Potentially avoidable 30-day hospital readmissions in medical patients: derivation and validation of a prediction model

IMPORTANCE Because effective interventions to reduce hospital readmissions are often expensive to implement, a score to predict potentially avoidable readmissions may help target the patients most likely to benefit. OBJECTIVE To derive and internally validate a prediction model for potentially avoidable 30-day hospital readmissions in medical patients using administrative and clinical data readily available prior to discharge. DESIGN Retrospective cohort study. SETTING Academic medical center in Boston, Massachusetts. PARTICIPANTS All patient discharges from any medical services between July 1, 2009, and June 30, 2010. MAIN OUTCOME MEASURES Potentially avoidable 30-day readmissions to 3 hospitals of the Partners HealthCare network were identified using a validated computerized algorithm based on administrative data (SQLape). A simple score was developed using multivariable logistic regression, with two-thirds of the sample randomly selected as the derivation cohort and one-third as the validation cohort. RESULTS Among 10 731 eligible discharges, 2398 discharges (22.3%) were followed by a 30-day readmission, of which 879 (8.5% of all discharges) were identified as potentially avoidable. The prediction score identified 7 independent factors, referred to as the HOSPITAL score: h emoglobin at discharge, discharge from an o ncology service, s odium level at discharge, p rocedure during the index admission, i ndex t ype of admission, number of a dmissions during the last 12 months, and l ength of stay. In the validation set, 26.7% of the patients were classified as high risk, with an estimated potentially avoidable readmission risk of 18.0% (observed, 18.2%). The HOSPITAL score had fair discriminatory power (C statistic, 0.71) and had good calibration. CONCLUSIONS AND RELEVANCE This simple prediction model identifies before discharge the risk of potentially avoidable 30-day readmission in medical patients. This score has potential to easily identify patients who may need more intensive transitional care interventions.

Universally Applicable Model for the Quantitative Determination of Lake Sediment Composition Using Fourier Transform Infrared Spectroscopy

ABSTRACT: Fourier transform infrared spectroscopy (FTIRS) can provide detailed information on organic and minerogenic constituents of sediment records. Based on a large number of sediment samples of varying age (0�340 000 yrs) and from very diverse lake settings in Antarctica, Argentina, Canada, Macedonia/Albania, Siberia, and Sweden, we have developed universally applicable calibration models for the quantitative determination of biogenic silica (BSi; n = 816), total inorganic carbon (TIC; n = 879), and total organic carbon (TOC; n = 3164) using FTIRS. These models are based on the differential absorbance of infrared radiation at specific wavelengths with varying concentrations of individual parameters, due to molecular vibrations associated with each parameter. The calibration models have low prediction errors and the predicted values are highly correlated with conventionally measured values (R = 0.94�0.99). Robustness tests indicate the accuracy of the newly developed FTIRS calibration models is similar to that of conventional geochemical analyses. Consequently FTIRS offers a useful and rapid alternative to conventional analyses for the quantitative determination of BSi, TIC, and TOC. The rapidity, cost-effectiveness, and small sample size required enables FTIRS determination of geochemical properties to be undertaken at higher resolutions than would otherwise be possible with the same resource allocation, thus providing crucial sedimentological information for climatic and environmental reconstructions.

An Ensemble Kalman Filter multi-tracer assimilation: Determining uncertain ocean model parameters for improved climate-carbon cycle projections

An Ensemble Kalman Filter is applied to assimilate observed tracer fields in various combinations in the Bern3D ocean model. Each tracer combination yields a set of optimal transport parameter values that are used in projections with prescribed CO2 stabilization pathways. The assimilation of temperature and salinity fields yields a too vigorous ventilation of the thermocline and the deep ocean, whereas the inclusion of CFC-11 and radiocarbon improves the representation of physical and biogeochemical tracers and of ventilation time scales. Projected peak uptake rates and cumulative uptake of CO2 by the ocean are around 20% lower for the parameters determined with CFC-11 and radiocarbon as additional target compared to those with salinity and temperature only. Higher surface temperature changes are simulated in the Greenland–Norwegian–Iceland Sea and in the Southern Ocean when CFC-11 is included in the Ensemble Kalman model tuning. These findings highlights the importance of ocean transport calibration for the design of near-term and long-term CO2 emission mitigation strategies and for climate projections.

Calibration of cosmogenic noble gas production in ordinary chondrites based on 36 Cl- 36 Ar ages. Part 1: Refined produced rates for cosmogenic 21 Ne and 38 Ar

We measured the concentrations and isotopic compositions of He, Ne, and Ar in bulk samples and metal separates of 14 ordinary chondrite falls with long exposure ages and high metamorphic grades. In addition, we measured concentrations of the cosmogenic radionuclides 10Be, 26Al, and 36Cl in metal separates and in the nonmagnetic fractions of the selected meteorites. Using cosmogenic 36Cl and 36Ar measured in the metal separates, we determined 36Cl-36Ar cosmic-ray exposure (CRE) ages, which are shielding-independent and therefore particularly reliable. Using the cosmogenic noble gases and radionuclides, we are able to decipher the CRE history for the studied objects. Based on the correlation 3He/21Ne versus 22Ne/21Ne, we demonstrate that, among the meteorites studied, only one suffered significant diffusive losses (about 35%). The data confirm that the linear correlation 3He/21Ne versus 22Ne/21Ne breaks down at high shielding. Using 36Cl-36Ar exposure ages and measured noble gas concentrations, we determine 21Ne and 38Ar production rates as a function of 22Ne/21Ne. The new data agree with recent model calculations for the relationship between 21Ne and 38Ar production rates and the 22Ne/21Ne ratio, which does not always provide unique shielding information. Based on the model calculations, we determine a new correlation line for 21Ne and 38Ar production rates as a function of the shielding indicator 22Ne/21Ne for H, L, and LL chondrites with preatmospheric radii less than about 65 cm. We also calculated the 10Be/21Ne and 26Al/21Ne production rate ratios for the investigated samples, which show good agreement with recent model calculations.

THE CALIBRATION AND IMPLEMENTATION OF CR-39 NUCLEAR TRACK DETECTOR MATERIAL AS A FAST NEUTRON MICRODOSIMETER

A detailed microdosimetric characterization of the M. D. Anderson 42 MeV (p,Be) fast neutron beam was performed using the techniques of microdosimetry and a 1/2 inch diameter Rossi proportional counter. These measurements were performed at 5, 15, and 30 cm depths on the central axis, 3 cm inside, and 3 cm outside the field edge for 10 $\times$ 10 and 20 $\times$ 20 cm field sizes. Spectra were also measured at 5 and 15 cm depth on central axis for a 6 $\times$ 6 cm field size. Continuous slowing down approximation calculations were performed to model the nuclear processes that occur in the fast neutron beam. Irradiation of the CR-39 was performed using a tandem electrostatic accelerator for protons of 10, 6, and 3 MeV and alpha particles of 15, 10, and 7 MeV incident energy on target at angles of incidence from 0 to 85 degrees. The critical angle as well as track etch rate and normal incidence diameter versus linear energy transfer (LET) were obtained from these measurements. The bulk etch rate was also calculated from these measurements. Dose response of the material was studied, and the angular distribution of charged particles created by the fast neutron beam was measured with CR-39. The efficiency of CR-39 was calculated versus that of the Rossi chamber, and an algorithm was devised for derivation of LET spectra from the major and minor axis dimensions of the observed tracks. The CR-39 was irradiated in the same positions as the Rossi chamber, and the derived spectra were compared directly. ^

Copula calibration

We propose notions of calibration for probabilistic forecasts of general multivariate quantities. Probabilistic copula calibration is a natural analogue of probabilistic calibration in the univariate setting. It can be assessed empirically by checking for the uniformity of the copula probability integral transform (CopPIT), which is invariant under coordinate permutations and coordinatewise strictly monotone transformations of the predictive distribution and the outcome. The CopPIT histogram can be interpreted as a generalization and variant of the multivariate rank histogram, which has been used to check the calibration of ensemble forecasts. Climatological copula calibration is an analogue of marginal calibration in the univariate setting. Methods and tools are illustrated in a simulation study and applied to compare raw numerical model and statistically postprocessed ensemble forecasts of bivariate wind vectors.

Sensitivity and fragmentation calibration of the ROSINA double focusing mass spectrometer

The goal of this work has been to calibrate sensitivities and fragmentation pattern of various molecules as well as further characterize the lab model of the ROSINA Double Focusing Mass Spectrometer (DFMS) on board ESA’s Rosetta spacecraft bound to comet 67P/Churyumov-Gerasimenko. The detailed calibration and characterization of the instrument is key to understand and interpret the results in the coma of the comet. A static calibration was performed for the following species: Ne, Ar, Kr, Xe, H2O, N2, CO2, CH4, C2H6, C3H8, C4H10, and C2H4. The purpose of the calibration was to obtain sensitivities for all detectors and emissions, the fragmentation behavior of the ion source and to show the capabilities to measure isotopic ratios at the comet. The calibration included the recording of different correction factors to evaluate the data, including a detailed investigation of the detector gain. The quality of the calibration that could be tested for different gas mixtures including the calibration of the density inside the ion source when calibration gas from the gas calibration unit is introduced. In conclusion the calibration shows that DFMS meets the design requirements and that DFMS will be able to measure the D/H at the comet and help shed more light on the puzzle about the origin of water on Earth.

Bayesian and survival model for tumor relapse status and disease-specific survival, with applications to breast cancer

Breast cancer is the most common non-skin cancer and the second leading cause of cancer-related death in women in the United States. Studies on ipsilateral breast tumor relapse (IBTR) status and disease-specific survival will help guide clinic treatment and predict patient prognosis.^ After breast conservation therapy, patients with breast cancer may experience breast tumor relapse. This relapse is classified into two distinct types: true local recurrence (TR) and new ipsilateral primary tumor (NP). However, the methods used to classify the relapse types are imperfect and are prone to misclassification. In addition, some observed survival data (e.g., time to relapse and time from relapse to death)are strongly correlated with relapse types. The first part of this dissertation presents a Bayesian approach to (1) modeling the potentially misclassified relapse status and the correlated survival information, (2) estimating the sensitivity and specificity of the diagnostic methods, and (3) quantify the covariate effects on event probabilities. A shared frailty was used to account for the within-subject correlation between survival times. The inference was conducted using a Bayesian framework via Markov Chain Monte Carlo simulation implemented in softwareWinBUGS. Simulation was used to validate the Bayesian method and assess its frequentist properties. The new model has two important innovations: (1) it utilizes the additional survival times correlated with the relapse status to improve the parameter estimation, and (2) it provides tools to address the correlation between the two diagnostic methods conditional to the true relapse types.^ Prediction of patients at highest risk for IBTR after local excision of ductal carcinoma in situ (DCIS) remains a clinical concern. The goals of the second part of this dissertation were to evaluate a published nomogram from Memorial Sloan-Kettering Cancer Center, to determine the risk of IBTR in patients with DCIS treated with local excision, and to determine whether there is a subset of patients at low risk of IBTR. Patients who had undergone local excision from 1990 through 2007 at MD Anderson Cancer Center with a final diagnosis of DCIS (n=794) were included in this part. Clinicopathologic factors and the performance of the Memorial Sloan-Kettering Cancer Center nomogram for prediction of IBTR were assessed for 734 patients with complete data. Nomogram for prediction of 5- and 10-year IBTR probabilities were found to demonstrate imperfect calibration and discrimination, with an area under the receiver operating characteristic curve of .63 and a concordance index of .63. In conclusion, predictive models for IBTR in DCIS patients treated with local excision are imperfect. Our current ability to accurately predict recurrence based on clinical parameters is limited.^ The American Joint Committee on Cancer (AJCC) staging of breast cancer is widely used to determine prognosis, yet survival within each AJCC stage shows wide variation and remains unpredictable. For the third part of this dissertation, biologic markers were hypothesized to be responsible for some of this variation, and the addition of biologic markers to current AJCC staging were examined for possibly provide improved prognostication. The initial cohort included patients treated with surgery as first intervention at MDACC from 1997 to 2006. Cox proportional hazards models were used to create prognostic scoring systems. AJCC pathologic staging parameters and biologic tumor markers were investigated to devise the scoring systems. Surveillance Epidemiology and End Results (SEER) data was used as the external cohort to validate the scoring systems. Binary indicators for pathologic stage (PS), estrogen receptor status (E), and tumor grade (G) were summed to create PS+EG scoring systems devised to predict 5-year patient outcomes. These scoring systems facilitated separation of the study population into more refined subgroups than the current AJCC staging system. The ability of the PS+EG score to stratify outcomes was confirmed in both internal and external validation cohorts. The current study proposes and validates a new staging system by incorporating tumor grade and ER status into current AJCC staging. We recommend that biologic markers be incorporating into revised versions of the AJCC staging system for patients receiving surgery as the first intervention.^ Chapter 1 focuses on developing a Bayesian method to solve misclassified relapse status and application to breast cancer data. Chapter 2 focuses on evaluation of a breast cancer nomogram for predicting risk of IBTR in patients with DCIS after local excision gives the statement of the problem in the clinical research. Chapter 3 focuses on validation of a novel staging system for disease-specific survival in patients with breast cancer treated with surgery as the first intervention. ^

Age model and color measurements of sediment cores from the eastern equatorial Pacific

High-resolution records of glacial-interglacial variations in biogenic carbonate, opal, and detritus (derived from non-destructive core log measurements of density, P-wave velocity and color; r >= 0.9) from 15 sediment sites in the eastern equatorial (sampling resolution is ~1 kyr) clear response to eccentricity and precession forcing. For the Peru Basin, we generate a high-resolution (21 kyr increment) orbitally-based chronology for the last 1.3 Ma. Spectral analysis indicates that the 100 kyr cycle became dominant at roughly 1.2 Ma, 200-300 kyr earlier than reported for other paleoclimatic records. The response to orbital forcing is weaker since the Mid-Brunhes Dissolution Event (at 400 ka). A west-east reconstruction of biogenic sedimentation in the Peru Basin (four cores; 91-85°W) distinguishes equatorial and coastal upwelling systems in the western and eastern sites, respectively. A north-south reconstruction perpendicular to the equatorial upwelling system (11 cores, 11°N-°3S) shows high carbonate contents (>= 50%) between 6°N and 4°S and highly variable opal contents between 2°N and 4°S. Carbonate cycles B-6, B-8, B-10, B-12, B-14, M-2, and M-6 are well developed with B-10 (430 ka) as the most prominent cycle. Carbonate highs during glacials and glacial-interglacial transitions extended up to 400 km north and south compared to interglacial or interglacial^glacial carbonate lows. Our reconstruction thus favors glacial-interglacial expansion and contraction of the equatorial upwelling system rather than shifting north or south. Elevated accumulation rates are documented near the equator from 6°N to 4°S and from 2°N to 4°S for carbonate and opal, respectively. Accumulation rates are higher during glacials and glacial-interglacial transitions in all cores, whereas increased dissolution is concentrated on Peru Basin sediments close to the carbonate compensation depth and occurred during interglacials or interglacial-glacial transitions.

Digital surface model, hillshade and Lambertian reflectance model of the rock glaciers Oelgrube and Aeusseres Hochebenkar (Oetztal Alps, Tyrol, Austria)

With full-waveform (FWF) lidar systems becoming increasingly available from different commercial manufacturers, the possibility for extracting physical parameters of the scanned surfaces in an area-wide sense, as addendum to their geometric representation, has risen as well. The mentioned FWF systems digitize the temporal profiles of the transmitted laser pulse and of its backscattered echoes, allowing for a reliable determination of the target distance to the instrument and of physical target quantities by means of radiometric calibration, one of such quantities being the diffuse Lambertian reflectance. The delineation of glaciers is a time-consuming task, commonly performed manually by experts and involving field trips as well as image interpretation of orthophotos, digital terrain models and shaded reliefs. In this study, the diffuse Lambertian reflectance was compared to the glacier outlines mapped by experts. We start the presentation with the workflow for analysis of FWF data, their direct georeferencing and the calculation of the diffuse Lambertian reflectance by radiometric calibration; this workflow is illustrated for a large FWF lidar campaign in the Ötztal Alps (Tyrol, Austria), operated with an Optech ALTM 3100 system. The geometric performance of the presented procedure was evaluated by means of a relative and an absolute accuracy assessment using strip differences and orthophotos, resp. The diffuse Lambertian reflectance was evaluated at two rock glaciers within the mentioned lidar campaign. This feature showed good performance for the delineation of the rock glacier boundaries, especially at their lower parts.

Age model, stable isotopes, major element proportions and endmember unmixing results from four western tropical Atlantic cores

We investigate changes in the delivery and oceanic transport of Amazon sediments related to terrestrial climate variations over the last 250 ka. We present high-resolution geochemical records from four marine sediment cores located between 5 and 12° N along the northern South American margin. The Amazon River is the sole source of terrigenous material for sites at 5 and 9° N, while the core at 12° N receives a mixture of Amazon and Orinoco detrital particles. Using an endmember unmixing model, we estimated the relative proportions of Amazon Andean material ("%-Andes", at 5 and 9° N) and of Amazon material ("%-Amazon", at 12° N) within the terrigenous fraction. The %-Andes and %-Amazon records exhibit significant precessional variations over the last 250 ka that are more pronounced during interglacials in comparison to glacial periods. High %-Andes values observed during periods of high austral summer insolation reflect the increased delivery of suspended sediments by Andean tributaries and enhanced Amazonian precipitation, in agreement with western Amazonian speleothem records. Increased Amazonian rainfall reflects the intensification of the South American monsoon in response to enhanced land-ocean thermal gradient and moisture convergence. However, low %-Amazon values obtained at 12° N during the same periods seem to contradict the increased delivery of Amazon sediments. We propose that reorganizations in surface ocean currents modulate the northwestward transport of Amazon material. In agreement with published records, the seasonal North Brazil Current retroflection is intensified (or prolonged in duration) during cold substages of the last 250 ka (which correspond to intervals of high DJF or low JJA insolation) and deflects eastward the Amazon sediment and freshwater plume.

Bulk stable carbon and oxygen isotopes from ODP Site 1258, and Fe intensities from ODP Site 1262, and minimal tuning age model options for ODP Site 1258 and 1262

Timing is crucial to understanding the causes and consequences of events in Earth history. The calibration of geological time relies heavily on the accuracy of radioisotopic and astronomical dating. Uncertainties in the computations of Earth's orbital parameters and in radioisotopic dating have hampered the construction of a reliable astronomically calibrated time scale beyond 40 Ma. Attempts to construct a robust astronomically tuned time scale for the early Paleogene by integrating radioisotopic and astronomical dating are only partially consistent. Here, using the new La2010 and La2011 orbital solutions, we present the first accurate astronomically calibrated time scale for the early Paleogene (47-65 Ma) uniquely based on astronomical tuning and thus independent of the radioisotopic determination of the Fish Canyon standard. Comparison with geological data confirms the stability of the new La2011 solution back to ~54 Ma. Subsequent anchoring of floating chronologies to the La2011 solution using the very long eccentricity nodes provides an absolute age of 55.530 {plus minus} 0.05 Ma for the onset of the Paleocene/Eocene Thermal Maximum (PETM), 54.850 {plus minus} 0.05 Ma for the early Eocene ash -17, and 65.250 {plus minus} 0.06 Ma for the K/Pg boundary. The new astrochronology presented here indicates that the intercalibration and synchronization of U/Pb and 40Ar/39Ar radiometric geochronology is much more challenging than previously thought.

Stable isotope record and age model for sapropel stratigraphy of ODP Site 160-967

Stable oxygen isotope data from four holes drilled at the Ocean Drilling Program Site 967, which is located on the lower northern slope of the Eratosthenes Seamount, provide a continuous record of Eastern Mediterranean surface-water conditions during the last 3.2 Ma. A high-resolution stratigraphy for the Pliocene-Pleistocene sequence was established by using a combination of astronomical calibration of sedimentary cycles, nannofossil stratigraphy, and stable oxygen isotope fluctuations. Sapropels and color cycles are present throughout the last 3.2 Ma at Site 967, and their ages, as determined by calibration against the precessional component of the astronomical record, are consistent with those estimated for the sapropels of the classical land-based marine sequences of the Punta Piccola, San Nicola, Singa, and Vrica sections (southern Italy). The Site 967 oxygen isotope record shows large amplitude fluctuations mainly caused by variations in surface water salinity throughout the entire period. Spectral analysis shows that fluctuations in the d18O record were predominantly influenced by orbital obliquity and precessional forcing from 3.2 to 1 Ma, and all main orbital frequencies characterize the d18O record for the last million years. The start of sapropel formation at 3.2 Ma indicates a possible link between sapropel formation and the build up of northern hemisphere ice sheets. The dominance of the obliquity cycle in the interval from 3.2-1 Ma further points to the sensitivity of Eastern Mediterranean climate to the fluctuations in the volume of Arctic ice sheets. An intensification of negative isotope anomalies at Site 967, relative to the open ocean, supports a link between high run-off (during warm periods) and sapropel formation. freshwater input would have inhibited deep-water formation, which led to stagnation of deeper waters. Comparison with the land sections also confirms that differential preservation and diagenesis play a key role in sapropel occurrence.