An n-of-1 trial service in clinical practice: Testing the effectiveness of stimulants for attention-deficit/hyperactivity disorder

OBJECTIVE. We sought to describe the clinical use of n-of-1 trials for attention-deficit/hyperactivity disorder in publicly and privately funded family and specialized pediatric practice in Australia. METHODS. We used a within-patient randomized, double-blind, crossover comparison of stimulant (dexamphetamine or methylphenidate) versus placebo or alternative stimulant using 3 pairs of treatment periods. Trials were conducted from a central location using mail and telephone communication, with local supervision by the patients' clinicians. PATIENTS. Our study population included children with clinically diagnosed attention-deficit/ hyperactivity disorder who were aged 5 to 16 years and previously stabilized on an optimal dose of stimulant. They were selected because treatment effectiveness was uncertain. MAIN OUTCOME MEASURES. Our measures included number of patients recruited, number of doctors who used the service, geographic spread, completion rates, response rate, and post-n-of-1 trial decisions. RESULTS. Forty-five doctors across Australia requested 108 n-of-1 trials, of which 86 were completed. In 69 drug-versus-placebo comparisons, 29 children responded better to stimulant than placebo. Immediately posttrial, 19 of 25 drug-versus-placebo responders stayed on the same stimulant, and 13 of 24 nonresponders ceased or switched stimulants. In 40 of 63 for which data were available, posttrial management was consistent with the trial results. For all types of n-of-1 trials, management changed for 28 of 64 children for whom information was available. DISCUSSION. Attention-deficit/hyperactivity disorder n-of-1 trials can be implemented successfully by mail and telephone communication. This type of trial can be valuable in clarifying treatment effect when it is uncertain, and in this series, they had a noticeable impact on short-term management.

Outcomes of service encounter quality in a business-to-business context

Service encounter quality is an area of growing interest to researchers and managers alike, yet little is known about the effects of face-to-face service encounter quality within a business-to-business setting. In this paper, a psychometrically sound measure of such service encounter quality is proposed, and consequences of this construct are empirically assessed. Both a literature review and a dyadic in-depth interview approach were used to develop a conceptual framework and a pool of items to capture service encounter quality. A mail survey of customers was undertaken, and a response rate of 36% was obtained. Data analysis was conducted via confirmatory factor analysis and structural equation modeling. Findings reveal a four-factor structure of service encounter quality, encompassing professionalism, civility, friendliness and competence dimensions. Service encounter quality was found to be directly related to customer satisfaction and service quality perceptions, and indirectly to loyalty. The importance of these findings for practitioners and for future research on service encounter quality is discussed.

The effects of mailing design characteristics on direct mail campaign performance

Designing effective direct mail pieces is considered a key success factor in direct marketing. However, related published empirical research is scarce while design recommendations are manifold and often conflicting. Compared with prior work, our study aims to provide more elaborate and empirically validated findings for the effects of direct mail design characteristics by analyzing 677 direct mail campaigns from non-profit organizations and financial service providers. We investigate the effects of (1) various envelope characteristics and observable cues on opening rates, and (2) characteristics of the envelope content on the keeping rates of direct mail campaigns. We show that visual design elements on the outer envelope – rather than sender-related details – are the predominant drivers of opening rates. Factors such as letter length, provision of sender information in the letter, and personalization positively influence the keeping rate. We also observe that opening and keeping rates are uncorrelated at the campaign level, implying that opening direct mail pieces is only a necessary condition for responding to offers, but not per se a driver of direct mail response.

Designing an E-Mail Prototype to Enhance Effective Communication and Task Management: A Case Study

This paper deals with communicational breakdowns and misunderstandings in computer mediated communication (CMC) and ways to recover from them or to prevent them. The paper describes a case study of CMC conducted in a company named Artigiani. We observed communication and conducted content analysis of e-mail messages, focusing on message exchanges between customer service representatives (CSRs) and their contacts. In addition to task management difficulties, we identified communication breakdowns that result from differences between perspectives, and from the lack of contextual information, mainly technical background and professional jargon at the customers’ side. We examined possible ways to enhance CMC and accordingly designed a prototype for an e-mail user interface that emphasizes a communicational strategy called contextualization as a central component for obtaining effective communication and for supporting effective management and control of organizational activities, especially handling orders, price quoting, and monitoring the supply and installation of products.

Essays in Empirical Operations Management: Bayesian Learning of Service Quality and Structural Estimation of Complementary Product Pricing and Inventory Management

This dissertation contributes to the rapidly growing empirical research area in the field of operations management. It contains two essays, tackling two different sets of operations management questions which are motivated by and built on field data sets from two very different industries --- air cargo logistics and retailing.

The first essay, based on the data set obtained from a world leading third-party logistics company, develops a novel and general Bayesian hierarchical learning framework for estimating customers' spillover learning, that is, customers' learning about the quality of a service (or product) from their previous experiences with similar yet not identical services. We then apply our model to the data set to study how customers' experiences from shipping on a particular route affect their future decisions about shipping not only on that route, but also on other routes serviced by the same logistics company. We find that customers indeed borrow experiences from similar but different services to update their quality beliefs that determine future purchase decisions. Also, service quality beliefs have a significant impact on their future purchasing decisions. Moreover, customers are risk averse; they are averse to not only experience variability but also belief uncertainty (i.e., customer's uncertainty about their beliefs). Finally, belief uncertainty affects customers' utilities more compared to experience variability.

The second essay is based on a data set obtained from a large Chinese supermarket chain, which contains sales as well as both wholesale and retail prices of un-packaged perishable vegetables. Recognizing the special characteristics of this particularly product category, we develop a structural estimation model in a discrete-continuous choice model framework. Building on this framework, we then study an optimization model for joint pricing and inventory management strategies of multiple products, which aims at improving the company's profit from direct sales and at the same time reducing food waste and thus improving social welfare.

Collectively, the studies in this dissertation provide useful modeling ideas, decision tools, insights, and guidance for firms to utilize vast sales and operations data to devise more effective business strategies.

Market reforms and privatisation in the English National Health Service

The article examines developments in the marketisation and privatisation of the English National Health Service, primarily since 1997. It explores the use of competition and contracting out in ancillary services and the levering into public services of private finance for capital developments through the Private Finance Initiative. A substantial part of the article examines the repeated restructuring of the health service as a market in clinical services, initially as an internal market but subsequently as a market increasing opened up to private sector involvement. Some of the implications of market processes for NHS staff and for increased privatisation are discussed. The article examines one episode of popular resistance to these developments, namely the movement of opposition to the 2011 health and social care legislative proposals. The article concludes with a discussion of the implications of these system reforms for the founding principles of the NHS and the sustainability of the service.

Assessing variation in personal health service delivery and workplace smoking ban enforcement by local health departments

Thesis (Ph.D.)--University of Washington, 2016-08

An overview on how failure analysis contributes to flight safety in the Portuguese Air Force

Failure analysis has been, throughout the years, a fundamental tool used in the aerospace sector, supporting assessments performed by sustainment and design engineers mainly related to failure modes and material suitability. The predicted service life of aircrafts often exceeds 40 years, and the design assured life rarely accounts for all in service loads and in service environmental menaces that aging aircrafts must deal with throughout their service lives. From the most conservative safe-life conceptual design approaches to the most recent on-condition based design approaches, assessing the condition and predicting the failure modes of components and materials are essential for the development of adequate preventive and corrective maintenance actions as well as for the accomplishment and optimization of scheduled maintenance programs of aircrafts. Moreover, as the operational conditions of aircrafts may vary significantly from operator to operator (especially in military aircraft), it is necessary to access if the defined maintenance programs are adequate to guarantee the continuous reliability and safe usage of the aircrafts, preventing catastrophic failures which bear significant maintenance and repair costs, and that may lead to the loss of human lives. Thus being, failure analysis and material investigations performed as part of aircraft accidents and incidents investigations arise as powerful tools of the utmost importance for safety assurance and cost reduction within the aeronautical and aerospace sectors. The Portuguese Air Force (PRTAF) has operated different aircrafts throughout its long existence, and in some cases, has operated a particular type of aircraft for more than 30 years, gathering a great amount of expertise in: assessing failure modes of the aircrafts materials; conducting aircrafts accidents and incidents investigations (sometimes with the participation of the aircraft manufacturers and/or other operators); and in the development of design and repair solutions for in-service related problems. This paper addresses several studies to support the thesis that failure analysis plays a key role in flight safety improvement within the PRTAF. It presents a short summary of developed

Microbiological assessment of indoor air quality at different hospital sites

Poor hospital indoor air quality (IAQ) may lead to hospital-acquired infections, sick hospital syndrome and various occupational hazards. Air-control measures are crucial for reducing dissemination of airborne biological particles in hospitals. The objective of this study was to perform a survey of bioaerosol quality in different sites in a Portuguese Hospital, namely the operating theater (OT), the emergency service (ES) and the surgical ward (SW). Aerobic mesophilic bacterial counts (BCs) and fungal load (FL) were assessed by impaction directly onto tryptic soy agar and malt extract agar supplemented with antibiotic chloramphenicol (0.05%) plates, respectively using a MAS-100 air sampler. The ES revealed the highest airborne microbial concentrations (BC range 240-736 CFU/m(3) CFU/m(3); FL range 27-933 CFU/m(3)), exceeding, at several sampling sites, conformity criteria defined in national legislation [6]. Bacterial concentrations in the SW (BC range 99-495 CFU/m(3)) and the OT (BC range 12-170 CFU/m(3)) were under recommended criteria. While fungal levels were below 1 CFU/m(3) in the OT, in the SW (range 1-32 CFU/m(3)), there existed a site with fungal indoor concentrations higher than those detected outdoors. Airborne Gram-positive cocci were the most frequent phenotype (88%) detected from the measured bacterial population in all indoor environments. Staphylococcus (51%) and Micrococcus (37%) were dominant among the bacterial genera identified in the present study. Concerning indoor fungal characterization, the prevalent genera were Penicillium (41%) and Aspergillus (24%). Regular monitoring is essential for assessing air control efficiency and for detecting irregular introduction of airborne particles via clothing of visitors and medical staff or carriage by personal and medical materials. Furthermore, microbiological survey data should be used to clearly define specific air quality guidelines for controlled environments in hospital settings.

Urban air mobility: modelling the future transport system

The advances in the aviation field, particularly the development of electric flying vehicles, as UAV and eVTOL, paved the way for setting Urban Air Mobility (UAM) services. UAM would provide services for passengers, goods and emergencies and could offer faster trips than ground ones. It is expected that early UAM operations will be performed at Very Low-Level airspace as 0-500 m Above Ground Level. The purpose of this research is to both explore the main features of UAM and test an aerial network model, which could be integrated in a multimodal transport system where ground and aerial mobility services are provided. Analyses on UAM transport system involved two sub-systems: the transport demand sub-system, i.e., the mobility requirements, and the transport supply sub-system, i.e., the service and facilities enabling mobility. At first, the UAM demand levels and features for an Airport Shuttle service have been explored through a suitable survey, by combining Revealed and Stated Preference methodologies, and by calibrating some discrete mode choice models. Then, the focus has been on the transport supply model for UAM services, by focusing on both the ground access points (vertiports) and the aerial network model. A suitable three-dimensional urban aerial network (3D-UAN) model that could support fast aerial connections between O/D pairs has been proposed. Some tests have been implemented to verify the feasibility of the proposed model. Some flying vehicles supporting an Airport Shuttle service have been simulated on the aerial network, which has been specified in terms of both topological features and link transport costs. The preliminary results have showed that the proposed 3D-UAN model could be suitable for supporting UAM services. As for transport engineering, the UAM system framework proposed in this thesis paves the way for further research on air-ground multimodality in urban areas.

Nanomolar Levels Of Pahs In Extracts From Urban Air Induce Mapk Signaling In Hepg2 Cells.

Polycyclic aromatic hydrocarbons (PAHs) are common environmental pollutants that occur naturally in complex mixtures. Many of the adverse health effects of PAHs including cancer are linked to the activation of intracellular stress response signaling. This study has investigated intracellular MAPK signaling in response to PAHs in extracts from urban air collected in Stockholm, Sweden and Limeira, Brazil, in comparison to BP in HepG2 cells. Nanomolar concentrations of PAHs in the extracts induced activation of MEK4 signaling with down-stream increased gene expression of several important stress response mediators. Involvement of the MEK4/JNK pathway was confirmed using siRNA and an inhibitor of JNK signaling resulting in significantly reduced MAPK signaling transactivated by the AP-1 transcription factors ATF2 and c-Jun. ATF2 was also identified as a sensitive stress responsive protein with activation observed at extract concentrations equivalent to 0.1 nM BP. We show that exposure to low levels of environmental PAH mixtures more strongly activates these signaling pathways compared to BP alone suggesting effects due to interactions. Taken together, this is the first study showing the involvement of MEK4/JNK/AP-1 pathway in regulating the intracellular stress response after exposure to nanomolar levels of PAHs in environmental mixtures.

[principles Of Universality, Comprehensiveness And Equity In A Hearing Health Care Service].

This article analyzed whether the practices of hearing health care were consistent with the principles of universality, comprehensiveness and equity from the standpoint of professionals. It involved qualitative research conducted at a Medium Complexity Hearing Health Care Center. A social worker, three speech therapists, a physician and a psychologist constituted the study subjects. Interviews were conducted as well as observation registered in a field diary. The thematic analysis technique was used in the analysis of the material. The analysis of interviews resulted in the construction of the following themes: Universality and access to hearing health, Comprehensive Hearing Health Care and Hearing Health and Equity. The study identified issues that interfere with the quality of service and run counter to the principles of Brazilian Unified Health System. The conclusion reached was that a relatively simple investment in training and professional qualification can bring about significant changes in order to promote a more universal, comprehensive and equitable health service.

A retrospective study of Traumatic Dental Injuries in a Brazilian dental urgency service

Epidemiologic aspects of traumatic dental injuries (TDI) were evaluated in the permanent dentition in a sample of 847 patients treated at the Dental Urgency Service of the Dental School of the Federal University of Goiás, Brazil, between May 2000 and May 2008. The statistical treatment analyzed data from frequency distribution and chi-square test. The level of significance was set at 5% for all analyses. The results showed a higher incident among males (610; 72.01%) with mean age of 6-10 year-old. Uncomplicated crown fracture (without pulp exposure) (502; 26.95%), avulsion (341; 18.30%) and complicated crown fracture (with pulp exposure) (330; 17.71%) were the most prevalent TDI. The prevalence of trauma throughout the years showed proportionality, being observed a larger number of cases between July and September (249; 29.39%). The most affected teeth were the maxillary central incisors (65.65%), followed by the maxillary left lateral incisors (19.67%). In 311 participants (18.25%), only one tooth was involved, while in most patients (536; 81.75%), TDI occurred in more than one tooth. Significant proportion (82.27%) of traumatized teeth presented completely formed root apex. The main etiologic factors involved in TDI were falls (51.71%), traffic accidents (22.90%) and violence (5.67%). Based on the obtained data, it may be concluded that accurate policies of TDI prevention must be established, capable of stimulating the exposure of appropriate protocols for management of these lesions. The prevalence of TDI in Goiânia subpopulation is compared to the prevalence reported in epidemiological studies in others populations.

Air pollution and hospital admissions for respiratory diseases in the subequatorial Amazon: a time series approach

The objective of the study is to evaluate the effect of the daily variation in concentrations of fine particulate matter (diameter less than 2.5µm - PM2.5) resulting from the burning of biomass on the daily number of hospitalizations of children and elderly people for respiratory diseases, in Alta Floresta and Tangará da Serra in the Brazilian Amazon in 2005. This is an ecological time series study that uses data on daily number of hospitalizations of children and the elderly for respiratory diseases, and estimated concentration of PM2.5. In Alta Floresta, the percentage increases in the relative risk (%RR) of hospitalization for respiratory diseases in children were significant for the whole year and for the dry season with 3-4 day lags. In the dry season these measurements reach 6% (95%CI: 1.4-10.8). The associations were sig-nificant for moving averages of 3-5 days. The %RR for the elderly was significant for the current day of the drought, with a 6.8% increase (95%CI: 0.5-13.5) for each additional 10µg/m3 of PM2.5. No as-sociations were verified for Tangara da Serra. The PM2.5 from the burning of biomass increased hospitalizations for respiratory diseases in children and the elderly.

Measuring air pressure with a polymeric gas sensor

In this communication we describe the application of a conductive polymer gas sensor as an air pressure sensor. The device consists of a thin doped poly(4'-hexyloxy-2,5-biphenylene ethylene) (PHBPE) film deposited on an interdigitated metallic electrode. The sensor is cheap, easy to fabricate, lasts for several months, and is suitable for measuring air pressures in the range between 100 and 700 mmHg.