Fatigue, physical performance, and systemic inflammation in patients with chronic obstructive pulmonary disease

Thesis (Ph.D.)--University of Washington, 2016-06

A composite leading indicator of the inflation cycle for the Euro area

We evaluate the performance of composite leading indicators of turning points of inflation in the Euro area, constructed by combining the techniques of Fourier analysis and Kalman filters with the National Bureau of Economic Research methodology. In addition, the study compares the empirical performance of Euro Simple Sum and Divisia monetary aggregates and provides a tentative answer to the issue of whether or not the UK should join the Euro area. Our findings suggest that, first, the cyclical pattern of the different composite leading indicators very closely reflect that of the inflation cycle for the Euro area; second, the empirical performance of the Euro Divisia is better than its Simple Sum counterpart and third, the UK is better out of the Euro area. © 2005 Taylor & Francis Group Ltd.

Impact of senescence and disease on the structural and functional performance of the visual pathway

The diagnosis and monitoring of ocular disease presents considerable clinical difficulties for two main reasons i) the substantial physiological variation of anatomical structure of the visual pathway and ii) constraints due to technical limitations of diagnostic hardware. These are further confounded by difficulties in detecting early loss or change in visual function due to the masking of disease effects, for example, due to a high degree of redundancy in terms of nerve fibre number along the visual pathway. This thesis addresses these issues across three areas of study: 1. Factors influencing retinal thickness measures and their clinical interpretation As the retina is the principal anatomical site for damage associated with visual loss, objective measures of retinal thickness and retinal nerve fibre layer thickness are key to the detection of pathology. In this thesis the ability of optical coherence tomography (OCT) to provide repeatable and reproducible measures of retinal structure at the macula and optic nerve head is investigated. In addition, the normal physiological variations in retinal thickness and retinal nerve fibre layer thickness are explored. Principal findings were: • Macular retinal thickness and optic nerve head measurements are repeatable and reproducible for normal subjects and diseased eyes • Macular and retinal nerve fibre layer thickness around the optic nerve correlate negatively with axial length, suggesting that larger eyes have thinner retinae, potentially making them more susceptible to damage or disease • Foveola retinal thickness increases with age while retinal nerve fibre layer thickness around the optic nerve head decreases with age. Such findings should be considered during examination of the eye with suspect pathology or in long-term disease monitoring 2. Impact of glucose control on retinal anatomy and function in diabetes Diabetes is a major health concern in the UK and worldwide and diabetic retinopathy is a major cause of blindness in the working population. Objective, quantitative measurements of retinal thickness. particularly at the macula provide essential information regarding disease progression and the efficacy of treatment. Functional vision loss in diabetic patients is commonly observed in clinical and experimental studies and is thought to be affected by blood glucose levels. In the first study of its kind, the short term impact of fluctuations in blood glucose levels on retinal structure and function over a 12 hour period in patients with diabetes are investigated. Principal findings were: • Acute fluctuations in blood glucose levels are greater in diabetic patients than normal subjects • The fluctuations in blood glucose levels impact contrast sensitivity scores. SWAP visual fields, intraocular pressure and diastolic pressure. This effect is similar for type 1 and type 2 diabetic patients despite the differences in their physiological status. • Long-term metabolic control in the diabetic patient is a useful predictor in the fluctuation of contrast sensitivity scores. • Large fluctuations in blood glucose levels and/or visual function and structure may be indicative of an increased risk of development or progression of retinopathy 3. Structural and functional damage of the visual pathway in glaucomatous optic neuropathy The glaucomatous eye undergoes a number of well documented pathological changes including retinal nerve fibre loss and optic nerve head damage which is correlated with loss of functional vision. In experimental glaucoma there is evidence that glaucomatous damage extends from retinal ganglion cells in the eye, along the visual pathway, to vision centres in the brain. This thesis explores the effects of glaucoma on retinal nerve fibre layer thickness, ocular anterior anatomy and cortical structure, and its correlates with visual function in humans. Principal findings were: • In the retina, glaucomatous retinal nerve fibre layer loss is less marked with increasing distance from the optic nerve head, suggesting that RNFL examination at a greater distance than traditionally employed may provide invaluable early indicators of glaucomatous damage • Neuroretinal rim area and retrobulbar optic nerve diameter are strong indicators of visual field loss • Grey matter density decreases at a rate of 3.85% per decade. There was no clear evidence of a disease effect • Cortical activation as measured by fMRI was a strong indicator of functional damage in patients with significant neuroretinal rim loss despite relatively modest visual field defects These investigations have shown that the effects of senescence are evident in both the anterior and posterior visual pathway. A variety of anatomical and functional diagnostic protocols for the investigation of damage to the visual pathway in ocular disease are required to maximise understanding of the disease processes and thereby optimising patient care.

Selection & development of short-term project team members:developmental stability as an indicator of interpersonal skills

Short-term project teams do not have the advantage of prior performance or long-term membership to facilitate development of effective team performance. Research suggests interpersonal skills are crucial to success but this is under researched longitudinally. Evolutionary psychology can provide a lens to explain how people develop differing levels of interpersonal skills via the relationship between fluctuating asymmetry and pro-social behaviours. This research aims to investigate the relationship between fluctuating asymmetry and interpersonal skills, the impact of training and to further the evolutionary psychology field by embedding research in a real-world context as opposed to solely in laboratory or student settings.

Climate change performance measurement, control and accountability in English local areas

Purpose – This paper aims to consider how climate change performance is measured and accounted for within the performance framework for local authority areas in England adopted in 2008. It critically evaluates the design of two mitigation and one adaptation indicators that are most relevant to climate change. Further, the potential for these performance indicators to contribute to climate change mitigation and adaptation is discussed. Design/methodology/approach – The authors begin by examining the importance of the performance framework and the related Local Area Agreements (LAAs), which were negotiated for all local areas in England between central government and Local Strategic Partnerships (LSPs). This development is located within the broader literature relating to new public management. The potential for this framework to assist in delivering the UK's climate change policy objectives is researched in a two-stage process. First, government publications and all 150 LAAs were analysed to identify the level of priority given to the climate change indicators. Second, interviews were conducted in spring 2009 with civil servants and local authority officials from the English West Midlands who were engaged in negotiating the climate change content of the LAAs. Findings – Nationally, the authors find that 97 per cent of LAAs included at least one climate change indicator as a priority. The indicators themselves, however, are perceived to be problematic – in terms of appropriateness, accuracy and timeliness. In addition, concerns were identified about the level of local control over the drivers of climate change performance and, therefore, a question is raised as to how LSPs can be held accountable for this. On a more positive note, for those concerned about climate change, the authors do find evidence that the inclusion of these indicators within the performance framework has helped to move climate change up the agenda for local authorities and their partners. However, actions by the UK's new coalition government to abolish the national performance framework and substantially reduce public expenditure potentially threaten this advance. Originality/value – This paper offers an insight into a new development for measuring climate change performance at a local level, which is relatively under-researched. It also contributes to knowledge of accountability within a local government setting and provides a reference point for further research into the potential role of local actions to address the issue of climate change.

Pink shrimp as an indicator for restoration of everglades ecosystems

The pink shrimp, Farfantepenaeus duorarum, familiar to most Floridians as either food or bait shrimp, is ubiquitous in South Florida coastal and offshore waters and is proposed as an indicator for assessing restoration of South Florida's southern estuaries: Florida Bay, Biscayne Bay, and the mangrove estuaries of the lower southwest coast. Relationships between pink shrimp and salinity have been determined in both field and laboratory studies. Salinity is directly relevant to restoration because the salinity regimes of South Florida estuaries, critical nursery habitat for the pink shrimp, will be altered by changes in the quantity, timing, and distribution of freshwater inflow planned as part of the Comprehensive Everglades Restoration Project (CERP). Here we suggest performance measures based on pink shrimp density (number per square meter) in the estuaries and propose a restoration assessment and scoring scheme using these performance measures that can readily be communicated to managers, policy makers, and the interested public. The pink shrimp is an appropriate restoration indicator because of its ecological as well as its economic importance and also because scientific interest in pink shrimp in South Florida has produced a wealth of information about the species and relatively long time series of data on both juveniles in estuarine nursery habitats and adults on the fishing grounds. We suggest research needs for improving the pink shrimp performance measure.

Developing performance measures of mangrove wetlands using simulation models of hydrology, nutrient biogeochemistry, and community dynamics

The goal of mangrove restoration projects should be to improve community structure and ecosystem function of degraded coastal landscapes. This requires the ability to forecast how mangrove structure and function will respond to prescribed changes in site conditions including hydrology, topography, and geophysical energies. There are global, regional, and local factors that can explain gradients of regulators (e.g., salinity, sulfides), resources (nutrients, light, water), and hydroperiod (frequency, duration of flooding) that collectively account for stressors that result in diverse patterns of mangrove properties across a variety of environmental settings. Simulation models of hydrology, nutrient biogeochemistry, and vegetation dynamics have been developed to forecast patterns in mangroves in the Florida Coastal Everglades. These models provide insight to mangrove response to specific restoration alternatives, testing causal mechanisms of system degradation. We propose that these models can also assist in selecting performance measures for monitoring programs that evaluate project effectiveness. This selection process in turn improves model development and calibration for forecasting mangrove response to restoration alternatives. Hydrologic performance measures include soil regulators, particularly soil salinity, surface topography of mangrove landscape, and hydroperiod, including both the frequency and duration of flooding. Estuarine performance measures should include salinity of the bay, tidal amplitude, and conditions of fresh water discharge (included in the salinity value). The most important performance measures from the mangrove biogeochemistry model should include soil resources (bulk density, total nitrogen, and phosphorus) and soil accretion. Mangrove ecology performance measures should include forest dimension analysis (transects and/or plots), sapling recruitment, leaf area index, and faunal relationships. Estuarine ecology performance measures should include the habitat function of mangroves, which can be evaluated with growth rate of key species, habitat suitability analysis, isotope abundance of indicator species, and bird census. The list of performance measures can be modified according to the model output that is used to define the scientific goals during the restoration planning process that reflect specific goals of the project.

Roseate spoonbill reproduction as an indicator for restoration of the Everglades and the Everglades estuaries

Ecological monitoring is key to successful ecosystem restoration. Because all components within an ecosystem cannot be monitored, it is important to select indicators that are representative of the system, integrate system responses, clearly respond to system change, can be effectively and efficiently monitored, and are easily communicated. The roseate spoonbill is one ecological indicator species that meets these criteria within the Everglades ecosystem. Monitoring of roseate spoonbills in Florida Bay over the past 70 years has shown that aspects of this species’ reproduction respond to changes in hydrology and corresponding changes in prey abundance and availability. This indicator uses nesting location, nest numbers and nesting success in response to food abundance and availability. In turn, prey abundance is a function of hydrological conditions (especially water depth) and salinity. Metrics and targets for these performance measures were established based on previous findings. Values of each metric were translated into indices and identified as stoplight colors with green indicating that a given target has been met, yellow indicating that conditions are below the target, but within an acceptable range of it, and red indicating the measure is performing poorly in relation to the target.

Eastern oysters (Crassostrea virginica) as an indicator for restoration of Everglades Ecosystems

The Comprehensive Everglades Restoration Plan (CERP) attempts to restore hydrology in the Northern and Southern Estuaries of Florida. Reefs of the Eastern oyster Crassostrea virginica are a dominant feature of the estuaries along the Southwest Florida coast. Oysters are benthic, sessile, filter-feeding organisms that provide ecosystem services by filtering the water column and providing food, shelter and habitat for associated organisms. As such, the species is an excellent sentinel organism for examining the impacts of restoration on estuarine ecosystems. The implementation of CERP attempts to improve: the hydrology and spatial and structural characteristics of oyster reefs, the recruitment and survivorship of C. virginica, and the reef-associated communities of organisms. This project links biological responses and environmental conditions relative to hydrological changes as a means of assessing positive or negative trends in oyster responses and population trends. Using oyster responses, we have developed a communication tool (i.e., Stoplight Report Card) based on CERP performance measures that can distinguish between responses to restoration and natural patterns. The Stoplight Report Card system is a communication tool that uses Monitoring and Assessment Program (MAP) performance measures to grade an estuary's response to changes brought about by anthropogenic input or restoration activities. The Stoplight Report Card consists of both a suitability index score for each organism metric as well as a trend score (− decreasing trend, +/− no change in trend, and + increasing trend). Based on these two measures, a component score (e.g., living density) is calculated by averaging the suitability index score and the trend score. The final index score is obtained by taking the geometric score of each component, which is then translated into a stoplight color for success (green), caution (yellow), or failure (red). Based on the data available for oyster populations and the responses of oysters in the Caloosahatchee Estuary, the system is currently at stage “caution.” This communication tool instantly conveys the status of the indicator and the suitability, while trend curves provide information on progress towards reaching a target. Furthermore, the tool has the advantage of being able to be applied regionally, by species, and collectively, in concert with other species, system-wide.

UK consensus project on quality in palliative day services: developing a quality indicator set using the RAND/UCLA appropriateness method

Introduction
Evaluating quality of palliative day services is essential for assessing care across diverse settings, and for monitoring quality improvement approaches.

Aim
To develop a set of quality indicators for assessment of all aspects (structure, process and outcome) of care in palliative day services.

Methods
Using a modified version of the RAND/UCLA appropriateness method (Fitch et al., 2001), a multidisciplinary panel of 16 experts independently completed a survey rating the appropriateness of 182 potential quality indicators previously identified during a systematic evidence review. Panel members then attended a one day, face-to-face meeting where indicators were discussed and subsequently re-rated. Panel members were also asked to rate the feasibility and necessity of measuring each indicator.

Results
71 indicators classified as inappropriate during the survey were removed based on median appropriateness ratings and level of agreement. Following the panel discussions, a further 60 were removed based on appropriateness and feasibility ratings, level of agreement and assessment of necessity. Themes identified during the panel discussion and findings of the evidence review were used to translate the remaining 51 indicators into a final set of 27.

Conclusion
The final indicator set included information on rationale and supporting evidence, methods of assessment, risk adjustment, and recommended performance levels. Further implementation work will test the suitability of this ‘toolkit’ for measurement and benchmarking. The final indicator set provides the basis for standardised assessment of quality across services, including care delivered in community and primary care settings.

Reference

• Fitch K, Bernstein SJ, Aguilar MD, et al. The RAND/UCLA Appropriateness Method User’s Manual. Santa Monica, CA: RAND Corporation; 2001. http://www.rand.org/pubs/monograph_reports/MR1269

Obstruction and infiltration: a proposal of a quality indicator.

Background The quest for continuous improvement of the quality of provided care is the objective of nursing care. However, the insertion and permanence of a peripheral venous catheter has been associated to complications, thus making a systematic evaluation of the performance of professionals and the management of health services important. Objective: Analyse complications that caused removal of intravenous catheters. Methods A prospective study with 64 patients of a health service of Portugal, from July to September/2015. Included patients with age 18 years, with a peripheral venous catheter. Descriptive analysis using SPSS. Ethical requirements were met. Results Two hundred three (203) intravenous catheters, in 64 patients, most elderly (section 95.3 %), with mean age of 80 years were evaluated. The catheters remained inserted between one and 12 days (mean 2 days), 66 % of the devices were removed because of complications, such as: removal by the patient (17.7 %), obstruction (17.2 %), infiltration (14.8 %), phlebitis (9.4 %) and fluid exiting the insertion site (6.4 %). The prevalence of obstruction and infiltration per patient was respectively 36 % and 39 %. Conclusions Obstruction and infiltration were the complications of higher prevalence that led to the removal and reinsertion of a new peripheral venous catheter with the possibility of increased pain, infection and hospital costs. Faced with the risk of compromising patient safety and being able to contribute to the improvement of health care, we suggest the inclusion of obstruction and infiltration in the indicators of quality of care, in order to have systematic evaluation of results, (re)plan and implement preventive measures.

THE USE OF THE EARLY WARNING INDICATOR REPORT TO IMPACT NINTH GRADE PROMOTION RATES IN A LARGE URBAN SCHOOL DISTRICT

Abstract The purpose of this study was to examine how four high schools used an Early Warning Indicator Report (EWIR) to improve ninth grade promotion rates. Ninth grade on-time promotion is an early predictor of a student’s likelihood to graduate (Bornsheuer, Polonyi, Andrews, Fore, & Onwuegbuzie, 2011; Leckrone & Griffith, 2006; Roderick, Kelley-Kemple, Johnson, & Beechum, 2014; Zvoch, 2006). The analysis revealed both similarities and differences in the ways that the four schools used the EWIR. The research took place in a large urban school district in the Mid-Atlantic. Sixteen participants from four high schools and the district’s central office voluntarily participated in face-to-face interviews. The researcher utilized a qualitative case study method to examine the implementation of the EWIR system in Wyatt School District. The interview data was transcribed and analyzed, along with district documents, to identify categories in this cross case analysis. Three primary themes emerged from the data: (1) targeted school structures for EWIR implementation, (2) the EWIR identified necessary supports for students, and (3) the central office support for school staff. The findings revealed the various ways that the target schools implemented the EWIR in their buildings and the level of support that they received from the central office that aided them in using the EWIR to improve ninth grade promotion rates. Based on the findings of this study, the researcher provided a number of key recommendations: (1) Districts should provide professional development to schools to ensure that schools have the support they need to implement the EWIR successfully; (2) There should be increased accountability from the central office for schools using the EWIR to identify impactful interventions for ninth graders; and (3) The district needs to assign dedicated central office staff to support the implementation of the EWIR in high schools across the district. As schools continue to face the challenge of improving ninth grade promotion rates, effective use of an Early Warning Indicator Report is recommended to provide school and district staff with data needed to impact overall student performance.

An A Posteriori Error Indicator for Discontinuous Galerkin Approximations of Fourth Order Elliptic Problems

We introduce a residual-based a posteriori error indicator for discontinuous Galerkin discretizations of the biharmonic equation with essential boundary conditions. We show that the indicator is both reliable and efficient with respect to the approximation error measured in terms of a natural energy norm, under minimal regularity assumptions. We validate the performance of the indicator within an adaptive mesh refinement procedure and show its asymptotic exactness for a range of test problems.

The relationship between start performance and race outcome in elite 500-m short-track speed skating

Initial short-track speed-skating 14-m start performance has substantial influence on 500-m race outcome at the international level, yet the relationship has not been systematically quantified. The purpose of this investigation was to examine the relationship between rank position entering first corner (RPEFC) and race outcome and to understand how this relationship changes with competition round and absolute race intensity. Data were compiled from 2011-2014 World Cup seasons and 2010 and 2014 Olympic Winter Games. Association between RPEFC and race outcome was determined through Kendall tau-rank correlations. A visual comparison was made of how the relationship changes with relative competition level (race tau correlations were sorted by competition round) and with race intensity (race tau correlations were sorted by within-event winning time). A very large relationship between RPEFC and race outcome was observed (correlations for cohort, τ = .60; men, τ = .53; women, τ= .67). When examined by competition round (quarter- to A-finals), no substantial change in relationship was observed (men, τ= .57-.46; women, τ= .73-.53). However, when the start-performance relationship was considered by within-event winning time, the relationship strength increased with decreasing time (men, τ = .61 to .46; women, τ = .76 to .57; fastest to 7th- and 8th-fastest combined, respectively). These results establish and quantify RPEFC as an important aspect of elite short-track 500-m race outcome. RPEFC as an indicator of race outcome becomes increasingly important with absolute race intensity, suggesting that RPEFC capability is a discriminating factor for competitors of similar top speed and speed endurance.