Disaggregating residential water demand for improved forecasts and decision making

NASA Astrophysics Data System (ADS)

Woodard, G.; Brookshire, D.; Chermak, J.; Krause, K.; Roach, J.; Stewart, S.; Tidwell, V.

2003-04-01

Residential water demand is the product of population and per capita demand. Estimates of per capita demand often are based on econometric models of demand, usually based on time series data of demand aggregated at the water provider level. Various studies have examined the impact of such factors as water pricing, weather, and income, with many other factors and details of water demand remaining unclear. Impacts of water conservation programs often are estimated using simplistic engineering calculations. Partly as a result of this, policy discussions regarding water demand management often focus on water pricing, water conservation, and growth control. Projecting water demand is often a straight-forward, if fairly uncertain process of forecasting population and per capita demand rates. SAHRA researchers are developing improved forecasts of residential water demand by disaggregating demand to the level of individuals, households, and specific water uses. Research results based on high-resolution water meter loggers, household-level surveys, economic experiments and recent census data suggest that changes in wealth, household composition, and individual behavior may affect demand more than changes in population or the stock of landscape plants, water-using appliances and fixtures, generally considered the primary determinants of demand. Aging populations and lower fertility rates are dramatically reducing household size, thereby increasing the number of households and residences for a given population. Recent prosperity and low interest rates have raised home ownership rates to unprecented levels. These two trends are leading to increased per capita outdoor water demand. Conservation programs have succeeded in certain areas, such as promoting drought-tolerant native landscaping, but have failed in other areas, such as increasing irrigation efficiency or curbing swimming pool water usage. Individual behavior often is more important than the household's stock of water-using fixtures, and ranges from hedonism (installing pools and whirlpool tubs) to satisficing (adjusting irrigation timers only twice per year) to acting on deeply-held conservation ethics in ways that not only fail any benefit-cost test, but are discouraged, or even illegal (reuse of gray water and black water). Research findings are being captured in dynamic simulation models that integrate social and natural science to create tools to assist water resource managers in providing sustainable water supplies and improving residential water demand forecasts. These models feature simple, graphical user interfaces and output screens that provide decision makers with visual, easy-to-understand information at the basin level. The models reveal connections between various supply and demand components, and highlight direct impacts and feedback mechanisms associated with various policy options.

Design of the Bottom-up Innovation project--a participatory, primary preventive, organizational level intervention on work-related stress and well-being for workers in Dutch vocational education.

PubMed

Schelvis, Roosmarijn M C; Oude Hengel, Karen M; Wiezer, Noortje M; Blatter, Birgitte M; van Genabeek, Joost A G M; Bohlmeijer, Ernst T; van der Beek, Allard J

2013-08-15

In the educational sector job demands have intensified, while job resources remained the same. A prolonged disbalance between demands and resources contributes to lowered vitality and heightened need for recovery, eventually resulting in burnout, sickness absence and retention problems. Until now stress management interventions in education focused mostly on strengthening the individual capacity to cope with stress, instead of altering the sources of stress at work at the organizational level. These interventions have been only partly effective in influencing burnout and well-being. Therefore, the "Bottom-up Innovation" project tests a two-phased participatory, primary preventive organizational level intervention (i.e. a participatory action approach) that targets and engages all workers in the primary process of schools. It is hypothesized that participating in the project results in increased occupational self-efficacy and organizational efficacy. The central research question: is an organization focused stress management intervention based on participatory action effective in reducing the need for recovery and enhancing vitality in school employees in comparison to business as usual? The study is designed as a controlled trial with mixed methods and three measurement moments: baseline (quantitative measures), six months and 18 months (quantitative and qualitative measures). At first follow-up short term effects of taking part in the needs assessment (phase 1) will be determined. At second follow-up the long term effects of taking part in the needs assessment will be determined as well as the effects of implemented tailored workplace solutions (phase 2). A process evaluation based on quantitative and qualitative data will shed light on whether, how and why the intervention (does not) work(s). "Bottom-up Innovation" is a combined effort of the educational sector, intervention providers and researchers. Results will provide insight into (1) the relation between participating in the intervention and occupational and organizational self-efficacy, (2) how an improved balance between job demands and job resources might affect need for recovery and vitality, in the short and long term, from an organizational perspective, and (3) success and fail factors for implementation of an organizational intervention. Netherlands Trial Register NTR3284.

Effect of adhesive stiffness and thickness on stress distributions in structural finger joints

Treesearch

Leslie H. Groom; Robert J. Leichti

1994-01-01

Environmental, political. and socioeconomic actions over the past several years have resulted in a decreased wood supply at a time when there is an increased demand for forest products. This combination of increased demand and decreased supply has forced more emphasis on engineered wood products, a varied category usually connected with adhesively-bonded end joints, of...

Effect of adhesive stiffness and thickness on stress distributions in structural finger joints

Treesearch

Leslie H. Groom; Robert J. Leichti

1994-01-01

Environmental, political, and socioeconomic actions over the past several years have resulted in a decreased wood supply at a time when there is an increased demand for forest products. This combination of increased demand and decreased supply has forced more emphasis on engineered wood products, a varied category usually connected with adhesively-bonded end joints, of...

[Doctor shopping: the difficult-to-manage patient].

PubMed

de Zwaan, Martina; Müller, Astrid

2006-08-01

Medically unexplained symptoms and bodily dysfunctions are the single most prevalent class of symptoms in primary care. Differences in opinion as to the cause of the illness between the patients and the health care professionals make somatoform disorders a challenge for the patient-doctor relationship, and frequently produce negative feelings in health care professionals. The patients are usually reluctant to consider psychosocial aspects of their illness to be a factor. Early recognition of patients with somatization tendencies would be beneficial so that more effective treatment could begin sooner and unnecessary treatment be avoided. In order not to reinforce the patient's symptomatology, physicians should schedule appointments in a time contingent rather than a symptom contingent manner. Repetition of different tests should be avoided despite patients' demands in order not to further exacerbate the disorder. In many patients, psychotherapy should be recommended, although motivational work should already be initiated at the primary care stage.

Transdiagnostic Cognitive Behavioral Therapy Versus Treatment as Usual in Adult Patients With Emotional Disorders in the Primary Care Setting (PsicAP Study): Protocol for a Randomized Controlled Trial

PubMed Central

Muñoz-Navarro, Roger; Wood, Cristina Mae; Limonero, Joaquín T; Medrano, Leonardo Adrián; Ruiz-Rodríguez, Paloma; Gracia-Gracia, Irene; Dongil-Collado, Esperanza; Iruarrizaga, Iciar; Chacón, Fernando; Santolaya, Francisco

2016-01-01

Background Demand for primary care (PC) services in Spain exceeds available resources. Part of this strong demand is due to the high prevalence of emotional disorders (EDs)—anxiety, depression, and somatic symptom disorders—and related comorbidities such as pain or chronic illnesses. EDs are often under- or misdiagnosed by general practitioners (GPs) and, consequently, treatment is frequently inadequate. Objective We aim to compare the short- and long-term effectiveness of group-delivered transdiagnostic cognitive behavioral therapy (TD-CBT) versus treatment as usual (TAU) in the treatment of EDs in the PC setting in Spain. We also aim to compare the effect of these treatments on disability, quality of life, cognitive-emotional factors, and treatment satisfaction. Methods Here we present the study design of a two-arm, single-blind, randomized controlled trial (N=1126) to compare TAU to TD-CBT for EDs. TAU will consist primarily of pharmacological treatment and practical advice from the GP while TD-CBT will be administered in seven 90-minute group sessions held over a period ranging from 12 to 14 weeks. Psychological assessments are carried out at baseline (ie, pretreatment); posttreatment; and at 3-, 6-, and 12-month follow-up. The study is conducted in approximately 26 PC centers from the National Health System in Spain. Results This study was initiated in December 2013 and will remain open to new participants until recruitment and follow-up has been completed. We expect all posttreatment evaluations to be completed by December 2017, and follow-up will end in December 2018. Conclusions We expect the TD-CBT group to have better results compared to TAU on all posttreatment measures and that this improvement will be maintained during follow-up. This project could serve as a model for use in other areas or services of the National Health System in Spain and even in other countries. ClinicalTrial International Standard Randomized Controlled Trial Number (ISRCTN): 58437086; http://www.isrctn.com/ISRCTN58437086 (Archived by WebCite at http://www.webcitation.org/6mbYjQSn3) PMID:28011446

CAREER GUIDE FOR DEMAND OCCUPATIONS.

ERIC Educational Resources Information Center

LEE, E.R.; WELCH, JOHN L.

THIS PUBLICATION UPDATES THE "CAREER GUIDE FOR DEMAND OCCUPATIONS" PUBLISHED IN 1959 AND PROVIDES COUNSELORS WITH INFORMATION ABOUT OCCUPATIONS IN DEMAND IN MANY AREAS WHICH REQUIRE PREEMPLOYMENT TRAINING. IT PRESENTS, IN COLUMN FORM, THE EDUCATION AND OTHER TRAINING USUALLY REQUIRED BY EMPLOYERS, HIGH SCHOOL SUBJECTS OF PARTICULAR PERTINENCE TO…

Investigation on Reservoir Operation of Agricultural Water Resources Management for Drought Mitigation

NASA Astrophysics Data System (ADS)

Cheng, C. L.

2015-12-01

Investigation on Reservoir Operation of Agricultural Water Resources Management for Drought Mitigation Chung-Lien Cheng, Wen-Ping Tsai, Fi-John Chang* Department of Bioenvironmental Systems Engineering, National Taiwan University, Da-An District, Taipei 10617, Taiwan, ROC.Corresponding author: Fi-John Chang (changfj@ntu.edu.tw) AbstractIn Taiwan, the population growth and economic development has led to considerable and increasing demands for natural water resources in the last decades. Under such condition, water shortage problems have frequently occurred in northern Taiwan in recent years such that water is usually transferred from irrigation sectors to public sectors during drought periods. Facing the uneven spatial and temporal distribution of water resources and the problems of increasing water shortages, it is a primary and critical issue to simultaneously satisfy multiple water uses through adequate reservoir operations for sustainable water resources management. Therefore, we intend to build an intelligent reservoir operation system for the assessment of agricultural water resources management strategy in response to food security during drought periods. This study first uses the grey system to forecast the agricultural water demand during February and April for assessing future agricultural water demands. In the second part, we build an intelligent water resources system by using the non-dominated sorting genetic algorithm-II (NSGA-II), an optimization tool, for searching the water allocation series based on different water demand scenarios created from the first part to optimize the water supply operation for different water sectors. The results can be a reference guide for adequate agricultural water resources management during drought periods. Keywords: Non-dominated sorting genetic algorithm-II (NSGA-II); Grey System; Optimization; Agricultural Water Resources Management.

Elderly demand for family-based care and support: evidence from a social intervention strategy.

PubMed

Aboagye, Emmanuel; Agyemang, Otuo Serebour; Tjerbo, Trond

2013-12-06

This paper examines the influence of the national health insurance scheme on elderly demand for family-based care and support. It contributes to the growing concern on the rapid increase in the elderly population globally using micro-level social theory to examine the influence the health insurance has on elderly demand for family support. A qualitative case study approach is applied to construct a comprehensive and thick description of how the national health insurance scheme influences the elderly in their demand for family support.Through focused interviews and direct observation of six selected cases, in-depth information on primary carers, living arrangement and the interaction between the health insurance as structure and elders as agents are analyzed. The study highlights that the interaction between the elderly and the national health insurance scheme has produced a new stratum of relationship between the elderly and their primary carers. Consequently, this has created equilibrium between the elderly demand for support and support made available by their primary carers. As the demand of the elderly for support is declining, supply of support by family members for the elderly is also on the decline.

Elderly Demand for Family-based Care and Support: Evidence from a Social Intervention Strategy

PubMed Central

Aboagye, Emmanuel; Agyemang, Otuo Serebour; Tjerbo, Trond

2014-01-01

This paper examines the influence of the national health insurance scheme on elderly demand for family-based care and support. It contributes to the growing concern on the rapid increase in the elderly population globally using micro-level social theory to examine the influence the health insurance has on elderly demand for family support. A qualitative case study approach is applied to construct a comprehensive and thick description of how the national health insurance scheme influences the elderly in their demand for family support. Through focused interviews and direct observation of six selected cases, in-depth information on primary carers, living arrangement and the interaction between the health insurance as structure and elders as agents are analyzed. The study highlights that the interaction between the elderly and the national health insurance scheme has produced a new stratum of relationship between the elderly and their primary carers. Consequently, this has created equilibrium between the elderly demand for support and support made available by their primary carers. As the demand of the elderly for support is declining, supply of support by family members for the elderly is also on the decline. PMID:24576369

Design of the Bottom-up Innovation project - a participatory, primary preventive, organizational level intervention on work-related stress and well-being for workers in Dutch vocational education

PubMed Central

2013-01-01

Background In the educational sector job demands have intensified, while job resources remained the same. A prolonged disbalance between demands and resources contributes to lowered vitality and heightened need for recovery, eventually resulting in burnout, sickness absence and retention problems. Until now stress management interventions in education focused mostly on strengthening the individual capacity to cope with stress, instead of altering the sources of stress at work at the organizational level. These interventions have been only partly effective in influencing burnout and well-being. Therefore, the “Bottom-up Innovation” project tests a two-phased participatory, primary preventive organizational level intervention (i.e. a participatory action approach) that targets and engages all workers in the primary process of schools. It is hypothesized that participating in the project results in increased occupational self-efficacy and organizational efficacy. The central research question: is an organization focused stress management intervention based on participatory action effective in reducing the need for recovery and enhancing vitality in school employees in comparison to business as usual? Methods/Design The study is designed as a controlled trial with mixed methods and three measurement moments: baseline (quantitative measures), six months and 18 months (quantitative and qualitative measures). At first follow-up short term effects of taking part in the needs assessment (phase 1) will be determined. At second follow-up the long term effects of taking part in the needs assessment will be determined as well as the effects of implemented tailored workplace solutions (phase 2). A process evaluation based on quantitative and qualitative data will shed light on whether, how and why the intervention (does not) work(s). Discussion “Bottom-up Innovation” is a combined effort of the educational sector, intervention providers and researchers. Results will provide insight into (1) the relation between participating in the intervention and occupational and organizational self-efficacy, (2) how an improved balance between job demands and job resources might affect need for recovery and vitality, in the short and long term, from an organizational perspective, and (3) success and fail factors for implementation of an organizational intervention. Trial registration number Netherlands Trial Register NTR3284 PMID:23947538

[Centralization of health services in primary care in summer: Patients and professionals view during two consecutive years].

PubMed

Giménez, N; Martínez, J M; Clanchet, T

2015-01-01

The Spanish primary health care, gateway and pillar of the Health Care System has his resources increasingly constrained by current crisis. To know the opinion of users and professionals on two primary care centers which centralized in August 2011 and 2012 the attendance of seven primary care centers. Two questionnaires were designed: a telephone survey of a random sample of users and a self-completed questionnaire for health care professionals. The variables were scored on a scale of 1-10 (low to high). Cronbach's coefficient α>0,84. 1293 people responded (836 users and 357 professionals). Users rated, in 2011, the satisfaction with 6.7 points in August and 7.3 points the rest of the year (P<.001). And, in 2012, with 7.7 points in August and 8.1 points the rest of the year (P<.001). Health care professionals, rated their satisfaction with 6.8 points in 2011 and 7.3 points in 2012. The waiting time was the only variable best scores in August that the rest of the year. The perception of the solution given in consultation did not change. Satisfaction, marking, care and treatment were highest rated in the regular center than in the reference center (P<.001). The centralization of primary health care during periods of reduced demand could reduce costs while maintaining quality. The experience of centralizing primary care services during August was perceived as acceptable and improved over time. Users showed a slight, but significant, preference for their usual primary care center. Copyright © 2014 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.

Demand for Primary Schooling in Rural Mali: Should User Fees Be Increased?

ERIC Educational Resources Information Center

Birdsall, Nancy; Orivel, Francois

1996-01-01

Assesses the effect of school fees on primary school attendance, using household and school survey data from rural Mali. Estimates elasticity of demand regarding fees and compares it with effects of distance and quality on enrollment. User fees can provide a partial solution to the quality/enrollment problem, but cannot solve the distance problem.…

Liberian macroeconomy and simulation of sectoral energy demand: 1981-2000

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

Hill, L.J.

1984-06-01

The primary purpose of this report is to document the results of a research effort on end-use, sector energy demand in Liberia, West Africa over the 1981-2000 time horizon. The research was undertaken as one component of a much broader integrated energy assessment of Liberia. Other components of the assessment, however, focused on current energy supply and consumption together with future energy supply options for Liberia. This particular report is devoted exclusively to a discussion of Liberian energy demand. The methodology utilized to simulate Liberian sectoral energy demand over the period 1981-2000 involved the recursive interaction of a macroeconomic modelmore » and individual, econometrically-estimated sectoral demand equations. That is, given the projections for gross output in the Liberian economy from the macroeconomic model, sectoral energy demand was simulated. The individual energy demand equations were estimated on the basis of economic variables that are theorized to influence energy consumption in the respective sectors (e.g., price, output). The primary conclusion drawn from the analysis is that, besides being sensitive to changes in international economic activity, the demand for energy in Liberia over the 1981 to 2000 horizon is highly sensitive to internal production of its two primary exports: iron ore and rubber. More specifically, as characterized in the four scenarios, future growth in Liberian energy demand is contingent on the output of three companies: the Liberian American Swedish Mining Company, the Bong Mining Company, and the Firestone Rubber Company. Therefore, expansion of Liberia's energy supply capacity in the future should proceed cautiously. 16 references, 6 figures, 15 tables.« less

Expenditures and use of wraparound health insurance for employed people with disabilities.

PubMed

Gettens, John; Hoffman, Denise; Henry, Alexis D

2016-04-01

The Affordable Care Act (ACA) provides health insurance to many working-age adults with disabilities, but we do not expect the new coverage or existing insurance options to fully meet their employment-related health care needs. Wraparound services have the potential to foster employment among people with disabilities. We use Massachusetts, which implemented health care reform in 2006, as a case study to estimate the wraparound health care expenditures and use for workers with disabilities. We identified a group of employed, working-age people with disabilities whose primary health insurance is Medicare or private insurance and who use the Medicaid Buy-In Program for wraparound coverage. We analyzed claims to estimate expenditures and use. Wraparound expenditures averaged $427 per member per month. Community-based services for both mental and non-mental health, which are generally not covered by Medicare or private insurance, accounted for 63% of all expenditures. The number who used community-based services was low, but the expenditures were high. The majority of the remaining expenditures were for services usually covered by primary insurance including: inpatient and outpatient, pharmacy and professional services. Expenditures were higher for people with Medicare compared to private insurance. This case study suggests that, from a total program cost perspective, wraparound demand is greatest for community-based services. From a member utilization perspective, the demand is greatest for coverage that alleviates out-of-pocket costs for services provided by primary insurance. Additional analysis is needed to further assess the design options for wraparound programs and their feasibility. Copyright © 2016 Elsevier Inc. All rights reserved.

Home Visiting Programs: What the Primary Care Clinician Should Know.

PubMed

Finello, Karen Moran; Terteryan, Araksi; Riewerts, Robert J

2016-04-01

Responsibilities for primary care clinicians are rapidly expanding ascomplexities in families' lives create increased disparities in health and developmental outcomes for young children. Despite the demands on primary care clinicians to promote health in the context of complex family and community factors, most primary care clinicians are operating in an environment of limited training and a shortage of resources for supporting families. Partnerships with evidence-based home visiting programs for very young children and their families can provide a resource that will help to reduce the impact of adverse early childhood experiences and facilitate health equity. Home visiting programs in the United States are typically voluntary and designed to be preventative in nature, although families are usually offered services based on significant risk criteria since the costs associated with universal approaches have been considered prohibitive. Programs may be funded within the health (physical orbehavioral/mental health), child welfare, early education, or early intervention systems or by private foundation dollars focused primarily on oneof the above systems (e.g., health), with a wide range of outcomes targeted by the programs and funders. Services may be primarily focused on the child, the parent, or parent-child interactions. Services include the development of targeted and individualized intervention strategies, better coaching of parents, and improved modeling of interactions that may assist struggling families. This paper provides a broad overview ofthe history of home visiting, theoretical bases of home visiting programs, key components of evidence-based models, outcomes typically targeted, research on effectiveness, cost information, challenges and benefits of home visiting, and funding/sustainability concerns. Significance for primary care clinicians isdescribed specifically and information relevant for clinicians is emphasized throughout the paper. Copyright © 2016 Mosby, Inc. All rights reserved.

Sleep Efficiency Modulates Associations Between Family Stress and Adolescent Depressive Symptoms and Negative Affect.

PubMed

Chiang, Jessica J; Kim, Joanna J; Almeida, David M; Bower, Julienne E; Dahl, Ronald E; Irwin, Michael R; McCreath, Heather; Fuligni, Andrew J

2017-10-01

The goal of this study was to determine whether sleep moderates the associations between family-related stress and depressive symptoms and negative affect outcomes during adolescence. We combined traditional survey measures of stress and depressive symptoms with daily assessments of stress and negative affect to examine whether sleep differentially impacts the link between chronic and acute experiences of stress and affect. Participants were 316 adolescents from ethnically diverse backgrounds. Primary caregivers and adolescents reported on stressful family events during the past 12 and 3 months, respectively. Adolescents also reported on their daily experiences of family demands for 15 days and wore actigraph watches for the assessment of sleep during the first eight nights. Regression analyses revealed that more stressful family events were related to more depressive symptoms. This relation was stronger among adolescents with lower sleep efficiency. The same pattern emerged for the relation between daily family demands and negative affect aggregated across the 15 days. Daily-level analyses indicated that daily negative affect was related to daily family demands when sleep efficiency was higher than usual, but only among European American adolescents. These findings suggest that chronic experiences of lower sleep efficiency, but not sleep duration, may render adolescents more vulnerable to the negative effects of family stress on emotional adjustment. A more complex picture emerged for the role of prior night's sleep in the day-to-day variation in negative affect reactivity to family stress. Copyright © 2017 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.

Demand Intensity, Market Parameters and Policy Responses towards Demand and Supply of Private Supplementary Tutoring in China

ERIC Educational Resources Information Center

Kwok, Percy Lai Yin

2010-01-01

Based on some longitudinal studies of private tutoring in twelve cities, towns, municipalities and provinces of China, the paper endeavours to depict demand intensity, articulate market parameters and reflect on policy responses towards the demand-supply mechanism of the vast shadowy educational phenomena at primary and secondary levels. Such…

The Intellectual Demands of the Intended Primary Science Curriculum in Korea and Singapore: An Analysis Based on Revised Bloom's Taxonomy

ERIC Educational Resources Information Center

Lee, Yew-Jin; Kim, Mijung; Yoon, Hye-Gyoung

2015-01-01

While there has been a remarkable worldwide convergence in the emphases of primary science curricula over the last four decades, the cognitive and knowledge demands that they make on learners have not been well-researched. Without knowing what these intellectual or epistemic requirements are when learning science in school, issues concerning…

Metallization problems with concentrator cells

NASA Technical Reports Server (NTRS)

Iles, P. A.

1983-01-01

Cells used with concentrators have similar contact requirements to other cells, but operation at high intensity imposes more than the usual demands on the metallization. Overall contact requirements are listed and concentrator cell requirements are discussed.

To what extent does sociodemographic composition of the neighbourhood explain regional differences in demand of primary out-of-hours care: a multilevel study.

PubMed

Jansen, Tessa; Zwaanswijk, Marieke; Hek, Karin; de Bakker, Dinny

2015-05-06

In the Netherlands, primary out-of-hours (OOH) care is provided by large scale General Practitioner (GP) cooperatives. GP cooperatives can be contacted by patients living in the area surrounding the GP cooperative (catchment area) at hours when the patient's own general practice is closed. The frequency of primary OOH care use substantially differs between GP cooperative catchment areas. To enable a better match between supply and demand of OOH services, understanding of the factors associated with primary OOH care use is essential. The present study evaluated the contribution of sociodemographic composition of the neighbourhood in explaining differences in primary OOH care use between GP cooperative catchment areas. Data about patients' contacts with primary OOH services (n = 1,668,047) were derived from routine electronic health records of 21 GP cooperatives participating in the NIVEL Primary Care Database in 2012. The study sample is representative for the Dutch population (for age and gender). Data were matched with sociodemographic characteristics (e.g. gender, age, low-income status, degree of urbanisation) on postcode level. Multilevel linear regression models included postcode level (first level), nested within GP cooperative catchment areas (second level). We investigated whether contacts in primary OOH care were associated with neighbourhood sociodemographic characteristics. The demand of primary OOH care was significantly higher in neighbourhoods with more women, low-income households, non-Western immigrants, neighbourhoods with a higher degree of urbanisation, and low neighbourhood socioeconomic status. Conversely, lower demand was associated with neighbourhoods with more 5 to 24 year old inhabitants. Sociodemographic neighbourhood characteristics explained a large part of the variation between GP cooperatives (R-squared ranging from 8% to 52%). Nevertheless, the multilevel models also showed that a considerable amount of variation in demand between GP cooperatives remained unexplained by sociodemographic characteristics, particularly regarding high-urgency contacts. Although part of the variation between GP cooperatives could not be attributed to neighbourhood characteristics, the sociodemographic composition of the neighbourhood is a fair predictor of the demand of primary OOH care. Accordingly, this study provides a useful starting point for an improved planning of the supply of primary OOH care.

Data feedback and behavioural change intervention to improve primary care prescribing safety (EFIPPS): multicentre, three arm, cluster randomised controlled trial.

PubMed

Guthrie, Bruce; Kavanagh, Kimberley; Robertson, Chris; Barnett, Karen; Treweek, Shaun; Petrie, Dennis; Ritchie, Lewis; Bennie, Marion

2016-08-18

 To evaluate the effectiveness of feedback on safety of prescribing compared with moderately enhanced usual care.  Three arm, highly pragmatic cluster randomised trial.  262/278 (94%) primary care practices in three Scottish health boards.  Practices were randomised to: "usual care," consisting of emailed educational material with support for searching to identify patients (88 practices at baseline, 86 analysed); usual care plus feedback on practice's high risk prescribing sent quarterly on five occasions (87 practices, 86 analysed); or usual care plus the same feedback incorporating a behavioural change component (87 practices, 86 analysed).  The primary outcome was a patient level composite of six prescribing measures relating to high risk use of antipsychotics, non-steroidal anti-inflammatories, and antiplatelets. Secondary outcomes were the six individual measures. The primary analysis compared high risk prescribing in the two feedback arms against usual care at 15 months. Secondary analyses examined immediate change and change in trend of high risk prescribing associated with implementation of the intervention within each arm.  In the primary analysis, high risk prescribing as measured by the primary outcome fell from 6.0% (3332/55 896) to 5.1% (2845/55 872) in the usual care arm, compared with 5.9% (3341/56 194) to 4.6% (2587/56 478) in the feedback only arm (odds ratio 0.88 (95% confidence interval 0.80 to 0.96) compared with usual care; P=0.007) and 6.2% (3634/58 569) to 4.6% (2686/58 582) in the feedback plus behavioural change component arm (0.86 (0.78 to 0.95); P=0.002). In the pre-specified secondary analysis of change in trend within each arm, the usual care educational intervention had no effect on the existing declining trend in high risk prescribing. Both types of feedback were associated with significantly more rapid decline in high risk prescribing after the intervention compared with before.  Feedback of prescribing safety data was effective at reducing high risk prescribing. The intervention would be feasible to implement at scale in contexts where electronic health records are in general use.Trial registration Clinical trials NCT01602705. 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.

Chapter 10: Peak Demand and Time-Differentiated Energy Savings Cross-Cutting Protocol. The Uniform Methods Project: Methods for Determining Energy Efficiency Savings for Specific Measures

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

Kurnik, Charles W; Stern, Frank; Spencer, Justin

Savings from electric energy efficiency measures and programs are often expressed in terms of annual energy and presented as kilowatt-hours per year (kWh/year). However, for a full assessment of the value of these savings, it is usually necessary to consider the measure or program's impact on peak demand as well as time-differentiated energy savings. This cross-cutting protocol describes methods for estimating the peak demand and time-differentiated energy impacts of measures implemented through energy efficiency programs.

Isolated primary lymphedema tarda of the upper limb.

PubMed

Shariati, Farzaneh; Ravari, Hasan; Kazemzadeh, Gholamhossein; Sadeghi, Ramin

2013-03-01

Primary lymphedema tarda is considered as a congenital disease with late presentation. Primary lymphedema tarda usually affects lower limbs, and primary lymphedema tarda of the upper limbs usually accompanies lower limb lymphedema. In the current case report, we present an 80-year-old male patient with isolated left upper limb swelling that lymphoscintigraphy imaging proved to be lymphedema.

Usual Primary Care Provider Characteristics of a Patient-Centered Medical Home and Mental Health Service Use.

PubMed

Jones, Audrey L; Cochran, Susan D; Leibowitz, Arleen; Wells, Kenneth B; Kominski, Gerald; Mays, Vickie M

2015-12-01

The benefits of the patient-centered medical home (PCMH) over and above that of a usual source of medical care have yet to be determined, particularly for adults with mental health disorders. To examine qualities of a usual provider that align with PCMH goals of access, comprehensiveness, and patient-centered care, and to determine whether PCMH qualities in a usual provider are associated with the use of mental health services (MHS). Using national data from the Medical Expenditure Panel Survey, we conducted a lagged cross-sectional study of MHS use subsequent to participant reports of psychological distress and usual provider and practice characteristics. A total of 2,358 adults, aged 18-64 years, met the criteria for serious psychological distress and reported on their usual provider and practice characteristics. We defined "usual provider" as a primary care provider/practice, and "PCMH provider" as a usual provider that delivered accessible, comprehensive, patient-centered care as determined by patient self-reporting. The dependent variable, MHS, included self-reported mental health visits to a primary care provider or mental health specialist, counseling, and psychiatric medication treatment over a period of 1 year. Participants with a usual provider were significantly more likely than those with no usual provider to have experienced a primary care mental health visit (marginal effect [ME] = 8.5, 95 % CI = 3.2-13.8) and to have received psychiatric medication (ME = 15.5, 95 % CI = 9.4-21.5). Participants with a PCMH were additionally more likely than those with no usual provider to visit a mental health specialist (ME = 7.6, 95 % CI = 0.7-14.4) and receive mental health counseling (ME = 8.5, 95 % CI = 1.5-15.6). Among those who reported having had any type of mental health visit, participants with a PCMH were more likely to have received mental health counseling than those with only a usual provider (ME = 10.0, 95 % CI = 1.0-19.0). Access to a usual provider is associated with increased receipt of needed MHS. Patients who have a usual provider with PCMH qualities are more likely to receive mental health counseling.

Looking at Practice: Revealing the Knowledge Demands of Teaching Data Handling in the Primary Classroom

ERIC Educational Resources Information Center

Leavy, Aisling

2015-01-01

In the evolving field of mathematics education, there is the need to maintain the relationship between what is presented in college level preparation courses and the skills required to teach mathematics in classrooms. This research examines the knowledge demands placed on 73 pre-service primary teachers as they use lesson study to plan and teach…

A Computerized Decision Support System for Depression in Primary Care

PubMed Central

Kurian, Benji T.; Trivedi, Madhukar H.; Grannemann, Bruce D.; Claassen, Cynthia A.; Daly, Ella J.; Sunderajan, Prabha

2009-01-01

Objective: In 2004, results from The Texas Medication Algorithm Project (TMAP) showed better clinical outcomes for patients whose physicians adhered to a paper-and-pencil algorithm compared to patients who received standard clinical treatment for major depressive disorder (MDD). However, implementation of and fidelity to the treatment algorithm among various providers was observed to be inadequate. A computerized decision support system (CDSS) for the implementation of the TMAP algorithm for depression has since been developed to improve fidelity and adherence to the algorithm. Method: This was a 2-group, parallel design, clinical trial (one patient group receiving MDD treatment from physicians using the CDSS and the other patient group receiving usual care) conducted at 2 separate primary care clinics in Texas from March 2005 through June 2006. Fifty-five patients with MDD (DSM-IV criteria) with no significant difference in disease characteristics were enrolled, 32 of whom were treated by physicians using CDSS and 23 were treated by physicians using usual care. The study's objective was to evaluate the feasibility and efficacy of implementing a CDSS to assist physicians acutely treating patients with MDD compared to usual care in primary care. Primary efficacy outcomes for depression symptom severity were based on the 17-item Hamilton Depression Rating Scale (HDRS17) evaluated by an independent rater. Results: Patients treated by physicians employing CDSS had significantly greater symptom reduction, based on the HDRS17, than patients treated with usual care (P < .001). Conclusions: The CDSS algorithm, utilizing measurement-based care, was superior to usual care for patients with MDD in primary care settings. Larger randomized controlled trials are needed to confirm these findings. Trial Registration: clinicaltrials.gov Identifier: NCT00551083 PMID:19750065

A computerized decision support system for depression in primary care.

PubMed

Kurian, Benji T; Trivedi, Madhukar H; Grannemann, Bruce D; Claassen, Cynthia A; Daly, Ella J; Sunderajan, Prabha

2009-01-01

In 2004, results from The Texas Medication Algorithm Project (TMAP) showed better clinical outcomes for patients whose physicians adhered to a paper-and-pencil algorithm compared to patients who received standard clinical treatment for major depressive disorder (MDD). However, implementation of and fidelity to the treatment algorithm among various providers was observed to be inadequate. A computerized decision support system (CDSS) for the implementation of the TMAP algorithm for depression has since been developed to improve fidelity and adherence to the algorithm. This was a 2-group, parallel design, clinical trial (one patient group receiving MDD treatment from physicians using the CDSS and the other patient group receiving usual care) conducted at 2 separate primary care clinics in Texas from March 2005 through June 2006. Fifty-five patients with MDD (DSM-IV criteria) with no significant difference in disease characteristics were enrolled, 32 of whom were treated by physicians using CDSS and 23 were treated by physicians using usual care. The study's objective was to evaluate the feasibility and efficacy of implementing a CDSS to assist physicians acutely treating patients with MDD compared to usual care in primary care. Primary efficacy outcomes for depression symptom severity were based on the 17-item Hamilton Depression Rating Scale (HDRS(17)) evaluated by an independent rater. Patients treated by physicians employing CDSS had significantly greater symptom reduction, based on the HDRS(17), than patients treated with usual care (P < .001). The CDSS algorithm, utilizing measurement-based care, was superior to usual care for patients with MDD in primary care settings. Larger randomized controlled trials are needed to confirm these findings. clinicaltrials.gov Identifier: NCT00551083.

A comparison of the efficacy of organic and mixed-organic polymers with polyaluminium chloride in chemically assisted primary sedimentation (CAPS).

PubMed

De Feo, G; Galasso, M; Landi, R; Donnarumma, A; De Gisi, S

2013-01-01

CAPS is the acronym for chemically assisted primary sedimentation, which consists of adding chemicals to raw urban wastewater to increase the efficacy of coagulation, flocculation and sedimentation. The principal benefits of CAPS are: upgrading of urban wastewater treatment plants; increasing efficacy of primary sedimentation; and the major production of energy from the anaerobic digestion of primary sludge. Metal coagulants are usually used because they are both effective and cheap, but they can cause damage to the biological processes of anaerobic digestion. Generally, biodegradable compounds do not have these drawbacks, but they are comparatively more expensive. Both metal coagulants and biodegradable compounds have preferential and penalizing properties in terms of CAPS application. The problem can be solved by means of a multi-criteria analysis. For this purpose, a series of tests was performed in order to compare the efficacy of several organic and mixed-organic polymers with that of polyaluminium chloride (PACl) under specific conditions. The multi-criteria analysis was carried out coupling the simple additive weighting method with the paired comparison technique as a tool to evaluate the criteria priorities. Five criteria with the following priorities were used: chemical oxygen demand (COD) removal > turbidity, SV60 > coagulant dose, and coagulant cost. The PACl was the best alternative in 70% of the cases. The CAPS process using PACl made it possible to obtain an average COD removal of 68% compared with 38% obtained, on average, with natural sedimentation and 61% obtained, on average, with the best PACl alternatives (cationic polyacrylamide, natural cationic polymer, dicyandiamide resin).

An evaluation of primary care led dementia diagnostic services in Bristol.

PubMed

Dodd, Emily; Cheston, Richard; Fear, Tina; Brown, Ellie; Fox, Chris; Morley, Clare; Jefferies, Rosalyn; Gray, Richard

2014-11-29

Typically people who go to see their GP with a memory problem will be initially assessed and those patients who seem to be at risk will be referred onto a memory clinic. The demographic forces mean that memory services will need to expand to meet demand. An alternative may be to expand the role of primary care in dementia diagnosis and care. The aim of this study was to contrast patient, family member and professional experience of primary and secondary (usual) care led memory services. A qualitative, participatory study. A topic guide was developed by the peer and professional panels. Data were collected through peer led interviews of people with dementia, their family members and health professionals. Eleven (21%) of the 53 GP practices in Bristol offered primary care led dementia services. Three professional panels were held and were attended by 9 professionals; nine carers but no patients were involved in the three peer panels. These panels identified four main themes: GPs rarely make independent dementia diagnosis; GPs and memory nurses work together; patients and carers generally experience a high quality diagnostic service; an absence of post diagnostic support. Evidence relating to these themes was collected through a total of 46 participants took part; 23 (50%) in primary care and 23 (50%) in the memory service. Patients and carers were generally satisfied with either primary or secondary care led approaches to dementia diagnosis. Their major concern, shared with many health care professionals, was a lack of post diagnostic support.

Adaptive threshold determination for efficient channel sensing in cognitive radio network using mobile sensors

NASA Astrophysics Data System (ADS)

Morshed, M. N.; Khatun, S.; Kamarudin, L. M.; Aljunid, S. A.; Ahmad, R. B.; Zakaria, A.; Fakir, M. M.

2017-03-01

Spectrum saturation problem is a major issue in wireless communication systems all over the world. Huge number of users is joining each day to the existing fixed band frequency but the bandwidth is not increasing. These requirements demand for efficient and intelligent use of spectrum. To solve this issue, the Cognitive Radio (CR) is the best choice. Spectrum sensing of a wireless heterogeneous network is a fundamental issue to detect the presence of primary users' signals in CR networks. In order to protect primary users (PUs) from harmful interference, the spectrum sensing scheme is required to perform well even in low signal-to-noise ratio (SNR) environments. Meanwhile, the sensing period is usually required to be short enough so that secondary (unlicensed) users (SUs) can fully utilize the available spectrum. CR networks can be designed to manage the radio spectrum more efficiently by utilizing the spectrum holes in primary user's licensed frequency bands. In this paper, we have proposed an adaptive threshold detection method to detect presence of PU signal using free space path loss (FSPL) model in 2.4 GHz WLAN network. The model is designed for mobile sensors embedded in smartphones. The mobile sensors acts as SU while the existing WLAN network (channels) works as PU. The theoretical results show that the desired threshold range detection of mobile sensors mainly depends on the noise floor level of the location in consideration.

Pricing for scarcity? An efficiency analysis of increasing block tariffs

NASA Astrophysics Data System (ADS)

Monteiro, Henrique; Roseta-Palma, Catarina

2011-06-01

Water pricing schedules often contain significant nonlinearities, such as the increasing block tariff (IBT) structure that is abundantly applied for residential users. The IBT is frequently supported as a good tool for achieving the goals of equity, water conservation, and revenue neutrality but seldom has been grounded on efficiency justifications. In particular, existing literature on water pricing establishes that although efficient schedules will depend on demand and supply characteristics, IBT cannot usually be recommended. In this paper, we consider whether the explicit inclusion of scarcity considerations can strengthen the appeal of IBT. Results show that when both demand and costs react to climate factors, increasing marginal prices may come about as a response to a combination of water scarcity and customer heterogeneity. We derive testable conditions and then illustrate their application through an estimation of Portuguese residential water demand. We show that the recommended tariff schedule hinges crucially on the choice of functional form for demand.

Resource use and costs of type 2 diabetes patients receiving managed or protocolized primary care: a controlled clinical trial.

PubMed

van der Heijden, Amber A W A; de Bruijne, Martine C; Feenstra, Talitha L; Dekker, Jacqueline M; Baan, Caroline A; Bosmans, Judith E; Bot, Sandra D M; Donker, Gé A; Nijpels, Giel

2014-06-25

The increasing prevalence of diabetes is associated with increased health care use and costs. Innovations to improve the quality of care, manage the increasing demand for health care and control the growth of health care costs are needed. The aim of this study is to evaluate the care process and costs of managed, protocolized and usual care for type 2 diabetes patients from a societal perspective. In two distinct regions of the Netherlands, both managed and protocolized diabetes care were implemented. Managed care was characterized by centralized organization, coordination, responsibility and centralized annual assessment. Protocolized care had a partly centralized organizational structure. Usual care was characterized by a decentralized organizational structure. Using a quasi-experimental control group pretest-posttest design, the care process (guideline adherence) and costs were compared between managed (n = 253), protocolized (n = 197), and usual care (n = 333). We made a distinction between direct health care costs, direct non-health care costs and indirect costs. Multivariate regression models were used to estimate differences in costs adjusted for confounding factors. Because of the skewed distribution of the costs, bootstrapping methods (5000 replications) with a bias-corrected and accelerated approach were used to estimate 95% confidence intervals (CI) around the differences in costs. Compared to usual and protocolized care, in managed care more patients were treated according to diabetes guidelines. Secondary health care use was higher in patients under usual care compared to managed and protocolized care. Compared to usual care, direct costs were significantly lower in managed care (€-1.181 (95% CI: -2.597 to -334)) while indirect costs were higher (€ 758 (95% CI: -353 to 2.701), although not significant. Direct, indirect and total costs were lower in protocolized care compared to usual care (though not significantly). Compared to usual care, managed care was significantly associated with better process in terms of diabetes care, fewer secondary care consultations and lower health care costs. The same trends were seen for protocolized care, however they were not statistically significant. Current Controlled trials: ISRCTN66124817.

Resource use and costs of type 2 diabetes patients receiving managed or protocolized primary care: a controlled clinical trial

PubMed Central

2014-01-01

Background The increasing prevalence of diabetes is associated with increased health care use and costs. Innovations to improve the quality of care, manage the increasing demand for health care and control the growth of health care costs are needed. The aim of this study is to evaluate the care process and costs of managed, protocolized and usual care for type 2 diabetes patients from a societal perspective. Methods In two distinct regions of the Netherlands, both managed and protocolized diabetes care were implemented. Managed care was characterized by centralized organization, coordination, responsibility and centralized annual assessment. Protocolized care had a partly centralized organizational structure. Usual care was characterized by a decentralized organizational structure. Using a quasi-experimental control group pretest-posttest design, the care process (guideline adherence) and costs were compared between managed (n = 253), protocolized (n = 197), and usual care (n = 333). We made a distinction between direct health care costs, direct non-health care costs and indirect costs. Multivariate regression models were used to estimate differences in costs adjusted for confounding factors. Because of the skewed distribution of the costs, bootstrapping methods (5000 replications) with a bias-corrected and accelerated approach were used to estimate 95% confidence intervals (CI) around the differences in costs. Results Compared to usual and protocolized care, in managed care more patients were treated according to diabetes guidelines. Secondary health care use was higher in patients under usual care compared to managed and protocolized care. Compared to usual care, direct costs were significantly lower in managed care (€-1.181 (95% CI: -2.597 to -334)) while indirect costs were higher (€758 (95% CI: -353 to 2.701), although not significant. Direct, indirect and total costs were lower in protocolized care compared to usual care (though not significantly). Conclusions Compared to usual care, managed care was significantly associated with better process in terms of diabetes care, fewer secondary care consultations and lower health care costs. The same trends were seen for protocolized care, however they were not statistically significant. Trial registration Current Controlled trials: ISRCTN66124817. PMID:24966055

Life cycle and hydrologic modeling of rainwater harvesting in urban neighborhoods: Implications of urban form and water demand patterns in the US and Spain.

PubMed

Petit-Boix, Anna; Devkota, Jay; Phillips, Robert; Vargas-Parra, María Violeta; Josa, Alejandro; Gabarrell, Xavier; Rieradevall, Joan; Apul, Defne

2018-04-15

Water management plays a major role in any city, but applying alternative strategies might be more or less feasible depending on the urban form and water demand. This paper aims to compare the environmental performance of implementing rainwater harvesting (RWH) systems in American and European cities. To do so, two neighborhoods with a water-stressed Mediterranean climate were selected in contrasting cities, i.e., Calafell (Catalonia, Spain) and Ukiah (California, US). Calafell is a high-density, tourist city, whereas Ukiah is a typical sprawled area. We studied the life cycle impacts of RWH in urban contexts by using runoff modeling before (i.e. business as usual) and after the implementation of this system. In general, cisterns were able to supply >75% of the rainwater demand for laundry and toilet flushing. The exception were multi-story buildings with roofs smaller than 200m 2 , where the catchment area was insufficient to meet demand. The implementation of RWH was environmentally beneficial with respect to the business-as-usual scenario, especially because of reduced runoff treatment needs. Along with soil features, roof area and water demand were major parameters that affected this reduction. RWH systems are more attractive in Calafell, which had 60% lower impacts than in Ukiah. Therefore, high-density areas can potentially benefit more from RWH than sprawled cities. Copyright © 2017 Elsevier B.V. All rights reserved.

Performance improvement: an active life cycle product management

NASA Astrophysics Data System (ADS)

Cucchiella, Federica; Gastaldi, Massimo; Lenny Koh, S. C.

2010-03-01

The management of the supply chain has gained importance in many manufacturing firms. Operational flexibility can be considered a crucial weapon to increase competitiveness in a turbulent marketplace. It reflects the ability of a firm to properly and rapidly respond to a variable and dynamic environment. For the firm operating in a fashion sector, the management of the supply chain is even more complex because the product life cycle is shorter than that of the firm operating in a non-fashion sector. The increase of firm flexibility level can be reached through the application of the real option theory inside the firm network. In fact, real option may increase the project value by allowing managers to more efficiently direct the production. The real option application usually analysed in literature does not take into account that the demands of products are well-defined by the product life cycle. Working on a fashion sector, the life cycle pattern is even more relevant because of an expected demand that grows according to a constant rate that does not capture the demand dynamics of the underlying fashion goods. Thus, the primary research objective of this article is to develop a model useful for the management of investments in a supply chain operating in a fashion sector where the system complexity is increased by the low level of unpredictability and stability that is proper of the mood phenomenon. Moreover, unlike the traditional model, a real option framework is presented here that considers fashion product characterised by uncertain stages of the production cycle.

Teaching and Managing: Conflicting Roles of the Department Chair.

ERIC Educational Resources Information Center

Hoffman, Susan; And Others

Community college department chairs are called upon to be colleagues and peers, managers, and teachers, with duties and responsibilities that are usually far more complex and demanding than any college document can convey. As a result of the demands of the position, department chairs may experience role conflict or strain. Role conflicts are…

THE EFFECT OF CHLORINE DEMAND ON INACTIVATION RATE CONSTANT

EPA Science Inventory

Ct (disinfectant concentration multiplied by exposure time) values are used by the US EPA to evaluate the efficacy of disinfection of microorganisms under various conditions of drinking water treatment conditions. First-order decay is usually assumed for the degradation of a disi...

Integration of Traditional Birth Attendants into Prevention of Mother-to-Child Transmission at Primary Health Facilities in Kaduna, North-West Nigeria.

PubMed

Nsirim, Reward O; Iyongo, Joseph A; Adekugbe, Olayinka; Ugochuku, Maureen

2015-03-31

One of the fundamental challenges to implementing successful prevention of mother-to-child transmission (PMTCT) programs in Nigeria is the uptake of PMTCT services at health facilities. Several issues usually discourage many pregnant women from receiving antenatal care services at designated health facilities within their communities. The CRS Nigeria PMTCT Project funded by the Global Fund in its Round 9 Phase 1 in Nigeria, sought to increase demand for HIV counseling and testing services for pregnant women at 25 supported primary health centers (PHCs) in Kaduna State, North-West Nigeria by integrating traditional birth attendants (TBAs) across the communities where the PHCs were located into the project. Community dialogues were held with the TBAs, community leaders and women groups. These dialogues focused on modes of mother to child transmission of HIV and the need for TBAs to refer their clients to PHCs for testing. Subsequently, data on number of pregnant women who were counseled, tested and received results was collected on a monthly basis from the 25 facilities using the national HIV/AIDS tools. Prior to this integration, the average number of pregnant women that were counseled, tested and received results was 200 pregnant women across all the 25 health facilities monthly. After the integration of TBAs into the program, the number of pregnant women that were counseled, tested and received results kept increasing month after month up to an average of 1500 pregnant women per month across the 25 health facilities. TBAs can thus play a key role in improving service uptake and utilization for pregnant women at primary health centers in the community - especially in the context of HIV/AIDS. They thus need to be integrated, rather than alienated, from primary healthcare service delivery.

Individual muscle contributions to push and recovery subtasks during wheelchair propulsion.

PubMed

Rankin, Jeffery W; Richter, W Mark; Neptune, Richard R

2011-04-29

Manual wheelchair propulsion places considerable physical demand on the upper extremity and is one of the primary activities associated with the high prevalence of upper extremity overuse injuries and pain among wheelchair users. As a result, recent effort has focused on determining how various propulsion techniques influence upper extremity demand during wheelchair propulsion. However, an important prerequisite for identifying the relationships between propulsion techniques and upper extremity demand is to understand how individual muscles contribute to the mechanical energetics of wheelchair propulsion. The purpose of this study was to use a forward dynamics simulation of wheelchair propulsion to quantify how individual muscles deliver, absorb and/or transfer mechanical power during propulsion. The analysis showed that muscles contribute to either push (i.e., deliver mechanical power to the handrim) or recovery (i.e., reposition the arm) subtasks, with the shoulder flexors being the primary contributors to the push and the shoulder extensors being the primary contributors to the recovery. In addition, significant activity from the shoulder muscles was required during the transition between push and recovery, which resulted in increased co-contraction and upper extremity demand. Thus, strengthening the shoulder flexors and promoting propulsion techniques that improve transition mechanics have much potential to reduce upper extremity demand and improve rehabilitation outcomes. Copyright © 2011 Elsevier Ltd. All rights reserved.

Hyponatremia due to Secondary Adrenal Insufficiency Successfully Treated by Dexamethasone with Sodium Chloride.

PubMed

Kazama, Itsuro; Tamada, Tsutomu; Nakajima, Toshiyuki

2015-08-28

Patients who were surgically treated for Cushing's syndrome postoperatively surrender to "primary" adrenal insufficiency. However, the preoperative over-secretion of cortisol or the postoperative administration of excessive glucocorticoids can cause "secondary" adrenal insufficiency, in which the prevalence of hyponatremia is usually lower than that of primary adrenal insufficiency. A 60-year-old woman with a past medical history of Cushing's syndrome developed hyponatremia with symptoms of acute glucocorticoid deficiency, such as prolonged general fatigue and anorexia, after upper respiratory tract infection. A decrease in the serum cortisol level and the lack of increase in the ACTH level, despite the increased demand for cortisol, enabled a diagnosis of "secondary" adrenal insufficiency. Although the initial fluid replacement therapy was not effective, co-administration of dexamethasone and sodium chloride quickly resolved her symptoms and ameliorated the refractory hyponatremia. In this case, the hypothalamic-pituitary axis of the patient was thought to have become suppressed long after the surgical treatment for Cushing's syndrome. This case suggested a mechanism of refractory hyponatremia caused by secondary adrenal insufficiency, for which the administration of dexamethasone and sodium chloride exerted additional therapeutic efficacy.

Into the Sunset: Reflections of an Interim Administrator.

ERIC Educational Resources Information Center

Marlowe, John

2000-01-01

One advantage to an interim administrative position is that the public cuts short-timers a little slack. Temporary administrators can learn on the job and become experts on specialized subjects. Personnel issues demand more time than interims possess. Such positions usually do not turn into long-term contracts. (MLH)

Attentional Demand of a Virtual Reality-Based Reaching Task in Nondisabled Older Adults.

PubMed

Chen, Yi-An; Chung, Yu-Chen; Proffitt, Rachel; Wade, Eric; Winstein, Carolee

2015-12-01

Attention during exercise is known to affect performance; however, the attentional demand inherent to virtual reality (VR)-based exercise is not well understood. We used a dual-task paradigm to compare the attentional demands of VR-based and non-VR-based (conventional, real-world) exercise: 22 non-disabled older adults performed a primary reaching task to virtual and real targets in a counterbalanced block order while verbally responding to an unanticipated auditory tone in one third of the trials. The attentional demand of the primary reaching task was inferred from the voice response time (VRT) to the auditory tone. Participants' engagement level and task experience were also obtained using questionnaires. The virtual target condition was more attention demanding (significantly longer VRT) than the real target condition. Secondary analyses revealed a significant interaction between engagement level and target condition on attentional demand. For participants who were highly engaged, attentional demand was high and independent of target condition. However, for those who were less engaged, attentional demand was low and depended on target condition (i.e., virtual > real). These findings add important knowledge to the growing body of research pertaining to the development and application of technology-enhanced exercise for elders and for rehabilitation purposes.

Attentional Demand of a Virtual Reality-Based Reaching Task in Nondisabled Older Adults

PubMed Central

Chen, Yi-An; Chung, Yu-Chen; Proffitt, Rachel; Wade, Eric; Winstein, Carolee

2015-01-01

Attention during exercise is known to affect performance; however, the attentional demand inherent to virtual reality (VR)-based exercise is not well understood. We used a dual-task paradigm to compare the attentional demands of VR-based and non-VR-based (conventional, real-world) exercise: 22 non-disabled older adults performed a primary reaching task to virtual and real targets in a counterbalanced block order while verbally responding to an unanticipated auditory tone in one third of the trials. The attentional demand of the primary reaching task was inferred from the voice response time (VRT) to the auditory tone. Participants' engagement level and task experience were also obtained using questionnaires. The virtual target condition was more attention demanding (significantly longer VRT) than the real target condition. Secondary analyses revealed a significant interaction between engagement level and target condition on attentional demand. For participants who were highly engaged, attentional demand was high and independent of target condition. However, for those who were less engaged, attentional demand was low and depended on target condition (i.e., virtual > real). These findings add important knowledge to the growing body of research pertaining to the development and application of technology-enhanced exercise for elders and for rehabilitation purposes. PMID:27004233

Exploring Global Patterns in Human Appropriation of Net Primary Production Using Earth Observation Satellites and Statistical Data

NASA Astrophysics Data System (ADS)

Imhoff, M.; Bounoua, L.

2004-12-01

A unique combination of satellite and socio-economic data were used to explore the relationship between human consumption and the carbon cycle. Biophysical models were applied to consumption data to estimate the annual amount of Earth's terrestrial net primary production humans require for food, fiber and fuel using the same modeling architecture as satellite-supported NPP measurements. The amount of Earth's NPP required to support human activities is a powerful measure of the aggregate human impacts on the biosphere and indicator of societal vulnerability to climate change. Equations were developed estimating the amount of landscape-level NPP required to generate all the products consumed by 230 countries including; vegetal foods, meat, milk, eggs, wood, fuel-wood, paper and fiber. The amount of NPP required was calculated on a per capita basis and projected onto a global map of population to create a spatially explicit map of NPP-carbon demand in units of elemental carbon. NPP demand was compared to a map of Earth's average annual net primary production or supply created using 17 years (1982-1998) of AVHRR vegetation index to produce a geographically accurate balance sheet of terrestrial NPP-carbon supply and demand. Globally, humans consume 20 percent of Earth's total net primary production on land. Regionally the NPP-carbon balance percentage varies from 6 to over 70 percent and locally from near 0 to over 30,000 percent in major urban areas. The uneven distribution of NPP-carbon supply and demand, indicate the degree to which various human populations rely on NPP imports, are vulnerable to climate change and suggest policy options for slowing future growth in NPP demand.

Teacher Supply and Demand in the ACT Schools Authority: Implications of Enrollment Projections 1981-1986. Research Report.

ERIC Educational Resources Information Center

Burkhardt, Geoffrey

An analysis of policy options concerning teacher supply and demand in the A.C.T. [Australian Capital Territory] Schools Authority from 1981 to 1986 is presented. Projections have indicated declining demand for primary school teachers, fewer promotions in primary schools, and the necessity of relocating teachers to areas of expansion. However,…

On Discipline: The Products and Process.

ERIC Educational Resources Information Center

Frasher, James

1982-01-01

One explanation for unexpectedly low stress levels among assistant principals may lie in "administrative attribution theory." The demand for school discipline by the public, school boards, teachers, and students should induce high levels of stress in assistant principals, because they are usually responsible for discipline enforcement,…

Base Stock Policy in a Join-Type Production Line with Advanced Demand Information

NASA Astrophysics Data System (ADS)

Hiraiwa, Mikihiko; Tsubouchi, Satoshi; Nakade, Koichi

Production control such as the base stock policy, the kanban policy and the constant work-in-process policy in a serial production line has been studied by many researchers. Production lines, however, usually have fork-type, join-type or network-type figures. In addition, in most previous studies on production control, a finished product is required at the same time as arrival of demand at the system. Demand information is, however, informed before due date in practice. In this paper a join-type (assembly) production line under base stock control with advanced demand information in discrete time is analyzed. The recursive equations for the work-in-process are derived. The heuristic algorithm for finding appropriate base stock levels of all machines at short time is proposed and the effect of advanced demand information is examined by simulation with the proposed algorithm. It is shown that the inventory cost can decreases with little backlogs by using the appropriate amount of demand information and setting appropriate base stock levels.

Estimation of the demand for commercial truck parking on interstate highways in Virginia

DOT National Transportation Integrated Search

2003-01-01

The steady growth of commercial truck traveling on most Interstate and primary highways has resulted in increasing demand for both public rest areas and private truck stops in Virginia. In addition, inadequate parking spaces for commercial trucks may...

System effects of primary energy reduction connected with operation of the CHP plants

NASA Astrophysics Data System (ADS)

Ziębik, Andrzej; Gładysz, Paweł

2017-06-01

The paper is devoted to explication of one of the advantages of heat and electricity cogeneration, rarely considered in technical literature. Usually attention is paid to the fact that heat losses of the heat distribution network are less severe in the case of cogeneration of heat in comparison with its separate production. But this conclusion is also true in other cases when the internal consumption of heat is significant. In this paper it has been proved in the case of two examples concerning trigeneration technology with an absorption chiller cooperating with a combined heat and power (CHP) plant and CHP plant integrated with amine post-combustion CO2 processing unit. In both considered cases it might be said that thanks to cogeneration we have to do with less severe consequences of significant demand of heat for internal purposes.

Are psychological treatments for depression in primary care cost-effective?

PubMed

Bosmans, Judith E; van Schaik, Digna J F; de Bruijne, Martine C; van Hout, Hein P J; van Marwijk, Harm W J; van Tulder, Maurits W; Stalman, Wim A B

2008-03-01

Depression is a highly prevalent condition that is associated with high levels of work absenteeism and high health care costs. Most patients are treated in primary care. A large group of patients prefers psychological treatments to antidepressants. To systematically review the evidence for the cost-effectiveness of psychological treatments, psychotherapy and counselling, in comparison with usual care or antidepressant treatment in adult primary care patients with depression. A computer-assisted search of MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Library was carried out. Two independent reviewers selected studies for the review, extracted data and assessed the methodological quality of the included studies. Seven studies were included in the review. Forms of psychotherapy that were evaluated were cognitive behavioural therapy, interpersonal psychotherapy and couple therapy. Usual care generally consisted of care as usually provided by the general practitioner. No conclusion can be drawn on the cost-effectiveness of the above mentioned forms of psychotherapy in comparison with usual care or antidepressant treatment. The cost-effectiveness of counselling in comparison with usual care and antidepressant therapy is yet to be established. Meta-analyses showed that psychotherapy was significantly more expensive than usual care, but not significantly more expensive than antidepressant treatment. Counselling was associated with no statistically significant differences in costs and effects in comparison with usual care in the pooled analysis. Based on this review, no firm conclusions on the cost-effectiveness of psychotherapy and counselling in primary care can be drawn. Most studies had methodological shortcomings, which limit the generalisibility of the results. Given the reluctance of patients to use antidepressants and the large economic impact of depression, policy makers have a need for well designed and sufficiently powered economic evaluations of psychological treatments. The available evidence seems to indicate that psychotherapy has more substantial clinical effects than counselling. Therefore, the emphasis should be on economic evaluations of forms of psychotherapy that have proved to be clinically effective. There are indications that the cost-effectiveness of depression treatment on the whole may be improved by incorporating psychological treatments into enhanced care models, tailored to the needs of individual patients and/or by providing them by trained nurses instead of psychologists or psychotherapists. Further research should investigate these patient tailored, stepped care treatment modalities for depression treatment.

What people want from sex and preexposure prophylaxis.

PubMed

Grant, Robert M; Koester, Kimberly A

2016-01-01

As demand for preexposure prophylaxis (PrEP) increases, we are learning more about what people want from sex and PrEP. PrEP demand has reached a tipping point in the USA and is increasing rapidly. Although the primary benefit of PrEP use is biological, to reduce risk of HIV infection, PrEP users often express an alternative set of social and emotional benefits that are provided by PrEP. These collateral benefits of PrEP have salience, affect, and are experienced in the present, which are compelling drivers of human behavior. PrEP use has been associated with feeling safe during sex, usually in contrast to ruminations related to fear of HIV or intimate partner violence or control. PrEP can create empowerment, or agency, defined as the capacity and autonomy to act on one's own behalf, because it provides control over one's vulnerability to HIV and relief to women and men who may otherwise worry about whether their partners will use a condom, take antiretroviral therapy, or disclose their HIV status accurately. Planning for sexual and social goals in calm moments is also empowering. These highly desired collateral benefits of PrEP could be undermined, or eliminated, if PrEP is implemented in ways that are coercive or that foment fear of sexual risk compensation, drug resistance, toxicity, or moral judgment. Current PrEP implementation provides direct and indirect benefits that are highly desired.

Does Physician Education on Depression Management Improve Treatment in Primary Care?

PubMed Central

Lin, Elizabeth H B; Simon, Gregory E; Katzelnick, David J; Pearson, Steven D

2001-01-01

OBJECTIVE To assess the effect of physician training on management of depression. DESIGN Primary care physicians were randomly assigned to a depression management intervention that included an educational program. A before-and-after design evaluated physician practices for patients not enrolled in the intervention trial. SETTING One hundred nine primary care physicians in 2 health maintenance organizations located in the Midwest and Northwest regions of the United States. PATIENTS/PARTICIPANTS Computerized pharmacy and visit data from a group of 124,893 patients who received visits or prescriptions from intervention and usual care physicians. INTERVENTIONS Primary care physicians received education on diagnosis and optimal management of depression over a 3-month training period. Methods of education included small group interactive discussions, expert demonstrations, role-play, and academic detailing of pharmacotherapy, criteria for urgent psychiatric referrals, and case reviews with psychiatric consultants. MEASUREMENTS AND MAIN RESULTS Pharmacy and visit data provided indicators of physician management of depression: rate of newly diagnosed depression, new prescription of antidepressant medication, and duration of pharmacotherapy. One year after the training period, intervention and usual care physicians did not differ significantly in the rate of new depression diagnosis (P = .95) or new prescription of antidepressant medicines (P = .10). Meanwhile, patients of intervention physicians did not differ from patients of usual care physicians in adequacy of pharmacotherapy (P = .53) as measured by 12 weeks of continuous antidepressant treatment. CONCLUSIONS After education on optimal management of depression, intervention physicians did not differ from their usual care colleagues in depression diagnosis or pharmacotherapy. PMID:11556942

Gender Differences in the Perception of Administrative Role Demands.

ERIC Educational Resources Information Center

Estler, Suzanne E.

Efforts to understand the relationship between gender and school administration have usually focused on explaining the limited numbers of women administrators. Explanations of leadership style differences have stressed sex-role socialization theory, though some researchers suggest that the structure of power, opportunity, and social proportions in…

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

Rodriguez, E.P.

Due to the active demographic and industrial growth, the permanent incorporation of new lands to agricultural and cattle industries, the increasing heavy pressure on the renewable natural resources, the demand for new articles and products for human, conford, and the growing needs of water for human, agricultural, industrial and energetic uses, the present situation of Colombia as a developing country points out to the urgent need of a permanent and effective action by the state, that has been delegated to the National Institute of Natural Renewable Resources and the Environment (Instituto Nacional de los Recursos Naturales Renovables y del Ambiente-INDERENA).more » Accordingly a national environmental policy is being implemented by INDEPENA, based on primary fields of activity such as Environmental Education, a system of environmental information and environmental planning, coupled with the necessary actions for control and protection of natural renewable resources. A dynamic cooperation with the neighbowring Latin American countries would imply a meaningful diminution of possible duplicated efforts that usually are the result of efforts carried on when each country individually attempts to solve problems of a common nature.« less

Information Broker/Free Lance Librarian--New Careers--New Library Services. Miscellaneous Studies No. 3

ERIC Educational Resources Information Center

Minor, Barbara B., Ed.

Proceedings of a workshop on the information broker--a person or organization that provides information on demand for a fee, usually to make a profit--includes edited transcripts of the following presentations: "Introduction," Maxine Davis; "The Free-Lance Alternative: Turning Traditional Skills New Directions," Susan Klement;…

One size fits some: the impact of patient treatment attitudes on the cost-effectiveness of a depression primary-care intervention.

PubMed

Pyne, Jeffrey M; Rost, Kathryn M; Farahati, Farah; Tripathi, Shanti P; Smith, Jeffrey; Williams, D Keith; Fortney, John; Coyne, James C

2005-06-01

Despite their impact on outcomes, the effect of patient treatment attitudes on the cost-effectiveness of health-care interventions is not widely studied. This study estimated the impact of patient receptivity to antidepressant medication on the cost-effectiveness of an evidence-based primary-care depression intervention. Twelve community primary-care practices were stratified and then randomized to enhanced (intervention) or usual care. Subjects included 211 patients beginning a new treatment episode for major depression. At baseline, 111 (52.6%) and 145 (68.7%) reported receptivity to antidepressant medication and counseling respectively. The intervention trained the primary-care teams to assess, educate, and monitor depressed patients. Twelve-month incremental (enhanced minus usual care) total costs and quality-adjusted life years (QALYs) were calculated. Among patients receptive to antidepressants, the mean incremental cost-effectiveness ratio was dollar 5,864 per QALY (sensitivity analyses up to dollar 14,689 per QALY). For patients not receptive to antidepressants, the mean incremental QALY score was negative (for both main and sensitivity analyses), or the intervention was at least no more effective than usual care. These findings suggest a re-thinking of the 'one size fits all' depression intervention, given that half of depressed primary-care patients may be non-receptive to antidepressant medication treatment. A brief assessment of treatment receptivity should occur early in the treatment process to identify patients most likely to benefit from primary-care quality improvement efforts for depression treatment. Patient treatment preferences are also important for the development, design, and analysis of depression interventions.

Effects of group-selection timber harvest in bottomland hardwoods on fall migrant birds

Treesearch

John C. Kilgo; Karl V. Miller; Winston P. Smith

1999-01-01

Due to projected demands for hardwood timber, development of silvicultural practices that provide for adequate regeneration in southeastern bottomland hardwoods without causing undue harm to wildlife resources is critical. Group-selection silviculture involves harvesting a small group of trees, which creates a canopy gap (usually

Tech Flex

ERIC Educational Resources Information Center

Demski, Jennifer

2012-01-01

On many college campuses, the 21st century classroom is the exception rather than the norm. Here's what usually happens: A forward-thinking administrator pushes for a pilot program to redesign a handful of classrooms. The resulting learning spaces are cutting edge and successful--in high demand among faculty and students alike. And that's as far…

Planting Cottonwoods on Bottomlands

Treesearch

Henry Bull; H. H. Muntz

1943-01-01

Eastern cottonwood (Populus deltoides virginiana) is one of the fastest-growing trees of commercial importance native to this country. The wood is in demand for a great variety of uses and usually brings good stumpage prices. Rapid growth and relatively high value make cottonwood a very desirable tree to grow in plantations.

Cost-effectiveness of a Primary Care Intervention to Treat Obesity

PubMed Central

Tsai, Adam G.; Wadden, Thomas A.; Volger, Sheri; Sarwer, David B.; Vetter, Marion; Kumanyika, Shiriki; Berkowitz, Robert I.; Diewald, Lisa; Perez, Joanna; Lavenberg, Jeffrey; Panigrahi, Eva R.; Glick, Henry A.

2013-01-01

Background Data on the cost-effectiveness of the behavioral treatment of obesity are not conclusive. The cost-effectiveness of treatment in primary care settings is particularly relevant. Methods We conducted a within-trial cost-effectiveness analysis of a primary care-based obesity intervention. Study participants were randomized to: Usual Care (quarterly visits with their primary care provider); Brief Lifestyle Counseling (Brief LC; quarterly provider visits plus monthly weight loss counseling visits; or Enhanced Brief Lifestyle Counseling (Enhanced Brief LC; all above interventions, plus choice of meal replacements or weight loss medication). A health care payer perspective was used. Intervention costs were estimated from tracking data obtained prospectively. Quality adjusted life years (QALYs) were estimated with the EuroQol-5D. We estimated cost per kilogram-year of weight loss and cost per QALY. Results Weight losses after 2 years were 1.7, 2.9, and 4.6 kg for Usual Care, Brief LC, and Enhanced Brief LC, respectively (p = 0.003 for comparison of Enhanced Brief LC vs. Usual Care). The incremental cost per kilogram-year lost was $292 for Enhanced Brief LC compared to Usual Care (95% CI $38 to $394). The incremental cost per QALY was $115,397, but the 95% CI were undefined. Comparison of short term cost per kg with published estimates of longer term cost per QALYs suggested that the intervention could be cost-effective over the long term (≥ 10 years). Conclusions A primary care intervention that included monthly counseling visits and a choice of meal replacements or weight loss medication could be a cost-effective treatment for obesity over the long term. However, additional studies are needed on the cost-effectiveness of behavioral treatment of obesity. PMID:23921780

Study on the Supply of and Demand for Teachers in Primary and Secondary Education.

ERIC Educational Resources Information Center

Organisation for Economic Cooperation and Development, Paris (France).

This international survey is the "consolidated report," bringing out problems raised and the means adopted to overcome persistent disequilibrium between the supply and demand for teachers, based on eleven "country studies" describing the situation in selected member countries (Austria, Denmark, France, Germany, Greece, Italy,…

[Therapy of traumatic anterior shoulder dislocation: current status of therapy in Germany. Are there scientifically verified therapy concepts?].

PubMed

Tingart, M; Bäthis, H; Bouillon, B; Tiling, T

2001-06-01

There are no generally accepted concepts for the treatment of traumatic anterior shoulder dislocation. The objective of this study was to ascertain the current treatment for traumatic shoulder dislocations in German hospitals and to compare this with the data reported in the literature. A total of 210 orthopedic surgery departments were asked for their treatment strategy in an anonymous country-wide survey; 103 questionnaires (49%) were returned for evaluation. Additional imaging (ultrasound, CT, MRI) beyond the routine X-rays is performed in 82% of clinics for primary shoulder dislocation (94% in recurrent dislocation). A young, athletic patient (< 30 years old) would be operated on for a primary traumatic shoulder dislocation in 73% of hospitals (98% in recurrent dislocation). In contrast, a patient of the same age, with a moderate level of sporting activity would be treated conservatively in 67% of cases (14% in recurrent dislocation). Similarly, for an active, middle-aged patient with a demanding job, 74% of responses favored conservative treatment after a primary dislocation and 6% after a recurrent dislocation. Older patients (> 65 years old) are usually treated conservatively after a primary or recurrent shoulder dislocation (99%, 69%). For a primary shoulder dislocation the most popular surgical reconstruction is a Bankart repair (75%). For recurrent shoulder dislocation several different operative techniques are seen (Bankart 29%, T-shift 26%, Putti-Platt 8%, Eden-Lange-Hybbinette 22%, Weber osteotomy 13%). Based on our literature review, we found: (1) The clinical examination of both shoulders is important to diagnose hyperlaxity; (2) Routine CT or MRI is not necessary for primary traumatic shoulder dislocations; (3) A young, athletic patient should undergo surgical reconstruction after a primary shoulder dislocation; (4) The operation of choice for primary and recurrent dislocation is the Bankart repair; (5) There is no sufficient evidence that an arthroscopic Bankart repair is as good as an open procedure; (6) There are limited indications for other operative techniques, as they are associated with a higher recurrence and arthrosis rate.

Improving health and productivity of depressed workers: a pilot randomized controlled trial of telephone cognitive behavioral therapy delivery in workplace settings.

PubMed

Bee, Penny E; Bower, Peter; Gilbody, Simon; Lovell, Karina

2010-01-01

To examine the feasibility of telephone-delivered cognitive behavioral therapy (T-CBT) in an occupational context, with reference to participant recruitment, treatment adherence, follow-up and effect. Eligible participants comprised all employees of a large communications company with authorized work absence due to mild/moderate mental health difficulties over a 10-month period. Fifty-three consenting participants were centrally randomized to 12 weeks T-CBT or usual care, with minimization on age, gender and illness severity. Primary (symptom severity) and secondary outcomes (self-rated work performance and productivity) were measured at baseline and 3-months via postal questionnaires. Intention-to-treat analysis comprised multiple regression modeling with adjustment for missing response predictors, minimization variables and baseline values. Twenty-three employees attended one or more T-CBT sessions. T-CBT was associated with medium-large effects sizes on clinical outcomes (0.63-0.77) and work productivity scores (0.75-0.88). Twenty-one patients failed to return 3-month primary outcome data. Non-respondents were more likely to be male and more severely ill. Delivery of T-CBT in an occupational context is feasible with evidence of potential effect. Larger-scale trials are warranted. These studies demand assertive outreach or telephone-based assessment strategies in order to maximize participant recruitment and follow-up. Copyright 2010 Elsevier Inc. All rights reserved.

Protocol and baseline data from The Inala Chronic Disease Management Service evaluation study: a health services intervention study for diabetes care.

PubMed

Askew, Deborah A; Jackson, Claire L; Ware, Robert S; Russell, Anthony

2010-05-24

Type 2 Diabetes Mellitus is one of the most disabling chronic conditions worldwide, resulting in significant human, social and economic costs and placing huge demands on health care systems. The Inala Chronic Disease Management Service aims to improve the efficiency and effectiveness of care for patients with type 2 diabetes who have been referred by their general practitioner to a specialist diabetes outpatient clinic. Care is provided by a multidisciplinary, integrated team consisting of an endocrinologist, diabetes nurse educators, General Practitioner Clinical Fellows (general practitioners who have undertaken focussed post-graduate training in complex diabetes care), and allied health personnel (a dietitian, podiatrist and psychologist). Using a geographical control, this evaluation study tests the impact of this model of diabetes care provided by the service on patient outcomes compared to usual care provided at the specialist diabetes outpatient clinic. Data collection at baseline, 6 and 12-months will compare the primary outcome (glycaemic control) and secondary outcomes (serum lipid profile, blood pressure, physical activity, smoking status, quality of life, diabetes self-efficacy and cost-effectiveness). This model of diabetes care combines the patient focus and holistic care valued by the primary care sector with the specialised knowledge and skills of hospital diabetes care. Our study will provide empirical evidence about the clinical effectiveness of this model of care. Australian New Zealand Clinical Trials Registry ACTRN12608000010392.

Effect of a Voucher Benefit on the Demand for Paid Personal Assistance

ERIC Educational Resources Information Center

Meng, Hongdao; Friedman, Bruce; Dick, Andrew W.; Wamsley, Brenda R.; Eggert, Gerald M.; Mukamel, Dana

2006-01-01

Purpose: We estimated the effect of a voucher benefit on the demand for personal assistance by Medicare beneficiaries aged 65 years or older who had functional disabilities. Design and Methods: We performed a secondary data analysis on 645 Medicare beneficiaries from the Medicare Primary and Consumer-Directed Care Demonstration (a randomized…

Effectiveness of a Geriatric Care Model for frail older adults in primary care: Results from a stepped wedge cluster randomized trial.

PubMed

Hoogendijk, Emiel O; van der Horst, Henriëtte E; van de Ven, Peter M; Twisk, Jos W R; Deeg, Dorly J H; Frijters, Dinnus H M; van Leeuwen, Karen M; van Campen, Jos P C M; Nijpels, Giel; Jansen, Aaltje P D; van Hout, Hein P J

2016-03-01

Primary care-based comprehensive care programs have the potential to improve outcomes in frail older adults. We evaluated the impact of the Geriatric Care Model (GCM) on the quality of life of community-dwelling frail older adults. A 24-month stepped wedge cluster randomized controlled trial was conducted between May 2010 and March 2013 in 35 primary care practices in the Netherlands, and included 1147 frail older adults. The intervention consisted of a geriatric in-home assessment by a practice nurse, followed by a tailored care plan. Reassessment occurred every six months. Nurses worked together with primary care physicians and were supervised and trained by geriatric expert teams. Complex patients were reviewed in multidisciplinary consultations. The primary outcome was quality of life (SF-12). Secondary outcomes were health-related quality of life, functional limitations, self-rated health, psychological wellbeing, social functioning and hospitalizations. Intention-to-treat analyses based on multilevel modeling showed no significant differences between the intervention group and usual care regarding SF-12 and most secondary outcomes. Only for IADL limitations we found a small intervention effect in patients who received the intervention for 18months (B=-0.25, 95%CI=-0.43 to -0.06, p=0.007), but this effect was not statistically significant after correction for multiple comparisons. The GCM did not show beneficial effects on quality of life in frail older adults in primary care, compared to usual care. This study strengthens the idea that comprehensive care programs add very little to usual primary care for this population. The Netherlands National Trial Register NTR2160. Copyright © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

An integrated and dynamic optimisation model for the multi-level emergency logistics network in anti-bioterrorism system

NASA Astrophysics Data System (ADS)

Liu, Ming; Zhao, Lindu

2012-08-01

Demand for emergency resources is usually uncertain and varies quickly in anti-bioterrorism system. Besides, emergency resources which had been allocated to the epidemic areas in the early rescue cycle will affect the demand later. In this article, an integrated and dynamic optimisation model with time-varying demand based on the epidemic diffusion rule is constructed. The heuristic algorithm coupled with the MATLAB mathematical programming solver is adopted to solve the optimisation model. In what follows, the application of the optimisation model as well as a short sensitivity analysis of the key parameters in the time-varying demand forecast model is presented. The results show that both the model and the solution algorithm are useful in practice, and both objectives of inventory level and emergency rescue cost can be controlled effectively. Thus, it can provide some guidelines for decision makers when coping with emergency rescue problem with uncertain demand, and offers an excellent reference when issues pertain to bioterrorism.

COST-UTILITY ANALYSIS OF PRIMARY PROPHYLAXIS, COMPARED WITH ON-DEMAND TREATMENT, FOR PATIENTS WITH SEVERE HEMOPHILIA TYPE A IN COLOMBIA.

PubMed

Castro Jaramillo, Héctor Eduardo; Moreno Viscaya, Mabel; Mejia, Aurelio E

2016-01-01

This article presents a cost-utility analysis from the Colombian health system perspective comparing primary prophylaxis to on-demand treatment using exogenous clotting factor VIII (FVIII) for patients with severe hemophilia type A. We developed a Markov model to estimate expected costs and outcomes (measured as quality-adjusted life-years, QALYs) for each strategy. Transition probabilities were estimated using published studies; utility weights were obtained from a sample of Colombian patients with hemophilia and costs were gathered using local data. Both deterministic and probabilistic sensitivity analysis were performed to assess the robustness of results. The additional cost per QALY gained of primary prophylaxis compared with on-demand treatment was 105,081,022 Colombian pesos (COP) (55,204 USD), and thus not considered cost-effective according to a threshold of up to three times the current Colombian gross domestic product (GDP) per-capita. When primary prophylaxis was provided throughout life using recombinant FVIII (rFVIII), which is much costlier than FVIII, the additional cost per QALY gained reached 174,159,553 COP (91,494 USD). using a decision rule of up to three times the Colombian GDP per capita, primary prophylaxis (with either FVIII or rFVIII) would not be considered as cost-effective in this country. However, a final decision on providing or preventing patients from primary prophylaxis as a gold standard of care for severe hemophilia type A should also consider broader criteria than the incremental cost-effectiveness ratio results itself. Only a price reduction of exogenous FVIII of 50 percent or more would make primary prophylaxis cost-effective in this context.

Phenotypes on demand via switchable target protein degradation in multicellular organisms

PubMed Central

Faden, Frederik; Ramezani, Thomas; Mielke, Stefan; Almudi, Isabel; Nairz, Knud; Froehlich, Marceli S.; Höckendorff, Jörg; Brandt, Wolfgang; Hoehenwarter, Wolfgang; Dohmen, R. Jürgen; Schnittger, Arp; Dissmeyer, Nico

2016-01-01

Phenotypes on-demand generated by controlling activation and accumulation of proteins of interest are invaluable tools to analyse and engineer biological processes. While temperature-sensitive alleles are frequently used as conditional mutants in microorganisms, they are usually difficult to identify in multicellular species. Here we present a versatile and transferable, genetically stable system based on a low-temperature-controlled N-terminal degradation signal (lt-degron) that allows reversible and switch-like tuning of protein levels under physiological conditions in vivo. Thereby, developmental effects can be triggered and phenotypes on demand generated. The lt-degron was established to produce conditional and cell-type-specific phenotypes and is generally applicable in a wide range of organisms, from eukaryotic microorganisms to plants and poikilothermic animals. We have successfully applied this system to control the abundance and function of transcription factors and different enzymes by tunable protein accumulation. PMID:27447739

The construction of a decision tool to analyse local demand and local supply for GP care using a synthetic estimation model

PubMed Central

2013-01-01

Background This study addresses the growing academic and policy interest in the appropriate provision of local healthcare services to the healthcare needs of local populations to increase health status and decrease healthcare costs. However, for most local areas information on the demand for primary care and supply is missing. The research goal is to examine the construction of a decision tool which enables healthcare planners to analyse local supply and demand in order to arrive at a better match. Methods National sample-based medical record data of general practitioners (GPs) were used to predict the local demand for GP care based on local populations using a synthetic estimation technique. Next, the surplus or deficit in local GP supply were calculated using the national GP registry. Subsequently, a dynamic internet tool was built to present demand, supply and the confrontation between supply and demand regarding GP care for local areas and their surroundings in the Netherlands. Results Regression analysis showed a significant relationship between sociodemographic predictors of postcode areas and GP consultation time (F [14, 269,467] = 2,852.24; P <0.001). The statistical model could estimate GP consultation time for every postcode area with >1,000 inhabitants in the Netherlands covering 97% of the total population. Confronting these estimated demand figures with the actual GP supply resulted in the average GP workload and the number of full-time equivalent (FTE) GP too much/too few for local areas to cover the demand for GP care. An estimated shortage of one FTE GP or more was prevalent in about 19% of the postcode areas with >1,000 inhabitants if the surrounding postcode areas were taken into consideration. Underserved areas were mainly found in rural regions. Conclusions The constructed decision tool is freely accessible on the Internet and can be used as a starting point in the discussion on primary care service provision in local communities and it can make a considerable contribution to a primary care system which provides care when and where people need it. PMID:24161015

The global potential of bioenergy on abandoned agriculture lands.

PubMed

Campbell, J Elliott; Lobell, David B; Genova, Robert C; Field, Christopher B

2008-08-01

Converting forest lands into bioenergy agriculture could accelerate climate change by emitting carbon stored in forests, while converting food agriculture lands into bioenergy agriculture could threaten food security. Both problems are potentially avoided by using abandoned agriculture lands for bioenergy agriculture. Here we show the global potential for bioenergy on abandoned agriculture lands to be less than 8% of current primary energy demand, based on historical land use data, satellite-derived land cover data, and global ecosystem modeling. The estimated global area of abandoned agriculture is 385-472 million hectares, or 66-110% of the areas reported in previous preliminary assessments. The area-weighted mean production of above-ground biomass is 4.3 tons ha(-1) y(-1), in contrast to estimates of up to 10 tons ha(-1) y(-1) in previous assessments. The energy content of potential biomass grown on 100% of abandoned agriculture lands is less than 10% of primary energy demand for most nations in North America, Europe, and Asia, but it represents many times the energy demand in some African nations where grasslands are relatively productive and current energy demand is low.

Scientific Challenges in Sustainable Energy Technology

NASA Astrophysics Data System (ADS)

Lewis, Nathan

2006-03-01

This presentation will describe and evaluate the challenges, both technical, political, and economic, involved with widespread adoption of renewable energy technologies. First, we estimate the available fossil fuel resources and reserves based on data from the World Energy Assessment and World Energy Council. In conjunction with the current and projected global primary power production rates, we then estimate the remaining years of supply of oil, gas, and coal for use in primary power production. We then compare the price per unit of energy of these sources to those of renewable energy technologies (wind, solar thermal, solar electric, biomass, hydroelectric, and geothermal) to evaluate the degree to which supply/demand forces stimulate a transition to renewable energy technologies in the next 20-50 years. Secondly, we evaluate the greenhouse gas buildup limitations on carbon-based power consumption as an unpriced externality to fossil-fuel consumption, considering global population growth, increased global gross domestic product, and increased energy efficiency per unit of globally averaged GDP, as produced by the Intergovernmental Panel on Climate Change (IPCC). A greenhouse gas constraint on total carbon emissions, in conjunction with global population growth, is projected to drive the demand for carbon-free power well beyond that produced by conventional supply/demand pricing tradeoffs, at potentially daunting levels relative to current renewable energy demand levels. Thirdly, we evaluate the level and timescale of R&D investment that is needed to produce the required quantity of carbon-free power by the 2050 timeframe, to support the expected global energy demand for carbon-free power. Fourth, we evaluate the energy potential of various renewable energy resources to ascertain which resources are adequately available globally to support the projected global carbon-free energy demand requirements. Fifth, we evaluate the challenges to the chemical sciences to enable the cost-effective production of carbon-free power on the needed scale by the 2050 timeframe. Finally, we discuss the effects of a change in primary power technology on the energy supply infrastructure and discuss the impact of such a change on the modes of energy consumption by the energy consumer and additional demands on the chemical sciences to support such a transition in energy supply.

Survival Sales Forecasting.

ERIC Educational Resources Information Center

Paradiso, James; Stair, Kenneth

Intended to provide insight into the dynamics of demand analysis, this paper presents an eight-step method for forecasting sales. Focusing on sales levels that must be achieved to enjoy targeted profits in favor of the usual approach of emphasizing how much will be sold within a given period, a sample situation is provided to illustrate this…

7 CFR 1710.115 - Final maturity.

Code of Federal Regulations, 2012 CFR

2012-01-01

... implementation of programs for demand side management and energy resource conservation and on and off grid renewable energy sources not owned by the borrower will be determined by RUS. Due to the uncertainty of... operation of a new system are a separate class of loans and usually have a final maturity of less than 10...

7 CFR 1710.115 - Final maturity.

Code of Federal Regulations, 2013 CFR

2013-01-01

... implementation of programs for demand side management and energy resource conservation and on and off grid renewable energy sources not owned by the borrower will be determined by RUS. Due to the uncertainty of... operation of a new system are a separate class of loans and usually have a final maturity of less than 10...

7 CFR 1710.115 - Final maturity.

Code of Federal Regulations, 2011 CFR

2011-01-01

... implementation of programs for demand side management and energy resource conservation and on and off grid renewable energy sources not owned by the borrower will be determined by RUS. Due to the uncertainty of... operation of a new system are a separate class of loans and usually have a final maturity of less than 10...

A Simultaneous Equation Demand Model for Block Rates

NASA Astrophysics Data System (ADS)

Agthe, Donald E.; Billings, R. Bruce; Dobra, John L.; Raffiee, Kambiz

1986-01-01

This paper examines the problem of simultaneous-equations bias in estimation of the water demand function under an increasing block rate structure. The Hausman specification test is used to detect the presence of simultaneous-equations bias arising from correlation of the price measures with the regression error term in the results of a previously published study of water demand in Tucson, Arizona. An alternative simultaneous equation model is proposed for estimating the elasticity of demand in the presence of block rate pricing structures and availability of service charges. This model is used to reestimate the price and rate premium elasticities of demand in Tucson, Arizona for both the usual long-run static model and for a simple short-run demand model. The results from these simultaneous equation models are consistent with a priori expectations and are unbiased.

Primary care physician shortages could be eliminated through use of teams, nonphysicians, and electronic communication.

PubMed

Green, Linda V; Savin, Sergei; Lu, Yina

2013-01-01

Most existing estimates of the shortage of primary care physicians are based on simple ratios, such as one physician for every 2,500 patients. These estimates do not consider the impact of such ratios on patients' ability to get timely access to care. They also do not quantify the impact of changing patient demographics on the demand side and alternative methods of delivering care on the supply side. We used simulation methods to provide estimates of the number of primary care physicians needed, based on a comprehensive analysis considering access, demographics, and changing practice patterns. We show that the implementation of some increasingly popular operational changes in the ways clinicians deliver care-including the use of teams or "pods," better information technology and sharing of data, and the use of nonphysicians-have the potential to offset completely the increase in demand for physician services while improving access to care, thereby averting a primary care physician shortage.

Referral interventions from primary to specialist care: a systematic review of international evidence

PubMed Central

Blank, Lindsay; Baxter, Susan; Woods, Helen Buckley; Goyder, Elizabeth; Lee, Andrew; Payne, Nick; Rimmer, Melanie

2014-01-01

Background Demand management defines any method used to monitor, direct, or regulate patient referrals. Strategies have been developed to manage the referral of patients to secondary care, with interventions that target primary care, specialist services, or infrastructure. Aim To review the international evidence on interventions to manage referral from primary to specialist care. Design and setting Systematic review. Method Iterative, systematic searches of published and unpublished sources public health, health management, management, and grey literature databases from health care and other industries were undertaken to identify recent, relevant studies. A narrative synthesis of the data was completed to structure the evidence into groups of similar interventions. Results The searches generated 8327 unique results, of which 140 studies were included. Interventions were grouped into four intervention categories: GP education (n = 50); process change (n = 49); system change (n = 38); and patient-focused (n = 3). It is clear that there is no ‘magic bullet’ to managing demand for secondary care services: although some groups of interventions may have greater potential for development, given the existing evidence that they can be effective in specific contexts. Conclusions To tackle demand management of primary care services, the focus cannot be on primary care alone; a whole-systems approach is needed because the introduction of interventions in primary care is often just the starting point of the referral process. In addition, more research is needed to develop and evaluate interventions that acknowledge the role of the patient in the referral decision. PMID:25452541

Hydrogen use projections and supply options

NASA Technical Reports Server (NTRS)

Manvi, R.; Fujita, T.

1976-01-01

Two projections of future hydrogen demand, based on the Ford technical fix and the Westinghouse nuclear electric economy energy supply and demand scenarios, are analyzed. It is suggested that hydrogen use will increase during the remainder of this century by at least a factor of five, and perhaps by a factor of twenty. Primary energy sources for producing hydrogen are discussed in terms of the transition from low to high demand for hydrogen.

Metabolic Profile of Wound-Induced Changes in Primary Carbon Metabolism in Sugarbeet Root

USDA-ARS?s Scientific Manuscript database

Injury to plant products induces respiration rate and increases the demand for respiratory substrates. Alterations in primary carbon metabolism are likely to support the elevated demand for respiratory substrates, although the nature of these alterations is unknown. To gain insight into the metabo...

Estimating the costs of induced abortion in Uganda: A model-based analysis

PubMed Central

2011-01-01

Background The demand for induced abortions in Uganda is high despite legal and moral proscriptions. Abortion seekers usually go to illegal, hidden clinics where procedures are performed in unhygienic environments by under-trained practitioners. These abortions, which are usually unsafe, lead to a high rate of severe complications and use of substantial, scarce healthcare resources. This study was performed to estimate the costs associated with induced abortions in Uganda. Methods A decision tree was developed to represent the consequences of induced abortion and estimate the costs of an average case. Data were obtained from a primary chart abstraction study, an on-going prospective study, and the published literature. Societal costs, direct medical costs, direct non-medical costs, indirect (productivity) costs, costs to patients, and costs to the government were estimated. Monte Carlo simulation was used to account for uncertainty. Results The average societal cost per induced abortion (95% credibility range) was $177 ($140-$223). This is equivalent to $64 million in annual national costs. Of this, the average direct medical cost was $65 ($49-86) and the average direct non-medical cost was $19 ($16-$23). The average indirect cost was $92 ($57-$139). Patients incurred $62 ($46-$83) on average while government incurred $14 ($10-$20) on average. Conclusion Induced abortions are associated with substantial costs in Uganda and patients incur the bulk of the healthcare costs. This reinforces the case made by other researchers--that efforts by the government to reduce unsafe abortions by increasing contraceptive coverage or providing safe, legal abortions are critical. PMID:22145859

Estimating the costs of induced abortion in Uganda: a model-based analysis.

PubMed

Babigumira, Joseph B; Stergachis, Andy; Veenstra, David L; Gardner, Jacqueline S; Ngonzi, Joseph; Mukasa-Kivunike, Peter; Garrison, Louis P

2011-12-06

The demand for induced abortions in Uganda is high despite legal and moral proscriptions. Abortion seekers usually go to illegal, hidden clinics where procedures are performed in unhygienic environments by under-trained practitioners. These abortions, which are usually unsafe, lead to a high rate of severe complications and use of substantial, scarce healthcare resources. This study was performed to estimate the costs associated with induced abortions in Uganda. A decision tree was developed to represent the consequences of induced abortion and estimate the costs of an average case. Data were obtained from a primary chart abstraction study, an on-going prospective study, and the published literature. Societal costs, direct medical costs, direct non-medical costs, indirect (productivity) costs, costs to patients, and costs to the government were estimated. Monte Carlo simulation was used to account for uncertainty. The average societal cost per induced abortion (95% credibility range) was $177 ($140-$223). This is equivalent to $64 million in annual national costs. Of this, the average direct medical cost was $65 ($49-86) and the average direct non-medical cost was $19 ($16-$23). The average indirect cost was $92 ($57-$139). Patients incurred $62 ($46-$83) on average while government incurred $14 ($10-$20) on average. Induced abortions are associated with substantial costs in Uganda and patients incur the bulk of the healthcare costs. This reinforces the case made by other researchers--that efforts by the government to reduce unsafe abortions by increasing contraceptive coverage or providing safe, legal abortions are critical.

Free Primary Education Policy: Coping Strategies in Public Primary Schools in Kakamega South District, Kakamega County, Kenya

ERIC Educational Resources Information Center

Mulinya, Lidoro Charles; Orodho, John Aluko

2015-01-01

This study examined the challenges of implementing free primary education and copping strategies in public primary schools in Kakamega South District, Kakamega County, Kenya. The study was premised on the demand and supply theory. A descriptive survey research design was adopted. The sample comprised 23 headteachers, 92 teachers and one Ministry…

The global anthropogenic gallium system: determinants of demand, supply and efficiency improvements.

PubMed

Løvik, Amund N; Restrepo, Eliette; Müller, Daniel B

2015-05-05

Gallium has been labeled as a critical metal due to rapidly growing consumption, importance for low-carbon technologies such as solid state lighting and photovoltaics, and being produced only as a byproduct of other metals (mainly aluminum). The global system of primary production, manufacturing, use and recycling has not yet been described or quantified in the literature. This prevents predictions of future demand, supply and possibilities for efficiency improvements on a system level. We present a description of the global anthropogenic gallium system and quantify the system using a combination of statistical data and technical parameters. We estimated that gallium was produced from 8 to 21% of alumina plants in 2011. The most important applications of gallium are NdFeB permanent magnets, integrated circuits and GaAs/GaP-based light-emitting diodes, demanding 22-37%, 16-27%, and 11-21% of primary metal production, respectively. GaN-based light-emitting diodes and photovoltaics are less important, both with 2-6%. We estimated that 120-170 tons, corresponding to 40-60% of primary production, ended up in production wastes that were either disposed of or stored. While demand for gallium is expected to rise in the future, our results indicated that it is possible to increase primary production substantially with conventional technology, as well as improve the system-wide material efficiency.

Role of primary sedimentation on plant-wide energy recovery and carbon footprint.

PubMed

Gori, Riccardo; Giaccherini, Francesca; Jiang, Lu-Man; Sobhani, Reza; Rosso, Diego

2013-01-01

The goal of this paper is to show the effect of primary sedimentation on the chemical oxygen demand (COD) and solids fractionation and consequently on the carbonaceous and energy footprints of wastewater treatment processes. Using a simple rational procedure for COD and solids fraction quantification, we quantify the effects of varying fractions on CO2 and CO2-equivalent mass flows, process energy demand and energy recovery. Then we analysed two treatment plants with similar biological nutrient removal processes in two different climatic regions and quantified the net benefit of gravity separation before biological treatment. In the cases analysed, primary settling increases the solid fraction of COD that is processed in anaerobic digestion, with an associated increase in biogas production and energy recovery, and a reduction in overall emissions of CO2 and CO2-equivalent from power importation.

Can vouchers make a difference to the use of private primary care services by older people? Experience from the healthcare reform programme in Hong Kong.

PubMed

Yam, Carrie H K; Liu, Su; Huang, Olivia H Y; Yeoh, E K; Griffiths, Sian M

2011-10-07

As part of its ongoing healthcare reform, the Hong Kong Government introduced a voucher scheme, intended for encouraging older patients to use primary healthcare services in the private sector, thereby, reducing burden on the overwhelmed public sector. The voucher program is also considered one of the strategies to further develop the public private partnership in healthcare, a policy direction of high political priority as indicated in the Chief Executive Policy Address in 2008-09. This study assessed whether the voucher scheme, as implemented so far, has reached its intended goals, and how it might be further improved in the context of public-private partnership. This was a cross-sectional study using structured questionnaires by face-to-face interviews with older people aged 70 or above in Hong Kong, the target group of the demand-side voucher program. 71.2% of 1,026 older people were aware of the new voucher scheme but only 35.0% had ever used it. The majority of the older people used the vouchers for acute curative services in the private sector (82.4%) and spent less on preventive services. Despite the provision of vouchers valued US$30 per year as an incentive to encourage the use of private primary care services, after 12-months of implementation, 66.2% of all respondents agreed with the statement that "the voucher scheme does not change their health seeking behaviours on seeing public or private healthcare professionals". The most common reasons for no change in their behaviours included "I am used to seeing doctors in the public system" and "The amount of the subsidy is too low". Those who usually used a mix of public and private doctors and those with better self-reported health condition compared to last year were more likely to perceive a change in their own health seeking behaviours. Our study showed that despite a reasonably high awareness of the voucher scheme, its usage was low. The voucher alone was not enough to realize the government's policy of greater use of the private primary care services. Greater publicity and more variety of media promotion would increase awareness but the effectiveness of vouchers in changing older people's behaviour needs to be revisited. Designating vouchers for use of preventive services with evidence-based practice could be considered. In addition to the demand-side subsidies, improving transparency and comparability of private services against the public sector might be necessary.

Can vouchers make a difference to the use of private primary care services by older people? Experience from the healthcare reform programme in Hong Kong

PubMed Central

2011-01-01

Background As part of its ongoing healthcare reform, the Hong Kong Government introduced a voucher scheme, intended for encouraging older patients to use primary healthcare services in the private sector, thereby, reducing burden on the overwhelmed public sector. The voucher program is also considered one of the strategies to further develop the public private partnership in healthcare, a policy direction of high political priority as indicated in the Chief Executive Policy Address in 2008-09. This study assessed whether the voucher scheme, as implemented so far, has reached its intended goals, and how it might be further improved in the context of public-private partnership. Methods This was a cross-sectional study using structured questionnaires by face-to-face interviews with older people aged 70 or above in Hong Kong, the target group of the demand-side voucher program. Results 71.2% of 1,026 older people were aware of the new voucher scheme but only 35.0% had ever used it. The majority of the older people used the vouchers for acute curative services in the private sector (82.4%) and spent less on preventive services. Despite the provision of vouchers valued US$30 per year as an incentive to encourage the use of private primary care services, after 12-months of implementation, 66.2% of all respondents agreed with the statement that "the voucher scheme does not change their health seeking behaviours on seeing public or private healthcare professionals". The most common reasons for no change in their behaviours included "I am used to seeing doctors in the public system" and "The amount of the subsidy is too low". Those who usually used a mix of public and private doctors and those with better self-reported health condition compared to last year were more likely to perceive a change in their own health seeking behaviours. Conclusions Our study showed that despite a reasonably high awareness of the voucher scheme, its usage was low. The voucher alone was not enough to realize the government's policy of greater use of the private primary care services. Greater publicity and more variety of media promotion would increase awareness but the effectiveness of vouchers in changing older people's behaviour needs to be revisited. Designating vouchers for use of preventive services with evidence-based practice could be considered. In addition to the demand-side subsidies, improving transparency and comparability of private services against the public sector might be necessary. PMID:21978140

Primary care physician assistant and advance practice nurses roles: Patient healthcare utilization, unmet need, and satisfaction.

PubMed

Everett, Christine M; Morgan, Perri; Jackson, George L

2016-12-01

Team-based care involving physician assistants (PAs) and advance practice nurses (APNs) is one strategy for improving access and quality of care. PA/APNs perform a variety of roles on primary care teams. However, limited research describes the relationship between PA/APN role and patient outcomes. We examined multiple outcomes associated with primary care PA/APN roles. In this cross-sectional survey analysis, we studied adult respondents to the 2010 Health Tracking Household Survey. Outcomes included primary care and emergency department visits, hospitalizations, unmet need, and satisfaction. PA/APN role was categorized as physician only (no PA/APN visits; reference), usual provider (PA/APN provide majority of primary care visits) or supplemental provider (physician as usual provider, PA/APN provide a subset of visits). Multivariable logistic and multinomial logistic regressions were performed. Compared to people with physician only care, patients with PA/APNs as usual providers [5-9 visits RRR=2.4 (CI 1.8-3.4), 10+ visits RRR=3.0 (CI 2.0-4.5): reference 2-4 visits] and supplemental providers had increased risk of having 5 or more primary care visits [5-9 visits RRR=1.3 (CI 1.0-1.6)]. Patients reporting PA/APN as supplemental providers had increased risk of emergency department utilization [2+ visits: RRR 1.8 (CI 1.3, 2.5)], and lower satisfaction [very dissatisfied: RRR 1.8 (CI 1.03-3.0)]. No differences were seen for hospitalizations or unmet need. Healthcare utilization patterns and satisfaction varied between adults with PA/APN in different roles, but reported unmet need did not. These findings suggest a wide range of outcomes should be considered when identifying the best PA/APN role on primary care teams. Copyright © 2016 Elsevier Inc. All rights reserved.

Comparison of the caries-protective effect of fluoride varnish with treatment as usual in nursery school attendees receiving preventive oral health support through the Childsmile oral health improvement programme - the Protecting Teeth@3 Study: a randomised controlled trial.

PubMed

Wright, William; Turner, Stephen; Anopa, Yulia; McIntosh, Emma; Wu, Olivia; Conway, David I; Macpherson, Lorna M D; McMahon, Alex D

2015-12-18

The Scottish Government set out its policy on addressing the poor oral health of Scottish children in 2005. This led to the establishment of Childsmile, a national programme designed to improve the oral health of children in Scotland. One element of the programme promotes daily tooth brushing in all nurseries in Scotland (Childsmile Core). A second targeted component (Childsmile Nursery) offers twice-yearly application of fluoride varnish to children attending nurseries in deprived areas. Studies suggest that fluoride varnish application can reduce caries in both adult and child populations. This trial aims to explore the effectiveness and cost-effectiveness of additional preventive value fluoride varnish application compared to Childsmile Core. The Protecting Teeth@3 Study is an ongoing 2 year parallel group randomised treatment as usual controlled trial. Three-year-old children attending the ante pre-school year are randomised (1:1) to the intervention arm (fluoride varnish & treatment as usual) or the control arm (treatment as usual). Children in the intervention arm will have Duraphat® fluoride varnish painted on the primary tooth surfaces and will continue to receive treatment as usual: the core Childsmile Nursery intervention. Children in the treatment as usual arm will receive the same series of contacts, without the application of varnish and will also continue with the Childsmile Core intervention. Interventions are undertaken by Childsmile trained extended duty dental nurses at six-monthly intervals. Participants receive a baseline dental inspection in nursery and an endpoint inspection in Primary 1 at the age of 5 years old. We will use primary and secondary outcome measures to compare the effectiveness of Duraphat® fluoride varnish plus treatment as usual with treatment as usual only in preventing any further dental decay. We will also undertake a full economic evaluation of the trial. This study is registered at ClinicalTrials.gov. Number: NCT01674933 (24 August 2012).

Primary lymphocytic lymphoma of lacrimal gland.

PubMed

Romero-Caballero, M D; Lozano-García, I; Gómez-Molina, C; Gil-Liñán, A I; Arcas, I

2017-02-01

We report a case of primary small-cell lymphocytic lacrimal gland lymphoma in a male diagnosed with primary antiphospholipid syndrome. These rare lymphomas are usually presented in the clinic as disseminations secondary to chronic lymphocytic leukaemia, and the primary site is rare in the orbit. Non-Hodgkin lymphomas are a heterogeneous group of tumours. Although treatment in the IE stage is usually radiotherapy, due to its association with antiphospholipid syndrome, systemic treatment with rituximab was administered. Copyright © 2016 Sociedad Española de Oftalmología. Publicado por Elsevier España, S.L.U. All rights reserved.

Residential demand for energy. Volume 1: Residential energy demand in the US

NASA Astrophysics Data System (ADS)

Taylor, L. D.; Blattenberger, G. R.; Rennhack, R. K.

1982-04-01

Updated and improved versions of the residential energy demand models that are currently used in EPRI's Demand 80/81 Model are presented. The primary objective of the study is the development and estimation of econometric demand models that take into account in a theoretically appropriate way the problems caused by decreasing-block pricing in the sale of electricity and natural gas. An ancillary objective is to take into account the impact on electricity, natural gas, and fuel oil demands of differences and changes in the availability of natural gas. Econometric models of residential demand are estimated for all three fuel tyes using time series data by state. Price and income elasticities for a number of alternative models are presented.

The water-food-energy nexus in Pakistan: a biophysical and socio-economic challenge

NASA Astrophysics Data System (ADS)

Grigg, Nicola; Foran, Tira; Darbas, Toni; Kirby, Mac; Colloff, Matthew J.; Ahmad, Mobin-ud-Din; Podger, Geoff

2018-02-01

We draw on previous work examining historical trends, likely future water use and food availability in Pakistan and extend the analysis to consider interactions with hydropower generation and the energy demand in food production due to pumping of groundwater for irrigation. Business-as-usual scenarios suggest growing demands for groundwater and energy use for food production as population grows rapidly. However, groundwater use is already unsustainable in many areas, and energy supply is failing to keep up with demand. Quantifying material linkages between water, food and energy provides a means to explore biophysical constraints. Characterising institutional constraints is equally important, as they can be significant barriers to effective stewardship of water, energy and food resources. The experience in Pakistan reinforces this finding, and we discuss the implications for hydrologists.

Looking at practice: revealing the knowledge demands of teaching data handling in the primary classroom

NASA Astrophysics Data System (ADS)

Leavy, Aisling

2015-09-01

In the evolving field of mathematics education, there is the need to maintain the relationship between what is presented in college level preparation courses and the skills required to teach mathematics in classrooms. This research examines the knowledge demands placed on 73 pre-service primary teachers as they use lesson study to plan and teach data handling in primary classrooms. Pre-service teachers are observed as they plan, teach and re-teach data lessons in classrooms. Problems of practice are identified and categorized using the Ball, Thames and Phelps (2008) subdomains of common content knowledge (CCK), specialized content knowledge (SCK), knowledge of content and students (KCS) and knowledge of content and teaching (KCT). The results provide insights into the specific knowledge demands placed on early career teachers when teaching data and statistics and identifies foci area that can be addressed in teacher preparation programs. The results illustrate that development of understandings in one knowledge subdomain can motivate and impact learning in another subdomain. These interrelationships were found to exist both within and between the domains of content and pedagogical content knowledge.

The new decision-making centres. An interview with L.C. Jain.

PubMed

Choudhury, A R

1993-08-01

The interview with the Indian economist and Indian Planning Commission member was directed to issues about nongovernmental organization's (NGOs) ability to function, women's representation on Panchayats, decentralized planning, social changes in Panchayati Raj Institutions, electoral issues, and local politics. With the establishment of Panchayats in every village, there will be greater demands on NGOs for resources for social and economic advancement and for creation of opportunities. About 1 million women will get elected to Panchayats and demand that government fulfill their needs. The disadvantaged who will be elected will demand development that serve the needs of the disadvantaged. There were four or five issues in decentralization: legal changes creating decentralization, dismantling of the centralized system and strategies, distribution of funds to Panchayats and development of private resources, and availability of money for hiring technical consultants by Panchayats. A hopeful sign was evidenced in the new leadership that demanded the effective functioning of primary schools and primary health centers. The bureaucracy has been oppressive, and villagers were eager to begin making decisions for themselves. Political parties at the local level were better able to get along because people demanded very practical results; gesturing about political postures became irrelevant.

A novel approach to quality improvement in a safety-net practice: concurrent peer review visits.

PubMed

Fiscella, Kevin; Volpe, Ellen; Winters, Paul; Brown, Melissa; Idris, Amna; Harren, Tricia

2010-12-01

Concurrent peer review visits are structured office visits conducted by clinician peers of the primary care clinician that are specifically designed to reduce competing demands, clinical inertia, and bias. We assessed whether a single concurrent peer review visit reduced clinical inertia and improved control of hypertension, hyperlipidemia, and diabetes control among underserved patients. We conducted a randomized encouragement trial to evaluate concurrent peer review visits with a community health center. Seven hundred twenty-seven patients with hypertension, hyperlipidemia, and/or diabetes who were not at goal for systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), and/or glycated hemoglobin (A1c) were randomly assigned to an invitation to participate in a concurrent peer review visit or to usual care. We compared change in these measures using mixed models and rates of therapeutic intensification during concurrent peer review visits with control visits. One hundred seventy-one patients completed a concurrent peer review visit. SBP improved significantly (p < .01) more among those completing concurrent peer review visits than among those who failed to respond to a concurrent peer review invitation or those randomized to usual care. There were no differences seen for changes in LDL-C or A1c. Concurrent peer review visits were associated with statistically significant greater clinician intensification of blood pressure (p < .001), lipid (p < .001), and diabetes (p < .005) treatment than either for control visits for patients in either the nonresponse group or usual care group. Concurrent peer review visits represent a promising strategy for improving blood pressure control and improving therapeutic intensification in community health centers.

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

Valin, Hugo; Sands, Ronald; van der Mensbrugghe, Dominique

Understanding the capacity of agricultural systems to feed the world population under climate change requires a good prospective vision on the future development of food demand. This paper reviews modeling approaches from ten global economic models participating to the AgMIP project, in particular the demand function chosen and the set of parameters used. We compare food demand projections at the horizon 2050 for various regions and agricultural products under harmonized scenarios. Depending on models, we find for a business as usual scenario (SSP2) an increase in food demand of 59-98% by 2050, slightly higher than FAO projection (54%). The prospectivemore » for animal calories is particularly uncertain with a range of 61-144%, whereas FAO anticipates an increase by 76%. The projections reveal more sensitive to socio-economic assumptions than to climate change conditions or bioenergy development. When considering a higher population lower economic growth world (SSP3), consumption per capita drops by 9% for crops and 18% for livestock. Various assumptions on climate change in this exercise do not lead to world calorie losses greater than 6%. Divergences across models are however notable, due to differences in demand system, income elasticities specification, and response to price change in the baseline.« less

Managing U.S. climate risk through mitigation: Insights from the American Climate Prospectus

NASA Astrophysics Data System (ADS)

Kopp, R. E., III; Hsiang, S. M.; Houser, T.; Larsen, K.; Rasmussen, D. M., Jr.; Jina, A.; Rising, J.; Delgado, M.; Mohan, S.; Muir-Wood, R.; Wilson, P. S.

2014-12-01

The American Climate Prospectus (ACP), the technical analysis underlying the Risky Business project, quantitatively assessed the economic risks posed to the United States by six categories of climate change impacts: crop yield, energy demand, coastal storm damage, criminal activity, labor productivity, and mortality [1]. At a national level, measured by impact on gross domestic product, increased mortality and decreased labor productivity pose the large risks, followed by increased energy demand and coastal damages. Changes in crop yield and crime have smaller impacts. The ACP was not intended to conduct a benefit-cost analysis of climate change mitigation. It assessed the economic consequences of future impacts on an economy with a structure equivalent to that of the current economy, not accounting for socio-economic development and adaptation, and did not assess the cost of mitigation. One of its primary goals was to inform adaptation decisions that are conventionally considered 'endogenous' in economic analyses of climate change. Nonetheless, its results provide insight into the potential of mitigation to manage climate risk. Differences between RCP 8.5 (moderately-high business-as-usual emissions), RCP 4.5 (moderate mitigation) and RCP 2.6 (extremely strong mitigation) are not apparent until mid-century and become significant only late in the century. For all impacts except coastal damages, mitigation significantly reduces uncertainty in late-century impact estimates. Nationally, mitigation significantly and monotonically reduces median projected labor productivity losses and violent crime. Switching from RCP 8.5 to RCP 4.5 also significantly reduces median projections of mortality and energy demand, but the domestic value to the U.S. of further mitigation to RCP 2.6 is less clear. The marginal benefits decline in part because some regions of the country (especially the Northwest) may experience increased crop yields, reduced mortality, and reduced energy demand under all RCPs. Because of the slow response time of sea level to change in emissions, the coastal risk reduction in the current century from mitigation is least clear. References: [1] T. Houser et al. (2014), American Climate Prospectus, www.climateprospectus.org.

Forecasting Brassica rapa: Merging climate models with genotype specific process models for evaluation whole species response to climate change.

NASA Astrophysics Data System (ADS)

Pleban, J. R.; Mackay, D. S.; Ewers, B. E.; Weinig, C.; Guadagno, C. L.

2016-12-01

Human society has modified agriculture management practices and utilized a variety of breeding approaches to adapt to changing environments. Presently a dual pronged challenge has emerged as environmental change is occurring more rapidly while the demand of population growth on food supply is rising. Knowledge of how current agricultural practices will respond to these challenges can be informed through crafted prognostic modeling approaches. Amongst the uncertainties associated with forecasting agricultural production in a changing environment is evaluation of the responses across the existing genotypic diversity of crop species. Mechanistic models of plant productivity provide a means of genotype level parameterization allowing for a prognostic evaluation of varietal performance under changing climate. Brassica rapa represents an excellent species for this type of investigation because of its wide cultivation as well as large morphological and physiological diversity. We incorporated genotypic parameterization of B. rapa genotypes based on unique CO2 assimilation strategies, vulnerabilities to cavitation, and root to leaf area relationships into the TREES model. Three climate drivers, following the "business-as-usual" greenhouse gas emissions scenario (RCP 8.5) from Coupled Model Intercomparison Project, Phase 5 (CMIP5) were considered: temperature (T) along with associated changes in vapor pressure deficit (VPD), increasing CO2, as well as alternatives in irrigation regime across a temporal scale of present day to 2100. Genotypic responses to these drivers were evaluated using net primary productivity (NPP) and percent loss hydraulic conductance (PLC) as a measure of tolerance for a particular watering regime. Genotypic responses to T were witnessed as water demand driven by increases in VPD at 2050 and 2100 drove some genotypes to greater PLC and in a subset of these saw periodic decreases in NPP during a growing season. Genotypes able to withstand the greater water demand showed lower NPP yields relative to hydraulically aggressive genotypes but saw limited PLC. Expansion of this analysis to large recombinant inbred populations may inform breeders in identification of trait combinations needed to meet the coupled challenge of rapid environmental change and increase food demand.

Human Appropriation of Net Primary Production - Can Earth Keep Up?

NASA Technical Reports Server (NTRS)

Imhoff, Marc L.

2006-01-01

The amount of Earth's vegetation or net primary production required to support human activities is powerful measure of aggregate human impacts on the biosphere. Biophysical models applied to consumption statistics were used to estimate the annual amount of net primary production in the form of elemental carbon required for food, fibre, and fuel-wood by the global population. The calculations were then compared to satellite-based estimates of Earth's average net primary production to produce a geographically explicit balance sheet of net primary production "supply" and "demand". Humans consume 20% of Earth's net primary production (11.5 petagrams carbon) annually and this percentage varies regionally from 6% (South America) to over 70% (Europe and Asia), and locally from near 0% (central Australia) to over 30,000% (New York City, USA). The uneven footprint of human consumption and related environmental impacts, indicate the degree to which human populations are vulnerable to climate change and suggest policy options for slowing future growth of NPP demand.

Adaptation of Educational Text to an Open Interactive Learning System: A Case Study for ReTuDiS

ERIC Educational Resources Information Center

Samarakou, M.; Fylladitakis, E. D.; Tsaganou, G.; Gelegenis, J.; Karolidis, D.; Prentakis, P.

2013-01-01

Theoretical education is mainly based on university text-books, which usually include texts not structured according to any theory of text comprehension. Structuring a text is a demanding process. Text should be organized and structured in order to include descriptions on micro and macro-level representation of the knowledge domain. Since this is…

Preliminary examination of metabolic syndrome response to motivational interviewing for weight loss as compared to an attentional control and usual care in primary care for individuals with and without binge-eating disorder.

PubMed

Barnes, Rachel D; Barber, Jessica A

2017-08-01

Motivational interviewing (MI) treatment for weight loss is being studied in primary care. The effect of such interventions on metabolic syndrome or binge eating disorder (BED), both highly related to excess weight, has not been examined in primary care. This study conducted secondary analyses from a randomized controlled trial to test the impact of MI for weight loss in primary care on metabolic syndrome. 74 adult participants with overweight/obesity recruited through primary care were randomized to 12weeks of either MI, an attentional control, or usual care. Participants completed measurements for metabolic syndrome at pre- and post-treatment. There were no statistically significant differences in metabolic syndrome rates at pre-, X 2 (2)=0.16, p=0.921, or post-, X 2 (2)=0.852, p=0.653 treatment. The rates in metabolic syndrome, however, decreased for MI (10.2%) and attentional control (13.8%) participants, but not for usual care. At baseline, metabolic syndrome rates did not differ significantly between participants with BED or without BED across treatments. At post-treatment, participants with BED were significantly more likely to meet criteria for metabolic syndrome than participants without BED, X 2 (1)=5.145, p=0.023, phi=0.273. Across treatments, metabolic syndrome remitted for almost a quarter of participants without BED (23.1%) but for 0% of those with BED. These preliminary results are based on a small sample and should be interpreted with caution, but they are the first to suggest that relatively low intensity MI weight loss interventions in primary care may decrease metabolic syndrome rates but not for individuals with BED. Copyright © 2017 Elsevier Ltd. All rights reserved.

A randomized trial of concurrent smoking-cessation and substance use disorder treatment in stimulant-dependent smokers.

PubMed

Winhusen, Theresa M; Brigham, Gregory S; Kropp, Frankie; Lindblad, Robert; Gardin, John G; Penn, Pat; Hodgkins, Candace; Kelly, Thomas M; Douaihy, Antoine; McCann, Michael; Love, Lee D; DeGravelles, Eliot; Bachrach, Ken; Sonne, Susan C; Hiott, Bob; Haynes, Louise; Sharma, Gaurav; Lewis, Daniel F; VanVeldhuisen, Paul; Theobald, Jeff; Ghitza, Udi

2014-04-01

To evaluate the impact of concurrent treatments for substance use disorder and nicotine-dependence for stimulant-dependent patients. A randomized, 10-week trial with follow-up at 3 and 6 months after smoking quit date conducted at 12 substance use disorder treatment programs between February 2010 and July 2012. Adults meeting DSM-IV-TR criteria for cocaine and/or methamphetamine dependence and interested in quitting smoking were randomized to treatment as usual (n = 271) or treatment as usual with smoking-cessation treatment (n = 267). All participants received treatment as usual for substance use disorder treatment. Participants assigned to treatment as usual with concurrent smoking-cessation treatment received weekly individual smoking cessation counseling and extended-release bupropion (300 mg/d) during weeks 1-10. During post-quit treatment (weeks 4-10), participants assigned to treatment as usual with smoking-cessation treatment received a nicotine inhaler and contingency management for smoking abstinence. Weekly proportion of stimulant-abstinent participants during the treatment phase, as assessed by urine drug screens and self-report, was the primary outcome. Secondary measures included other substance/nicotine use outcomes and treatment attendance. There were no significant treatment effects on stimulant-use outcomes, as measured by the primary outcome and stimulant-free days, on drug-abstinence, or on attendance. Participants assigned to treatment as usual with smoking-cessation treatment, relative to those assigned to treatment as usual, had significantly better outcomes for drug-free days at 6-month follow-up (χ(2)(1) = 4.09, P <.05), with a decrease in drug-free days from baseline of -1.3% in treatment as usual with smoking-cessation treatment and of -7.6% in treatment as usual. Participants receiving treatment as usual with smoking-cessation treatment, relative to those receiving treatment as usual, had significantly better outcomes on smoking point-prevalence abstinence (25.5% vs 2.2%; χ(2)(1) = 44.69, P < .001; OR =18.2). These results suggest that providing smoking-cessation treatment to illicit stimulant-dependent patients in outpatient substance use disorder treatment will not worsen, and may enhance, abstinence from nonnicotine substance use. ClinicalTrials.gov identifier: NCT01077024. © Copyright 2013 Physicians Postgraduate Press, Inc.

Combination of budesonide/formoterol on demand improves asthma control by reducing exercise-induced bronchoconstriction

PubMed Central

Lazarinis, Nikolaos; Jørgensen, Leif; Ekström, Tommy; Bjermer, Leif; Dahlén, Barbro; Pullerits, Teet; Hedlin, Gunilla; Carlsen, Kai-Håkon; Larsson, Kjell

2014-01-01

Background In mild asthma exercise-induced bronchoconstriction (EIB) is usually treated with inhaled short-acting β2 agonists (SABAs) on demand. Objective The hypothesis was that a combination of budesonide and formoterol on demand diminishes EIB equally to regular inhalation of budesonide and is more effective than terbutaline inhaled on demand. Methods Sixty-six patients with asthma (>12 years of age) with verified EIB were randomised to terbutaline (0.5 mg) on demand, regular budesonide (400 μg) and terbutaline (0.5 mg) on demand, or a combination of budesonide (200 μg)  + formoterol (6 μg) on demand in a 6-week, double-blind, parallel-group study (ClinicalTrials.gov identifier: NCT00989833). The patients were instructed to perform three to four working sessions per week. The main outcome was EIB 24 h after the last dosing of study medication. Results After 6 weeks of treatment with regular budesonide or budesonide+formoterol on demand the maximum post-exercise forced expiratory volume in 1 s fall, 24 h after the last medication, was 6.6% (mean; 95% CI −10.3 to −3.0) and 5.4% (−8.9 to −1.8) smaller, respectively. This effect was superior to inhalation of terbutaline on demand (+1.5%; −2.1 to +5.1). The total budesonide dose was approximately 2.5 times lower in the budesonide+formoterol group than in the regular budesonide group. The need for extra medication was similar in the three groups. Conclusions The combination of budesonide and formoterol on demand improves asthma control by reducing EIB in the same order of magnitude as regular budesonide treatment despite a substantially lower total steroid dose. Both these treatments were superior to terbutaline on demand, which did not alter the bronchial response to exercise. The results question the recommendation of prescribing SABAs as the only treatment for EIB in mild asthma. PMID:24092567

Scenario analysis of energy-based low-carbon development in China.

PubMed

Zhou, Yun; Hao, Fanghua; Meng, Wei; Fu, Jiafeng

2014-08-01

China's increasing energy consumption and coal-dominant energy structure have contributed not only to severe environmental pollution, but also to global climate change. This article begins with a brief review of China's primary energy use and associated environmental problems and health risks. To analyze the potential of China's transition to low-carbon development, three scenarios are constructed to simulate energy demand and CO₂ emission trends in China up to 2050 by using the Long-range Energy Alternatives Planning System (LEAP) model. Simulation results show that with the assumption of an average annual Gross Domestic Product (GDP) growth rate of 6.45%, total primary energy demand is expected to increase by 63.4%, 48.8% and 12.2% under the Business as Usual (BaU), Carbon Reduction (CR) and Integrated Low Carbon Economy (ILCE) scenarios in 2050 from the 2009 levels. Total energy-related CO₂ emissions will increase from 6.7 billiontons in 2009 to 9.5, 11, 11.6 and 11.2 billiontons; 8.2, 9.2, 9.6 and 9 billiontons; 7.1, 7.4, 7.2 and 6.4 billiontons in 2020, 2030, 2040 and 2050 under the BaU, CR and ILCE scenarios, respectively. Total CO₂ emission will drop by 19.6% and 42.9% under the CR and ILCE scenarios in 2050, compared with the BaU scenario. To realize a substantial cut in energy consumption and carbon emissions, China needs to make a long-term low-carbon development strategy targeting further improvement of energy efficiency, optimization of energy structure, deployment of clean coal technology and use of market-based economic instruments like energy/carbon taxation. Copyright © 2014. Published by Elsevier B.V.

Analysis, modeling, and simulation (AMS) testbed development and evaluation to support dynamic mobility applications (DMA) and active transportation and demand management (ATDM) programs - Pasadena calibration report : draft report.

DOT National Transportation Integrated Search

2017-03-01

The primary objective of this project is to develop multiple simulation testbeds/transportation models to evaluate the impacts of DMA connected vehicle applications and the active transportation and demand management (ATDM) strategies. The primary pu...

Tracing Primary PM2.5 emissions via Chinese supply chains

NASA Astrophysics Data System (ADS)

Meng, Jing; Liu, Junfeng; Xu, Yuan; Tao, Shu

2015-05-01

In this study, we examine a supply-chain approach to more effectively mitigate primary PM2.5 emissions in China from the perspectives of production, consumption and their linkages using structural path analysis. We identify the pattern of all supply chain paths using principal component analysis. To address the severe haze problems in China, it is important to understand how final demand purchase initiates production processes and ultimately leads to primary PM2.5 emission. We found that consumers’ demands on power and transportation mainly induce direct emissions, quite different from the demands on construction, industry and service products which largely drive emissions in upstream activities. We also found that nearly 80% of the economic sectors in China follow a similar pattern in generating primary PM2.5 emissions in electricity, cement and the ferrous metal industries; but only the construction sector increases the release of PM2.5 due to the production of non-metallic mineral products. These findings indicate that further reduction of end-of-pipe emissions in the power and transportation sectors will facilitate cleaner production in almost all the economic sectors. However, for urbanization induced emissions, China should mitigate PM2.5 emissions through the supply chain of construction, either severely reducing its life-cycle intensity or carefully planning to avoid extensive, unnecessary building activity.

What would menthol smokers do if menthol in cigarettes were banned? Behavioral intentions and simulated demand

PubMed Central

O'Connor, Richard J.; Bansal-Travers, Maansi; Carter, Lawrence P.; Cummings, K. Michael

2012-01-01

Aims The US Food and Drug Administration must consider whether to ban the use of menthol in cigarettes. This study examines how current smokers might respond to such a ban on menthol cigarettes. Design Convenience sample of adolescent and adult smokers recruited from an online survey panel. Setting United States, 2010. Participants 471 adolescent and adult current cigarette smokers. Measurements Respondents were asked a series of questions about how they might react if menthol cigarettes were banned. In addition, participants completed a simulation purchase task to estimate the demand for menthol and nonmenthol cigarettes across a range of prices. Findings Overall, 36% respondents said they always or usually smoked menthol cigarettes. When asked how they might respond to a ban on menthol cigarettes, 35% of current menthol smokers said they would stop smoking, and 25% said they would ‘find a way to buy a menthol brand.’ Those who reported they might quit tended to have greater current intentions to quit (OR=4.46), while those who reported they might seek illicit menthol cigarettes were far less likely to report current intentions to quit (OR = 0.06). Estimates for individual demand elasticity for preferred cigarette type were similar for menthol (α = .0051) and nonmenthol (α = .0049) smokers. Demand elasticity and peak consumption were related to usual cigarette type and cigarettes smoked per day, but did not appear to differ by race, gender, or age. Conclusions Preliminary evidence suggests that a significant minority of smokers of menthol cigarettes in the US would try to stop smoking altogether if such cigarettes were banned. PMID:22471735

Adult community health-promoting interventions in primary health care: A systematic review.

PubMed

March, Sebastià; Torres, Elena; Ramos, María; Ripoll, Joana; García, Atanasio; Bulilete, Oana; Medina, David; Vidal, Clara; Cabeza, Elena; Llull, Micaela; Zabaleta-del-Olmo, Edurne; Aranda, José Manuel; Sastre, Silvia; Llobera, Joan

2015-07-01

To examine evidence on the effectiveness of health-promoting community interventions carried out in primary health care. Systematic review of originals and systematic reviews of health-promoting community interventions with the participation of primary health care. A working definition of community activities was used in the inclusion criteria. Databases searched up to 2013: PUBMED, EMBASE, CINHAL, Web of SCIENCE, IBECS, IME, and PSICODOC. No restrictions on year of publication or design. Articles were reviewed by separate researchers to identify risks of bias. Fifty-one articles published between 1966 and 2013 were included: 11 systematic reviews and 40 originals that described 39 community interventions. There is evidence on the effectiveness of community interventions in reducing cardiovascular risk factors, encouraging physical exercise, preventing falls and improving self-care among chronic patients compared with usual individual care. The effectiveness of some interventions increases when the community is involved in their development. Most assessments show positive results despite design limitations. The community approach may be more effective than the individual in usual preventive interventions in primary care. There is a lack of evidence on many community interventions in primary care and further research is needed. Copyright © 2015 Elsevier Inc. All rights reserved.

Effect of task load and task load increment on performance and workload

NASA Technical Reports Server (NTRS)

Hancock, P. A.; Williams, G.

1993-01-01

The goal of adaptive automated task allocation is the 'seamless' transfer of work demand between human and machine. Clearly, at the present time, we are far from this objective. One of the barriers to achieving effortless human-machine symbiosis is an inadequate understanding of the way in which operators themselves seek to reallocate demand among their own personal 'resources.' The paper addresses this through an examination of workload response, which scales an individual's reaction to common levels of experienced external demand. The results indicate the primary driver of performance is the absolute level of task demand over the increment in that demand.

Identifying Online Graduate Learners' Perceived Barriers to Their Academic Success Utilizing a Delphi Study

ERIC Educational Resources Information Center

Banks, Karen Lee

2017-01-01

Nontraditional online adult graduate students ages 25 and older have unique challenges toward achieving their academic goals as compared to younger learners. These older graduate students usually already have families, careers, and other demands on their time. Deciding to pursue their advanced degrees is typically related to gaining a competitive…

"Work and Leisure in Country Schools in Wyoming." Country School Legacy: Humanities on the Frontier.

ERIC Educational Resources Information Center

Gulliford, Andrew; And Others

The country school legacy of Wyoming is rich in history, folklore, and tradition. Materials (many anecdotal) gathered from school records, oral histories, autobiographies, and memoirs provide glimpses into the diverse and demanding role of frontier teachers (who were mostly female and, by contract requirement, usually single) and the work and…

There's Gold in Those Contracts

ERIC Educational Resources Information Center

Diaz, Russell

2009-01-01

In 2006, when the author joined the staff at Dominican College (New York), he discovered that the network, computers, and IT contracts were in sorry shape. He also found that this kind of condition is common in small colleges. Such a state of affairs is usually brought about by the unrelenting demands placed on small IT staffs. IT staffers at…

Report on the Evaluation of Demand Forecasting Techniques for the Subsistence Commodity. Volume 1,

DTIC Science & Technology

1985-10-01

and Eggs 8915 Fruits and Vegetables 8920 Bakery and Cereal Products 8925 Sugar, Confectionary and Nuts I 8930 Jams , Jellies and Preserves 8935 Soups...period of the movement. Periods of 12 months may exist for ice cream, spare ribs, strawberries , etc. 4. Cycles are usually due to long term business

A protocol for a trial of homeopathic treatment for irritable bowel syndrome

PubMed Central

2012-01-01

Background Irritable bowel syndrome is a chronic condition with no known cure. Many sufferers seek complementary and alternative medicine including homeopathic treatment. However there is much controversy as to the effectiveness of homeopathic treatment. This three-armed study seeks to explore the effectiveness of individualised homeopathic treatment plus usual care compared to both an attention control plus usual care and usual care alone, for patients with irritable bowel syndrome. Methods/design This is a three-armed pragmatic randomised controlled trial using the cohort multiple randomised trial methodology. Patients are recruited to an irritable bowel syndrome cohort from primary and secondary care using GP databases and consultants lists respectively. From this cohort patients are randomly selected to be offered, 5 sessions of homeopathic treatment plus usual care, 5 sessions of supportive listening plus usual care or usual care alone. The primary clinical outcome is the Irritable Bowel Syndrome Symptom Severity at 26 weeks. From a power calculation, it is estimated that 33 people will be needed for the homeopathic treatment arm and 132 for the usual care arm, to detect a minimal clinical difference at 80 percent power and 5 percent significance allowing for loss to follow up. An unequal group size has been used for reasons of cost. Analysis will be by intention to treat and will compare homeopathic treatment with usual care at 26 weeks as the primary analysis, and homeopathic treatment with supportive listening as an additional analysis. Discussion This trial has received NHS approval and results are expected in 2013. Trial registration Current Controlled Trials ISRCTN90651143 PMID:23131064

THE COST-EFFECTIVENESS OF COGNITIVE BEHAVIOR THERAPY FOR BORDERLINE PERSONALITY DISORDER: RESULTS FROM THE BOSCOT TRIAL

PubMed Central

Palmer, Stephen; Davidson, Kate; Tyrer, Peter; Gumley, Andrew; Tata, Philip; Norrie, John; Murray, Heather; Seivewright, Helen

2007-01-01

Borderline personality disorder places a significant burden on healthcare providers and other agencies. This study evaluated the cost-effectiveness of cognitive behavior therapy plus treatment as usual compared to treatment as usual alone for patients with borderline personality disorder. The economic analysis was conducted alongside a multi-center, randomized controlled trial. The costs of primary and secondary healthcare utilization, alongside the wider economic costs, were estimated from medical records and patient self-report. The primary outcome measure used was the quality-adjusted life year (QALY), assessed using EuroQol. On average, total costs per patient in the cognitive behavior therapy group were lower than patients receiving usual care alone (−£689), although this group also reported a lower quality of life (−0.11 QALYs). These differences were small and did not approach conventional levels of statistical significance. The use of cognitive therapy for borderline personality disorder does not appear to demonstrate any significant cost-effective advantage based on the results of this study. PMID:17032159

Thinking Styles of Primary School Teachers in Beijing, China

ERIC Educational Resources Information Center

Wang, Ying; Pang, Nicholas Sun-Keung

2013-01-01

Previous studies on teachers' thinking have usually related to teaching and learning, and concentrated on classroom-level outcomes. In this study, an organizational and administrative perspective was adopted in examining teachers' thinking style. Data collected were from a sample of 268 in-service teachers from 6 primary schools in Beijing, China.…

Working Alongside Scientists: Impacts on Primary Teacher Beliefs and Knowledge about Science and Science Education

ERIC Educational Resources Information Center

Anderson, Dayle; Moeed, Azra

2017-01-01

Current curriculum demands require primary teachers to teach about the Nature of Science; yet, few primary teachers have had opportunity to learn about science as a discipline. Prior schooling and vicarious experiences of science may shape their beliefs about science and, as a result, their science teaching. This qualitative study describes the…

Usual medical treatments or levonorgestrel-IUS for women with heavy menstrual bleeding: long-term randomised pragmatic trial in primary care.

PubMed

Kai, Joe; Middleton, Lee; Daniels, Jane; Pattison, Helen; Tryposkiadis, Konstantinos; Gupta, Janesh

2016-12-01

Heavy menstrual bleeding (HMB) is a common, chronic problem affecting women and health services. However, long-term evidence on treatment in primary care is lacking. To assess the effectiveness of commencing the levonorgestrel-releasing intrauterine system (LNG-IUS) or usual medical treatments for women presenting with HMB in general practice. A pragmatic, multicentre, parallel, open-label, long term, randomised controlled trial in 63 primary care practices across the English Midlands. In total, 571 women aged 25-50 years, with HMB were randomised to LNG-IUS or usual medical treatment (tranexamic/mefenamic acid, combined oestrogen-progestogen, or progesterone alone). The primary outcome was the patient reported Menorrhagia Multi-Attribute Scale (MMAS, measuring effect of HMB on practical difficulties, social life, psychological and physical health, and work and family life; scores from 0 to 100). Secondary outcomes included surgical intervention (endometrial ablation/hysterectomy), general quality of life, sexual activity, and safety. At 5 years post-randomisation, 424 (74%) women provided data. While the difference between LNG-IUS and usual treatment groups was not significant (3.9 points; 95% confidence interval = -0.6 to 8.3; P = 0.09), MMAS scores improved significantly in both groups from baseline (mean increase, 44.9 and 43.4 points, respectively; P<0.001 for both comparisons). Rates of surgical intervention were low in both groups (surgery-free survival was 80% and 77%; hazard ratio 0.90; 95% CI = 0.62 to 1.31; P = 0.6). There was no difference in generic quality of life, sexual activity scores, or serious adverse events. Large improvements in symptom relief across both groups show treatment for HMB can be successfully initiated with long-term benefit and with only modest need for surgery. © British Journal of General Practice 2016.

Trip-specific training enhances recovery after large postural disturbances for which there is NO expectation.

PubMed

Oludare, Simisola O; Pater, Mackenzie L; Rosenblatt, Noah J; Grabiner, Mark D

2018-03-01

Informed consent usually provides foreknowledge of experimental methods that can potentially increase expectation of stimuli and, therefore, influence the response. We determined the effects of increased expectation and trip-specific training on the recovery response following a treadmill-delivered, trip-specific disturbance. To deliver unexpected disturbances, subjects were deceived during the informed consent process. The primary hypothesis was that the recovery response following an expected postural disturbance would be characterized by trunk kinematics that have been shown to decrease the likelihood of a fall, compared to following an unexpected postural disturbance. We further hypothesized that following an unexpected postural disturbance, the recovery response of the subjects who had completed a trip-specific training protocol would be more biomechanically favorable to recovery compared to those of subjects who had not received the training. Young adults were randomized into Untrained or Trained groups. During the informed consent process, the purpose of the study was explained to subjects in both groups as being to determine the effect of trip-specific training on postural sway while performing an attention-demanding task. Untrained subjects completed two trials during which they minimized their postural sway. During the second trial, an unexpected disturbance was delivered while they performed the attention-demanding task. Trained subjects performed a pre-training postural sway trial, followed by the delivery of a series of expected, training disturbances. Finally, an unexpected disturbance was delivered while they minimized postural sway and performed the attention-demanding task. Expectation significantly improved trunk kinematics (p < .05). In addition, participation in the trip-specific training protocol following the unexpected disturbance the trunk kinematics of the Trained subjects were more biomechanically favorable to recovery than those of the Untrained subjects (p < .01). Improved trunk kinematics following trip-specific training may be independent of the extent to which the disturbance is expected. Copyright © 2018 Elsevier B.V. All rights reserved.

Essays on the economics of natural gas pipelines

NASA Astrophysics Data System (ADS)

Oliver, Matthew E.

The natural gas pipeline transportation industry is comprised of a primary market and a secondary market. In the primary market, pipelines sell 'firm' transport capacity contracts to gas traders, local distribution companies, and other parties. The (per unit) secondary market value of transport is rarely comparable to the regulated primary market two-part tariff. When and where available capacity in the secondary market is scarce, its value can far exceed the primary market tariffs paid by firm contract holders, generating scarcity rents. The following essays demonstrate that this phenomenon has predictable effects on natural gas spot prices, firm capacity reservations, the pipeline's capacity construction and expansion decisions, and the economic welfare of producers and consumers at the market hubs connected by the pipeline. Chapter 1 provides a theoretical framework for understanding how pipeline congestion affects natural gas spot prices within the context of the current regulatory environment, and empirically quantifies this effect over a specific regional pipeline network. As available pipeline capacity over a given route connecting two hubs becomes scarce, the spot prices for gas at the hubs are driven apart---a phenomenon indicative of some market friction that inhibits the ability of spot price arbitrage to fully integrate the two prices, undermining economic efficiency. The theoretical component of Chapter 1 illuminates a potential source of this friction: the deregulated structure of the secondary market for gas transportation services. To support and quantify the predictions of the theoretical model, the empirical component demonstrates that the effect of congestion on the secondary market value of transport---the key factor in driving apart spot prices---can be quite strong. Coefficient estimates indicate that dramatic increases in transport costs are likely to result from marginal increases in congestion. This result has important implications because upward pressure on the demand for pipeline transport is imminent, owing to the recent surge in available natural gas reserve estimates and the expected growth in consumption demand over the foreseeable future. Chapter 2 derives optimality conditions for capacity and two-part tariff structure in the primary market, when demand for the shipping service in the secondary market is stochastic but stationary. Based on their individual demand distributions, the overall demand distribution, and the two-part tariff structure, natural gas traders reserve firm capacity contracts over a given transportation route served by a single pipeline. The traders' individual demands sum to the aggregate demand for primary market capacity reservations over the route. The aggregate capacity reservation demand function then feeds into the pipeline's profit-maximization problem, which for comparison is analyzed under three alternative regulatory regimes: unregulated monopoly, Ramsey second-best solution, and rate-of-return regulation. For each case, the optimality conditions are parameterized and solved numerically. Results demonstrate that optimal capacity under rate-of-return regulation is lower than what would occur under a Ramsey second-best solution, exacerbating the congestion issue discussed in Chapter 1, and ultimately reducing overall social welfare. Chapter 3 examines a natural gas trader's willingness to contract expanded capacity over a given pipeline route, when demand in the secondary market is stochastic and increasing over time. A discrete time and scale framework provides the template for analyzing the trader's behavior and solving for his optimal expansion contracting strategy through time. Willingness to contract in any period hinges on the trade-off between the value of the option to contract expanded capacity (now or in a future period), and the 'spread option' value of utilizing contracted capacity to ship gas. The rate-of-return regulated primary market two-part tariff and the unregulated secondary market value of transport each affect these option values, but the latter provides a strong incentive to the trader to both delay and suppress his willingness to contract expanded capacity relative to the demand for gas shipping services. As a result, the pipeline is chronically congested. Relating this to the results of Chapters 1 and 2, there are likely to be strong welfare effects associated with this behavior. (Abstract shortened by UMI.)

Student Teachers' Distinctive Contributions to Research on Primary School Children's Beliefs about Knowledge and Knowing

ERIC Educational Resources Information Center

Kershner, Ruth; Hargreaves, Linda

2012-01-01

Student teachers' research is usually valued more for its contribution to their professional learning than for its contribution to the research topic itself. This paper reports on a research collaboration with eight student primary teachers in England, intended to build on a previously established project investigating young children's…

Relations of Instructional Tasks to Teacher-Student Discourse in Mathematics Classrooms of Chinese Primary Schools

ERIC Educational Resources Information Center

Ni, Yujing; Zhou, Dehui; Li, Xiaoqing; Li, Qiong

2014-01-01

This study, based on observation of 90 fifth-grade mathematics classes in Chinese elementary schools, examined how the task features, high cognitive demand, multiple representations, and multiple solution methods may relate to classroom discourse. Results indicate that high cognitive demand tasks were associated with teachers' use higher order…

Investigating the Literacy, Numeracy and ICT Demands of Primary Teacher Education

ERIC Educational Resources Information Center

de Silva Joyce, Helen; Feez, Susan; Chan, Eveline; Tobias, Stephen

2014-01-01

Pre-service teacher education programs are required to graduate students who meet externally determined standards in literacy and numeracy. However, little is known about the literacy, numeracy and ICT knowledge and skills demanded of teacher education students as they complete assessment tasks on which successful completion of their teaching…

Customer premises services market demand assessment 1980 - 2000: Volume 2

NASA Technical Reports Server (NTRS)

Gamble, R. B.; Saporta, L.; Heidenrich, G. A.

1983-01-01

Potential customer premises service (CPS), telecommunication services, potential CPS user classes, a primary research survey, comparative economics, market demand forcasts, distance distribution of traffic, segmentation of market demand, and a nationwide traffic distribution model are discussed.

Evaluation of a mid-career investigator career development award: Assessing the ability of OppNet K18 awardees to obtain NIH follow-on research funding.

PubMed

Pomeroy-Carter, Cassidy A; Williams, Sharon R; Han, Xueying; Elwood, William N; Zuckerman, Brian L

2018-01-01

The National Institutes of Health (NIH) K18 award mechanism provides funded opportunities for established investigators to gain knowledge in fields outside of their primary disciplines, but outcomes associated with these awards have not been evaluated to date. NIH's Basic Behavioral and Social Sciences Opportunity Network (OppNet) is one of the few initiatives that has used this award mechanism. We explored how the unique features of K18 awards affect the ability of recipients to obtain follow-on NIH research funding. We compared outcomes (ability to obtain follow-on funding and interval between receipt of the primary award and receipt of the first follow-on award) associated with OppNet K18 awards to findings from evaluations of other NIH career development (K) awards, which usually target early-career investigators. We hypothesized that K18 award recipients might be (1) more successful than are other K award recipients in obtaining follow-on NIH research funding due to their career experience or (2) less successful due to the competing demands of other projects. By analyzing follow-on NIH research awards and interview data, we found that OppNet K18 award recipients were at least as successful as were other K award recipients in obtaining follow-on funding and may have been more successful by certain measures. K18 awards produce their outcomes with a lower investment per investigator than do other K awards, suggesting continued or enhanced use of the mechanism.

Evaluation of a mid-career investigator career development award: Assessing the ability of OppNet K18 awardees to obtain NIH follow-on research funding

PubMed Central

Williams, Sharon R.; Han, Xueying; Elwood, William N.; Zuckerman, Brian L.

2018-01-01

The National Institutes of Health (NIH) K18 award mechanism provides funded opportunities for established investigators to gain knowledge in fields outside of their primary disciplines, but outcomes associated with these awards have not been evaluated to date. NIH’s Basic Behavioral and Social Sciences Opportunity Network (OppNet) is one of the few initiatives that has used this award mechanism. We explored how the unique features of K18 awards affect the ability of recipients to obtain follow-on NIH research funding. We compared outcomes (ability to obtain follow-on funding and interval between receipt of the primary award and receipt of the first follow-on award) associated with OppNet K18 awards to findings from evaluations of other NIH career development (K) awards, which usually target early-career investigators. We hypothesized that K18 award recipients might be (1) more successful than are other K award recipients in obtaining follow-on NIH research funding due to their career experience or (2) less successful due to the competing demands of other projects. By analyzing follow-on NIH research awards and interview data, we found that OppNet K18 award recipients were at least as successful as were other K award recipients in obtaining follow-on funding and may have been more successful by certain measures. K18 awards produce their outcomes with a lower investment per investigator than do other K awards, suggesting continued or enhanced use of the mechanism. PMID:29438411

Planning and Enacting Mathematical Tasks of High Cognitive Demand in the Primary Classroom

ERIC Educational Resources Information Center

Georgius, Kelly

2013-01-01

This study offers an examination of two primary-grades teachers as they learn to transfer knowledge from professional development into their classrooms. I engaged in planning sessions with each teacher to help plan tasks of high cognitive demand, including anticipating and planning for classroom discourse that would occur around the task. A…

Exploring the Cognitive Demand and Features of Problem Solving Tasks in Primary Mathematics Classrooms

ERIC Educational Resources Information Center

McCormick, Melody

2016-01-01

Student learning is greatest in classrooms where students engage in problem solving tasks that are cognitively demanding. However, there are growing concerns that many Australian students are given limited opportunities to engage in these types of tasks. 108 upper primary school teachers were surveyed to examine task features and cognitive demand…

Impact of Primary Care Intensive Management on High-Risk Veterans' Costs and Utilization: A Randomized Quality Improvement Trial.

PubMed

Yoon, Jean; Chang, Evelyn; Rubenstein, Lisa V; Park, Angel; Zulman, Donna M; Stockdale, Susan; Ong, Michael K; Atkins, David; Schectman, Gordon; Asch, Steven M

2018-06-05

Primary care models that offer comprehensive, accessible care to all patients may provide insufficient resources to meet the needs of patients with complex conditions who have the greatest risk for hospitalization. To assess whether augmenting usual primary care with team-based intensive management lowers utilization and costs for high-risk patients. Randomized quality improvement trial. (ClinicalTrials.gov: NCT03100526). 5 U.S. Department of Veterans Affairs (VA) medical centers. Primary care patients at high risk for hospitalization who had a recent acute care episode. Locally tailored intensive management programs providing care coordination, goals assessment, health coaching, medication reconciliation, and home visits through an interdisciplinary team, including a physician or nurse practitioner, a nurse, and psychosocial experts. Utilization and costs (including intensive management program expenses) 12 months before and after randomization. 2210 patients were randomly assigned, 1105 to intensive management and 1105 to usual care. Patients had a mean age of 63 years and an average of 7 chronic conditions; 90% were men. Of the patients assigned to intensive management, 487 (44%) received intensive outpatient care (that is, ≥3 encounters in person or by telephone) and 204 (18%) received limited intervention. From the pre- to postrandomization periods, mean inpatient costs decreased more for the intensive management than the usual care group (-$2164 [95% CI, -$7916 to $3587]). Outpatient costs increased more for the intensive management than the usual care group ($2636 [CI, $524 to $4748]), driven by greater use of primary care, home care, telephone care, and telehealth. Mean total costs were similar in the 2 groups before and after randomization. Sites took up to several months to contact eligible patients, limiting the time between treatment and outcome assessment. Only VA costs were assessed. High-risk patients with access to an intensive management program received more outpatient care with no increase in total costs. Veterans Health Administration Primary Care Services.

Market-based demand forecasting promotes informed strategic financial planning.

PubMed

Beech, A J

2001-11-01

Market-based demand forecasting is a method of estimating future demand for a healthcare organization's services by using a broad range of data that describe the nature of demand within the organization's service area. Such data include the primary and secondary service areas, the service-area populations by various demographic groupings, discharge utilization rates, market size, and market share by service line and organizationwide. Based on observable market dynamics, strategic planners can make a variety of explicit assumptions about future trends regarding these data to develop scenarios describing potential future demand. Financial planners then can evaluate each scenario to determine its potential effect on selected financial and operational measures, such as operating margin, days cash on hand, and debt-service coverage, and develop a strategic financial plan that covers a range of contingencies.

Incidence and prevalence of hyperhidrosis.

PubMed

Moraites, Eleni; Vaughn, Olushola Akinshemoyin; Hill, Samantha

2014-10-01

Hyperhidrosis is a skin disorder characterized by excessive sweating that often causes significant impairment in social, occupational, and emotional wellbeing. Hyperhidrosis is thought to affect 2.8% of the US population and can be of primary or secondary origin. Primary hyperhidrosis is usually bilateral, symmetric, and focal. The most common focal sites include, but are not limited to, the palms, soles, and axillae. Secondary hyperhidrosis is usually caused by an underlying medical condition or medication. Secondary hyperhidrosis must be ruled out before a diagnosis of primary hyperhidrosis is made. Copyright © 2014 Elsevier Inc. All rights reserved.

A Stage Matched Physical Activity Intervention in Military Primary Care

DTIC Science & Technology

2000-05-26

usually offered as tertiary prevention ; i.e. prevention directed toward minimizing residual disability from existing diseases and helping the...through effective behavior modification is not usually offered as primary prevention (Pender, 1996). Little is being done to assist relatively...program has ended (Belisle, Roskies, & Levesque, 1987; Harris, Caspersen, DeFriese, & Estes, 1989). One of the three criteria used by the US Preventive

Dissemination of Cognitive Therapy for Panic Disorder in Primary Care

PubMed Central

Grey, Nick; Salkovskis, Paul; Quigley, Alexandra; Clark, David M.; Ehlers, Anke

2011-01-01

This study investigated whether brief training in cognitive therapy for panic disorder (Clark et al., 1994) can improve the outcomes that primary care therapists obtain with their patients. Seven primary care therapists treated 36 patients meeting DSM-IV (APA, 1994) criteria for panic disorder with or without agoraphobia in general practice surgeries. Outcomes for the cohort of patients whom the therapists treated with their usual methods (treatment-as-usual) before the training (N = 12) were compared with those obtained with similar patients treated by the same therapists after brief training and ongoing supervision in cognitive therapy (CT) for panic disorder (N = 24). Treatment-as-usual led to significant improvements in panic severity, general anxiety, and depression. However, only a small proportion (17% of the intent-to-treat sample) became panic free and there was no improvement in agoraphobic avoidance. Patients treated with CT achieved significantly better outcomes on all measures of panic attacks, including panic-free rate (54%, intent-to-treat), and showed significantly greater improvements in agoraphobic avoidance and patient-rated general anxiety. In conclusion, cognitive therapy for panic disorder can be successfully disseminated in primary care with a brief therapist training and supervision programme that leads to significant improvements in patient outcomes. PMID:22661906

Effect of guided self-determination youth intervention integrated into outpatient visits versus treatment as usual on glycemic control and life skills: a randomized clinical trial in adolescents with type 1 diabetes.

PubMed

Husted, Gitte R; Thorsteinsson, Birger; Esbensen, Bente Appel; Gluud, Christian; Winkel, Per; Hommel, Eva; Zoffmann, Vibeke

2014-08-12

Providing care for adolescents with type 1 diabetes is complex, demanding, and often unsuccessful. Guided self-determination (GSD) is a life skills approach that has been proven effective in caring for adults with type 1 diabetes. To improve care, GSD was revised for adolescents, their parents, and interdisciplinary healthcare providers (HCP) to create GSD-Youth (GSD-Y). We evaluated the impact of GSD-Y after it was integrated into pediatric outpatient visits versus treatment-as-usual, focusing on glycemic control and the development of life skills in adolescents with type 1 diabetes. Seventy-one adolescents (mean age: 15 years, mean duration of diabetes: 5.7 years, mean HbA1c: 77 mmol/mol (9.1%), upon entering the study) from two pediatric departments were randomized into a GSD-Y group (n = 37, GSD-Y was provided during individual outpatient sessions) versus a treatment-as-usual group (n = 34). The primary outcome was the HbA1c measurement. The secondary outcomes were life skills development (assessed by self-reported psychometric scales), self-monitored blood glucose levels, and hypo- and hyperglycemic episodes. The analysis followed an intention-to-treat basis. Fifty-seven adolescents (80%) completed the trial, and 53 (75%) completed a six-month post-treatment follow-up. No significant effect of GSD-Y on the HbA1c could be detected in a mixed-model analysis after adjusting for the baseline HbA1c levels and the identity of the HCP (P = 0.85). GSD-Y significantly reduced the amotivation for diabetes self-management after adjusting for the baseline value (P = 0.001). Compared with the control group, the trial completion was prolonged in the GSD-Y group (P <0.001), requiring more visits (P = 0.05) with a higher rate of non-attendance (P = 0.01). GSD-Y parents participated in fewer of the adolescents' visits (P = 0.05) compared with control parents. Compared with treatment-as-usual, GSD-Y did not improve HbA1c levels, but it did decrease adolescents' amotivation for diabetes self-management. ISRCTN 54243636, registered on 10 January 2010. Life skills for adolescents with type 1 diabetes and their parents.

Efficacy of a cognitive and behavioural psychotherapy applied by primary care psychologists in patients with mixed anxiety-depressive disorder: a research protocol.

PubMed

Jauregui, Amale; Ponte, Joaquín; Salgueiro, Monika; Unanue, Saloa; Donaire, Carmen; Gómez, Maria Cruz; Burgos-Alonso, Natalia; Grandes, Gonzalo

2015-03-20

In contrast with the recommendations of clinical practice guidelines, the most common treatment for anxiety and depressive disorders in primary care is pharmacological. The aim of this study is to assess the efficacy of a cognitive-behavioural psychological intervention, delivered by primary care psychologists in patients with mixed anxiety-depressive disorder compared to usual care. This is an open-label, multicentre, randomized, and controlled study with two parallel groups. A random sample of 246 patients will be recruited with mild-to-moderate mixed anxiety-depressive disorder, from the target population on the lists of 41 primary care doctors. Patients will be randomly assigned to the intervention group, who will receive standardised cognitive-behavioural therapy delivered by psychologists together with usual care, or to a control group, who will receive usual care alone. The cognitive-behavioural therapy intervention is composed of eight individual 60-minute face-to face sessions conducted in eight consecutive weeks. A follow-up session will be conducted over the telephone, for reinforcement or referral as appropriate, 6 months after the intervention, as required. The primary outcome variable will be the change in scores on the Short Form-36 General Health Survey. We will also measure the change in the frequency and intensity of anxiety symptoms (State-Trait Anxiety Inventory) and depression (Beck Depression Inventory) at baseline, and 3, 6 and 12 months later. Additionally, we will collect information on the use of drugs and health care services. The aim of this study is to assess the efficacy of a primary care-based cognitive-behavioural psychological intervention in patients with mixed anxiety-depressive disorder. The international scientific evidence has demonstrated the need for psychologists in primary care. However, given the differences between health policies and health services, it is important to test the effect of these psychological interventions in our geographical setting. NCT01907035 (July 22, 2013).

Protocol and baseline data from The Inala Chronic Disease Management Service evaluation study: a health services intervention study for diabetes care

PubMed Central

2010-01-01

Background Type 2 Diabetes Mellitus is one of the most disabling chronic conditions worldwide, resulting in significant human, social and economic costs and placing huge demands on health care systems. The Inala Chronic Disease Management Service aims to improve the efficiency and effectiveness of care for patients with type 2 diabetes who have been referred by their general practitioner to a specialist diabetes outpatient clinic. Care is provided by a multidisciplinary, integrated team consisting of an endocrinologist, diabetes nurse educators, General Practitioner Clinical Fellows (general practitioners who have undertaken focussed post-graduate training in complex diabetes care), and allied health personnel (a dietitian, podiatrist and psychologist). Methods/Design Using a geographical control, this evaluation study tests the impact of this model of diabetes care provided by the service on patient outcomes compared to usual care provided at the specialist diabetes outpatient clinic. Data collection at baseline, 6 and 12-months will compare the primary outcome (glycaemic control) and secondary outcomes (serum lipid profile, blood pressure, physical activity, smoking status, quality of life, diabetes self-efficacy and cost-effectiveness). Discussion This model of diabetes care combines the patient focus and holistic care valued by the primary care sector with the specialised knowledge and skills of hospital diabetes care. Our study will provide empirical evidence about the clinical effectiveness of this model of care. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12608000010392. PMID:20492731

Learning outside the Primary Classroom

ERIC Educational Resources Information Center

Sedgwick, Fred

2012-01-01

In "Learning Outside the Primary Classroom," the educationalist and writer Fred Sedgwick explores in a practical way the many opportunities for intense learning that children and teachers can find outside the confines of the usual learning environment, the classroom. This original work is based on tried and tested methods from UK primary…

A mindfulness-based intervention to increase resilience to stress in university students (the Mindful Student Study): a pragmatic randomised controlled trial.

PubMed

Galante, Julieta; Dufour, Géraldine; Vainre, Maris; Wagner, Adam P; Stochl, Jan; Benton, Alice; Lathia, Neal; Howarth, Emma; Jones, Peter B

2018-02-01

The rising number of young people going to university has led to concerns about an increasing demand for student mental health services. We aimed to assess whether provision of mindfulness courses to university students would improve their resilience to stress. We did this pragmatic randomised controlled trial at the University of Cambridge, UK. Students aged 18 years or older with no severe mental illness or crisis (self-assessed) were randomly assigned (1:1), via remote survey software using computer-generated random numbers, to receive either an 8 week mindfulness course adapted for university students (Mindfulness Skills for Students [MSS]) plus mental health support as usual, or mental health support as usual alone. Participants and the study management team were aware of group allocation, but allocation was concealed from the researchers, outcome assessors, and study statistician. The primary outcome was self-reported psychological distress during the examination period, as measured with the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), with higher scores indicating more distress. The primary analysis was by intention to treat. This trial is registered with the Australia and New Zealand Clinical Trials Registry, number ACTRN12615001160527. Between Sept 28, 2015, and Jan 15, 2016, we randomly assigned 616 students to the MSS group (n=309) or the support as usual group (n=307). 453 (74%) participants completed the CORE-OM during the examination period and 182 (59%) MSS participants completed at least half of the course. MSS reduced distress scores during the examination period compared with support as usual, with mean CORE-OM scores of 0·87 (SD 0·50) in 237 MSS participants versus 1·11 (0·57) in 216 support as usual participants (adjusted mean difference -0·14, 95% CI -0·22 to -0·06; p=0·001), showing a moderate effect size (β -0·44, 95% CI -0·60 to -0·29; p<0·0001). 123 (57%) of 214 participants in the support as usual group had distress scores above an accepted clinical threshold compared with 88 (37%) of 235 participants in the MSS group. On average, six students (95% CI four to ten) needed to be offered the MSS course to prevent one from experiencing clinical levels of distress. No participants had adverse reactions related to self-harm, suicidality, or harm to others. Our findings show that provision of mindfulness training could be an effective component of a wider student mental health strategy. Further comparative effectiveness research with inclusion of controls for non-specific effects is needed to define a range of additional, effective interventions to increase resilience to stress in university students. University of Cambridge and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care East of England. Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.

Cytological Diagnosis of Primary Thyroid Tuberculosis.

PubMed

Goyal, P; Mittal, D; Ghosh, S; Agrawal, D; Sehgal, S; Singh, S

2015-01-01

Primary thyroid tuberculosis is an extremely rare disease, even in countries where other forms of tuberculosis are abundant. TT has no age bar but usually affects women in fourth and fifth decade. Hereby, we report a case of 16-years-old girl presented with complaint of progressively increasing, painful thyroid swelling. Diagnosis of TT was made on cytology and there was no evidence of involvement of any other organ by tuberculosis. Despite of its rarity, TT is usually misdiagnosed. So, a clinician should always consider this entity in the differential diagnosis of thyroid swelling. Fine needle aspiration cytology is the best diagnostic method and can result in the avoidance of unnecessary thyroid surgeries.

Focus on Resiliency: A Process Improvement Approach to Security Introducing the Resiliency Engineering Framework

DTIC Science & Technology

2006-11-06

operational environment -1 No operational boundaries Pervasiveness of technology Expanding and rapidly changing risk profile High dependency on upstream...partners Successes are short-lived Skills have shorter longevity Less resources, more demands 5 © 2006 Carnegie Mellon University y Resiliency...involved Usually bolted on as an afterthought Security seen as technical problem Searching for magic bullet: CobiT , ITIL, ISO17799 Poorly defined and

Multispecialty physician networks in Ontario.

PubMed

Stukel, Therese A; Glazier, Richard H; Schultz, Susan E; Guan, Jun; Zagorski, Brandon M; Gozdyra, Peter; Henry, David A

2013-01-01

Large multispecialty physician group practices, with a central role for primary care practitioners, have been shown to achieve high-quality, low-cost care for patients with chronic disease. We assessed the extent to which informal multispecialty physician networks in Ontario could be identified by using health administrative data to exploit natural linkages among patients, physicians, and hospitals based on existing patient flow. We linked each Ontario resident to his or her usual provider of primary care over the period from fiscal year 2008/2009 to fiscal year 2010/2011. We linked each specialist to the hospital where he or she performed the most inpatient services. We linked each primary care physician to the hospital where most of his or her ambulatory patients were admitted for non-maternal medical care. Each resident was then linked to the same hospital as his or her usual provider of primary care. We computed "loyalty" as the proportion of care to network residents provided by physicians and hospitals within their network. Smaller clusters were aggregated to create networks based on a minimum population size, distance, and loyalty. Networks were not constrained geographically. We identified 78 multispecialty physician networks, comprising 12,410 primary care physicians, 14,687 specialists, and 175 acute care hospitals serving a total of 12,917,178 people. Median network size was 134,723 residents, 125 primary care physicians, and 143 specialists. Virtually all eligible residents were linked to a usual provider of primary care and to a network. Most specialists (93.5%) and primary care physicians (98.2%) were linked to a hospital. Median network physician loyalty was 68.4% for all physician visits and 81.1% for primary care visits. Median non-maternal admission loyalty was 67.4%. Urban networks had lower loyalties and were less self-contained but had more health care resources. We demonstrated the feasibility of identifying informal multispecialty physician networks in Ontario on the basis of patterns of health care-seeking behaviour. Networks were reasonably self-contained, in that individual residents received most of their care from providers within their respective networks. Formal constitution of networks could foster accountability for efficient, integrated care through care management tools and quality improvement, the ideas behind "accountable care organizations."

Levonorgestrel intrauterine system versus medical therapy for menorrhagia.

PubMed

Gupta, Janesh; Kai, Joe; Middleton, Lee; Pattison, Helen; Gray, Richard; Daniels, Jane

2013-01-10

Menorrhagia is a common problem, yet evidence to inform decisions about therapy is limited. In a pragmatic, multicenter, randomized trial, we compared the levonorgestrel-releasing intrauterine system (levonorgestrel-IUS) with usual medical treatment in women with menorrhagia who presented to their primary care providers. We randomly assigned 571 women with menorrhagia to treatment with levonorgestrel-IUS or usual medical treatment (tranexamic acid, mefenamic acid, combined estrogen-progestogen, or progesterone alone). The primary outcome was the patient-reported score on the Menorrhagia Multi-Attribute Scale (MMAS) (ranging from 0 to 100, with lower scores indicating greater severity), assessed over a 2-year period. Secondary outcomes included general quality-of-life and sexual-activity scores and surgical intervention. MMAS scores improved from baseline to 6 months in both the levonorgestrel-IUS group and the usual-treatment group (mean increase, 32.7 and 21.4 points, respectively; P<0.001 for both comparisons). The improvements were maintained over a 2-year period but were significantly greater in the levonorgestrel-IUS group than in the usual-treatment group (mean between-group difference, 13.4 points; 95% confidence interval, 9.9 to 16.9; P<0.001). Improvements in all MMAS domains (practical difficulties, social life, family life, work and daily routine, psychological well-being, and physical health) were significantly greater in the levonorgestrel-IUS group than in the usual-treatment group, and this was also true for seven of the eight quality-of-life domains. At 2 years, more of the women were still using the levonorgestrel-IUS than were undergoing the usual medical treatment (64% vs. 38%, P<0.001). There were no significant between-group differences in the rates of surgical intervention or sexual-activity scores. There were no significant differences in serious adverse events between groups. In women with menorrhagia who presented to primary care providers, the levonorgestrel-IUS was more effective than usual medical treatment in reducing the effect of heavy menstrual bleeding on quality of life. (Funded by the National Institute of Health Research Health Technology Assessment Programme; ECLIPSE Controlled-Trials.com number, ISRCTN86566246.).

Prospective surveillance study of haemophilia A patients switching from moroctocog alfa or other factor VIII products to moroctocog alfa albumin-free cell culture (AF-CC) in usual care settings.

PubMed

Parra Lopez, Rafael; Nemes, Laszlo; Jimenez-Yuste, Victor; Rusen, Luminita; Cid, Ana R; Charnigo, Robert J; Baumann, James A; Smith, Lynne; Korth-Bradley, Joan M; Rendo, Pablo

2015-10-01

This prospective, open-label, postauthorisation safety surveillance study assessed clinically significant inhibitor development in patients with severe haemophilia A transitioning from moroctocog alfa or other factor VIII (FVIII) replacement products to reformulated moroctocog alfa (AF-CC). Males aged ≥ 12 years with severe haemophilia A (FVIII:C) < 1 IU/dl), > 150 exposure days (EDs) to recombinant or plasma-derived FVIII products, and no detectable inhibitor at screening were enrolled. Primary end point was the incidence of clinically significant FVIII inhibitor development. Secondary end points included annualised bleeding rate (ABR), less-than-expected therapeutic effect (LETE), and FVIII recovery. Patients were assigned to one of two cohorts based on whether they were transitioning to moroctocog alfa (AF-CC) from moroctocog alfa (cohort 1; n=146) or from another recombinant or plasma-derived FVIII product (cohort 2; n=62). Mean number of EDs on study was 94 (range, 1-139). Six positive FVIII inhibitor results, as determined by local laboratories, were reported in four patients; none were confirmed by a central laboratory, no inhibitor-related clinical manifestations were reported, and all anti-FVIII antibody assays were negative. Median ABRs were 23.4 and 3.4 in patients categorised at baseline as following on-demand and prophylactic regimens, respectively; 86.5% of bleeding episodes resolved after one infusion. LETE incidence was 0.06% and 0.19% in the on-demand and prophylaxis settings, respectively. FVIII recovery remained constant throughout the study. No new safety concerns were identified. This study found no increased risk of clinically significant FVIII inhibitor development in patients transitioning from moroctocog alfa or other FVIII replacement products to moroctocog alfa (AF-CC).

Disfigured anatomies and imperfect analogies: body integrity identity disorder and the supposed right to self-demanded amputation of healthy body parts.

PubMed

Patrone, D

2009-09-01

Patients with the controversial diagnosis of body integrity identity disorder (BIID) report an emotional discomfort with having a body part (usually a limb) that they feel should not be there. This discomfort is so strong that it interferes with routine functioning and, in a majority of cases, BIID patients are motivated to seek amputation of the limb. Although patient requests to receive the best available treatment are generally respected, BIID demands for amputation, at present, are not. However, what little has been said in the ethics literature on the subject tends to favour doing so in cases of BIID. The general argument is that BIID demands should be respected, first, because of the importance that is already placed on respecting autonomy in medical decision-making contexts and second, because of the potential harm of not providing amputation coupled with the fact that no alternative means of relieving suffering exists. The defence of the right to self-demanded amputation is thus typically supported by the use of analogies with other unproblematical cases in order to show that the denial of BIID patient demands is inconsistent with conventional medical norms and practices. This paper criticises the appropriateness of the particular analogies that are thought to shed light on the allegedly unproblematical nature of BIID demands and argues that a proper understanding of the respect for autonomy in the medical decision-making context prohibits agreeing to BIID demands for amputation.

Primary bone marrow oedema syndromes.

PubMed

Patel, Sanjeev

2014-05-01

MRI scanning in patients with rheumatological conditions often shows bone marrow oedema, which can be secondary to inflammatory, degenerative, infective or malignant conditions but can also be primary. The latter condition is of uncertain aetiology and it is also uncertain whether it represents a stage in the progression to osteonecrosis in some patients. Patients with primary bone marrow oedema usually have lower limb pain, commonly the hip, knee, ankle or feet. The diagnosis is one of exclusion with the presence of typical MRI findings. Treatment is usually conservative and includes analgesics and staying off the affected limb. The natural history is that of gradual resolution of symptoms over a number of months. Evidence for medical treatment is limited, but open-label studies suggest bisphosphonates may help in the resolution of pain and improve radiological findings. Surgical decompression is usually used as a last resort.

Effect of Physically Active Academic Lessons on Body Mass Index and Physical Fitness in Primary School Children

ERIC Educational Resources Information Center

de Greeff, Johannes W.; Hartman, Esther; Mullender-Wijnsma, Marijke J.; Bosker, Roel J.; Doolaard, Simone; Visscher, Chris

2016-01-01

Background: Preventing overweight and improving physical fitness in primary school children is a worldwide challenge, and physically active intervention programs usually come with the cost of academic instruction time. This study aimed to investigate effects of physically active academic lessons on body mass index (BMI) and physical fitness in…

Two new species of Chrysopathes (Cnidaria : Anthozoa : Antipatharia) from the western Atlantic

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

Opresko, Dennis M; Loiola, L. de Laia

2008-02-01

Two new species of Chrysopathes are described, C. oligocrada from Yucatan and Brazil, and C. micracantha from the southeastern coast of the U.S. and Brazil. Chrysopathes oligocrada is characterized by lateral pinnules mostly 7 8 mm long (to 2 cm); 18 21 primary pinnules per cm; anterior-most primary pinnules with no more than one secondary pinnule (absent on some); some posterior primaries with a single secondary pinnule; lateral primary pinnules usually simple, rarely with a single subpinnule; tertiary pinnules absent; pinnular spines to 0.07 mm. This species is similar to C. formosa Opresko 2003 from the Pacific; the latter speciesmore » differing in density of pinnulation (15 18 per cm) and size of the spines (to 0.16 mm). Chrysopathes micracantha is characterized by lateral pinnules mostly 5 6 mm long (to 2 cm); 24 33 primary pinnules per cm; anterior and posterior primary pinnules with as many as two subopposite secondary pinnules; lateral primary pinnules usually simple but with subpinnules on the thicker branches and stem; tertiary pinnules rarely present; pinnular spines to 0.1 mm. Chrysopathes micracantha is similar to C. speciosa Opresko 2003 from the Pacific, the latter species differing in a greater number of secondary pinnules per primary (three or more) and in size of the spines (to 0.18 mm).« less

The effect of managed care on the incomes of primary care and specialty physicians.

PubMed

Simon, C J; Dranove, D; White, W D

1998-08-01

To determine the effects of managed care growth on the incomes of primary care and specialist physicians. Data on physician income and managed care penetration from the American Medical Association, Socioeconomic Monitoring System (SMS) Surveys for 1985 and 1993. We use secondary data from the Area Resource File and U.S. Census publications to construct geographical socioeconomic control variables, and we examine data from the National Residency Matching Program. Two-stage least squares regressions are estimated to determine the effect of local managed care penetration on specialty-specific physician incomes, while controlling for factors associated with local variation in supply and demand and accounting for the potential endogeneity of managed care penetration. The SMS survey is an annual telephone survey conducted by the American Medical Association of approximately one percent of nonfederal, post-residency U.S. physicians. Response rates average 60-70 percent, and analysis is weighted to account for nonresponse bias. The incomes of primary care physicians rose most rapidly in states with higher managed care growth, while the income growth of hospital-based specialists was negatively associated with managed care growth. Incomes of medical subspecialists were not significantly affected by managed care growth over this period. These findings are consistent with trends in postgraduate training choices of new physicians. Evidence is consistent with a relative increase in the demand for primary care physicians and a decline in the demand for some specialists under managed care. Market adjustments have important implications for health policy and physician workforce planning.

A Study on Design-Oriented Demands of VR via ZMET-QFD Model for Industrial Design Education and Students' Learning

ERIC Educational Resources Information Center

Liang, Yo-Wen; Lee, An-Sheng; Liu, Shuo-Fang

2016-01-01

The difficulty of Virtual Reality application in industrial design education and learning is VR engineers cannot comprehend what the important functions or elements are for students. In addition, a general-purpose VR usually confuses the students and provides neither good manipulation means nor useful toolkits. To solve these problems, the…

Water Harvesting II: Working toward Being Green

ERIC Educational Resources Information Center

Farenga, Stephen J.; Ness, Daniel; Craven, John A.

2008-01-01

As you have read in the previous "After the Bell" column, water harvesting is a process of diverting and collecting rainwater. One of the main reasons to harvest rainwater is to reduce the demand on local sources of water. The objective of the harvesting procedure is to gather water from a weather event that is usually lost as runoff and either…

Interim Feasibility Assessment Method for Solar Heating and Cooling of Army Buildings

DTIC Science & Technology

1976-05-01

Solar Heating and Cooling System Diagram Conventional Flat-Plate Collector ...tank. The sunlight falling on the array warms a fluid (usually glycol and water), which is pumped through the solar collectors . The heat from this...the system an SYSTEM DIAGRAM auxiliary healer capable of supplying all or part of the heating or cooling demand. Solar Collectors The function

Newly Qualified Teachers' Needs of Support for Professional Competences in Four European Countries: Finland, the United Kingdom, Portugal, and Belgium

ERIC Educational Resources Information Center

Harju, Vilhelmiina; Niemi, Hannele

2016-01-01

The first few years in the teaching profession are usually demanding. Although initial teacher education forms an essential foundation for teachers' work, it cannot fully prepare new teachers for the complexities of working life. This study focuses on investigating the need for professional development support among newly qualified teachers to…

Is the available cropland and water enough for food demand? A global perspective of the Land-Water-Food nexus

NASA Astrophysics Data System (ADS)

Ibarrola-Rivas, M. J.; Granados-Ramírez, R.; Nonhebel, S.

2017-12-01

Land and water are essential local resources for food production but are limited. The main drivers of increasing food demand are population growth and dietary changes, which depend on the socioeconomic situation of the population. These two factors affect the availability of local resources: population growth reduces the land and water per person; and adoption of affluent diets increases the demand for land and water per person. This study shows potentials of global food supply by linking food demand drivers with national land and water availability. Whether the available land and water is enough to meet national food demand was calculated for 187 countries. The calculations were performed for the past situation (1960 and 2010) and to assess four future scenarios (2050) to discuss different paths of diets, population numbers and agricultural expansion. Inclusion of the demand perspective in the analysis has shown stronger challenges for future global food supply than have other studies. The results show that with the "business as usual" scenario, 40% of the global population in 2050 will live in countries with not enough land nor water to meet the demands of their population. Restriction to basic diets will be the most effective in lowering both land and water constraints. Our results identify both food production and food demand factors, and the regions that may experience the strongest challenges in 2050.

Energy demand forecasting

NASA Astrophysics Data System (ADS)

Energy demand forecasting and its connection with national energy policies and decisions is examined in light of recent, sharply revised estimates of future energy requirements. Techniques of economic projects are examined. Modeling of energy demands is discussed. Renewable energy sources are discussed. The shift away from reliance of domestic users on oil and natural gas toward electricity as a primary energy resource is examined in the context of the need to conserve energy and expand generating capacity in order to avoid a significant electricity shortfall.

Early detection versus primary prevention in the PLCO flexible sigmoidoscopy screening trial: Which has the greatest impact on mortality?

PubMed

Doroudi, Maryam; Schoen, Robert E; Pinsky, Paul F

2017-12-15

Screening for colorectal cancer (CRC) with flexible sigmoidoscopy (FS) has been shown to reduce CRC mortality. The current study examined whether the observed mortality reduction was due primarily to the prevention of incident CRC via removal of adenomatous polyps or to the early detection of cancer and improved survival. The Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial randomized 154,900 men and women aged 55 to 74 years. Individuals underwent FS screening at baseline and at 3 or 5 years versus usual care. CRC-specific survival was analyzed using Kaplan-Meier curves and proportional hazards modeling. The authors estimated the percentage of CRC deaths averted by early detection versus primary prevention using a model that applied intervention arm survival rates to CRC cases in the usual-care arm and vice versa. A total of 1008 cases of CRC in the intervention arm and 1291 cases of CRC in the usual-care arm were observed. Through 13 years of follow-up, there was no significant difference noted between the trial arms with regard to CRC-specific survival for all CRC (68% in the intervention arm vs 65% in the usual-care arm; P =.16) or proximal CRC (68% vs 62%, respectively; P = .11) cases; however, survival in distal CRC cases was found to be higher in the intervention arm compared with the usual-care arm (77% vs 66%; P<.0001). Within each arm, symptom-detected cases had significantly worse survival compared with screen-detected cases. Overall, approximately 29% to 35% of averted CRC deaths were estimated to be due to early detection and 65% to 71% were estimated to be due to primary prevention. CRC-specific survival was similar across arms in the PLCO trial, suggesting a limited role for early detection in preventing CRC deaths. Modeling suggested that approximately two-thirds of avoided deaths were due to primary prevention. Future CRC screening guidelines should emphasize primary prevention via the identification and removal of precursor lesions. Cancer 2017;123:4815-22. © 2017 American Cancer Society. © 2017 American Cancer Society.

Alerts in electronic medical records to promote a colorectal cancer screening programme: a cluster randomised controlled trial in primary care.

PubMed

Guiriguet, Carolina; Muñoz-Ortiz, Laura; Burón, Andrea; Rivero, Irene; Grau, Jaume; Vela-Vallespín, Carmen; Vilarrubí, Mercedes; Torres, Miquel; Hernández, Cristina; Méndez-Boo, Leonardo; Toràn, Pere; Caballeria, Llorenç; Macià, Francesc; Castells, Antoni

2016-07-01

Participation rates in colorectal cancer screening are below recommended European targets. To evaluate the effectiveness of an alert in primary care electronic medical records (EMRs) to increase individuals' participation in an organised, population-based colorectal cancer screening programme when compared with usual care. Cluster randomised controlled trial in primary care centres of Barcelona, Spain. Participants were males and females aged 50-69 years, who were invited to the first round of a screening programme based on the faecal immunochemical test (FIT) (n = 41 042), and their primary care professional. The randomisation unit was the physician cluster (n = 130) and patients were blinded to the study group. The control group followed usual care as per the colorectal cancer screening programme. In the intervention group, as well as usual care, an alert to health professionals (cluster level) to promote screening was introduced in the individual's primary care EMR for 1 year. The main outcome was colorectal cancer screening participation at individual participant level. In total, 67 physicians and 21 619 patients (intervention group) and 63 physicians and 19 423 patients (control group) were randomised. In the intention-to-treat analysis screening participation was 44.1% and 42.2% respectively (odds ratio 1.08, 95% confidence interval [CI] = 0.97 to 1.20, P = 0.146). However, in the per-protocol analysis screening uptake in the intervention group showed a statistically significant increase, after adjusting for potential confounders (OR, 1.11; 95% CI = 1.02 to 1.22; P = 0.018). The use of an alert in an individual's primary care EMR is associated with a statistically significant increased uptake of an organised, FIT-based colorectal cancer screening programme in patients attending primary care centres. © British Journal of General Practice 2016.

Patient navigation for breast and colorectal cancer treatment: a randomized trial.

PubMed

Fiscella, Kevin; Whitley, Elizabeth; Hendren, Samantha; Raich, Peter; Humiston, Sharon; Winters, Paul; Jean-Pierre, Pascal; Valverde, Patricia; Thorland, William; Epstein, Ronald

2012-10-01

There is limited high-quality evidence about the impact of patient navigation (PN) on outcomes for patients with diagnosed cancer. We pooled data from two sites from the national Patient Navigation Research Program. Patients (n = 438) with newly diagnosed breast (n = 353) or colorectal cancer (n = 85) were randomized to PN or usual care. Trained lay navigators met with patients randomized to PN to help them assess treatment barriers and identify resources to overcome barriers. We used intent-to-treat analysis to assess time to completion of primary treatment, psychologic distress (impact of events scale), and satisfaction (patient satisfaction with cancer-related care) within 3 months after initiation of cancer treatment. The sample was predominantly middle-aged (mean age = 57) and female (90%); 44% were race-ethnic minorities (44%), 46% reported lower education levels, 18% were uninsured, and 9% reported a non-English primary language. The randomized groups were comparable in baseline characteristics. Primary analysis showed no statistically significant group differences in time to completion of primary cancer treatment, satisfaction with cancer-related care, or psychologic distress. Subgroup analysis showed that socially disadvantaged patients (i.e., uninsured, low English proficiency, and non-English primary language) who received PN reported higher satisfaction than those receiving usual care (all P < 0.05). Navigated patients living alone reported greater distress than those receiving usual care. Although the primary analysis showed no overall benefit, the subgroup analysis suggests that PN may improve satisfaction with care for certain disadvantaged individuals. PN for cancer patients may not necessarily reduce treatment time nor distress. 2012 AACR

Perspectives: Using Results from HRSA's Health Workforce Simulation Model to Examine the Geography of Primary Care.

PubMed

Streeter, Robin A; Zangaro, George A; Chattopadhyay, Arpita

2017-02-01

Inform health planning and policy discussions by describing Health Resources and Services Administration's (HRSA's) Health Workforce Simulation Model (HWSM) and examining the HWSM's 2025 supply and demand projections for primary care physicians, nurse practitioners (NPs), and physician assistants (PAs). HRSA's recently published projections for primary care providers derive from an integrated microsimulation model that estimates health workforce supply and demand at national, regional, and state levels. Thirty-seven states are projected to have shortages of primary care physicians in 2025, and nine states are projected to have shortages of both primary care physicians and PAs. While no state is projected to have a 2025 shortage of primary care NPs, many states are expected to have only a small surplus. Primary care physician shortages are projected for all parts of the United States, while primary care PA shortages are generally confined to Midwestern and Southern states. No state is projected to have shortages of all three provider types. Projected shortages must be considered in the context of baseline assumptions regarding current supply, demand, provider-service ratios, and other factors. Still, these findings suggest geographies with possible primary care workforce shortages in 2025 and offer opportunities for targeting efforts to enhance workforce flexibility. © Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

The Effects of a Technology-Aided Learning Environment on the Improvement of a Primary Special Education School

ERIC Educational Resources Information Center

Karal, Hasan

2015-01-01

The changes demanded by technology are reshaping people's expectations of education. These changing demands and expectations have introduced certain concepts, such as individuals who have become skilled at learning and the learning organization. Individuals and schools, as the most basic unit of educational organizations, should demonstrate a…

Decentralisation de l'enseignement: Financements Axes sur la Demande. Le Developpement en Marche. (Decentralization of Education. Demand Side Financing. Directions in Development.)

ERIC Educational Resources Information Center

Patrinos, Harry Anthony; Ariasingam, David Lakshmanan

Central governments' supply-side expansions of schooling have not equally benefited all members of society, especially girls, indigenous peoples, tribal groups, disadvantaged minorities, and the poor. Public spending on education is often inefficient, higher education is subsidized at primary education's expense, and costs are becoming…

Using an internet intervention to support self-management of low back pain in primary care: findings from a randomised controlled feasibility trial (SupportBack)

PubMed Central

Geraghty, Adam W A; Stanford, Rosie; Stuart, Beth; Little, Paul; Roberts, Lisa C; Foster, Nadine E; Hill, Jonathan C; Hay, Elaine M; Turner, David; Malakan, Wansida; Leigh, Linda; Yardley, Lucy

2018-01-01

Objective To determine the feasibility of a randomised controlled trial of an internet intervention for low back pain (LBP) using three arms: (1) usual care, (2) usual care plus an internet intervention or (3) usual care plus an internet intervention with additional physiotherapist telephone support. Design and setting A three-armed randomised controlled feasibility trial conducted in 12 general practices in England. Participants Primary care patients aged over 18 years, with current LBP, access to the internet and without indicators of serious spinal pathology or systemic illness. Interventions The ‘SupportBack’ internet intervention delivers a 6-week, tailored programme, focused on graded goal setting, self-monitoring and provision of tailored feedback to encourage physical activity. Additional physiotherapist telephone support consisted of three brief telephone calls over a 4-week period, to address any concerns and provide reassurance. Outcomes The primary outcomes were the feasibility of the trial design including recruitment, adherence and retention at follow-up. Secondary descriptive and exploratory analyses were conducted on clinical outcomes including LBP-related disability at 3 months follow-up. Results Primary outcomes: 87 patients with LBP were recruited (target 60–90) over 6 months, and there were 3 withdrawals. Adherence to the intervention was higher in the physiotherapist-supported arm, compared with the stand-alone internet intervention. Trial physiotherapists adhered to the support protocol. Overall follow-up rate on key clinical outcomes at 3 months follow-up was 84%. Conclusions This study demonstrated the feasibility of a future definitive randomised controlled trial to determine the clinical and cost-effectiveness of the SupportBack intervention in primary care patients with LBP. Trial registration number ISRCTN31034004; Results. PMID:29525768

TDM Case Studies and Commuter Testimonials

DOT National Transportation Integrated Search

1998-01-01

When the effects of Travel demand management (TDM) are quantified, it's usually : in terms of mode splits, vehicle miles traveled, average vehicle ridership, : pounds of pollutants saved, and so forth. But to fully appreciate the effect of : TDM stra...

Speed estimation for air quality analysis.

DOT National Transportation Integrated Search

2005-05-01

Average speed is an essential input to the air quality analysis model MOBILE6 for emission factor calculation. Traditionally, speed is obtained from travel demand models. However, such models are not usually calibrated to speeds. Furthermore, for rur...

Primary Mouse Myoblast Purification using Magnetic Cell Separation.

PubMed

Sincennes, Marie Claude; Wang, Yu Xin; Rudnicki, Michael A

2017-01-01

Primary myoblasts can be isolated from mouse muscle cell extracts and cultured in vitro. Muscle cells are usually dissociated manually by mincing with razor blades or scissors in a collagenase/dispase solution. Primary myoblasts are then gradually enriched by pre-plating on collagen-coated plates, based on the observation that mouse fibroblasts attach quickly to collagen-coated plates, and are less adherent. Here, we describe an automated muscle dissociation protocol. We also propose an alternative to pre-plating using magnetic bead separation of primary myoblasts, which improve myoblast purity by minimizing fibroblast contamination.

Demand assessment and price-elasticity estimation of quality-improved primary health care in Palestine: a contribution from the contingent valuation method.

PubMed

Mataria, Awad; Luchini, Stéphane; Daoud, Yousef; Moatti, Jean-Paul

2007-10-01

This paper proposes a new methodology to assess demand and price-elasticity for health care, based on patients' stated willingness to pay (WTP) values for certain aspects of health care quality improvements. A conceptual analysis of how respondents consider contingent valuation (CV) questions allowed us to specify a probability density function of stated WTP values, and consequently, to model a demand function for quality-improved health care, using a parametric survival approach. The model was empirically estimated using a CV study intended to assess patients' values for improving the quality of primary health care (PHC) services in Palestine. A random sample of 499 individuals was interviewed following medical consultation in four PHC centers. Quality was assessed using a multi-attribute approach; and respondents valued seven specific quality improvements using a decomposed valuation scenario and a payment card elicitation technique. Our results suggest an inelastic demand at low user fees levels, and when the price-increase is accompanied with substantial quality-improvements. Nevertheless, demand becomes more and more elastic if user fees continue to rise. On the other hand, patients' reactions to price-increase turn out to depend on their level of income. Our results can be used to design successful health care financing strategies that include a consideration of patients' preferences and financial capacities. John Wiley & Sons, Ltd.

[Elderly, poor, solitary and marginal patients: geriatric vulnerability in emergency services].

PubMed

Marín Gámez, N; Kessel Sardiñas, H; López Martínez, G; Barnosi Marín, A; Montoya Vergel, J; Navarro Corral, A; Delgado Rodríguez, M

1998-07-01

Status is a powerful determinant of health, and it may influence on the demand of Hospital emergency services. The aim of our investigation is to assess whether elderly patients usually wandering emergency services gather more negative socioeconomic conditions. A cross-sectional study on 800 randomised patients cared in emergency services was carried out. A questionnaire about economic, educational and professional levels, domestic violence, loneliness and life style was applied. A crude analysis was used to assess the age-factor (>/= 65 y.o.) by BMDP (PC 90). The trial was approved by the local Bioethics board. Low incomes, low educational level and loneliness were clinic and statistically related with age (65 and more). Data is offered as n (%), X2 and p < 0.0001 (Fisher exact Test two sided p value). Elderly patients frequently demanding hospital emergency services gather more vulnerability conditions, not merely medical. Low incomes, low educational level and loneliness are probably working as key factors on the geriatric demand of emergency services.

The moderating effect of control over work scheduling and overtime on the relationship between workload demands and perceived job risk.

PubMed

Näswall, Katharina; Burt, Christopher D B; Pearce, Megan

2015-01-01

This study investigated the impact of workload demands on perceived job risk using the Job Demand-Control model as a research framework. The primary objective was to test the hypothesis that employee control over work scheduling and overtime would moderate the relationship between workload demands and perceived job risk. Ninety-six participants working in a variety of industries completed measures of workload demands, and of control over work scheduling and overtime, and a measure of perceived job risk. Workload demands predicted higher perceptions of job risk. However, the results also suggest that control over overtime moderated this relationship, where those with the combination of high workload demands and low control over overtime reported higher levels of perceived risk. The results indicate that the JDC model is applicable to safety research. The results suggest that employee control over workload demands is an important variable to consider in terms of managing workplace safety. The present study also points to important areas for future research to explore in order to further understand the connection between demands and safety.

A review of urologic cancer patients with multiple primary malignancies.

PubMed

Mydlo, J H; Agins, J A; Donohoe, J; Grob, B M

2001-08-01

Much has been written on the treatment of solitary or multiple metastatic nodules that sometimes present in patients with urological malignancies. However, relatively little has been published regarding those patients with urological cancer who have another concomitant primary non-urologic tumor. We describe several cases of patients who presented with a urologic malignancy and a secondary non-urologic tumor. We also reviewed the literature using MEDLINE to gather information concerning this rare occurrence. We found that secondary malignancies, although not very common, are being increasingly reported. They are usually detected during the preoperative work-up of the primary tumor, usually by CT scan, ultrasound, or chest X-ray. Most authors suggest that treatment should be directed at the more aggressive lesion first, which would improve the overall status of the patient, and thus allow a better response from therapy for the secondary lesion. While patients with multiple primary malignancies are rare, the urologist should be alerted to this possibility when evaluating the patient for the initially presenting or detected tumor.

Humanities-Oriented Accents in Teaching Mathematics to Prospective Primary School Teachers

ERIC Educational Resources Information Center

Tabov, Jordan; Gortcheva, Iordanka

2016-01-01

Our research includes undergraduate students who major in primary school education. Their academic background is prevailingly in the humanities. This poses specific demands on their mathematics instruction at university. To attract them to their mathematics course and raise its effectiveness, we use a series of activities. Writing assignments…

Financing care for the uninsured: the dilemma vexes New Jersey hospitals and payers.

PubMed

Wells, E V

1996-05-01

New Jersey's diverse constituencies and special interest groups don't usually agree on a public policy issue. However, almost everyone in the public policy arena agrees that hospitals should treat people who show up in emergency departments with problems requiring medical attention. For over a decade, Garden State policymakers, payers, and providers have faced the dilemma of excess demand on hospitals that treat the uninsured. This demand has risen due to increasing health care costs, development of costly technology, state deregulation of hospital payments, and employers' reluctance to insure workers and their families coupled with a mobile workforce holding part-time and seasonal jobs. The fiscal solvency of inner-city hospitals is threatened yet the problem continues to elude resolution.

Identifying Potential Markets for Behind-the-Meter Battery Energy Storage:

Science.gov Websites

interval (usually 15 minutes) during a billing period. In many cases, these demand charges can account for therefore potential business cases for energy storage-were found in states not typically known for having

[Pediatric home ventilation--practical approach].

PubMed

Rath-Wacenovsky, Regina

2015-09-01

Out-of-hospital ventilation represents only a marginal area of paediatric therapeutic concepts. In Austria, the proportion of children to be supplied with invasive and non-invasive ventilation increases significantly, together with the challenges of caring for their long-term demands. Neuromuscular diseases accounted for almost the sole indication group. Premature and newborn infants with persistent respiratory failures are an increasing group, needing more extensive care due to additional comorbidities. Children with congenital disorder have often been tracheotomised in order to secure their airway, and non-invasive ventilation as a bridge- or long-term therapy gains in importance more and more. Usually, infants with primary or secondary CNS disorders suffer from respiratory complications and eventually from chronic respiratory insufficiencies during adolescence or young adulthood. Here, invasive or non-invasive ventilation can contribute both to a significant stabilisation of health status and also quality of life. Spirit of research, experience, appropriate support structures, and appropriate networking constitute the most relevant quality- and success criteria for home care.

Effects of Structured Self-Reflection on the Development of Authentic Leadership Practices among Queensland Primary School Principals

ERIC Educational Resources Information Center

Branson, Christopher

2007-01-01

This article reports on research that explored the concept of authentic leadership with seven principals of Catholic primary schools in Brisbane, Australia. Recent developments in leadership theory have promoted the concept of authentic leadership for addressing the leadership demands associated with our seemingly ever-changing and unpredictable,…

A Case for Enhancing Environmental Education Programs in Schools: Reflecting on Primary School Students' Knowledge and Attitudes

ERIC Educational Resources Information Center

Treagust, David F.; Amarant, Arlene; Chandrasegaran, A. L.; Won, Mihye

2016-01-01

Environmental education in schools is of increasing importance as the world population increases with the subsequent demand on resources and the potential for increased pollution. In an effort to enhance the standing of environmental education in the school curriculum, this study was designed to determine primary students' knowledge about the…

Cost-effectiveness of a primary care treatment program for depression in low-income women in Santiago, Chile.

PubMed

Araya, Ricardo; Flynn, Terry; Rojas, Graciela; Fritsch, Rosemarie; Simon, Greg

2006-08-01

The authors compared the incremental cost-effectiveness of a stepped-care, multicomponent program with usual care for the treatment of depressed women in primary care in Santiago, Chile. A cost-effectiveness study was conducted of a previous randomized controlled trial involving 240 eligible women with DSM-IV major depression who were selected from a consecutive sample of adult women attending primary care clinics. The patients were randomly allocated to usual care or a multicomponent stepped-care program led by a nonmedical health care worker. Depression-free days and health care costs derived from local sources were assessed after 3 and 6 months. A health service perspective was used in the economic analysis. Complete data were determined for 80% of the randomly assigned patients. After we adjusted for initial severity, women receiving the stepped-care program had a mean of 50 additional depression-free days over 6 months relative to patients allocated to usual care. The stepped-care program was marginally more expensive than usual care (an extra 216 Chilean pesos per depression-free day). There was a 90% probability that the incremental cost of obtaining an extra depression-free day with the intervention would not exceed 300 pesos (1.04 US dollars). The stepped-care program was significantly more effective and marginally more expensive than usual care for the treatment of depressed women in primary care. Small investments to improve depression appear to yield larger gains in poorer environments. Simple and inexpensive treatment programs tested in developing countries might provide good study models for developed countries.

Cost-Effectiveness of Collaborative Care for Depression in UK Primary Care: Economic Evaluation of a Randomised Controlled Trial (CADET)

PubMed Central

Green, Colin; Richards, David A.; Hill, Jacqueline J.; Gask, Linda; Lovell, Karina; Chew-Graham, Carolyn; Bower, Peter; Cape, John; Pilling, Stephen; Araya, Ricardo; Kessler, David; Bland, J. Martin; Gilbody, Simon; Lewis, Glyn; Manning, Chris; Hughes-Morley, Adwoa; Barkham, Michael

2014-01-01

Background Collaborative care is an effective treatment for the management of depression but evidence on its cost-effectiveness in the UK is lacking. Aims To assess the cost-effectiveness of collaborative care in a UK primary care setting. Methods An economic evaluation alongside a multi-centre cluster randomised controlled trial comparing collaborative care with usual primary care for adults with depression (n = 581). Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER) were calculated over a 12-month follow-up, from the perspective of the UK National Health Service and Personal Social Services (i.e. Third Party Payer). Sensitivity analyses are reported, and uncertainty is presented using the cost-effectiveness acceptability curve (CEAC) and the cost-effectiveness plane. Results The collaborative care intervention had a mean cost of £272.50 per participant. Health and social care service use, excluding collaborative care, indicated a similar profile of resource use between collaborative care and usual care participants. Collaborative care offered a mean incremental gain of 0.02 (95% CI: –0.02, 0.06) quality-adjusted life-years over 12 months, at a mean incremental cost of £270.72 (95% CI: –202.98, 886.04), and resulted in an estimated mean cost per QALY of £14,248. Where costs associated with informal care are considered in sensitivity analyses collaborative care is expected to be less costly and more effective, thereby dominating treatment as usual. Conclusion Collaborative care offers health gains at a relatively low cost, and is cost-effective compared with usual care against a decision-maker willingness to pay threshold of £20,000 per QALY gained. Results here support the commissioning of collaborative care in a UK primary care setting. PMID:25121991

Demand for Agricultural Extension Services among Small-Scale Maize Farmers: Micro-Level Evidence from Kenya

ERIC Educational Resources Information Center

Gido, Eric O.; Sibiko, Kenneth W.; Ayuya, Oscar I.; Mwangi, Joseph K.

2015-01-01

Purpose: The objective of the study was to determine the level and determinants of demand for extension services among small-scale maize farmers in Kenya. Design/methodology/approach: Based on an exploratory research design, primary data were collected from a sample of 352 households through face-to-face interviews. Focus group discussions were…

The Teacher Workforce in Australia: Supply, Demand and Data Issues. Policy Insights, Issue #2

ERIC Educational Resources Information Center

Weldon, Paul R.

2015-01-01

This paper provides a brief overview of the current teacher workforce situation in Australia. It highlights workforce trends and projected growth, and areas where the collection and analysis of additional data may assist in the targeting of effective policy. Demand for teachers is on the rise. The population of primary students is set to increase…

Investing in America's Data Science and Analytics Talent: The Case for Action

ERIC Educational Resources Information Center

Business-Higher Education Forum, 2017

2017-01-01

Increasingly US jobs require data science and analytics skills. Can we meet the demand? The current shortage of skills in the national job pool demonstrates that business-as-usual strategies won't satisfy the growing need. If we are to unlock the promise and potential of data and all the technologies that depend on it, employers and educators will…

The cost of a primary care-based childhood obesity prevention intervention

PubMed Central

2014-01-01

Background United States pediatric guidelines recommend that childhood obesity counseling be conducted in the primary care setting. Primary care-based interventions can be effective in improving health behaviors, but also costly. The purpose of this study was to evaluate the cost of a primary care-based obesity prevention intervention targeting children between the ages of two and six years who are at elevated risk for obesity, measured against usual care. Methods High Five for Kids was a cluster-randomized controlled clinical trial that aimed to modify children’s nutrition and TV viewing habits through a motivational interviewing intervention. We assessed visit-related costs from a societal perspective, including provider-incurred direct medical costs, provider-incurred equipment costs, parent time costs and parent out-of-pocket costs, in 2011 dollars for the intervention (n = 253) and usual care (n = 192) groups. We conducted a net cost analysis using both societal and health plan costing perspectives and conducted one-way sensitivity and uncertainty analyses on results. Results The total costs for the intervention group and usual care groups in the first year of the intervention were $65,643 (95% CI [$64,522, $66,842]) and $12,192 (95% CI [$11,393, $13,174]). The mean costs for the intervention and usual care groups were $259 (95% CI [$255, $264]) and $63 (95% CI [$59, $69]) per child, respectively, for a incremental difference of $196 (95% CI [$191, $202]) per child. Children in the intervention group attended a mean of 2.4 of a possible 4 in-person visits and received 0.45 of a possible 2 counseling phone calls. Provider-incurred costs were the primary driver of cost estimates in sensitivity analyses. Conclusions High Five for Kids was a resource-intensive intervention. Further studies are needed to assess the cost-effectiveness of the intervention relative to other pediatric obesity interventions. Trial registration ClinicalTrials.gov Identifier: NCT00377767. PMID:24472122

The cost of a primary care-based childhood obesity prevention intervention.

PubMed

Wright, Davene R; Taveras, Elsie M; Gillman, Matthew W; Horan, Christine M; Hohman, Katherine H; Gortmaker, Steven L; Prosser, Lisa A

2014-01-29

United States pediatric guidelines recommend that childhood obesity counseling be conducted in the primary care setting. Primary care-based interventions can be effective in improving health behaviors, but also costly. The purpose of this study was to evaluate the cost of a primary care-based obesity prevention intervention targeting children between the ages of two and six years who are at elevated risk for obesity, measured against usual care. High Five for Kids was a cluster-randomized controlled clinical trial that aimed to modify children's nutrition and TV viewing habits through a motivational interviewing intervention. We assessed visit-related costs from a societal perspective, including provider-incurred direct medical costs, provider-incurred equipment costs, parent time costs and parent out-of-pocket costs, in 2011 dollars for the intervention (n = 253) and usual care (n =192) groups. We conducted a net cost analysis using both societal and health plan costing perspectives and conducted one-way sensitivity and uncertainty analyses on results. The total costs for the intervention group and usual care groups in the first year of the intervention were $65,643 (95% CI [$64,522, $66,842]) and $12,192 (95% CI [$11,393, $13,174]). The mean costs for the intervention and usual care groups were $259 (95% CI [$255, $264]) and $63 (95% CI [$59, $69]) per child, respectively, for a incremental difference of $196 (95% CI [$191, $202]) per child. Children in the intervention group attended a mean of 2.4 of a possible 4 in-person visits and received 0.45 of a possible 2 counseling phone calls. Provider-incurred costs were the primary driver of cost estimates in sensitivity analyses. High Five for Kids was a resource-intensive intervention. Further studies are needed to assess the cost-effectiveness of the intervention relative to other pediatric obesity interventions.

Teaming up: feasibility of an online treatment environment for adolescents with type 1 diabetes.

PubMed

Boogerd, Emiel A; Noordam, Cees; Kremer, Jan Am; Prins, Judith B; Verhaak, Chris M

2014-08-01

To evaluate the feasibility of an online interactive treatment environment for adolescents with type 1 diabetes, called Sugarsquare, to supplement usual care. Sugarsquare provides easily accessible contact with the diabetes team, peer support, and treatment overview. Of 120 eligible patients, 62 adolescents aged 11-21 (M = 15.23, SD = 2.00) were assigned to a usual-care group (n = 31) or a usual-care + intervention group (n = 31). Feasibility was assessed in terms of acceptability, demand, practicability, integration, and efficacy in a 9-month study-period. Assessment of acceptability and demand revealed that 20 adolescents in the intervention group (65%) logged in at least once; 16 adolescents (52%) logged in repeatedly. Usage resulted in 5795 page-views, 3580 chat-messages, 427 forum-messages, and in 40 private interactions between 11 adolescents (35%) and professionals. Assessment of practicability revealed that all 13 professionals (100%) accessed the intervention. Slow processing speed and security procedures formed obstacles for usage. Assessment of integration showed that international standards for diabetes care (International Diabetes Federation/International Society for Pediatric and Adolescent Diabetes/American Diabetes Association) were met. Assessment of efficacy revealed improvement in the intervention group in evaluation of care (Patients' Evaluation of Quality of Diabetes), F(1,30) = 5.35, p < 0.05, and quality of life, communication (PedsQL), F(1,30) = 11.65, p <0.05. The latter was correlated with posted chat-messages (r = 0.42, p < 0.05). No between-group differences were found. This study shows that Sugarsquare is feasible in adolescents with type 1 diabetes. It meets a demand in adolescents and can support professionals when organizing on-going care according to international standards. Results are promising and next steps are a full-scale randomized controlled trial and subsequent implementation in daily care. © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

An Approximation Solution to Refinery Crude Oil Scheduling Problem with Demand Uncertainty Using Joint Constrained Programming

PubMed Central

Duan, Qianqian; Yang, Genke; Xu, Guanglin; Pan, Changchun

2014-01-01

This paper is devoted to develop an approximation method for scheduling refinery crude oil operations by taking into consideration the demand uncertainty. In the stochastic model the demand uncertainty is modeled as random variables which follow a joint multivariate distribution with a specific correlation structure. Compared to deterministic models in existing works, the stochastic model can be more practical for optimizing crude oil operations. Using joint chance constraints, the demand uncertainty is treated by specifying proximity level on the satisfaction of product demands. However, the joint chance constraints usually hold strong nonlinearity and consequently, it is still hard to handle it directly. In this paper, an approximation method combines a relax-and-tight technique to approximately transform the joint chance constraints to a serial of parameterized linear constraints so that the complicated problem can be attacked iteratively. The basic idea behind this approach is to approximate, as much as possible, nonlinear constraints by a lot of easily handled linear constraints which will lead to a well balance between the problem complexity and tractability. Case studies are conducted to demonstrate the proposed methods. Results show that the operation cost can be reduced effectively compared with the case without considering the demand correlation. PMID:24757433

An approximation solution to refinery crude oil scheduling problem with demand uncertainty using joint constrained programming.

PubMed

Duan, Qianqian; Yang, Genke; Xu, Guanglin; Pan, Changchun

2014-01-01

This paper is devoted to develop an approximation method for scheduling refinery crude oil operations by taking into consideration the demand uncertainty. In the stochastic model the demand uncertainty is modeled as random variables which follow a joint multivariate distribution with a specific correlation structure. Compared to deterministic models in existing works, the stochastic model can be more practical for optimizing crude oil operations. Using joint chance constraints, the demand uncertainty is treated by specifying proximity level on the satisfaction of product demands. However, the joint chance constraints usually hold strong nonlinearity and consequently, it is still hard to handle it directly. In this paper, an approximation method combines a relax-and-tight technique to approximately transform the joint chance constraints to a serial of parameterized linear constraints so that the complicated problem can be attacked iteratively. The basic idea behind this approach is to approximate, as much as possible, nonlinear constraints by a lot of easily handled linear constraints which will lead to a well balance between the problem complexity and tractability. Case studies are conducted to demonstrate the proposed methods. Results show that the operation cost can be reduced effectively compared with the case without considering the demand correlation.

Importance of food-demand management for climate mitigation

NASA Astrophysics Data System (ADS)

Bajželj, Bojana; Richards, Keith S.; Allwood, Julian M.; Smith, Pete; Dennis, John S.; Curmi, Elizabeth; Gilligan, Christopher A.

2014-10-01

Recent studies show that current trends in yield improvement will not be sufficient to meet projected global food demand in 2050, and suggest that a further expansion of agricultural area will be required. However, agriculture is the main driver of losses of biodiversity and a major contributor to climate change and pollution, and so further expansion is undesirable. The usual proposed alternative--intensification with increased resource use--also has negative effects. It is therefore imperative to find ways to achieve global food security without expanding crop or pastureland and without increasing greenhouse gas emissions. Some authors have emphasized a role for sustainable intensification in closing global `yield gaps' between the currently realized and potentially achievable yields. However, in this paper we use a transparent, data-driven model, to show that even if yield gaps are closed, the projected demand will drive further agricultural expansion. There are, however, options for reduction on the demand side that are rarely considered. In the second part of this paper we quantify the potential for demand-side mitigation options, and show that improved diets and decreases in food waste are essential to deliver emissions reductions, and to provide global food security in 2050.

Meeting China's electricity needs through clean energy sources: A 2030 low-carbon energy roadmap

NASA Astrophysics Data System (ADS)

Hu, Zheng

China is undergoing rapid economic development that generates significant increase in energy demand, primarily for electricity. Energy supply in China is heavily relying on coal, which leads to high carbon emissions. This dissertation explores opportunities for meeting China's growing power demand through clean energy sources. The utilization of China's clean energy sources as well as demand-side management is still at the initial phase. Therefore, development of clean energy sources would require substantial government support in order to be competitive in the market. One of the widely used means to consider clean energy in power sector supplying is Integrated Resource Strategic Planning, which aims to minimize the long term electricity costs while screening various power supply options for the power supply and demand analysis. The IRSP tool tackles the energy problem from the perspective of power sector regulators, and provides different policy scenarios to quantify the impacts of combined incentives. Through three scenario studies, Business as Usual, High Renewable, and Renewable and Demand Side Management, this dissertation identifies the optimized scenario for China to achieve the clean energy target of 2030. The scenarios are assessed through energy, economics, environment, and equity dimensions.

Towards environmentally sustainable human behaviour: targeting non-conscious and conscious processes for effective and acceptable policies

NASA Astrophysics Data System (ADS)

Marteau, Theresa M.

2017-05-01

Meeting climate change targets to limit global warming to 2°C requires rapid and large reductions in demand for products that most contribute to greenhouse gas (GHG) emissions. These include production of bulk materials (e.g. steel and cement), energy supply (e.g. fossil fuels) and animal source foods (particularly ruminants and their products). Effective strategies to meet these targets require transformative changes in supply as well as demand, involving changes in economic, political and legal systems at local, national and international levels, building on evidence from many disciplines. This paper outlines contributions from behavioural science in reducing demand. Grounded in dual-process models of human behaviour (involving non-conscious and conscious processes) this paper considers first why interventions aimed at changing population values towards the environment are usually insufficient or unnecessary for reducing demand although they may be important in increasing public acceptability of policies that could reduce demand. It then outlines two sets of evidence from behavioural science towards effective systems-based strategies, to identify interventions likely to be effective at: (i) reducing demand for products that contribute most to GHG emissions, mainly targeting non-conscious processes and (ii) increasing public acceptability for policy changes to enable these interventions, targeting conscious processes. This article is part of the themed issue 'Material demand reduction'.

Towards environmentally sustainable human behaviour: targeting non-conscious and conscious processes for effective and acceptable policies.

PubMed

Marteau, Theresa M

2017-06-13

Meeting climate change targets to limit global warming to 2°C requires rapid and large reductions in demand for products that most contribute to greenhouse gas (GHG) emissions. These include production of bulk materials (e.g. steel and cement), energy supply (e.g. fossil fuels) and animal source foods (particularly ruminants and their products). Effective strategies to meet these targets require transformative changes in supply as well as demand, involving changes in economic, political and legal systems at local, national and international levels, building on evidence from many disciplines. This paper outlines contributions from behavioural science in reducing demand. Grounded in dual-process models of human behaviour (involving non-conscious and conscious processes) this paper considers first why interventions aimed at changing population values towards the environment are usually insufficient or unnecessary for reducing demand although they may be important in increasing public acceptability of policies that could reduce demand. It then outlines two sets of evidence from behavioural science towards effective systems-based strategies, to identify interventions likely to be effective at: (i) reducing demand for products that contribute most to GHG emissions, mainly targeting non-conscious processes and (ii) increasing public acceptability for policy changes to enable these interventions, targeting conscious processes.This article is part of the themed issue 'Material demand reduction'. © 2017 The Authors.

Towards environmentally sustainable human behaviour: targeting non-conscious and conscious processes for effective and acceptable policies

PubMed Central

2017-01-01

Meeting climate change targets to limit global warming to 2°C requires rapid and large reductions in demand for products that most contribute to greenhouse gas (GHG) emissions. These include production of bulk materials (e.g. steel and cement), energy supply (e.g. fossil fuels) and animal source foods (particularly ruminants and their products). Effective strategies to meet these targets require transformative changes in supply as well as demand, involving changes in economic, political and legal systems at local, national and international levels, building on evidence from many disciplines. This paper outlines contributions from behavioural science in reducing demand. Grounded in dual-process models of human behaviour (involving non-conscious and conscious processes) this paper considers first why interventions aimed at changing population values towards the environment are usually insufficient or unnecessary for reducing demand although they may be important in increasing public acceptability of policies that could reduce demand. It then outlines two sets of evidence from behavioural science towards effective systems-based strategies, to identify interventions likely to be effective at: (i) reducing demand for products that contribute most to GHG emissions, mainly targeting non-conscious processes and (ii) increasing public acceptability for policy changes to enable these interventions, targeting conscious processes. This article is part of the themed issue ‘Material demand reduction’. PMID:28461435

Cost-effectiveness of a vocational enablement protocol for employees with hearing impairment; design of a randomized controlled trial

PubMed Central

2012-01-01

Background Hearing impairment at the workplace, and the resulting psychosocial problems are a major health problem with substantial costs for employees, companies, and society. Therefore, it is important to develop interventions to support hearing impaired employees. The objective of this article is to describe the design of a randomized controlled trial evaluating the (cost-) effectiveness of a Vocational Enablement Protocol (VEP) compared with usual care. Methods/Design Participants will be selected with the 'Hearing and Distress Screener'. The study population will consist of 160 hearing impaired employees. The VEP intervention group will be compared with usual care. The VEP integrated care programme consists of a multidisciplinary assessment of auditory function, work demands, and personal characteristics. The goal of the intervention is to facilitate participation in work. The primary outcome measure of the study is 'need for recovery after work'. Secondary outcome measures are coping with hearing impairment, distress, self-efficacy, psychosocial workload, job control, general health status, sick leave, work productivity, and health care use. Outcome measures will be assessed by questionnaires at baseline, and 3, 6, 9, and 12 months after baseline. The economic evaluation will be performed from both a societal and a company perspective. A process evaluation will also be performed. Discussion Interventions addressing occupational difficulties of hearing impaired employees are rare but highly needed. If the VEP integrated care programme proves to be (cost-) effective, the intervention can have an impact on the well-being of hearing impaired employees, and thereby, on the costs for the company as well for the society. Trial registration Netherlands Trial Register (NTR): NTR2782 PMID:22380920

Collaborative care for depression in European countries: a systematic review and meta-analysis.

PubMed

Sighinolfi, Cecilia; Nespeca, Claudia; Menchetti, Marco; Levantesi, Paolo; Belvederi Murri, Martino; Berardi, Domenico

2014-10-01

This is a systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the effectiveness of collaborative care compared to Primary Care Physician's (PCP's) usual care in the treatment of depression, focusing on European countries. A systematic review of English and non-English articles, from inception to March 2014, was performed using database PubMed, British Nursing Index and Archive, Ovid Medline (R), PsychINFO, Books@Ovid, PsycARTICLES Full Text, EMBASE Classic+Embase, DARE (Database of Abstract of Reviews of Effectiveness) and the Cochrane Library electronic database. Search term included depression, collaborative care, physician family and allied health professional. RCTs comparing collaborative care to usual care for depression in primary care were included. Titles and abstracts were independently examined by two reviewers, who extracted from the included trials information on participants' characteristics, type of intervention, features of collaborative care and type of outcome measure. The 17 papers included, regarding 15 RCTs, involved 3240 participants. Primary analyses showed that collaborative care models were associated with greater improvement in depression outcomes in the short term, within 3 months (standardized mean difference (SMD) -0.19, 95% CI=-0.33; -0.05; p=0.006), medium term, between 4 and 11 months (SMD -0.24, 95% CI=-0.39; -0.09; p=0.001) and medium-long term, from 12 months and over (SMD -0.21, 95% CI=-0.37; -0.04; p=0.01), compared to usual care. The present review, specifically focusing on European countries, shows that collaborative care is more effective than treatment as usual in improving depression outcomes. Copyright © 2014 Elsevier Inc. All rights reserved.

The impact of demand management strategies on parents’ decision-making for out-of-hours primary care: findings from a survey in The Netherlands

PubMed Central

Giesen, Marie-Jeanne; Keizer, Ellen; van de Pol, Julia; Knoben, Joris; Wensing, Michel; Giesen, Paul

2017-01-01

Objective To explore the potential impact of demand management strategies on patient decision-making in medically non-urgent and urgent scenarios during out-of-hours for children between the ages of 0 and 4 years. Design and methods We conducted a cross-sectional survey with paper-based case scenarios. A survey was sent to all 797 parents of children aged between 0 and 4 years from four Dutch general practitioner (GP) practices. Four demand management strategies (copayment, online advice, overview medical cost and GP appointment next morning) were incorporated in two medically non-urgent and two urgent case scenarios. Combining the case scenarios with the demand management strategies resulted in 16 cases (four scenarios each with four demand management strategies). Each parent randomly received a questionnaire with three different case scenarios with three different demand strategies and a baseline case scenario without a demand management strategy. Results The response rate was 47.4%. The strategy online advice led to more medically appropriate decision-making for both non-urgent case scenarios (OR 0.26; 95% CI 0.11 to 0.58) and urgent case scenarios (OR 0.16; 95% CI 0.08 to 0.32). Overview of medical cost (OR 0.59; 95% CI 0.38 to 0.92) and a GP appointment planned the next morning (OR 0.57; 95% CI 0.34 to 0.97) had some influence on patient decisions for urgent cases, but not for non-urgent cases. Copayment had no influence on patient decisions. Conclusion Online advice has the highest potential to reduce medically unnecessary use. Furthermore it enhanced safety of parents' decisions on seeking help for their young children during out-of-hours primary care. Valid online information on health symptoms for patients should be promoted. PMID:28487458

The impact of demand management strategies on parents' decision-making for out-of-hours primary care: findings from a survey in The Netherlands.

PubMed

Giesen, Marie-Jeanne; Keizer, Ellen; van de Pol, Julia; Knoben, Joris; Wensing, Michel; Giesen, Paul

2017-05-09

To explore the potential impact of demand management strategies on patient decision-making in medically non-urgent and urgent scenarios during out-of-hours for children between the ages of 0 and 4 years. We conducted a cross-sectional survey with paper-based case scenarios. A survey was sent to all 797 parents of children aged between 0 and 4 years from four Dutch general practitioner (GP) practices. Four demand management strategies (copayment, online advice, overview medical cost and GP appointment next morning) were incorporated in two medically non-urgent and two urgent case scenarios. Combining the case scenarios with the demand management strategies resulted in 16 cases (four scenarios each with four demand management strategies). Each parent randomly received a questionnaire with three different case scenarios with three different demand strategies and a baseline case scenario without a demand management strategy. The response rate was 47.4%. The strategy online advice led to more medically appropriate decision-making for both non-urgent case scenarios (OR 0.26; CI 0.11 to 0.58) and urgent case scenarios (OR 0.16; CI 0.08 to 0.32). Overview of medical cost (OR 0.59; CI 0.38 to 0.92) and a GP appointment planned the next morning (OR 0.57; CI 0.34 to 0.97) had some influence on patient decisions for urgent cases, but not for non-urgent cases. Copayment had no influence on patient decisions. Online advice has the highest potential to reduce medically unnecessary use. Furthermore it enhanced safety of parents' decisions on seeking help for their young children during out-of-hours primary care. Valid online information on health symptoms for patients should be promoted. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Crowd medical services in the English Football League: remodelling the team for the 21st century using a realist approach

PubMed Central

Leary, Alison; Kemp, Anthony; Greenwood, Peter; Hart, Nick; Agnew, James; Barrett, John; Punshon, Geoffrey

2017-01-01

Objectives To evaluate the new model of providing care based on demand. This included reconfiguration of the workforce to manage workforce supply challenges and meet demand without compromising the quality of care. Design Currently the Sports Ground Safety Authority recommends the provision of crowd medical cover at English Football League stadia. The guidance on provision of services has focused on extreme circumstances such as the Hillsborough disaster in 1989, while the majority of demand on present-day services is from patients with minor injuries, exacerbations of injuries and pre-existing conditions. A new model of care was introduced in the 2009/2010 season to better meet demand. A realist approach was taken. Data on each episode of care were collected over 14 consecutive football league seasons at Millwall FC divided into two periods, preimplementation of changes and postimplementation of changes. Data on workforce retention and volunteer satisfaction were also collected. Setting The data were obtained from one professional football league team (Millwall FC) located in London, UK. Primary and secondary outcomes The primary outcome was to examine the demand for crowd medical services. The secondary outcome was to remodel the service to meet these demands. Results In total, 981 episodes of care were recorded over the evaluation period of 14 years. The groups presenting, demographic and type of presentation did not change over the evaluation. First aiders were involved in 87.7% of episodes of care, nurses in 44.4% and doctors 17.8%. There was a downward trend in referrals to hospital. Workforce feedback was positive. Conclusions The new workforce model has met increased service demands while reducing the number of referrals to acute care. It involves the first aid workforce in more complex care and key decision-making and provides a flexible registered healthcare professional team to optimise the skill mix of the team. PMID:29273665

Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial

PubMed Central

Littlewood, Elizabeth; Hewitt, Catherine; Brierley, Gwen; Tharmanathan, Puvan; Araya, Ricardo; Barkham, Michael; Bower, Peter; Cooper, Cindy; Gask, Linda; Kessler, David; Lester, Helen; Lovell, Karina; Parry, Glenys; Richards, David A; Andersen, Phil; Brabyn, Sally; Knowles, Sarah; Shepherd, Charles; Tallon, Debbie; White, David

2015-01-01

Study question How effective is supported computerised cognitive behaviour therapy (cCBT) as an adjunct to usual primary care for adults with depression? Methods This was a pragmatic, multicentre, three arm, parallel randomised controlled trial with simple randomisation. Treatment allocation was not blinded. Participants were adults with symptoms of depression (score ≥10 on nine item patient health questionnaire, PHQ-9) who were randomised to receive a commercially produced cCBT programme (“Beating the Blues”) or a free to use cCBT programme (MoodGYM) in addition to usual GP care. Participants were supported and encouraged to complete the programme via weekly telephone calls. Control participants were offered usual GP care, with no constraints on the range of treatments that could be accessed. The primary outcome was severity of depression assessed with the PHQ-9 at four months. Secondary outcomes included health related quality of life (measured by SF-36) and psychological wellbeing (measured by CORE-OM) at four, 12, and 24 months and depression at 12 and 24 months. Study answer and limitations Participants offered commercial or free to use cCBT experienced no additional improvement in depression compared with usual GP care at four months (odds ratio 1.19 (95% confidence interval 0.75 to 1.88) for Beating the Blues v usual GP care; 0.98 (0.62 to 1.56) for MoodGYM v usual GP care). There was no evidence of an overall difference between either programme compared with usual GP care (0.99 (0.57 to 1.70) and 0.68 (0.42 to 1.10), respectively) at any time point. Commercially provided cCBT conferred no additional benefit over free to use cCBT or usual GP care at any follow-up point. Uptake and use of cCBT was low, despite regular telephone support. Nearly a quarter of participants (24%) had dropped out by four months. The study did not have enough power to detect small differences so these cannot be ruled out. Findings cannot be generalised to cCBT offered with a much higher level of guidance and support. What this study adds Supported cCBT does not substantially improve depression outcomes compared with usual GP care alone. In this study, neither a commercially available nor free to use computerised CBT intervention was superior to usual GP care. Funding, competing interests, data sharing Commissioned and funded by the UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme (project No 06/43/05). The authors have no competing interests. Requests for patient level data will be considered by the REEACT trial management group Trial registration Current Controlled Trials ISRCTN91947481. PMID:26559241

California's 2050 travel demand : anticipating an era of climate change and energy constraints.

DOT National Transportation Integrated Search

2008-05-30

The long-term context for Californias transportation systems is one of significant transformation. Neither business as usual or slow incremental change are likely to represent the future because of climate change mitigation and energy supply...

Regional Disease Vector Ecology Profile: The Middle East

DTIC Science & Technology

1999-10-01

meningoencephalitis, or diphasic milk disease. Human disease of the Far Eastern subtype is usually clinically more severe in the acute phase and...bites of infected ticks or by crushing infected ticks on abraded skin. Infection can also be acquired from the consumption of raw milk or...unpasteurized milk products, usually from goats. Natural infections have been recorded in 16 species of ixodid ticks. Ixodes ricinus is the primary vector

Comparative Effectiveness of a Technology-Facilitated Depression Care Management Model in Safety-Net Primary Care Patients With Type 2 Diabetes: 6-Month Outcomes of a Large Clinical Trial

PubMed Central

Ell, Kathleen; Jin, Haomiao; Vidyanti, Irene; Chou, Chih-Ping; Lee, Pey-Jiuan; Gross-Schulman, Sandra; Sklaroff, Laura Myerchin; Belson, David; Nezu, Arthur M; Hay, Joel; Wang, Chien-Ju; Scheib, Geoffrey; Di Capua, Paul; Hawkins, Caitlin; Liu, Pai; Ramirez, Magaly; Wu, Brian W; Richman, Mark; Myers, Caitlin; Agustines, Davin; Dasher, Robert; Kopelowicz, Alex; Allevato, Joseph; Roybal, Mike; Ipp, Eli; Haider, Uzma; Graham, Sharon; Mahabadi, Vahid; Guterman, Jeffrey

2018-01-01

Background Comorbid depression is a significant challenge for safety-net primary care systems. Team-based collaborative depression care is effective, but complex system factors in safety-net organizations impede adoption and result in persistent disparities in outcomes. Diabetes-Depression Care-management Adoption Trial (DCAT) evaluated whether depression care could be significantly improved by harnessing information and communication technologies to automate routine screening and monitoring of patient symptoms and treatment adherence and allow timely communication with providers. Objective The aim of this study was to compare 6-month outcomes of a technology-facilitated care model with a usual care model and a supported care model that involved team-based collaborative depression care for safety-net primary care adult patients with type 2 diabetes. Methods DCAT is a translational study in collaboration with Los Angeles County Department of Health Services, the second largest safety-net care system in the United States. A comparative effectiveness study with quasi-experimental design was conducted in three groups of adult patients with type 2 diabetes to compare three delivery models: usual care, supported care, and technology-facilitated care. Six-month outcomes included depression and diabetes care measures and patient-reported outcomes. Comparative treatment effects were estimated by linear or logistic regression models that used generalized propensity scores to adjust for sampling bias inherent in the nonrandomized design. Results DCAT enrolled 1406 patients (484 in usual care, 480 in supported care, and 442 in technology-facilitated care), most of whom were Hispanic or Latino and female. Compared with usual care, both the supported care and technology-facilitated care groups were associated with significant reduction in depressive symptoms measured by scores on the 9-item Patient Health Questionnaire (least squares estimate, LSE: usual care=6.35, supported care=5.05, technology-facilitated care=5.16; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.02); decreased prevalence of major depression (odds ratio, OR: supported care vs usual care=0.45, technology-facilitated care vs usual care=0.33; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.007); and reduced functional disability as measured by Sheehan Disability Scale scores (LSE: usual care=3.21, supported care=2.61, technology-facilitated care=2.59; P value: supported care vs usual care=.04, technology-facilitated care vs usual care=.03). Technology-facilitated care was significantly associated with depression remission (technology-facilitated care vs usual care: OR=2.98, P=.04); increased satisfaction with care for emotional problems among depressed patients (LSE: usual care=3.20, technology-facilitated care=3.70; P=.05); reduced total cholesterol level (LSE: usual care=176.40, technology-facilitated care=160.46; P=.01); improved satisfaction with diabetes care (LSE: usual care=4.01, technology-facilitated care=4.20; P=.05); and increased odds of taking an glycated hemoglobin test (technology-facilitated care vs usual care: OR=3.40, P<.001). Conclusions Both the technology-facilitated care and supported care delivery models showed potential to improve 6-month depression and functional disability outcomes. The technology-facilitated care model has a greater likelihood to improve depression remission, patient satisfaction, and diabetes care quality. PMID:29685872

Understanding and responding when things go wrong: key principles for primary care educators.

PubMed

McNab, Duncan; Bowie, Paul; Ross, Alastair; Morrison, Jill

2016-07-01

Learning from events with unwanted outcomes is an important part of workplace based education and providing evidence for medical appraisal and revalidation. It has been suggested that adopting a 'systems approach' could enhance learning and effective change. We believe the following key principles should be understood by all healthcare staff, especially those with a role in developing and delivering educational content for safety and improvement in primary care. When things go wrong, professional accountability involves accepting there has been a problem, apologising if necessary and committing to learn and change. This is easier in a 'Just Culture' where wilful disregard of safe practice is not tolerated but where decisions commensurate with training and experience do not result in blame and punishment. People usually attempt to achieve successful outcomes, but when things go wrong the contribution of hindsight and attribution bias as well as a lack of understanding of conditions and available information (local rationality) can lead to inappropriately blame 'human error'. System complexity makes reduction into component parts difficult; thus attempting to 'find-and-fix' malfunctioning components may not always be a valid approach. Finally, performance variability by staff is often needed to meet demands or cope with resource constraints. We believe understanding these core principles is a necessary precursor to adopting a 'systems approach' that can increase learning and reduce the damaging effects on morale when 'human error' is blamed. This may result in 'human error' becoming the starting point of an investigation and not the endpoint.

Medical resource inventory model for emergency preparation with uncertain demand and stochastic occurrence time under considering different risk preferences at the airport

PubMed Central

Pan, Wei; Guo, Ying; Jin, Lei; Liao, ShuJie

2017-01-01

With the high accident rate of civil aviation, medical resource inventory becomes more important for emergency management at the airport. Meanwhile, medical products usually are time-sensitive and short lifetime. Moreover, we find that the optimal medical resource inventory depends on multiple factors such as different risk preferences, the material shelf life and so on. Thus, it becomes very complex in a real-life environment. According to this situation, we construct medical resource inventory decision model for emergency preparation at the airport. Our model is formulated in such a way as to simultaneously consider uncertain demand, stochastic occurrence time and different risk preferences. For solving this problem, a new programming is developed. Finally, a numerical example is presented to illustrate the proposed method. The results show that it is effective for determining the optimal medical resource inventory for emergency preparation with uncertain demand and stochastic occurrence time under considering different risk preferences at the airport. PMID:28931007

Medical resource inventory model for emergency preparation with uncertain demand and stochastic occurrence time under considering different risk preferences at the airport.

PubMed

Pan, Wei; Guo, Ying; Jin, Lei; Liao, ShuJie

2017-01-01

With the high accident rate of civil aviation, medical resource inventory becomes more important for emergency management at the airport. Meanwhile, medical products usually are time-sensitive and short lifetime. Moreover, we find that the optimal medical resource inventory depends on multiple factors such as different risk preferences, the material shelf life and so on. Thus, it becomes very complex in a real-life environment. According to this situation, we construct medical resource inventory decision model for emergency preparation at the airport. Our model is formulated in such a way as to simultaneously consider uncertain demand, stochastic occurrence time and different risk preferences. For solving this problem, a new programming is developed. Finally, a numerical example is presented to illustrate the proposed method. The results show that it is effective for determining the optimal medical resource inventory for emergency preparation with uncertain demand and stochastic occurrence time under considering different risk preferences at the airport.

Disease management in the treatment of patients with chronic heart failure who have universal access to health care: a randomized controlled trial.

PubMed

Kalter-Leibovici, Ofra; Freimark, Dov; Freedman, Laurence S; Kaufman, Galit; Ziv, Arnona; Murad, Havi; Benderly, Michal; Silverman, Barbara G; Friedman, Nurit; Cukierman-Yaffe, Tali; Asher, Elad; Grupper, Avishay; Goldman, Dorit; Amitai, Miriam; Matetzky, Shlomi; Shani, Mordechai; Silber, Haim

2017-05-01

The efficacy of disease management programs in improving the outcome of heart failure patients remains uncertain and may vary across health systems. This study explores whether a countrywide disease management program is superior to usual care in reducing adverse health outcomes and improving well-being among community-dwelling adult patients with moderate-to-severe chronic heart failure who have universal access to advanced health-care services and technologies. In this multicenter open-label trial, 1,360 patients recruited after hospitalization for heart failure exacerbation (38%) or from the community (62%) were randomly assigned to either disease management or usual care. Disease management, delivered by multi-disciplinary teams, included coordination of care, patient education, monitoring disease symptoms and patient adherence to medication regimen, titration of drug therapy, and home tele-monitoring of body weight, blood pressure and heart rate. Patients assigned to usual care were treated by primary care practitioners and consultant cardiologists. The primary composite endpoint was the time elapsed till first hospital admission for heart failure exacerbation or death from any cause. Secondary endpoints included the number of all hospital admissions, health-related quality of life and depression during follow-up. Intention-to-treat comparisons between treatments were adjusted for baseline patient data and study center. During the follow-up, 388 (56.9%) patients assigned to disease management and 387 (57.1%) assigned to usual care had a primary endpoint event. The median (range) time elapsed until the primary endpoint event or end of study was 2.0 (0-5.0) years among patients assigned to disease management, and 1.8 (0-5.0) years among patients assigned to usual care (adjusted hazard ratio, 0.908; 95% confidence interval, 0.788 to 1.047). Hospital admissions were mostly (70%) unrelated to heart failure. Patients assigned to disease management had a better health-related quality of life and a lower depression score during follow-up. This comprehensive disease management intervention was not superior to usual care with respect to the primary composite endpoint, but it improved health-related quality of life and depression. A disease-centered approach may not suffice to make a significant impact on hospital admissions and mortality in patients with chronic heart failure who have universal access to health care. Clinicaltrials.gov identifier: NCT00533013 . Trial registration date: 9 August 2007. Initial protocol release date: 20 September 2007.

[Care concepts in mass casualty incidents and disasters. Concept for primary care clinic].

PubMed

Adams, H A; Flemming, A; Lange, C; Koppert, W; Krettek, C

2015-02-01

Patient care in mass casualty incidents and disaster strongly demand a joint approach of all preclinical and clinical forces. Special emphasis must be placed on immediate triage, establishment and preservation of transportability of high-risk patients and their clinical treatment as soon as possible. During limited mass casualties, the preclinical rescue station additionally serves as a buffer for patients, whereby in case of disaster, the focus on transportation of high-risk patients is imperative. Primary care hospitals are a decisive part in the chain of medical supply and are confronted with great challenges, which demand detailed emergency plans and also repeated exercises. In planning and exercises, special attention should be given to the cooperation with the fire department and other medical services.

Pupils' Beliefs in Cultural Interpretations of "Heat" Associated with Anger: A Comparative Study of Ten Ethnic Communities in Kenya

ERIC Educational Resources Information Center

Okere, Mark I. O.; Keraro, Fred N.; Anditi, Zephania

2012-01-01

Emerging evidence indicates that culture influences pupils learning of science. However, the influence of culture on science learning is usually not considered when developing science curricular for both primary and secondary schools. This study investigated the extent to which primary and secondary school pupils believe in cultural…

Tapentadol versus tramadol in the management of low back pain in the emergency department: Impact of use on the need for reassessments.

PubMed

Guillén-Astete, Carlos A; Cardona-Carballo, César; de la Casa-Resino, Cristina

2017-11-01

Nontraumatic musculoskeletal disorders are the main reason for presentation to the emergency department (ED), with rachialgia (back pain) being the most common reason to request medical assessment among them. This also generates the highest demand for reassessments due to poor pain control or onset of adverse reactions to the treatment prescribed in the initial assessment.A retrospective observational study based on usual clinical practice was conducted in patients attending the ED due to low back pain during a period of 24 months. The primary objective was to determine the demand for reassessments in the ED by these patients in the following 30 days, according to the type of therapeutic approach used in the initial assessment.A total of 732 patients who requested medical assessment due to back pain in the ED of our hospital were analyzed, 91 of whom were treated with tapentadol whereas 641 received another treatment. In the first month after the initial assessment, reassessments were less common in the tapentadol group; this difference was significant from days 8 to 15 (P = 0.001, odds ratio [OR] 0.252 with 95% confidence interval [CI] 0.100-0.635) and days 15 to 30 (P < 10, OR 0.277 with 95% CI 0.136-0.563). Patients who received tapentadol also had a better clinical evolution of pain compared to those who did not receive it (P < 10) and to those who received tramadol (P < 10).In this study in patients with back pain, tapentadol shows clear advantages over the other analgesics analyzed, in terms of pain control and less need for reassessments.

Primary healthcare in transition – a qualitative study of how managers perceived a system change

PubMed Central

2013-01-01

Background Primary healthcare in Sweden has undergone widespread reforms in recent years, including freedom of choice regarding provider, freedom of establishment and increased privatisation. The key aims of the reforms were to strengthen the role of the patient and improve performance in terms of access and responsiveness. The aim of this study was to explore how managers at publicly owned primary healthcare centres perceived the transition of the primary healthcare system and the impact it has had on their work. Methods In this qualitative study, 24 managers of publicly owned primary healthcare centres in the metropolitan region of Gothenburg were recruited. Semi-structured interviews were conducted and data were analysed using content analysis inspired by Silverman. Results The analysis revealed two core themes: The transition is perceived as a rapid change, enforced mainly through financial incentives and Prioritisation conflicts arise between patient groups with different needs, demands and levels of empowerment. The transition has produced powerful and rapid effects that were considered to be both positive and negative. While the new financial incentives were seen as a driving force and a tool for change, they also became a stress factor due to uncertainty, competition with other primary healthcare centres and negative feelings associated with staff cutbacks. The shift in power towards the patient improved access and service but also led to more patients with unreasonable demands. Managers found it difficult to prioritise correctly between patient groups with different needs, demands and levels of empowerment and they were concerned about potentially negative effects on less empowered patients, e.g. multi-morbid patients. Managers also experienced shortcomings in their change management skills. Conclusions This qualitative study shows the complexity of the system change and describes the different effects and perceptions of the transition from a manager’s perspective. This suggests a need for improved follow-up and control in order to monitor and govern system changes and ensure development towards a more effective and sustainable primary healthcare system. PMID:24090138

Primary healthcare in transition--a qualitative study of how managers perceived a system change.

PubMed

Maun, Andy; Nilsson, Kerstin; Furåker, Carina; Thorn, Jörgen

2013-10-03

Primary healthcare in Sweden has undergone widespread reforms in recent years, including freedom of choice regarding provider, freedom of establishment and increased privatisation. The key aims of the reforms were to strengthen the role of the patient and improve performance in terms of access and responsiveness. The aim of this study was to explore how managers at publicly owned primary healthcare centres perceived the transition of the primary healthcare system and the impact it has had on their work. In this qualitative study, 24 managers of publicly owned primary healthcare centres in the metropolitan region of Gothenburg were recruited. Semi-structured interviews were conducted and data were analysed using content analysis inspired by Silverman. The analysis revealed two core themes: The transition is perceived as a rapid change, enforced mainly through financial incentives and Prioritisation conflicts arise between patient groups with different needs, demands and levels of empowerment. The transition has produced powerful and rapid effects that were considered to be both positive and negative. While the new financial incentives were seen as a driving force and a tool for change, they also became a stress factor due to uncertainty, competition with other primary healthcare centres and negative feelings associated with staff cutbacks. The shift in power towards the patient improved access and service but also led to more patients with unreasonable demands. Managers found it difficult to prioritise correctly between patient groups with different needs, demands and levels of empowerment and they were concerned about potentially negative effects on less empowered patients, e.g. multi-morbid patients. Managers also experienced shortcomings in their change management skills. This qualitative study shows the complexity of the system change and describes the different effects and perceptions of the transition from a manager's perspective. This suggests a need for improved follow-up and control in order to monitor and govern system changes and ensure development towards a more effective and sustainable primary healthcare system.

Inclusion of tank configurations as a variable in the cost optimization of branched piped-water networks

NASA Astrophysics Data System (ADS)

Hooda, Nikhil; Damani, Om

2017-06-01

The classic problem of the capital cost optimization of branched piped networks consists of choosing pipe diameters for each pipe in the network from a discrete set of commercially available pipe diameters. Each pipe in the network can consist of multiple segments of differing diameters. Water networks also consist of intermediate tanks that act as buffers between incoming flow from the primary source and the outgoing flow to the demand nodes. The network from the primary source to the tanks is called the primary network, and the network from the tanks to the demand nodes is called the secondary network. During the design stage, the primary and secondary networks are optimized separately, with the tanks acting as demand nodes for the primary network. Typically the choice of tank locations, their elevations, and the set of demand nodes to be served by different tanks is manually made in an ad hoc fashion before any optimization is done. It is desirable therefore to include this tank configuration choice in the cost optimization process itself. In this work, we explain why the choice of tank configuration is important to the design of a network and describe an integer linear program model that integrates the tank configuration to the standard pipe diameter selection problem. In order to aid the designers of piped-water networks, the improved cost optimization formulation is incorporated into our existing network design system called JalTantra.

Effectiveness of a Blended Physical Therapist Intervention in People With Hip Osteoarthritis, Knee Osteoarthritis, or Both: A Cluster-Randomized Controlled Trial.

PubMed

Kloek, Corelien J J; Bossen, Daniël; Spreeuwenberg, Peter M; Dekker, Joost; de Bakker, Dinny H; Veenhof, Cindy

2018-05-17

Integrating physical therapy sessions and an online application (e-Exercise) might support people with hip osteoarthritis (OA), knee OA, or both (hip/knee OA) in taking an active role in the management of their chronic condition and may reduce the number of physical therapy sessions. The objective of this study was to investigate the short- and long-term effectiveness of e-Exercise compared to usual physical therapy in people with hip/knee OA. The design was a prospective, single-blind, multicenter, superiority, cluster- randomized controlled trial. The setting included 143 primary care physical therapist practices. The participants were 208 people with hip/knee OA and were 40 to 80 years of age. e-Exercise is a 3-month intervention in which about 5 face-to-face physical therapy sessions were integrated with an online application consisting of graded activity, exercise, and information modules. Usual physical therapy was conducted according to the Dutch physical therapy guidelines on hip and knee osteoarthritis. Primary outcomes, measured at baseline after 3 and 12 months, were physical functioning and free-living physical activity. Secondary outcome measures were pain, tiredness, quality of life, self-efficacy, and the number of physical therapy sessions. The e-Exercise group (N = 109) received, on average, 5 face-to-face sessions; the usual physical therapy group (N = 99) received 12. No significant differences in primary outcomes between the e-Exercise group and the usual physical therapy group were found. Within-group analyses for both groups showed a significant improvement in physical functioning. After 3 months, participants in the e-Exercise group reported an increase in physical activity; however, no objectively measured differences in physical activity were found. With respect to secondary outcomes, after 12 months, sedentary behavior significantly increased in the e-Exercise group compared with the usual physical therapy group. In both groups, there were significant improvements for pain, tiredness, quality of life, and self-efficacy. The response rate at 12 months was 65%. The blended intervention e-Exercise was not more effective than usual physical therapy in people with hip/knee osteoarthritis.

Effects of allergen and trigger factor avoidance advice in primary care on asthma control: a randomized-controlled trial.

PubMed

Bobb, C; Ritz, T; Rowlands, G; Griffiths, C

2010-01-01

Allergy contributes significantly to asthma exacerbation, yet avoidance of triggers, in particular allergens, is rarely addressed in detail in regular asthma review in primary care. To determine whether structured, individually tailored allergen and trigger avoidance advice, given as part of a primary care asthma review, improves lung function and asthma control. In a randomized-controlled trial 214 adults with asthma in six general practices were either offered usual care during a primary care asthma review or usual care with additional allergen and trigger identification (by skin prick testing and structured allergy assessment) and avoidance advice according to a standardized protocol by trained practice nurses. Main outcome measures were lung function, asthma control, asthma self-efficacy. Both intervention groups were equivalent in demographic and asthma-related variables at baseline. At 3-6-month follow-up, patients receiving the allergen and trigger avoidance review showed significant improvements in lung function (assessed by blinded research nurses) compared with those receiving usual care. Significantly more patients in the intervention group than in the control group showed improvements in forced expiratory volume in 1 s > or =15%. No significant differences were found in self-report measures of asthma control. Asthma-specific self-efficacy improved in both groups but did not differ between groups. Allergen and trigger identification and avoidance advice, given as part of a structured asthma review delivered in primary care by nurses results in clinically important improvements in lung function but not self-report of asthma control. ISRCTN45684820.

Evaluating and Managing Acute Low Back Pain in the Primary Care Setting

PubMed Central

Atlas, Steven J; Deyo, Richard A

2001-01-01

Acute low back pain is a common reason for patient calls or visits to a primary care clinician. Despite a large differential diagnosis, the precise etiology is rarely identified, although musculoligamentous processes are usually suspected. For most patients, back symptoms are nonspecific, meaning that there is no evidence for radicular symptoms or underlying systemic disease. Because episodes of acute, nonspecific low back pain are usually self-limited, many patients treat themselves without contacting their primary care clinician. When patients do call or schedule a visit, evaluation and management by primary care clinicians is appropriate. The history and physical examination usually provide clues to the rare but potentially serious causes of low back pain, as well as to identify patients at risk for prolonged recovery. Diagnostic testing, including plain x-rays, is often unnecessary during the initial evaluation. For patients with acute, nonspecific low back pain, the primary emphasis of treatment should be conservative care, time, reassurance, and education. Current recommendations focus on activity as tolerated (though not active exercise while pain is severe) and minimal if any bed rest. Referral for physical treatments is most appropriate for patients whose symptoms are not improving over 2 to 4 weeks. Specialty referral should be considered for patients with a progressive neurologic deficit, failure of conservative therapy, or an uncertain or serious diagnosis. The prognosis for most patients is good, although recurrence is common. Thus, educating patients about the natural history of acute low back pain and how to prevent future episodes can help ensure reasonable expectations. PMID:11251764

Measuring patient-centered medical home access and continuity in clinics with part-time clinicians.

PubMed

Rosland, Ann-Marie; Krein, Sarah L; Kim, Hyunglin Myra; Greenstone, Clinton L; Tremblay, Adam; Ratz, David; Saffar, Darcy; Kerr, Eve A

2015-05-01

Common patient-centered medical home (PCMH) performance measures value access to a single primary care provider (PCP), which may have unintended consequences for clinics that rely on part-time PCPs and team-based care. Retrospective analysis of 110,454 primary care visits from 2 Veterans Health Administration clinics from 2010 to 2012. Multi-level models examined associations between PCP availability in clinic, and performance on access and continuity measures. Patient experiences with access and continuity were compared using 2012 patient survey data (N = 2881). Patients of PCPs with fewer half-day clinic sessions per week were significantly less likely to get a requested same-day appointment with their usual PCP (predicted probability 17% for PCPs with 2 sessions/week, 20% for 5 sessions/week, and 26% for 10 sessions/week). Among requests that did not result in a same-day appointment with the usual PCP, there were no significant differences in same-day access to a different PCP, or access within 2 to 7 days with patients' usual PCP. Overall, patients had >92% continuity with their usual PCP at the hospital-based site regardless of PCP sessions/week. Patients of full-time PCPs reported timely appointments for urgent needs more often than patients of part-time PCPs (82% vs 71%; P < .01), but reported similar experiences with routine access and continuity. Part-time PCP performance appeared worse when using measures focused on same-day access to patients' usual PCP. However, clinic-level same-day access, same-week access to the usual PCP, and overall continuity were similar for patients of part-time and full-time PCPs. Measures of in-person access to a usual PCP do not capture alternate access approaches encouraged by PCMH, and often used by part-time providers, such as team-based or non-face-to-face care.

Evaluating the association between the built environment and primary care access for new Medicaid enrollees in an urban environment using Walk and Transit Scores.

PubMed

Chaiyachati, Krisda H; Hom, Jeffrey K; Hubbard, Rebecca A; Wong, Charlene; Grande, David

2018-03-01

Worse health outcomes among those living in poverty are due in part to lower rates of health insurance and barriers to care. As the Affordable Care Act reduced financial barriers, identifying persistent barriers to accessible health care continues to be important. We examined whether the built environment as reflected by Walk Score™ (a measure of walkability to neighborhood resources) and Transit Score™ (a measure of transit access) is associated with having a usual source of care among low-income adults, newly enrolled in Medicaid. We received responses from 312 out of 1000 new Medicaid enrollees in Philadelphia, a large, densely populated urban area, who were surveyed between 2015 and 2016 to determine if they had identified a usual source of outpatient primary care. Respondents living at an address with a low Walk Scores (< 70) had 84% lower odds of having a usual source of care (OR 0.16, 95% CI 0.04-0.61). Transit scores were not associated with having a usual source of care. Walk Score may be a tool for policy makers and providers of care to identify populations at risk for worse primary care access.

Global Human Appropriation of Net Primary Production and Associated Resource Decoupling: 2010-2050.

PubMed

Zhou, Chuanbin; Elshkaki, Ayman; Graedel, T E

2018-02-06

Human appropriation of net primary production (HANPP) methodology has previously been developed to assess the intensity of anthropogenic extraction of biomass resources. However, there is limited analysis concerning future trends of HANPP. Here we present four scenarios for global biomass demand and HANPP harv (the most key component of HANPP) from 2010 to 2050 by incorporating data on expanded historical drivers and disaggregated biomass demand (food, wood material, and fuelwood). The results show that the biomass demand has the lowest value in the equitability world scenario (an egalitarian vision) and the highest value in the security foremost scenario (an isolationist vision). The biomass demand for food and materials increases over time, while fuelwood demand decreases over time. Global HANPP harv rises to between 8.5 and 10.1 Pg C/yr in 2050 in the four scenarios, 14-35% above its value in 2010, and some 50% of HANPP harv is calculated to be crop residues, wood residues, and food losses in the future. HANPP harv in developing regions (Asia, Africa, and Latin America) increases faster than that in more-developed regions (North America and Europe), due to urbanization, population growth, and increasing income. Decoupling of HANPP harv and socioeconomic development is also discussed in this work.

What would menthol smokers do if menthol in cigarettes were banned? Behavioral intentions and simulated demand.

PubMed

O'Connor, Richard J; Bansal-Travers, Maansi; Carter, Lawrence P; Cummings, K Michael

2012-07-01

  The US Food and Drug Administration must consider whether to ban the use of menthol in cigarettes. This study examines how current smokers might respond to such a ban on menthol cigarettes.   Convenience sample of adolescent and adult smokers recruited from an online survey panel.   United States, 2010.   A total of 471 adolescent and adult current cigarette smokers.   Respondents were asked a series of questions about how they might react if menthol cigarettes were banned. In addition, participants completed a simulation purchase task to estimate the demand for menthol and non-menthol cigarettes across a range of prices.   Overall, 36.1% of respondents said they always (18.9%) or usually (17.2%) smoked menthol cigarettes. When asked how they might respond to a ban on menthol cigarettes, 35% of current menthol smokers said they would stop smoking, and 25% said they would 'find a way to buy a menthol brand'. Those who reported they might quit tended to have greater current intentions to quit [odds ratio (OR) = 4.47], while those who reported that they might seek illicit menthol cigarettes were far less likely to report current intentions to quit (OR = 0.06). Estimates for demand elasticity for preferred cigarette type were similar for menthol (α = 0.0051) and non-menthol (α = 0.0049) smokers. Demand elasticity and peak consumption were related to usual cigarette type and cigarettes smoked per day, but did not appear to differ by race, gender or age.   Preliminary evidence suggests that a significant minority of smokers of menthol cigarettes in the United States would try to stop smoking altogether if such cigarettes were banned. © 2012 The Authors, Addiction © 2012 Society for the Study of Addiction.

Droughts in the US: Modeling and Forecasting for Agriculture-Water Management and Adaptation

NASA Astrophysics Data System (ADS)

Perveen, S.; Devineni, N.; Lall, U.

2012-12-01

More than half of all US counties are currently mired in a drought that is considered the worst in decades. A persistent drought can not only lead to widespread impacts on water access with interstate implications (as has been shown in the Southeast US and Texas), chronic scarcity can emerge as a risk in regions where fossil aquifers have become the primary source of supply and are being depleted at rates much faster than recharge (e.g., Midwestern US). The standardized drought indices on which the drought declarations are made in the US so far consider only the static decision frameworks—where only the supply is the control variable and not the water consumption. If a location has low demands, drought as manifest in the usual indices does not really have "proportionate" social impact. Conversely, a modest drought as indicated by the traditional measures may have significant impacts where demand is close to the climatological mean value of precipitation. This may also lead to drought being declared too late or too soon. Against this fact, the importance of improved drought forecasting and preparedness for different sectors of the economy becomes increasingly important. The central issue we propose to address through this paper is the construction and testing of a drought index that considers regional water demands for specific purposes (e.g., crops, municipal use) and their temporal distribution over the year for continental US. Here, we have highlighted the use of the proposed index for three main sectors: (i) water management organizations, (ii) optimizing agricultural water use, and (iii) supply chain water risk. The drought index will consider day-to-day climate variability and sectoral demands to develop aggregate regional conditions or disaggregated indices for water users. For the daily temperature and precipitation data, we are using NLDAS dataset that is available from 1949 onwards. The national agricultural statistics services (NASS) online database has been accessed for the agricultural data at the county level. Preliminary analyses show that large parts of Midwest and Southern parts of Florida and California are prone to multiyear droughts. This can primarily be attributed to high agricultural and/or urban water demands coupled with high interannual variability in supply. We propose to develop season-ahead and monthly updated forecasts of the drought index for informing the drought management plans. Given the already customized (sector specific) nature of the proposed drought index and its ability to represent the variability in both supply and demand, the early warning or forecasting of the index would not only complement the drought early warning systems in place by the national integrated drought information system (NIDIS) but also help in prescribing the ameliorative measures for adaptation.

Multispecialty physician networks in Ontario

PubMed Central

Stukel, Therese A; Glazier, Richard H; Schultz, Susan E; Guan, Jun; Zagorski, Brandon M; Gozdyra, Peter; Henry, David A

2013-01-01

Background Large multispecialty physician group practices, with a central role for primary care practitioners, have been shown to achieve high-quality, low-cost care for patients with chronic disease. We assessed the extent to which informal multispecialty physician networks in Ontario could be identified by using health administrative data to exploit natural linkages among patients, physicians, and hospitals based on existing patient flow. Methods We linked each Ontario resident to his or her usual provider of primary care over the period from fiscal year 2008/2009 to fiscal year 2010/2011. We linked each specialist to the hospital where he or she performed the most inpatient services. We linked each primary care physician to the hospital where most of his or her ambulatory patients were admitted for non-maternal medical care. Each resident was then linked to the same hospital as his or her usual provider of primary care. We computed “loyalty” as the proportion of care to network residents provided by physicians and hospitals within their network. Smaller clusters were aggregated to create networks based on a minimum population size, distance, and loyalty. Networks were not constrained geographically. Results We identified 78 multispecialty physician networks, comprising 12 410 primary care physicians, 14 687 specialists, and 175 acute care hospitals serving a total of 12 917 178 people. Median network size was 134 723 residents, 125 primary care physicians, and 143 specialists. Virtually all eligible residents were linked to a usual provider of primary care and to a network. Most specialists (93.5%) and primary care physicians (98.2%) were linked to a hospital. Median network physician loyalty was 68.4% for all physician visits and 81.1% for primary care visits. Median non-maternal admission loyalty was 67.4%. Urban networks had lower loyalties and were less self-contained but had more health care resources. Interpretation We demonstrated the feasibility of identifying informal multispecialty physician networks in Ontario on the basis of patterns of health care–seeking behaviour. Networks were reasonably self-contained, in that individual residents received most of their care from providers within their respective networks. Formal constitution of networks could foster accountability for efficient, integrated care through care management tools and quality improvement, the ideas behind “accountable care organizations.” PMID:24348884

Cost-Effectiveness of Primary Care Management With or Without Early Physical Therapy for Acute Low Back Pain: Economic Evaluation of a Randomized Clinical Trial.

PubMed

Fritz, Julie M; Kim, Minchul; Magel, John S; Asche, Carl V

2017-03-01

Economic evaluation of a randomized clinical trial. Compare costs and cost-effectiveness of usual primary care management for patients with acute low back pain (LBP) with or without the addition of early physical therapy. Low back pain is among the most common and costly conditions encountered in primary care. Early physical therapy after a new primary care consultation for acute LBP results in small clinical improvement but cost-effectiveness of a strategy of early physical therapy is unknown. Economic evaluation was conducted alongside a randomized clinical trial of patients with acute, nonspecific LBP consulting a primary care provider. All patients received usual primary care management and education, and were randomly assigned to receive four sessions of physical therapy or usual care of delaying referral consideration to permit spontaneous recovery. Data were collected in a randomized trial involving 220 participants age 18 to 60 with LBP <16 days duration without red flags or signs of nerve root compression. The EuroQoL EQ-5D health states were collected at baseline and after 1-year and used to compute the quality adjusted life year (QALY) gained. Direct (health care utilization) and indirect (work absence or reduced productivity) costs related to LBP were collected monthly and valued using standard costs. The incremental cost-effectiveness ratio was computed as incremental total costs divided by incremental QALYs. Early physical therapy resulted in higher total 1-year costs (mean difference in adjusted total costs = $580, 95% CI: $175, $984, P = 0.005) and better quality of life (mean difference in QALYs = 0.02, 95% CI: 0.005, 0.35, P = 0.008) after 1-year. The incremental cost-effectiveness ratio was $32,058 (95% CI: $10,629, $151,161) per QALY. Our results support early physical therapy as cost-effective relative to usual primary care after 1 year for patients with acute, nonspecific LBP. 2.

Multiple neoplasms, single primaries, and patient survival

PubMed Central

Amer, Magid H

2014-01-01

Background Multiple primary neoplasms in surviving cancer patients are relatively common, with an increasing incidence. Their impact on survival has not been clearly defined. Methods This was a retrospective review of clinical data for all consecutive patients with histologically confirmed cancer, with emphasis on single versus multiple primary neoplasms. Second primaries discovered at the workup of the index (first) primary were termed simultaneous, if discovered within 6 months of the index primary were called synchronous, and if discovered after 6 months were termed metachronous. Results Between 2005 and 2012, of 1,873 cancer patients, 322 developed second malignancies; these included two primaries (n=284), and three or more primaries (n=38). Forty-seven patients had synchronous primaries and 275 had metachronous primaries. Patients with multiple primaries were predominantly of Caucasian ancestry (91.0%), with a tendency to develop thrombosis (20.2%), had a strong family history of similar cancer (22.3%), and usually presented with earlier stage 0 through stage II disease (78.9%). When compared with 1,551 patients with a single primary, these figures were 8.9%, 15.6%, 18.3%, and 50.9%, respectively (P≤0.001). Five-year survival rates were higher for metachronous cancers (95%) than for synchronous primaries (59%) and single primaries (59%). The worst survival rate was for simultaneous concomitant multiple primaries, being a median of 1.9 years. The best survival was for patients with three or more primaries (median 10.9 years) and was similar to the expected survival for the age-matched and sex-matched general population (P=0.06991). Conclusion Patients with multiple primaries are usually of Caucasian ancestry, have less aggressive malignancies, present at earlier stages, frequently have a strong family history of similar cancer, and their cancers tend to have indolent clinical behavior with longer survival rates, possibly related to genetic predisposition. PMID:24623992

The steel scrap age.

PubMed

Pauliuk, Stefan; Milford, Rachel L; Müller, Daniel B; Allwood, Julian M

2013-04-02

Steel production accounts for 25% of industrial carbon emissions. Long-term forecasts of steel demand and scrap supply are needed to develop strategies for how the steel industry could respond to industrialization and urbanization in the developing world while simultaneously reducing its environmental impact, and in particular, its carbon footprint. We developed a dynamic stock model to estimate future final demand for steel and the available scrap for 10 world regions. Based on evidence from developed countries, we assumed that per capita in-use stocks will saturate eventually. We determined the response of the entire steel cycle to stock saturation, in particular the future split between primary and secondary steel production. During the 21st century, steel demand may peak in the developed world, China, the Middle East, Latin America, and India. As China completes its industrialization, global primary steel production may peak between 2020 and 2030 and decline thereafter. We developed a capacity model to show how extensive trade of finished steel could prolong the lifetime of the Chinese steelmaking assets. Secondary steel production will more than double by 2050, and it may surpass primary production between 2050 and 2060: the late 21st century can become the steel scrap age.

Dealing with the predicted increase in demand for revision total knee arthroplasty: challenges, risks and opportunities.

PubMed

Hamilton, D F; Howie, C R; Burnett, R; Simpson, A H R W; Patton, J T

2015-06-01

Worldwide rates of primary and revision total knee arthroplasty (TKA) are rising due to increased longevity of the population and the burden of osteoarthritis. Revision TKA is a technically demanding procedure generating outcomes which are reported to be inferior to those of primary knee arthroplasty, and with a higher risk of complication. Overall, the rate of revision after primary arthroplasty is low, but the number of patients currently living with a TKA suggests a large potential revision healthcare burden. Many patients are now outliving their prosthesis, and consideration must be given to how we are to provide the necessary capacity to meet the rising demand for revision surgery and how to maximise patient outcomes. The purpose of this review was to examine the epidemiology of, and risk factors for, revision knee arthroplasty, and to discuss factors that may enhance patient outcomes. ©2015 The British Editorial Society of Bone & Joint Surgery.

A self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy: a randomised controlled trial (the SELF study).

PubMed

Littlewood, Chris; Bateman, Marcus; Brown, Kim; Bury, Julie; Mawson, Sue; May, Stephen; Walters, Stephen J

2016-07-01

To evaluate the clinical effectiveness of a self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy. Multi-centre pragmatic unblinded parallel group randomised controlled trial. UK National Health Service. Patients with a clinical diagnosis of rotator cuff tendinopathy. The intervention was a programme of self-managed exercise prescribed by a physiotherapist in relation to the most symptomatic shoulder movement. The control group received usual physiotherapy treatment. The primary outcome measure was the Shoulder Pain & Disability Index (SPADI) at three months. Secondary outcomes included the SPADI at six and twelve months. A total of 86 patients (self-managed loaded exercise n=42; usual physiotherapy n=44) were randomised. Twenty-six patients were excluded from the analysis because of lack of primary outcome data at the 3 months follow-up, leaving 60 (n=27; n=33) patients for intention to treat analysis. For the primary outcome, the mean SPADI score at three months was 32.4 (SD 20.2) for the self-managed group, and 30.7 (SD 19.7) for the usual physiotherapy treatment group; mean difference adjusted for baseline score: 3.2 (95% Confidence interval -6.0 to +12.4 P = 0.49).By six and twelve months there remained no significant difference between the groups. This study does not provide sufficient evidence of superiority of one intervention over the other in the short-, mid- or long-term and hence a self-management programme based around a single exercise appears comparable to usual physiotherapy treatment. © The Author(s) 2015.

Acupuncture and Counselling for Depression in Primary Care: A Randomised Controlled Trial

PubMed Central

MacPherson, Hugh; Richmond, Stewart; Bland, Martin; Brealey, Stephen; Gabe, Rhian; Hopton, Ann; Keding, Ada; Lansdown, Harriet; Perren, Sara; Sculpher, Mark; Spackman, Eldon; Torgerson, David; Watt, Ian

2013-01-01

Background Depression is a significant cause of morbidity. Many patients have communicated an interest in non-pharmacological therapies to their general practitioners. Systematic reviews of acupuncture and counselling for depression in primary care have identified limited evidence. The aim of this study was to evaluate acupuncture versus usual care and counselling versus usual care for patients who continue to experience depression in primary care. Methods and Findings In a randomised controlled trial, 755 patients with depression (Beck Depression Inventory BDI-II score ≥20) were recruited from 27 primary care practices in the North of England. Patients were randomised to one of three arms using a ratio of 2∶2∶1 to acupuncture (302), counselling (302), and usual care alone (151). The primary outcome was the difference in mean Patient Health Questionnaire (PHQ-9) scores at 3 months with secondary analyses over 12 months follow-up. Analysis was by intention-to-treat. PHQ-9 data were available for 614 patients at 3 months and 572 patients at 12 months. Patients attended a mean of ten sessions for acupuncture and nine sessions for counselling. Compared to usual care, there was a statistically significant reduction in mean PHQ-9 depression scores at 3 months for acupuncture (−2.46, 95% CI −3.72 to −1.21) and counselling (−1.73, 95% CI −3.00 to −0.45), and over 12 months for acupuncture (−1.55, 95% CI −2.41 to −0.70) and counselling (−1.50, 95% CI −2.43 to −0.58). Differences between acupuncture and counselling were not significant. In terms of limitations, the trial was not designed to separate out specific from non-specific effects. No serious treatment-related adverse events were reported. Conclusions In this randomised controlled trial of acupuncture and counselling for patients presenting with depression, after having consulted their general practitioner in primary care, both interventions were associated with significantly reduced depression at 3 months when compared to usual care alone. Trial Registration Controlled-Trials.com ISRCTN63787732 Please see later in the article for the Editors' Summary PMID:24086114

Effectiveness of a Proactive Primary Care Program on Preserving Daily Functioning of Older People: A Cluster Randomized Controlled Trial.

PubMed

Bleijenberg, Nienke; Drubbel, Irene; Schuurmans, Marieke J; Dam, Hester Ten; Zuithoff, Nicolaas P A; Numans, Mattijs E; de Wit, Niek J

2016-09-01

To determine the effectiveness of a proactive primary care program on the daily functioning of older people in primary care. Single-blind, three-arm, cluster-randomized controlled trial with 1-year follow-up. Primary care setting, 39 general practices in the Netherlands. Community-dwelling people aged 60 and older (N = 3,092). A frailty screening intervention using routine electronic medical record data to identify older people at risk of adverse events followed by usual care from a general practitioner; after the screening intervention, a nurse-led care program consisting of a comprehensive geriatric assessment, evidence-based care planning, care coordination, and follow-up; usual care. Primary outcome was daily functioning measured using the Katz-15 (6 activities of daily living (ADLs), 8 instrumental activities of daily living (IADLs), one mobility item (range 0-15)); higher scores indicate greater dependence. Secondary outcomes included quality of life, primary care consultations, hospital admissions, emergency department visits, nursing home admissions, and mortality. The participants in both intervention arms had less decline in daily functioning than those in the usual care arm at 12 months (mean Katz-15 score: screening arm, 1.87, 95% confidence interval (CI) = 1.77-1.97; screening and nurse-led care arm, 1.88, 95% CI = 1.80-1.96; control group, 2.03, 95% CI = 1.92-2.13; P = .03). No differences in quality of life were observed. Participants in both intervention groups had less decline than those in the control group at 1-year follow-up. Despite the statistically significant effect, the clinical relevance is uncertain at this point because of the small differences. Greater customizing of the intervention combined with prolonged follow-up may lead to more-robust results. © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.

Using the electronic health record to build a culture of practice safety: evaluating the implementation of trigger tools in one general practice.

PubMed

Margham, Tom; Symes, Natalie; Hull, Sally A

2018-04-01

Identifying patients at risk of harm in general practice is challenging for busy clinicians. In UK primary care, trigger tools and case note reviews are mainly used to identify rates of harm in sample populations. This study explores how adaptions to existing trigger tool methodology can identify patient safety events and engage clinicians in ongoing reflective work around safety. Mixed-method quantitative and narrative evaluation using thematic analysis in a single East London training practice. The project team developed and tested five trigger searches, supported by Excel worksheets to guide the case review process. Project evaluation included summary statistics of completed worksheets and a qualitative review focused on ease of use, barriers to implementation, and perception of value to clinicians. Trigger searches identified 204 patients for GP review. Overall, 117 (57%) of cases were reviewed and 62 (53%) of these cases had patient safety events identified. These were usually incidents of omission, including failure to monitor or review. Key themes from interviews with practice members included the fact that GPs' work is generally reactive and GPs welcomed an approach that identified patients who were 'under the radar' of safety. All GPs expressed concern that the tool might identify too many patients at risk of harm, placing further demands on their time. Electronic trigger tools can identify patients for review in domains of clinical risk for primary care. The high yield of safety events engaged clinicians and provided validation of the need for routine safety checks. © British Journal of General Practice 2018.

Electrochemistry and Storage

NASA Technical Reports Server (NTRS)

Thaller, L. H.

1984-01-01

The term electrochemistry implies the use of devices that convert chemical energy into electrical energy and sometimes vice versa. These devices are usually composed of some number of individual cells that are connected together to form a battery. In the cases where these devices cannot be electrically recharged they are usually referred to as primary batteries, whereas if these batteries can be charged and recharged repeatedly, they are called secondary batteries. The past and present uses of primary and secondary batteries in aerospace applications are discussed.

[Demand for training and availability of health science professionals in Peru].

PubMed

Jiménez, M Michelle; Mantilla, Eduardo; Huayanay-Espinoza, Carlos A; Gil, Karina; García, Hernán; Miranda, J Jaime

2015-01-01

To describe the availability and demand of professional training programs for eight health science professions in Peru. Study the profiles of the physicians, nurses and midwives that these programs train and their competencies to work at the primary health care level. Cross-sectional study using data on the volume of applicants, students and graduates of these eight professional training programs during the period 2007 - 2011. In addition, the curricula of professional training programs for physicians, nurses and midwives from public and private universities were analyzed, along with competency profiles developed by Professional Colleges and the Ministry of Health. Admission rates in public and private universities vary by program: 4% and 28% respectively for medical schools, and 18% and 90% for nursing. Graduation rates were estimated at approximately 43% and 53% of students entering medicine and nursing training programs respectively. Contrasting the profiles of recently graduated professionals in medicine, nursing and midwifery, with the skills required by the Ministry of Health for professionals working in primary care the first level of care, indicate that these recently graduated professionals are not necessarily or specifically trained to work in primary care. Demand for professional training in health sciences exists and its supply is met predominantly by private universities. Competency profiles developed by the MOH for the basic professional health team in primary care shows a clear disconnect regarding the current supply of trained professionals.

A randomized trial of a lay person-led self-management group intervention for back pain patients in primary care.

PubMed

Von Korff, M; Moore, J E; Lorig, K; Cherkin, D C; Saunders, K; González, V M; Laurent, D; Rutter, C; Comite, F

1998-12-01

Randomized, controlled trial. To evaluate a four-session self-management group intervention for patients with pain in primary care, led by trained lay persons with back pain. The intervention was designed to reduce patient worries, encourage self-care, and reduce activity limitations. Randomized trials of educational interventions suggest that activating interventions may improve back pain outcomes. Expert opinion increasingly regards effective self-management of back pain as important in achieving good outcomes. In this study, an educational intervention designed to activate patients and support effective self-management was evaluated. Six to 8 weeks after a primary care visit for back pain, patients were invited to participate in an educational program to improve back pain self-management. Those showing interest by returning a brief questionnaire became eligible for the study. Participants (n = 255) randomly were assigned to either a self-management group intervention or to a usual care control group. The effect of the intervention, relative to usual care, was assessed 3, 6, and 12 months after randomization, controlling for baseline values. The intervention consisted of a four-session group applying problem-solving techniques to back pain self-management, supplemented by educational materials (book and videos) supporting active management of back pain. The groups were led by lay persons trained to implement a fully structured group protocol. The control group received usual care, supplemented by a book on back pain care. Participants randomly assigned to the self-management groups reported significantly less worry about back pain and expressed more confidence in self-care. Roland Disability Questionnaire Scores were significantly lower among participants in the self-management groups relative to the usual care controls at 6 months (P = 0.007), and this difference was sustained at 12 months at borderline significance levels (P = 0.09). Among self-management group participants, 48% showed a 50% or greater reduction in Roland Disability Questionnaire Score at 6 months, compared with 33% among the usual care controls. Self-management groups led by trained lay persons following a structured protocol were more effective than usual care in reducing worries, producing positive attitudes toward self-care, and reducing activity limitations among patients with back pain in primary care.

The Impact of Uncertain Physical Parameters on HVAC Demand Response

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

Sun, Yannan; Elizondo, Marcelo A.; Lu, Shuai

HVAC units are currently one of the major resources providing demand response (DR) in residential buildings. Models of HVAC with DR function can improve understanding of its impact on power system operations and facilitate the deployment of DR technologies. This paper investigates the importance of various physical parameters and their distributions to the HVAC response to DR signals, which is a key step to the construction of HVAC models for a population of units with insufficient data. These parameters include the size of floors, insulation efficiency, the amount of solid mass in the house, and efficiency of the HVAC units.more » These parameters are usually assumed to follow Gaussian or Uniform distributions. We study the effect of uncertainty in the chosen parameter distributions on the aggregate HVAC response to DR signals, during transient phase and in steady state. We use a quasi-Monte Carlo sampling method with linear regression and Prony analysis to evaluate sensitivity of DR output to the uncertainty in the distribution parameters. The significance ranking on the uncertainty sources is given for future guidance in the modeling of HVAC demand response.« less

Cognitive behavioural therapy as an adjunct to pharmacotherapy for primary care based patients with treatment resistant depression: results of the CoBalT randomised controlled trial.

PubMed

Wiles, Nicola; Thomas, Laura; Abel, Anna; Ridgway, Nicola; Turner, Nicholas; Campbell, John; Garland, Anne; Hollinghurst, Sandra; Jerrom, Bill; Kessler, David; Kuyken, Willem; Morrison, Jill; Turner, Katrina; Williams, Chris; Peters, Tim; Lewis, Glyn

2013-02-02

Only a third of patients with depression respond fully to antidepressant medication but little evidence exists regarding the best next-step treatment for those whose symptoms are treatment resistant. The CoBalT trial aimed to examine the effectiveness of cognitive behavioural therapy (CBT) as an adjunct to usual care (including pharmacotherapy) for primary care patients with treatment resistant depression compared with usual care alone. This two parallel-group multicentre randomised controlled trial recruited 469 patients aged 18-75 years with treatment resistant depression (on antidepressants for ≥6 weeks, Beck depression inventory [BDI] score ≥14 and international classification of diseases [ICD]-10 criteria for depression) from 73 UK general practices. Participants were randomised, with a computer generated code (stratified by centre and minimised according to baseline BDI score, whether the general practice had a counsellor, previous treatment with antidepressants, and duration of present episode of depression) to one of two groups: usual care or CBT in addition to usual care, and were followed up for 12 months. Because of the nature of the intervention it was not possible to mask participants, general practitioners, CBT therapists, or researchers to the treatment allocation. Analyses were by intention to treat. The primary outcome was response, defined as at least 50% reduction in depressive symptoms (BDI score) at 6 months compared with baseline. This trial is registered, ISRCTN38231611. Between Nov 4, 2008, and Sept 30, 2010, we assigned 235 patients to usual care, and 234 to CBT plus usual care. 422 participants (90%) were followed up at 6 months and 396 (84%) at 12 months, finishing on Oct 31, 2011. 95 participants (46%) in the intervention group met criteria for response at 6 months compared with 46 (22%) in the usual care group (odds ratio 3·26, 95% CI 2·10-5·06, p<0·001). Before this study, no evidence from large-scale randomised controlled trials was available for the effectiveness of augmentation of antidepressant medication with CBT as a next-step for patients whose depression has not responded to pharmacotherapy. Our study has provided robust evidence that CBT as an adjunct to usual care that includes antidepressants is an effective treatment, reducing depressive symptoms in this population. National Institute for Health Research Health Technology Assessment. Copyright © 2013 Elsevier Ltd. All rights reserved.

Primary extracranial meningioma of the mandible.

PubMed

Mosqueda-Taylor, Adalberto; Domínguez-Malagon, Hugo; Cano-Valdez, Ana-Maria; Montiel-Hernandez, Ana-Maria

2009-04-01

Meningiomas are benign tumors of mesodermal origin that arise from arachnoid cell clusters that penetrate the dura to form arachnoid villi. These neoplasms represent one of the most common neoplasms developing within the central nervous system and are usually located at points of entry of vessels and nerves through the dura. Extracranial meningiomas (EM) comprise only 2% of all meningiomas, and only six cases of primary EM of the jawbones have been described to date. They may arise as an extension of intracranial meningiomas or as primary tumors and may be clinically indistinguishable from other benign tumours of the jaws, as they usually present as a well-delineated unencapsulated tumors. In this article a case of primary intramandibular primary EM that appeared as a well-defined osteolytic radiolucent lesion of the jaw is reported. The salient clinico-pathological features of this case is compared to those previously reported in the literature and differential diagnosis and therapeutic considerations are discussed.

Working Conditions and Workplace Barriers to Vocal Health in Primary School Teachers.

PubMed

Munier, Caitriona; Farrell, Rory

2016-01-01

The purpose of this study was to identify the working conditions and workplace barriers to vocal health in primary school teachers. The relationship between working conditions and voice is analyzed. This is a survey study in 42 randomized schools from a restricted geographical area. An 85-item questionnaire was administered to 550 primary school teachers in 42 schools in Dublin. It was designed to obtain information on demographics, vocal use patterns, vocal health, work organization, working conditions, and teacher's perceptions of the conditions in teaching that might cause a voice problem. The relationship between voice and overstretched work demands, and voice and class size, was examined. A chi-squared test was run to test the null hypothesis that the variables overstretched work demands and voice and class size and voice are independent. Subjects were given the opportunity to give their opinion on their working conditions and on the availability of advice and support within the workplace. A final question sought their opinion on what should be included in a voice care program. A 55% response rate was obtained (n = 304). It was found with 96.52% confidence that the variables overstretched work demands and voice are related. Likewise, it was found that the variables class size and voice are related with 99.97% confidence. There are workplace barriers to vocal health. The working conditions of primary school teachers need to be fully adapted to promote vocal health. Changes by education and health policy makers are needed to achieve this goal. There is a need for future research which focuses on the working conditions of teachers. Copyright © 2016. Published by Elsevier Inc.

Patient Perspectives on the Learning Health System: The Importance of Trust and Shared Decision Making.

PubMed

Kelley, Maureen; James, Cyan; Alessi Kraft, Stephanie; Korngiebel, Diane; Wijangco, Isabelle; Rosenthal, Emily; Joffe, Steven; Cho, Mildred K; Wilfond, Benjamin; Lee, Sandra Soo-Jin

2015-01-01

We conducted focus groups to assess patient attitudes toward research on medical practices in the context of usual care. We found that patients focus on the implications of this research for their relationship with and trust in their physicians. Patients view research on medical practices as separate from usual care, demanding dissemination of information and in most cases, individual consent. Patients expect information about this research to come through their physician, whom they rely on to identify and filter associated risks. In general, patients support this research, but worry that participation in research involving randomization may undermine individualized care that acknowledges their unique medical histories. These findings suggest the need for public education on variation in practice among physicians and the need for a collaborative approach to the governance of research on medical practices that addresses core values of trust, transparency, and partnership.

Primary and community care workforce planning and development.

PubMed

Hurst, Keith

2006-09-01

This article reports a study that provided primary and community care managers with information, allowing them to: (a) evaluate the size and mix of their workforce; and (b) develop knowledgeable and skilled teams to meet the demands of growing and changing services. Primary and community care services are growing in the United Kingdom, but workforce planning and development, despite their wide-ranging cost and quality implications, have not received the same attention. Indeed, most primary and community care workforce planning and development issues are universal. Demand 1-1 side workforce planning is concerned not only with the number, but also with staff mix; but how these autonomous and isolated practitioners spend their time is unique. The other side of the equation, workforce supply, raises many recruitment and retention challenges for managers in many countries. Any country's main workforce planning methods apply equally well to primary care, but each is flawed. A second, main problem is that the methods lead to fragmented services, whereas modern workforce planning methods should be multidisciplinary. Consequently, it has never been more important for managers to have data and algorithms to develop appropriate care teams. A large and versatile workforce database, profiling 304 English primary care trusts using demographic, socio-economic, mortality, morbidity, staffing and performance workforce-related variables, compiled in 2002 and updated yearly, is described. Data were supplemented with a systematic literature review leading to a 340-item annotated bibliography; and qualitative interviews with managers. Workforce size and mix are historical and irrational at best. Moreover, the number of variables that influence staffing is growing, thereby complicating workforce planning. Evaluating and adjusting the size and mix of teams using empirically determined community demand and performance variables based on the area's socio-economic characteristics is feasible.

Effects of co-occurring depression on treatment for anxiety disorders: analysis of outcomes from a large primary care effectiveness trial.

PubMed

Campbell-Sills, Laura; Sherbourne, Cathy D; Roy-Byrne, Peter; Craske, Michelle G; Sullivan, Greer; Bystritsky, Alexander; Lang, Ariel J; Chavira, Denise A; Rose, Raphael D; Shaw Welch, Stacy; Stein, Murray B

2012-12-01

Co-occurring depression is common in patients seeking treatment for anxiety; however, the literature on the effects of depression on anxiety treatment outcomes is inconclusive. The current study evaluated prescriptive and prognostic effects of depression on anxiety treatment outcomes in a large primary care sample. Data were analyzed from a randomized controlled effectiveness trial that compared coordinated anxiety learning and management (CALM) to usual care. The study enrolled 1,004 patients between June 2006 and April 2008. Patients were referred by their primary care provider and met DSM-IV criteria for generalized anxiety disorder, panic disorder, posttraumatic stress disorder, and/or social anxiety disorder. They were treated for approximately 3 to 12 months with CALM (computer-assisted cognitive-behavioral therapy, medication management, or their combination) or usual care. Outcomes were evaluated by blinded assessment at 6, 12, and 18 months. Effects of baseline major depressive disorder (MDD) on anxiety symptoms, anxiety-related disability, and response/remission rates were evaluated using statistical models accounting for baseline anxiety and patient demographics. MDD did not moderate the effects of CALM (relative to usual care) on anxiety symptoms, anxiety-related disability, or response/remission rates. Greater improvements in anxiety symptoms and anxiety-related disability were observed in depressed patients, regardless of treatment assignment (P values < .005). However, cross-sectionally depressed patients displayed higher anxiety symptom and anxiety-related disability scores at baseline and all subsequent assessments (P values < .001). Depressed patients also displayed lower remission rates at each follow-up (P values < .001). CALM had comparable advantages over usual care for patients with and without MDD. Depressed patients displayed more severe anxiety symptoms and anxiety-related disability at baseline, but their clinical improvement was substantial and larger in magnitude than that observed in the nondepressed patients. Results support the use of empirically supported interventions for anxiety disorders in patients with co-occurring depression. ClinicalTrials.gov identifier: NCT00347269. © Copyright 2012 Physicians Postgraduate Press, Inc.

The Enhancement of Musical and Other Learning for Both Teachers and Students through a Weekly Choir Session

ERIC Educational Resources Information Center

Heyning, Lyndell

2010-01-01

Primary schools are such busy demanding places. Educators are concerned with a crowded curriculum and high emphasis placed on the development and cultivation of literacy and numeracy concepts. Teachers are generally concerned with the delivery and teaching expectations of all key learning areas of the primary school curriculum. However, the…

Effect of Patient Experience on Bypassing a Primary Care Gatekeeper: a Multicenter Prospective Cohort Study in Japan.

PubMed

Aoki, Takuya; Yamamoto, Yosuke; Ikenoue, Tatsuyoshi; Kaneko, Makoto; Kise, Morito; Fujinuma, Yasuki; Fukuhara, Shunichi

2018-05-01

To discuss how best to implement the gatekeeping functionality of primary care; identifying the factors that cause patients to bypass their primary care gatekeepers when seeking care should be beneficial. To examine the association between patient experience with their primary care physicians and bypassing them to directly obtain care from higher-level healthcare facilities. This prospective cohort study was conducted in 13 primary care clinics in Japan. We assessed patient experience of primary care using the Japanese version of Primary Care Assessment Tool (JPCAT), which comprises six domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. The primary outcome was the patient bypassing their usual primary care physician to seek care at a hospital, with this occurring at least once in a year. We used a Bayesian hierarchical model to adjust clustering within clinics and individual covariates. Data were analyzed from 205 patients for whom a physician at a clinic served as their usual primary care physician. The patient follow-up rate was 80.1%. After adjustment for patients' sociodemographic and health status characteristics, the JPCAT total score was found to be inversely associated with patient bypass behavior (odds ratio per 1 SD increase, 0.44; 95% credible interval, 0.21-0.88). The results of various sensitivity analyses were consistent with those of the primary analysis. We found that patient experience of primary care in Japan was inversely associated with bypassing a primary care gatekeeper to seek care at higher-level healthcare facilities, such as hospitals. Our findings suggest that primary care providers' efforts to improve patient experience should help to ensure appropriate use of healthcare services under loosely regulated gatekeeping systems; further studies are warranted.

Alerts in electronic medical records to promote a colorectal cancer screening programme: a cluster randomised controlled trial in primary care

PubMed Central

Guiriguet, Carolina; Muñoz-Ortiz, Laura; Burón, Andrea; Rivero, Irene; Grau, Jaume; Vela-Vallespín, Carmen; Vilarrubí, Mercedes; Torres, Miquel; Hernández, Cristina; Méndez-Boo, Leonardo; Toràn, Pere; Caballeria, Llorenç; Macià, Francesc; Castells, Antoni

2016-01-01

Background Participation rates in colorectal cancer screening are below recommended European targets. Aim To evaluate the effectiveness of an alert in primary care electronic medical records (EMRs) to increase individuals’ participation in an organised, population-based colorectal cancer screening programme when compared with usual care. Design and setting Cluster randomised controlled trial in primary care centres of Barcelona, Spain. Method Participants were males and females aged 50–69 years, who were invited to the first round of a screening programme based on the faecal immunochemical test (FIT) (n = 41 042), and their primary care professional. The randomisation unit was the physician cluster (n = 130) and patients were blinded to the study group. The control group followed usual care as per the colorectal cancer screening programme. In the intervention group, as well as usual care, an alert to health professionals (cluster level) to promote screening was introduced in the individual’s primary care EMR for 1 year. The main outcome was colorectal cancer screening participation at individual participant level. Results In total, 67 physicians and 21 619 patients (intervention group) and 63 physicians and 19 423 patients (control group) were randomised. In the intention-to-treat analysis screening participation was 44.1% and 42.2% respectively (odds ratio 1.08, 95% confidence interval [CI] = 0.97 to 1.20, P = 0.146). However, in the per-protocol analysis screening uptake in the intervention group showed a statistically significant increase, after adjusting for potential confounders (OR, 1.11; 95% CI = 1.02 to 1.22; P = 0.018). Conclusion The use of an alert in an individual’s primary care EMR is associated with a statistically significant increased uptake of an organised, FIT-based colorectal cancer screening programme in patients attending primary care centres. PMID:27266861

Symbiotic and synergistic community-based volunteer home visiting program for postpartum families.

PubMed

Misener, T R; Knox, P D

1990-09-01

Community health nurses who focus on the needs of the community as client, and not simply individual and family services, are aware of the demand for increased services. This demand, however, is usually coupled with the absence of resources to deliver the needed services. Therefore, leaders in community agencies must consider attracting nurses as volunteers to augment resources. Volunteer service can be highly synergistic when a symbiotic relationship exists between the agency and the volunteer. A one-year volunteer home visiting program was developed to provide services to families with new infants at one U.S. Army installation in the western United States. We assume the program methodology would be successful in civilian communities as well as other client populations.

A hybrid of monopoly and perfect competition model for hi-tech products

NASA Astrophysics Data System (ADS)

Yang, P. C.; Wee, H. M.; Pai, S.; Yang, H. J.; Wee, P. K. P.

2010-11-01

For Hi-tech products, the demand rate, the component cost as well as the selling price usually decline significantly with time. In the case of perfect competition, shortages usually result in lost sales; while in a monopoly, shortages will be completely backordered. However, neither perfect competition nor monopoly exists. Therefore, there is a need to develop a replenishment model considering a hybrid of perfect competition and monopoly when the cost, price and demand are decreasing simultaneously. A numerical example and sensitivity analysis are carried out to illustrate this model. The results show that a higher decline-rate in the component cost leads to a smaller service level and a larger replenishment interval. When the component cost decline rate increases and the selling price decline rate decreases simultaneously, the replenishment interval decreases. In perfect competition it is better to have a high service level, while for the case with monopoly, keeping a low service level is better due to complete backordering.

[The Hessian care monitor. Transparency on regional labor markets].

PubMed

Lauxen, O; Bieräugel, R

2013-08-01

The Hessian Care Monitor is a Web-based monitoring system of the regional care labor market. It contains information on the current labor market and on future developments. Official statistics are analyzed, primary data are collected, and forecasts are calculated. Since 2008, the demand for nurses in Hesse has been higher than the supply. In 2010, there was a lack of more than 4,400 nurses. Moreover, in 2025, around 5,500 additional nurses will be needed to meet the increasing demand arising from demographic changes. However, there are three different regional patterns: regions with high current shortages but little additional demand in the future; regions with low current shortages but large future needs; and regions with high current shortages and large future demand. Appropriate strategies for handling labor shortages have to be selected according to the different regional patterns.

Organizational commitment among general practitioners: a cross-sectional study of the role of psychosocial factors.

PubMed

Kuusio, Hannamaria; Heponiemi, Tarja; Sinervo, Timo; Elovainio, Marko

2010-06-01

To examine whether general practitioners (GP) working in primary health care have lower organizational commitment compared with physicians working in other health sectors. The authors also tested whether psychosocial factors (job demands, job control, and colleague consultation) explain these differences in commitment between GPs and other physicians. Cross-sectional postal questionnaire. Setting and participants. A postal questionnaire was sent to a random sample of physicians (n = 5000) drawn from the Finnish Association database in 2006. A total of 2841 physicians (response rate 57%) returned the questionnaire, of which 2657 (545 GPs and 2090 other physicians) fulfilled all the participant criteria. Organizational commitment was measured with two different indicators: intention to change jobs and low affective commitment. GPs were less committed to their organizations than other physicians. Work-related psychosocial factors (high job demands, low job control, and poor colleague consultation) were all significant risk factors for low organizational commitment. The evidence collected suggests that policies that reduce psychological demands, such as job demands and low control, may contribute to better organizational commitment and, thus, alleviate the shortages of physicians in primary care. Furthermore, giving GPs a stronger say in decisions concerning their work and providing them with more variety in work tasks may even improve the quality of primary care. The strategies for workplace development should focus on redesigning jobs and identifying GPs at higher risk, such as those with especially high job strain.

Closing data gaps for LCA of food products: estimating the energy demand of food processing.

PubMed

Sanjuán, Neus; Stoessel, Franziska; Hellweg, Stefanie

2014-01-21

Food is one of the most energy and CO2-intensive consumer goods. While environmental data on primary agricultural products are increasingly becoming available, there are large data gaps concerning food processing. Bridging these gaps is important; for example, the food industry can use such data to optimize processes from an environmental perspective, and retailers may use this information for purchasing decisions. Producers and retailers can then market sustainable products and deliver the information demanded by governments and consumers. Finally, consumers are increasingly interested in the environmental information of foods in order to lower their consumption impacts. This study provides estimation tools for the energy demand of a representative set of food process unit operations such as dehydration, evaporation, or pasteurization. These operations are used to manufacture a variety of foods and can be combined, according to the product recipe, to quantify the heat and electricity demand during processing. In combination with inventory data on the production of the primary ingredients, this toolbox will be a basis to perform life cycle assessment studies of a large number of processed food products and to provide decision support to the stakeholders. Furthermore, a case study is performed to illustrate the application of the tools.

Thermal optimum design for tracking primary mirror of Space Telescope

NASA Astrophysics Data System (ADS)

Pan, Hai-jun; Ruan, Ping; Li, Fu; Wang, Hong-Wei

2011-08-01

In the conventional method, the structural parameters of primary mirror are usually optimized just by the requirement of mechanical performance. Because the influences of structural parameters on thermal stability are not taken fully into account in this simple method, the lightweight optimum design of primary mirror usually brings the bad thermal stability, especially in the complex environment. In order to obtain better thermal stability, a new method about structure-thermal optimum design of tracking primary mirror is discussed. During the optimum process, both the lightweight ratio and thermal stability will be taken into account. The structure-thermal optimum is introduced into the analysis process and commenced after lightweight design as the secondary optimum. Using the engineering analysis of software ANSYS, a parameter finite element analysis (FEA) model of mirror is built. On the premise of appropriate lightweight ratio, the RMS of structure-thermal deformation of mirror surface and lightweight ratio are assigned to be state variables, and the maximal RMS of temperature gradient load to be object variable. The results show that certain structural parameters of tracking primary mirror have different influences on mechanical performance and thermal stability, even they are opposite. By structure-thermal optimizing, the optimized mirror model discussed in this paper has better thermal stability than the old one under the same thermal loads, which can drastically reduce difficulty in thermal control.

Effects of a long-term lifestyle intervention program with Mediterranean diet and exercise for the management of patients with metabolic syndrome in a primary care setting.

PubMed

Gomez-Huelgas, R; Jansen-Chaparro, S; Baca-Osorio, A J; Mancera-Romero, J; Tinahones, F J; Bernal-López, M R

2015-06-01

The impact of a lifestyle intervention (LSI) program for the long-term management of subjects with metabolic syndrome in a primary care setting is not known. This 3-year prospective controlled trial randomized adult subjects with metabolic syndrome to receive intensive LSI or to usual care in a community health centre in Malaga, Spain. LSI subjects received instruction on Mediterranean diet and a regular aerobic exercise program by their primary care professionals. Primary outcome included changes from baseline on different components of metabolic syndrome (abdominal circumference, blood pressure, HDL-cholesterol, fasting plasma glucose and triglycerides). Among the 2,492 subjects screened, 601 subjects with metabolic syndrome (24.1%) were randomized to LSI (n = 298) or to usual care (n = 303); of them, a 77% and a 58%, respectively, completed the study. At the end of the study period, LSI resulted in significant differences vs. usual care in abdominal circumference (-0.4 ± 6 cm vs. + 2.1 ± 6.7 cm, p < 0.001), systolic blood pressure (-5.5 ± 15 mmHg vs. -0.6 ± 19 mmHg, p = 0.004), diastolic blood pressure (-4.6 ± 10 mmHg vs. -0.2 ± 13 mmHg, p < 0.001) and HDL-cholesterol (+4 ± 12 mg/dL vs. + 2 ± 12 mg/dL, p = 0.05); however, there were no differences in fasting plasma glucose and triglyceride concentration (-4 ± 35 mg/dl vs. -1 ± 32 mg/dl, p = 0.43 and -0.4 ± 83 mg/dl vs. +6 ± 113 mg/dl, p = 0.28). Intensive LSI counseling provided by primary care professionals resulted in significant improvements in abdominal circumference, blood pressure and HDL-cholesterol but had limited effects on glucose and triglyceride levels in patients with metabolic syndrome. Copyright © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Osteoporosis improvement: a large-scale randomized controlled trial of patient and primary care physician education.

PubMed

Solomon, Daniel H; Katz, Jeffrey N; Finkelstein, Joel S; Polinski, Jennifer M; Stedman, Margaret; Brookhart, M Alan; Arnold, Marilyn; Gauthier, Suzanne; Avorn, Jerry

2007-11-01

We conducted a randomized controlled trial within the setting of a large drug benefit plan for Medicare beneficiaries. Primary care physicians and their patients were randomized to usual care, patient intervention only, physician intervention only, or both interventions. There was no difference in the probability of the primary composite endpoint (BMD test or osteoporosis medication) or in either of its components comparing the combined intervention group with usual care (risk ratio = 1.04; 95% CI, 0.85-1.26). Fractures from osteoporosis are associated with substantial morbidity, mortality, and cost. However, only a minority of at-risk older adults receives screening and/or treatment for this condition. We evaluated the effect of educational interventions for osteoporosis targeting at-risk patients, primary care physicians, or both. We conducted a randomized controlled trial within the setting of a large drug benefit plan for Medicare beneficiaries. Primary care physicians and their patients were randomized to usual care, patient intervention only, physician intervention only, or both interventions. The at-risk patients were women >or=65 yr of age, men and women >or=65 yr of age with a prior fracture, and men and women >or=65 yr of age who used oral glucocorticoids. The primary outcome studied was a composite of either undergoing a BMD test or initiating a medication used for osteoporosis. The secondary outcome was a hip, humerus, spine, or wrist fracture. We randomized 828 primary care physicians and their 13,455 eligible at-risk patients into four study arms. Physician and patient characteristics were very similar across all four groups. Across all four groups, the rate of the composite outcome was 10.3 per 100 person-years and did not differ between the usual care and the combined intervention groups (p = 0.5). In adjusted Cox proportional hazards models, there was no difference in the probability of the primary composite endpoint comparing the combined intervention group with usual care (risk ratio = 1.04; 95% CI, 0.85-1.26). There was also no difference in either of the components of the composite endpoint. The probability of fracture during follow-up was 4.2 per 100 person-years and did not differ by treatment assignment (p = 0.9). In this trial, a relatively brief program of patient and/or physician education did not work to improve the management of osteoporosis. More intensive efforts should be considered for future quality improvement programs for osteoporosis.

Upper GI and small bowel series

MedlinePlus

... the stomach may indicate the following problems: Gastric cancer Gastric ulcer - benign Gastritis Polyps (a tumor that is usually noncancerous and grows on the mucus membrane ) Pyloric stenosis ... ring Primary or idiopathic intestinal pseudo-obstruction

Fourier Transformation Theory for Averaged Functions, with Application to Very Long Baseline Radio Interferometry.

DTIC Science & Technology

1981-02-01

primary parameters affecting the SNR. For an earth-based interferometer, the physical aperture may usually be constructed adequately large to keep the...bandwidth Av cent--.c. on vo0 by an interferometer with frequency characteristic F(v) and primary power pattern G(s-s ) (defined as the product of the...infinitely narrow beam for the primary power pattern, G(g- 0 ) = (;-S )] we have where we have assumed a flat frequency response and included as a

REDUCING SUICIDAL IDEATION AND DEPRESSION IN OLDER PRIMARY CARE PATIENTS: 24-MONTH OUTCOMES OF THE PROSPECT STUDY

PubMed Central

Alexopoulos, George S.; Reynolds, Charles F.; Bruce, Martha L.; Katz, Ira R.; Raue, Patrick J.; Mulsant, Benoit H.; Oslin, David; Have, Thomas Ten

2010-01-01

Objective The PROSPECT Study evaluated the impact of a care management intervention on suicidal ideation and depression in older primary care patients. This is the first report of outcomes over a 2-year period. Method The subjects (N=599) were older (>=60 years) patients with major or minor depression selected after screening 9,072 randomly identified patients of 20 primary care practices randomly assigned to the PROSPECT intervention or usual care. The intervention consisted of services of 15 trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 24 months. Results Intervention patients had a higher likelihood to receive antidepressants and or psychotherapy (84.9–89% vs. 49–59%) and a 2.2 times greater decline in suicidal ideation than usual care patients over 24 months. Treatment response occurred earlier in intervention patients and continued to increase from the 18th to the 24th month, while there was no appreciable increase in usual care patients during the same period. Among patients with major depression, a greater number achieved remission in the intervention than the usual care group at 4 (26.6 vs. 15.2%), 8 (36% vs. 22.5%), and 24 (45.4% vs. 31.5%) months. Patients with minor depression had favorable outcomes regardless of treatment assignment. Conclusions Sustained collaborative care maintains high utilization of antidepressant treatment, reduces suicidal ideation, and improves the outcomes of major depression over two years. These observations suggest that sustained collaborative care increases depression-free days. PMID:19528195

Economic effects of immigrants on native and foreign-born workers: complementarity, substitutability, and other channels of influence.

PubMed

Greenwood, M J; Hunt, G L

1995-04-01

The authors use Standard Metropolitan Statistical Area (SMSA) data constructed from 1980 census microdata files and other sources to estimate a structural model of native/foreign-born labor demand and labor supply which distinguishes the effects upon real wages of each type of labor and on the employment of natives. The authors specify, econometrically estimate, and simulate the structural model which incorporates not only a production structure channel through which immigrants influence area real wages and employment, but also demand and native labor supply channels. It is noted that while these are not the only channels through which immigrants may affect native workers, the model nonetheless constitutes a step in the direction of a general equilibrium approach. In the production structure channel, immigrants and natives are found to be substitutes in production. Immigration lowers foreign-born wage rates and leads to lower wages for natives. The negative effects of the production channel usually are ameliorated through the demand channel. Further, immigrants add to local demand through their earnings and potentially through non-labor income, while also lowering unit costs and local prices which enhances real incomes and potentially net exports, and thus the demands for local output and area labor. The author discusses findings of interest from the simulation results based upon an analysis of all areas.

Organizational downsizing and alcohol use: A national study of U.S. workers during the Great Recession.

PubMed

Frone, Michael R

2018-02-01

Organizational downsizing, which represents the reduction of an organization's workforce, results in a stressful work environment for those who survive the downsizing. However, we know little about the association between surviving an organizational downsizing and employee alcohol use. This study explored the association between exposure to organizational downsizing and four dimensions of alcohol use during the Great Recession. Also explored were the moderating influences of length of recession exposure, state drinking culture, gender, age, education, family income, and financial demands. Data for this study came from a national telephone survey of U.S. workers that was conducted from December 2008 to April 2011 (N=2296). The results revealed that exposure to organizational downsizing was positively associated with usual frequency of drinking, number of drinks consumed per usual drinking occasion, and both the frequency of binge drinking and drinking to intoxication. Length of exposure to the recession moderated the association between organizational downsizing exposure and usual number of drinks consumed. The conditional effects revealed that this association became stronger as length of exposure to the recession increased. Furthermore, age moderated the associations between organizational downsizing exposure and the usual number of drinks consumed and the frequency of binge drinking and intoxication. The conditional effects revealed that these associations were positive and significant among young survivors (ages 40 or younger), but were nonsignificant among middle-aged survivors (over 40years of age). State drinking culture, gender, education, family income, and financial demands did not moderate the associations between organizational downsizing exposure and alcohol use. Copyright © 2017 Elsevier Ltd. All rights reserved.

Do Pediatricians Ask About Adverse Childhood Experiences in Pediatric Primary Care?

PubMed

Kerker, Bonnie D; Storfer-Isser, Amy; Szilagyi, Moira; Stein, Ruth E K; Garner, Andrew S; O'Connor, Karen G; Hoagwood, Kimberly E; Horwitz, Sarah M

2016-03-01

The stress associated with adverse childhood experiences (ACEs) has immediate and long-lasting effects. The objectives of this study were to examine 1) how often pediatricians ask patients' families about ACEs, 2) how familiar pediatricians are with the original ACE study, and 3) physician/practice characteristics, physicians' mental health training, and physicians' attitudes/beliefs that are associated with asking about ACEs. Data were collected from 302 nontrainee pediatricians exclusively practicing general pediatrics who completed the 2013 American Academy of Pediatrics Periodic Survey. Pediatricians indicated whether they usually, sometimes, or never inquired about or screened for 7 ACEs. Sample weights were used to reduce nonresponse bias. Weighted descriptive and logistic regression analyses were conducted. Only 4% of pediatricians usually asked about all 7 ACEs; 32% did not usually ask about any. Less than 11% of pediatricians reported being very or somewhat familiar with the ACE study. Pediatricians who screened/inquired about ACEs usually asked about maternal depression (46%) and parental separation/divorce (42%). Multivariable analyses showed that pediatricians had more than twice the odds of usually asking about ACEs if they disagreed that they have little effect on influencing positive parenting skills, disagreed that screening for social emotional risk factors within the family is beyond the scope of pediatricians, or were very interested in receiving further education on managing/treating mental health problems in children and adolescents. Few pediatricians ask about all ACEs. Pediatric training that emphasizes the importance of social/emotional risk factors may increase the identification of ACEs in pediatric primary care. Copyright © 2016 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

DIABETES, DEPRESSION, AND DEATH: A RANDOMIZED CONTROLLED TRIAL OF A DEPRESSION TREATMENT PROGRAM FOR OLDER ADULTS BASED IN PRIMARY CARE (PROSPECT)

PubMed Central

Bogner, Hillary R; Morales, Knashawn H; Post, Edward P; Bruce, Martha L

2009-01-01

OBJECTIVE Our a priori hypothesis was that depressed patients with diabetes in practices implementing a depression management program would have a decreased risk of mortality compared to depressed patients with diabetes in usual care practices. RESEARCH DESIGN AND METHODS Multi-site practice-randomized controlled trial PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) with patient recruitment from 5/99-8/01 and supplemented with a search of the National Death Index. Twenty primary care practices participated from New York City, Philadelphia, and Pittsburgh. In all, 584 participants who were identified though a two-stage, age-stratified (60-74; 75+) depression screening of randomly sampled patients and were classified as depressed with complete information on diabetes status are included in these analyses. Of all the 584 participants, 123 (21.2%) reported a history of diabetes. A depression care manager worked with primary care physicians to provide algorithm-based care. Vital status was assessed at 5 years. RESULTS After a median follow-up of 52.0 months, 110 depressed patients had died. Depressed patients with diabetes in the Intervention Condition were less likely to have died during the 5-year follow-up interval than were depressed persons with diabetes in Usual Care after accounting for baseline differences among patients (adjusted hazard ratio 0.49, 95% CI [0.24, 0.98]). CONCLUSIONS Older depressed primary care patients with diabetes in practices implementing depression care management were less likely to die over the course of a 5-year interval than were depressed patients with diabetes in usual care practices. PMID:17717284

Properties of a Soybean Oil-based Surfactant and Its Application in Microbubble Preparation

USDA-ARS?s Scientific Manuscript database

Since microbubbles are thermodynamically unstable, surfactants are usually added to improve their stability. Demand for the use of vegetable oil-based surfactants has been increasing due to safety and environmental concerns. This work investigates a soybean oil-based surfactant and its application...

EDUCATION FOR HEALTH TECHNICIANS--AN OVERVIEW.

ERIC Educational Resources Information Center

KINSINGER, ROBERT E.

AS DEFINED, HEALTH SERVICE TECHNICIANS ARE NORMALLY PREPARED FOR ENTRY INTO THEIR OCCUPATIONS BY PURSUING A POST-SECONDARY EDUCATIONAL PROGRAM THAT DOES NOT DEMAND A BACCALAUREATE DEGREE BUT USUALLY INCLUDES A COMBINATION OF THEORY, PRACTICAL KNOWLEDGE, MANUAL SKILL, AND WHEN APPROPRIATE, ACTUAL CLINICAL PRACTICE. EXAMPLES OF SUCH TECHNICIANS…

Supply and Demand Diversity

ERIC Educational Resources Information Center

Galuszka, Peter

2007-01-01

Public universities in Virginia, as in many states, have generally not paid much attention to diversity among their suppliers. For years, state expenditures for outside contracts went to the usual suspects--White contractors from well-established companies. Four years ago, former Governor Mark Warner, a progressive Democrat from the high…

Developing the Bench: Building An Effective Homeland Security Undergraduate Program

DTIC Science & Technology

2008-03-01

transient group. A total career lasts about twenty to twenty-five years; roles in senior leadership typically are assumed in the latter 25% of a...career. Senior command positions usually last about two years. All of these factors combine to create a constant influx of new senior leadership ...senior leader or academician, but it would provide the foundation for leadership development. B. THE DEMAND FOR THOSE ON THE BENCH According to

Clinical outcomes in managed-care patients with coronary heart disease treated aggressively in lipid-lowering disease management clinics: the alliance study.

PubMed

Koren, Michael J; Hunninghake, Donald B

2004-11-02

This study sought to determine if an aggressive, focused low-density lipoprotein cholesterol (LDL-C)-lowering strategy was superior to usual care for coronary heart disease (CHD) patients enrolled in health maintenance organization or Veterans Administration settings. Statin therapy benefits are well established. No prospective, randomized studies have tested strategies to optimize these benefits in a "real-world" setting. A total of 2,442 CHD patients with hyperlipidemia were randomized to either an aggressive treatment arm using atorvastatin or usual care and followed for 51.5 months on average. Atorvastatin-group patients were titrated to LDL-C goals of <80 mg/dl (2.1 mmol/l) or a maximum atorvastatin dose of 80 mg/day. Usual-care patients received any treatment deemed appropriate by their regular physicians. End point assessments were complete in 958 atorvastatin-group and 941 usual-care patients. Partial assessments occurred in 259 patients in the atorvastatin group and 284 patients in the usual care group who did not complete four years of study participation because of adverse events, withdrawn consent, or follow-up loss. The primary efficacy parameter was time to first cardiovascular event. A total of 289 (23.7%) patients in the atorvastatin group compared with 333 (27.7%) patients in the usual care group experienced a primary outcome (hazard ratio, 0.83; 95% confidence interval 0.71 to 0.97, p = 0.02). This reduction in morbidity was largely due to fewer non-fatal myocardial infarctions (4.3% vs. 7.7%, p = 0.0002). Levels of LDL-C were reduced more (34.3% vs. 23.3%, p < 0.0001) and National Cholesterol Education Program goals (LDL-C <100 mg/dl) more likely met at end-of-study visits (72.4% vs. 40.0%) in patients receiving atorvastatin compared with those receiving usual care. An aggressive, focused statin therapy management strategy outperformed usual care in health maintenance organization and Veterans Administration clinic patients with CHD.

Usual source of care and the quality of primary care: a survey of patients in Guangdong province, China.

PubMed

Du, Zhicheng; Liao, Yu; Chen, Chien-Chou; Hao, Yuantao; Hu, Ruwei

2015-07-31

Usual source of care (USC) refers to the provider or place a patient consults when sick or in need of medical advice. No studies have been conducted in China to compare the quality of primary care provided with or without USC. The purpose of this study was to fill this gap in the literature by examining the quality of primary care provided between those having a USC and those without. Results of the study would provide implications for policymakers in terms of improving primary care performance in China, and help guide patients in their health care seeking behaviors. A cross-sectional survey with patients was conducted in Guangdong province of China, using the Chinese validated Primary Care Assessment Tool (PCAT). ANOVA was performed to compare the overall and ten domains of primary care quality for patients with and without USC. Multivariate analyses were used to assess the association between USC and quality of primary care attributes while controlling for sociodemographic and health care characteristics. The study added evidence that having a USC can provide higher quality of primary care to patients than those without a USC. Results of this study showed that the PCAT score associated with those having a USC was significantly higher than those not having a USC. Moreover, the study showed that having a usual provider of care was also independently and significantly associated with patients' satisfaction with care. This study added evidence that in China, patients with a USC reported higher quality of medical care experiences compared with those without a USC. The efforts to improve quality of care should include policies promoting USC.

Association of Structured Virtual Visits for Hypertension Follow-Up in Primary Care with Blood Pressure Control and Use of Clinical Services.

PubMed

Levine, David Michael; Dixon, Ronald F; Linder, Jeffrey A

2018-04-23

Optimal management of hypertension requires frequent monitoring and follow-up. Novel, pragmatic interventions have the potential to engage patients, maintain blood pressure control, and enhance access to busy primary care practices. "Virtual visits" are structured asynchronous online interactions between a patient and a clinician to extend medical care beyond the initial office visit. To compare blood pressure control and healthcare utilization between patients who received virtual visits compared to usual hypertension care. Propensity score-matched, retrospective cohort study with adjustment by difference-in-differences. Primary care patients with hypertension. Patient participation in at least one virtual visit for hypertension. Usual care patients did not use a virtual visit but were seen in-person for hypertension. Adjusted difference in mean systolic blood pressure, primary care office visits, specialist office visits, emergency department visits, and inpatient admissions in the 180 days before and 180 days after the in-person visit. Of the 1051 virtual visit patients and 24,848 usual care patients, we propensity score-matched 893 patients from each group. Both groups were approximately 61 years old, 44% female, 85% White, had about five chronic conditions, and about 20% had a mean pre-visit systolic blood pressure of 140-160 mmHg. Compared to usual care, virtual visit patients had an adjusted 0.8 (95% CI, 0.3 to 1.2) fewer primary care office visits. There was no significant adjusted difference in systolic blood pressure control (0.6 mmHg [95% CI, - 2.0 to 3.1]), specialist visits (0.0 more visits [95% CI, - 0.3 to 0.3]), emergency department visits (0.0 more visits [95% CI, 0.0 to 0.01]), or inpatient admissions (0.0 more admissions [95% CI, 0.0 to 0.1]). Among patients with reasonably well-controlled hypertension, virtual visit participation was associated with equivalent blood pressure control and reduced in-office primary care utilization.

Clinical and cost-effectiveness of computerised cognitive behavioural therapy for depression in primary care: Design of a randomised trial

PubMed Central

de Graaf, L Esther; Gerhards, Sylvia AH; Evers, Silvia MAA; Arntz, Arnoud; Riper, Heleen; Severens, Johan L; Widdershoven, Guy; Metsemakers, Job FM; Huibers, Marcus JH

2008-01-01

Background Major depression is a common mental health problem in the general population, associated with a substantial impact on quality of life and societal costs. However, many depressed patients in primary care do not receive the care they need. Reason for this is that pharmacotherapy is only effective in severely depressed patients and psychological treatments in primary care are scarce and costly. A more feasible treatment in primary care might be computerised cognitive behavioural therapy. This can be a self-help computer program based on the principles of cognitive behavioural therapy. Although previous studies suggest that computerised cognitive behavioural therapy is effective, more research is necessary. Therefore, the objective of the current study is to evaluate the (cost-) effectiveness of online computerised cognitive behavioural therapy for depression in primary care. Methods/Design In a randomised trial we will compare (a) computerised cognitive behavioural therapy with (b) treatment as usual by a GP, and (c) computerised cognitive behavioural therapy in combination with usual GP care. Three hundred mild to moderately depressed patients (aged 18–65) will be recruited in the general population by means of a large-scale Internet-based screening (N = 200,000). Patients will be randomly allocated to one of the three treatment groups. Primary outcome measure of the clinical evaluation is the severity of depression. Other outcomes include psychological distress, social functioning, and dysfunctional beliefs. The economic evaluation will be performed from a societal perspective, in which all costs will be related to clinical effectiveness and health-related quality of life. All outcome assessments will take place on the Internet at baseline, two, three, six, nine, and twelve months. Costs are measured on a monthly basis. A time horizon of one year will be used without long-term extrapolation of either costs or quality of life. Discussion Although computerised cognitive behavioural therapy is a promising treatment for depression in primary care, more research is needed. The effectiveness of online computerised cognitive behavioural therapy without support remains to be evaluated as well as the effects of computerised cognitive behavioural therapy in combination with usual GP care. Economic evaluation is also needed. Methodological strengths and weaknesses are discussed. Trial registration The study has been registered at the Netherlands Trial Register, part of the Dutch Cochrane Centre (ISRCTN47481236). PMID:18590518

The efficacy of interactive, motion capture-based rehabilitation on functional outcomes in an inpatient stroke population: a randomized controlled trial.

PubMed

Cannell, John; Jovic, Emelyn; Rathjen, Amy; Lane, Kylie; Tyson, Anna M; Callisaya, Michele L; Smith, Stuart T; Ahuja, Kiran Dk; Bird, Marie-Louise

2018-02-01

To compare the efficacy of novel interactive, motion capture-rehabilitation software to usual care stroke rehabilitation on physical function. Randomized controlled clinical trial. Two subacute hospital rehabilitation units in Australia. In all, 73 people less than six months after stroke with reduced mobility and clinician determined capacity to improve. Both groups received functional retraining and individualized programs for up to an hour, on weekdays for 8-40 sessions (dose matched). For the intervention group, this individualized program used motivating virtual reality rehabilitation and novel gesture controlled interactive motion capture software. For usual care, the individualized program was delivered in a group class on one unit and by rehabilitation assistant 1:1 on the other. Primary outcome was standing balance (functional reach). Secondary outcomes were lateral reach, step test, sitting balance, arm function, and walking. Participants (mean 22 days post-stroke) attended mean 14 sessions. Both groups improved (mean (95% confidence interval)) on primary outcome functional reach (usual care 3.3 (0.6 to 5.9), intervention 4.1 (-3.0 to 5.0) cm) with no difference between groups ( P = 0.69) on this or any secondary measures. No differences between the rehabilitation units were seen except in lateral reach (less affected side) ( P = 0.04). No adverse events were recorded during therapy. Interactive, motion capture rehabilitation for inpatients post stroke produced functional improvements that were similar to those achieved by usual care stroke rehabilitation, safely delivered by either a physical therapist or a rehabilitation assistant.

Incentive Elasticity of Demand for Bike/Walk Program

DOT National Transportation Integrated Search

2008-12-29

The primary objective of this research is to estimate the "incentive" (price) elasticity of demand for using non-motorized transportation (specifically walking and bicycling) to work. Results can be used directly in the formation of local policies to...

Effect of Primary Care Intervention on Breastfeeding Duration and Intensity

PubMed Central

Stuebe, Alison; Barnett, Josephine; Labbok, Miriam H.; Fletcher, Jason; Bernstein, Peter S.

2014-01-01

Objectives. We determined the effectiveness of primary care–based, and pre- and postnatal interventions to increase breastfeeding. Methods. We conducted 2 trials at obstetrics and gynecology practices in the Bronx, New York, from 2008 to 2011. The Provider Approaches to Improved Rates of Infant Nutrition & Growth Study (PAIRINGS) had 2 arms: usual care versus pre- and postnatal visits with a lactation consultant (LC) and electronically prompted guidance from prenatal care providers (EP). The Best Infant Nutrition for Good Outcomes (BINGO) study had 4 arms: usual care, LC alone, EP alone, or LC+EP. Results. In BINGO at 3 months, high intensity was greater for the LC+EP (odds ratio [OR] = 2.72; 95% confidence interval [CI] = 1.08, 6.84) and LC (OR = 3.22; 95% CI = 1.14, 9.09) groups versus usual care, but not for the EP group alone. In PAIRINGS at 3 months, intervention rates exceeded usual care (OR = 2.86; 95% CI = 1.21, 6.76); the number needed to treat to prevent 1 dyad from nonexclusive breastfeeding at 3 months was 10.3 (95% CI = 5.6, 50.7). Conclusions. LCs integrated into routine care alone and combined with EP guidance from prenatal care providers increased breastfeeding intensity at 3 months postpartum. PMID:24354834

Fostering Writing in Upper Primary Grades: A Study into the Distinct and Combined Impact of Explicit Instruction and Peer Assistance

ERIC Educational Resources Information Center

De Smedt, Fien; Van Keer, Hilde

2018-01-01

As writing is a complex and resource demanding task, high-quality writing instruction is indispensable from primary grades on to support beginning writers in developing effective writing skills. Writing research should therefore provide teachers and schools with evidence-based guidelines for teaching writing in daily practice. In this respect, the…

Seasonality and Access to Education: The Case of Primary Education in Sub-Saharan Africa. Research Monograph No. 31

ERIC Educational Resources Information Center

Hadley, Sierd

2010-01-01

This paper draws together research on seasonality, child labour and education in the context of primary education in sub-Saharan Africa. It describes how income poverty and demand for labour can fluctuate within and between years, affecting participation and progression through school systems. It highlights how analysis of the private and public…

Protecting-group-free synthesis of amines: synthesis of primary amines from aldehydes via reductive amination.

PubMed

Dangerfield, Emma M; Plunkett, Catherine H; Win-Mason, Anna L; Stocker, Bridget L; Timmer, Mattie S M

2010-08-20

New methodology for the protecting-group-free synthesis of primary amines is presented. By optimizing the metal hydride/ammonia mediated reductive amination of aldehydes and hemiacetals, primary amines were selectively prepared with no or minimal formation of the usual secondary and tertiary amine byproduct. The methodology was performed on a range of functionalized aldehyde substrates, including in situ formed aldehydes from a Vasella reaction. These reductive amination conditions provide a valuable synthetic tool for the selective production of primary amines in fewer steps, in good yields, and without the use of protecting groups.

Controlled, cross-sectional MRI evaluation of joint status in severe haemophilia A patients treated with prophylaxis vs. on demand

PubMed Central

Oldenburg, J; Zimmermann, R; Katsarou, O; Theodossiades, G; Zanon, E; Niemann, B; Kellermann, E; Lundin, B

2015-01-01

In patients with haemophilia A, factor VIII (FVIII) prophylaxis reduces bleeding frequency and joint damage compared with on-demand therapy. To assess the effect of prophylaxis initiation age, magnetic resonance imaging (MRI) was used to evaluate bone and cartilage damage in patients with severe haemophilia A. In this cross-sectional, multinational investigation, patients aged 12–35 years were assigned to 1 of 5 groups: primary prophylaxis started at age <2 years (group 1); secondary prophylaxis started at age 2 to <6 years (group 2), 6 to <12 years (group 3), or 12−18 years (group 4); or on-demand treatment (group 5). Joint status at ankles and knees was assessed using Compatible Additive MRI scoring (maximum and mean ankle; maximum and mean of all 4 joints) and Gilbert scores in the per-protocol population (n = 118). All prophylaxis groups had better MRI joint scores than the on-demand group. MRI scores generally increased with current patient age and later start of prophylaxis. Ankles were the most affected joints. In group 1 patients currently aged 27−35 years, the median of maximum ankle scores was 0.0; corresponding values in groups 4 and 5 were 17.0 and 18.0, respectively [medians of mean index joint scores: 0.0 (group 1), 8.1 (group 2) and 13.8 (group 4)]. Gilbert scores revealed outcomes less pronounced than MRI scores. MRI scores identified pathologic joint status with high sensitivity. Prophylaxis groups had lower annualized joint bleeds and MRI scores vs. the on-demand group. Primary prophylaxis demonstrated protective effects against joint deterioration compared with secondary prophylaxis. PMID:25470205

Scientific challenges in sustainable energy technology

NASA Astrophysics Data System (ADS)

Lewis, Nathan

2006-04-01

We describe and evaluate the technical, political, and economic challenges involved with widespread adoption of renewable energy technologies. First, we estimate fossil fuel resources and reserves and, together with the current and projected global primary power production rates, estimate the remaining years of oil, gas, and coal. We then compare the conventional price of fossil energy with that from renewable energy technologies (wind, solar thermal, solar electric, biomass, hydroelectric, and geothermal) to evaluate the potential for a transition to renewable energy in the next 20-50 years. Secondly, we evaluate - per the Intergovernmental Panel on Climate Change - the greenhouse constraint on carbon-based power consumption as an unpriced externality to fossil-fuel use, considering global population growth, increased global gross domestic product, and increased energy efficiency per unit GDP. This constraint is projected to drive the demand for carbon-free power well beyond that produced by conventional supply/demand pricing tradeoffs, to levels far greater than current renewable energy demand. Thirdly, we evaluate the level and timescale of R&D investment needed to produce the required quantity of carbon-free power by the 2050 timeframe. Fourth, we evaluate the energy potential of various renewable energy resources to ascertain which resources are adequately available globally to support the projected demand. Fifth, we evaluate the challenges to the chemical sciences to enable the cost-effective production of carbon-free power required. Finally, we discuss the effects of a change in primary power technology on the energy supply infrastructure and discuss the impact of such a change on the modes of energy consumption by the energy consumer and additional demands on the chemical sciences to support such a transition in energy supply.

Demand-side management: Why ratemaking should`nt control tax policy

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

Haney, J.D.

1995-01-01

As utilities spend money on demand-side management (DSM) programs, they usually deduct their costs currently as ordinary and necessary business expenses. However, state regulators may force deferral of DSM costs for ratemaking purposes, with possible consequences on tax returns. When regulators defer DSM costs, the Internal Revenue Service (IRS) has offered several theories to challenge current tax deductions. One theory requires capitilization instead of a current deduction if regulators include the DSM cost in rate base and provide for a rate of return on the balance. The IRS explained this theory two years ago in a White Paper on conservationmore » expenses: The direct relationship between a rate of return allowed by the Regulator for conservation expenditures allowed in rate base and future profits establishes a prima facie case for capitalization under the future benefit standard. The authors believe that IRS policy should not be linked to ratemaking decisions.« less

Tapentadol versus tramadol in the management of low back pain in the emergency department

PubMed Central

Guillén-Astete, Carlos A.; Cardona-Carballo, César; de la Casa-Resino, Cristina

2017-01-01

Abstract Nontraumatic musculoskeletal disorders are the main reason for presentation to the emergency department (ED), with rachialgia (back pain) being the most common reason to request medical assessment among them. This also generates the highest demand for reassessments due to poor pain control or onset of adverse reactions to the treatment prescribed in the initial assessment. A retrospective observational study based on usual clinical practice was conducted in patients attending the ED due to low back pain during a period of 24 months. The primary objective was to determine the demand for reassessments in the ED by these patients in the following 30 days, according to the type of therapeutic approach used in the initial assessment. A total of 732 patients who requested medical assessment due to back pain in the ED of our hospital were analyzed, 91 of whom were treated with tapentadol whereas 641 received another treatment. In the first month after the initial assessment, reassessments were less common in the tapentadol group; this difference was significant from days 8 to 15 (P = 0.001, odds ratio [OR] 0.252 with 95% confidence interval [CI] 0.100–0.635) and days 15 to 30 (P < 10−4, OR 0.277 with 95% CI 0.136–0.563). Patients who received tapentadol also had a better clinical evolution of pain compared to those who did not receive it (P < 10−4) and to those who received tramadol (P < 10−4). In this study in patients with back pain, tapentadol shows clear advantages over the other analgesics analyzed, in terms of pain control and less need for reassessments. PMID:29137025

Wrist osteoarthritis.

PubMed

Laulan, J; Marteau, E; Bacle, G

2015-02-01

Painful wrist osteoarthritis can result in major functional impairment. Most cases are related to posttraumatic sequel, metabolic arthropathies, or inflammatory joint disease, although wrist osteoarthritis occurs as an idiopathic condition in a small minority of cases. Surgery is indicated only when conservative treatment fails. The main objective is to ensure pain relief while restoring strength. Motion-preserving procedures are usually preferred, although residual wrist mobility is not crucial to good function. The vast array of available surgical techniques includes excisional arthroplasty, limited and total fusion, total wrist denervation, partial and total arthroplasty, and rib-cartilage graft implantation. Surgical decisions rest on the cause and extent of the degenerative wrist lesions, degree of residual mobility, and patient's wishes and functional demand. Proximal row carpectomy and four-corner fusion with scaphoid bone excision are the most widely used surgical procedures for stage II wrist osteoarthritis secondary to scapho-lunate advanced collapse (SLAC) or scaphoid non-union advanced collapse (SNAC) wrist. Proximal row carpectomy is not indicated in patients with stage III disease. Total wrist denervation is a satisfactory treatment option in patients of any age who have good range of motion and low functional demands; furthermore, the low morbidity associated with this procedure makes it a good option for elderly patients regardless of their range of motion. Total wrist fusion can be used not only as a revision procedure, but also as the primary surgical treatment in heavy manual labourers with wrist stiffness or generalised wrist-joint involvement. The role for pyrocarbon implants, rib-cartilage graft implantation, and total wrist arthroplasty remains to be determined, given the short follow-ups in available studies. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

[Working conditions and common mental disorders among primary health care workers from Botucatu, São Paulo State].

PubMed

Braga, Ludmila Candida de; Carvalho, Lidia Raquel de; Binder, Maria Cecília Pereira

2010-06-01

Common mental disorders (CMD) present high prevalence among general populations and workers with important individual and social consequences. This cross-sectional and descriptive study explores the relationship between psychological job demands, job control degree and job support and prevalence of CMD among primary health care workers of Botucatu - SP. The data collection was carried out using an unidentified self-administered questionnaire, with emphasis on items relating to demand-control-support situation and occurrence of CMD (Self Reporting Questionnaire, SRQ-20). The data were stored using the software Excel / Office XP 2003, and the statistical analyses were performed in SAS system. It was evidenced that 42.6% of primary health care workers presented CMD. The observed association - high prevalence of CMD with high-strain job (Karasek model) and low prevalence of CMD with low-strain job - indicates that, in the studied city, primary health care work conditions are contributive factors to workers' illness. The survey reveals the need of interventions aiming at caring the workers and also gets better work conditions and increase social support at work.

Corticospinal control of the thumb-index grip depends on precision of force control: a transcranial magnetic stimulation and functional magnetic resonance imagery study in humans.

PubMed

Bonnard, M; Galléa, C; De Graaf, J B; Pailhous, J

2007-02-01

The corticospinal system (CS) is well known to be of major importance for controlling the thumb-index grip, in particular for force grading. However, for a given force level, the way in which the involvement of this system could vary with increasing demands on precise force control is not well-known. Using transcranial magnetic stimulation and functional magnetic resonance imagery, the present experiments investigated whether increasing the precision demands while keeping the averaged force level similar during an isometric dynamic low-force control task, involving the thumb-index grip, does affect the corticospinal excitability to the thumb-index muscles and the activation of the motor cortices, primary and non-primary (supplementary motor area, dorsal and ventral premotor and in the contralateral area), at the origin of the CS. With transcranial magnetic stimulation, we showed that, when precision demands increased, the CS excitability increased to either the first dorsal interosseus or the opponens pollicis, and never to both, for similar ongoing electromyographic activation patterns of these muscles. With functional magnetic resonance imagery, we demonstrated that, for the same averaged force level, the amplitude of blood oxygen level-dependent signal increased in relation to the precision demands in the hand area of the contralateral primary motor cortex in the contralateral supplementary motor area, ventral and dorsal premotor area. Together these results show that, during the course of force generation, the CS integrates online top-down information to precisely fit the motor output to the task's constraints and that its multiple cortical origins are involved in this process, with the ventral premotor area appearing to have a special role.

Interaction among general practitioners age and patient load in the prediction of job strain, decision latitude and perception of job demands. A cross-sectional study.

PubMed

Vanagas, Giedrius; Bihari-Axelsson, Susanna

2004-12-07

It is widely recognized and accepted that job strain adversely impacts the workforce. Individual responses to stressful situations can vary greatly and it has been shown that certain people are more likely to experience high levels of stress in their job than others. Studies highlighted that there can be age differences in job strain perception. Cross-sectional postal survey of 300 Lithuanian general practitioners. Psychosocial stress was investigated with a questionnaire based on the Reeder scale. Job demands were investigated with the Karasek scale. The analysis included descriptive statistics; logistic regression beta coefficients to find out predictors and interactions between characteristics and predictors. Response rate was 66% (N = 197). Logistic regression as significant predictors for job strain assigned - duration of work in primary care; for job demands- age and duration of working in primary care; for decision latitude- age and patient load.The interactions with regard to job strain showed that GP's age and job strain are negatively associated to a low patient load. Lower decision latitude for older GP age is strongly related to higher patient load. Job demands and GP age are slightly positively related at low patient load. Lithuanian GP's have high patient load and are at risk of stress, they have high job demands and low decision latitude. Older GP's perceive less strain, lower job demands and higher decision latitude in case of low patient load. Young GP's decision latitude has week association to patient load. Regarding to the changes in patient load younger GP's perceive it more sensitively as changes in job demands.

Effect of integrated care for sick listed patients with chronic low back pain: economic evaluation alongside a randomised controlled trial.

PubMed

Lambeek, Ludeke C; Bosmans, Judith E; Van Royen, Barend J; Van Tulder, Maurits W; Van Mechelen, Willem; Anema, Johannes R

2010-11-30

To evaluate the cost effectiveness, cost utility, and cost-benefit of an integrated care programme compared with usual care for sick listed patients with chronic low back pain. Economic evaluation alongside a randomised controlled trial with 12 months' follow-up. Primary care (10 physiotherapy practices, one occupational health service, one occupational therapy practice) and secondary care (five hospitals) in the Netherlands, 2005-9. 134 adults aged 18-65 sick listed because of chronic low back pain: 66 were randomised to integrated care and 68 to usual care. Integrated care consisted of a workplace intervention based on participatory ergonomics, with involvement of a supervisor, and a graded activity programme based on cognitive behavioural principles. Usual care was provided by general practitioners and occupational physicians according to Dutch guidelines. The primary outcome was duration until sustainable return to work. The secondary outcome was quality adjusted life years (QALYs), measured using EuroQol. Total costs in the integrated care group (£13 165, SD £13 600) were significantly lower than in the usual care group (£18 475, SD £13 616). Cost effectiveness planes and acceptability curves showed that integrated care was cost effective compared with usual care for return to work and QALYs gained. The cost-benefit analyses showed that every £1 invested in integrated care would return an estimated £26. The net societal benefit of integrated care compared with usual care was £5744. Implementation of an integrated care programme for patients sick listed with chronic low back pain has a large potential to significantly reduce societal costs, increase effectiveness of care, improve quality of life, and improve function on a broad scale. Integrated care therefore has large gains for patients and society as well as for employers.

MANPOWER AND THE GROWTH OF PRODUCER SERVICES.

ERIC Educational Resources Information Center

GREENFIELD, HARRY I.

PRODUCER SERVICES, THOSE SERVICES WHICH BUSINESS FIRMS, NONPROFIT INSTITUTIONS, AND GOVERNMENTS PROVIDE AND USUALLY SELL TO THE PRODUCER RATHER THAN TO THE CONSUMER, AND THE FACTORS AFFECTING THEIR SUPPLY AND DEMAND ARE ANALYZED. APPROXIMATELY 8.5 MILLION WORKERS, OR ABOUT 13 PERCENT OF THE TOTAL, ARE EMPLOYED IN PRODUCER SERVICES. DURING THE…

Synthesis and physical properties of new estolide esters

USDA-ARS?s Scientific Manuscript database

Vegetable oil-based oils usually fail to meet the rigorous demands of industrial lubricants by not having acceptable low temperature properties, pour point (PP) and/or cloud point (CP). The oleic estolide was esterified with a series of 16 different alcohols that were either branched or straight-cha...

Oh to Be Rid of Administrative Wimps!

ERIC Educational Resources Information Center

Weissberg, Robert

2007-01-01

Contemporary university administrators are usually wimps, and timidity in facing easily enraged campus radicals only invites outrageous demands which, in turn, subvert intellectual life. This must be changed. For much of human history leaders had to display physical valor and this trait should be restored to the college administrator job…

Manipulation strategies for massive space payloads

NASA Technical Reports Server (NTRS)

Book, Wayne J.

1991-01-01

The industrial and environmental applications for robots with a relatively large workspace has increased significantly in the last few years. To accommodate the demands, the manipulator is usually designed with long, lightweight links that are inherently flexible. Ongoing research at Georgia Tech into the behavior and design of these flexible links is discussed.

Academy Breaks the Isolation of Special Education Directors

ERIC Educational Resources Information Center

WestEd, 2014

2014-01-01

Most special education administrators do not get the chance to network regularly with professional peers to discuss job challenges and strategies. School-district special education directors routinely juggle complex, difficult, time-consuming, and emotion-laden job demands, but when things get tough, they usually find themselves solving problems…

School Social Work: A Shared Responsibility

ERIC Educational Resources Information Center

Foulks, Sara L.

1973-01-01

This article suggests ways in which the school social worker can help school administration with the demands of community pressure groups while still performing their usual functions (direct services to parents and children and consultation with school personnel). It is proposed that special teams of social workers be formulated whose specialized…

24 CFR 290.3 - Definitions.

Code of Federal Regulations, 2012 CFR

2012-04-01

... section 202 of the Housing Act of 1959, or a hospital, intermediate care facility, nursing home, group... anticipated demand (e.g., the housing market is balanced), as well as those in which there is an excess supply... turnover of rental housing, and, usually, by high levels of rent inflation. HUD will make the determination...

24 CFR 290.3 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-04-01

... section 202 of the Housing Act of 1959, or a hospital, intermediate care facility, nursing home, group... anticipated demand (e.g., the housing market is balanced), as well as those in which there is an excess supply... turnover of rental housing, and, usually, by high levels of rent inflation. HUD will make the determination...

24 CFR 290.3 - Definitions.

Code of Federal Regulations, 2013 CFR

2013-04-01

... section 202 of the Housing Act of 1959, or a hospital, intermediate care facility, nursing home, group... anticipated demand (e.g., the housing market is balanced), as well as those in which there is an excess supply... turnover of rental housing, and, usually, by high levels of rent inflation. HUD will make the determination...

24 CFR 290.3 - Definitions.

Code of Federal Regulations, 2014 CFR

2014-04-01

... section 202 of the Housing Act of 1959, or a hospital, intermediate care facility, nursing home, group... anticipated demand (e.g., the housing market is balanced), as well as those in which there is an excess supply... turnover of rental housing, and, usually, by high levels of rent inflation. HUD will make the determination...

24 CFR 290.3 - Definitions.

Code of Federal Regulations, 2011 CFR

2011-04-01

... section 202 of the Housing Act of 1959, or a hospital, intermediate care facility, nursing home, group... anticipated demand (e.g., the housing market is balanced), as well as those in which there is an excess supply... turnover of rental housing, and, usually, by high levels of rent inflation. HUD will make the determination...

The CIPRUS study, a nurse-led psychological treatment for patients with undifferentiated somatoform disorder in primary care: study protocol for a randomised controlled trial.

PubMed

Sitnikova, Kate; Leone, Stephanie S; Zonneveld, Lyonne N L; van Marwijk, Harm W J; Bosmans, Judith E; van der Wouden, Johannes C; van der Horst, Henriëtte E

2017-05-03

Up to a third of patients presenting medically unexplained physical symptoms in primary care may have a somatoform disorder, of which undifferentiated somatoform disorder (USD) is the most common type. Psychological interventions can reduce symptoms associated with USD and improve functioning. Previous research has either been conducted in secondary care or interventions have been provided by general practitioners (GPs) or psychologists in primary care. As efficiency and cost-effectiveness are imperative in primary care, it is important to investigate whether nurse-led interventions are effective as well. The aim of this study is to examine the effectiveness and cost-effectiveness of a short cognitive behavioural therapy (CBT)-based treatment for patients with USD provided by mental health nurse practitioners (MHNPs), compared to usual care. In a cluster randomised controlled trial, 212 adult patients with USD will be assigned to the intervention or care as usual. The intervention group will be offered a short, individual CBT-based treatment by the MHNP in addition to usual GP care. The main goal of the intervention is that patients become less impaired by their physical symptoms and cope with symptoms in a more effective way. In six sessions patients will receive problem-solving treatment. The primary outcome is improvement in physical functioning, measured by the physical component summary score of the RAND-36. Secondary outcomes include health-related quality of life measured by the separate subscales of the RAND-36, somatization (PHQ-15) and symptoms of depression and anxiety (HADS). Problem-solving skills, health anxiety, illness perceptions, coping, mastery and working alliance will be assessed as potential mediators. Assessments will be done at 0, 2, 4, 8 and 12 months. An economic evaluation will be conducted from a societal perspective with quality of life as the primary outcome measure assessed by the EQ-5D-5L. Health care, patient and lost productivity costs will be assessed with the Tic-P. We expect that the intervention will improve physical functioning and is cost-effective compared to usual care. If so, more patients might successfully be treated in general practice, decreasing the number of referrals to specialist care. Dutch Trial Registry, identifier: NTR4686 , Registered on 14 July 2014.

A coupled nuclear reactor thermal energy storage system for enhanced load following operation

NASA Astrophysics Data System (ADS)

Alameri, Saeed A.

Nuclear power plants usually provide base-load electric power and operate most economically at a constant power level. In an energy grid with a high fraction of renewable energy sources, future nuclear reactors may be subject to significantly variable power demands. These variable power demands can negatively impact the effective capacity factor of the reactor and result in severe economic penalties. Coupling the reactor to a large Thermal Energy Storage (TES) block will allow the reactor to better respond to variable power demands. In the system described in this thesis, a Prismatic-core Advanced High Temperature Reactor (PAHTR) operates at constant power with heat provided to a TES block that supplies power as needed to a secondary energy conversion system. The PAHTR is designed to have a power rating of 300 MW th, with 19.75 wt% enriched Tri-Structural-Isotropic UO 2 fuel and a five year operating cycle. The passive molten salt TES system will operate in the latent heat region with an energy storage capacity of 150 MWd. Multiple smaller TES blocks are used instead of one large block to enhance the efficiency and maintenance complexity of the system. A transient model of the coupled reactor/TES system is developed to study the behavior of the system in response to varying load demands. The model uses six-delayed group point kinetics and decay heat models coupled to thermal-hydraulic and heat transfer models of the reactor and TES system. Based on the transient results, the preferred TES design consists of 1000 blocks, each containing 11000 LiCl phase change material tubes. A safety assessment of major reactor events demonstrates the inherent safety of the coupled system. The loss of forced circulation study determined the minimum required air convection heat removal rate from the reactor core and the lowest possible reduced primary flow rate that can maintain the reactor in a safe condition. The loss of ultimate heat sink study demonstrated the ability of the TES to absorb the decay heat of the reactor fuel while cooling the PAHTR after an emergency shutdown. The simulated reactivity insertion accident assessment determined the maximum allowable reactivity insertion to the PAHTR as a function of shutdown response times.

The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consultation requests in general practice: a cluster randomised controlled trial comparing general practitioner-led and nurse-led management systems with usual care (the ESTEEM trial).

PubMed

Campbell, John L; Fletcher, Emily; Britten, Nicky; Green, Colin; Holt, Tim; Lattimer, Valerie; Richards, David A; Richards, Suzanne H; Salisbury, Chris; Taylor, Rod S; Calitri, Raff; Bowyer, Vicky; Chaplin, Katherine; Kandiyali, Rebecca; Murdoch, Jamie; Price, Linnie; Roscoe, Julia; Varley, Anna; Warren, Fiona C

2015-02-01

Telephone triage is proposed as a method of managing increasing demand for primary care. Previous studies have involved small samples in limited settings, and focused on nurse roles. Evidence is limited regarding the impact on primary care workload, costs, and patient safety and experience when triage is used to manage patients requesting same-day consultations in general practice. In comparison with usual care (UC), to assess the impact of GP-led telephone triage (GPT) and nurse-led computer-supported telephone triage (NT) on primary care workload and cost, patient experience of care, and patient safety and health status for patients requesting same-day consultations in general practice. Pragmatic cluster randomised controlled trial, incorporating economic evaluation and qualitative process evaluation. General practices (n = 42) in four regions of England, UK (Devon, Bristol/Somerset, Warwickshire/Coventry, Norfolk/Suffolk). Patients requesting same-day consultations. Practices were randomised to GPT, NT or UC. Data collection was not blinded; however, analysis was conducted by a statistician blinded to practice allocation. Primary - primary care contacts [general practice, out-of-hours primary care, accident and emergency (A&E) and walk-in centre attendances] in the 28 days following the index consultation request. Secondary - resource use and costs, patient safety (deaths and emergency hospital admissions within 7 days of index request, and A&E attendance within 28 days), health status and experience of care. Of 20,990 eligible randomised patients (UC n = 7283; GPT n = 6695; NT n = 7012), primary outcome data were analysed for 16,211 patients (UC n = 5572; GPT n = 5171; NT n = 5468). Compared with UC, GPT and NT increased primary outcome contacts (over 28-day follow-up) by 33% [rate ratio (RR) 1.33, 95% confidence interval (CI) 1.30 to 1.36] and 48% (RR 1.48, 95% CI 1.44 to 1.52), respectively. Compared with GPT, NT was associated with a marginal increase in primary outcome contacts by 4% (RR 1.04, 95% CI 1.01 to 1.08). Triage was associated with a redistribution of primary care contacts. Although GPT, compared with UC, increased the rate of overall GP contacts (face to face and telephone) over the 28 days by 38% (RR 1.38, 95% CI 1.28 to 1.50), GP face-to-face contacts were reduced by 39% (RR 0.61, 95% CI 0.54 to 0.69). NT reduced the rate of overall GP contacts by 16% (RR 0.84, 95% CI 0.78 to 0.91) and GP face-to-face contacts by 20% (RR 0.80, 95% CI 0.71 to 0.90), whereas nurse contacts increased. The increased rate of primary care contacts in triage arms is largely attributable to increased telephone contacts. Estimated overall patient-clinician contact time on the index day increased in triage (GPT = 10.3 minutes; NT = 14.8 minutes; UC = 9.6 minutes), although patterns of clinician use varied between arms. Taking account of both the pattern and duration of primary outcome contacts, overall costs over the 28-day follow-up were similar in all three arms (approximately £75 per patient). Triage appeared safe, and no differences in patient health status were observed. NT was somewhat less acceptable to patients than GPT or UC. The process evaluation identified the complexity associated with introducing triage but found no consistency across practices about what works and what does not work when implementing it. Introducing GPT or NT was associated with a redistribution of primary care workload for patients requesting same-day consultations, and at similar cost to UC. Although triage seemed to be safe, investigation of the circumstances of a larger number of deaths or admissions after triage might be warranted, and monitoring of these events is necessary as triage is implemented. Current Controlled Trials ISRCTN20687662. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 13. See the NIHR Journals Library website for further project information.

The quality of surface waters in Texas

USGS Publications Warehouse

Rawson, Jack

1974-01-01

The discharge-weighted average concentrations of dissolved solids, chloride, and ,sulfate for many of the principal streams in Texas are less than 500 mg/l (millijgraljls per liter), 250 mg/l, and 250 mg/l, respectively. At 65 of 131 sites on streams that were sampled at least 10 times, the biochemical oxygen demand of at least half the samples exceeded 3.0 mg/l. At 20 of the sites, the dissolved-oxygen content of at least half the samples was less than 5.0 mg/l. The higher concentrations of minor elements usually were detected in waters from urban areas, indicating a relation to man's activities. Small amounts of some pesticides are widely distributed in low concentrations. The higher concentrations usually were detected in waters from urban areas.

Comparative Effectiveness of a Technology-Facilitated Depression Care Management Model in Safety-Net Primary Care Patients With Type 2 Diabetes: 6-Month Outcomes of a Large Clinical Trial.

PubMed

Wu, Shinyi; Ell, Kathleen; Jin, Haomiao; Vidyanti, Irene; Chou, Chih-Ping; Lee, Pey-Jiuan; Gross-Schulman, Sandra; Sklaroff, Laura Myerchin; Belson, David; Nezu, Arthur M; Hay, Joel; Wang, Chien-Ju; Scheib, Geoffrey; Di Capua, Paul; Hawkins, Caitlin; Liu, Pai; Ramirez, Magaly; Wu, Brian W; Richman, Mark; Myers, Caitlin; Agustines, Davin; Dasher, Robert; Kopelowicz, Alex; Allevato, Joseph; Roybal, Mike; Ipp, Eli; Haider, Uzma; Graham, Sharon; Mahabadi, Vahid; Guterman, Jeffrey

2018-04-23

Comorbid depression is a significant challenge for safety-net primary care systems. Team-based collaborative depression care is effective, but complex system factors in safety-net organizations impede adoption and result in persistent disparities in outcomes. Diabetes-Depression Care-management Adoption Trial (DCAT) evaluated whether depression care could be significantly improved by harnessing information and communication technologies to automate routine screening and monitoring of patient symptoms and treatment adherence and allow timely communication with providers. The aim of this study was to compare 6-month outcomes of a technology-facilitated care model with a usual care model and a supported care model that involved team-based collaborative depression care for safety-net primary care adult patients with type 2 diabetes. DCAT is a translational study in collaboration with Los Angeles County Department of Health Services, the second largest safety-net care system in the United States. A comparative effectiveness study with quasi-experimental design was conducted in three groups of adult patients with type 2 diabetes to compare three delivery models: usual care, supported care, and technology-facilitated care. Six-month outcomes included depression and diabetes care measures and patient-reported outcomes. Comparative treatment effects were estimated by linear or logistic regression models that used generalized propensity scores to adjust for sampling bias inherent in the nonrandomized design. DCAT enrolled 1406 patients (484 in usual care, 480 in supported care, and 442 in technology-facilitated care), most of whom were Hispanic or Latino and female. Compared with usual care, both the supported care and technology-facilitated care groups were associated with significant reduction in depressive symptoms measured by scores on the 9-item Patient Health Questionnaire (least squares estimate, LSE: usual care=6.35, supported care=5.05, technology-facilitated care=5.16; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.02); decreased prevalence of major depression (odds ratio, OR: supported care vs usual care=0.45, technology-facilitated care vs usual care=0.33; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.007); and reduced functional disability as measured by Sheehan Disability Scale scores (LSE: usual care=3.21, supported care=2.61, technology-facilitated care=2.59; P value: supported care vs usual care=.04, technology-facilitated care vs usual care=.03). Technology-facilitated care was significantly associated with depression remission (technology-facilitated care vs usual care: OR=2.98, P=.04); increased satisfaction with care for emotional problems among depressed patients (LSE: usual care=3.20, technology-facilitated care=3.70; P=.05); reduced total cholesterol level (LSE: usual care=176.40, technology-facilitated care=160.46; P=.01); improved satisfaction with diabetes care (LSE: usual care=4.01, technology-facilitated care=4.20; P=.05); and increased odds of taking an glycated hemoglobin test (technology-facilitated care vs usual care: OR=3.40, P<.001). Both the technology-facilitated care and supported care delivery models showed potential to improve 6-month depression and functional disability outcomes. The technology-facilitated care model has a greater likelihood to improve depression remission, patient satisfaction, and diabetes care quality. ©Shinyi Wu, Kathleen Ell, Haomiao Jin, Irene Vidyanti, Chih-Ping Chou, Pey-Jiuan Lee, Sandra Gross-Schulman, Laura Myerchin Sklaroff, David Belson, Arthur M Nezu, Joel Hay, Chien-Ju Wang, Geoffrey Scheib, Paul Di Capua, Caitlin Hawkins, Pai Liu, Magaly Ramirez, Brian W Wu, Mark Richman, Caitlin Myers, Davin Agustines, Robert Dasher, Alex Kopelowicz, Joseph Allevato, Mike Roybal, Eli Ipp, Uzma Haider, Sharon Graham, Vahid Mahabadi, Jeffrey Guterman. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 23.04.2018.

Coping and compromise: a qualitative study of how primary health care providers respond to health reform in China.

PubMed

Zhang, Mingji; Wang, Wei; Millar, Ross; Li, Guohong; Yan, Fei

2017-08-04

Health reform in China since 2009 has emphasized basic public health services to enhance the function of Community Health Services as a primary health care facility. A variety of studies have documented these efforts, and the challenges these have faced, yet up to now the experience of primary health care (PHC) providers in terms of how they have coped with these changes remains underdeveloped. Despite the abundant literature on psychological coping processes and mechanisms, the application of coping research within the context of human resources for health remains yet to be explored. This research aims to understand how PHC providers coped with the new primary health care model and the job characteristics brought about by these changes. Semi-structured interviews with primary health care workers were conducted in Jinan city of Shandong province in China. A maximum variation sampling method selected 30 PHC providers from different specialties. Thematic analysis was used drawing on a synthesis of theories related to the Job Demands-Resources model, work adjustment, and the model of exit, voice, loyalty and neglect to understand PHC providers' coping strategies. Our interviews identified that the new model of primary health care significantly affected the nature of primary health work and triggered a range of PHC providers' coping processes. The results found that health workers perceived their job as less intensive than hospital medical work but often more trivial, characterized by heavy workload, blurred job description, unsatisfactory income, and a lack of professional development. However, close relationship with community and low work pressure were satisfactory. PHC providers' processing of job demands and resources displayed two ways of interaction: aggravation and alleviation. Processing of job demands and resources led to three coping strategies: exit, passive loyalty, and compromise with new roles and functions. Primary health care providers employed coping strategies of exit, passive loyalty, and compromise to deal with changes in primary health work. In light of these findings, our paper concludes that it is necessary for the policymakers to provide further job resources for CHS, and involve health workers in policy-making. The introduction of particular professional training opportunities to support job role orientation for PHC providers is advocated.

Navigating the Language and Demands of School Leadership in an Age of High-Stakes Accountability: A Case Study of High School Principals

ERIC Educational Resources Information Center

Bonasera, Mark

2012-01-01

Today's public school principals lead under conditions of significant pressures for change. At the local level, principals are the primary receivers and interpreters of the discourses and demands for change coming from central administration. Principals must make sense of these discourses and demands for change at the local school level, and they…

The health literacy demands of electronic personal health records (e-PHRs): An integrative review to inform future inclusive research.

PubMed

Hemsley, Bronwyn; Rollo, Megan; Georgiou, Andrew; Balandin, Susan; Hill, Sophie

2018-01-01

To integrate the findings of research on electronic personal health records (e-PHRs) for an understanding of their health literacy demands on both patients and providers. We sought peer-reviewed primary research in English addressing the health literacy demands of e-PHRs that are online and allow patients any degree of control or input to the record. A synthesis of three theoretical models was used to frame the analysis of 24 studies. e-PHRs pose a wide range of health literacy demands on both patients and health service providers. Patient participation in e-PHRs relies not only on their level of education and computer literacy, and attitudes to sharing health information, but also upon their executive function, verbal expression, and understanding of spoken and written language. The multiple health literacy demands of e-PHRs must be considered when implementing population-wide initiatives for storing and sharing health information using these systems. The health literacy demands of e-PHRs are high and could potentially exclude many patients unless strategies are adopted to support their use of these systems. Developing strategies for all patients to meet or reduce the high health literacy demands of e-PHRs will be important in population-wide implementation. Copyright © 2017 Elsevier B.V. All rights reserved.

Supply and demand analysis for flood insurance by using logistic regression model: case study at Citarum watershed in South Bandung, West Java, Indonesia

NASA Astrophysics Data System (ADS)

Sidi, P.; Mamat, M.; Sukono; Supian, S.

2017-01-01

Floods have always occurred in the Citarum river basin. The adverse effects caused by floods can cover all their property, including the destruction of houses. The impact due to damage to residential buildings is usually not small. Indeed, each of flooding, the government and several social organizations providing funds to repair the building. But the donations are given very limited, so it cannot cover the entire cost of repair was necessary. The presence of insurance products for property damage caused by the floods is considered very important. However, if its presence is also considered necessary by the public or not? In this paper, the factors that affect the supply and demand of insurance product for damaged building due to floods are analyzed. The method used in this analysis is the ordinal logistic regression. Based on the analysis that the factors that affect the supply and demand of insurance product for damaged building due to floods, it is included: age, economic circumstances, family situations, insurance motivations, and lifestyle. Simultaneously that the factors affecting supply and demand of insurance product for damaged building due to floods mounted to 65.7%.

A randomised trial of non-mydriatic ultra-wide field retinal imaging versus usual care to screen for diabetic eye disease: rationale and protocol for the Clearsight trial

PubMed Central

Mahon, Lewis W; Klar, Neil S; Schulz, David C; Gonder, John R; Hramiak, Irene M; Mahon, Jeffrey L

2017-01-01

Introduction Suboptimal screening for diabetic eye disease is a major cause of preventable vision loss. Screening barriers include mydriasis and the extra time patients need to attend dedicated eye screening appointments. In the Clearsight trial, we are testing whether screening by non-mydriatic ultra-wide field (NM UWF) imaging on the day patients attend their diabetes outpatient clinic visit improves detection of clinically important eye disease compared with usual screening. Methods and analysis Patients with diabetes due for a screening eye exam by the 2013 Canadian Diabetes Association (CDA) practice guidelines are being randomised to on-site screening by NM UWF imaging on the day of their clinic visit or to usual screening where, per CDA guidelines, they are encouraged to arrange an exam by an optometrist. The primary outcome is actionable eye disease (AED) based on a need for referral to ophthalmology and/or increased ocular surveillance. The primary analysis will use an intention-to-screen approach that compares the proportions of detected AED between on-site and usual screening groups under a superiority hypothesis in favour of on-site screening. With 740 randomised participants, the study will have 80% power to detect ≥5% absolute increase in the AED rate among on-site screening versus usual screening participants. This difference translates into a number-needed-to-screen by on-site screening of 20 to detect 1 additional person with AED. Ethics and dissemination The protocol was approved by the institutional review board of Western University. The findings of the trial will be disseminated directly to participants and through peer-reviewed publications and conference presentations. Trial registration number ClinicalTrials.Gov NCT02579837 (registered 16 October 2015). Protocol issue date 18 November 2015. PMID:28775182

Group physical therapy for veterans with knee osteoarthritis: study design and methodology.

PubMed

Allen, Kelli D; Bongiorni, Dennis; Walker, Tessa A; Bartle, John; Bosworth, Hayden B; Coffman, Cynthia J; Datta, Santanu K; Edelman, David; Hall, Katherine S; Hansen, Gloria; Jennings, Caroline; Lindquist, Jennifer H; Oddone, Eugene Z; Senick, Margaret J; Sizemore, John C; St John, Jamie; Hoenig, Helen

2013-03-01

Physical therapy (PT) is a key component of treatment for knee osteoarthritis (OA) and can decrease pain and improve function. Given the expected rise in prevalence of knee OA and the associated demand for treatment, there is a need for models of care that cost-effectively extend PT services for patients with this condition. This manuscript describes a randomized clinical trial of a group-based physical therapy program that can potentially extend services to more patients with knee OA, providing a greater number of sessions per patient, at lower staffing costs compared to traditional individual PT. Participants with symptomatic knee OA (n = 376) are randomized to either a 12-week group-based PT program (six 1 h sessions, eight patients per group, led by a physical therapist and physical therapist assistant) or usual PT care (two individual visits with a physical therapist). Participants in both PT arms receive instruction in an exercise program, information on joint care and protection, and individual consultations with a physical therapist to address specific functional and therapeutic needs. The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index (self-reported pain, stiffness, and function), and the secondary outcome is the Short Physical Performance Test Protocol (objective physical function). Outcomes are assessed at baseline and 12-week follow-up, and the primary outcome is also assessed via telephone at 24-week follow-up to examine sustainability of effects. Linear mixed models will be used to compare outcomes for the two study arms. An economic cost analysis of the PT interventions will also be conducted. Published by Elsevier Inc.

Disruption in neural phase synchrony is related to identification of inattentional deafness in real-world setting.

PubMed

Callan, Daniel E; Gateau, Thibault; Durantin, Gautier; Gonthier, Nicolas; Dehais, Frédéric

2018-06-01

Individuals often have reduced ability to hear alarms in real world situations (e.g., anesthesia monitoring, flying airplanes) when attention is focused on another task, sometimes with devastating consequences. This phenomenon is called inattentional deafness and usually occurs under critical high workload conditions. It is difficult to simulate the critical nature of these tasks in the laboratory. In this study, dry electroencephalography is used to investigate inattentional deafness in real flight while piloting an airplane. The pilots participating in the experiment responded to audio alarms while experiencing critical high workload situations. It was found that missed relative to detected alarms were marked by reduced stimulus evoked phase synchrony in theta and alpha frequencies (6-14 Hz) from 120 to 230 ms poststimulus onset. Correlation of alarm detection performance with intertrial coherence measures of neural phase synchrony showed different frequency and time ranges for detected and missed alarms. These results are consistent with selective attentional processes actively disrupting oscillatory coherence in sensory networks not involved with the primary task (piloting in this case) under critical high load conditions. This hypothesis is corroborated by analyses of flight parameters showing greater maneuvering associated with difficult phases of flight occurring during missed alarms. Our results suggest modulation of neural oscillation is a general mechanism of attention utilizing enhancement of phase synchrony to sharpen alarm perception during successful divided attention, and disruption of phase synchrony in brain networks when attentional demands of the primary task are great, such as in the case of inattentional deafness. © 2018 Wiley Periodicals, Inc.

Effectiveness of fluticasone furoate plus vilanterol on asthma control in clinical practice: an open-label, parallel group, randomised controlled trial.

PubMed

Woodcock, Ashley; Vestbo, Jørgen; Bakerly, Nawar Diar; New, John; Gibson, J Martin; McCorkindale, Sheila; Jones, Rupert; Collier, Susan; Lay-Flurrie, James; Frith, Lucy; Jacques, Loretta; Fletcher, Joanne L; Harvey, Catherine; Svedsater, Henrik; Leather, David

2017-11-18

Evidence for management of asthma comes from closely monitored efficacy trials done in highly selected patient groups. There is a need for randomised trials that are closer to usual clinical practice. We did an open-label, randomised, controlled, two-arm effectiveness trial at 74 general practice clinics in Salford and South Manchester, UK. Patients aged 18 years or older with a general practitioner's diagnosis of symptomatic asthma and on maintenance inhaler therapy were randomly assigned to initiate treatment with a once-daily inhaled combination of either 100 μg or 200 μg fluticasone furoate with 25 μg vilanterol or optimised usual care and followed up for 12 months. The primary endpoint was the percentage of patients who achieved an asthma control test (ACT) score of 20 or greater or an increase in ACT score from baseline of 3 or greater at 24 weeks (termed responders), in patients with a baseline ACT score less than 20 (the primary effectiveness analysis population). All effectiveness analyses were done according to the intention-to-treat principle. This study is registered with ClinicalTrials.gov, number NCT01706198. Between Nov 12, 2012, and Dec 16, 2016, 4725 patients were enrolled and 4233 randomly assigned to initiate treatment with fluticasone furoate and vilanterol (n=2114) or usual care (n=2119). 1207 patients (605 assigned to usual care, 602 to fluticasone furoate and vilanterol) had a baseline ACT score greater than or equal to 20 and were thus excluded from the primary effectiveness analysis population. At week 24, the odds of being a responder were higher for patients who initiated treatment with fluticasone furoate and vilanterol than for those on usual care (977 [71%] of 1373 in the fluticasone furoate and vilanterol group vs 784 [56%] of 1399 in the usual care group; odds ratio [OR] 2·00 [95% CI 1·70-2·34], p<0·0001). At week 24, the adjusted mean ACT score increased by 4·4 points from baseline in patients initiated with fluticasone furoate and vilanterol, compared with 2·8 points in the usual care group (difference 1·6 [95% CI 1·3-2·0], p<0·0001). This result was consistent for the duration of the study. Pneumonia was uncommon, with no differences between groups; there was no difference in other serious adverse events between the groups. In patients with a general practitioner's diagnosis of symptomatic asthma and on maintenance inhaler therapy, initiation of a once-daily treatment regimen of combined fluticasone furoate and vilanterol improved asthma control without increasing the risk of serious adverse events when compared with optimised usual care. GlaxoSmithKline. Copyright © 2017 Elsevier Ltd. All rights reserved.

Radial forces in a misaligned radial face seal

NASA Technical Reports Server (NTRS)

Etsion, I.

1978-01-01

Radial forces on the primary seal ring of a flat misaligned seal are analyzed, taking into account the radial variation in seal clearance. An analytical solution for both hydrostatic and hydrodynamic effects is presented that covers the whole range from zero to full angular misalignment. The net radial force on the primary seal ring is always directed so as to produce a radial eccentricity which generates inward pumping. Although the radial force is usually very small, in some cases it may be one of the reasons for excessive leakage through both the primary and secondary seals of a radial face seal.

Radial forces in a misaligned radial face seal

NASA Technical Reports Server (NTRS)

Etsion, I.

1977-01-01

Radial forces on the primary seal ring of a flat misaligned seal are analyzed, taking into account the radial variation in seal clearance. An analytical solution for both hydrostatic and hydrodynamic effects is presented that covers the whole range from zero to full angular misalignment. The net radial force on the primary seal ring is always directed so as to produce a radial eccentricity which generates inward pumping. Although the radial force is usually very small, in some cases it may be one of the reasons for excessive leakage through both the primary and secondary seals of a radial face seal.

Systematic review of integrated models of health care delivered at the primary-secondary interface: how effective is it and what determines effectiveness?

PubMed

Mitchell, Geoffrey K; Burridge, Letitia; Zhang, Jianzhen; Donald, Maria; Scott, Ian A; Dart, Jared; Jackson, Claire L

2015-01-01

Integrated multidisciplinary care is difficult to achieve between specialist clinical services and primary care practitioners, but should improve outcomes for patients with chronic and/or complex chronic physical diseases. This systematic review identifies outcomes of different models that integrate specialist and primary care practitioners, and characteristics of models that delivered favourable clinical outcomes. For quality appraisal, the Cochrane Risk of Bias tool was used. Data are presented as a narrative synthesis due to marked heterogeneity in study outcomes. Ten studies were included. Publication bias cannot be ruled out. Despite few improvements in clinical outcomes, significant improvements were reported in process outcomes regarding disease control and service delivery. No study reported negative effects compared with usual care. Economic outcomes showed modest increases in costs of integrated primary-secondary care. Six elements were identified that were common to these models of integrated primary-secondary care: (1) interdisciplinary teamwork; (2) communication/information exchange; (3) shared care guidelines or pathways; (4) training and education; (5) access and acceptability for patients; and (6) a viable funding model. Compared with usual care, integrated primary-secondary care can improve elements of disease control and service delivery at a modestly increased cost, although the impact on clinical outcomes is limited. Future trials of integrated care should incorporate design elements likely to maximise effectiveness.

Effectiveness of Collaborative Care for Depression in Public-Sector Primary Care Clinics Serving Latinos.

PubMed

Lagomasino, Isabel T; Dwight-Johnson, Megan; Green, Jennifer M; Tang, Lingqi; Zhang, Lily; Duan, Naihua; Miranda, Jeanne

2017-04-01

Quality improvement interventions for depression care have been shown to be effective for improving quality of care and depression outcomes in settings with primarily insured patients. The aim of this study was to determine the impact of a collaborative care intervention for depression that was tailored for low-income Latino patients seen in public-sector clinics. A total of 400 depressed patients from three public-sector primary care clinics were enrolled in a randomized controlled trial of a tailored collaborative care intervention versus enhanced usual care. Social workers without previous mental health experience served as depression care specialists for the intervention patients (N=196). Depending on patient preference, they delivered a cognitive-behavioral therapy (CBT) intervention or facilitated antidepressant medication given by primary care providers or both. In enhanced usual care, patients (N=204) received a pamphlet about depression, a letter for their primary care provider stating that they had a positive depression screen, and a list of local mental health resources. Intent-to-treat analyses examined clinical and process-of-care outcomes at 16 weeks. Compared with patients in the enhanced usual care group, patients in the intervention group had significantly improved depression, quality of life, and satisfaction outcomes (p<.001 for all). Intervention patients also had significantly improved quality-of-care indicators, including the proportion of patients receiving either psychotherapy or antidepressant medication (77% versus 21%, p<.001). Collaborative care for depression can greatly improve care and outcomes in public-sector clinics. Social workers without prior mental health experience can effectively provide CBT and manage depression care.

Job Demands & Pesticide Exposure among Immigrant Latino Farmworkers

PubMed Central

Grzywacz, Joseph G.; Quandt, Sara A.; Vallejos, Quirina M.; Whalley, Lara E.; Chen, Haiying; Isom, Scott; Barr, Dana B.; Arcury, Thomas A.

2010-01-01

The goal of this study was to understand the potential threat of job stressors to farmworker health. To accomplish this goal we studied pesticide exposure, an issue with immediate and long-term health consequences, and predictions from the demands-control model of occupational stress. Longitudinal, self-report data and urine samples were collected at monthly intervals from a cohort of Latino farmworkers (N=287) during the 2007 agricultural season. The primary hypothesis was that greater exposure to psychological demands, physical exertion, and hazardous work conditions are associated with greater odds of detecting DAP urinary pesticide metabolites, biomarkers indicating exposure to pesticides. Contrary to this hypothesis, results indicated that none of the elements of the Demands-Control model were independently associated with detection of DAP urinary pesticide metabolites. However, analyses produced several interaction effects, including evidence that high levels of control may buffer the effects of physical job demands on detection of DAP urinary pesticide metabolites. PMID:20604632

Centrally Assisted Collaborative Telecare for Posttraumatic Stress Disorder and Depression Among Military Personnel Attending Primary Care: A Randomized Clinical Trial.

PubMed

Engel, Charles C; Jaycox, Lisa H; Freed, Michael C; Bray, Robert M; Brambilla, Donald; Zatzick, Douglas; Litz, Brett; Tanielian, Terri; Novak, Laura A; Lane, Marian E; Belsher, Bradley E; Olmsted, Kristine L Rae; Evatt, Daniel P; Vandermaas-Peeler, Russ; Unützer, Jürgen; Katon, Wayne J

2016-07-01

It is often difficult for members of the US military to access high-quality care for posttraumatic stress disorder (PTSD) and depression. To determine effectiveness of a centrally assisted collaborative telecare (CACT) intervention for PTSD and depression in military primary care. The STEPS-UP study (Stepped Enhancement of PTSD Services Using Primary Care) is a randomized trial comparing CACT with usual integrated mental health care for PTSD or depression. Patients, mostly men in their 20s, were enrolled from 18 primary care clinics at 6 military installations from February 2012 to August 2013 with 12-month follow-up completed in October 2014. Randomization was to CACT (n = 332) or usual care (n = 334). The CACT patients received 12 months of stepped psychosocial and pharmacologic treatment with nurse telecare management of caseloads, symptoms, and treatment. Primary outcomes were severity scores on the PTSD Diagnostic Scale (PDS; scored 0-51) and Symptom Checklist depression items (SCL-20; scored 0-4). Secondary outcomes were somatic symptoms, pain severity, health-related function, and mental health service use. Of 666 patients, 81% were male and the mean (SD) age was 31.1 (7.7) years. The CACT and usual care patients had similar baseline mean (SD) PDS PTSD (29.4 [9.4] vs 28.9 [8.9]) and SCL-20 depression (2.1 [0.6] vs 2.0 [0.7]) scores. Compared with usual care, CACT patients reported significantly greater mean (SE) 12-month decrease in PDS PTSD scores (-6.07 [0.68] vs -3.54 [0.72]) and SCL-20 depression scores -0.56 [0.05] vs -0.31 [0.05]). In the CACT group, significantly more participants had 50% improvement at 12 months compared with usual care for both PTSD (73 [25%] vs 49 [17%]; relative risk, 1.6 [95% CI, 1.1-2.4]) and depression (86 [30%] vs 59 [21%]; relative risk, 1.7 [95% CI, 1.1-2.4]), with a number needed to treat for a 50% improvement of 12.5 (95% CI, 6.9-71.9) and 11.1 (95% CI, 6.2-50.5), respectively. The CACT patients had significant improvements in somatic symptoms (difference between mean 12-month Patient Health Questionnaire 15 changes, -1.37 [95% CI, -2.26 to -0.47]) and mental health-related functioning (difference between mean 12-month Short Form-12 Mental Component Summary changes, 3.17 [95% CI, 0.91 to 5.42]), as well as increases in telephone health contacts and appropriate medication use. Central assistance for collaborative telecare with stepped psychosocial management modestly improved outcomes of PTSD and depression among military personnel attending primary care. clinicaltrials.gov Identifier: NCT01492348.

China Energy Databook. Revision 4

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

Sinton, J. E.; Fridley, D. G.; Levine, M. D.

1996-09-01

The Energy Analysis Program at LBL first became involved in Chinese energy issues through a joint China-US symposium on markets and energy demand held in Nanjing Nov. 1988. EAP began to collaborate on projects with the Energy Research Institute of China`s State Planning Commission. It was decided to compile, assess, and organize Chinese energy data. Primary interest was to use the data to help understand the historical evolution and likely future of the Chinese energy system; thus the primary criterion was to relate the data to the structure of energy supply and demand in the past and to indicate probablemore » developments (eg, as indicated by patterns of investment). Caveats are included in forewords to both the 1992 and 1996 editions. A chapter on energy prices is included in the 1996 edition. 1993 energy consumption data are not included since there was a major disruption in energy statistical collection in China that year.« less

Satellite Supported Estimates of Human Rate of NPP Carbon Use on Land: Challenges Ahead

NASA Astrophysics Data System (ADS)

Imhoff, M. L.; Bounoua, L.; Zhang, P.; Wolfe, R. E.

2010-12-01

The human demand for products of photosynthesis is a powerful measure of the aggregate impact of human action on the biosphere and indicator of societal vulnerability to climate change. We show results from several studies that use satellite and statistical data to estimate the amount of Earth’s net primary production (NPP) on land required to support regional and global use of food, fiber and NPP-based fuel products across a ten-year period. Earth’s planetary NPP ‘supply’ was estimated using AVHRR vegetation index and MODIS derived NPP products to establish a baseline extending from 1982 - 2005. NPP carbon ‘demand’ was estimated by applying biophysical models to consumption data from the UN Food and Agriculture Organization to calculate the annual amount of NPP required for the products consumed. Results show that globally, humans consume more than 20% of Earth’s total net primary production on land and that both populations and per capita consumption increased between 1995 and 2005. Regionally, the NPP-carbon balance percentage varies from 6% to over 70% and locally from near 0% to over 30,000% in major urban areas. Large uncertainties exist in both supply and demand calculations but while the supply trend varies in sign demand continues to rise. Scenarios modeling the impact of per capita consumption, population growth, and technology suggest that NPP demand as percent of supply is likely to increase substantially in the next 40 years despite better harvesting and processing efficiencies.

The effectiveness and cost-effectiveness of lay counsellor-delivered psychological treatments for harmful and dependent drinking and moderate to severe depression in primary care in India: PREMIUM study protocol for randomized controlled trials.

PubMed

Patel, Vikram; Weobong, Benedict; Nadkarni, Abhijit; Weiss, Helen A; Anand, Arpita; Naik, Smita; Bhat, Bhargav; Pereira, Jesina; Araya, Ricardo; Dimidjian, Sona; Hollon, Steven D; King, Michael; McCambridge, Jim; McDaid, David; Murthy, Pratima; Velleman, Richard; Fairburn, Christopher G; Kirkwood, Betty

2014-04-02

The leading mental health causes of the global burden of disease are depression in women and alcohol use disorders in men. A major hurdle to the implementation of evidence-based psychological treatments in primary care in developing countries is the non-availability of skilled human resources. The aim of these trials is to evaluate the effectiveness and cost-effectiveness of two psychological treatments developed for the treatment of depression and alcohol use disorders in primary care in India. This study protocol is for parallel group, randomized controlled trials (Healthy Activity Program for moderate to severe depression, Counselling for Alcohol Problems for harmful and dependent drinking) in eight primary health centres in Goa, India. Adult primary care attendees will be screened with the Patient Health Questionnaire for depression and, in men only, the Alcohol Use Disorders Identification Test for drinking problems. Screen-positive attendees will be invited to participate; men who screen positive for both disorders will be invited to participate in the Counselling for Alcohol Problems trial. Those who consent will be allocated in a 1:1 ratio to receive either the respective psychological treatment plus enhanced usual care or enhanced usual care only using a computer generated allocation sequence, stratified by primary health centre and, for depression, by sex. The enhanced usual care comprises providing primary health centre doctors with contextualized World Health Organization guidelines and screening results. Psychological treatments will be delivered by lay counsellors, over a maximum period of three months. Primary outcomes are severity of disorder and remission rates at three months post-enrolment and, for the Counselling for Alcohol Problems trial, drinking and the impact of drinking on daily lives. Secondary outcomes include severity of disorder and remission rates at 12 months, disability scores, suicidal behaviour and economic impact, and cost-effectiveness at three and 12 months. 500 participants with depression and 400 participants with harmful drinking will be recruited. Primary analyses will be intention-to-treat. These trials may offer a new approach for the treatment of moderate-severe depression and drinking problems in primary care that is potentially scalable as it relies on delivery by a single pool of lay counsellors. Both trials are registered with the International Society for the Registration of Clinical Trials (Healthy Activity Programme registration number ISRCTN95149997; Counselling for Alcohol Problems registration number ISRCTN76465238).

The effectiveness and cost-effectiveness of lay counsellor-delivered psychological treatments for harmful and dependent drinking and moderate to severe depression in primary care in India: PREMIUM study protocol for randomized controlled trials

PubMed Central

2014-01-01

Background The leading mental health causes of the global burden of disease are depression in women and alcohol use disorders in men. A major hurdle to the implementation of evidence-based psychological treatments in primary care in developing countries is the non-availability of skilled human resources. The aim of these trials is to evaluate the effectiveness and cost-effectiveness of two psychological treatments developed for the treatment of depression and alcohol use disorders in primary care in India. Methods/design This study protocol is for parallel group, randomized controlled trials (Healthy Activity Program for moderate to severe depression, Counselling for Alcohol Problems for harmful and dependent drinking) in eight primary health centres in Goa, India. Adult primary care attendees will be screened with the Patient Health Questionnaire for depression and, in men only, the Alcohol Use Disorders Identification Test for drinking problems. Screen-positive attendees will be invited to participate; men who screen positive for both disorders will be invited to participate in the Counselling for Alcohol Problems trial. Those who consent will be allocated in a 1:1 ratio to receive either the respective psychological treatment plus enhanced usual care or enhanced usual care only using a computer generated allocation sequence, stratified by primary health centre and, for depression, by sex. The enhanced usual care comprises providing primary health centre doctors with contextualized World Health Organization guidelines and screening results. Psychological treatments will be delivered by lay counsellors, over a maximum period of three months. Primary outcomes are severity of disorder and remission rates at three months post-enrolment and, for the Counselling for Alcohol Problems trial, drinking and the impact of drinking on daily lives. Secondary outcomes include severity of disorder and remission rates at 12 months, disability scores, suicidal behaviour and economic impact, and cost-effectiveness at three and 12 months. 500 participants with depression and 400 participants with harmful drinking will be recruited. Primary analyses will be intention-to-treat. Discussion These trials may offer a new approach for the treatment of moderate-severe depression and drinking problems in primary care that is potentially scalable as it relies on delivery by a single pool of lay counsellors. Trial registration Both trials are registered with the International Society for the Registration of Clinical Trials (Healthy Activity Programme registration number ISRCTN95149997; Counselling for Alcohol Problems registration number ISRCTN76465238). PMID:24690184

The strategic nature of individual change behavior: How physicians and their staff implement medical home care.

PubMed

Hoff, Timothy; Scott, Sarah

The patient-centered medical home (PCMH) model of care is central to primary care system success and transformation. Less is known about which PCMH activities primary care workers most frequently perform, if or why they might view that work more favorably, and how such work may function strategically to advance individual and organizational adaptation to new demands, as well as deliver good patient care. Understanding better how primary care physicians and staff perceive, experience, and use certain types of PCMH work for adapting to new demands looms a key imperative for gaining insights into PCMH implementation at the workplace level. Using a worker adaptation perspective that emphasizes the role of social learning and individual agency, this study explores the strategic nature of PCMH implementation through 51 in-depth interviews with physicians and staff in six accredited PCMHs. Select medical home activities were identified, in which primary care physicians and staff most engaged on a daily basis, and they fell into five distinct PCMH work domains labeled team care, medical home responsibilities, care management, access, and medication management. These activities had common features such as high levels of familiarity, simplicity, and camaraderie. In addition, through their experiences performing these activities, physicians and staff appeared to gain strategic benefits for themselves and the larger organization including enhanced self-efficacy and readiness for change. The findings show that particular forms of PCMH work not only advance patient care in favorable ways but also enhance individual and organizational capacity for adapting to this innovative model and its demands. This knowledge adds to our understanding of how to implement PCMH care in ways that are good for workers, primary care organizations, and patients and offers practical guidance as to which forms of PCMH work should be encouraged, incented, and rewarded.

Impact of living with bipolar patients: Making sense of caregivers’ burden

PubMed Central

Pompili, Maurizio; Harnic, Désirée; Gonda, Xenia; Forte, Alberto; Dominici, Giovanni; Innamorati, Marco; Fountoulakis, Konstantinos N; Serafini, Gianluca; Sher, Leo; Janiri, Luigi; Rihmer, Zoltan; Amore, Mario; Girardi, Paolo

2014-01-01

The aim of the present review was to examine objective and subjective burdens in primary caregivers (usually family members) of patients with bipolar disorder (BD) and to list which symptoms of the patients are considered more burdensome by the caregivers. In order to provide a critical review about caregiver’s burden in patients with bipolar disorder, we performed a detailed PubMed, BioMedCentral, ISI Web of Science, PsycINFO, Elsevier Science Direct and Cochrane Library search to identify all papers and book chapters in English published during the period between 1963 and November 2011. The highest levels of distress were caused by the patient’s behavior and the patient’s role dysfunction (work, education and social relationships). Furthermore, the caregiving role compromises other social roles occupied by the caregiver, becoming part of the heavy social cost of bipolar affective disorder. There is a need to better understand caregivers’ views and personal perceptions of the stresses and demands arising from caring for someone with BD in order to develop practical appropriate interventions and to improve the training of caregivers. PMID:24660140

Next-generation audit and feedback for inpatient quality improvement using electronic health record data: a cluster randomised controlled trial.

PubMed

Patel, Sajan; Rajkomar, Alvin; Harrison, James D; Prasad, Priya A; Valencia, Victoria; Ranji, Sumant R; Mourad, Michelle

2018-03-05

Audit and feedback improves clinical care by highlighting the gap between current and ideal practice. We combined best practices of audit and feedback with continuously generated electronic health record data to improve performance on quality metrics in an inpatient setting. We conducted a cluster randomised control trial comparing intensive audit and feedback with usual audit and feedback from February 2016 to June 2016. The study subjects were internal medicine teams on the teaching service at an urban tertiary care hospital. Teams in the intensive feedback arm received access to a daily-updated team-based data dashboard as well as weekly inperson review of performance data ('STAT rounds'). The usual feedback arm received ongoing twice-monthly emails with graphical depictions of team performance on selected quality metrics. The primary outcome was performance on a composite discharge metric (Discharge Mix Index, 'DMI'). A washout period occurred at the end of the trial (from May through June 2016) during which STAT rounds were removed from the intensive feedback arm. A total of 40 medicine teams participated in the trial. During the intervention period, the primary outcome of completion of the DMI was achieved on 79.3% (426/537) of patients in the intervention group compared with 63.2% (326/516) in the control group (P<0.0001). During the washout period, there was no significant difference in performance between the intensive and usual feedback groups. Intensive audit and feedback using timely data and STAT rounds significantly increased performance on a composite discharge metric compared with usual feedback. With the cessation of STAT rounds, performance between the intensive and usual feedback groups did not differ significantly, highlighting the importance of feedback delivery on effecting change. The trial was registered with ClinicalTrials.gov (NCT02593253). © 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.

Primary cicatricial alopecia: clinical features and management.

PubMed

Ross, Elizabeth K

2007-04-01

The primary cicatricial alopecias are an uncommon, complex group of disorders that result in permanent destruction of the hair follicle, usually involving scalp hair alone. Prompt diagnosis and treatment are needed to help thwart continued hair loss and the distress that often accompanies this hair loss. Nurses can facilitate the diagnostic and treatment process and, through educational and emotionally supportive measures, have a meaningful, positive impact on the patient's well being.

Mechanical properties of low-nickel stainless steel

NASA Technical Reports Server (NTRS)

Montano, J. W.

1978-01-01

Demand for improved corrosion-resistant steels, coupled with increased emphasis on conserving strategic metals, has led to development of family of stainless steels in which manganese and nitrogen are substituted for portion of usual nickel content. Advantages are approximately-doubled yield strength in annealed condition, better resistance to stress-corrosion cracking, retention of low magnetic permeability even after severe cold working, excellent strength and ductility at cryogenic temperatures, superior resistance to wear and galling, and excellent high-temperature properties.

Human Performance in Continuous/Sustained Operations and the Demands of Extended Work/Rest Schedules. An Annotated Bibliography

DTIC Science & Technology

1985-05-01

attempt to study the effect’s of mental fatigue on a simulated flight task. Special care is taken to separate mental from muscular fatigue because the...descriptions of other effects of atmospheric pressure changes -including aerotitis, gastrointestinal distension , aerosinusitis, aerodontia, bends, air...34 It, does not, however, deal with muscular fatigue" but with what is usually called . general fatigue. 130. Grandjean, E. P. (1970). Fatigue. American

Surface modification of NiTi by plasma based ion implantation for application in harsh environments

NASA Astrophysics Data System (ADS)

Oliveira, R. M.; Fernandes, B. B.; Carreri, F. C.; Gonçalves, J. A. N.; Ueda, M.; Silva, M. M. N. F.; Silva, M. M.; Pichon, L.; Camargo, E. N.; Otubo, J.

2012-12-01

The substitution of conventional components for NiTi in distinct devices such as actuators, valves, connectors, stents, orthodontic arc-wires, e.g., usually demands some kind of treatment to be performed on the surface of the alloy. A typical case is of biomaterials made of NiTi, in which the main drawback is the Ni out-diffusion, an issue that has been satisfactorily addressed by plasma based ion implantation (PBII). Even though PBII can tailor selective surface properties of diverse materials, usually, only thin modified layers are attained. When NiTi alloys are to be used in the harsh space environment, as is the case of devices designed to remotely release the solar panels and antenna arrays of satellites, e.g., superior mechanical and tribological properties are demanded. For this case the thickness of the modified layer must be larger than the one commonly achieved by conventional PBII. In this paper, new nitrogen PBII set up was used to treat samples of NiTi in moderate temperature of 450 °C, with negative voltage pulses of 7 kV/250 Hz/20 μs, in a process lasting 1 h. A rich nitrogen atomic concentration of 85 at.% was achieved on the near surface and nitrogen diffused at least for 11 μm depth. Tribological properties as well as corrosion resistance were evaluated.

Primary coal crushers grow to meet demand

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

Fiscor, S.

2009-09-15

Mine operators look for more throughput with less fines generation in primary crushers (defined here as single role crushers and two stage crushers). The article gives advice on crusher selection and application. Some factors dictating selection include the desired product size, capacity, Hard Grove grindability index, percentage of rock to be freed and hardness of that rock. The hardness of coal probably has greatest impact on product fineness. 2 refs., 1 fig., 1 tab.

Assessment of the relationship between perceptions of dental aesthetics and demand for orthodontic treatment in 10-11 year old school children in Birmingham, UK.

PubMed

Hamdan, A M; Singh, V; Rock, W P

2012-03-01

To examine the relationship between perceptions of dental aesthetics and demand for orthodontic treatment, and to determine whether the former can be used to predict the latter. A prospective cross sectional epidemiological survey of a random and representative sample of comprehensive primary schools in South Birmingham, UK. Participants were 389 randomly selected school children aged 10-11 years from 7 primary schools in South Birmingham. Their perceptions of dental aesthetics were determined using the Aesthetic Component (AC) of the Index of Orthodontic Treatment Need (IOTN). Demand for treatment was assessed by asking subjects if they wanted treatment with braces to correct their teeth. Only 2% of subjects assessed their dentition in the "definite need" for orthodontic treatment category. Demand for treatment was significantly greater in girls than boys (49% and 37% respectively, p < 0.05). Total demand (41%) was considerably greater than self assessed aesthetics in the "definite need" and "borderline need" categories combined (14%). Demand was accurately reflected in patients who perceived their dentition as having moderate to severe (AC 6-9) and very mild aesthetic impairment (AC 1). Perceptions of dental aesthetics using the AC of IOTN were able to predict demand for orthodontic treatment in patients with malocclusions of moderate to severe (AC 6-9) aesthetic impairment.

Cost-Effectiveness Analysis: Risk Stratification of Nonalcoholic Fatty Liver Disease (NAFLD) by the Primary Care Physician Using the NAFLD Fibrosis Score.

PubMed

Tapper, Elliot B; Hunink, M G Myriam; Afdhal, Nezam H; Lai, Michelle; Sengupta, Neil

2016-01-01

The complications of Nonalcoholic Fatty Liver Disease (NAFLD) are dependent on the presence of advanced fibrosis. Given the high prevalence of NAFLD in the US, the optimal evaluation of NAFLD likely involves triage by a primary care physician (PCP) with advanced disease managed by gastroenterologists. We compared the cost-effectiveness of fibrosis risk-assessment strategies in a cohort of 10,000 simulated American patients with NAFLD performed in either PCP or referral clinics using a decision analytical microsimulation state-transition model. The strategies included use of vibration-controlled transient elastography (VCTE), the NAFLD fibrosis score (NFS), combination testing with NFS and VCTE, and liver biopsy (usual care by a specialist only). NFS and VCTE performance was obtained from a prospective cohort of 164 patients with NAFLD. Outcomes included cost per quality adjusted life year (QALY) and correct classification of fibrosis. Risk-stratification by the PCP using the NFS alone costs $5,985 per QALY while usual care costs $7,229/QALY. In the microsimulation, at a willingness-to-pay threshold of $100,000, the NFS alone in PCP clinic was the most cost-effective strategy in 94.2% of samples, followed by combination NFS/VCTE in the PCP clinic (5.6%) and usual care in 0.2%. The NFS based strategies yield the best biopsy-correct classification ratios (3.5) while the NFS/VCTE and usual care strategies yield more correct-classifications of advanced fibrosis at the cost of 3 and 37 additional biopsies per classification. Risk-stratification of patients with NAFLD primary care clinic is a cost-effective strategy that should be formally explored in clinical practice.

Rupture of abdominal aortic aneurysm into sigmoid colon: A case report

PubMed Central

Aksoy, Murat; Yanar, Hakan; Taviloglu, Korhan; Ertekin, Cemalettin; Ayalp, Kemal; Yanar, Fatih; Guloglu, Recep; Kurtoglu, Mehmet

2006-01-01

Primary aorto-colic fistula is rarely reported in the literature. Although infrequently encountered, it is an important complication since it is usually fatal unless detected. Primary aorto-colic fistula is a spontaneous rupture of abdominal aortic aneurysm into the lumen of the adjacent colon loop. Here we report a case of primary aorto-colic fistula in a 54-year old male. The fistulated sigmoid colon was repaired by end-to-end anastomosis. Despite inotropic support, the patient died of sepsis and multiorgan failure on the first postoperative day. PMID:17167850

Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial.

PubMed

Bruce, Martha L; Ten Have, Thomas R; Reynolds, Charles F; Katz, Ira I; Schulberg, Herbert C; Mulsant, Benoit H; Brown, Gregory K; McAvay, Gail J; Pearson, Jane L; Alexopoulos, George S

2004-03-03

Suicide rates are highest in late life; the majority of older adults who die by suicide have seen a primary care physician in preceding months. Depression is the strongest risk factor for late-life suicide and for suicide's precursor, suicidal ideation. To determine the effect of a primary care intervention on suicidal ideation and depression in older patients. Randomized controlled trial known as PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) with patient recruitment from 20 primary care practices in New York City, Philadelphia, and Pittsburgh regions, May 1999 through August 2001. Two-stage, age-stratified (60-74, > or =75 years) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of screened negative patients. This analysis included patients with a depression diagnosis (N = 598). Treatment guidelines tailored for the elderly with care management compared with usual care. Assessment of suicidal ideation and depression severity at baseline, 4 months, 8 months, and 12 months. Rates of suicidal ideation declined faster (P =.01) in intervention patients compared with usual care patients; at 4 months, in the intervention group, raw rates of suicidal ideation declined 12.9% points (29.4% to 16.5%) compared with 3.0% points (20.1% to 17.1% in usual care [P =.01]). Among patients reporting suicidal ideation, resolution of ideation was faster among intervention patients (P =.03); differences peaked at 8 months (70.7% vs 43.9% resolution; P =.005). Intervention patients had a more favorable course of depression in both degree and speed of symptom reduction; group difference peaked at 4 months. The effects on depression were not significant among patients with minor depression unless suicidal ideation was present. Evidence of the intervention's effectiveness in community-based primary care with a heterogeneous sample of depressed patients introduces new challenges related to its sustainability and dissemination. The intervention's effectiveness in reducing suicidal ideation, regardless of depression severity, reinforces its role as a prevention strategy to reduce risk factors for suicide in late life.

Remission in Depressed Geriatric Primary Care Patients: A Report From the PROSPECT Study

PubMed Central

Alexopoulos, George S.; Katz, Ira R.; Bruce, Martha L.; Heo, Moonseong; Have, Thomas Ten; Raue, Patrick; Bogner, Hillary R.; Schulberg, Herbert C.; Mulsant, Benoit H.; Reynolds, Charles F.

2009-01-01

Objective This study compared time to first remission for elderly depressed patients in primary care for practices that implemented a care management model versus those providing usual care. In addition, it sought to identify risk factors for nonremission that could guide treatment planning and referral to care managers or specialists. Method Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) data were analyzed. Participants were older patients (≥60 years) selected following screening of 9,072 randomly identified primary care patients. The present analysis examined patients with major depression and a 24-item Hamilton Depression Rating Scale score of 18 or greater who were followed for at least 4 months (N=215). Primary care practices were randomly assigned to offer the PROSPECT intervention or usual care. The intervention consisted of services of trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 18 months. Results First remission occurred earlier and was more common among patients receiving the intervention than among those receiving usual care. For all patients, limitations in physical and emotional functions predicted poor remission rate. Patients experiencing hopelessness were more likely to achieve remission if treated in intervention practices. Similarly, the intervention was more effective in patients with low baseline anxiety. Conclusions Longitudinal assessment of depression, hopelessness, anxiety, and physical and emotional functional limitations in depressed older primary care patients is critical. Patients with prominent symptoms or impairment in these areas may be candidates for care management or mental health care, since they are at risk for remaining depressed and disabled. PMID:15800144

Telemetered electromyography of the supinators and pronators of the forearm in gibbons and chimpanzees: implications for the fundamental positional adaptation of hominoids.

PubMed

Stern, J T; Larson, S G

2001-07-01

Extant apes are similar to one another, and different from monkeys, in features granting them greater range of forearm rotation and greater size of the muscles that produce this motion. Although these traits may have been independently acquired by the various apes, the possibility arises that such features reflect adaptation to the stem behavior of the hominoid lineage. Anticipating that knowledge of forearm rotatory muscle recruitment during brachiation, vertical climbing, arm-hanging during feeding, and voluntary reaching might point to this stem behavior, we undertook telemetered electromyographic experiments on the supinator, pronator quadratus, ulnar head of pronator teres, and a variety of other upper limb muscles in two gibbons and four chimpanzees. The primary rotator muscles of the hominoid forearm were recruited at high levels in a variety of behaviors. As had been suspected by previous researchers, the supinator is usually active during the support phase of armswinging, but we observed numerous instances of this behavior during which the muscle was inactive. No other muscle took over its role. Kinetic analyses are required to determine how apes can execute body rotation of armswinging without active muscular effort. The one behavior that is common to most extant apes, is rare in monkeys, and which places a consistently great demand on the primary forearm rotatory muscles, is hang-feeding. The muscles of the supporting limb are essential to properly position the body; those of the free limb are essential for grasping food. Since the greater range of forearm rotation characterizing apes is also best explained by adaptation to this behavior, we join previous authors who assert that it lies at the very origin of the Hominoidea. Copyright 2001 Wiley-Liss, Inc.

Effectiveness of Problem-Solving Therapy for Older, Primary Care Patients with Depression: Results from the IMPACT Project

ERIC Educational Resources Information Center

Arean, Patricia; Hegel, Mark; Vannoy, Steven; Fan, Ming-Yu; Unuzter, Jurgen

2008-01-01

Purpose: We compared a primary-care-based psychotherapy, that is, problem-solving therapy for primary care (PST-PC), to community-based psychotherapy in treating late-life major depression and dysthymia. Design and Methods: The data here are from the IMPACT study, which compared collaborative care within a primary care clinic to care as usual in…

Naturalistic assessment of demand for cigarettes, snus, and nicotine gum.

PubMed

Stein, Jeffrey S; Wilson, A George; Koffarnus, Mikhail N; Judd, Michael C; Bickel, Warren K

2017-01-01

Behavioral economic measures of demand provide estimates of tobacco product abuse liability and may predict effects of policy-related price regulation on consumption of existing and emerging tobacco products. In the present study, we examined demand for snus, a smokeless tobacco product, in comparison to both cigarettes and medicinal nicotine. We used both a naturalistic method in which participants purchased these products for use outside the laboratory, as well as laboratory-based self-administration procedures. Cigarette smokers (N = 42) used an experimental income to purchase their usual brand of cigarettes and either snus or gum (only one product available per session) across a range of prices, while receiving all products they purchased from one randomly selected price. In a separate portion of the study, participants self-administered these products during laboratory-based, progressive ratio sessions. Demand elasticity (sensitivity of purchasing to price) was significantly greater for snus than cigarettes. Elasticity for gum was intermediate between snus and cigarettes but was not significantly different than either. Demand intensity (purchasing unconstrained by price) was significantly lower for gum compared to cigarettes, with no significant difference observed between snus and cigarettes. Results of the laboratory-based, progressive ratio sessions were generally discordant with measures of demand elasticity, with significantly higher "breakpoints" for cigarettes compared to gum and no significant differences between other study products. Moreover, breakpoints and product purchasing were generally uncorrelated across tasks. Under naturalistic conditions, snus appears more sensitive to price manipulation than either cigarettes or nicotine gum in existing smokers.

Retrospective Analog Year Analyses Using NASA Satellite Precipitation and Soil Moisture Data to Improve USDA's World Agricultural Supply and Demand Estimates

NASA Technical Reports Server (NTRS)

Teng, William; Shannon, Harlan; Mladenova, Iliana; Fang, Fan

2010-01-01

A primary goal of the U.S. Department of Agriculture (USDA) is to expand markets for U.S. agricultural products and support global economic development. The USDA World Agricultural Outlook Board (WAOB) supports this goal by coordinating monthly World Agricultural Supply and Demand Estimates (WASDE) for the U.S. and major foreign producing countries. Because weather has a significant impact on crop progress, conditions, and production, WAOB prepares frequent agricultural weather assessments, in a GIS-based, Global Agricultural Decision Support Environment (GLADSE). The main goal of this project, thus, is to improve WAOB's estimates by integrating NASA remote sensing soil moisture observations and research results into GLADSE (See diagram below). Soil moisture is currently a primary data gap at WAOB.

Interventions to Improve Access to Primary Care for People Who Are Homeless: A Systematic Review

PubMed Central

2016-01-01

Background People who are homeless encounter barriers to primary care despite having greater needs for health care, on average, than people who are not homeless. We evaluated the effectiveness of interventions to improve access to primary care for people who are homeless. Methods We performed a systematic review to identify studies in English published between January 1, 1995, and July 8, 2015, comparing interventions to improve access to a primary care provider with usual care among people who are homeless. The outcome of interest was access to a primary care provider. The risk of bias in the studies was evaluated, and the quality of the evidence was assessed according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. Results From a total of 4,047 citations, we identified five eligible studies (one randomized controlled trial and four observational studies). With the exception of the randomized trial, the risk of bias was considered high in the remaining studies. In the randomized trial, people who were homeless, without serious mental illness, and who received either an outreach intervention plus clinic orientation or clinic orientation alone, had improved access to a primary care provider compared with those receiving usual care. An observational study that compared integration of primary care and other services for people who are homeless with usual care did not observe any difference in access to a primary care provider between the two groups. A small observational study showed improvement among participants with a primary care provider after receiving an intervention consisting of housing and supportive services compared with the period before the intervention. The quality of the evidence was considered moderate for both the outreach plus clinic orientation and clinic orientation alone, and low to very low for the other interventions. Despite limitations, the literature identified reports of interventions developed to overcome barriers in access to primary care in people who are homeless. The interventions studied are complex and include multiple components that are consistent with proposed dimensions of access to care (availability, affordability, and acceptability). Conclusions Our systematic review of the literature identified various types of interventions that seek to improve access to primary care by attempting to address barriers to care encountered by people who are homeless. Moderate-quality evidence indicates that orientation to clinic services (either alone or combined with outreach) improves access to a primary care provider in adults who are homeless, without serious mental illness, and living in urban centres. PMID:27099645

Interventions to Improve Access to Primary Care for People Who Are Homeless: A Systematic Review.

PubMed

2016-01-01

People who are homeless encounter barriers to primary care despite having greater needs for health care, on average, than people who are not homeless. We evaluated the effectiveness of interventions to improve access to primary care for people who are homeless. We performed a systematic review to identify studies in English published between January 1, 1995, and July 8, 2015, comparing interventions to improve access to a primary care provider with usual care among people who are homeless. The outcome of interest was access to a primary care provider. The risk of bias in the studies was evaluated, and the quality of the evidence was assessed according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. From a total of 4,047 citations, we identified five eligible studies (one randomized controlled trial and four observational studies). With the exception of the randomized trial, the risk of bias was considered high in the remaining studies. In the randomized trial, people who were homeless, without serious mental illness, and who received either an outreach intervention plus clinic orientation or clinic orientation alone, had improved access to a primary care provider compared with those receiving usual care. An observational study that compared integration of primary care and other services for people who are homeless with usual care did not observe any difference in access to a primary care provider between the two groups. A small observational study showed improvement among participants with a primary care provider after receiving an intervention consisting of housing and supportive services compared with the period before the intervention. The quality of the evidence was considered moderate for both the outreach plus clinic orientation and clinic orientation alone, and low to very low for the other interventions. Despite limitations, the literature identified reports of interventions developed to overcome barriers in access to primary care in people who are homeless. The interventions studied are complex and include multiple components that are consistent with proposed dimensions of access to care (availability, affordability, and acceptability). Our systematic review of the literature identified various types of interventions that seek to improve access to primary care by attempting to address barriers to care encountered by people who are homeless. Moderate-quality evidence indicates that orientation to clinic services (either alone or combined with outreach) improves access to a primary care provider in adults who are homeless, without serious mental illness, and living in urban centres.

Genetics Home Reference: dihydrolipoamide dehydrogenase deficiency

MedlinePlus

... begin anytime from infancy to adulthood, is the primary symptom. The liver problems are usually associated with recurrent vomiting and ... of Ashkenazi Jewish descent. This population typically has liver disease as the primary symptom. In other populations, the prevalence of dihydrolipoamide ...

Interdisciplinary Scholarship.

ERIC Educational Resources Information Center

Aronoff, S.

It is increasingly demanded that our academic institutions, having been the primary source of the material structuring our civilization, also be the vehicle for finding solutions for its ills. Society is pressuring the university to establish multidisciplinary programs as the most suitable mechanism for meeting these demands. This will require…

The I-Tribe Community Pharmacy Practice Model: professional pharmacy unshackled.

PubMed

Alston, Greg L; Waitzman, Jennifer A

2013-01-01

To describe a mechanism by which pharmacists could create a disruptive innovation to provide professional primary care services via a Web-based delivery model. Several obstacles have prevented pharmacists from using available technology to develop business models that capitalize on their clinical skills in primary care. Community practice has experienced multiple sustaining innovations that have improved dispensing productivity but have not stimulated sufficient demand for pharmacy services to disrupt the marketplace and provide new opportunities for pharmacists. Pharmacists are in a unique position to bridge the gap between demand for basic primary medical care and access to a competent medical professional. Building on the historic strengths of community pharmacy practice, modern pharmacists could provide a disruptive innovation in the marketplace for primary care by taking advantage of new technology and implementing the I-Tribe Community Pharmacy Practice Model (I-Tribe). This model would directly connect pharmacists to patients through an interactive, secure Web presence that would liberate the relationship from geographic restrictions. The I-Tribe is a disruptive innovation that could become the foundation for a vibrant market in pharmacist professional service offerings. The I-Tribe model could benefit society by expanding access to primary medical care while simultaneously providing a new source of revenue for community practice pharmacists. Entrepreneurial innovation through I-Tribe pharmacy would free pharmacists to become the care providers envisioned by the profession's thought leaders.

[Strengthening primary health care: a strategy to maximize coordination of care].

PubMed

de Almeida, Patty Fidelis; Fausto, Márcia Cristina Rodrigues; Giovanella, Lígia

2011-02-01

To describe and analyze the actions developed in four large cities to strengthen the family health strategy (FHS) in Brazil. Case studies were carried out in Aracaju, Belo Horizonte, Florianópolis, and Vitória based on semi-structured interviews with health care managers. In addition, a cross-sectional study was conducted with questionnaires administered to a sample of FHS workers and services users. Actions needed to strengthen primary health care services were identified in all four cities. These include increasing the number of services offered at the primary health care level, removing barriers to access, restructuring primary services as the entry point to the health care system, enhancing problem-solving capacity (diagnostic and therapeutic support and networking between health units to organize the work process, training, and supervision), as well as improving articulation between surveillance and care actions. The cities studied have gained solid experience in the reorganization of the health care model based on a strengthening of health primary care and of the capacity to undertake the role of health care coordinator. However, to make the primary care level the customary entry point and first choice for users, additional actions are required to balance supplier-induced and consumer-driven demands. Consumer driven demand is the biggest challenge for the organization of teamwork processes. Support for and recognition of FHS as a basis for primary health care is still an issue. Initiatives to make FHS better known to the population, health care professionals at all levels, and civil society organizations are still needed.

Physician losses from Medicare and Medicaid discounts: How real are they?

PubMed Central

Cromwell, Jerry; Burstein, Philip

1985-01-01

Physicians' claims that extensive Medicare and Medicaid fee discounting imposes an inequitable burden on them are examined using survey data from the Health Care Financing Administration on 5,000 primary care physicians. A definite fee hierarchy is documented, with the physician's usual charge at the top and Medicare and Medicaid allowables at the bottom. Under usual, customary, and reasonable methods, physicians can use fees to maximize payment, and insurer attempts to control fees result in both sides participating in a revenue maximization-expenditure control game. Raising Medicare and Medicaid allowables to the physician's usual fee is shown to result in large windfall gains that are unnecessary and unjustified in terms of work effort, human capital investment, or eliciting an adequate supply of practitioners. PMID:10311339

Cost-effectiveness of computerized cognitive-behavioural therapy for the treatment of depression in primary care: findings from the Randomised Evaluation of the Effectiveness and Acceptability of Computerised Therapy (REEACT) trial.

PubMed

Duarte, A; Walker, S; Littlewood, E; Brabyn, S; Hewitt, C; Gilbody, S; Palmer, S

2017-07-01

Computerized cognitive-behavioural therapy (cCBT) forms a core component of stepped psychological care for depression. Existing evidence for cCBT has been informed by developer-led trials. This is the first study based on a large independent pragmatic trial to assess the cost-effectiveness of cCBT as an adjunct to usual general practitioner (GP) care compared with usual GP care alone and to establish the differential cost-effectiveness of a free-to-use cCBT programme (MoodGYM) in comparison with a commercial programme (Beating the Blues) in primary care. Costs were estimated from a healthcare perspective and outcomes measured using quality-adjusted life years (QALYs) over 2 years. The incremental cost-effectiveness of each cCBT programme was compared with usual GP care. Uncertainty was estimated using probabilistic sensitivity analysis and scenario analyses were performed to assess the robustness of results. Neither cCBT programme was found to be cost-effective compared with usual GP care alone. At a £20 000 per QALY threshold, usual GP care alone had the highest probability of being cost-effective (0.55) followed by MoodGYM (0.42) and Beating the Blues (0.04). Usual GP care alone was also the cost-effective intervention in the majority of scenario analyses. However, the magnitude of the differences in costs and QALYs between all groups appeared minor (and non-significant). Technically supported cCBT programmes do not appear any more cost-effective than usual GP care alone. No cost-effective advantage of the commercially developed cCBT programme was evident compared with the free-to-use cCBT programme. Current UK practice recommendations for cCBT may need to be reconsidered in the light of the results.

The efficacy of interactive, motion capture-based rehabilitation on functional outcomes in an inpatient stroke population: a randomized controlled trial

PubMed Central

Cannell, John; Jovic, Emelyn; Rathjen, Amy; Lane, Kylie; Tyson, Anna M; Callisaya, Michele L; Smith, Stuart T; Ahuja, Kiran DK; Bird, Marie-Louise

2017-01-01

Objective: To compare the efficacy of novel interactive, motion capture-rehabilitation software to usual care stroke rehabilitation on physical function. Design: Randomized controlled clinical trial. Setting: Two subacute hospital rehabilitation units in Australia. Participants: In all, 73 people less than six months after stroke with reduced mobility and clinician determined capacity to improve. Interventions: Both groups received functional retraining and individualized programs for up to an hour, on weekdays for 8–40 sessions (dose matched). For the intervention group, this individualized program used motivating virtual reality rehabilitation and novel gesture controlled interactive motion capture software. For usual care, the individualized program was delivered in a group class on one unit and by rehabilitation assistant 1:1 on the other. Main measures: Primary outcome was standing balance (functional reach). Secondary outcomes were lateral reach, step test, sitting balance, arm function, and walking. Results: Participants (mean 22 days post-stroke) attended mean 14 sessions. Both groups improved (mean (95% confidence interval)) on primary outcome functional reach (usual care 3.3 (0.6 to 5.9), intervention 4.1 (−3.0 to 5.0) cm) with no difference between groups (P = 0.69) on this or any secondary measures. No differences between the rehabilitation units were seen except in lateral reach (less affected side) (P = 0.04). No adverse events were recorded during therapy. Conclusion: Interactive, motion capture rehabilitation for inpatients post stroke produced functional improvements that were similar to those achieved by usual care stroke rehabilitation, safely delivered by either a physical therapist or a rehabilitation assistant. PMID:28719977

How Americans Would Slim Down Public Education

ERIC Educational Resources Information Center

Farkas, Steve; Duffett, Ann

2012-01-01

With public school budgets pinched and educational demands rising, "business as usual" is becoming less and less tenable in American schools. Taxpayers, parents, teachers, principals, and students are expected to do more with fewer resources. But what's the best way to go about slimming down and shaping up the system of public education?…

Learning about Learning: What Every New Teacher Needs to Know

ERIC Educational Resources Information Center

Pomerance, Laura; Greenberg, Julie; Walsh, Kate

2016-01-01

Every year about 190,000 teacher candidates graduate from traditional teacher preparation programs believing they are ready to begin the relentlessly demanding career of teaching. Each of these aspiring teachers will have taken at least one education psychology course or instructional methods course (usually both) designed to teach them how…

Understanding Clinician Information Demands and Synthesis of Clinical Documents in Electronic Health Record Systems

ERIC Educational Resources Information Center

Farri, Oladimeji Feyisetan

2012-01-01

Large quantities of redundant clinical data are usually transferred from one clinical document to another, making the review of such documents cognitively burdensome and potentially error-prone. Inadequate designs of electronic health record (EHR) clinical document user interfaces probably contribute to the difficulties clinicians experience while…

Let's Cooperate II: The Costs and Benefits of Cooperation Between Recreation/Park and Education Agencies.

ERIC Educational Resources Information Center

Committee for Recreation/Education Cooperation, CA.

The ideas and the information in this handbook illustrate the experiences of local recreation and education agencies that started cooperative programs in the face of declining resources and increasing demand for improved services. Funding distribution in California usually gives schools financial latitude in facilities and transporation, while…

ICT in Preschool: Friend or Foe? The Significance of Norms in a Changing Practice

ERIC Educational Resources Information Center

Lindahl, Mats Gunnar; Folkesson, Anne-Mari

2012-01-01

Societal change and prescriptions in curricula demand a change in educational practice. This can create conflicts between practitioners' usual practices (norms) and those prescribed by curricula. One example is the introduction of Information and Communication Technology (ICT) into preschool practice. Hence, our aim is to analyse how norms are…

Education and Family in Conflict

ERIC Educational Resources Information Center

Lee, Jihye

2011-01-01

In recent years, the demands of high-quality education have become a source of problems in South Korea, forming a new type of separated family. When the parents send their children to foreign countries for advanced education, the fathers, the wives, and children are separated for a significantly long period of time. Usually, the fathers, called…

The Wage Is Right!

ERIC Educational Resources Information Center

Alden, Lori

2004-01-01

As they work to master the supply-and-demand model, high school economics students spend considerable time studying competitive markets for such goods as wheat, apples, and corn. They usually spend less time studying markets for labor. That is a shame, because high school students have a vital interest in understanding why some jobs pay more than…

Metacognitive Load--Useful, or Extraneous Concept? Metacognitive and Self-Regulatory Demands in Computer-Based Learning

ERIC Educational Resources Information Center

Schwonke, Rolf

2015-01-01

Instructional design theories such as the "cognitive load theory" (CLT) or the "cognitive theory of multimedia learning" (CTML) explain learning difficulties in (computer-based) learning usually as a result of design deficiencies that hinder effective schema construction. However, learners often struggle even in well-designed…

Adaptive Game Based Learning Using Brain Measures for Attention--Some Explorations

ERIC Educational Resources Information Center

van der Pal, Jelke; Roos, Christopher; Sewnath, Ghanshaam; Rosheuvel, Christian

2016-01-01

The prospective use of low fidelity simulation and gaming in aviation training is high, and may facilitate individual, personal training needs in usually asynchronous training setting. Without direct feedback from, or intervention by, an instructor, adaptivity of the training environment is in high demand to ensure training sessions maintain an…

Why Poetry Matters

ERIC Educational Resources Information Center

Parini, Jay

2008-01-01

Poetry does not matter to most people. They go about their business as usual, rarely consulting Shakespeare, Wordsworth, or Frost. One has to wonder if poetry has any place in the 21st century, when music videos and satellite television offer daunting competition for poems, which demand a good deal of attention and considerable analytic skills, as…

TQM in a Multi-Campus Public University.

ERIC Educational Resources Information Center

Zargar, Ali M.

Running a university is fast becoming more challenging than managing a large corporation, in part due to greater quality demands by more groups in the face of shrinking resources and budget cuts. This paper argues against universities conducting business as usual in the face of societal change and increasingly greater challenges, and presents…

Econophysics of a ranked demand and supply resource allocation problem

NASA Astrophysics Data System (ADS)

Priel, Avner; Tamir, Boaz

2018-01-01

We present a two sided resource allocation problem, between demands and supplies, where both parties are ranked. For example, in Big Data problems where a set of different computational tasks is divided between a set of computers each with its own resources, or between employees and employers where both parties are ranked, the employees by their fitness and the employers by their package benefits. The allocation process can be viewed as a repeated game where in each iteration the strategy is decided by a meta-rule, based on the ranks of both parties and the results of the previous games. We show the existence of a phase transition between an absorbing state, where all demands are satisfied, and an active one where part of the demands are always left unsatisfied. The phase transition is governed by the ratio between supplies and demand. In a job allocation problem we find positive correlation between the rank of the workers and the rank of the factories; higher rank workers are usually allocated to higher ranked factories. These all suggest global emergent properties stemming from local variables. To demonstrate the global versus local relations, we introduce a local inertial force that increases the rank of employees in proportion to their persistence time in the same factory. We show that such a local force induces non trivial global effects, mostly to benefit the lower ranked employees.

Integrated economic and experimental framework for screening of primary recovery technologies for high cell density CHO cultures

PubMed Central

Popova, Daria; Stonier, Adam; Pain, David; Titchener‐Hooker, Nigel J.

2016-01-01

Abstract Increases in mammalian cell culture titres and densities have placed significant demands on primary recovery operation performance. This article presents a methodology which aims to screen rapidly and evaluate primary recovery technologies for their scope for technically feasible and cost‐effective operation in the context of high cell density mammalian cell cultures. It was applied to assess the performance of current (centrifugation and depth filtration options) and alternative (tangential flow filtration (TFF)) primary recovery strategies. Cell culture test materials (CCTM) were generated to simulate the most demanding cell culture conditions selected as a screening challenge for the technologies. The performance of these technology options was assessed using lab scale and ultra scale‐down (USD) mimics requiring 25–110mL volumes for centrifugation and depth filtration and TFF screening experiments respectively. A centrifugation and depth filtration combination as well as both of the alternative technologies met the performance selection criteria. A detailed process economics evaluation was carried out at three scales of manufacturing (2,000L, 10,000L, 20,000L), where alternative primary recovery options were shown to potentially provide a more cost‐effective primary recovery process in the future. This assessment process and the study results can aid technology selection to identify the most effective option for a specific scenario. PMID:27067803

Origami-inspired, on-demand deployable and collapsible mechanical metamaterials with tunable stiffness

NASA Astrophysics Data System (ADS)

Zhai, Zirui; Wang, Yong; Jiang, Hanqing

2018-03-01

Origami has been employed to build deployable mechanical metamaterials through folding and unfolding along the crease lines. Deployable metamaterials are usually flexible, particularly along their deploying and collapsing directions, which unfortunately in many cases leads to an unstable deployed state, i.e., small perturbations may collapse the structure along the same deployment path. Here we create an origami-inspired mechanical metamaterial with on-demand deployability and selective collapsibility through energy analysis. This metamaterial has autonomous deployability from the collapsed state and can be selectively collapsed along two different paths, embodying low stiffness for one path and substantially high stiffness for another path. The created mechanical metamaterial yields load-bearing capability in the deployed direction while possessing great deployability and collapsibility. The principle in this work can be utilized to design and create versatile origami-inspired mechanical metamaterials that can find many applications.

Configuration complexity assessment of convergent supply chain systems

NASA Astrophysics Data System (ADS)

Modrak, Vladimir; Marton, David

2014-07-01

System designers usually generate alternative configurations of supply chains (SCs) by varying especially fixed assets to satisfy a desired production scope and rate. Such alternatives often vary in associated costs and other facets including degrees of complexity. Hence, a measure of configuration complexity can be a tool for comparison and decision-making. This paper presents three approaches to assessment of configuration complexity and their applications to designing convergent SC systems. Presented approaches are conceptually distinct ways of measuring structural complexity parameters based on different preconditions and circumstances of assembly systems which are typical representatives of convergent SCs. There are applied two similar approaches based on different preconditions that are related to demand shares. Third approach does not consider any special condition relating to character of final product demand. Subsequently, we propose a framework for modeling of assembly SC models, which are dividing to classes.

Origami-inspired, on-demand deployable and collapsible mechanical metamaterials with tunable stiffness.

PubMed

Zhai, Zirui; Wang, Yong; Jiang, Hanqing

2018-02-27

Origami has been employed to build deployable mechanical metamaterials through folding and unfolding along the crease lines. Deployable metamaterials are usually flexible, particularly along their deploying and collapsing directions, which unfortunately in many cases leads to an unstable deployed state, i.e., small perturbations may collapse the structure along the same deployment path. Here we create an origami-inspired mechanical metamaterial with on-demand deployability and selective collapsibility through energy analysis. This metamaterial has autonomous deployability from the collapsed state and can be selectively collapsed along two different paths, embodying low stiffness for one path and substantially high stiffness for another path. The created mechanical metamaterial yields load-bearing capability in the deployed direction while possessing great deployability and collapsibility. The principle in this work can be utilized to design and create versatile origami-inspired mechanical metamaterials that can find many applications. Copyright © 2018 the Author(s). Published by PNAS.

Origami-inspired, on-demand deployable and collapsible mechanical metamaterials with tunable stiffness

PubMed Central

Zhai, Zirui; Wang, Yong

2018-01-01

Origami has been employed to build deployable mechanical metamaterials through folding and unfolding along the crease lines. Deployable metamaterials are usually flexible, particularly along their deploying and collapsing directions, which unfortunately in many cases leads to an unstable deployed state, i.e., small perturbations may collapse the structure along the same deployment path. Here we create an origami-inspired mechanical metamaterial with on-demand deployability and selective collapsibility through energy analysis. This metamaterial has autonomous deployability from the collapsed state and can be selectively collapsed along two different paths, embodying low stiffness for one path and substantially high stiffness for another path. The created mechanical metamaterial yields load-bearing capability in the deployed direction while possessing great deployability and collapsibility. The principle in this work can be utilized to design and create versatile origami-inspired mechanical metamaterials that can find many applications. PMID:29440441

Effect of Human and Sheep Lung Orientation on Primary Blast Injury Induced by Single Blast

DTIC Science & Technology

2010-09-01

may be injured by m ore than one of these mechanisms in any given event. Primary blast in juries ( PBI ) are exclusively caused by the blast...overpressure. A PBI usually affects air-containing organs such as t he lung, ears and gastrointestinal tract. Secon dary blast injuries are caused by...orientation on blast injuries predicted in human and sheep models. From th is study, it is predicted that the greatest reduction in lung PBI may be

Estimation of 18-kip equivalent on primary and interstate road systems in Virginia.

DOT National Transportation Integrated Search

1972-01-01

For pavement design purposes, the Virginia Department of Highways uses the AASHO method of determining the 18-kip equivalent single axle load (EWL-18). The evaluation of the EWL-18 is based on on-location truck axle weight studies that usually are ca...

Problem-Solving Treatment and Coping Styles in Primary Care for Minor Depression

ERIC Educational Resources Information Center

Oxman, Thomas E.; Hegel, Mark T.; Hull, Jay G.; Dietrich, Allen J.

2008-01-01

Research was undertaken to compare problem-solving treatment for primary care (PST-PC) with usual care for minor depression and to examine whether treatment effectiveness was moderated by coping style. PST-PC is a 6-session, manual-based, psychosocial skills intervention. A randomized controlled trial was conducted in 2 academic, primary care…

Modelling supply and demand of bioenergy from short rotation coppice and Miscanthus in the UK.

PubMed

Bauen, A W; Dunnett, A J; Richter, G M; Dailey, A G; Aylott, M; Casella, E; Taylor, G

2010-11-01

Biomass from lignocellulosic energy crops can contribute to primary energy supply in the short term in heat and electricity applications and in the longer term in transport fuel applications. This paper estimates the optimal feedstock allocation of herbaceous and woody lignocellulosic energy crops for England and Wales based on empirical productivity models. Yield maps for Miscanthus, willow and poplar, constrained by climatic, soil and land use factors, are used to estimate the potential resource. An energy crop supply-cost curve is estimated based on the resource distribution and associated production costs. The spatial resource model is then used to inform the supply of biomass to geographically distributed demand centres, with co-firing plants used as an illustration. Finally, the potential contribution of energy crops to UK primary energy and renewable energy targets is discussed. Copyright 2010 Elsevier Ltd. All rights reserved.

Predicting Outcome in Computerized Cognitive Behavioral Therapy for Depression in Primary Care: A Randomized Trial

ERIC Educational Resources Information Center

de Graaf, L. Esther; Hollon, Steven D.; Huibers, Marcus J. H.

2010-01-01

Objective: To explore pretreatment and short-term improvement variables as potential moderators and predictors of 12-month follow-up outcome of unsupported online computerized cognitive behavioral therapy (CCBT), usual care, and CCBT combined with usual care for depression. Method: Three hundred and three depressed patients were randomly allocated…

An enriched medical home intervention using community health workers improves adherence to immunization schedules.

PubMed

Pati, Susmita; Ladowski, Kristi L; Wong, Angie T; Huang, Jiayu; Yang, Jie

2015-11-17

Disparities in childhood vaccination rates persist. To evaluate the impact of an enriched medical home intervention using community health workers on improving immunization adherence among young children. The intervention group received home visits from trained community health workers to support families in adhering to recommended care while the comparison group received usual care (i.e. no home visits/reminders). Immunization history and socio-demographic data were collected using medical records and a validated questionnaire. The doubly robust estimation of risk difference, which combines weighting via propensity score and outcome regression model, was used to compare immunization adherence rates between two groups. Primary care practices affiliated with a suburban tertiary care academic medical center serving a socioeconomically diverse population. The study sample included children ≤ 2 years of age at enrollment who crossed at least one age time point of 3, 7, 15, or 24 months during their 6 months post-enrollment period. The primary outcome was age-specific immunization up-to-date status defined by CDC guidelines. The primary predictor was participation in the intervention. The analysis included 201 children in the usual care group and 110 children in the intervention group. The usual care and intervention groups were divided into subgroups of newborn and infant/toddler to account for prior immunization history. After adjusting for differences in group characteristics, we found a significant absolute increase in the up-to-date immunization likelihood for both newborns (20.9%, p=0.01) and infants/toddlers (16.8%, p=0.01) receiving the intervention when compared to their peers receiving usual clinical care. Our findings demonstrate the positive impact of an enriched medical home intervention using community health worker home visitation on early childhood immunization up-to-date status. With further study, this model may provide a cost-effective approach to improving childhood vaccination rates, especially for vulnerable groups. Copyright © 2015 Elsevier Ltd. All rights reserved.

Patient, Provider, and Combined Interventions for Managing Osteoarthritis in Primary Care: A Cluster Randomized Trial.

PubMed

Allen, Kelli D; Oddone, Eugene Z; Coffman, Cynthia J; Jeffreys, Amy S; Bosworth, Hayden B; Chatterjee, Ranee; McDuffie, Jennifer; Strauss, Jennifer L; Yancy, William S; Datta, Santanu K; Corsino, Leonor; Dolor, Rowena J

2017-03-21

A single-site study showed that a combined patient and provider intervention improved outcomes for patients with knee osteoarthritis, but it did not assess separate effects of the interventions. To examine whether patient-based, provider-based, and patient-provider interventions improve osteoarthritis outcomes. Cluster randomized trial with assignment to patient, provider, and patient-provider interventions or usual care. (ClinicalTrials.gov: NCT01435109). 10 Duke University Health System community-based primary care clinics. 537 outpatients with symptomatic hip or knee osteoarthritis. The telephone-based patient intervention focused on weight management, physical activity, and cognitive behavioral pain management. The provider intervention involved electronic delivery of patient-specific osteoarthritis treatment recommendations to providers. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score at 12 months. Secondary outcomes were objective physical function (Short Physical Performance Battery) and depressive symptoms (Patient Health Questionnaire). Linear mixed models assessed the difference in improvement among groups. No difference was observed in WOMAC score changes from baseline to 12 months in the patient (-1.5 [95% CI, -5.1 to 2.0]; P = 0.40), provider (2.5 [CI, -0.9 to 5.9]; P = 0.152), or patient-provider (-0.7 [CI, -4.2 to 2.8]; P = 0.69) intervention groups compared with usual care. All groups had improvements in WOMAC scores at 12 months (range, -3.7 to -7.7). In addition, no differences were seen in objective physical function or depressive symptoms at 12 months in any of the intervention groups compared with usual care. The study involved 1 health care network. Data on provider referrals were not collected. Contrary to a previous study of a combined patient and provider intervention for osteoarthritis in a Department of Veterans Affairs medical center, this study found no statistically significant improvements in the osteoarthritis intervention groups compared with usual care. National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Pharmacist intervention in primary care to improve outcomes in patients with left ventricular systolic dysfunction.

PubMed

Lowrie, Richard; Mair, Frances S; Greenlaw, Nicola; Forsyth, Paul; Jhund, Pardeep S; McConnachie, Alex; Rae, Brian; McMurray, John J V

2012-02-01

Meta-analysis of small trials suggests that pharmacist-led collaborative review and revision of medical treatment may improve outcomes in heart failure. We studied patients with left ventricular systolic dysfunction in a cluster-randomized controlled, event driven, trial in primary care. We allocated 87 practices (1090 patients) to pharmacist intervention and 87 practices (1074 patients) to usual care. The intervention was delivered by non-specialist pharmacists working with family doctors to optimize medical treatment. The primary outcome was a composite of death or hospital admission for worsening heart failure. This trial is registered, number ISRCTN70118765. The median follow-up was 4.7 years. At baseline, 86% of patients in both groups were treated with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. In patients not receiving one or other of these medications, or receiving less than the recommended dose, treatment was started, or the dose increased, in 33.1% of patients in the intervention group and in 18.5% of the usual care group [odds ratio (OR) 2.26, 95% CI 1.64-3.10; P< 0.001]. At baseline, 62% of each group were treated with a β-blocker and the proportions starting or having an increase in the dose were 17.9% in the intervention group and 11.1% in the usual care group (OR 1.76, 95% CI 1.31-2.35; P< 0.001). The primary outcome occurred in 35.8% of patients in the intervention group and 35.4% in the usual care group (hazard ratio 0.97, 95% CI 0.83-1.14; P = 0.72). There was no difference in any secondary outcome. A low-intensity, pharmacist-led collaborative intervention in primary care resulted in modest improvements in prescribing of disease-modifying medications but did not improve clinical outcomes in a population that was relatively well treated at baseline.

Evaluation of a combined lifestyle intervention for overweight and obese patients in primary health care: a quasi-experimental design.

PubMed

Verberne, Lisa D M; Hendriks, Marike R C; Rutten, Geert M; Spronk, Inge; Savelberg, Hans H C M; Veenhof, Cindy; Nielen, Mark M J

2016-12-01

Combined lifestyle interventions (CLIs) are designed to reduce risk factors for lifestyle-related diseases through increasing physical activity and improvement of dietary behaviour. To evaluate the effects of a CLI for overweight and obese patients on lifestyle-related risk factors and health care consumption, in comparison to usual care. Data on anthropometric and metabolic measurements, morbidity, drugs prescriptions and general practitioner (GP) consultations were extracted from electronic health records (timeframe: July 2009-August 2013). Using a quasi-experimental design, health outcomes of 127 patients who participated in a 1-year CLI were compared to a group of 254 matched patients that received usual care. Baseline to post-intervention changes in health outcomes between intervention and comparison group were evaluated using mixed model analyses. Compared to baseline, both groups showed reductions in body mass index (BMI), blood pressure, total cholesterol and low density lipoprotein cholesterol in year post-intervention. For these outcome measures, no significant differences in changes were observed between intervention and comparison group. A significant improvement of 0.08 mmol/l in high density lipoprotein (HDL) cholesterol was observed for the intervention group above the comparison group (P < 0.01). No significant intergroup differences were shown in drugs prescriptions and number of GP consultations. A CLI for overweight and obese patients in primary health care resulted in similar effects on health outcomes compared to usual care. Only an improvement on HDL cholesterol was shown. This study indicates that implementation and evaluation of a lifestyle intervention in primary health care is challenging due to political and financial barriers. © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Work, exercise, and space flight. 2: Modification of adaptation by exercise (exercise prescription)

NASA Technical Reports Server (NTRS)

Thornton, William

1989-01-01

The fundamentals of exercise theory on earth must be rigorously understood and applied to prevent adaptation to long periods of weightlessness. Locomotor activity, not weight, determines the capacity or condition of the largest muscles and bones in the body and usually also determines cardio-respiratory capacity. Absence of this activity results in rapid atrophy of muscle, bone, and cardio-respiratory capacity. Upper body muscle and bone are less affected depending upon the individual's usual, or 1-g, activities. Methodology is available to prevent these changes but space operations demand that it be done in the most efficient fashion, i.e., shortest time. At this point in time we can reasonably select the type of exercise and methods of obtaining it, but additional work in 1-g will be required to optimize the time.

Theory-driven group-based complex intervention to support self-management of osteoarthritis and low back pain in primary care physiotherapy: protocol for a cluster randomised controlled feasibility trial (SOLAS)

PubMed Central

Hurley, Deirdre A; Hall, Amanda M; Currie-Murphy, Laura; Pincus, Tamar; Kamper, Steve; Maher, Chris; McDonough, Suzanne M; Lonsdale, Chris; Walsh, Nicola E; Guerin, Suzanne; Segurado, Ricardo; Matthews, James

2016-01-01

Introduction International clinical guidelines consistently endorse the promotion of self-management (SM), including physical activity for patients with chronic low back pain (CLBP) and osteoarthritis (OA). Patients frequently receive individual treatment and advice to self-manage from physiotherapists in primary care, but the successful implementation of a clinical and cost-effective group SM programme is a key priority for health service managers in Ireland to maximise long-term outcomes and efficient use of limited and costly resources. Methods/analysis This protocol describes an assessor-blinded cluster randomised controlled feasibility trial of a group-based education and exercise intervention underpinned by self-determination theory designed to support an increase in SM behaviour in patients with CLBP and OA in primary care physiotherapy. The primary care clinic will be the unit of randomisation (cluster), with each clinic randomised to 1 of 2 groups providing the Self-management of Osteoarthritis and Low back pain through Activity and Skills (SOLAS) intervention or usual individual physiotherapy. Patients are followed up at 6 weeks, 2 and 6 months. The primary outcomes are the (1) acceptability and demand of the intervention to patients and physiotherapists, (2) feasibility and optimal study design/procedures and sample size for a definitive trial. Secondary outcomes include exploratory analyses of: point estimates, 95% CIs, change scores and effect sizes in physical function, pain and disability outcomes; process of change in target SM behaviours and selected mediators; and the cost of the intervention to inform a definitive trial. Ethics/dissemination This feasibility trial protocol was approved by the UCD Human Research Ethics—Sciences Committee (LS-13-54 Currie-Hurley) and research access has been granted by the Health Services Executive Primary Care Research Committee in January 2014. The study findings will be disseminated to the research, clinical and health service communities through publication in peer-reviewed journals, presentation at national and international academic and clinical conferences. Trial registration number ISRCTN 49875385; Pre-results. PMID:26801470

Theory-driven group-based complex intervention to support self-management of osteoarthritis and low back pain in primary care physiotherapy: protocol for a cluster randomised controlled feasibility trial (SOLAS).

PubMed

Hurley, Deirdre A; Hall, Amanda M; Currie-Murphy, Laura; Pincus, Tamar; Kamper, Steve; Maher, Chris; McDonough, Suzanne M; Lonsdale, Chris; Walsh, Nicola E; Guerin, Suzanne; Segurado, Ricardo; Matthews, James

2016-01-21

International clinical guidelines consistently endorse the promotion of self-management (SM), including physical activity for patients with chronic low back pain (CLBP) and osteoarthritis (OA). Patients frequently receive individual treatment and advice to self-manage from physiotherapists in primary care, but the successful implementation of a clinical and cost-effective group SM programme is a key priority for health service managers in Ireland to maximise long-term outcomes and efficient use of limited and costly resources. This protocol describes an assessor-blinded cluster randomised controlled feasibility trial of a group-based education and exercise intervention underpinned by self-determination theory designed to support an increase in SM behaviour in patients with CLBP and OA in primary care physiotherapy. The primary care clinic will be the unit of randomisation (cluster), with each clinic randomised to 1 of 2 groups providing the Self-management of Osteoarthritis and Low back pain through Activity and Skills (SOLAS) intervention or usual individual physiotherapy. Patients are followed up at 6 weeks, 2 and 6 months. The primary outcomes are the (1) acceptability and demand of the intervention to patients and physiotherapists, (2) feasibility and optimal study design/procedures and sample size for a definitive trial. Secondary outcomes include exploratory analyses of: point estimates, 95% CIs, change scores and effect sizes in physical function, pain and disability outcomes; process of change in target SM behaviours and selected mediators; and the cost of the intervention to inform a definitive trial. This feasibility trial protocol was approved by the UCD Human Research Ethics-Sciences Committee (LS-13-54 Currie-Hurley) and research access has been granted by the Health Services Executive Primary Care Research Committee in January 2014. The study findings will be disseminated to the research, clinical and health service communities through publication in peer-reviewed journals, presentation at national and international academic and clinical conferences. ISRCTN 49875385; Pre-results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Cryogenic parallel, single phase flows: an analytical approach

NASA Astrophysics Data System (ADS)

Eichhorn, R.

2017-02-01

Managing the cryogenic flows inside a state-of-the-art accelerator cryomodule has become a demanding endeavour: In order to build highly efficient modules, all heat transfers are usually intercepted at various temperatures. For a multi-cavity module, operated at 1.8 K, this requires intercepts at 4 K and at 80 K at different locations with sometimes strongly varying heat loads which for simplicity reasons are operated in parallel. This contribution will describe an analytical approach, based on optimization theories.

Targets and self-management for the control of blood pressure in stroke and at risk groups (TASMIN-SR): protocol for a randomised controlled trial.

PubMed

O'Brien, Claire; Bray, Emma P; Bryan, Stirling; Greenfield, Sheila M; Haque, M Sayeed; Hobbs, F D Richard; Jones, Miren I; Jowett, Sue; Kaambwa, Billingsley; Little, Paul; Mant, Jonathan; Penaloza, Cristina; Schwartz, Claire; Shackleford, Helen; Varghese, Jinu; Williams, Bryan; McManus, Richard J

2013-03-23

Self-monitoring of hypertension with self-titration of antihypertensives (self-management) results in lower systolic blood pressure for at least one year. However, few people in high risk groups have been evaluated to date and previous work suggests a smaller effect size in these groups. This trial therefore aims to assess the added value of self-management in high risk groups over and above usual care. The targets and self-management for the control of blood pressure in stroke and at risk groups (TASMIN-SR) trial will be a pragmatic primary care based, unblinded, randomised controlled trial of self-management of blood pressure (BP) compared to usual care. Eligible patients will have a history of stroke, coronary heart disease, diabetes or chronic kidney disease and will be recruited from primary care. Participants will be individually randomised to either usual care or self-management. The primary outcome of the trial will be difference in office SBP between intervention and control groups at 12 months adjusted for baseline SBP and covariates. 540 patients will be sufficient to detect a difference in SBP between self-management and usual care of 5 mmHg with 90% power. Secondary outcomes will include self-efficacy, lifestyle behaviours, health-related quality of life and adverse events. An economic analysis will consider both within trial costs and a model extrapolating the results thereafter. A qualitative analysis will gain insights into patients' views, experiences and decision making processes. The results of the trial will be directly applicable to primary care in the UK. If successful, self-management of blood pressure in people with stroke and other high risk conditions would be applicable to many hundreds of thousands of individuals in the UK and beyond. ISRCTN87171227.

Improving diabetes care among patients overdue for recommended testing: a randomized controlled trial of automated telephone outreach.

PubMed

Simon, Steven R; Trinacty, Connie Mah; Soumerai, Stephen B; Piette, John D; Meigs, James B; Shi, Ping; Ensroth, Arthur; Ross-Degnan, Dennis

2010-07-01

The study's objective was to assess the effects of automated telephone outreach with speech recognition (ATO-SR) on diabetes-related testing. We identified 1,200 health plan members who were overdue for diabetes-related testing and randomly allocated 600 to ATO-SR and 600 to usual care (no intervention). The intervention included three interactive calls encouraging recommended testing. The primary outcome was retinopathy testing, since this was the health plan's principal goal. Tests for glycemia, hyperlipidemia, and nephropathy were secondary outcomes. In total, 232 participants (39%) verbally responded to the calls. There was no difference between the intervention and the usual care groups in the primary outcome (adjusted hazard ratio 0.93 [95% CI 0.71-1.22]) and no effect of the intervention on any of the secondary outcomes. Fewer than 40% of the patients randomized to ATO-SR interacted verbally with the system. The intervention had no effect on the study's outcomes.

Implementing practice management strategies to improve patient care: the EPIC project.

PubMed

Attwell, David; Rogers-Warnock, Leslie; Nemis-White, Joanna

2012-01-01

Healthcare gaps, the difference between usual care and best care, are evident in Canada, particularly with respect to our aging, ailing population. Primary care practitioners are challenged to identify, prevent and close care gaps in their practice environment given the competing demands of informed, litigious patients with complex medical needs, ever-evolving scientific evidence with new treatment recommendations across many disciplines and an enhanced emphasis on quality and accountability in healthcare. Patient-centred health and disease management partnerships using measurement, feedback and communication of practice patterns and outcomes have been shown to narrow care gaps. Practice management strategies such as the use of patient registries and recall systems have also been used to help practitioners better understand, follow and proactively manage populations of patients in their practice. The Enhancing Practice to Improve Care project was initiated to determine the impact of a patient-centred health and disease management partnership using practice management strategies to improve patient care and outcomes for patients with chronic kidney disease (CKD). Forty-four general practices from four regions of British Columbia participated and, indeed, demonstrated that care and outcomes for patients with CKD could be improved via the implementation of practice management strategies in a patient-centred partnership measurement model of health and disease management.

Ethical issues in healthcare financing.

PubMed

Maharaj, S R; Paul, T J

2011-07-01

The four goals of good healthcare are to relieve symptoms, cure disease, prolong life and improve quality of life. Access to healthcare has been a perpetual challenge to healthcare providers who must take into account important factors such as equity, efficiency and effectiveness in designing healthcare systems to meet the four goals of good healthcare. The underlying philosophy may designate health as being a basic human right, an investment, a commodity to be bought and sold, a political demand or an expenditure. The design, policies and operational arrangements will usually reflect which of the above philosophies underpin the healthcare system, and consequently, access. Mechanisms for funding include fee-for-service, cost sharing (insurance, either private or government sponsored) free-of-fee at point of delivery (payments being made through general taxes, health levies, etc) or cost-recovery. For each of these methods of financial access to healthcare services, there are ethical issues which can compromise the four principles of ethical practices in healthcare, viz beneficence, non-maleficence, autonomy and justice. In times of economic recession, providing adequate healthcare will require governments, with support from external agencies, to focus on poverty reduction strategies through provision of preventive services such as immunization and nutrition, delivered at primary care facilities. To maximize the effect of such policies, it will be necessary to integrate policies to fashion an intersectoral approach.

Collection of family health history for assessment of chronic disease risk in primary care.

PubMed

Powell, Karen P; Christianson, Carol A; Hahn, Susan E; Dave, Gaurav; Evans, Leslie R; Blanton, Susan H; Hauser, Elizabeth; Agbaje, Astrid; Orlando, Lori A; Ginsburg, Geoffrey S; Henrich, Vincent C

2013-01-01

Family health history can predict a patient's risk for common complex diseases. This project assessed the completeness of family health history data in medical charts and evaluated the utility of these data for performing risk assessments in primary care. Family health history data were collected and analyzed to determine the presence of quality indicators that are necessary for effective and accurate assessment of disease risk. More than 99% of the 390 paper charts analyzed contained information about family health history, which was usually scattered throughout the chart. Information on the health of the patient's parents was collected more often than information on the health of other relatives. Key information that was often not collected included age of disease onset, affected side of the family, and second-degree relatives affected. Less than 4% of patient charts included family health histories that were informative enough to accurately assess risk for common complex diseases. Limitations of this study include the small number of charts reviewed per provider, the fact that the sample consisted of primary care providers in a single geographic location, and the inability to assess ethnicity, consanguinity, and other indicators of the informativeness of family health history. The family health histories collected in primary care are usually not complete enough to assess the patient's risk for common complex diseases. This situation could be improved with use of tools that analyze the family health history information collected and provide risk-stratified decision support recommendations for primary care.

Creative treatment of bipolar disorders.

PubMed

Tavčar, Rok

2015-09-01

Bipolar disorder is a mental disorder with chronic and remitting course. The disorder is related to high mortality and severely impairs everyday functioning. Therefore a scientifically sound and practical approach to treatment is needed. Making a long-term treatment plan usually also demands some creativity. The patient is interested in a number of issues, from the choice of therapy in acute phases to long-term treatment. Usual questions are how long shall I take the medications, do I really need all those pills or can we decrease the dosage of some drugs? This paper discussed the above mentioned questions in light of latest publications in this field.

Industrial companies' demand for energy based on a micro panel database -- Effects of CO{sub 2} taxation and agreements on energy savings

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

Bjoerner, T.B.; Togeby, M.

1999-07-01

An econometric panel data analysis of industrial demand for electricity and energy is presented. In the panel energy consumption, production and value added are observed at company level. The authors estimate price and production elasticities for electricity and total energy (i.e. measuring the X per cent change in demand of say electricity of a one per cent increase in the price of electricity). The estimated price and production elasticities are allowed to vary according to company characteristics such as industrial sub-sector, company size, energy intensity and type of ownership. Most previous econometric studies on industrial energy demand use aggregate data,more » while a couple of micro level studies mainly employ cross-section analysis. To the knowledge this is only the second econometric study on industrial energy demand based on a large micro panel database. More than 2,700 Danish industrial companies during the period 1983 to 1995 are included in the model (covering the majority of all Danish industrial energy consumption). One advantage of micro data is that these data can be used to estimate the effect of an instrument like voluntary energy agreements. By entering a voluntary energy agreement a Danish company avoids paying the usual CO{sub 2} tax. Preliminary analyses suggest that there is a large positive gross reduction of electricity and total energy consumption of companies with energy agreements. However, the authors also find that companies would have had about the same reduction in electricity consumption if they had not entered into an agreement, but instead paid the full CO{sub 2} tax. Thus, the analysis suggests that the net effect on electricity use of the voluntary energy agreements is very low (perhaps even negative).« less

Diagnosing phosphorus limitations in natural terrestrial ecosystems in carbon cycle models

NASA Astrophysics Data System (ADS)

Sun, Yan; Peng, Shushi; Goll, Daniel S.; Ciais, Philippe; Guenet, Bertrand; Guimberteau, Matthieu; Hinsinger, Philippe; Janssens, Ivan A.; Peñuelas, Josep; Piao, Shilong; Poulter, Benjamin; Violette, Aurélie; Yang, Xiaojuan; Yin, Yi; Zeng, Hui

2017-07-01

Most of the Earth System Models (ESMs) project increases in net primary productivity (NPP) and terrestrial carbon (C) storage during the 21st century. Despite empirical evidence that limited availability of phosphorus (P) may limit the response of NPP to increasing atmospheric CO2, none of the ESMs used in the previous Intergovernmental Panel on Climate Change assessment accounted for P limitation. We diagnosed from ESM simulations the amount of P need to support increases in carbon uptake by natural ecosystems using two approaches: the demand derived from (1) changes in C stocks and (2) changes in NPP. The C stock-based additional P demand was estimated to range between -31 and 193 Tg P and between -89 and 262 Tg P for Representative Concentration Pathway (RCP) 2.6 and RCP8.5, respectively, with negative values indicating a P surplus. The NPP-based demand, which takes ecosystem P recycling into account, results in a significantly higher P demand of 648-1606 Tg P for RCP2.6 and 924-2110 Tg P for RCP8.5. We found that the P demand is sensitive to the turnover of P in decomposing plant material, explaining the large differences between the NPP-based demand and C stock-based demand. The discrepancy between diagnosed P demand and actual P availability (potential P deficit) depends mainly on the assumptions about availability of the different soil P forms. Overall, future P limitation strongly depends on both soil P availability and P recycling on ecosystem scale.

Diagnosing phosphorus limitations in natural terrestrial ecosystems in carbon cycle models.

PubMed

Sun, Yan; Peng, Shushi; Goll, Daniel S; Ciais, Philippe; Guenet, Bertrand; Guimberteau, Matthieu; Hinsinger, Philippe; Janssens, Ivan A; Peñuelas, Josep; Piao, Shilong; Poulter, Benjamin; Violette, Aurélie; Yang, Xiaojuan; Yin, Yi; Zeng, Hui

2017-07-01

Most of the Earth System Models (ESMs) project increases in net primary productivity (NPP) and terrestrial carbon (C) storage during the 21st century. Despite empirical evidence that limited availability of phosphorus (P) may limit the response of NPP to increasing atmospheric CO 2 , none of the ESMs used in the previous Intergovernmental Panel on Climate Change assessment accounted for P limitation. We diagnosed from ESM simulations the amount of P need to support increases in carbon uptake by natural ecosystems using two approaches: the demand derived from (1) changes in C stocks and (2) changes in NPP. The C stock-based additional P demand was estimated to range between -31 and 193 Tg P and between -89 and 262 Tg P for Representative Concentration Pathway (RCP) 2.6 and RCP8.5, respectively, with negative values indicating a P surplus. The NPP-based demand, which takes ecosystem P recycling into account, results in a significantly higher P demand of 648-1606 Tg P for RCP2.6 and 924-2110 Tg P for RCP8.5. We found that the P demand is sensitive to the turnover of P in decomposing plant material, explaining the large differences between the NPP-based demand and C stock-based demand. The discrepancy between diagnosed P demand and actual P availability (potential P deficit) depends mainly on the assumptions about availability of the different soil P forms. Overall, future P limitation strongly depends on both soil P availability and P recycling on ecosystem scale.

On-demand Droplet Manipulation via Triboelectrification

NASA Astrophysics Data System (ADS)

Wang, Wei; Vahabi, Hamed; Cackovic, Matthew; Jiang, Rui; Kota, Arun

2017-11-01

Controlled manipulation of liquid droplets has attracted tremendous interest across different scientific fields over the past two decades. To date, a variety of external stimuli-mediated methods such as magnetic field, electric field, and light have been developed for manipulating droplets on surfaces. However, these methods usually have drawbacks such as complex fabrication of manipulation platform, low droplet motility, expensive actuation system and lack of precise control. In this work, we demonstrate the controlled manipulation of liquid droplet with both high (e.g., water) and low (e.g., n-hexadecane) dielectric strengths on a smooth, slippery surface via triboelectric effect. Our highly simple, facile and portable methodology enables on-demand, precise manipulation of droplets using solely the electrostatic attraction or repulsion force, which is exerted on the droplet by a simple charged actuator (e.g., Teflon film). We envision that our triboelectric effect enabled droplet manipulation methodology will open a new avenue for droplet based lab-on-a-chip systems, energy harvesting devices and biomedical applications.

A Universal Rig for Supporting Large Hammer Drills: Reduced Injury Risk and Improved Productivity

PubMed Central

Rempel, David; Barr, Alan

2015-01-01

Drilling holes into concrete with heavy hammer and rock drills is one of the most physically demanding tasks performed in commercial construction and poses risks for musculoskeletal disorders, noise induced hearing loss, hand arm vibration syndrome and silicosis. The aim of this study was to (1) use a participatory process to develop a rig to support pneumatic rock drills or large electric hammer drills in order to reduce the health risks and (2) evaluate the usability of the rig. Seven prototype rigs for supporting large hammer drills were developed and modified with feedback from commercial contractors and construction workers. The final design was evaluated by laborers and electricians (N=29) who performed their usual concrete drilling with the usual method and the new rig. Subjective regional fatigue was significantly less in the neck, shoulders, hands and arms, and lower back) when using the universal rig compared to the usual manual method. Usability ratings for the rig were significantly better than the usual method on stability, control, drilling, accuracy, and vibration. Drilling time was reduced by approximately 50% with the rig. Commercial construction contractors, laborers and electricians who use large hammer drills for drilling many holes should consider using such a rig to prevent musculoskeletal disorders, fatigue, and silicosis. PMID:26005290

Social problem solving in carers of young people with a first episode of psychosis: a randomized controlled trial.

PubMed

McCann, Terence V; Cotton, Sue M; Lubman, Dan I

2017-08-01

Caring for young people with first-episode psychosis is difficult and demanding, and has detrimental effects on carers' well-being, with few evidence-based resources available to assist carers to deal with the problems they are confronted with in this situation. We aimed to examine if completion of a self-directed problem-solving bibliotherapy by first-time carers of young people with first-episode psychosis improved their social problem solving compared with carers who only received treatment as usual. A randomized controlled trial was carried out through two early intervention psychosis services in Melbourne, Australia. A sample of 124 carers were randomized to problem-solving bibliotherapy or treatment as usual. Participants were assessed at baseline, 6- and 16-week follow-up. Intent-to-treat analyses were used and showed that recipients of bibliotherapy had greater social problem-solving abilities than those receiving treatment as usual, and these effects were maintained at both follow-up time points. Our findings affirm that bibliotherapy, as a low-cost complement to treatment as usual for carers, had some effects in improving their problem-solving skills when addressing problems related to the care and support of young people with first-episode psychosis. © 2015 The Authors. Early Intervention in Psychiatry published by Wiley Publishing Asia Pty Ltd.

Life cycle optimization model for integrated cogeneration and energy systems applications in buildings

NASA Astrophysics Data System (ADS)

Osman, Ayat E.

Energy use in commercial buildings constitutes a major proportion of the energy consumption and anthropogenic emissions in the USA. Cogeneration systems offer an opportunity to meet a building's electrical and thermal demands from a single energy source. To answer the question of what is the most beneficial and cost effective energy source(s) that can be used to meet the energy demands of the building, optimizations techniques have been implemented in some studies to find the optimum energy system based on reducing cost and maximizing revenues. Due to the significant environmental impacts that can result from meeting the energy demands in buildings, building design should incorporate environmental criteria in the decision making criteria. The objective of this research is to develop a framework and model to optimize a building's operation by integrating congregation systems and utility systems in order to meet the electrical, heating, and cooling demand by considering the potential life cycle environmental impact that might result from meeting those demands as well as the economical implications. Two LCA Optimization models have been developed within a framework that uses hourly building energy data, life cycle assessment (LCA), and mixed-integer linear programming (MILP). The objective functions that are used in the formulation of the problems include: (1) Minimizing life cycle primary energy consumption, (2) Minimizing global warming potential, (3) Minimizing tropospheric ozone precursor potential, (4) Minimizing acidification potential, (5) Minimizing NOx, SO 2 and CO2, and (6) Minimizing life cycle costs, considering a study period of ten years and the lifetime of equipment. The two LCA optimization models can be used for: (a) long term planning and operational analysis in buildings by analyzing the hourly energy use of a building during a day and (b) design and quick analysis of building operation based on periodic analysis of energy use of a building in a year. A Pareto-optimal frontier is also derived, which defines the minimum cost required to achieve any level of environmental emission or primary energy usage value or inversely the minimum environmental indicator and primary energy usage value that can be achieved and the cost required to achieve that value.

Integrated collaborative care for major depression comorbid with a poor prognosis cancer (SMaRT Oncology-3): a multicentre randomised controlled trial in patients with lung cancer.

PubMed

Walker, Jane; Hansen, Christian Holm; Martin, Paul; Symeonides, Stefan; Gourley, Charlie; Wall, Lucy; Weller, David; Murray, Gordon; Sharpe, Michael

2014-09-01

The management of depression in patients with poor prognosis cancers, such as lung cancer, creates specific challenges. We aimed to assess the efficacy of an integrated treatment programme for major depression in patients with lung cancer compared with usual care. Symptom Management Research Trials (SMaRT) Oncology-3 is a parallel-group, multicentre, randomised controlled trial. We enrolled patients with lung cancer and major depression from three cancer centres and their associated clinics in Scotland, UK. Participants were randomly assigned in a 1:1 ratio to the depression care for people with lung cancer treatment programme or usual care by a database software algorithm that used stratification (by trial centre) and minimisation (by age, sex, and cancer type) with allocation concealment. Depression care for people with lung cancer is a manualised, multicomponent collaborative care treatment that is systematically delivered by a team of cancer nurses and psychiatrists in collaboration with primary care physicians. Usual care is provided by primary care physicians. The primary outcome was depression severity (on the Symptom Checklist Depression Scale [SCL-20], range 0-4) averaged over the patient's time in the trial (up to a maximum of 32 weeks). Trial statisticians and data collection staff were masked to treatment allocation, but patients and clinicians could not be masked to the allocations. Analyses were by intention to treat. This trial is registered with Current Controlled Trials, number ISRCTN75905964. 142 participants were recruited between Jan 5, 2009, and Sept 9, 2011; 68 were randomly allocated to depression care for people with lung cancer and 74 to usual care. 43 (30%) of 142 patients had died by 32 weeks, all of which were cancer-related deaths. No intervention-related serious adverse events occurred. 131 (92%) of 142 patients provided outcome data (59 in the depression care for people with lung cancer group and 72 in the usual care group) and were included in the intention-to-treat primary analysis. Average depression severity was significantly lower in patients allocated to depression care for people with lung cancer (mean score on the SCL-20 1·24 [SD 0·64]) than in those allocated to usual care (mean score 1·61 [SD 0·58]); difference -0·38 (95% CI -0·58 to -0·18); standardised mean difference -0·62 (95% CI -0·94 to -0·29). Self-rated depression improvement, anxiety, quality of life, role functioning, perceived quality of care, and proportion of patients achieving a 12-week treatment response were also significantly better in the depression care for people with lung cancer group than in the usual care group. Our findings suggest that major depression can be treated effectively in patients with a poor prognosis cancer; integrated depression care for people with lung cancer was substantially more efficacious than was usual care. Larger trials are now needed to estimate the effectiveness and cost-effectiveness of this care programme in this patient population, and further adaptation of the treatment will be necessary to address the unmet needs of patients with major depression and even shorter life expectancy. Cancer Research UK and Chief Scientist Office of the Scottish Government. Copyright © 2014 Elsevier Ltd. All rights reserved.

Green Walls as an Approach in Grey Water Treatment

NASA Astrophysics Data System (ADS)

Rysulova, Martina; Kaposztasova, Daniela; Vranayova, Zuzana

2017-10-01

Grey water contributes significantly to waste water parameters such as biochemical oxygen demand (BOD), chemical oxygen demand (COD), total suspended solids (TSS), total phosphorus (Ptotal), total nitrogen (Ntotal), ammonium, boron, metals, salts, surfactants, synthetic chemicals, oils and greases, xenobiotic substances and microorganisms. Concentration of these pollutants and the water quality highlights the importance of treatment process in grey water systems. Treatment technologies operating under low energy and maintenance are usually preferred, since they are more cost effective for users. Treatment technologies based on natural processes represent an example of such technology including vegetated wall. Main aim of this paper is to introduce the proposal of vegetated wall managing grey water and brief characteristic of proposed system. Is expected that prepared experiment will establish the purifying ability and the potential of green wall application as an efficient treatment technology.

A network approach to decentralized coordination of energy production-consumption grids.

PubMed

Omodei, Elisa; Arenas, Alex

2018-01-01

Energy grids are facing a relatively new paradigm consisting in the formation of local distributed energy sources and loads that can operate in parallel independently from the main power grid (usually called microgrids). One of the main challenges in microgrid-like networks management is that of self-adapting to the production and demands in a decentralized coordinated way. Here, we propose a stylized model that allows to analytically predict the coordination of the elements in the network, depending on the network topology. Surprisingly, almost global coordination is attained when users interact locally, with a small neighborhood, instead of the obvious but more costly all-to-all coordination. We compute analytically the optimal value of coordinated users in random homogeneous networks. The methodology proposed opens a new way of confronting the analysis of energy demand-side management in networked systems.

Recent development in the application of alternative sterilization technologies to prepared dishes: A review.

PubMed

Huang, Mengsha; Zhang, Min; Bhandari, Bhesh

2018-01-23

Sterilization is one of the most effective food preservation methods. Conventional thermal sterilization commonly used in food industry usually causes the deterioration of food quality. Flavor, aroma, and texture, among other attributes, are significantly affected by thermal sterilization. However, demands of consumers for nutritious and safe dishes with a minimum change in their original textural and sensory properties are growing rapidly. In order to meet these demands, new approaches have been explored in the last few years to extend the shelf-life of dishes. This review discusses advantages and disadvantages of currently available physical sterilization technologies, including irradiation (eg. Gamma rays, X-rays, e-beams), microwave and radio frequency when used in prepared dishes. The preservation effect of these technologies on prepared dishes are normally evaluated by microbiological and sensory analyses.

Communication Planning for Effective Nutrition Programs.

ERIC Educational Resources Information Center

Colle, Royal D.

Primary health and nutrition have been linked with communication in a variety of well-publicized projects. This partnership between communication and nutrition was made necessary by the confrontation between an expanded demand for services and limited resources for meeting the demand. Senior officials have a substantial role to play in seeing that…

Summary Report. Indiana College-Level Manpower Study Report Number 8.

ERIC Educational Resources Information Center

Greenberg, Robert M.

Selected findings of seven previously published reports of the College-Level Manpower Study are summarized. Factors involving both manpower supply and demand were investigated and educational and occupational areas in which major supply/demand imbalances exist were determined. The primary goal was to investigate the manpower supply/demand…

Urea cycle disorders: a case report of a successful treatment with liver transplant and a literature review.

PubMed

Foschi, Francesco Giuseppe; Morelli, Maria Cristina; Savini, Sara; Dall'Aglio, Anna Chiara; Lanzi, Arianna; Cescon, Matteo; Ercolani, Giorgio; Cucchetti, Alessandro; Pinna, Antonio Daniele; Stefanini, Giuseppe Francesco

2015-04-07

The urea cycle is the final pathway for nitrogen metabolism. Urea cycle disorders (UCDs) include a variety of genetic defects, which lead to inefficient urea synthesis. Elevated blood ammonium level is usually dominant in the clinical pattern and the primary manifestations affect the central nervous system. Herein, we report the case of a 17-year-old girl who was diagnosed with UCD at the age of 3. Despite a controlled diet, she was hospitalized several times for acute attacks with recurrent life risk. She came to our attention for a hyperammonemic episode. We proposed an orthotopic liver transplant (OLT) as a treatment; the patient and her family were in complete agreement. On February 28, 2007, she successfully received a transplant. Following the surgery, she has remained well, and she is currently leading a normal life. Usually for UCDs diet plays the primary therapeutic role, while OLT is often considered as a last resort. Our case report and the recent literature data on the quality of life and prognosis of traditionally treated patients vs OLT patients, support OLT as a primary intervention to prevent life-threatening acute episodes and chronic mental impairment.

Demanding stories: television coverage of sustainability, climate change and material demand

PubMed Central

2017-01-01

This paper explores the past, present and future role of broadcasting, above all via the medium of television, in shaping how societies talk, think about and act on climate change and sustainability issues. The paper explores these broad themes via a focus on the important but relatively neglected issue of material demand and opportunities for its reduction. It takes the outputs and decision-making of one of the world's most influential broadcasters, the BBC, as its primary focus. The paper considers these themes in terms of stories, touching on some of the broader societal frames of understanding into which they can be grouped. Media decision-makers and producers from a range of genres frequently return to the centrality of ‘story’ in the development, commissioning and production of an idea. With reference to specific examples of programming, and drawing on interviews with media practitioners, the paper considers the challenges of generating broadcast stories that can inspire engagement in issues around climate change, and specifically material demand. The concluding section proposes actions and approaches that might help to establish material demand reduction as a prominent way of thinking about climate change and environmental issues more widely. This article is part of the themed issue ‘Material demand reduction’. PMID:28461439

A future Demand Side Management (DSM) opportunity for utility as variable renewable penetrate scale up using agriculture.

NASA Astrophysics Data System (ADS)

Ines, A.; Bhattacharjee, A.; Modi, V.; Robertson, A. W.; Lall, U.; Kocaman Ayse, S.; Chaudhary, S.; Kumar, A.; Ganapathy, A.; Kumar, A.; Mishra, V.

2015-12-01

Energy demand management, also known as demand side management (DSM), is the modification of consumer demand for energy through various methods such as smart metering, incentive based schemes, payments for turning off loads or rescheduling loads. Usually, the goal of demand side management is to encourage the consumer to use less power during periods of peak demand, or to move the time of energy use to off-peak times. Peak demand management does not necessarily decrease total energy consumption, but could be expected to reduce the need for investments in networks and/or power plants for meeting peak demands. Electricity use can vary dramatically on short and medium time frames, and the pricing system may not reflect the instantaneous cost as additional higher-cost that are brought on-line. In addition, the capacity or willingness of electricity consumers to adjust to prices by altering elasticity of demand may be low, particularly over short time frames. In the scenario of Indian grid setup, the retail customers do not follow real-time pricing and it is difficult to incentivize the utility companies for continuing the peak demand supply. A question for the future is how deeper penetration of renewable will be handled? This is a challenging problem since one has to deal with high variability, while managing loss of load probabilities. In the case of managing the peak demand using agriculture, in the future as smart metering matures with automatic turn on/off for a pump, it will become possible to provide an ensured amount of water or energy to the farmer while keeping the grid energized for 24 hours. Supply scenarios will include the possibility of much larger penetration of solar and wind into the grid. While, in absolute terms these sources are small contributors, their role will inevitably grow but DSM using agriculture could help reduce the capital cost. The other option is of advancing or delaying pump operating cycle even by several hours, will still ensure soil moisture requirements met while, balancing the overall system load with generation, reducing critical power mismatches. Through this presentation the author will describe different techniques and results from field experiments in India.

Improving the local relevance of large scale water demand predictions: the way forward

NASA Astrophysics Data System (ADS)

Bernhard, Jeroen; Reynaud, Arnaud; de Roo, Ad

2016-04-01

Securing adequate availability of fresh water is of vital importance for socio-economic development of present and future Europe. Due to strong heterogeneity in climate conditions, some regions receive an abundant supply of water, where other areas almost completely depend on limited river discharge from upstream catchments. Furthermore, water demand differs greatly between regions due to differences in population density and local presence of intensive water using industries and agriculture. This results in many situations all across Europe where competition between water users translates into relative scarcity and economic damage. Additionally it is expected that inter-related economic and demographic developments, as well as climate change are to only further increase the need for efficient management of our water resources in the future. Successful policy making for such complex problems requires a good understanding of the system and reliable forecasting of conditions. The extent and complexity of the water use system however, stands in high contrast with the poor state of available data and lack of reliable predictions for this multi-disciplinary topic. Although the matching of available water to its demand is a European-wide problem, the amount of data with pan-European coverage is limited and usually with a national resolution at best. This is hindering researchers and policy makers because it usually makes large scale water demand predictions little relevant due to the strong regional heterogenic nature of the problem. We present in our study a first attempt of European-wide water demand predictions based on consistent regional data and econometric methods for the household and industry sector. We gathered data on water consumption, water prices and other relevant variables at the highest spatial detail available from national statistical offices and other organizational bodies. This database provides the most detailed up to date picture of present water use and water prices. Subsequently, econometric estimates allow us to make a monetary valuation of water and identify the dominant drivers of domestic and industrial water demand per country. Combined with socio-economic, demographic and climate scenarios we made predictions for future Europe. Since this is a first attempt we obtained mixed results between countries when it comes to data availability and therefore model uncertainty. For some countries we have been able to develop robust predictions based on vast amounts of data while some other countries proved more challenging. We do feel however, that large scale predictions based on regional data are the way forward to provide relevant scientific policy support. In order to improve on our work it is imperative to further expand our database of consistent regional data. We are looking forward to any kind of input and would be very interested in sharing our data to collaborate towards a better understanding of the water use system.

Effectiveness of collaborative stepped care for anxiety disorders in primary care: a pragmatic cluster randomised controlled trial.

PubMed

Muntingh, Anna; van der Feltz-Cornelis, Christina; van Marwijk, Harm; Spinhoven, Philip; Assendelft, Willem; de Waal, Margot; Adèr, Herman; van Balkom, Anton

2014-01-01

Collaborative stepped care (CSC) may be an appropriate model to provide evidence-based treatment for anxiety disorders in primary care. In a cluster randomised controlled trial, the effectiveness of CSC compared to care as usual (CAU) for adults with panic disorder (PD) or generalised anxiety disorder (GAD) in primary care was evaluated. Thirty-one psychiatric nurses who provided their services to 43 primary care practices in the Netherlands were randomised to deliver CSC (16 psychiatric nurses, 23 practices) or CAU (15 psychiatric nurses, 20 practices). CSC was provided by the psychiatric nurses (care managers) in collaboration with the general practitioner and a consultant psychiatrist. The intervention consisted of 3 steps, namely guided self-help, cognitive behavioural therapy and antidepressants. Anxiety symptoms were measured with the Beck Anxiety Inventory (BAI) at baseline and after 3, 6, 9 and 12 months. We recruited 180 patients with a DSM-IV diagnosis of PD or GAD, of whom 114 received CSC and 66 received usual primary care. On the BAI, CSC was superior to CAU [difference in gain scores from baseline to 3 months: -5.11, 95% confidence interval (CI) -8.28 to -1.94; 6 months: -4.65, 95% CI -7.93 to -1.38; 9 months: -5.67, 95% CI -8.97 to -2.36; 12 months: -6.84, 95% CI -10.13 to -3.55]. CSC, with guided self-help as a first step, was more effective than CAU for primary care patients with PD or GAD.

Primary Care Collaborative Memory Clinics: Building Capacity for Optimized Dementia Care.

PubMed

Lee, Linda; Hillier, Loretta M; Molnar, Frank; Borrie, Michael J

2017-01-01

Increasingly, primary care collaborative memory clinics (PCCMCs) are being established to build capacity for person-centred dementia care. This paper reflects on the significance of PCCMCs within the system of care for older adults, supported with data from ongoing evaluation studies. Results highlight timelier access to assessment with a high proportion of patients being managed in primary care within a person-centred approach to care. Enhancing primary care capacity for dementia care with interprofessional and collaborative care will strengthen the system's ability to respond to increasing demands for service and mitigate the growth of wait times to access geriatric specialist assessment.

Development of a Decision Model for Selection of Appropriate Timely Delivery Techniques for Highway Projects

DOT National Transportation Integrated Search

2009-04-01

"The primary umbrella method used by the Oregon Department of Transportation (ODOT) to ensure on-time performance in standard construction contracting is liquidated damages. The assessment value is usually a matter of some judgment. In practice...

[Policies and innovation in mental healthcare: limits to decoupling from the performance of the SUS].

PubMed

Ribeiro, José Mendes; Inglez-Dias, Aline

2011-12-01

We studied Brazilian policies on mental health with respect to normative, supply and demand and financing aspects. We concluded that the sustainability of innovations in psychiatric reform depends on enhanced financing and integration with primary care community services, on the overall performance of SUS and the reduction of autonomous and exclusive services in primary care. There is high and rising pressure in demand for services measured in DALY and the incidence of disease. The reduction observed in psychiatric beds was accompanied by the systemic reduction, though with selective reduction for psychiatric hospitalizations. CAPS services have institutional limits due to the model adopted of direct public administration and local government capacity. Secondary data available show that: (i) SUS has a virtual monopoly on general outpatient and hospital services; (ii) mental health specialists belong mostly to SUS; (iii) most mental health services are outpatient services; (iv) few CAPS have day-bed services available; and (v) there is reduced federal financing for these innovations.

An analytics approach to designing patient centered medical homes.

PubMed

Ajorlou, Saeede; Shams, Issac; Yang, Kai

2015-03-01

Recently the patient centered medical home (PCMH) model has become a popular team based approach focused on delivering more streamlined care to patients. In current practices of medical homes, a clinical based prediction frame is recommended because it can help match the portfolio capacity of PCMH teams with the actual load generated by a set of patients. Without such balances in clinical supply and demand, issues such as excessive under and over utilization of physicians, long waiting time for receiving the appropriate treatment, and non-continuity of care will eliminate many advantages of the medical home strategy. In this paper, by using the hierarchical generalized linear model with multivariate responses, we develop a clinical workload prediction model for care portfolio demands in a Bayesian framework. The model allows for heterogeneous variances and unstructured covariance matrices for nested random effects that arise through complex hierarchical care systems. We show that using a multivariate approach substantially enhances the precision of workload predictions at both primary and non primary care levels. We also demonstrate that care demands depend not only on patient demographics but also on other utilization factors, such as length of stay. Our analyses of a recent data from Veteran Health Administration further indicate that risk adjustment for patient health conditions can considerably improve the prediction power of the model.

On-demand tramadol hydrochloride use in premature ejaculation treatment.

PubMed

Kaynar, Mehmet; Kilic, Ozcan; Yurdakul, Talat

2012-01-01

To determine the efficacy of tramadol in premature ejaculation (PE) treatment compared with placebo. A single-blind, placebo-controlled, crossover study was conducted with 60 lifelong (primary) patients with PE. The patients were randomized into 2 groups, each consisting of 30 patients, who took tramadol or placebo on demand. PE was defined as an intravaginal ejaculation latency time of ≤60 seconds in 90% of intercourse episodes. The efficacy of the drugs was assessed using the intravaginal ejaculation latency time, ability of ejaculation control, and sexual satisfaction scores after an 8-week treatment period. All participants completed the study voluntarily. Two groups were similar in terms of the patient demographics. Increases in the intravaginal ejaculation latency time, ability of ejaculation control, and sexual satisfaction score between the placebo and tramadol groups were compared with the baseline values in both groups. At the end of study period, the tramadol group had significantly (P<.001) greater values for all 3 parameters compared with those in the placebo group. On-demand use of low-dose tramadol is effective for lifelong PE. Currently, selective seratonin reuptake inhibitors such as dapoxetine, are a more popular treatment option for PE. However, tramadol might be considered an alternative agent for primary PE treatment. Copyright © 2012 Elsevier Inc. All rights reserved.

Variable primary producer responses to nutrient and temperature manipulations in mesocosms: temperature usually trumps nutrient effects

EPA Science Inventory

Mesocosm experiments have been used to evaluate the impacts of nutrient loading on estuarine plant communities in order to develop nutrient response relationships. Mesocosm eutrophication studies tend to focus on long residence time systems. In the Pacific Northwest, many estuari...

7 CFR 201.56-9 - Mallow family, Malvaceae.

Code of Federal Regulations, 2011 CFR

2011-01-01

... seed: Cotton, kenaf, and okra. (a) General description. (1) Germination habit: Epigeal dicot. (2) Food... develop on the hypocotyl in cotton. (4) Root system: A primary root, with secondary roots usually developing within the test period. Areas of yellowish pigmentation may develop on the root in cotton. (b...

7 CFR 201.56-9 - Mallow family, Malvaceae.

Code of Federal Regulations, 2010 CFR

2010-01-01

... seed: Cotton, kenaf, and okra. (a) General description. (1) Germination habit: Epigeal dicot. (2) Food... develop on the hypocotyl in cotton. (4) Root system: A primary root, with secondary roots usually developing within the test period. Areas of yellowish pigmentation may develop on the root in cotton. (b...

Does capitation matter? Impacts on access, use, and quality.

PubMed

Zuvekas, Samuel H; Hill, Steven C

2004-01-01

Provider capitation may constrain costs, but it also may reduce access and quality of care. We examine the impacts of capitating the usual source of care of enrollees in health maintenance organizations (HMOs). We account for the endogeneity of capitation and other characteristics using generalized methods of moments (GMM) estimation on a sample from the Medical Expenditure Panel Survey for 1996 and 1997. Being organized as a group/staff HMO generally has stronger impact on access and quality than capitation. Capitation by itself may increase access to consumers' usual sources of care, improve primary preventive care, and reduce coordination, but estimates with GMM were not statistically significant.

Effectiveness of an integrated telehealth service for patients with depression: a pragmatic randomised controlled trial of a complex intervention.

PubMed

Salisbury, Chris; O'Cathain, Alicia; Edwards, Louisa; Thomas, Clare; Gaunt, Daisy; Hollinghurst, Sandra; Nicholl, Jon; Large, Shirley; Yardley, Lucy; Lewis, Glyn; Foster, Alexis; Garner, Katy; Horspool, Kimberley; Man, Mei-See; Rogers, Anne; Pope, Catherine; Dixon, Padraig; Montgomery, Alan A

2016-06-01

Many countries are exploring the potential of telehealth interventions to manage the rising number of people with chronic disorders. However, evidence of the effectiveness of telehealth is ambiguous. Based on an evidence-based conceptual framework, we developed an integrated telehealth service (the Healthlines Service) for chronic disorders and assessed its effectiveness in patients with depression. We aimed to compare the Healthlines Depression Service plus usual care with usual care alone. This study was a pragmatic, multicentre, randomised controlled trial with participants recruited from 43 general practices in three areas of England. To be eligible, participants needed to have access to the internet and email, a Patient Health Questionnaire 9 (PHQ-9) score of at least 10, and a confirmed diagnosis of depression. Participants were individually assigned (1:1) to either the Healthlines Depression Service plus usual care or usual care alone. Random assignment was done by use of a web-based automated randomisation system, stratified by site and minimised by practice and PHQ-9 score. Participants were aware of their allocation, but outcomes were analysed masked. The Healthlines Service consisted of regular telephone calls from non-clinical, trained health advisers who followed standardised scripts generated by interactive software. After an initial assessment and goal-setting telephone call, the advisers called each participant on six occasions over 4 months, and then made up to three more calls at intervals of roughly 2 months to provide reinforcement and to detect relapse. Advisers supported participants in the use of online resources (including computerised cognitive behavioural therapy) and sought to encourage healthier lifestyles, optimise medication, and improve treatment adherence. The primary outcome was the proportion of participants responding to the intervention (defined as PHQ-9 <10 and reduction in PHQ-9 of ≥5 points) at 4 months after randomisation. The primary analysis was based on the intention-to-treat principle without imputation and all serious adverse events were investigated. This trial is registered with Current Controlled Trials, number ISRCTN 14172341. Between July 24, 2012, and July 31, 2013, we recruited 609 participants, randomly assigning 307 to the Healthlines Service plus usual care and 302 to usual care. Primary outcome data were available for 525 (86%) participants. At 4 months, 68 (27%) of 255 individuals in the intervention group had a treatment response compared with 50 (19%) of 270 individuals in the usual care group (adjusted odds ratio 1·7, 95% CI 1·1-2·5, p=0·019). Compared with usual care alone, intervention participants reported improvements in anxiety, better access to support and advice, greater satisfaction with the support they received, and improvements in self-management and health literacy. During the trial, 70 adverse events were reported by participants, one of which was related to the intervention (increased anxiety from discussing depression) and was not serious. This telehealth service based on non-clinically trained health advisers supporting patients in use of internet resources was both acceptable and effective compared with usual care. Our results provide support for the development and assessment of similar interventions in other chronic disorders to expand care provision. National Institute for Health Research (NIHR). Copyright © 2016 Salisbury et al. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd.. All rights reserved.

Primary health care lessons from the northeast of Brazil: the Agentes de Saúde Program.

PubMed

Cufino Svitone, E; Garfield, R; Vasconcelos, M I; Araujo Craveiro, V

2000-05-01

Market-led economic reforms are usually viewed as being in conflict with government-stimulated socioeconomic development for disadvantaged groups. Nevertheless, Ceará, a poor state in the Northeast of Brazil, has since 1987 pursued both of those strategies simultaneously. One part of that approach has been a program of nurse-directed auxiliary health workers serving about 5 million people--almost all the persons outside the capital city and half of those in the capital. The system requires that the auxiliaries, called agentes de saúde, live in the local communities that they serve. The health agents visit each home once a month to carry out a small number of priority health activities. While health agent positions are in high demand, the minimum-wage salary that the agents receive makes up only a small portion of the state budget. A key aspect of the system is timely and comprehensive information, which is based on agent visits and is managed by trained nurses. Since the health agents system was launched, there has been a rapid decline in infant mortality, a rapid rise in immunization, identification of bottlenecks limiting the utilization of other medical resources, and timely interventions in times of crisis. The health agents system has combined administrative decentralization with financial centralization during a period of electoral democratization. The system has strengthened Ceará's commitment to primary care even as market-oriented changes have reduced the overall role of government. The Ceará program is being copied throughout the Northeast and other regions of Brazil. The key role that nurses play in the Ceará program in organizing and leading a system of basic primary care in poor neighborhoods and rural areas may provide useful lessons for other countries. In addition, Ceará does not have many of the favorable characteristics of other countries that have successfully invested in primary health care. Ceará thus represents a more achievable model for other countries, where, like Brazil, income, educational levels, and land tenure equity are limited.

Randomised controlled feasibility trial of a web-based weight management intervention with nurse support for obese patients in primary care

PubMed Central

2014-01-01

Background There is a need for cost-effective weight management interventions that primary care can deliver to reduce the morbidity caused by obesity. Automated web-based interventions might provide a solution, but evidence suggests that they may be ineffective without additional human support. The main aim of this study was to carry out a feasibility trial of a web-based weight management intervention in primary care, comparing different levels of nurse support, to determine the optimal combination of web-based and personal support to be tested in a full trial. Methods This was an individually randomised four arm parallel non-blinded trial, recruiting obese patients in primary care. Following online registration, patients were randomly allocated by the automated intervention to either usual care, the web-based intervention only, or the web-based intervention with either basic nurse support (3 sessions in 3 months) or regular nurse support (7 sessions in 6 months). The main outcome measure (intended as the primary outcome for the main trial) was weight loss in kg at 12 months. As this was a feasibility trial no statistical analyses were carried out, but we present means, confidence intervals and effect sizes for weight loss in each group, uptake and retention, and completion of intervention components and outcome measures. Results All randomised patients were included in the weight loss analyses (using Last Observation Carried Forward). At 12 months mean weight loss was: usual care group (n = 43) 2.44 kg; web-based only group (n = 45) 2.30 kg; basic nurse support group (n = 44) 4.31 kg; regular nurse support group (n = 47) 2.50 kg. Intervention effect sizes compared with usual care were: d = 0.01 web-based; d = 0.34 basic nurse support; d = 0.02 regular nurse support. Two practices deviated from protocol by providing considerable weight management support to their usual care patients. Conclusions This study demonstrated the feasibility of delivering a web-based weight management intervention supported by practice nurses in primary care, and suggests that the combination of the web-based intervention with basic nurse support could provide an effective solution to weight management support in a primary care context. Trial registration Current Controlled Trials ISRCTN31685626. PMID:24886516

Lives of Quality in the Face of Challenge in Israel

ERIC Educational Resources Information Center

Neikrug, S.; Roth, D.; Judes, J.

2011-01-01

Purpose: The purpose of this study is to describe and analyse the quality of life of Israeli families raising a child with a disability while challenged with all the usual demands of family life. Methods: Respondents were main caregivers of 103 children with disability receiving services at Beit Issie Shapiro, a service agency in Israel. The…

Embedded, real-time UAV control for improved, image-based 3D scene reconstruction

Treesearch

Jean Liénard; Andre Vogs; Demetrios Gatziolis; Nikolay Strigul

2016-01-01

Unmanned Aerial Vehicles (UAVs) are already broadly employed for 3D modeling of large objects such as trees and monuments via photogrammetry. The usual workflow includes two distinct steps: image acquisition with UAV and computationally demanding postflight image processing. Insufficient feature overlaps across images is a common shortcoming in post-flight image...

The Past as Prologue: Examining the Consequences of Business as Usual. Center Paper 01-93.

ERIC Educational Resources Information Center

Jones, Dennis P.; And Others

This study examined the ability of California to meet increased demand for postsecondary education without significantly altering the basic historical assumptions and policies that have governed relations between the state and its institutions of higher learning. Results of a series of analyses that estimated projected enrollments and costs under…

Policy Directions for U. S. Agriculture; Long-Range Choices in Farming and Rural Living.

ERIC Educational Resources Information Center

Clawson, Marion

A comprehensive view of agriculture is presented in this volume written to aid critical re-examination of long-range agricultural policy. Farm people, rural institutions and services, rural towns, the spatial organization of agriculture, and its capital structure, in addition to the usual subjects of agricultural output, demand, trade, price, and…

Communication Consulting from Academe to the "Real World."

ERIC Educational Resources Information Center

Seiler, William J.; Dunning, David

Before adding consulting, training, or other work to the usual responsibilities of teaching, academicians must make a number of decisions. These include whether to work in or outside of academe, how much time they have available, whether they can meet the physical and mental demands of consulting, how to arrange for initial contacts, and how much…

The Use of Metaphors as a Parametric Design Teaching Model: A Case Study

ERIC Educational Resources Information Center

Agirbas, Asli

2018-01-01

Teaching methodologies for parametric design are being researched all over the world, since there is a growing demand for computer programming logic and its fabrication process in architectural education. The computer programming courses in architectural education are usually done in a very short period of time, and so students have no chance to…

[Multiple recurrent eccrine porocarcinoma with inguinal metastasis. A case report].

PubMed

Acosta-Arencibia, Aida; Abrante-Expósito, Begoña; Ramos-Gordillo, Matilde

2016-01-01

Eccrine porocarcinoma, first described in 1963, is a rare malignant lesion arising from the eccrine sweat glands. It is usually a primary tumour, or even more common, a malignant degeneration of an eccrine poroma. It usually affects older persons and is located most commonly on the lower extremities. About 20% of eccrine porocarcinoma will recur after treatment. The treatment is wide local excision of the primary lesion. This uncommon skin tumour has a locally aggressive behaviour and a high recurrence rate. An 82 year-old man presenting with multiple recurrent eccrine porocarcinoma with inguinal metastasis. The treatment was a radical excision and inguinal lymphadenectomy. There were no postoperative complications, but there was local recurrence after six months. Early diagnosis and wide excision is the best way to achieve a good prognosis, due to the aggressiveness of this tumour. Copyright © 2015. Published by Masson Doyma México S.A.

[Demand for cigarettes and tax increases in El Salvador].

PubMed

Ramos-Carbajales, Alejandro; González-Rozada, Martín; Vallarino, Hugo

2016-10-01

Analyze short- and long-term elasticities of demand for cigarettes in El Salvador as a tool for supporting recommendations on tax increases to reduce prevalence and consumption through price increases. Demand for cigarettes in El Salvador was analyzed through an econometric time-series model using a database from El Salvador's General Directorate of Internal Taxes (DGII) and the General Directorate of Statistics and Census (DIGESTYC). The analysis period was quarterly: 2000Q1-2012Q4. The usual tests were done to prevent a spurious econometric estimation. It was found that the variables volume sales, actual sale prices, and actual per capita income exhibited first-order cointegration; this result makes it possible to use an error correction model with short- and long-term elasticity estimates. Only long-term elasticities were found to be statistically significant to 5%. Results show long-term price elasticity (5 quarters) of -0.9287 and income price elasticity of 0.9978. Absolute price elasticity is somewhat high, although it is within the levels estimated in other studies in low per-capita income countries. A tax increase from a base amount of US$1.04 per pack of 20 cigarettes to US$1.66 within three years would reduce demand by 20% to 31% and would increase tax revenues by 9% to 22%.

Non Hodgkin lymphoma of the ureter: a rare disease.

PubMed

Celia, Antonio; De Stefani, Stefano; Bruschi, Morgan; Micali, Salvatore; Sighinolfi, Maria Chiara; Bianchi, Giampaolo

2004-12-01

Non urotelial malignant neoplasm of the ureter has been rarely described, usually arising from muscular, vascular and nervous tissue. Primary lymphoma of the ureter is an uncommon finding; we report a case of primary Non Hodgkin Lymphoma of the ureter in young woman.

Telemonitoring and/or self-monitoring of blood pressure in hypertension (TASMINH4): protocol for a randomised controlled trial.

PubMed

Franssen, Marloes; Farmer, Andrew; Grant, Sabrina; Greenfield, Sheila; Heneghan, Carl; Hobbs, Richard; Hodgkinson, James; Jowett, Susan; Mant, Jonathan; Martin, Una; Milner, Siobhan; Monahan, Mark; Ogburn, Emma; Perera-Salazar, Rafael; Schwartz, Claire; Yu, Ly-Mee; McManus, Richard J

2017-02-13

Self-monitoring of hypertension is associated with lower systolic blood pressure (SBP). However, evidence for the use of self-monitoring to titrate antihypertensive medication by physicians is equivocal. Furthermore, there is some evidence for the efficacy of telemonitoring in the management of hypertension but it is not clear what this adds over and above self-monitoring. This trial aims to evaluate whether GP led antihypertensive titration using self-monitoring results in lower SBP compared to usual care and whether telemonitoring adds anything to self-monitoring alone. This will be a pragmatic primary care based, unblinded, randomised controlled trial of self-monitoring of BP with or without telemonitoring compared to usual care. Eligible patients will have poorly controlled hypertension (>140/90 mmHg) and will be recruited from primary care. Participants will be individually randomised to either usual care, self-monitoring alone, or self-monitoring with telemonitoring. The primary outcome of the trial will be difference in clinic SBP between intervention and control groups at 12 months adjusted for baseline SBP, gender, BP target and practice. At least 1110 patients will be sufficient to detect a difference in SBP between self-monitoring with or without telemonitoring and usual care of 5 mmHg with 90% power with an adjusted alpha of 0.017 (2-sided) to adjust for all three pairwise comparisons. Other outcomes will include adherence of anti-hypertensive medication, lifestyle behaviours, health-related quality of life, and adverse events. An economic analysis will consider both within trial costs and a model extrapolating the results thereafter. A qualitative sub study will gain insights into the views, experiences and decision making processes of patients and health care professionals focusing on the acceptability of self-monitoring and telemonitoring in the routine management of hypertension. The results of the trial will be directly applicable to primary care in the UK. If successful, self-monitoring of BP in people with hypertension would be applicable to hundreds of thousands of individuals in the UK. ISRCTN 83571366 . Registered 17 July 2014.

A Comparison of the Effects of 2 Types of Massage and Usual Care on Chronic Low Back Pain: A Randomized, Controlled Trial

PubMed Central

Cherkin, Daniel C.; Sherman, Karen J.; Kahn, Janet; Wellman, Robert; Cook, Andrea J.; Johnson, Eric; Erro, Janet; Delaney, Kristin; Deyo, Richard A.

2013-01-01

Background Few studies have evaluated the effectiveness of massage for back pain. Objective To evaluate the effectiveness of two types of massage for chronic back pain. Design Single-blind parallel group randomized controlled trial. Setting Integrated health care delivery system in Seattle area. Patients 401 persons 20 to 65 years of age with non-specific chronic low back pain. Interventions Ten treatments over 10 weeks of Structural Massage (intended to identify and alleviate musculoskeletal contributors to pain through focused soft-tissue manipulation) (n=132) or Relaxation Massage (intended to decrease pain and dysfunction by inducing relaxation) (n=136). Treatments provided by 27 experienced licensed massage therapists. Comparison group received continued usual care (n=133). Study presented as comparison of usual care with two types of massage. Measurements Primary outcomes were the Roland Disability Questionnaire (RDQ) and the Symptom Bothersomeness scale measured at 10 weeks. Outcomes also measured after 26 and 52 weeks. Results At 10 weeks, the massage groups had similar functional outcomes that were superior to those for usual care. The adjusted mean RDQ scores were 2.9 and 2.4 points lower for the relaxation and structural massage groups, respectively, compared to usual care (95% CIs: [1.8, 4.0] and [1.4, 3.5]). Adjusted mean symptom bothersomeness scores were 1.7 points and 1.4 points lower with relaxation and structural massage, respectively, versus usual care (95% CIs: [1.2, 2.2] and [0.8, 1.9]). The beneficial effects of relaxation massage on function (but not on symptom reduction) persisted at 52 weeks, but were small. Limitations Restricted to single site; therapists and patients not blinded to treatment. Conclusions This study confirms the results of smaller trials that massage is an effective treatment for chronic back pain with benefits lasting at least 6 months, and also finds no evidence of a clinically-meaningful difference in the effectiveness of two distinct types of massage. Primary Funding Source National Center for Complementary and Alternative Medicine PMID:21727288

The Draft National Curriculum for Primary Mathematics

ERIC Educational Resources Information Center

Thompson, Ian

2012-01-01

Draft curriculum documents offer a glimpse of the future. They demand a response as all too often the devil is in the detail. What are the devils and maybe demons that await primary mathematics? This forensic consideration of the content of the draft curriculum for primary mathematics catalogues a lack of evidence to underpin proposals. Is the…

Expert patient self-management program versus usual care in bronchiectasis: a randomized controlled trial.

PubMed

Lavery, Katherine A; O'Neill, Brenda; Parker, Michael; Elborn, J Stuart; Bradley, Judy M

2011-08-01

To investigate the efficacy of a disease-specific Expert Patient Programme (EPP) compared with usual care in patients with bronchiectasis. Proof-of-concept randomized controlled trial. Regional respiratory center. Adult patients (N=64; age, >18y) with a primary diagnosis of bronchiectasis based on a respiratory physician's assessment including a computed tomographic scan. Patients were randomly assigned to an intervention (usual care plus EPP; n=32) or control group (usual care only; n=32). The primary outcome measure was the Chronic Disease Self-efficacy Scale (CDSS). Other outcome measures included the Revised Illness Perception Questionnaire (IPQ-R), the St Georges Respiratory Questionnaire, and standard EPP questionnaires. Data were collected at baseline, postintervention, and 3 and 6 months postintervention. This disease-specific EPP for patients with bronchiectasis significantly improved self-efficacy in 6 of 10 subscales (CDSS subscales: exercise regularly [P=.02]; get information about disease [P=.03]; obtain help from community, family, and friends [P=.06]; communicate with physician [P=.85]; manage disease in general [P=.05]; do chores [P=.04]; social/recreational activities [P=.03]; manage symptoms [P<.01]; manage shortness of breath [P=.08]; control/manage depression [P=.01]) compared with usual care. There was no improvement on IPQ-R score. Patients who received the intervention reported more symptoms and decreased quality of life between 3 and 6 months postintervention and an increase in some components of self reported health care use. Patients receiving the disease-specific EPP indicated they were satisfied with the intervention and learned new self-management techniques. There were no significant differences in lung function over time. This original study indicates that a disease-specific EPP results in short-term improvements in self-efficacy. Based on these positive preliminary findings, a larger adequately powered study is justified to investigate the efficacy of a disease-specific EPP in patients with bronchiectasis. Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Naturalistic assessment of demand for cigarettes, snus, and nicotine gum

PubMed Central

Stein, Jeffrey S.; Wilson, A. George; Koffarnus, Mikhail N.; Judd, Michael C.

2017-01-01

Rationale Behavioral economic measures of demand provide estimates of tobacco product abuse liability and may predict effects of policy-related price regulation on consumption of existing and emerging tobacco products. Objective In the present study, we examined demand for snus, a smokeless tobacco product, in comparison to both cigarettes and medicinal nicotine. We used both a naturalistic method in which participants purchased these products for use outside the laboratory, as well as laboratory-based self-administration procedures. Methods Cigarette smokers (N = 42) used an experimental income to purchase their usual brand of cigarettes and either snus or gum (only one product available per session) across a range of prices, while receiving all products they purchased from one randomly selected price. In a separate portion of the study, participants self-administered these products during laboratory-based, progressive ratio sessions. Result Demand elasticity (sensitivity of purchasing to price) was significantly greater for snus than cigarettes. Elasticity for gum was intermediate between snus and cigarettes but was not significantly different than either. Demand intensity (purchasing unconstrained by price) was significantly lower for gum compared to cigarettes, with no significant difference observed between snus and cigarettes. Results of the laboratory-based, progressive ratio sessions were generally discordant with measures of demand elasticity, with significantly higher “breakpoints” for cigarettes compared to gum and no significant differences between other study products. Moreover, breakpoints and product purchasing were generally uncorrelated across tasks. Conclusions Under naturalistic conditions, snus appears more sensitive to price manipulation than either cigarettes or nicotine gum in existing smokers. PMID:27730273

Randomized, multicenter study: on-demand versus continuous maintenance treatment with esomeprazole in patients with non-erosive gastroesophageal reflux disease.

PubMed

Bayerdörffer, Ekkehard; Bigard, Marc-Andre; Weiss, Werner; Mearin, Fermín; Rodrigo, Luis; Dominguez Muñoz, Juan Enrique; Grundling, Hennie; Persson, Tore; Svedberg, Lars-Erik; Keeling, Nanna; Eklund, Stefan

2016-04-14

Most patients with gastroesophageal reflux disease experience symptomatic relapse after stopping acid-suppressive medication. The aim of this study was to compare willingness to continue treatment with esomeprazole on-demand versus continuous maintenance therapy for symptom control in patients with non-erosive reflux disease (NERD) after 6 months. This multicenter, open-label, randomized, parallel-group study enrolled adults with NERD who were heartburn-free after 4 weeks' treatment with esomeprazole 20 mg daily. Patients received esomeprazole 20 mg daily continuously or on-demand for 6 months. The primary variable was discontinuation due to unsatisfactory treatment. On-demand treatment was considered non-inferior if the upper limit of the one-sided 95 % confidence interval (CI) for the difference between treatments was <10 %. Of 877 patients enrolled, 598 were randomized to maintenance treatment (continuous: n = 297; on-demand: n = 301). Discontinuation due to unsatisfactory treatment was 6.3 % for on-demand and 9.8 % for continuous treatment (difference -3.5 % [90 % CI: -7.1 %, 0.2 %]). In total, 82.1 and 86.2 % of patients taking on-demand and continuous therapy, respectively, were satisfied with the treatment of heartburn and regurgitation symptoms, a secondary variable (P = NS). Mean study drug consumption was 0.41 and 0.91 tablets/day, respectively. Overall, 5 % of the on-demand group developed reflux esophagitis versus none in the continuous group (P < 0.0001). The Gastrointestinal Symptom Rating Scale Reflux dimension was also improved for continuous versus on-demand treatment. Esomeprazole was well tolerated. In terms of willingness to continue treatment, on-demand treatment with esomeprazole 20 mg was non-inferior to continuous maintenance treatment and reduced medication usage in patients with NERD who had achieved symptom control with initial esomeprazole treatment. ClinicalTrials.gov identifier (NCT number): NCT02670642 ; Date of registration: December 2015.

Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial.

PubMed

McManus, Richard J; Mant, Jonathan; Franssen, Marloes; Nickless, Alecia; Schwartz, Claire; Hodgkinson, James; Bradburn, Peter; Farmer, Andrew; Grant, Sabrina; Greenfield, Sheila M; Heneghan, Carl; Jowett, Susan; Martin, Una; Milner, Siobhan; Monahan, Mark; Mort, Sam; Ogburn, Emma; Perera-Salazar, Rafael; Shah, Syed Ahmar; Yu, Ly-Mee; Tarassenko, Lionel; Hobbs, F D Richard

2018-03-10

Studies evaluating titration of antihypertensive medication using self-monitoring give contradictory findings and the precise place of telemonitoring over self-monitoring alone is unclear. The TASMINH4 trial aimed to assess the efficacy of self-monitored blood pressure, with or without telemonitoring, for antihypertensive titration in primary care, compared with usual care. This study was a parallel randomised controlled trial done in 142 general practices in the UK, and included hypertensive patients older than 35 years, with blood pressure higher than 140/90 mm Hg, who were willing to self-monitor their blood pressure. Patients were randomly assigned (1:1:1) to self-monitoring blood pressure (self-montoring group), to self-monitoring blood pressure with telemonitoring (telemonitoring group), or to usual care (clinic blood pressure; usual care group). Randomisation was by a secure web-based system. Neither participants nor investigators were masked to group assignment. The primary outcome was clinic measured systolic blood pressure at 12 months from randomisation. Primary analysis was of available cases. The trial is registered with ISRCTN, number ISRCTN 83571366. 1182 participants were randomly assigned to the self-monitoring group (n=395), the telemonitoring group (n=393), or the usual care group (n=394), of whom 1003 (85%) were included in the primary analysis. After 12 months, systolic blood pressure was lower in both intervention groups compared with usual care (self-monitoring, 137·0 [SD 16·7] mm Hg and telemonitoring, 136·0 [16·1] mm Hg vs usual care, 140·4 [16·5]; adjusted mean differences vs usual care: self-monitoring alone, -3·5 mm Hg [95% CI -5·8 to -1·2]; telemonitoring, -4·7 mm Hg [-7·0 to -2·4]). No difference between the self-monitoring and telemonitoring groups was recorded (adjusted mean difference -1·2 mm Hg [95% CI -3·5 to 1·2]). Results were similar in sensitivity analyses including multiple imputation. Adverse events were similar between all three groups. Self-monitoring, with or without telemonitoring, when used by general practitioners to titrate antihypertensive medication in individuals with poorly controlled blood pressure, leads to significantly lower blood pressure than titration guided by clinic readings. With most general practitioners and many patients using self-monitoring, it could become the cornerstone of hypertension management in primary care. National Institute for Health Research via Programme Grant for Applied Health Research (RP-PG-1209-10051), Professorship to RJM (NIHR-RP-R2-12-015), Oxford Collaboration for Leadership in Applied Health Research and Care, and Omron Healthcare UK. Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.

Effectiveness of Fluticasone Furoate-Vilanterol for COPD in Clinical Practice.

PubMed

Vestbo, Jørgen; Leather, David; Diar Bakerly, Nawar; New, John; Gibson, J Martin; McCorkindale, Sheila; Collier, Susan; Crawford, Jodie; Frith, Lucy; Harvey, Catherine; Svedsater, Henrik; Woodcock, Ashley

2016-09-29

Evidence for the management of chronic obstructive pulmonary disease (COPD) comes from closely monitored efficacy trials involving groups of patients who were selected on the basis of restricted entry criteria. There is a need for randomized trials to be conducted in conditions that are closer to usual clinical practice. In a controlled effectiveness trial conducted in 75 general practices, we randomly assigned 2799 patients with COPD to a once-daily inhaled combination of fluticasone furoate at a dose of 100 μg and vilanterol at a dose of 25 μg (the fluticasone furoate-vilanterol group) or to usual care (the usual-care group). The primary outcome was the rate of moderate or severe exacerbations among patients who had had an exacerbation within 1 year before the trial. Secondary outcomes were the rates of primary care contact (contact with a general practitioner, nurse, or other health care professional) and secondary care contact (inpatient admission, outpatient visit with a specialist, or visit to the emergency department), modification of the initial trial treatment for COPD, and the rate of exacerbations among patients who had had an exacerbation within 3 years before the trial, as assessed in a time-to-event analysis. The rate of moderate or severe exacerbations was significantly lower, by 8.4% (95% confidence interval, 1.1 to 15.2), with fluticasone furoate-vilanterol therapy than with usual care (P=0.02). There was no significant difference in the annual rate of COPD-related contacts to primary or secondary care. There were no significant between-group differences in the rates of the first moderate or severe exacerbation and the first severe exacerbation in the time-to-event analyses. There were no excess serious adverse events of pneumonia in the fluticasone furoate-vilanterol group. The numbers of other serious adverse events were similar in the two groups. In patients with COPD and a history of exacerbations, a once-daily treatment regimen of combined fluticasone furoate and vilanterol was associated with a lower rate of exacerbations than usual care, without a greater risk of serious adverse events. (Funded by GlaxoSmithKline; Salford Lung Study ClinicalTrials.gov number, NCT01551758 .).

Envisioning a Low-Cost Solar Future: Exploring the Potential Impact of Achieving the SunShot 2030 Targets for Photovoltaics

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

Cole, Wesley J; Frew, Bethany A; Gagnon, Pieter J

In the context of recent dramatic solar energy cost reductions, the U.S. Department of Energy set new levelized cost of energy goals for photovoltaics (PV) to achieve by 2030 to enable significantly greater PV adoption: $0.03/kWh for utility-scale, $0.04/kWh for commercial, and $0.05/kWh for residential PV systems. We analyze the potential impacts of achieving these 'SunShot 2030' cost targets for the contiguous United States using the Regional Energy Deployment System (ReEDS) and Distributed Generation (dGen) capacity expansion models. We consider the impacts under a wide range of future conditions. We find that PV could provide 13%-18% of U.S. electricity demandmore » in 2030 and 28%-64% of demand if the SunShot 2030 goals are achieved, with PV deployment increasing in every state. The availability of low-cost storage has the largest impact on projected deployment, followed by natural gas prices and electricity demand. For comparison, PV deployed under a business-as-usual scenario could provide only 5% of generation in 2030 and 17% in 2050. We find that the high levels of PV deployment explored here lead to lower electricity prices and system costs, lower carbon dioxide emissions, lower water consumption, increased renewable energy curtailment, and increased storage deployment compared with the business-as-usual scenario.« less

Toward a Systematic Approach to Generating Demand for Voluntary Medical Male Circumcision: Insights and Results From Field Studies

PubMed Central

Sgaier, Sema K; Baer, James; Rutz, Daniel C; Njeuhmeli, Emmanuel; Seifert-Ahanda, Kim; Basinga, Paulin; Parkyn, Rosie; Laube, Catharine

2015-01-01

By the end of 2014, an estimated 8.5 million men had undergone voluntary medical male circumcision (VMMC) for HIV prevention in 14 priority countries in eastern and southern Africa, representing more than 40% of the global target. However, demand, especially among men most at risk for HIV infection, remains a barrier to realizing the program's full scale and potential impact. We analyzed current demand generation interventions for VMMC by reviewing the available literature and reporting on field visits to programs in 7 priority countries. We present our findings and recommendations using a framework with 4 components: insight development; intervention design; implementation and coordination to achieve scale; and measurement, learning, and evaluation. Most program strategies lacked comprehensive insight development; formative research usually comprised general acceptability studies. Demand generation interventions varied across the countries, from advocacy with community leaders and community mobilization to use of interpersonal communication, mid- and mass media, and new technologies. Some shortcomings in intervention design included using general instead of tailored messaging, focusing solely on the HIV preventive benefits of VMMC, and rolling out individual interventions to address specific barriers rather than a holistic package. Interventions have often been scaled-up without first being evaluated for effectiveness and cost-effectiveness. We recommend national programs create coordinated demand generation interventions, based on insights from multiple disciplines, tailored to the needs and aspirations of defined subsets of the target population, rather than focused exclusively on HIV prevention goals. Programs should implement a comprehensive intervention package with multiple messages and channels, strengthened through continuous monitoring. These insights may be broadly applicable to other programs where voluntary behavior change is essential to achieving public health benefits. PMID:26085019

National health insurance reform in South Africa: estimating the implications for demand for private health insurance.

PubMed

Okorafor, Okore Apia

2012-05-01

A recent health reform proposal in South Africa proposes universal access to a comprehensive package of healthcare services in the public sector, through the implementation of a national health insurance (NHI) scheme. Implementation of the scheme is likely to involve the introduction of a payroll tax. It is implied that the introduction of the payroll tax will significantly reduce the size of the private health insurance market. The objective of this study was to estimate the impact of an NHI payroll tax on the demand for private health insurance in South Africa, and to explore the broader implications for health policy. The study applies probit regression analysis on household survey data to estimate the change in demand for private health insurance as a result of income shocks arising from the proposed NHI. The introduction of payroll taxes for the proposed NHI was estimated to result in a reduction to private health insurance membership of 0.73%. This suggests inelasticity in the demand for private health insurance. In the literature on the subject, this inelasticity is usually due to quality differences between alternatives. In the South African context, there may be other factors at play. An NHI tax may have a very small impact on the demand for private health insurance. Although additional financial resources will be raised through a payroll tax under the proposed NHI reform, systemic problems within the South African health system can adversely affect the ability of the NHI to translate additional finances into better quality healthcare. If these systemic challenges are not adequately addressed, the introduction of a payroll tax could introduce inefficiencies within the South African health system.

[Practical nursing training in the University School of Nursing of the Community of Madrid. Opinion of students and health professionals. Qualitative study with discussion groups].

PubMed

Pérez Andrés, Cristina; Alameda Cuesta, Almudena; Albéniz Lizarraga, Carmen

2002-01-01

In the nursing schools, the contrast between what is taught in the classrooms and what is practiced at the health care centers usually creates a great deal of confusion on the part of the students. The objective of this research is to ascertain the opinion of the students and of the professionals at the health care centers where they are doing their training with regard thereto in order to detect their problems and see what differences exist between primary and specialized care. This research was conducted throughout the first half of 2000 employing qualitative methodology, by means of four discussion groups comprised of students, former students, primary care training advisors and nursing professionals at the hospitals where the students of the school in question are doing their nursing training. The initial involvement employed was indirect. The comments of the nursing students and of their training advisors with regard to the practice nursing during the diploma studies reveal dissatisfaction on the part of both of these groups. In all of the groups point out anxiety as the leading factor involved in their teaching as well as learning activities and during professional training. The lack of identification as a group of professionals seems to be related to the lack of recognition on the part of the others, the demand for a degree being granted for their college studies and for the setting up of specialities would contribute to their social recognition and, as a result thereof, to their identification as a professional group. Until a solution is provided to the anxiety which the nursing professionals feel with regard to their professional practice, which they pass on to their students during nursing training, it will not be possible to achieve a higher degree of satisfaction with nursing training experiences either on the part of the training advisors or on the part of the students.

The experience of work-life balance across family-life stages in Switzerland: a cross-sectional questionnaire-based study.

PubMed

Wepfer, Ariane G; Brauchli, Rebecca; Jenny, Gregor J; Hämmig, Oliver; Bauer, Georg F

2015-12-24

The division of paid and unpaid labor in families continues to be highly gendered with men doing more paid work and women doing more unpaid care work. This is especially true for life stages with young children. Our study investigates the subjective experience of demands in the work and the private domain and the experience of work-life balance across family-life stages as a consequence of this gendered division of labor. We used data from a survey study on work-life issues and health in four large companies in Switzerland (N = 3664). In line with our hypotheses, subjective work and private demands were predicted by an interaction of family-life stages and gender. Specifically, during the primary child-rearing family-life stages, women experience more private demands than men while men experience more work demands, regardless of level of employment. Furthermore, women who work part time experience more work-life balance than women who work full time and more than men who work part or full time during the primary child-rearing family-life stages. Results are discussed in terms of a gendered work-life experience across the life course and the need for part-time work for both genders. Finally, conclusions are drawn concerning our results' implications for public health considerations.

Analysis, modeling, and simulation (AMS) testbed development and evaluation to support dynamic mobility applications (DMA) and active transportation and demand management (ATDM) programs — evaluation summary for DMA program.

DOT National Transportation Integrated Search

2017-07-04

The primary objective of this project is to develop multiple simulation testbeds/transportation models to evaluate the impacts of Dynamic Mobility Application (DMA) connected vehicle applications and Active Transportation and Demand management (ATDM)...

Analysis, modeling, and simulation (AMS) testbed development and evaluation to support dynamic mobility applications (DMA) and active transportation and demand management (ATDM) programs : summary report for the Chicago testbed.

DOT National Transportation Integrated Search

2017-04-01

The primary objective of this project is to develop multiple simulation testbeds and transportation models to evaluate the impacts of Connected Vehicle Dynamic Mobility Applications (DMA) and Active Transportation and Demand Management (ATDM) strateg...

Analysis, Modeling, and Simulation (AMS) Testbed Development and Evaluation to Support Dynamic Mobility Applications (DMA) and Active Transportation and Demand Management (ATDM) Programs : Evaluation Report for the Chicago Testbed

DOT National Transportation Integrated Search

2017-04-01

The primary objective of this project is to develop multiple simulation testbeds and transportation models to evaluate the impacts of Connected Vehicle Dynamic Mobility Applications (DMA) and Active Transportation and Demand Management (ATDM) strateg...

Analysis, modeling, and simulation (AMS) testbed development and evaluation to support dynamic mobility applications (DMA) and active transportation and demand management (ATDM) programs — evaluation report for ATDM program.

DOT National Transportation Integrated Search

2017-07-16

The primary objective of this project is to develop multiple simulation testbeds/transportation models to evaluate the impacts of Dynamic Mobility Applications (DMA) and the Active Transportation and Demand Management (ATDM) strategies. Specifically,...

Workforce: Nevada

ERIC Educational Resources Information Center

Western Interstate Commission for Higher Education, 2006

2006-01-01

In Nevada, the demand for well-educated employees will only increase over the next several years. In the decade leading up to 2012, healthcare occupations will see growth of 47 percent. Teachers will be in demand: over 1,100 new primary and secondary educators will need to be hired each year. Managers will see their ranks swell by 44 percent, with…

A dynamic model of stress and sustained attention

NASA Technical Reports Server (NTRS)

Hancock, P. A.; Warm, Joel S.

1989-01-01

Arguments are presented that an integrated view of stress and performance must consider the task demanding a sustained attention as a primary source of cognitive stress. A dynamic model is developed on the basis of the concept of adaptability in both physiological and psychological terms, that addresses the effects of stress on vigilance and, potentially, a wide variety of attention-demanding performance tasks. The model provides an insight into the failure of an operator under the driving influences of stress and opens a number of potential avenues through which solutions to the complex challenge of stress and performance might be posed.

The linguistic demands of the Common Core State Standards for reading and writing informational text in the primary grades.

PubMed

Roberts, Kathryn L

2012-05-01

Forty-five states and four U.S. territories have committed to implementing the new Common Core State Standards, with the goal of graduating students from our K-12 programs who are ready for college and careers. For many, the new standards represent a shift in genre focus, giving much more specific attention to informational genres. Beginning in the primary grades, the standards set high expectations for students' interaction with informational text, many of which are significantly more linguistically demanding than the standards that they replace. These increased demands are likely to pose difficulties not only for students currently receiving language support, but also for students without identified delays or disabilities. This article describes several of the kindergarten through fifth-grade standards related to informational text, highlighting the linguistic demands that each poses. In addition, instructional strategies are provided that teachers and speech-language pathologists can use to support the understanding and formulation of informational text for listening, reading, speaking, and writing. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Effects of the Multidisciplinary Risk Assessment and Management Program for Patients with Diabetes Mellitus (RAMP-DM) on biomedical outcomes, observed cardiovascular events and cardiovascular risks in primary care: a longitudinal comparative study.

PubMed

Jiao, Fang Fang; Fung, Colman Siu Cheung; Wong, Carlos King Ho; Wan, Yuk Fai; Dai, Daisy; Kwok, Ruby; Lam, Cindy Lo Kuen

2014-08-21

To assess whether the Multidisciplinary Risk Assessment and Management Program for Patients with Diabetes Mellitus (RAMP-DM) led to improvements in biomedical outcomes, observed cardiovascular events and predicted cardiovascular risks after 12-month intervention in the primary care setting. A random sample of 1,248 people with diabetes enrolled to RAMP-DM for at least 12 months was selected and 1,248 people with diabetes under the usual primary care were matched by age, sex, and HbA1c level at baseline as the usual care group. Biomedical and cardiovascular outcomes were measured at baseline and at 12-month after the enrollment. Difference-in-differences approach was employed to measure the effect of RAMP-DM on the changes in biomedical outcomes, proportion of subjects reaching treatment targets, observed and predicted cardiovascular risks. Compared to the usual care group, RAMP-DM group had lower cardiovascular events incidence (1.21% vs 2.89%, P = 0.003), and net decrease in HbA1c (-0.20%, P < 0.01), SBP (-3.62 mmHg, P < 0.01) and 10-year cardiovascular disease (CVD) risks (total CVD risk, -2.06%, P < 0.01; coronary heart disease (CHD) risk, -1.43%, P < 0.01; stroke risk, -0.71%, P < 0.01). The RAMP-DM subjects witnessed significant rises in the proportion of reaching treatment targets of HbA1c, and SBP/DBP. After adjusting for confounding variables, the significance remained for HbA1c, predicted CHD and stroke risks. The RAMP-DM resulted in greater improvements in HbA1c and reduction in observed and predicted cardiovascular risks at 12 months follow-up, which indicated a risk-stratification multidisciplinary intervention was an effective strategy for managing Chinese people with diabetes in the primary care setting. ClinicalTrials.gov, NCT02034695.

Intervention to improve social and family support for caregivers of dependent patients: ICIAS study protocol.

PubMed

Rosell-Murphy, Magdalena; Bonet-Simó, Josep M; Baena, Esther; Prieto, Gemma; Bellerino, Eva; Solé, Francesc; Rubio, Montserrat; Krier, Ilona; Torres, Pascuala; Mimoso, Sonia

2014-03-25

Despite the existence of formal professional support services, informal support (mainly family members) continues to be the main source of eldercare, especially for those who are dependent or disabled. Professionals on the primary health care are the ideal choice to educate, provide psychological support, and help to mobilize social resources available to the informal caregiver.Controversy remains concerning the efficiency of multiple interventions, taking a holistic approach to both the patient and caregiver, and optimum utilization of the available community resources. .For this reason our goal is to assess whether an intervention designed to improve the social support for caregivers effectively decreases caregivers burden and improves their quality of life. CONTROLled, multicentre, community intervention trial, with patients and their caregivers randomized to the intervention or control group according to their assigned Primary Health Care Team (PHCT). Primary Health Care network (9 PHCTs). Primary informal caregivers of patients receiving home health care from participating PHCTs. Required sample size is 282 caregivers (141 from PHCTs randomized to the intervention group and 141 from PHCTs randomized to the control group. a) PHCT professionals: standardized training to implement caregivers intervention. b) Caregivers: 1 individualized counselling session, 1 family session, and 4 educational group sessions conducted by participating PHCT professionals; in addition to usual home health care visits, periodic telephone follow-up contact and unlimited telephone support. Caregivers and dependent patients: usual home health care, consisting of bimonthly scheduled visits, follow-up as needed, and additional attention upon request.Data analysisDependent variables: Caregiver burden (short-form Zarit test), caregivers' social support (Medical Outcomes Study), and caregivers' reported quality of life (SF-12)INDEPENDENT VARIABLES: a) Caregiver: sociodemographic data, Goldberg Scale, Apgar family questionnaire, Holmes and Rahe Psychosocial Stress Scale, number of chronic diseases. b) Dependent patient: sociodemographic data, level of dependency (Barthel Index), cognitive impairment (Pfeiffer test). If the intervention intended to improve social and family support is effective in reducing the burden on primary informal caregivers of dependent patients, this model can be readily applied throughout usual PHCT clinical practice. Clinical trials registrar: NCT02065427.

Intervention to improve social and family support for caregivers of dependent patients: ICIAS study protocol

PubMed Central

2014-01-01

Background Despite the existence of formal professional support services, informal support (mainly family members) continues to be the main source of eldercare, especially for those who are dependent or disabled. Professionals on the primary health care are the ideal choice to educate, provide psychological support, and help to mobilize social resources available to the informal caregiver. Controversy remains concerning the efficiency of multiple interventions, taking a holistic approach to both the patient and caregiver, and optimum utilization of the available community resources. .For this reason our goal is to assess whether an intervention designed to improve the social support for caregivers effectively decreases caregivers burden and improves their quality of life. Methods/design Design: Controlled, multicentre, community intervention trial, with patients and their caregivers randomized to the intervention or control group according to their assigned Primary Health Care Team (PHCT). Study area: Primary Health Care network (9 PHCTs). Study participants: Primary informal caregivers of patients receiving home health care from participating PHCTs. Sample: Required sample size is 282 caregivers (141 from PHCTs randomized to the intervention group and 141 from PHCTs randomized to the control group. Intervention: a) PHCT professionals: standardized training to implement caregivers intervention. b) Caregivers: 1 individualized counselling session, 1 family session, and 4 educational group sessions conducted by participating PHCT professionals; in addition to usual home health care visits, periodic telephone follow-up contact and unlimited telephone support. Control: Caregivers and dependent patients: usual home health care, consisting of bimonthly scheduled visits, follow-up as needed, and additional attention upon request. Data analysis Dependent variables: Caregiver burden (short-form Zarit test), caregivers’ social support (Medical Outcomes Study), and caregivers’ reported quality of life (SF-12) Independent variables: a) Caregiver: sociodemographic data, Goldberg Scale, Apgar family questionnaire, Holmes and Rahe Psychosocial Stress Scale, number of chronic diseases. b) Dependent patient: sociodemographic data, level of dependency (Barthel Index), cognitive impairment (Pfeiffer test). Discussion If the intervention intended to improve social and family support is effective in reducing the burden on primary informal caregivers of dependent patients, this model can be readily applied throughout usual PHCT clinical practice. Trial registration Clinical trials registrar: NCT02065427 PMID:24666438

Age, occupational demands and the risk of serious work injury.

PubMed

Smith, P M; Berecki-Gisolf, J

2014-12-01

Interest in the relationship between age and serious work injury is increasing, given the ageing of the workforce in many industrialized economies. To examine if the relationship between age and risk of serious musculoskeletal injury differs when the physical demands of work are higher from those when they are lower. A secondary analysis of workers' compensation claims in the State of Victoria, Australia, combined with estimates of the insured labour force. We focused on musculoskeletal claims, which required 10 days of absence or health care expenditures beyond a pecuniary threshold. Regression models examined the relationship between age and claim-risk across workers with different occupational demands, as well as the relationship between occupational demands and musculoskeletal claim-risk across different age groups. Older age and greater physical demands at work were associated with an increased risk of musculoskeletal claims. In models stratified by occupational demands, we observed the relationship between age and claim-risk was steeper when occupational demands were higher. We also observed that the relationship between occupational demands and risk of work injury claim peaked among workers aged 25-44, attenuating among those aged 45 and older. This study's results suggest that although older workers and occupations with higher demands should be the targets of primary preventive efforts related to serious musculoskeletal injuries, there may also be gains in targeting middle-aged workers in the most physically demanding occupations. © The Author 2014. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Science friction: data, metadata, and collaboration.

PubMed

Edwards, Paul N; Mayernik, Matthew S; Batcheller, Archer L; Bowker, Geoffrey C; Borgman, Christine L

2011-10-01

When scientists from two or more disciplines work together on related problems, they often face what we call 'science friction'. As science becomes more data-driven, collaborative, and interdisciplinary, demand increases for interoperability among data, tools, and services. Metadata--usually viewed simply as 'data about data', describing objects such as books, journal articles, or datasets--serve key roles in interoperability. Yet we find that metadata may be a source of friction between scientific collaborators, impeding data sharing. We propose an alternative view of metadata, focusing on its role in an ephemeral process of scientific communication, rather than as an enduring outcome or product. We report examples of highly useful, yet ad hoc, incomplete, loosely structured, and mutable, descriptions of data found in our ethnographic studies of several large projects in the environmental sciences. Based on this evidence, we argue that while metadata products can be powerful resources, usually they must be supplemented with metadata processes. Metadata-as-process suggests the very large role of the ad hoc, the incomplete, and the unfinished in everyday scientific work.

Hydrological Drought in the Anthropocene: Impacts of Local Water Extraction and Reservoir Regulation in the U.S.: Hydrological Drought in the Anthropocene

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

Wan, Wenhua; Zhao, Jianshi; Li, Hong-Yi

Hydrological drought is a substantial negative deviation from normal hydrologic conditions and is influenced by climate and human activities such as water management. By perturbing the streamflow regime, climate change and water management may significantly alter drought characteristics in the future. Here we utilize a high-resolution integrated modeling framework that represents water management in terms of both local surface water extraction and reservoir regulation, and use the Standardized Streamflow Index (SSI) to quantify hydrological drought. We explore the impacts of water management on hydrological drought over the contiguous US in a warming climate with and without emissions mitigation. Despite themore » uncertainty of climate change impacts, local surface water extraction consistently intensifies drought that dominates at the regional to national scale. However, reservoir regulation alleviates drought by enhancing summer flow downstream of reservoirs. The relative dominance of drought intensification or relief is largely determined by the water demand, with drought intensification dominating in regions with intense water demand such as the Great Plains and California, while drought relief dominates in regions with low water demand. At the national level, water management increases the spatial extent of extreme drought despite some alleviations of moderate to severe drought. In an emissions mitigation scenario with increased irrigation demand for bioenergy production, water management intensifies drought more than the business-as-usual scenario at the national level, so the impacts of emissions mitigation must be evaluated by considering its benefit in reducing warming and evapotranspiration against its effects on increasing water demand and intensifying drought.« less

Hydrological Drought in the Anthropocene: Impacts of Local Water Extraction and Reservoir Regulation in the U.S.

NASA Astrophysics Data System (ADS)

Wan, Wenhua; Zhao, Jianshi; Li, Hong-Yi; Mishra, Ashok; Ruby Leung, L.; Hejazi, Mohamad; Wang, Wei; Lu, Hui; Deng, Zhiqun; Demissisie, Yonas; Wang, Hao

2017-11-01

Hydrological drought is a substantial negative deviation from normal hydrologic conditions and is influenced by climate and human activities such as water management. By perturbing the streamflow regime, climate change and water management may significantly alter drought characteristics in the future. Here we utilize a high-resolution integrated modeling framework that represents water management in terms of both local surface water extraction and reservoir regulation and use the Standardized Streamflow Index to quantify hydrological drought. We explore the impacts of water management on hydrological drought over the contiguous U.S. in a warming climate with and without emissions mitigation. Despite the uncertainty of climate change impacts, local surface water extraction consistently intensifies drought that dominates at the regional to national scale. However, reservoir regulation alleviates drought by enhancing summer flow downstream of reservoirs. The relative dominance of drought intensification or relief is largely determined by the water demand, with drought intensification dominating in regions with intense water demand such as the Great Plains and California, while drought relief dominates in regions with low water demand. At the national level, water management increases the spatial extent of extreme drought despite some alleviations of moderate to severe drought. In an emissions mitigation scenario with increased irrigation demand for bioenergy production, water management intensifies drought more than the business-as-usual scenario at the national level, so the impacts of emissions mitigation must be evaluated by considering its benefit in reducing warming and evapotranspiration against its effects on increasing water demand and intensifying drought.

“The problem often is that we do not have a family spokesperson but a spokesgroup”: Family Member Informal Roles in End-of-Life Decision-Making in Adult ICUs

PubMed Central

Quinn, Jill R.; Schmitt, Madeline; Baggs, Judith Gedney; Norton, Sally A.; Dombeck, Mary T.; Sellers, Craig R.

2013-01-01

Background To support the process of effective family decision-making, it is important to recognize and understand informal roles various family members may play in the end-of-life decision-making process. Objective The purpose of this study was to describe some informal roles consistently enacted by family members involved in the process of end-of-life decision-making in intensive care units (ICUs). Methods Ethnographic study. Data were collected via participant observation with field notes and semi-structured interviews on four ICUs in an academic health center in the mid-Atlantic United States from 2001 to 2004. The units studied were a medical ICU, a surgical ICU, a burn and trauma ICU, and a cardiovascular ICU. Participants Participants included health care clinicians, patients, and family members. Results Informal roles for family members consistently observed were:, Primary Caregiver, Primary Decision Maker, Family Spokesperson, Out-of-Towner, Patient Wishes Expert, Protector, Vulnerable Member, and Health Care Expert. The identified informal roles were part of family decision making processes, and each role was part of a potentially complicated family dynamic for end-of-life decision-making within the family system, and between the family and health care domains. Conclusions These informal roles reflect the diverse responses to demands for family decision making in what is usually a novel and stressful situation. Identification and description of these family member informal roles can assist clinicians to recognize and understand the functions of these roles in family decision making at the end-of-life, and guide development of strategies to support and facilitate increased effectiveness of family discussions and decision-making processes. PMID:22210699

Design considerations and rationale of a multi-center trial to sustain weight loss: the Weight Loss Maintenance Trial.

PubMed

Brantley, Phillip; Appel, Lawrence; Hollis, Jack; Stevens, Victor; Ard, Jamy; Champagne, Catherine; Elmer, Patricia; Harsha, David; Myers, Valerie; Proschan, Michael; William, Vollmer; Svetkey, Laura

2008-01-01

The Weight Loss Maintenance Trial (WLM) is a multi-center, randomized, controlled trial that compares the effects of two 30-month maintenance interventions, i.e., Personal Contact (PC) and Interactive Technology (IT) to a self-directed usual care control group (SD), in overweight or obese individuals who are at high risk for cardiovascular disease. This paper provides an overview of the design and methods, and design considerations and lessons learned from this trial. All participants received a 6-month behavioral weight loss program consisting of weekly group sessions. Participants who lost 4 kg were randomized to one of three conditions (PC, IT, or SD). The PC condition provided monthly contacts with an interventionist primarily via telephone and quarterly face-to-face visits. The IT condition provided frequent, individualized contact through a tailored, website system. Both the PC and IT maintenance programs encouraged the DASH dietary pattern and employed theory-based behavioral techniques to promote maintenance. Design considerations included choice of study population, frequency and type of intervention visits, and choice of primary outcome. Overweight or obese persons with CVD risk factors were studied. The pros and cons of studying this population while excluding others are presented. We studied intervention contact strategies that made fewer demands on participant time and travel, while providing frequent opportunities for interaction. The primary outcome variable for the trial was change in weight from randomization to end of follow-up (30 months). Limits to generalizability are discussed. Individuals in need of weight loss strategies may have been excluded due to barriers associated with internet use. Other participants may have been excluded secondary to a comorbid condition. This paper highlights the design and methods of WLM and informs readers of discussions of critical issues and lessons learned from the trial.

9 CFR 381.118 - Ingredients statement.

Code of Federal Regulations, 2014 CFR

2014-01-01

... exceptions of onions, garlic and celery, whose primary function in food is seasoning rather than nutritional... fermentation products thereof, whose primary function in food is flavoring rather than nutritional. Natural... section whose function is flavoring, either in whole or in part, must be designated by its common or usual...

9 CFR 381.118 - Ingredients statement.

Code of Federal Regulations, 2013 CFR

2013-01-01

... exceptions of onions, garlic and celery, whose primary function in food is seasoning rather than nutritional... fermentation products thereof, whose primary function in food is flavoring rather than nutritional. Natural... section whose function is flavoring, either in whole or in part, must be designated by its common or usual...

9 CFR 381.118 - Ingredients statement.

Code of Federal Regulations, 2012 CFR

2012-01-01

... exceptions of onions, garlic and celery, whose primary function in food is seasoning rather than nutritional... fermentation products thereof, whose primary function in food is flavoring rather than nutritional. Natural... section whose function is flavoring, either in whole or in part, must be designated by its common or usual...

9 CFR 381.118 - Ingredients statement.

Code of Federal Regulations, 2011 CFR

2011-01-01

... and celery, whose primary function in food is seasoning rather than nutritional and from which no... fermentation products thereof, whose primary function in food is flavoring rather than nutritional. Natural... section whose function is flavoring, either in whole or in part, must be designated by its common or usual...

7 CFR 201.56-8 - Flax family, Linaceae.

Code of Federal Regulations, 2011 CFR

2011-01-01

...: Flax. (a) General description. (1) Germination habit: Epigeal dicot. (Due to the mucilaginous nature of... development within the test period. (4) Root system: A primary root, with secondary roots usually developing... markedly shortened, curled, or thickened. (4) Root: (i) None. (ii) Weak, stubby, or missing primary root...

7 CFR 201.56-8 - Flax family, Linaceae.

Code of Federal Regulations, 2010 CFR

2010-01-01

...: Flax. (a) General description. (1) Germination habit: Epigeal dicot. (Due to the mucilaginous nature of... development within the test period. (4) Root system: A primary root, with secondary roots usually developing... markedly shortened, curled, or thickened. (4) Root: (i) None. (ii) Weak, stubby, or missing primary root...

A novel microgrid demand-side management system for manufacturing facilities

NASA Astrophysics Data System (ADS)

Harper, Terance J.

Thirty-one percent of annual energy consumption in the United States occurs within the industrial sector, where manufacturing processes account for the largest amount of energy consumption and carbon emissions. For this reason, energy efficiency in manufacturing facilities is increasingly important for reducing operating costs and improving profits. Using microgrids to generate local sustainable power should reduce energy consumption from the main utility grid along with energy costs and carbon emissions. Also, microgrids have the potential to serve as reliable energy generators in international locations where the utility grid is often unstable. For this research, a manufacturing process that had approximately 20 kW of peak demand was matched with a solar photovoltaic array that had a peak output of approximately 3 KW. An innovative Demand-Side Management (DSM) strategy was developed to manage the process loads as part of this smart microgrid system. The DSM algorithm managed the intermittent nature of the microgrid and the instantaneous demand of the manufacturing process. The control algorithm required three input signals; one from the microgrid indicating the availability of renewable energy, another from the manufacturing process indicating energy use as a percent of peak production, and historical data for renewable sources and facility demand. Based on these inputs the algorithm had three modes of operation: normal (business as usual), curtailment (shutting off non-critical loads), and energy storage. The results show that a real-time management of a manufacturing process with a microgrid will reduce electrical consumption and peak demand. The renewable energy system for this research was rated to provide up to 13% of the total manufacturing capacity. With actively managing the process loads with the DSM program alone, electrical consumption from the utility grid was reduced by 17% on average. An additional 24% reduction was accomplished when the microgrid and DSM program was enabled together, resulting in a total reduction of 37%. On average, peak demand was reduced by 6%, but due to the intermittency of the renewable source and the billing structure for peak demand, only a 1% reduction was obtained. During a billing period, it only takes one day when solar irradiance is poor to affect the demand reduction capabilities. To achieve further demand reduction, energy storage should be introduced and integrated.

Cost-effectiveness of a transitional pharmaceutical care program for patients discharged from the hospital

PubMed Central

van der Knaap, Ronald; Bouhannouch, Fatiha; Borgsteede, Sander D.; Janssen, Marjo J. A.; Siegert, Carl E. H.; Egberts, Toine C. G.; van den Bemt, Patricia M. L. A.; van Wier, Marieke F.; Bosmans, Judith E.

2017-01-01

Background To improve continuity of care at hospital admission and discharge and to decrease medication errors pharmaceutical care programs are developed. This study aims to determine the cost-effectiveness of the COACH program in comparison with usual care from a societal perspective. Methods A controlled clinical trial was performed at the Internal Medicine department of a general teaching hospital. All admitted patients using at least one prescription drug were included. The COACH program consisted of medication reconciliation, patient counselling at discharge, and communication to healthcare providers in primary care. The primary outcome was the proportion of patients with an unplanned rehospitalisation within three months after discharge. Also, the number of quality-adjusted life-years (QALYs) was assessed. Cost data were collected using cost diaries. Uncertainty surrounding cost differences and incremental cost-effectiveness ratios between the groups was estimated by bootstrapping. Results In the COACH program, 168 patients were included and in usual care 151 patients. There was no significant difference in the proportion of patients with unplanned rehospitalisations (mean difference 0.17%, 95% CI -8.85;8.51), and in QALYs (mean difference -0.0085, 95% CI -0.0170;0.0001). Total costs for the COACH program were non-significantly lower than usual care (-€1160, 95% CI -3168;847). Cost-effectiveness planes showed that the program was not cost-effective compared with usual care for unplanned rehospitalisations and QALYs gained. Conclusion The COACH program was not cost-effective in comparison with usual care. Future studies should focus on high risk patients and include other outcomes (e.g. adverse drug events) as this may increase the chances of a cost-effective intervention. Dutch trial register NTR1519 PMID:28445474

Utilizing role theory to help employed parents cope with children's chronic illness.

PubMed

Major, Debra A

2003-02-01

Role theory is utilized to detail a six-step process for developing balanced coping through role negotiation. As applied in this paper, the role theory framework provides health educators with a useful tool for helping employed parents cope with a child's chronic illness. The emphasis is on partnering with parents or primary caregivers to identify, understand and manage the multiple role demands of working parents with chronically ill children. Role theory suggests ways health educators can support balanced coping by educating families about the demands of a child's illness, and helping to reduce those demands, helping to increase family resources, supporting parents and facilitating role negotiation. The ultimate goal is the development of balanced coping strategies that (1) meet the medical and emotional needs of the ill child, (2) allow parents to maintain their physical and mental health, and (3) enable parents to meet the demands of their other roles (e.g. paid employment).

Examination of simplified travel demand model. [Internal volume forecasting model

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

Smith, R.L. Jr.; McFarlane, W.J.

1978-01-01

A simplified travel demand model, the Internal Volume Forecasting (IVF) model, proposed by Low in 1972 is evaluated as an alternative to the conventional urban travel demand modeling process. The calibration of the IVF model for a county-level study area in Central Wisconsin results in what appears to be a reasonable model; however, analysis of the structure of the model reveals two primary mis-specifications. Correction of the mis-specifications leads to a simplified gravity model version of the conventional urban travel demand models. Application of the original IVF model to ''forecast'' 1960 traffic volumes based on the model calibrated for 1970more » produces accurate estimates. Shortcut and ad hoc models may appear to provide reasonable results in both the base and horizon years; however, as shown by the IVF mode, such models will not always provide a reliable basis for transportation planning and investment decisions.« less

Gemination or fusion? - challenge for dental practitioners (case study).

PubMed

Chipashvili, N; Vadachkoria, D; Beshkenadze, E

2011-05-01

Gemination and fusion are anomalies in size, shape and structure of teeth. Gemination more frequently affects the primary teeth, but it may occur in permanent dentitions, usually in the incisor region. Geminated teeth are typically disfigured in appearance due to irregularities of the enamel. Fused teeth can have separated pulpal space, one pulp chamber and two canals or take the form of a large bifid crown with one pulpal space. It is hard to differentiate between fusion and gemination, especially if the supernumerary tooth bud is fused with the adjacent one. Usually, fusion may be differentiated from germination by a reduced number of teeth. An exception is in the unusual case in which the fusion is between a supernumerary tooth and normal tooth. A 20-year-old male referred to us at - "UniDent" - Dental Clinic, Training and Research Center. The patient complained about the large, unusual maxillary central incisors, lip irritation and aesthetic problems. According clinical examination and radiological findings, clinical diagnose was - bilateral germination of central incisors. Several treatment methods have been described in the literature with respect to the different types and morphological variations of fused and geminated teeth, including endodontic, direct\\indirect restorative, surgical, periodontal and/or orthodontic treatment. Our patient has demanded for better aesthetics and he choose the treatment option to make two separate PFM crowns. In the beginning of treatment, the length of tooth 11 was 9.5mm, after prosthodontic treatment it has become 11.5mm. For tooth 21, it was 9.9 millimeter and became - 10.8 mm, while the primary width of right central incisor appeared 13.2 millimeter and was narrowed until 10.8 mm. 12.8 mm was the - width of left central incisor, which finally became - 10.4 mm. Despite the considerable number of cases reported in the literature, the differential diagnosis between these abnormalities is very difficult, as well as, to find guideline of proper outcome of treatment therapy of abovementioned abnormalities. That's why, the aesthetic rehabilitation of doubled teeth, has been suggested, to depend upon the patient's desires, but at the same time, avoid treatment plans with aggressive management.

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

Bhattarai, Bishnu; Kouzelis, Konstantinos; Mendaza, Iker

The gradual active load penetration in low voltage distribution grids is expected to challenge their network capacity in the near future. Distribution system operators should for this reason resort to either costly grid reinforcements or to demand side management mechanisms. Since demand side management implementation is usually cheaper, it is also the favorable solution. To this end, this article presents a framework for handling grid limit violations, both voltage and current, to ensure a secure and qualitative operation of the distribution grid. This framework consists of two steps, namely a proactive centralized and subsequently a reactive decentralized control scheme. Themore » former is employed to balance the one hour ahead load while the latter aims at regulating the consumption in real-time. In both cases, the importance of fair use of electricity demand flexibility is emphasized. Thus, it is demonstrated that this methodology aids in keeping the grid status within preset limits while utilizing flexibility from all flexibility participants.« less

Materials flow of indium in the United States in 2008 and 2009

USGS Publications Warehouse

Goonan, Thomas G.

2012-01-01

Indium is a material that has many applications. It is used by anyone who watches television or views a computer screen. It is found in solar energy arrays and in soldering applications that are required to be lead free. In 2009, about 550 metric tons (t) of indium metal was produced from primary sources world-wide; it was estimated that the United States consumed about 110 t of indium metal (20 percent of world primary production). However, when imports of consumer products that contain indium are considered, the United States consumed about 200 t of indium (36 percent of world primary production). When one considers the recovery from the low-efficiency sputtering process that coats indium-tin oxide onto glass and other surfaces, the recycling rate (within the manufacturing process that uses indium-tin oxide in flat panel displays approaches 36 percent. However, indium recovery from old scrap generated from end-of-life consumer products is not sufficiently economic to add significantly to secondary production. Between 1988 and 2010, indium prices averaged $381 per kilogram (in constant 2000 dollars). However, prices have been quite volatile (deviating from the average of $381 per kilogram by ±$199 per kilogram, a 52 percent difference from the average), reflecting short-term disequilibrium of supply and demand but also responsiveness of supply to demand. The dynamics of zinc smelting govern the primary supply of indium because indium is a byproduct of zinc smelting. Secondary indium supply, which accounts for about one-half of total indium supply, is governed by indium prices and technological advances in recovery. Indium demand is expected to grow because the number and volume of cutting edge technology applications that depend on indium are expected to grow.

Physicians, the Affordable Care Act, and primary care: disruptive change or business as usual?

PubMed

Jacobson, Peter D; Jazowski, Shelley A

2011-08-01

The Patient Protection and Affordable Care Act 1 (ACA) presages disruptive change in primary care delivery. With expanded access to primary care for millions of new patients, physicians and policymakers face increased pressure to solve the perennial shortage of primary care practitioners. Despite the controversy surrounding its enactment, the ACA should motivate organized medicine to take the lead in shaping new strategies for meeting the nation's primary care needs. In this commentary, we argue that physicians should take the lead in developing policies to address the primary care shortage. First, physicians and medical professional organizations should abandon their long-standing opposition to non-physician practitioners (NPPs) as primary care providers. Second, physicians should re-imagine how primary care is delivered, including shifting routine care to NPPs while retaining responsibility for complex patients and oversight of the new primary care arrangements. Third, the ACA's focus on wellness and prevention creates opportunities for physicians to integrate population health into primary care practice.

The immediate and long-term effects of a walking-skill program compared to usual physiotherapy care in patients who have undergone total knee arthroplasty (TKA): a randomized controlled trial.

PubMed

Bruun-Olsen, Vigdis; Heiberg, Kristi Elisabeth; Wahl, Astrid Klopstad; Mengshoel, Anne Marit

2013-01-01

To examine the immediate and long-term effects of a walking-skill program compared with usual physiotherapy on physical function, pain and perceived self-efficacy in patients after total knee arthroplasty (TKA). A single blind randomized controlled trial design was applied. Fifty-seven patients with primary TKA, mean age of 69 years (SD ± 9), were randomly assigned to a walking-skill program emphasizing weight-bearing exercises or usual physiotherapy. Outcomes were assessed before the interventions started at 6 weeks postoperatively (T1), directly after the interventions at 12-14 weeks (T2) and 9 months after the interventions (T3). Walking was the primary outcome, assessed by the 6 min walk test (6MWT). The secondary outcomes were timed stair climbing, timed stands, Figure-of-eight test, Index of muscle function, active knee range of motion, Knee Injury and Osteoarthritis Outcome Score and self-efficacy score. From T1 to T2, a better 6MWT score was found in favor of the walking-skill program of 39 m (2-76), p = 0.04. The difference between the groups in 6MWT persisted at T3, 44 m (8-80), p = 0.02. No differences in other outcome measures were found. The walking-skill program had better effect on walking than usual physiotherapy. Weight bearing was tolerated. Implications for Rehabilitation Weight-bearing exercises are tolerated by the patients in the early stage after TKA. Physiotherapy that focuses on learning different ways of walking through practice may be a plausible way to train patients after TKA.

Early rehabilitation after total knee replacement surgery: a multicenter, noninferiority, randomized clinical trial comparing a home exercise program with usual outpatient care.

PubMed

Han, Annie S Y; Nairn, Lillias; Harmer, Alison R; Crosbie, Jack; March, Lyn; Parker, David; Crawford, Ross; Fransen, Marlene

2015-02-01

To determine, at 6 weeks postsurgery, if a monitored home exercise program (HEP) is not inferior to usual care rehabilitation for patients undergoing primary unilateral total knee replacement (TKR) surgery for osteoarthritis. We conducted a multicenter, randomized clinical trial. Patients ages 45-75 years were allocated at the time of hospital discharge to usual care rehabilitation (n = 196) or the HEP (n = 194). Outcomes assessed 6 weeks after surgery included the Western Ontario and McMaster Universities Osteoarthritis Index pain and physical function subscales, knee range of motion, and the 50-foot walk time. The upper bound of the 95% confidence interval (95% CI) mean difference favoring usual care was used to determine noninferiority. At 6 weeks after surgery there were no significant differences between usual care and HEP, respectively, for pain (7.4 and 7.2; 95% CI mean difference [MD] -0.7, 0.9), physical function (22.5 and 22.4; 95% CI MD -2.5, 2.6), knee flexion (96° and 97°; 95% CI MD -4°, 2°), knee extension (-7° and -6°; 95% CI MD -2°, 1°), or the 50-foot walk time (12.9 and 12.9 seconds; 95% CI MD -0.8, 0.7 seconds). At 6 weeks, 18 patients (9%) allocated to usual care and 11 (6%) to the HEP did not achieve 80° knee flexion. There was no difference between the treatment allocations in the number of hospital readmissions. The HEP was not inferior to usual care as an early rehabilitation protocol after primary TKR. Copyright © 2015 by the American College of Rheumatology.

Diagnosing phosphorus limitations in natural terrestrial ecosystems in carbon cycle models

DOE PAGES

Sun, Yan; Peng, Shushi; Goll, Daniel S.; ...

2017-04-28

Most of the Earth System Models (ESMs) project increases in net primary productivity (NPP) and terrestrial carbon (C) storage during the 21st century. Despite empirical evidence that limited availability of phosphorus (P) may limit the response of NPP to increasing atmospheric CO 2, none of the ESMs used in the previous Intergovernmental Panel on Climate Change assessment accounted for P limitation. We diagnosed from ESM simulations the amount of P need to support increases in carbon uptake by natural ecosystems using two approaches: the demand derived from changes in C stocks and changes in NPP. The C stock-based additional Pmore » demand was estimated to range between -31 and 193 Tg P and between -89 and 262 Tg P for Representative Concentration Pathway (RCP) 2.6 and RCP8.5, respectively, with negative values indicating a P surplus. The NPP-based demand, which takes ecosystem P recycling into account, results in a significantly higher P demand of 648–1606 Tg P for RCP2.6 and 924–2110 Tg P for RCP8.5. We found that the P demand is sensitive to the turnover of P in decomposing plant material, explaining the large differences between the NPP-based demand and C stock-based demand. The discrepancy between diagnosed P demand and actual P availability (potential P deficit) depends mainly on the assumptions about availability of the different soil P forms. Altogether, future P limitation strongly depends on both soil P availability and P recycling on ecosystem scale.« less

Dependency of global primary bioenergy crop potentials in 2050 on food systems, yields, biodiversity conservation and political stability.

PubMed

Erb, Karl-Heinz; Haberl, Helmut; Plutzar, Christoph

2012-08-01

The future bioenergy crop potential depends on (1) changes in the food system (food demand, agricultural technology), (2) political stability and investment security, (3) biodiversity conservation, (4) avoidance of long carbon payback times from deforestation, and (5) energy crop yields. Using a biophysical biomass-balance model, we analyze how these factors affect global primary bioenergy potentials in 2050. The model calculates biomass supply and demand balances for eleven world regions, eleven food categories, seven food crop types and two livestock categories, integrating agricultural forecasts and scenarios with a consistent global land use and NPP database. The TREND scenario results in a global primary bioenergy potential of 77 EJ/yr, alternative assumptions on food-system changes result in a range of 26-141 EJ/yr. Exclusion of areas for biodiversity conservation and inaccessible land in failed states reduces the bioenergy potential by up to 45%. Optimistic assumptions on future energy crop yields increase the potential by up to 48%, while pessimistic assumptions lower the potential by 26%. We conclude that the design of sustainable bioenergy crop production policies needs to resolve difficult trade-offs such as food vs. energy supply, renewable energy vs. biodiversity conservation or yield growth vs. reduction of environmental problems of intensive agriculture.

Dependency of global primary bioenergy crop potentials in 2050 on food systems, yields, biodiversity conservation and political stability

PubMed Central

Erb, Karl-Heinz; Haberl, Helmut; Plutzar, Christoph

2012-01-01

The future bioenergy crop potential depends on (1) changes in the food system (food demand, agricultural technology), (2) political stability and investment security, (3) biodiversity conservation, (4) avoidance of long carbon payback times from deforestation, and (5) energy crop yields. Using a biophysical biomass-balance model, we analyze how these factors affect global primary bioenergy potentials in 2050. The model calculates biomass supply and demand balances for eleven world regions, eleven food categories, seven food crop types and two livestock categories, integrating agricultural forecasts and scenarios with a consistent global land use and NPP database. The TREND scenario results in a global primary bioenergy potential of 77 EJ/yr, alternative assumptions on food-system changes result in a range of 26–141 EJ/yr. Exclusion of areas for biodiversity conservation and inaccessible land in failed states reduces the bioenergy potential by up to 45%. Optimistic assumptions on future energy crop yields increase the potential by up to 48%, while pessimistic assumptions lower the potential by 26%. We conclude that the design of sustainable bioenergy crop production policies needs to resolve difficult trade-offs such as food vs. energy supply, renewable energy vs. biodiversity conservation or yield growth vs. reduction of environmental problems of intensive agriculture. PMID:23576836

Minimally disruptive medicine: the evidence and conceptual progress supporting a new era of healthcare.

PubMed

Abu Dabrh, A M; Gallacher, K; Boehmer, K R; Hargraves, I G; Mair, F S

2015-01-01

Patients with chronic conditions or multimorbidity, and often their caregivers, have to adjust their lives and mobilise their capacity (ability) to respond to the workload (demands) imposed by treatments and the care of their conditions. There is a continuous and complex interaction between workload and capacity. When capacity proves insufficient to address the treatment workload, creating a burden, patients may place a lower priority on other aspects of their lives, or reduce engagement with healthcare. Guidelines usually focus on disease-centred outcomes without consideration of limited capacity or demanding workload (burden) from treatment regimens. It seems reasonable to consider that healthcare needs reshaping so that care that pursues goals important to patients as well as those suggested by evidence-based medicine. This can be achieved by using shared decision approaches guided by the expertise of clinicians to deliver optimal care while minimising the burden of treatment on patients, their caregivers, and the healthcare system. What we need is minimally disruptive medicine.

Generic medicines: Greek physicians' perceptions and prescribing practices.

PubMed

Tsiantou, V; Zavras, D; Kousoulakou, H; Geitona, M; Kyriopoulos, J

2009-10-01

The penetration of generic drugs in the Greek pharmaceutical market is placed among the weakest in the EU. The Greek regulatory framework does not systematically support the development of this subsector and physicians are not provided with incentives for prescribing generics. The aim of this study was to investigate the prescribing profile of physicians in Greece with a focus on the factors that influence their decision on generics prescribing. A structured questionnaire was sent by mail to a random national sample of 1463 physicians, stratified by sex, specialty and geographical region. The response rate was 82.3%. Greek physicians have a positive view on generics but they prefer to prescribe the original products. According to our analysis, physician's age and their opinion on generics' efficacy and effectiveness are identified as important determinants of their prescribing decision. The primary reason that could make them change their prescribing habits is the appearance of side-effects. Patients' insurance coverage and income, as well as the drug cost are also referred as factors that influence their prescribing decision. Despite the fact that they do not usually prescribe generics in their clinical practice, they are willing to substitute an original drug by a generic product. Our findings suggest that Greek physicians could be persuaded to prescribe generic medicines, if a generic promotion policy was introduced in the country. To develop such a policy, a set of supply side and demand-side measures should be implemented along with provision of information on generics to physicians during their education and clinical practice.

Effectiveness of Cognitive-Behavioral Treatment for Panic Disorder versus Treatment as Usual in a Managed Care Setting

ERIC Educational Resources Information Center

Addis, Michael E.; Hatgis, Christina; Krasnow, Aaron D.; Jacob, Karen; Bourne, Leslie; Mansfield, Abigail

2004-01-01

Eighty clients enrolled in a managed care health plan who identified panic disorder as their primary presenting problem were randomly assigned to treatment by a therapist recently trained in a manual-based empirically supported psychotherapy (M. G. Craske, E. Meadows, & D. H. Barlow, 1994) or a therapist conducting treatment as usual (TAU).…

Cost-effectiveness of acupuncture in an employee population: A retrospective analysis.

PubMed

Borah, Bijan J; Naessens, James M; Glasgow, Amy E; Bauer, Brent A; Chon, Tony Y

2017-04-01

To determine whether acupuncture is a cost-effective adjunct to usual care for Mayo Clinic employees and their dependents experiencing pain symptoms. Retrospective review of the medical and billing records of 466 employee-patients and their dependents who had received acupuncture as part of their care and 466 propensity score-matched control patients. Usual care in combination with acupuncture compared with usual care alone. The primary outcome measure was the total costs of care for all medical care and pharmacy services incurred from 1year before the index visit to 14 months after the index date. Secondary outcomes included the number of hospital visits, total inpatient days, emergency department visits, primary care or general medicine office visits, specialty office visits, and physical therapy services. Pain scores (patient-rated scores from 0 to 10) were extracted from the medical record, if available. Costs of care were similar between the 2 groups. No cost savings were noted for the acupuncture group. Several limitations to the study may have precluded a finding of cost-effectiveness. Future studies should include prospective evaluation of costs and other outcomes in a comparison between acupuncture and usual care in a randomized control trial. Copyright © 2017 Elsevier Ltd. All rights reserved.

PHYSICAL AND BIOLOGICAL CONTROLS ON DISSOLVED OXYGEN DYNAMICS IN PENSACOLA BAY, FL

EPA Science Inventory

Nutrient enrichment of estuaries and coastal waters can contribute to hypoxia (low dissolved oxygen) by increasing primary production and biological oxygen demand. Other factors, however, contribute to hypoxia and affect the susceptibility of coastal waters to hypoxia. Hypoxia fo...

[Frequent attendance: the primary care professional's perceptions on the influence of social factors and health care system organisation].

PubMed

Sandín-Vázquez, M; Conde-Espejo, P

2011-01-01

FREQUENT ATTENDANCE: The primary care professional's perceptions on the influence of social factors and health care system organisation. To find out the primary care (PC) professional's perceptions on the social factors and healthcare system organisation that influence frequent attendance. A qualitative study using semi-structured interviews in Primary Care Centres of six Health Areas in the Community of Madrid. Eighteen interviews were conducted, three per area (two physicians and one nurse). Structural sampling was carried out with regards to the variables that could influence the discourse: health area, occupation, sex and number of years worked. The transcriptions were analysed by two investigators and an agreement of interpretation was reached. Among the social factors, health professionals perceived as determining factors: the influence of the media and the medicalization of society, lack of health education and self-care abilities of the population and contextual factors of the patient (social, work and family). Among the health care organisation factors that could influence frequent attendance were, system saturation, appointment on demand, fear of potential lawsuits by the patient, chronic patients protocols, administrative consultations, professional behaviour, and poor coordination with specialised care. According to PC professionals, there are multiple environmental factors, both social and healthcare system organisational factors that encourage frequent attendance. Within the scope of health care system, organisational actions (such as teamwork and coordination with specialists) would help to manage demand. Copyright © 2010 SECA. Published by Elsevier Espana. All rights reserved.

Upper aerodigestive tract cancer and the lung: a tale of two aspirations.

PubMed

Vaideeswar, P; Ghodke, R

2012-01-01

Patients with upper aerodigestive epithelial cancers frequently develop second primary cancers due to common risk factors or develop distant metastases depending on the locoregional status of the primary tumor. In most instances, the organ affected is the lung. Pulmonary spread usually occurs due to hematogenous or lymphatic dissemination. The following is a report of two patients with upper aerodigestive tract squamous cell carcinomas who developed lung metastases due to aspiration, a route not well documented in recent literature.

USEPA'S SITE PROGRAM IMPACT ON THE DEVELOPMENT AND USE OF INNOVATIVE HAZARDOUS WASTE TREATMENT

EPA Science Inventory

The USEPA's SITE Program was created to meet the increased demand for innovative technologies for hazardous waste treatment. The primary mission of the SITe Program is to expedite the cleanup of sites on the NPL. The SITE Program has two components: The Demonstration Program and ...

Sequence Learning and Selection Difficulty

ERIC Educational Resources Information Center

Rowland, Lee A.; Shanks, David R.

2006-01-01

The authors studied the role of attention as a selection mechanism in implicit learning by examining the effect on primary sequence learning of performing a demanding target-selection task. Participants were trained on probabilistic sequences in a novel version of the serial reaction time (SRT) task, with dual- and triple-stimulus participants…

Technological challenges for boosting coal production with environmental sustainability.

PubMed

Ghose, Mrinal K

2009-07-01

The global energy requirement has grown at a phenomenon rate and the consumption of primary energy sources has been a very high positive growth. This paper focuses on the consumption of different primary energy sources and it identifies that coal will continue to remain as the prime energy source in foreseeable future. It examines the energy requirement perspective for India and demand of coal as the prime energy source. Economic development and poverty alleviation depend on securing affordable energy sources and Indian coal mining industry offers a bright future for the country's energy security, provided the industry is allowed to develop by supportive government policies and adopts latest technologies for mining. It is an irony that in-spite of having a plentiful reserves, India is not able to jack up coal production to meet its current and future demand. It discusses the strategies to be adopted for growth and meeting the coal demand. But such energy are very much concerned with environmental degradation and must be driven by contemporary managerial acumen addressing environmental and social challenges effectively The paper highlights the emissions of greenhouse gases due to burning of fossil fuels and environmental consequences of global warming and sea-level rise. Technological solutions for environment friendly coal mining and environmental laws for the abatement of environmental degradation are discussed in this paper.

Development of a decision model for selection of appropriate timely delivery techniques for highway projects : final report, April 2009.

DOT National Transportation Integrated Search

2009-04-01

The primary umbrella method used by the Oregon Department of Transportation (ODOT) to ensure on-time performance in standard construction contracting is liquidated damages. The assessment value is usually a matter of some judgment. In practice,...

Immunofluorescence Staining — EDRN Public Portal

Cancer.gov

Direct immunofluorescence method is used to detect the deposit of immunoglobulins, complement components, fibrinogen, etc. in tissues. This technique is usually performed on frozen sections. The primary antibody is conjugated to fluorescein binds directly with the antigen and can be detected by the fluorescent tag using a fluorescent microscope.

Can Neuroscience Construct a Literate Gendered Culture?

ERIC Educational Resources Information Center

Whitehead, David

2011-01-01

The construction of boys as a gendered culture is not usually associated with neuroscience. Exceptions are publications and presentations by consultants on boys' education who adopt a "brain-based" perspective. From a neuroscience perspective, my analysis indicates the selective use of primary neuroscience research to construct and perpetuate…

Comprehensive process model of clinical information interaction in primary care: results of a "best-fit" framework synthesis.

PubMed

Veinot, Tiffany C; Senteio, Charles R; Hanauer, David; Lowery, Julie C

2018-06-01

To describe a new, comprehensive process model of clinical information interaction in primary care (Clinical Information Interaction Model, or CIIM) based on a systematic synthesis of published research. We used the "best fit" framework synthesis approach. Searches were performed in PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Library and Information Science Abstracts, Library, Information Science and Technology Abstracts, and Engineering Village. Two authors reviewed articles according to inclusion and exclusion criteria. Data abstraction and content analysis of 443 published papers were used to create a model in which every element was supported by empirical research. The CIIM documents how primary care clinicians interact with information as they make point-of-care clinical decisions. The model highlights 3 major process components: (1) context, (2) activity (usual and contingent), and (3) influence. Usual activities include information processing, source-user interaction, information evaluation, selection of information, information use, clinical reasoning, and clinical decisions. Clinician characteristics, patient behaviors, and other professionals influence the process. The CIIM depicts the complete process of information interaction, enabling a grasp of relationships previously difficult to discern. The CIIM suggests potentially helpful functionality for clinical decision support systems (CDSSs) to support primary care, including a greater focus on information processing and use. The CIIM also documents the role of influence in clinical information interaction; influencers may affect the success of CDSS implementations. The CIIM offers a new framework for achieving CDSS workflow integration and new directions for CDSS design that can support the work of diverse primary care clinicians.

Water balance in irrigation districts. Uncertainty in on-demand pressurized networks

NASA Astrophysics Data System (ADS)

Sánchez-Calvo, Raúl; Rodríguez-Sinobas, Leonor; Juana, Luis; Laguna, Francisco Vicente

2015-04-01

In on-demand pressurized irrigation distribution networks, applied water volume is usually controlled opening a valve during a calculated time interval, and assuming constant flow rate. In general, pressure regulating devices for controlling the discharged flow rate by irrigation units are needed due to the variability of pressure conditions. A pressure regulating valve PRV is the commonly used pressure regulating device in a hydrant, which, also, executes the open and close function. A hydrant feeds several irrigation units, requiring a wide range in flow rate. In addition, some flow meters are also available, one as a component of the hydrant and the rest are placed downstream. Every land owner has one flow meter for each group of field plots downstream the hydrant. Ideal PRV performance would maintain a constant downstream pressure. However, the true performance depends on both upstream pressure and the discharged flow rate. Theoretical flow rates values have been introduced into a PRV behavioral model, validated in laboratory, coupled with an on-demand irrigation district waterworks, composed by a distribution network and a multi-pump station. Variations on flow rate are simulated by taking into account the consequences of variations on climate conditions and also decisions in irrigation operation, such us duration and frequency application. The model comprises continuity, dynamic and energy equations of the components of both the PRV and the water distribution network. In this work the estimation of water balance terms during the irrigation events in an irrigation campaign has been simulated. The effect of demand concentration peaks has been estimated.

Unveiling the Teachers' Profiles through an INSET (In Service Training) Course of Greek Primary School Teachers in the Pedagogy of ICT (Information and Communications Technology) In-Classroom Instruction

ERIC Educational Resources Information Center

Amanatidis, Nikolaos

2015-01-01

To meet the increasing demand for change in the infusion of ICT pedagogy in education a nationwide project was launched in Greece on May 2008. An INSET course for primary school teachers in the pedagogy of ICT in classroom instruction. The writer, aimed to study the teachers' views about certain aspects of the training experience in terms of the…

Behavior Intervention for Students with Externalizing Behavior Problems: Primary-Level Standard Protocol

ERIC Educational Resources Information Center

Benner, Gregory J.; Nelson, J. Ron; Sanders, Elizabeth A.; Ralston, Nicole C.

2012-01-01

This article examined the efficacy of a primary-level, standard-protocol behavior intervention for students with externalizing behavioral disorders. Elementary schools were randomly assigned to treatment (behavior intervention) or control (business as usual) conditions, and K-3 students were screened for externalizing behavior risk status. The…

Effective Primary Schools in Geographically Isolated Areas of Vietnam

ERIC Educational Resources Information Center

Ikeda, Miyako

2010-01-01

This study identifies the major characteristics of "effective" primary schools in isolated areas in Vietnam. It suggests areas in which the implementation of beneficial changes can occur. Pupils in isolated areas of Vietnam are, in many respects, educationally disadvantaged. Usually, these pupils are in schools that have fewer…

Primary pelvic hydatid cyst with sciatic compression.

PubMed

Nouira, F; Chouikh, T; Charieg, A; Ghorbel, S; Jlidi, S; Chaouachi, B

2011-01-01

Hydatid cysts are endemic in certain regions of the world and particulary in North Africa. They are usually located in the liver, lung, and spleen, though many uncommon locations have been reported. This is the first report of a child with primary pelvic hydatid disease causing a sciatic compression.