Description of the SAGhE Cohort: A Large European Study of Mortality and Cancer Incidence Risks after Childhood Treatment with Recombinant Growth Hormone.

BACKGROUND The long-term safety of growth hormone treatment is uncertain. Raised risks of death and certain cancers have been reported inconsistently, based on limited data or short-term follow-up by pharmaceutical companies. PATIENTS AND METHODS The SAGhE (Safety and Appropriateness of Growth Hormone Treatments in Europe) study assembled cohorts of patients treated in childhood with recombinant human growth hormone (r-hGH) in 8 European countries since the first use of this treatment in 1984 and followed them for cause-specific mortality and cancer incidence. Expected rates were obtained from national and local general population data. The cohort consisted of 24,232 patients, most commonly treated for isolated growth failure (53%), Turner syndrome (13%) and growth hormone deficiency linked to neoplasia (12%). This paper describes in detail the study design, methods and data collection and discusses the strengths, biases and weaknesses consequent on this. CONCLUSION The SAGhE cohort is the largest and longest follow-up cohort study of growth hormone-treated patients with follow-up and analysis independent of industry. It forms a major resource for investigating cancer and mortality risks in r-hGH patients. The interpretation of SAGhE results, however, will need to take account of the methods of cohort assembly and follow-up in each country.

Death after Sexual Intercourse

Sexuality is an essential aspect of quality of life. Nevertheless, sexual intercourse is physically challenging and leads to distinct changes in blood pressure, heart, and respiratory rate that may lead to vital complications. We present a case report of a 22-year-old female suffering from subarachnoid hemorrhage after sexual intercourse. The patient was immediately transported to hospital by emergency medical services and, after diagnosis, transferred to a tertiary hospital with neurosurgical expertise but died within 24 hours. After postcoital headaches, subarachnoid hemorrhage is the second most common cause of neurological complications of sexual intercourse and therefore patients admitted to an emergency department with headache after sexual intercourse should always be carefully evaluated by cerebral imaging.

Impact of Diabetic Status on Outcomes After Revascularization With Drug-Eluting Stents in Relation to Coronary Artery Disease Complexity: Patient-Level Pooled Analysis of 6081 Patients.

BACKGROUND Diabetes mellitus and angiographic coronary artery disease complexity are intertwined and unfavorably affect prognosis after percutaneous coronary interventions, but their relative impact on long-term outcomes after percutaneous coronary intervention with drug-eluting stents remains controversial. This study determined drug-eluting stents outcomes in relation to diabetic status and coronary artery disease complexity as assessed by the Synergy Between PCI With Taxus and Cardiac Surgery (SYNTAX) score. METHODS AND RESULTS In a patient-level pooled analysis from 4 all-comers trials, 6081 patients were stratified according to diabetic status and according to the median SYNTAX score ≤11 or >11. The primary end point was major adverse cardiac events, a composite of cardiac death, myocardial infarction, and clinically indicated target lesion revascularization within 2 years. Diabetes mellitus was present in 1310 patients (22%), and new-generation drug-eluting stents were used in 4554 patients (75%). Major adverse cardiac events occurred in 173 diabetics (14.5%) and 436 nondiabetic patients (9.9%; P<0.001). In adjusted Cox regression analyses, SYNTAX score and diabetes mellitus were both associated with the primary end point (P<0.001 and P=0.028, respectively; P for interaction, 0.07). In multivariable analyses, diabetic versus nondiabetic patients had higher risks of major adverse cardiac events (hazard ratio, 1.25; 95% confidence interval, 1.03-1.53; P=0.026) and target lesion revascularization (hazard ratio, 1.54; 95% confidence interval, 1.18-2.01; P=0.002) but similar risks of cardiac death (hazard ratio, 1.41; 95% confidence interval, 0.96-2.07; P=0.08) and myocardial infarction (hazard ratio, 0.89; 95% confidence interval, 0.64-1.22; P=0.45), without significant interaction with SYNTAX score ≤11 or >11 for any of the end points. CONCLUSIONS In this population treated with predominantly new-generation drug-eluting stents, diabetic patients were at increased risk for repeat target-lesion revascularization consistently across the spectrum of disease complexity. The SYNTAX score was an independent predictor of 2-year outcomes but did not modify the respective effect of diabetes mellitus. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00297661, NCT00389220, NCT00617084, and NCT01443104.

Influence of previous surgery on patient-rated outcome after surgery for degenerative disorders of the lumbar spine.

PURPOSE Few studies have used multivariate models to quantify the effect of multiple previous spine surgeries on patient-oriented outcome after spine surgery. This study sought to quantify the effect of prior spine surgery on 12-month postoperative outcomes in patients undergoing surgery for different degenerative disorders of the lumbar spine. METHODS The study included 4940 patients with lumbar degenerative disease documented in the Spine Tango Registry of EUROSPINE, the Spine Society of Europe, from 2004 to 2015. Preoperatively and 12 months postoperatively, patients completed the multidimensional Core Outcome Measures Index (COMI; 0-10 scale). Patients' medical history and surgical details were recorded using the Spine Tango Surgery 2006 and 2011 forms. Multiple linear regression models were used to investigate the relationship between the number of previous surgeries and the 12-month postoperative COMI score, controlling for the baseline COMI score and other potential confounders. RESULTS In the adjusted model including all cases, the 12-month COMI score showed a 0.37-point worse value [95 % confidence intervals (95 % CI) 0.29-0.45; p < 0.001] for each additional prior spine surgery. In the subgroup of patients with lumbar disc herniation, the corresponding effect was 0.52 points (95 % CI 0.27-0.77; p < 0.001) and in lumbar degenerative spondylolisthesis, 0.40 points (95 % CI 0.17-0.64; p = 0.001). CONCLUSIONS We were able to demonstrate a clear "dose-response" effect for previous surgery: the greater the number of prior spine surgeries, the systematically worse the outcome at 12 months' follow-up. The results of this study can be used when considering or consenting a patient for further surgery, to better inform the patient of the likely outcome and to set realistic expectations.

Pitfalls of practicing cancer epidemiology in resource-limited settings: the case of survival and loss to follow-up after a diagnosis of Kaposi's sarcoma in five countries across sub-Saharan Africa.

BACKGROUND Survival after diagnosis is a fundamental concern in cancer epidemiology. In resource-rich settings, ambient clinical databases, municipal data and cancer registries make survival estimation in real-world populations relatively straightforward. In resource-poor settings, given the deficiencies in a variety of health-related data systems, it is less clear how well we can determine cancer survival from ambient data. METHODS We addressed this issue in sub-Saharan Africa for Kaposi's sarcoma (KS), a cancer for which incidence has exploded with the HIV epidemic but for which survival in the region may be changing with the recent advent of antiretroviral therapy (ART). From 33 primary care HIV Clinics in Kenya, Uganda, Malawi, Nigeria and Cameroon participating in the International Epidemiologic Databases to Evaluate AIDS (IeDEA) Consortia in 2009-2012, we identified 1328 adults with newly diagnosed KS. Patients were evaluated from KS diagnosis until death, transfer to another facility or database closure. RESULTS Nominally, 22% of patients were estimated to be dead by 2 years, but this estimate was clouded by 45% cumulative lost to follow-up with unknown vital status by 2 years. After adjustment for site and CD4 count, age <30 years and male sex were independently associated with becoming lost. CONCLUSIONS In this community-based sample of patients diagnosed with KS in sub-Saharan Africa, almost half became lost to follow-up by 2 years. This precluded accurate estimation of survival. Until we either generally strengthen data systems or implement cancer-specific enhancements (e.g., tracking of the lost) in the region, insights from cancer epidemiology will be limited.

Long-term Outcome After Monosegmental L4/5 Stabilization for Degenerative Spondylolisthesis With the Dynesys Device.

STUDY DESIGN Retrospective analysis of prospectively collected clinical data. OBJECTIVE To assess the long-term outcome of patients with monosegmental L4/5 degenerative spondylolisthesis treated with the dynamic Dynesys device. SUMMARY OF BACKGROUND DATA The Dynesys system has been used as a semirigid, lumbar dorsal pedicular stabilization device since 1994. Good short-term results have been reported, but little is known about the long-term outcome after treatment for degenerative spondylolisthesis at the L4/5 level. METHODS A total of 39 consecutive patients with symptomatic degenerative lumbar spondylolisthesis at the L4/5 level were treated with bilateral decompression and Dynesys instrumentation. At a mean follow-up of 7.2 years (range, 5.0-11.2 y), they underwent clinical and radiographic evaluation and quality of life assessment. RESULTS At final follow-up, back pain improved in 89% and leg pain improved in 86% of patients compared with preoperative status. Eighty-three percent of patients reported global subjective improvement. Ninety-two percent would undergo the surgery again. Eight patients (21%) required further surgery because of symptomatic adjacent segment disease (6 cases), late-onset infection (1 case), and screw breakage (1 case). In 9 cases, radiologic progression of spondylolisthesis at the operated segment was found. Seventy-four percent of operated segments showed limited flexion-extension range of <4 degrees. Adjacent segment pathology, although without clinical correlation, was diagnosed at the L5/S1 (17.9%) and L3/4 (28.2%) segments. In 4 cases, asymptomatic screw loosening was observed. CONCLUSIONS Monosegmental Dynesys instrumentation of degenerative spondylolisthesis at L4/5 shows good long-term results. The rate of secondary surgeries is comparable to other dorsal instrumentation devices. Residual range of motion in the stabilized segment is reduced, and the rate of radiologic and symptomatic adjacent segment degeneration is low. Patient satisfaction is high. Dynesys stabilization of symptomatic L4/5 degenerative spondylolisthesis is a possible alternative to other stabilization devices.

The Role of Goods Trade Networks for Services Trade Volume

In this paper, we address the role of countries’ goods-trade networks for their services-trade volume. The paper employs a large cross section of bilateral trade data on aggregate cross-border goods and services sales and illustrates that the depth and overlap of two countries’ services networks induce a positive direct impact on their services-trade volume. The evidence takes into account that goods trade flows and networks are potentially endogenous so that the estimated direct effects support a causal interpretation. We find that the magnitude of the multilateral goods-trade network effect on the bilateral services-trade volume is much larger than that of bilateral goods-trade volume.

Modes of Supply for US Exports of Services

We examine the choice of modes of delivery in services based on US data, including both cross-border exports and sales through foreign affiliates. We focus on characteristics of destination markets and how this impacts on mode choice. We find that market size, distance and policy all play a role in where firms establish, and in how many markets firms enter. The importance of sales through affiliates relative to total foreign sales also depends on factors like market size, geographic and economic distance and the policy regime in place. Precisely, how important these factors are depends on the sector in question.

Public service use by residents of Jackson Hinds Gardens before and after enrollment

Homelessness is associated with high use of public services such as health care and criminal justice services. Intervention designs to reverse homelessness have broadly fallen into two categories: either standard care which employs requisitely addressing the causes of homelessness, or housing first, which emphasizes provision of permanent housing without requisitely addressing the causes of homelessness. Multiple cities have recently commenced housing first interventions. Locally, Houston’s first housing first development is the Jackson Hinds Gardens project. The purpose of this study is to analyze the public service use of residents of housing first in Houston. Residents of Jackson Hinds Gardens who have been enrolled for at least 6 months were evaluated for public service use for an equal amount of time preceding and during their residence at Jackson Hinds. Resident interactions with county health services and criminal justice entities were determined by electronic database searches; these data were supplemented by life experience interview data. Service usage values pre- and post-enrollment at Jackson Hinds Gardens were compared by paired t-test analyses. We found that ER and inpatient usage decreased following enrollment in Jackson Hinds, although these reductions were not significant. In contrast, outpatient care and number of medications significantly increased following enrollment. These analyses inform on the effects of housing first in another major city, as well as informing the ethical considerations regarding housing first versus standard care. ^

Use of contraception and contraceptive services among U.S. Hispanic women: 2006--2008

This study investigates the association between race/ethnicity and acculturation variables (language preference and nativity) with use of contraception and contraceptive services among Mexican/Mexican American and “other” Hispanic women aged 15-44 when compared to non- Hispanic white women.^ Data was analyzed from the 2006-2008 National Survey of Family Growth. The sample contained 3357 women aged 15-44. Multivariate logistic regression analysis was used to examine the association between race/ethnicity and acculturation variables and contraceptive-related behaviors adjusted for other known covariates. ^ After multivariate analysis, neither nativity nor language preference were significantly associated with contraception use or contraceptive services. Mexican/Mexican American women did not differ in their contraception-related behaviors when compared to non-Hispanic whites. Other Hispanic women, however, were less likely to obtain contraceptive services than non-Hispanic whites (OR=0.67, 95% CI=0.45-1.00). Women aged 30-39 and 40-44 were less likely to obtain contraception and contraceptive services than those aged 15-19. Single women were less likely to use contraception (OR=0.72, 95% CI=0.56-0.92) and contraceptive services (OR=0.69, 95% CI=0.53-0.89) than married/co-habiting women. Women with healthcare coverage were more likely to use contraception and contraceptive services than uninsured women.^ Among Hispanic women of different origin groups, age, marital status, and healthcare coverage were stronger indicators of contraception-related behavior than race/ethnicity, language preference, and nativity. Reproductive health programs that target increased use of contraception and contraceptive services among Hispanic origin groups should specifically target women who are over 30, single, and uninsured.^

Assessment of executive function before and after vitamin D replacement in vulnerable adults who self-neglect

Purpose: Self-neglect (SN) is the inability to maintain self-care needs. It is thought that older adults who have impaired executive function (EF) develop the inability to do self-care and to protect themselves. The specific aims were to (1) determine the feasibility of using multiple EF measures with community-dwelling elders with SN, (2) identify changes in EF between baseline and 5-months in community-dwelling elders with SN who receive 50,000 IU or 400 IU of oral vitamin D monthly and (2) explore changes in specific dimensions of EF between the groups. ^ Methods: Fifty adults, 65 years of age and older, were recruited from Adult Protective Services with confirmed SN. A research nurse administered the following tests at baseline and five-months: Delis-Kaplan Card Sort Test (D-KEFS), Executive Interview (EXIT 25), CLOX Drawing Test (CLOX I, II), Trails Making Test A and B (TMT A & B) and the Mini-Mental State Examination (MMSE). Demographic data was collected at baseline and serum 25-OHD levels were collected at baseline and five-months. ^ Results: Older adults with SN were more likely to fail the CLOX1 and D-KEFS, while passing the MMSE, CLOX II, TMT A & B and the EXIT 25. At five-months, the only statistically significant difference between groups was in the TMT A & B test scores; the control group did better than the treatment group. There was a non-significant increase in serum vitamin D levels for both groups and no difference between groups. ^ Conclusions: Results from this study provide support that individuals who SN will complete a battery of EF tests and that they exhibit the following impairments consistent with executive dysfunction: 'concept generation', 'planning', 'inhibition', and 'spatial working memory'. Utilizing only one EF measure in individuals with intact cognition may result in unidentification of individuals with executive dysfunction, thus delaying necessary treatment. Future studies should attempt to determine different etiologies of executive dysfunction and determine if early treatment can prevent or reverse SN. ^ Key Words: Self-neglect, Executive Dysfunction, Executive Function, Adult Protective Services, Community-dwelling, Vitamin D ^

The University Compost Facility after Three Years

The University Compost Facility, 52274 260th St., Ames, Iowa has completed three full years of operation. The facility is managed by the ISU Research Farms and has a separate revolving account that receives fees and sales, and pays expenses. The facility is designed to be self-supporting, i.e. not receive allocations for its operations. The facility consists of seven, 80 × 140 ft hoop barns and a new 55 × 120 ft hoop barn, all with paved floors. The facility also has a Mettler-Toledo electronic scale with a 10 ft × 70 ft platform to weigh all materials. Key machinery is 1) compost turner, a used pull-type Aeromaster PT-170, 14 ft wide made by Midwest Biosystems, Tampico, IL; 2) a converted dump truck trailer used to construct windrows and haul material; 3) telehandler, Caterpillar TH407 with cab and 2.75 cubic yard bucket; and 4) tractor, John Deere 7520 (125 hp) with IVT (Infinite Variable Transmission) and front-wheel assist used to pull the turner and dump trailer.

Cuba's social policy after the disintegration of the Soviet Union -- social development as legitimacy of regime and its economy effectiveness

Since the disintegration of the Soviet Union, Cuba has experienced a severe economic crisis, and the country's social policy has played an important role in showing the people a raison-d'etre for the revolution. This role has become even stronger in recent years, as internal and external actors demand political reforms and economic liberalization. This article first examines the Cuban government's use of social development to counter the demands for changes. It then looks at the extent that government social policy contributes economically to improving the Cuban living standard. The article demonstrates empirically how the leadership emphasizes their social accomplishments whenever demands for change come, and then shows that after the suspension of Soviet aid, Cuban social policy has been able to provide services mainly by relying on human capital and reducing quality materially because of the shortage of foreign reserves. This has limited the economic effectiveness of the services.

A policy-driven architecture for supporting joint degrees through e-learning services

En un mercado de educación superior cada vez más competitivo, la colaboración entre universidades es una efectiva estrategia para acceder al mercado global. El desarrollo de titulaciones conjuntas es un importante mecanismo para fortalecer las colaboraciones académicas y diversificar los conocimientos. Las titulaciones conjuntas están siendo cada vez más implementadas en las universidades de todo el mundo. En Europa, el proceso de Bolonia y el programa Erasmus, están fomentado el reconocimiento de titulaciones conjuntas y dobles y promoviendo la colaboración entre las instituciones académicas. En el imparable proceso de la globalización y convergencia educativa, el uso de sistemas de e-learning para soportar cursos tanto semipresencial como online es una tendencia en crecimiento. Dado que los sistemas de e-learning soportan una amplia variedad de cursos, es necesario encontrar una solución adecuada que permita a las universidades soportar y gestionar las titulaciones conjuntas a través de sus sistemas de e-learning en conformidad con los acuerdos de colaboración establecidos por las universidades participantes. Esta tesis doctoral abordará las siguientes preguntas de investigación: 1. ¿Qué factores deben tenerse en cuenta en la implementación y gestión de titulaciones conjuntas? 2. ¿Cómo pueden los sistemas actuales de e-learning soportar el desarrollo de titulaciones conjuntas? 3. ¿Qué otros servicios y sistemas necesitan ser adaptados por las universidades interesadas en participar en una titulación conjunta a través de sus sistemas de e-learning? La implementación de titulaciones conjuntas a través de sistemas de e-learning es compleja e implica retos técnicos, administrativos, culturales, financieros, jurídicos y de seguridad. Esta tesis doctoral propone una serie de contribuciones que pueden ayudar a resolver algunos de los retos identificados. En primer lugar se ha elaborado un modelo conceptual que incluye la información del contexto de las titulaciones conjuntas que es relevante para la implementación de estas titulaciones en los sistemas de e-learning. Después de definir el modelo conceptual, se ha propuesto una arquitectura basada en políticas para la implementación de titulaciones interinstitucionales a través de sistemas de e-learning de acuerdo a los términos estipulados en los acuerdos de colaboración que son firmados por las universidades participantes. El autor se ha centrado en el componente de gestión de flujos de trabajo de esta arquitectura. Por último y con el fin de permitir la interoperabilidad de repositorios de objetos educativos, los componentes básicos a implementar han sido identificados y validados. El uso de servicios multimedia en educación es una tendencia creciente, proporcionando servicios de e-learning que permiten mejorar la comunicación y la interacción entre profesores y alumnos. Dentro de estos servicios, nos hemos centrado en el uso de la videoconferencia y la grabación de clases como servicios adecuados para el desarrollo de cursos impartidos en escenarios de educación colaborativos. Las contribuciones han sido validadas en proyectos de investigación de ámbito nacional y europeo en los que el autor ha participado. Abstract In an increasingly competitive higher education market, collaboration between universities is an effective strategy for gaining access to the global market. The development of joint degrees is an important mechanism for strengthening academic research collaborations and diversifying knowledge. Joint degrees are becoming increasingly implemented in universities around the world. In Europe, the Bologna process and the Erasmus programme have encouraged both the global recognition of joint and double degrees and promoted close collaboration between academic institutions. In the unstoppable process of globalization and educational convergence, the use of e-learning systems for supporting both blended and online courses is becoming a growing trend. Since e-learning systems covers a wide range of courses, it becomes necessary to find a suitable solution that enables universities to support and manage joint degrees through their e-learning systems in accordance with the collaboration agreements established by the universities involved. This dissertation will address the following research questions: 1. What factors need to be considered in the implementation and management of joint degrees? 2. How can the current e-learning systems support the development of joint degrees? 3. What other services and systems need to be adapted by universities interested in participating in a joint degree through their e-learning systems? The implementation of joint degrees using e-learning systems is complex and involves technical, administrative, security, cultural, financial and legal challenges. This dissertation proposes a series of contributions to help solve some of the identified challenges. One of the cornerstones of this proposal is a conceptual model of all the relevant issues related to the support of joint degrees by means of e-learning systems. After defining the conceptual model, this dissertation proposes a policy-driven architecture for implementing inter-institutional degree collaborations through e-learning systems as stipulated by a collaboration agreement signed by two universities. The author has focused on the workflow management component of this architecture. Finally, the building blocks for achieving interoperability of learning object repositories have been identified and validated. The use of multimedia services in education is a growing trend, providing rich e-learning services that improve the communication and interaction between teachers and students. Within these e-learning services, we have focused on the use of videoconferencing and lecture recording as the best-suited services to support collaborative learning scenarios. The contributions have been validated within national and European research projects that the author has been involved in.

Auto component supply chain: a path to global India

Supply chain management works to bring the supplier, the distributor, and the customer into one cohesive process. The Supply Chain Council defined supply chain as ‘Supply Chain: The flow and transformation of raw materials into products from suppliers through production and distribution facilities to the ultimate consumer., and then Sunil Chopra and Meindl, (2001) have define Supply chain management as ‘Supply Chain Management involves the flows between and among stages in a supply chain to maximize total profitability.’ After 1950, supply chain management got a boost with the production and manufacturing sector getting highest attention. The inventory became the responsibility of the marketing, accounting and production areas. Order processing was part of accounting and sales. Supply chain management became one of the most powerful engines of business transformation. It is the one area where operational efficiency can be gained. It reduces organizations costs and enhances customer service. With the liberalization of world trade, globalization, and emergence of the new markets, many organizations have customers and competitions throughout the world, either directly or indirectly. Business communities are aware that global competitiveness is the key to the success of a business. Competitiveness is ability to produce, distribute and provide products and services for the open market in competition with others. The supply chain, a critical link between supplier, producer and customer is emerged now as an essential business process and a strategic lever, potential value contributor a differentiator for the success of any business. Supply chain management is the management of all internal and external processes or functions to satisfy a customer’s order (from raw materials through conversion and manufacture through logistics delivery.). Goods-either in raw form or processed, whole sale or retailed distribution, business or technology services, in everyday life- in the business or household- directly or indirectly supply chain is ubiquitously associated in expanding socio-economic development. Supply chain growth competitive performance and supporting strong growth impulse at micro as well as micro economic levels. Keeping the India vision at the core of the objective, the role of supply chain is to take up social economic challenges, improve competitive advantages, develop strategies, built capabilities, enhance value propositions, adapt right technology, collaborate with stakeholders and deliver environmentally sustainable outcomes with minimum resources.