The feasibility of self-report advance directives among elderly patients with cognitive impairment

The central objective of this dissertation was to determine the feasibility of self-completed advance directives (AD) in older persons suffering from mild and moderate stages of dementia. This was accomplished by identifying differences in ability to complete AD among elderly subjects with increasing degrees of dementia and cognitive incompetence. Secondary objectives were to describe and compare advance directives completed by elders and identified proxy decision makers. Secondary objectives were accomplished by measuring the agreement between advance directives completed by proxy and elder, and comparing that agreement across groups defined by the elder's cognitive status. This cross-sectional study employed a structured interview to elicit AD, followed by a similar interview with a proxy decision maker identified by the elder. A stratified sampling scheme recruited elders with normal cognition, mild, and moderate forms of dementia using the Mini Mental-State Exam (MMSE). The Hopkins Competency Assessment Test (HCAT) was used for evaluation of competency to make medical decisions. Analysis was conducted on "between group" (non-demented $\leftrightarrow$ mild dementia $\leftrightarrow$ moderate dementia, and competent $\leftrightarrow$ incompetent) and "within group" (elder $\leftrightarrow$ family member) variation.^ The 118 elderly subjects interviewed were generally male, Caucasian, and of low socioeconomic status. Mean age was 77. Overall, elders preferred a "trial of therapy" regarding AD rather than to "always receive the therapy". No intervention was refused outright more often than it was accepted. A test-retest of elders' AD revealed stable responses. Eleven logic checks measured appropriateness of AD responses independent of preference. No difference was found in logic error rates between elders grouped by MMSE or HCAT. Agreement between proxy and elder responses showed significant dissimilarity, indicating that proxies were not making the same medical decisions as the elders.^ Conclusions based on these data are: (1) Self reporting AD is feasible among elders showing signs of cognitive impairment and they should be given all opportunities to complete advance directives, (2) variation in preferences for advance directives in cognitively impaired elders should not be assumed to be the effects of their impairment alone, (3) proxies do not appear to forego life-prolonging interventions in the face of increasing impairment in their ward, however, their advance directives choices are frequently not those of the elder they represent. ^

Mistreatment and self-neglect in community dwelling older adults: Studies of construct validity, measurement invariance and latent classes

Mistreatment and self-neglect significantly increase the risk of dying in older adults. It is estimated that 1 to 2 million older adults experience elder mistreatment and self-neglect every year in the United States. Currently, there are no elder mistreatment and self-neglect assessment tools with construct validity and measurement invariance testing and no studies have sought to identify underlying latent classes of elder self-neglect that may have differential mortality rates. Using data from 11,280 adults with Texas APS substantiated elder mistreatment and self-neglect 3 studies were conducted to: (1) test the construct validity and (2) the measurement invariance across gender and ethnicity of the Texas Adult Protective Services (APS) Client Assessment and Risk Evaluation (CARE) tool and (3) identify latent classes associated with elder self-neglect. Study 1 confirmed the construct validity of the CARE tool following adjustments to the initial hypothesized CARE tool. This resulted in the deletion of 14 assessment items and a final assessment with 5 original factors and 43 items. Cross-validation for this model was achieved. Study 2 provided empirical evidence for factor loading and item-threshold invariance of the CARE tool across gender and between African-Americans and Caucasians. The financial status domain of the CARE tool did not function properly for Hispanics and thus, had to be deleted. Subsequent analyses showed factor loading and item-threshold invariance across all 3 ethnic groups with the exception of some residual errors. Study 3 identified 4-latent classes associated with elder self-neglect behaviors which included individuals with evidence of problems in the areas of (1) their environment, (2) physical and medical status, (3) multiple domains and (4) finances. Overall, these studies provide evidence supporting the use of APS CARE tool for providing unbiased and valid investigations of mistreatment and neglect in older adults with different demographic characteristics. Furthermore, the findings support the underlying notion that elder self-neglect may not only occur along a continuum, but that differential types may exist. All of which, have very important potential implications for social and health services distributed to vulnerable mistreated and neglected older adults.^

ATTITUDES TOWARD AND UTILIZATION OF NON-INVASIVE PRENATAL TESTING FOR CHROMOSOME ANEUPLOIDY AMONG OB/GYNS

Prenatal diagnosis is traditionally made via invasive procedures such as amniocentesis and chorionic villus sampling (CVS). However, both procedures carry a risk of complications, including miscarriage. Many groups have spent years searching for a way to diagnose a chromosome aneuploidy without putting the fetus or the mother at risk for complications. Non-invasive prenatal testing (NIPT) for chromosome aneuploidy became commercially available in the fall of 2011, with detection rates similar to those of invasive procedures for the common autosomal aneuploidies (Palomaki et al., 2011; Ashoor et al. 2012; Bianchi et al. 2012). Eventually NIPT may become the diagnostic standard of care and reduce invasive procedure-related losses (Palomaki et al., 2011). The integration of NIPT into clinical practice has potential to revolutionize prenatal diagnosis; however, it also raises some crucial issues for practitioners. Now that the test is clinically available, no studies have looked at the physicians that will be ordering the testing or referring patients to practitioners who do. This study aimed to evaluate the attitudes of OB/GYN’s and how they are incorporating the test into clinical practice. Our study shows that most physicians are offering this new, non-invasive technology to their patients, and that their practices were congruent with the literature and available professional society opinions. Those physicians who do not offer NIPT to their patients would like more literature on the topic as well as instructive guidelines from their professional societies. Additionally, this study shows that the practices and attitudes of MFMs and OBs differ. Our population feels that the incorporation of NIPT will change their practices by lowering the amount of invasive procedures, possibly replacing maternal serum screening, and that it will simplify prenatal diagnosis. However, those physicians who do not offer NIPT to their patients are not quite sure how the test will affect their clinical practice. From this study we are able to glean how physicians are incorporating this new technology into their practice and how they feel about the addition to their repertoire of tests. This knowledge gives insight as to how to best move forward with the quickly changing field of prenatal diagnosis.

Self -management behavior in patients with cystic fibrosis

Self-management is being promoted in cystic fibrosis (CF). However, it has not been well studied. Principal aims of this research were (1) to evaluate psychometric properties of a CF disease status measure, the NIH Clinical Score; (2) to develop and validate a measure of self-management behavior, the SMQ-CF scale, and (3) to examine the relation between self-management and disease status in CF patients over two years.^ In study 1, NIH Clinical Scores for 200 patients were used. The scale was examined for internal consistency, interrater reliability, and content validity using factor analysis. The Cronbach's alpha (.81) and interrater reliability (.90) for the total scale were high. General scale items were less reliable. Factor analysis indicated that most of the variance in disease status is accounted for by Factor 1 which consists of pulmonary disease items.^ The SMQ-CF measures the performance of CF self-management. Pilot testing was done with 98 CF primary caregivers. Internal consistency reliability, social desirability bias, and content validity using factor analysis were examined. Internal consistency was good (alpha =.95). Social desirability correlation was low (r =.095). Twelve factors identified were consistent with conceptual groupings of behaviors. Around two hundred caregivers from two CF centers were surveyed and multivariate analysis of variance was used to assess construct validity. Results confirmed expected relations between self-management, patient age, and disease status. Patient age accounted for 50% and disease status 18% of the variance in the SMQ-CF scale.^ It was hypothesized that self-management would positively affect future disease status. Data from 199 CF patients (control and education intervention groups) were examined. Models of hypothesized relations were tested using LISREL structural equation modeling. Results indicated that the relations between baseline self-management and Time 1 disease status were not significant. Significant relations were observed in self-management behaviors from time 1 to time 2 and patterns of significant relations differed between the two groups.^ This research has contributed to refinements in the ability to measure self-management behavior and disease status outcomes in cystic fibrosis. In addition, it provides the first steps in exploratory behavioral analysis with regard to self-management in this disease. ^

Probability sampling protocol of classification maps from spaceborne/airborne image

To deliver sample estimates provided with the necessary probability foundation to permit generalization from the sample data subset to the whole target population being sampled, probability sampling strategies are required to satisfy three necessary not sufficient conditions: (i) All inclusion probabilities be greater than zero in the target population to be sampled. If some sampling units have an inclusion probability of zero, then a map accuracy assessment does not represent the entire target region depicted in the map to be assessed. (ii) The inclusion probabilities must be: (a) knowable for nonsampled units and (b) known for those units selected in the sample: since the inclusion probability determines the weight attached to each sampling unit in the accuracy estimation formulas, if the inclusion probabilities are unknown, so are the estimation weights. This original work presents a novel (to the best of these authors' knowledge, the first) probability sampling protocol for quality assessment and comparison of thematic maps generated from spaceborne/airborne Very High Resolution (VHR) images, where: (I) an original Categorical Variable Pair Similarity Index (CVPSI, proposed in two different formulations) is estimated as a fuzzy degree of match between a reference and a test semantic vocabulary, which may not coincide, and (II) both symbolic pixel-based thematic quality indicators (TQIs) and sub-symbolic object-based spatial quality indicators (SQIs) are estimated with a degree of uncertainty in measurement in compliance with the well-known Quality Assurance Framework for Earth Observation (QA4EO) guidelines. Like a decision-tree, any protocol (guidelines for best practice) comprises a set of rules, equivalent to structural knowledge, and an order of presentation of the rule set, known as procedural knowledge. The combination of these two levels of knowledge makes an original protocol worth more than the sum of its parts. The several degrees of novelty of the proposed probability sampling protocol are highlighted in this paper, at the levels of understanding of both structural and procedural knowledge, in comparison with related multi-disciplinary works selected from the existing literature. In the experimental session the proposed protocol is tested for accuracy validation of preliminary classification maps automatically generated by the Satellite Image Automatic MapperT (SIAMT) software product from two WorldView-2 images and one QuickBird-2 image provided by DigitalGlobe for testing purposes. In these experiments, collected TQIs and SQIs are statistically valid, statistically significant, consistent across maps and in agreement with theoretical expectations, visual (qualitative) evidence and quantitative quality indexes of operativeness (OQIs) claimed for SIAMT by related papers. As a subsidiary conclusion, the statistically consistent and statistically significant accuracy validation of the SIAMT pre-classification maps proposed in this contribution, together with OQIs claimed for SIAMT by related works, make the operational (automatic, accurate, near real-time, robust, scalable) SIAMT software product eligible for opening up new inter-disciplinary research and market opportunities in accordance with the visionary goal of the Global Earth Observation System of Systems (GEOSS) initiative and the QA4EO international guidelines.

Polypropylene fiber-reinforced self-compacting concrete for the reconstruction of the cathedral of La Laguna, Canary Island, Spain

High performance materials are needed for the reconstruction of such a singular building as a cathedral, since in addition to special mechanical properties, high self compact ability, high durability and high surface quality, are specified. Because of the project’s specifications, the use of polypropylene fiber-reinforced, self-compacting concrete was selected by the engineering office. The low quality of local materials and the lack of experience in applying macro polypropylene fiber for structural reinforcement with these components materials required the development of a pretesting program. To optimize the mix design, performance was evaluated following technical, economical and constructability criteria. Since the addition of fibers reduces concrete self-compactability, many trials were run to determine the optimal mix proportions. The variables introduced were paste volume; the aggregate skeleton of two or three fractions plus limestone filler; fiber type and dosage. Two mix designs were selected from the preliminary results. The first one was used as reference for self-compactability and mechanical properties. The second one was an optimized mix with a reduction in cement content of 20 kg/m3and fiber dosage of 1 kg/m3. For these mix designs, extended testing was carried out to measure the compression and flexural strength, modulus of elasticity, toughness, and water permeability resistance

Self-adaptive grids for noise mapping refinement

Noise maps are usually represented as contour or isolines maps describing the sound levels in a region. Using this kind of representation the user can easily find the noise level assigned to every location in the map. But the acoustic calculations behind the map are not performed for every single location on it; they are only performed in a grid of receivers. The results in this calculation grid are interpolated to draw the isolines or contours. Therefore, the resolution of the calculation grid and the way it was created (rectangular, triangulated, random…) have an effect on the resulting map. In this paper we describe a smart iterative procedure to optimize the quality of the map at a really low additional computational cost, using self-adaptive grids for the acoustic calculations. These self-adaptive grids add new receivers to the sampling grid in those locations where they are expected to be more useful, so that the performance at the output of the interpolator is enhanced. Self-adaptive sampling grids can be used for minimizing the overall error of the map (improving its quality), or for reducing calculation times, and can be also applied selectively to target areas or contour lines. This can be done by the user customizing the maximum number of iterations, the number of new receivers for each iteration, the target isolines, the target quality…

Fault Tolerance Analysis and Self-Healing Strategy of Autonomous, Evolvable Hardware Systems

This paper presents an analysis of the fault tolerance achieved by an autonomous, fully embedded evolvable hardware system, which uses a combination of partial dynamic reconfiguration and an evolutionary algorithm (EA). It demonstrates that the system may self-recover from both transient and cumulative permanent faults. This self-adaptive system, based on a 2D array of 16 (4×4) Processing Elements (PEs), is tested with an image filtering application. Results show that it may properly recover from faults in up to 3 PEs, that is, more than 18% cumulative permanent faults. Two fault models are used for testing purposes, at PE and CLB levels. Two self-healing strategies are also introduced, depending on whether fault diagnosis is available or not. They are based on scrubbing, fitness evaluation, dynamic partial reconfiguration and in-system evolutionary adaptation. Since most of these adaptability features are already available on the system for its normal operation, resource cost for self-healing is very low (only some code additions in the internal microprocessor core)

Using modular neural networks to model self-consciousness and self-representation for artificial entities

Self-consciousness implies not only self or group recognition, but also real knowledge of one’s own identity. Self-consciousness is only possible if an individual is intelligent enough to formulate an abstract self-representation. Moreover, it necessarily entails the capability of referencing and using this elf-representation in connection with other cognitive features, such as inference, and the anticipation of the consequences of both one’s own and other individuals’ acts. In this paper, a cognitive architecture for self-consciousness is proposed. This cognitive architecture includes several modules: abstraction, self-representation, other individuals'representation, decision and action modules. It includes a learning process of self-representation by direct (self-experience based) and observational learning (based on the observation of other individuals). For model implementation a new approach is taken using Modular Artificial Neural Networks (MANN). For model testing, a virtual environment has been implemented. This virtual environment can be described as a holonic system or holarchy, meaning that it is composed of autonomous entities that behave both as a whole and as part of a greater whole. The system is composed of a certain number of holons interacting. These holons are equipped with cognitive features, such as sensory perception, and a simplified model of personality and self-representation. We explain holons’ cognitive architecture that enables dynamic self-representation. We analyse the effect of holon interaction, focusing on the evolution of the holon’s abstract self-representation. Finally, the results are explained and analysed and conclusions drawn.

Detecting false testimonies in reputation systems using self-organizing maps

It has been demonstrated that rating trust and reputation of individual nodes is an effective approach in distributed environments in order to improve security, support decision-making and promote node collaboration. Nevertheless, these systems are vulnerable to deliberate false or unfair testimonies. In one scenario, the attackers collude to give negative feedback on the victim in order to lower or destroy its reputation. This attack is known as bad mouthing attack. In another scenario, a number of entities agree to give positive feedback on an entity (often with adversarial intentions). This attack is known as ballot stuffing. Both attack types can significantly deteriorate the performances of the network. The existing solutions for coping with these attacks are mainly concentrated on prevention techniques. In this work, we propose a solution that detects and isolates the abovementioned attackers, impeding them in this way to further spread their malicious activity. The approach is based on detecting outliers using clustering, in this case self-organizing maps. An important advantage of this approach is that we have no restrictions on training data, and thus there is no need for any data pre-processing. Testing results demonstrate the capability of the approach in detecting both bad mouthing and ballot stuffing attack in various scenarios.

Residential self-selection and geographical scales in trip frequency.

Neighbourhood representation and scale used to measure the built environment have been treated in many ways. However, it is anything but clear what representation of neighbourhood is the most feasible in the existing literature. This paper presents an exhaustive analysis of built environment attributes through three spatial scales. For this purpose multiple data sources are integrated, and a set of 943 observations is analysed. This paper simultaneously analyses the influence of two methodological issues in the study of the relationship between built environment and travel behaviour: (1) detailed representation of neighbourhood by testing different spatial scales; (2) the influence of unobserved individual sensitivity to built environment attributes. The results show that different spatial scales of built environment attributes produce different results. Hence, it is important to produce local and regional transport measures, according to geographical scale. Additionally, the results show significant sensitivity to built environment attributes depending on place of residence. This effect, called residential sorting, acquires different magnitudes depending on the geographical scale used to measure the built environment attributes. Spatial scales risk to the stability of model results. Hence, transportation modellers and planners must take into account both effects of self-selection and spatial scales.

Mechanical behaviour of laminated functionally graded fibre-reinforced self-compacting cementitious composites

El hormigón autocompactante (HAC) es una nueva tipología de hormigón o material compuesto base cemento que se caracteriza por ser capaz de fluir en el interior del encofrado o molde, llenándolo de forma natural, pasando entre las barras de armadura y consolidándose únicamente bajo la acción de su peso propio, sin ayuda de medios de compactación externos, y sin que se produzca segregación de sus componentes. Debido a sus propiedades frescas (capacidad de relleno, capacidad de paso, y resistencia a la segregación), el HAC contribuye de forma significativa a mejorar la calidad de las estructuras así como a abrir nuevos campos de aplicación del hormigón. Por otra parte, la utilidad del hormigón reforzado con fibras de acero (HRFA) es hoy en día incuestionable debido a la mejora significativa de sus propiedades mecánicas tales como resistencia a tracción, tenacidad, resistencia al impacto o su capacidad para absorber energía. Comparado con el HRFA, el hormigón autocompactante reforzado con fibras de acero (HACRFA) presenta como ventaja una mayor fluidez y cohesión ofreciendo, además de unas buenas propiedades mecánicas, importantes ventajas en relación con su puesta en obra. El objetivo global de esta tesis doctoral es el desarrollo de nuevas soluciones estructurales utilizando materiales compuestos base cemento autocompactantes reforzados con fibras de acero. La tesis presenta una nueva forma de resolver el problema basándose en el concepto de los materiales gradiente funcionales (MGF) o materiales con función gradiente (MFG) con el fin de distribuir de forma eficiente las fibras en la sección estructural. Para ello, parte del HAC se sustituye por HACRFA formando capas que presentan una transición gradual entre las mismas con el fin de obtener secciones robustas y exentas de tensiones entre capas con el fin de aplicar el concepto “MGF-laminados” a elementos estructurales tales como vigas, columnas, losas, etc. El proceso incluye asimismo el propio método de fabricación que, basado en la tecnología HAC, permite el desarrollo de interfases delgadas y robustas entre capas (1-3 mm) gracias a las propiedades reológicas del material. Para alcanzar dichos objetivos se ha llevado a cabo un amplio programa experimental cuyas etapas principales son las siguientes: • Definir y desarrollar un método de diseño que permita caracterizar de forma adecuada las propiedades mecánicas de la “interfase”. Esta primera fase experimental incluye: o las consideraciones generales del propio método de fabricación basado en el concepto de fabricación de materiales gradiente funcionales denominado “reología y gravedad”, o las consideraciones específicas del método de caracterización, o la caracterización de la “interfase”. • Estudiar el comportamiento mecánico sobre elementos estructurales, utilizando distintas configuraciones de MGF-laminado frente a acciones tanto estáticas como dinámicas con el fin de comprobar la viabilidad del material para ser usado en elementos estructurales tales como vigas, placas, pilares, etc. Los resultados indican la viabilidad de la metodología de fabricación adoptada, así como, las ventajas tanto estructurales como en reducción de costes de las soluciones laminadas propuestas. Es importante destacar la mejora en términos de resistencia a flexión, compresión o impacto del hormigón autocompactante gradiente funcional en comparación con soluciones de HACRFA monolíticos inclusos con un volumen neto de fibras (Vf) doble o superior. Self-compacting concrete (SCC) is an important advance in the concrete technology in the last decades. It is a new type of high performance concrete with the ability of flowing under its own weight and without the need of vibrations. Due to its specific fresh or rheological properties, such as filling ability, passing ability and segregation resistance, SCC may contribute to a significant improvement of the quality of concrete structures and open up new field for the application of concrete. On the other hand, the usefulness of steel fibre-reinforced concrete (SFRC) in civil engineering applications is unquestionable. SFRC can improve significantly the hardened mechanical properties such as tensile strength, impact resistance, toughness and energy absorption capacity. Compared to SFRC, self-compacting steel fibre-reinforced concrete (SCSFRC) is a relatively new type of concrete with high flowability and good cohesiveness. SCSFRC offers very attractive economical and technical benefits thanks to SCC rheological properties, which can be further extended, when combined with SFRC for improving their mechanical characteristics. However, for the different concrete structural elements, a single concrete mix is selected without an attempt to adapt the diverse fibre-reinforced concretes to the stress-strain sectional properly. This thesis focused on the development of high performance cement-based structural composites made of SCC with and without steel fibres, and their applications for enhanced mechanical properties in front of different types of load and pattern configurations. It presents a new direction for tackling the mechanical problem. The approach adopted is based on the concept of functionally graded cementitious composite (FGCC) where part of the plain SCC is strategically replaced by SCSFRC in order to obtain laminated functionally graded self-compacting cementitious composites, laminated-FGSCC, in single structural elements as beams, columns, slabs, etc. The approach also involves a most suitable casting method, which uses SCC technology to eliminate the potential sharp interlayer while easily forming a robust and regular reproducible graded interlayer of 1-3 mm by controlling the rheology of the mixes and using gravity at the same time to encourage the use of the powerful concept for designing more performance suitable and cost-efficient structural systems. To reach the challenging aim, a wide experimental programme has been carried out involving two main steps: • The definition and development of a novel methodology designed for the characterization of the main parameter associated to the interface- or laminated-FGSCC solutions: the graded interlayer. Work of this first part includes: o the design considerations of the innovative (in the field of concrete) production method based on “rheology and gravity” for producing FG-SCSFRC or as named in the thesis FGSCC, casting process and elements, o the design of a specific testing methodology, o the characterization of the interface-FGSCC by using the so designed testing methodology. • The characterization of the different medium size FGSCC samples under different static and dynamic loads patterns for exploring their possibilities to be used for structural elements as beams, columns, slabs, etc. The results revealed the efficiency of the manufacturing methodology, which allow creating robust structural sections, as well as the feasibility and cost effectiveness of the proposed FGSCC solutions for different structural uses. It is noticeable to say the improvement in terms of flexural, compressive or impact loads’ responses of the different FGSCC in front of equal strength class SCSFRC bulk elements with at least the double of overall net fibre volume fraction (Vf).

Hypothesis testing and earthquake prediction.

Requirements for testing include advance specification of the conditional rate density (probability per unit time, area, and magnitude) or, alternatively, probabilities for specified intervals of time, space, and magnitude. Here I consider testing fully specified hypotheses, with no parameter adjustments or arbitrary decisions allowed during the test period. Because it may take decades to validate prediction methods, it is worthwhile to formulate testable hypotheses carefully in advance. Earthquake prediction generally implies that the probability will be temporarily higher than normal. Such a statement requires knowledge of "normal behavior"--that is, it requires a null hypothesis. Hypotheses can be tested in three ways: (i) by comparing the number of actual earth-quakes to the number predicted, (ii) by comparing the likelihood score of actual earthquakes to the predicted distribution, and (iii) by comparing the likelihood ratio to that of a null hypothesis. The first two tests are purely self-consistency tests, while the third is a direct comparison of two hypotheses. Predictions made without a statement of probability are very difficult to test, and any test must be based on the ratio of earthquakes in and out of the forecast regions.

Recommendation of RILEM TC 178-TMC: Testing and modelling chloride penetration in concrete

This RILEM Technical Recommendation intends to give a general description of methods of sampling for obtaining chloride concentration profiles in concrete, applicable both for laboratory cast concrete specimens, for concrete cores taken from structures and for testing on site. These sampling procedures may be applied for obtaining concentration profiles of any other chemical species present in concrete.

Is Mindfulness Beneficial for Job Performance Following Positive and Negative Affective Events? The Attenuating Role of Mindfulness on Self-Serving Bias

Thesis (Ph.D.)--University of Washington, 2016-05