationship between total consumption of primary energy and greenhouse gas emission, multiple stepwise regression model was applied. The modeling results of CO2 emissions demonstrate a high relationship (0.97) with the hard coal consumption variable. Adjustment coefficient of the model to actual data is high and equal to 95%. The backward step regression model, in the case of CH4 emission, indicated the presence of hard coal (0.66), peat and fuel wood (0.34), solid waste fuels, as well as other sources (-0.64) as the most important variables. The adjusted coefficient is suitable and equals R2=0.90. For N2O emission modeling the obtained coefficient of determination is low and equal to 43%. A significant variable influencing the amount of N2O emission is the peat and wood fuel consumption. Copyright © 2015. Published by Elsevier B.V.

Payload/orbiter contamination control requirement study: Spacelab configuration contamination study

NASA Technical Reports Server (NTRS)

Bareiss, L. E.; Hetrick, M. A.; Ress, E. B.; Strange, D. A.

1976-01-01

The assessment of the Spacelab carrier induced contaminant environment was continued, and the ability of Spacelab to meet established contamination control criteria for the space transportation system program was determined. The primary areas considered included: (1) updating, refining, and improving the Spacelab contamination computer model and contamination analysis methodology, (2) establishing the resulting adjusted induced environment predictions for comparison with the applicable criteria, (3) determining the Spacelab design and operational requirements necessary to meet the criteria, (4) conducting mission feasibility analyses of the combined Spacelab/Orbiter contaminant environment for specific proposed mission and payload mixes, and (5) establishing a preliminary Spacelab mission support plan as well as model interface requirements; A summary of those activities conducted to date with respect to the modelling, analysis, and predictions of the induced environment, including any modifications in approach or methodology utilized in the contamination assessment of the Spacelab carrier, was presented.

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

Ehlen, Mark A.; Sun, Amy C.; Pepple, Mark A.

The potential impacts of man-made and natural disasters on chemical plants, complexes, and supply chains are of great importance to homeland security. To be able to estimate these impacts, we developed an agent-based chemical supply chain model that includes: chemical plants with enterprise operations such as purchasing, production scheduling, and inventories; merchant chemical markets, and multi-modal chemical shipments. Large-scale simulations of chemical-plant activities and supply chain interactions, running on desktop computers, are used to estimate the scope and duration of disruptive-event impacts, and overall system resilience, based on the extent to which individual chemical plants can adjust their internal operationsmore » (e.g., production mixes and levels) versus their external interactions (market sales and purchases, and transportation routes and modes). As a result, to illustrate how the model estimates the impacts of a hurricane disruption, a simple example model centered on 1,4-butanediol is presented.« less

A MODEL SYSTEM TO STUDY ANTIMICROBIAL STRATEGIES IN ENDODONTIC BIOFILMS

PubMed Central

Estrela, Carlos; Sydney, Gilson Blitzkow; Figueiredo, José Antonio Poli; Estrela, Cyntia Rodrigues de Araújo

2009-01-01

The purpose of this work was to develop a model system to study antimicrobial strategies in endodontic biofilms. Enterococcus faecalis suspension was colonized in 10 human root canals. Five milliliters of Brain Heart Infusion (BHI) were mixed with 5 mL of the bacterial inoculums (E. faecalis) and inoculated with sufficient volume to fill the root canal during 60 days. This procedure was repeated every 72 h, always using 24-h pure culture prepared and adjusted to No. 1 MacFarland turbidity standard. Biofilm formation was analyzed by scanning electron microscopy (SEM). E. faecalis consistently adhered to collagen structure, colonized dentin surface, progressed towards the dentinal tubules and formed a biofilm. The proposed biofilm model seems to be viable for studies on antimicrobial strategies, and allows for a satisfactory colonization time of selected bacterial species with virulence and adherence properties. PMID:19274391

Mixed model approaches for diallel analysis based on a bio-model.

PubMed

Zhu, J; Weir, B S

1996-12-01

A MINQUE(1) procedure, which is minimum norm quadratic unbiased estimation (MINQUE) method with 1 for all the prior values, is suggested for estimating variance and covariance components in a bio-model for diallel crosses. Unbiasedness and efficiency of estimation were compared for MINQUE(1), restricted maximum likelihood (REML) and MINQUE theta which has parameter values for the prior values. MINQUE(1) is almost as efficient as MINQUE theta for unbiased estimation of genetic variance and covariance components. The bio-model is efficient and robust for estimating variance and covariance components for maternal and paternal effects as well as for nuclear effects. A procedure of adjusted unbiased prediction (AUP) is proposed for predicting random genetic effects in the bio-model. The jack-knife procedure is suggested for estimation of sampling variances of estimated variance and covariance components and of predicted genetic effects. Worked examples are given for estimation of variance and covariance components and for prediction of genetic merits.

Mixed-location cerebral hemorrhage/microbleeds: Underlying microangiopathy and recurrence risk.

PubMed

Pasi, Marco; Charidimou, Andreas; Boulouis, Gregoire; Auriel, Eitan; Ayres, Alison; Schwab, Kristin M; Goldstein, Joshua N; Rosand, Jonathan; Viswanathan, Anand; Pantoni, Leonardo; Greenberg, Steven M; Gurol, M Edip

2018-01-09

To assess the predominant type of cerebral small vessel disease (SVD) and recurrence risk in patients who present with a combination of lobar and deep intracerebral hemorrhage (ICH)/microbleed locations (mixed ICH). Of 391 consecutive patients with primary ICH enrolled in a prospective registry, 75 (19%) had mixed ICH. Their demographics, clinical/laboratory features, and SVD neuroimaging markers were compared to those of 191 patients with probable cerebral amyloid angiopathy (CAA-ICH) and 125 with hypertensive strictly deep microbleeds and ICH (HTN-ICH). ICH recurrence and case fatality were also analyzed. Patients with mixed ICH showed a higher burden of vascular risk factors reflected by a higher rate of left ventricular hypertrophy, higher creatinine values, and more lacunes and severe basal ganglia (BG) enlarged perivascular spaces (EPVS) than patients with CAA-ICH (all p < 0.05). In multivariable models mixed ICH diagnosis was associated with higher creatinine levels (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.2-5.0, p = 0.010), more lacunes (OR 3.4, 95% CI 1.7-6.8), and more severe BG EPVS (OR 5.8, 95% CI 1.7-19.7) than patients with CAA-ICH. Conversely, when patients with mixed ICH were compared to patients with HTN-ICH, they were independently associated with older age (OR 1.03, 95% CI 1.02-1.1), more lacunes (OR 2.4, 95% CI 1.1-5.3), and higher microbleed count (OR 1.6, 95% CI 1.3-2.0). Among 90-day survivors, adjusted case fatality rates were similar for all 3 categories. Annual risk of ICH recurrence was 5.1% for mixed ICH, higher than for HTN-ICH but lower than for CAA-ICH (1.6% and 10.4%, respectively). Mixed ICH, commonly seen on MRI obtained during etiologic workup, appears to be driven mostly by vascular risk factors similar to HTN-ICH but demonstrates more severe parenchymal damage and higher ICH recurrence risk. Copyright © 2017 American Academy of Neurology.

The effect of symmetry on the U L3 NEXAFS of octahedral coordinated uranium(vi)

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

Bagus, Paul S.; Nelin, Connie J.; Ilton, Eugene S.

2017-03-21

We describe a detailed theoretical analysis of how distortions from ideal cubic or Oh symmetry affect the shape, in particular the width, of the U L3-edge NEXAFS for U(VI) in octahedral coordination. The full-width-half-maximum (FWHM) of the L3-edge white line decreases with increasing distortion from Oh symmetry due to the mixing of symmetry broken t2g and eg components of the excited state U(6d) orbitals. The mixing is allowed because of spin-orbit splitting of the ligand field split 6d orbitals. Especially for higher distortions, it is possible to identify a mixing between one of the t2g and one of the egmore » components, allowed in the double group representation when the spin-orbit interaction is taken into account. This mixing strongly reduces the ligand field splitting, which, in turn, leads to a narrowing of the U L3 white line. However, the effect of this mixing is partially offset by an increase in the covalent anti-bonding character of the highest energy spin-orbit split eg orbital. At higher distortions, mixing overwhelms the increasing anti-bonding character of this orbital which leads to an accelerated decrease in the FWHM with increasing distortion. Additional evidence for the effect of mixing of t2g and eg components is that the FWHM of the white line narrows whether the two axial U-O bond distances shorten or lengthen. Our ab initio theory uses relativistic wavefunctions for cluster models of the structures; empirical or semi-empirical parameters were not used to adjust prediction to experiment. A major advantage is that it provides a transparent approach for determining how the character and extent of the covalent mixing of the relevant U and O orbitals affect the U L3-edge white line.« less

Solid precipitation measurement intercomparison in Bismarck, North Dakota, from 1988 through 1997

USGS Publications Warehouse

Ryberg, Karen R.; Emerson, Douglas G.; Macek-Rowland, Kathleen M.

2009-01-01

A solid precipitation measurement intercomparison was recommended by the World Meteorological Organization (WMO) and was initiated after approval by the ninth session of the Commission for Instruments and Methods of Observation. The goal of the intercomparison was to assess national methods of measuring solid precipitation against methods whose accuracy and reliability were known. A field study was started in Bismarck, N. Dak., during the 1988-89 winter as part of the intercomparison. The last official field season of the WMO intercomparison was 1992-93; however, the Bismarck site continued to operate through the winter of 1996-97. Precipitation events at Bismarck were categorized as snow, mixed, or rain on the basis of descriptive notes recorded as part of the solid precipitation intercomparison. The rain events were not further analyzed in this study. Catch ratios (CRs) - the ratio of the precipitation catch at each gage to the true precipitation measurement (the corrected double fence intercomparison reference) - were calculated. Then, regression analysis was used to develop equations that model the snow and mixed precipitation CRs at each gage as functions of wind speed and temperature. Wind speed at the gages, functions of temperature, and upper air conditions (wind speed and air temperature at 700 millibars pressure) were used as possible explanatory variables in the multiple regression analysis done for this study. The CRs were modeled by using multiple regression analysis for the Tretyakov gage, national shielded gage, national unshielded gage, AeroChem gage, national gage with double fence, and national gage with Wyoming windshield. As in earlier studies by the WMO, wind speed and air temperature were found to influence the CR of the Tretyakov gage. However, in this study, the temperature variable represented the average upper air temperature over the duration of the event. The WMO did not use upper air conditions in its analysis. The national shielded and unshielded gages where found to be influenced by functions of wind speed only, as in other studies, but the upper air wind speed was used as an explanatory variable in this study. The AeroChem gage was not used in the WMO intercomparison study for 1987-93. The AeroChem gage had a highly varied CR at Bismarck, and a number of variables related to wind speed and temperature were used in the model for the CR. Despite extensive efforts to find a model for the national gage with double fence, no statistically significant regression model was found at the 0.05 level of statistical significance. The national gage with Wyoming windshield had a CR modeled by temperature and wind speed variables, and the regression relation had the highest coefficient of determination (R2 = 0.572) and adjusted coefficient of multiple determination (R2a = 0.476) of all of the models identified for any gage. Three of the gage CRs evaluated could be compared with those in the WMO intercomparison study for 1987-93. The WMO intercomparison had the advantage of a much larger dataset than this study. However, the data in this study represented a longer time period. Snow precipitation catch is highly varied depending on the equipment used and the weather conditions. Much of the variation is not accounted for in the WMO equations or in the equations developed in this study, particularly for unshielded gages. Extensive attempts at regression analysis were made with the mixed precipitation data, but it was concluded that the sample sizes were not large enough to model the CRs. However, the data could be used to test the WMO intercomparison equations. The mixed precipitation equations for the Tretyakov and national shielded gages are similar to those for snow in that they are more likely to underestimate precipitation when observed amounts were small and overestimate precipitation when observed amounts were relatively large. Mixed precipitation is underestimated by the WMO adjustment and t

Association between blood cholinesterase activity, organophosphate pesticide residues on hands, and health effects among chili farmers in Ubon Ratchathani Province, northeastern Thailand

PubMed

Nganchamung, Thitirat; Robson, Mark G; Siriwong, Wattasit

Use of pesticides has been documented to lead to several adverse health effects. Farmers are likely to be exposed to pesticides through dermal exposure as a result of mixing, loading, and spraying. Organophosphate pesticides (OPs) are widely used in most of the agricultural areas throughout Thailand. OPs are cholinesterase inhibitors and blood cholinesterase activity is used as a biomarker of OP effects. This study aims to determine the association between blood cholinesterase activity and organophosphate pesticide residues on chili farmer’s hands and their adverse health effects. Ninety chili farmers directly involved with pesticide applications (e.g. mixing, loading, spraying) were recruited and were interviewed face to face. Both enzymes, erythrocyte acetylcholinesterase (AChE) and plasma cholinesterase (PChE), were tested with the EQM Test-mate Cholinesterase Test System (Model 400). Hand wipe samples were used for collecting residues on both hands and OP residues for chlorpyrifos and profenofos were quantified using gas chromatography equipped with a flame photometric detector (GC-FPD). The average activity (±SD) of AChE and PChE was 2.73 (±0.88) and 1.58 (±0.56) U/mL, respectively. About 80.0% of the participants had detectable OP residues on hands. The median residues of chlorpyrifos and profenofos were found to be 0.02 and 0.03 mg/kg/two hands, respectively. Half of participants reported having some acute health symptoms within 48 hours after applying pesticides. When adjusted for gender, number of years working in chili farming, and frequency of pesticide use, AChE activity (Adjusted OR = 0.03, 95%CI: 0.01-0.13) and detected OP residues on hands (Adjusted OR = 0.15, 95%CI: 0.02-0.95) were significantly associated with having health effects, but no significant association was found in PChE activity (Adjusted OR = 2.09, 95%CI: 0.63-6.99). This study suggests that regular monitoring for blood cholinesterase and effective interventions to reduce pesticide exposure to prevent health effects should be provided to chili farmers.

Population Pharmacokinetics of Topiramate in Japanese Pediatric and Adult Patients With Epilepsy Using Routinely Monitored Data.

PubMed

Takeuchi, Masato; Yano, Ikuko; Ito, Satoko; Sugimoto, Mitsuhiro; Yamamoto, Shota; Yonezawa, Atsushi; Ikeda, Akio; Matsubara, Kazuo

2017-04-01

Topiramate is a second-generation antiepileptic drug used as monotherapy and adjunctive therapy in adults and children with partial seizures. A population pharmacokinetic (PPK) analysis was performed to improve the topiramate dosage adjustment for individualized treatment. Patients whose steady-state serum concentration of topiramate was routinely monitored at Kyoto University Hospital from April 2012 to March 2013 were included in the model-building data. A nonlinear mixed effects modeling program was used to evaluate the influence of covariates on topiramate pharmacokinetics. The obtained PPK model was evaluated by internal model validations, including goodness-of-fit plots and prediction-corrected visual predictive checks, and was externally confirmed using the validation data from January 2015 to December 2015. A total of 177 steady-state serum concentrations from 93 patients were used for the model-building analysis. The patients' age ranged from 2 to 68 years, and body weight ranged from 8.6 to 105 kg. The median serum concentration of topiramate was 1.7 mcg/mL, and half of the patients received carbamazepine coadministration. Based on a one-compartment model with first order absorption and elimination, the apparent volume of distribution was 105 L/70 kg, and the apparent clearance was allometrically related to the body weight as 2.25 L·h·70 kg without carbamazepine or phenytoin. Combination treatment with carbamazepine or phenytoin increased the apparent clearance to 3.51 L·h·70 kg. Goodness-of-fit plots, prediction-corrected visual predictive check, and external validation using the validation data from 43 patients confirmed an appropriateness of the final model. Simulations based on the final model showed that dosage adjustments allometrically scaling to body weight can equalize the serum concentrations in children of various ages and adults. The PPK model, using the power scaling of body weight, effectively elucidated the topiramate serum concentration profile ranging from pediatric to adult patients. Dosage adjustments based on body weight and concomitant antiepileptic drug help obtain the dosage of topiramate necessary to reach an effective concentration in each individual.

Cruise control for segmented flow.

PubMed

Abolhasani, Milad; Singh, Mayank; Kumacheva, Eugenia; Günther, Axel

2012-11-21

Capitalizing on the benefits of microscale segmented flows, e.g., enhanced mixing and reduced sample dispersion, so far requires specialist training and accommodating a few experimental inconveniences. For instance, microscale gas-liquid flows in many current setups take at least 10 min to stabilize and iterative manual adjustments are needed to achieve or maintain desired mixing or residence times. Here, we report a cruise control strategy that overcomes these limitations and allows microscale gas-liquid (bubble) and liquid-liquid (droplet) flow conditions to be rapidly "adjusted" and maintained. Using this strategy we consistently establish bubble and droplet flows with dispersed phase (plug) velocities of 5-300 mm s(-1), plug lengths of 0.6-5 mm and continuous phase (slug) lengths of 0.5-3 mm. The mixing times (1-5 s), mass transfer times (33-250 ms) and residence times (3-300 s) can therefore be directly imposed by dynamically controlling the supply of the dispersed and the continuous liquids either from external pumps or from local pressurized reservoirs. In the latter case, no chip-external pumps, liquid-perfused tubes or valves are necessary while unwanted dead volumes are significantly reduced.

[Characteristics of electroosmotic flow in open-tubular capillary electrochromatography with magnetic nanoparticle coating as mixed-mode stationary phase].

PubMed

Qin, Sasa; Zhou, Chaoran; Zhu, Yaxian; Ren, Zhiyu; Zhang, Lingyi; Fu, Honggang; Zhang, Weibing

2011-09-01

A novel open-tubular capillary electrochromatography (OT-CEC) column with magnetic nanoparticle coating as mixed-mode stationary phase was prepared. The mixed-mode stationary phases were obtained by mixing C18 and amino modified magnetic nanoparticles with different ratios. The mixed modified magnetic nanoparticles as stationary phase were introduced into the capillary by using external magnetic force. The magnetic nanoparticle coating can be easily regenerated by removing the external magnetic field, and applied to other separation modes. The characteristics of electroosmotic flow (EOF) were theoretically investigated through the effect of physicochemical properties of different stationary phases on EOF. The experiment was conducted under different ratios of mixed-mode stationary phases and coating lengths, and it was verified that the theoretical conclusions accorded with the experimental results. It was shown that the EOF can be easily adjusted by changing the ratio of stationary phases or the number of permanent magnets.

High Operating Temperature Barrier Infrared Detector with Tailorable Cutoff Wavelength

NASA Technical Reports Server (NTRS)

Ting, David Z. (Inventor); Hill, Cory J. (Inventor); Seibel, Alexander (Inventor); Bandara, Sumith Y. (Inventor); Gunapala, Sarath D. (Inventor)

2015-01-01

A barrier infrared detector with absorber materials having selectable cutoff wavelengths and its method of manufacture is described. A GaInAsSb absorber layer may be grown on a GaSb substrate layer formed by mixing GaSb and InAsSb by an absorber mixing ratio. A GaAlAsSb barrier layer may then be grown on the barrier layer formed by mixing GaSb and AlSbAs by a barrier mixing ratio. The absorber mixing ratio may be selected to adjust a band gap of the absorber layer and thereby determine a cutoff wavelength for the barrier infrared detector. The absorber mixing ratio may vary along an absorber layer growth direction. Various contact layer architectures may be used. In addition, a top contact layer may be isolated into an array of elements electrically isolated as individual functional detectors that may be used in a detector array, imaging array, or focal plane array.

Phase measurement by using a forced delay-line oscillator and its application for an acoustic fiber sensor.

PubMed

Fleyer, Michael; Horowitz, Moshe

2018-04-02

We demonstrate, theoretically and experimentally, a new method to measure small changes in the cavity length of oscillators. The method is based on the high sensitivity of the phase of forced delay-line oscillators to changes in their cavity length. The oscillator phase is directly detected by mixing the oscillator output with the injected signal. We describe a comprehensive theoretical model for studying the signal and the noise at the output of a general forced delay-line oscillator with an instantaneous gain saturation and an amplitude-to-phase conversion. The results indicate that the magnitude and the bandwidth of the oscillator response to a small perturbation can be controlled by adjusting the injection ratio and the injected frequency. For signals with a frequency that is smaller than the device bandwidth, the oscillator noise is dominated by the noise of the injected signal. This noise is highly suppressed by mixing the oscillator output with the injected signal. Hence, the device sensitivity at frequencies below its bandwidth is limited only by the internal noise that is added in a single roundtrip in the oscillator cavity. We demonstrate the use of a forced oscillator as an acoustic fiber sensor in an optoelectronic oscillator. A good agreement is obtained between theory and experiments. The magnitude of the output signal can be controlled by adjusting the injection ratio while the noise power at low frequencies is not enhanced as in sensors that are based on a free-running oscillator.

Occupational adjustment of the prospective payment system wage index

PubMed Central

Pope, Gregory C.

1989-01-01

In this article, the bias in the Medicare prospective payment system (PPS) hospital wage index that results from its failure to hold hospital occupation mix constant is examined. On average, the difference between the current PPS wage index and a fixed-occupation-mix Laspeyres index is small, approximately 2 percent. However, occupation-mix distortions are substantially larger for a small proportion of labor market areas, especially some in the South. Biases in the wage index resulting from its failure to appropriately account for labor substitution and intra-occupational worker characteristics are also analyzed but are not found to be significant. PMID:10313354

Declines in Outpatient Antimicrobial Use in Canada (1995–2010)

PubMed Central

Finley, Rita; Glass-Kaastra, Shiona K.; Hutchinson, Jim; Patrick, David M.; Weiss, Karl; Conly, John

2013-01-01

Background With rising reports of antimicrobial resistance in outpatient communities, surveillance of antimicrobial use is imperative for supporting stewardship programs. The primary objective of this article is to assess the levels of antimicrobial use in Canada over time. Methods Canadian antimicrobial use data from 1995 to 2010 were acquired and assessed by four metrics: population-adjusted prescriptions, Defined Daily Doses, spending on antimicrobials (inflation-adjusted), and average Defined Daily Doses per prescription. Linear mixed models were built to assess significant differences among years and antimicrobial groups, and to account for repeated measurements over time. Measures were also compared to published reports from European countries. Results Temporal trends in antimicrobial use in Canada vary by metric and antimicrobial grouping. Overall reductions were seen for inflation-adjusted spending, population-adjusted prescription rates and Defined Daily Doses, and increases were observed for the average number of Defined Daily Doses per prescription. The population-adjusted prescription and Defined Daily Doses values for 2009 were comparable to those reported by many European countries, while the average Defined Daily Dose per prescription for Canada ranked high. A significant reduction in the use of broad spectrum penicillins occurred between 1995 and 2004, coupled with increases in macrolide and quinolone use, suggesting that replacement of antimicrobial drugs may occur as new products arrive on the market. Conclusions There have been modest decreases of antimicrobial use in Canada over the past 15 years. However, continued surveillance of antimicrobial use coupled with data detailing antimicrobial resistance within bacterial pathogens affecting human populations is critical for targeting interventions and maintaining the effectiveness of these products for future generations. PMID:24146863

A novel mixed phospholipid functionalized monolithic column for early screening of drug induced phospholipidosis risk.

PubMed

Zhao, XiangLong; Chen, WeiJia; Liu, ZhengHua; Guo, JiaLiang; Zhou, ZhengYin; Crommen, Jacques; Moaddel, Ruin; Jiang, ZhengJin

2014-11-07

Drug-induced phospholipidosis (PLD) is characterized by the excessive accumulation of phospholipids, resulting in multilamellar vesicle structure within lysosomes. In the present study, a novel mixed phospholipid functionalized monolithic column was developed for the first time through a facile one-step co-polymerization approach. The phospholipid composition of the monolith can be adjusted quantitatively and accurately to mimic the mixed phospholipid environment of different biomembranes on a solid matrix. The mixed phospholipid functionalized monolith as a promising immobilized artificial membrane technique was used to study drug-phospholipid interaction. Scanning electron microscopy, elemental analysis, FT-IR spectra, ζ-potential analysis and micro-HPLC were carried out to characterize the physicochemical properties and separation performance of the monolith. Mechanism studies revealed that both hydrophobic and electrostatic interactions play an important role in the retention of analytes. The ratio of their contributions to retention can be easily manipulated by adjusting the composition of the mixed phospholipids, in order to better mimic the interaction between drugs and cell membrane. The obtained mixed phospholipid functionalized monolithic columns were applied to the screening of drug-induced PLD potency. Data from 79 drugs on the market demonstrated that the chromatographic hydrophobicity index referring to the mixed phospholipid functionalized monolith at pH 7.4 (CHI IAM7.4) for the selected drugs were highly correlated with the drug-induced PLD potency data obtained from other in vivo or in vitro assays. Moreover, the effect of the acidic phospholipid phosphatidylserine proportion on prediction accuracy was also investigated. The monolith containing 20% phosphatidylserine and 80% phosphatidylcholine exhibited the best prediction ability for the drug-induced PLD potency of the tested compounds. This research has led to the successful development of a novel and facile approach to prepare a mixed phospholipids functionalized monolith, which offers a reliable, cost-effective and high-throughput screening tool for early prediction of the PLD potency of drug candidates. Copyright © 2014 Elsevier B.V. All rights reserved.

Insulin resistance is associated with carotid intima-media thickness in non-diabetic subjects. A cross-sectional analysis of the ELSA-Brasil cohort baseline.

PubMed

Santos, Itamar S; Bittencourt, Márcio S; Goulart, Alessandra C; Schmidt, Maria Inês; Diniz, Maria de Fátima H S; Lotufo, Paulo A; Benseñor, Isabela M

2017-05-01

Epidemiological studies have analyzed the association between carotid intima-media thickness (CIMT) and insulin resistance, glucose levels or glycated hemoglobin with mixed results. We aimed to evaluate the association between CIMT and homeostasis model assessment - insulin resistance (HOMA-IR), fasting and post-load plasma glucose and glycated hemoglobin in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline. We included 8028 participants (aged 35-74 years) without diabetes or overt cardiovascular disease who had complete CIMT data at baseline. We built crude and adjusted linear and binary logistic models to evaluate the association between CIMT and (a) HOMA-IR; (b) fasting plasma glucose; (c) post-load plasma glucose; and (d) glycated hemoglobin. We also built post-hoc models, stratified by sex. In the fully-adjusted linear models, only the association between CIMT (in mm) and HOMA-IR remained significant (β = 0.004; 95% confidence interval [95%CI]:0.001 to 0.006). Consistent with these results, only the association between the highest age- sex- and race-specific CIMT quartile and HOMA-IR was significant in the adjusted logistic model (odds ratio [OR]:1.10; 95% CI:1.04-1.17). The association between HOMA-IR and the highest CIMT quartile remained significant in sex-specific analyses (OR:1.10; 95% CI:1.02-1.20 for men and OR:1.10; 95% CI:1.02-1.20 for women). We did not find an independent association between CIMT and glucose or glycated hemoglobin. We found a direct association between HOMA-IR and CIMT in a large sample of non-diabetic participants. Mechanisms unrelated to glucose homeostasis, as a direct effect of insulin on atherosclerosis, or medial hypertrophy, may be involved. Copyright © 2017 Elsevier B.V. All rights reserved.

Height, adiposity and body fat distribution and breast density in young women.

PubMed

Dorgan, Joanne F; Klifa, Catherine; Shepherd, John A; Egleston, Brian L; Kwiterovich, Peter O; Himes, John H; Gabriel, Kelley; Horn, Linda; Snetselaar, Linda G; Stevens, Victor J; Barton, Bruce A; Robson, Alan M; Lasser, Norman L; Deshmukh, Snehal; Hylton, Nola M

2012-07-13

Breast density is one of the strongest risk factors for breast cancer, but determinants of breast density in young women remain largely unknown. Associations of height, adiposity and body fat distribution with percentage dense breast volume (%DBV) and absolute dense breast volume (ADBV) were evaluated in a cross-sectional study of 174 healthy women, 25 to 29 years old. Adiposity and body fat distribution were measured by anthropometry and dual-energy X-ray absorptiometry (DXA), while %DBV and ADBV were measured by magnetic resonance imaging. Associations were evaluated using linear mixed-effects models. All tests of statistical significance are two-sided. Height was significantly positively associated with %DBV but not ADBV; for each standard deviation (SD) increase in height, %DBV increased by 18.7% in adjusted models. In contrast, all measures of adiposity and body fat distribution were significantly inversely associated with %DBV; a SD increase in body mass index (BMI), percentage fat mass, waist circumference and the android:gynoid fat mass ratio (A:G ratio) was each associated significantly with a 44.4 to 47.0% decrease in %DBV after adjustment for childhood BMI and other covariates. Although associations were weaker than for %DBV, all measures of adiposity and body fat distribution also were significantly inversely associated with ADBV before adjustment for childhood BMI. After adjustment for childhood BMI, however, only the DXA measures of percentage fat mass and A:G ratio remained significant; a SD increase in each was associated with a 13.8 to 19.6% decrease in ADBV. In mutually adjusted analysis, the percentage fat mass and the A:G ratio remained significantly inversely associated with %DBV, but only the A:G ratio was significantly associated with ADBV; a SD increase in the A:G ratio was associated with an 18.5% decrease in ADBV. Total adiposity and body fat distribution are independently inversely associated with %DBV, whereas in mutually adjusted analysis only body fat distribution (A:G ratio) remained significantly inversely associated with ADBV in young women. Research is needed to identify biological mechanisms underlying these associations.

A mixing timescale model for TPDF simulations of turbulent premixed flames

DOE PAGES

Kuron, Michael; Ren, Zhuyin; Hawkes, Evatt R.; ...

2017-02-06

Transported probability density function (TPDF) methods are an attractive modeling approach for turbulent flames as chemical reactions appear in closed form. However, molecular micro-mixing needs to be modeled and this modeling is considered a primary challenge for TPDF methods. In the present study, a new algebraic mixing rate model for TPDF simulations of turbulent premixed flames is proposed, which is a key ingredient in commonly used molecular mixing models. The new model aims to properly account for the transition in reactive scalar mixing rate behavior from the limit of turbulence-dominated mixing to molecular mixing behavior in flamelets. An a priorimore » assessment of the new model is performed using direct numerical simulation (DNS) data of a lean premixed hydrogen–air jet flame. The new model accurately captures the mixing timescale behavior in the DNS and is found to be a significant improvement over the commonly used constant mechanical-to-scalar mixing timescale ratio model. An a posteriori TPDF study is then performed using the same DNS data as a numerical test bed. The DNS provides the initial conditions and time-varying input quantities, including the mean velocity, turbulent diffusion coefficient, and modeled scalar mixing rate for the TPDF simulations, thus allowing an exclusive focus on the mixing model. Here, the new mixing timescale model is compared with the constant mechanical-to-scalar mixing timescale ratio coupled with the Euclidean Minimum Spanning Tree (EMST) mixing model, as well as a laminar flamelet closure. It is found that the laminar flamelet closure is unable to properly capture the mixing behavior in the thin reaction zones regime while the constant mechanical-to-scalar mixing timescale model under-predicts the flame speed. Furthermore, the EMST model coupled with the new mixing timescale model provides the best prediction of the flame structure and flame propagation among the models tested, as the dynamics of reactive scalar mixing across different flame regimes are appropriately accounted for.« less

A mixing timescale model for TPDF simulations of turbulent premixed flames

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

Kuron, Michael; Ren, Zhuyin; Hawkes, Evatt R.

Transported probability density function (TPDF) methods are an attractive modeling approach for turbulent flames as chemical reactions appear in closed form. However, molecular micro-mixing needs to be modeled and this modeling is considered a primary challenge for TPDF methods. In the present study, a new algebraic mixing rate model for TPDF simulations of turbulent premixed flames is proposed, which is a key ingredient in commonly used molecular mixing models. The new model aims to properly account for the transition in reactive scalar mixing rate behavior from the limit of turbulence-dominated mixing to molecular mixing behavior in flamelets. An a priorimore » assessment of the new model is performed using direct numerical simulation (DNS) data of a lean premixed hydrogen–air jet flame. The new model accurately captures the mixing timescale behavior in the DNS and is found to be a significant improvement over the commonly used constant mechanical-to-scalar mixing timescale ratio model. An a posteriori TPDF study is then performed using the same DNS data as a numerical test bed. The DNS provides the initial conditions and time-varying input quantities, including the mean velocity, turbulent diffusion coefficient, and modeled scalar mixing rate for the TPDF simulations, thus allowing an exclusive focus on the mixing model. Here, the new mixing timescale model is compared with the constant mechanical-to-scalar mixing timescale ratio coupled with the Euclidean Minimum Spanning Tree (EMST) mixing model, as well as a laminar flamelet closure. It is found that the laminar flamelet closure is unable to properly capture the mixing behavior in the thin reaction zones regime while the constant mechanical-to-scalar mixing timescale model under-predicts the flame speed. Furthermore, the EMST model coupled with the new mixing timescale model provides the best prediction of the flame structure and flame propagation among the models tested, as the dynamics of reactive scalar mixing across different flame regimes are appropriately accounted for.« less

Long-Term Coarse Particulate Matter Exposure and Heart Rate Variability in the Multi-Ethnic Study of Atherosclerosis (MESA)

PubMed Central

Adhikari, Richa; D’Souza, Jennifer; Solimon, Elsayed Z.; Burke, Gregory L.; Daviglus, Martha; Jacobs, David R.; Park, Sung Kyun; Sheppard, Lianne; Thorne, Peter S.; Kaufman, Joel D.; Larson, Timothy V.; Adar, Sara D.

2017-01-01

Background Reduced heart rate variability, a marker of impaired cardiac autonomic function, has been linked to short-term exposure to airborne particles. This research adds to the literature by examining associations with long-term exposures to coarse particles (PM10-2.5). Methods Using electrocardiogram recordings from 2,780 participants (45-84 years) from three Multi-Ethnic Study of Atherosclerosis sites, we assessed the standard deviation of normal-to-normal intervals (SDNN) and root-mean square differences of successive normal-to-normal intervals (rMSSD) at a baseline (2000-2002) and follow-up (2010-2012) examination (mean visits/person=1.5). Annual average concentrations of PM10-2.5 mass, copper, zinc, phosphorus, silicon, and endotoxin were estimated using site-specific spatial prediction models. We assessed associations for baseline heart rate variability and rate of change in heart rate variability over time using multivariable mixed models adjusted for time, sociodemographic, lifestyle, health, and neighborhood confounders, including co-pollutants. Results In our primary models adjusted for demographic and lifestyle factors and site, PM10-2.5 mass was associated with 1.0% (95% CI: -4.1, 2.1%) lower SDNN levels per interquartile range of 2 μg/m3. Stronger associations, however, were observed prior to site adjustment and with increasing residential stablity. Similar patterns were found for rMSSD. We found little evidence for associations with other chemical species and with with the rate of change in heart rate variability, though endotoxin was associated with increasing heart rate variability over time. Conclusion We found only weak evidence that long-term PM10-2.5 exposures are associated with lowered heart rate variability. Stronger associations among residentially stable individuals suggest that confirmatory studies are needed. PMID:27035690

Phthalate metabolites and bisphenol-A in association with circulating angiogenic biomarkers across pregnancy

PubMed Central

Ferguson, Kelly K.; McElrath, Thomas F.; Cantonwine, David E.; Mukherjee, Bhramar; Meeker, John D.

2015-01-01

Introduction Phthalates and bisphenol-a (BPA) are endocrine disrupting compounds with widespread exposure that have been linked in a number of epidemiologic studies to adverse birth outcomes and developmental effects. We hypothesized that these associations may be mediated in part through altered placental development and function consequent to exposure. To investigate this question, we examined associations between plasma biomarkers of angiogenesis and urinary biomarkers of exposure to phthalates and bisphenol-a (BPA) measured at repeated time points across pregnancy. Methods We utilized a nested case-control population consisting of 130 mothers who delivered preterm and 352 who delivered term from a prospective birth cohort. Placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) were measured in plasma samples collected from up to four visits during pregnancy (median 10, 18, 26, and 35 weeks). Phthalate metabolites and BPA were measured in urine samples collected at the same visits as indices of exposure. Results In linear mixed effects models adjusted for urine dilution and gestational age at sample collection, oxidized di-2-ethylhexyl phthalate (DEHP) metabolites were associated with decreases in PlGF as well as increases in the sFlt-1 to PlGF ratio. These results were slightly attenuated in fully adjusted models. Other phthalate metabolites did not show consistent relationships with either sFlt-1 or PlGF. BPA, however, was associated with increased sFlt-1 as well as the sFlt-1 to PlGF ratio in both crude and adjusted models. Discussion We observed associations between urinary DEHP metabolites and BPA and biomarkers of angiogenesis during pregnancy that may be indicative of disrupted placental development and/or function during gestation. PMID:25913709

Chronic discrimination and bodily pain in a multiethnic cohort of midlife women in the Study of Women's Health Across the Nation.

PubMed

Dugan, Sheila A; Lewis, Tené T; Everson-Rose, Susan A; Jacobs, Elizabeth A; Harlow, Siobán D; Janssen, Imke

2017-09-01

A growing literature links discrimination to key markers of biobehavioral health. While racial or ethnic differences in pain are seen in experimental and clinical studies, the authors were interested in how chronic discrimination contributes to pain within multiple racial or ethnic groups over time. Participants were 3056 African American, Caucasian, Chinese, Hispanic, and Japanese women from the Study of Women's Health Across the Nation. The Everyday Discrimination Scale was assessed from baseline through 13 follow-up examinations. The bodily pain subscale of the MOS 36-Item Short-Form Health Survey (SF-36) was assessed annually. There were large racial or ethnic differences in reports of discrimination and pain. Discrimination attributions also varied by race or ethnicity. In linear mixed model analyses, initially adjusted for age, education, and pain medications, chronic everyday discrimination was associated with more bodily pain in all ethnic groups (beta = -5.84; P < 0.002 for Japanese; beta = -6.17; P < 0.001 for African American; beta = -8.74; P < 0.001 for Chinese; beta = -10.54; P < 0.001 for Caucasians; beta = -12.82; P < 0.001 for Hispanic). Associations remained significant in all ethnic groups after adjusting for additional covariates in subsequent models until adding depressive symptoms as covariate; in the final fully-adjusted models, discrimination remained a significant predictor of pain for African American (beta = -4.50; P < 0.001), Chinese (beta = -6.62; P < 0.001), and Caucasian (beta = -7.86; P < 0.001) women. In this longitudinal study, experiences of everyday discrimination were strongly linked to reports of bodily pain for the majority of women. Further research is needed to determine if addressing psychosocial stressors, such as discrimination, with patients can enhance clinical management of pain symptoms.

Mixed-state bipolar I and II depression: time to remission and clinical characteristics.

PubMed

Shim, In Hee; Woo, Young Sup; Jun, Tae-Youn; Bahk, Won-Myong

2014-01-01

We compared the time to achieve remission and the clinical characteristics of patients with bipolar depressive mixed state and those with bipolar depressive non-mixed state. The subjects (N=131) were inpatients diagnosed between 2006 and 2012 with bipolar I or II disorder, depression and were classified into the following three groups: "pure depressive state" (PD, n=70), "sub-threshold mixed state" (SMX, n=38), and "depressive mixed state" (DMX, n=23). Diagnosis of a DMX was in accordance with Benazzi's definition: three or more manic symptoms in a depressive episode. The subjects' charts were retrospectively reviewed to ascertain the time to achieve remission from the index episode and to identify other factors, such as demographic and clinical characteristics, specific manic symptoms, and pharmacological treatment, that may have contributed to remission. The time to achieve remission was significantly longer in the DMX (p=0.022) and SMX (p=0.035) groups than in the PD group. Adjustment for covariates using a Cox proportional hazards model did not change these results. Clinically, subjects with a DMX were more likely to have manic symptoms in the index episode, especially inflated self-esteem and psychomotor agitation than those in the PD. We investigated only inpatients and therefore could not comment on outpatients. These findings showed that sub-syndromal manic symptoms in bipolar depression had different clinical characteristics and a more severe illness course, including a longer time to achieve remission, than did a pure depressive state. © 2013 Elsevier B.V. All rights reserved.

Results of a survey to determine demographic and business management factors associated with size and growth rate of rural mixed-animal veterinary practices.

PubMed

Brusk, Amy M; White, Brad J; Goehl, Dan R; Dhuyvetter, Kevin C

2010-12-15

To determine potential associations between demographic and business management factors and practice size and growth rate in rural mixed-animal veterinary practices. Cross-sectional survey. 54 mixed-animal practitioners. A cross-sectional survey (96 questions) was electronically disseminated. Responses were collected, and outcomes (number of veterinarians [NV], growth in number of veterinarians [NVG], gross practice income [GPI], growth in gross practice income [GPIG], gross practice income per veterinarian [GPIV], and growth in gross practice income per veterinarian [GPIVG]) were calculated. Bivariate analyses were performed and multivariable models created to determine associations between survey responses and outcomes of interest. Survey respondents were from mixed-animal practices, and most (46/54 [85.2%]) practiced in small communities (< 25,000 people). Study practices had a median ± SD NV of 2.3 ± 1.9 veterinarians, median GPI of $704,547 ± 754,839, and median GPIV of $282,065 ± 182,344. Multivariable regression analysis revealed several factors related to practice size, including the number of associate veterinarians and veterinary technicians in the practice, service fee structure, and employment of a business manager. Typically, practices had positive mean growth in NVG (4.4%), GPIG (8.5%), and GPIVG (8.1%), but growth rate was highly variable among practices. Factors associated with growth rate included main species interest, frequency for adjusting prices, use of a marketing plan, service fee structure, and sending a client newsletter. Mixed-animal practices had a large range in size and growth rate. Economic indices were impacted by common business management practices.

Increased resource utilization and overall morbidity are associated with general versus regional anesthesia for carotid endarterectomy in data collected by the Michigan Surgical Quality Collaborative.

PubMed

Hussain, Ahmad S; Mullard, Andrew; Oppat, William F; Nolan, Kevin D

2017-09-01

Advocates for performing carotid endarterectomy (CEA) under regional anesthesia (RA) cite reduction in hemodynamic instability and the ability for neurologic monitoring, but many still prefer general anesthesia (GA) as benefits of RA have not been clearly demonstrated, reliable RA may not be available in all centers, and a certain amount of movement by the patient during the procedure may not be uniformly tolerated. We evaluated the association of anesthesia type and perioperative morbidity and mortality as well as resource utilization in patients undergoing CEA using the Michigan Surgical Quality Collaborative (MSQC) database. Between 2012 and 2014, 4558 patients underwent CEA among the MSQC participating hospitals. Of these patients, 4008 underwent CEA under GA and 550 underwent CEA under RA. Data points were collected for each procedure, and a review of 30-day perioperative outcomes was conducted using the χ 2 test. Propensity score regression adjusted for case mix preoperative conditions as fixed effects, and a mixed model adjusted for site as a random effect. The two groups were similar in gender and incidence of hypertension, diabetes, congestive heart failure, and smoking history. The RA group tended to be of better functional status. After GA, there was a greater than twofold higher percentage of any morbidity (8.7% vs 4.2%). Further analysis demonstrated that patients undergoing GA had higher unadjusted rates for mortality (1.0% vs 0.0%), unplanned intubations (2.1% vs 0.6%), pneumonia (1.3% vs 0.0%), sepsis (0.8% vs 0.0%), and readmissions (9.2% vs 6.1%). Adjusting for case mix and random effect, there was statistically significantly higher overall morbidity (P = .0002), unplanned intubation (P = .0196), extended length of stay (P = .0007), emergency department visits (P = .0379), and readmissions (P = .0149) in the GA group. There was no statistically significant difference in incidence of myocardial infarction or cerebrovascular accident. Based on this analysis from the MSQC database, there is an associated increased morbidity and resource utilization with GA vs RA for CEA. This has implications for enterprise resource planning initiatives and the CEA value proposition in general, which is of special interest to both hospitals and payers. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

"Weekend effect" on stroke mortality revisited: Application of a claims-based stroke severity index in a population-based cohort study.

PubMed

Hsieh, Cheng-Yang; Lin, Huey-Juan; Chen, Chih-Hung; Li, Chung-Yi; Chiu, Meng-Jun; Sung, Sheng-Feng

2016-06-01

Previous studies have yielded inconsistent results on whether weekend admission is associated with increased mortality after stroke, partly because of differences in case mix. Claims-based studies generally lack sufficient information on disease severity and, thus, suffer from inadequate case-mix adjustment. In this study, we examined the effect of weekend admission on 30-day mortality in patients with ischemic stroke by using a claims-based stroke severity index.This was an observational study using a representative sample of the National Health Insurance claims data linked to the National Death Registry. We identified patients hospitalized for ischemic stroke, and examined the effect of weekend admission on 30-day mortality with vs without adjustment for stroke severity by using multilevel logistic regression analysis adjusting for patient-, physician-, and hospital-related factors. We analyzed 46,007 ischemic stroke admissions, in which weekend admissions accounted for 23.0%. Patients admitted on weekends had significantly higher 30-day mortality (4.9% vs 4.0%, P < 0.001) and stroke severity index (7.8 vs 7.4, P < 0.001) than those admitted on weekdays. In multivariate analysis without adjustment for stroke severity, weekend admission was associated with increased 30-day mortality (odds ratio (OR), 1.20; 95% confidence interval [CI], 1.08-1.34). This association became null after adjustment for stroke severity (OR, 1.07; 95% CI, 0.95-1.20).The "weekend effect" on stroke mortality might be attributed to higher stroke severity in weekend patients. While claims data are useful for examining stroke outcomes, adequate adjustment for stroke severity is warranted.

Hydro-Economic Modeling with Minimum Data Requirements: An Application to the São Francisco River Basin, Brazil

NASA Astrophysics Data System (ADS)

Torres, M.; Maneta, M.; Vosti, S.; Wallender, W.; Howitt, R.

2008-12-01

Policymakers have been charged with the efficient, equitable, and sustainable use of water resources of the São Francisco River Basin (SFRB), Brazil, and also with the promotion of economic growth and the reduction of poverty within the basin. To date, policymakers lack scientific evidence on the potential consequences for growth, poverty alleviation or environmental sustainability of alternative uses of water resources. To address these key knowledge gaps, we have linked a hydrologic and an economic model of agriculture to investigate how economic decisions affect available water, and vice versa. More specifically, the models are used to predict the effects of the application of Brazilian federal surface water use policies on farmer's net revenues and on the hydrologic system. The Economic Model of Agriculture. A spatially explicit, farm-level model capable of accommodating a broad array of farm sizes and farm/farmer characteristics is developed and used to predict the effects of alternative water policies and neighbors' water use patterns on crop mix choice. A production function comprised of seven categories of non-water-related inputs used in agriculture (land, fertilizers, pesticides, seeds, hired labor, family labor and machinery) and four water-related inputs used in agriculture (applied water, irrigation labor, irrigation capital and energy) is estimated. The parameters emerging from this estimated production function are then introduced into a non-linear, net revenue maximization positive mathematical programming algorithm that is used for simulations. The Hydrological Model. MIKE Basin, a semi-distributed hydrology model, is used to calculate water budgets for the SFRB. MIKE Basin calculates discharge at selected nodes by accumulating runoff down the river network; it simulates reservoirs using stage-area-storage and downstream release rule curves. The data used to run the model are discharge to calculate local runoff, precipitation, reference ET, crop coefficients to calculate adjusted transpiration, and reservoir operating rules. Linking the Hydro and Economic Models. Based on the crop mix and area under plow of a reference year the economic model of agriculture was calibrated. Following a Monte Carlo procedure, the statistical distribution of water flows was estimated at each of the 16 selected nodes in the SFRB. The 5th and 95th percentiles of that distribution were used as benchmarks of water availability for drought and wet years, respectively. After subtracting 2000 m3 s-1 reserved for downstream uses estimates of water availability are used as constraints in the net revenue maximization algorithm included in the model of agriculture economics. If water is binding, it will influence crop mix, area under plow and product mix choices. Results. The application of the Brazilian federal water use policies will have immediate and substantial effects on agricultural area and product mix. Agricultural incomes will fall, especially in downstream areas located near major river channels.

Control of the mixing time in vessels agitated by submerged recirculating jets.

PubMed

Kennedy, Stephen; Bhattacharjee, Pradipto K; Bhattacharya, Sati N; Eshtiaghi, Nicky; Parthasarathy, Rajarathinam

2018-01-01

Submerged recirculating jet mixing systems are an efficient and economical method of agitating large tanks with a high hydraulic residence time. Much work has been carried out in developing design correlations to aid the predictions of the mixing time in such systems, with the first such correlation being developed nearly 70 years ago. In most of these correlations, the mixing time depends directly on the volume of the vessel and inversely on the injection velocity of the submerged jet. This work demonstrates, for the first time, that the distance between the injection and suction nozzles also significantly affects the mixing time and can be used to control this time scale. The study introduces a non-dimensional quantity that can be used as an adjustable parameter in systems where such control is desired.

Control of the mixing time in vessels agitated by submerged recirculating jets

PubMed Central

Bhattacharjee, Pradipto K.; Bhattacharya, Sati N.; Eshtiaghi, Nicky; Parthasarathy, Rajarathinam

2018-01-01

Submerged recirculating jet mixing systems are an efficient and economical method of agitating large tanks with a high hydraulic residence time. Much work has been carried out in developing design correlations to aid the predictions of the mixing time in such systems, with the first such correlation being developed nearly 70 years ago. In most of these correlations, the mixing time depends directly on the volume of the vessel and inversely on the injection velocity of the submerged jet. This work demonstrates, for the first time, that the distance between the injection and suction nozzles also significantly affects the mixing time and can be used to control this time scale. The study introduces a non-dimensional quantity that can be used as an adjustable parameter in systems where such control is desired. PMID:29410817

A reassessment of soluble urokinase-type plasminogen activator receptor in glomerular disease

PubMed Central

Spinale, Joann M.; Mariani, Laura H.; Kapoor, Shiv; Zhang, Jidong; Weyant, Robert; Song, Peter X.; Wong, Hetty N.; Troost, Jonathan P.; Gadegbeku, Crystal A.; Gipson, Debbie S.; Kretzler, Matthias; Nihalani, Deepak; Holzman, Lawrence B.

2014-01-01

It has been suggested that soluble urokinase receptor (suPAR) is a causative circulating factor for and a biomarker of focal and segmental glomerulosclerosis (FSGS). Here we undertook validation of these assumptions in both mouse and human models. Injection of recombinant suPAR in wild-type mice did not induce proteinuria within 24 hours. Moreover, a disease phenotype was not seen in an inducible transgenic mouse model that maintained elevated suPAR concentrations for 6 weeks. Plasma and urine suPAR concentrations were evaluated as clinical biomarkers in 241 patients with glomerular disease from the prospective, longitudinal multi-center observational NEPTUNE cohort. The serum suPAR concentration at baseline inversely correlated with estimated glomerular filtration rate (eGFR) and the urine suPAR/creatinine ratio positively correlated with the urine protein/creatinine ratio. After adjusting for eGFR and urine protein, neither the serum nor urine suPAR level was an independent predictor of FSGS histopathology. A multivariable mixed-effects model of longitudinal data evaluated the association between the change in serum suPAR concentration from baseline with eGFR. After adjusting for baseline suPAR concentration, age, gender, proteinuria and time, the change in suPAR from baseline was associated with eGFR, but this association was not different for patients with FSGS as compared to other diagnoses. Thus, these results do not support a pathological role for suPAR in FSGS. PMID:25354239