Essays in Behavioral Personnel Economics

The thesis contemplates 4 papers and its main goal is to provide evidence on the prominent impact that behavioral analysis can play into the personnel economics domain.The research tool prevalently used in the thesis is the experimental analysis.The first paper provide laboratory evidence on how the standard screening model–based on the assumption that the pecuniary dimension represents the main workers’choice variable–fails when intrinsic motivation is introduced into the analysis.The second paper explores workers’ behavioral reactions when dealing with supervisors that may incur in errors in the assessment of their job performance.In particular,deserving agents that have exerted high effort may not be rewarded(Type-I errors)and undeserving agents that have exerted low effort may be rewarded(Type-II errors).Although a standard neoclassical model predicts both errors to be equally detrimental for effort provision,this prediction fails when tested through a laboratory experiment.Findings from this study suggest how failing to reward deserving agents is significantly more detrimental than rewarding undeserving agents.The third paper investigates the performance of two antithetic non-monetary incentive schemes on schooling achievement.The study is conducted through a field experiment.Students randomized to the main treatments have been incentivized to cooperate or to compete in order to earn additional exam points.Consistently with the theoretical model proposed in the paper,the level of effort in the competitive scheme proved to be higher than in the cooperative setting.Interestingly however,this result is characterized by a strong gender effect.The fourth paper exploits a natural experiment setting generated by the credit crunch occurred in the UK in the2007.The economic turmoil has negatively influenced the private sector,while public sector employees have not been directly hit by the crisis.This shock–through the rise of the unemployment rate and the increasing labor market uncertainty–has generated an exogenous variation in the opportunity cost of maternity leave in private sector labor force.This paper identifies the different responses.

Forensisch relevante SNP-Genotypisierung mittels elektronischer Microarray-Technologie

Die vorliegende Dissertation entstand im Rahmen eines multizentrischen EU-geförderten Projektes, das die Anwendungsmöglichkeiten von Einzelnukleotid-Polymorphismen (SNPs) zur Individualisierung von Personen im Kontext der Zuordnung von biologischen Tatortspuren oder auch bei der Identifizierung unbekannter Toter behandelt. Die übergeordnete Zielsetzung des Projektes bestand darin, hochauflösende Genotypisierungsmethoden zu etablieren und zu validieren, die mit hoher Genauigkeit aber geringen Aufwand SNPs im Multiplexformat simultan analysieren können. Zunächst wurden 29 Y-chromosomale und 52 autosomale SNPs unter der Anforderung ausgewählt, dass sie als Multiplex eine möglichst hohe Individualisierungschance aufweisen. Anschließend folgten die Validierungen beider Multiplex-Systeme und der SNaPshot™-Minisequenzierungsmethode in systematischen Studien unter Beteiligung aller Arbeitsgruppen des Projektes. Die validierte Referenzmethode auf der Basis einer Minisequenzierung diente einerseits für die kontrollierte Zusammenarbeit unterschiedlicher Laboratorien und andererseits als Grundlage für die Entwicklung eines Assays zur SNP-Genotypisierung mittels der elektronischen Microarray-Technologie in dieser Arbeit. Der eigenständige Hauptteil dieser Dissertation beschreibt unter Verwendung der zuvor validierten autosomalen SNPs die Neuentwicklung und Validierung eines Hybridisierungsassays für die elektronische Microarray-Plattform der Firma Nanogen Dazu wurden im Vorfeld drei verschiedene Assays etabliert, die sich im Funktionsprinzip auf dem Microarray unterscheiden. Davon wurde leistungsorientiert das Capture down-Assay zur Weiterentwicklung ausgewählt. Nach zahlreichen Optimierungsmaßnahmen hinsichtlich PCR-Produktbehandlung, gerätespezifischer Abläufe und analysespezifischer Oligonukleotiddesigns stand das Capture down-Assay zur simultanen Typisierung von drei Individuen mit je 32 SNPs auf einem Microarray bereit. Anschließend wurde dieses Verfahren anhand von 40 DNA-Proben mit bekannten Genotypen für die 32 SNPs validiert und durch parallele SNaPshot™-Typisierung die Genauigkeit bestimmt. Das Ergebnis beweist nicht nur die Eignung des validierten Analyseassays und der elektronischen Microarray-Technologie für bestimmte Fragestellungen, sondern zeigt auch deren Vorteile in Bezug auf Schnelligkeit, Flexibilität und Effizienz. Die Automatisierung, welche die räumliche Anordnung der zu untersuchenden Fragmente unmittelbar vor der Analyse ermöglicht, reduziert unnötige Arbeitsschritte und damit die Fehlerhäufigkeit und Kontaminationsgefahr bei verbesserter Zeiteffizienz. Mit einer maximal erreichten Genauigkeit von 94% kann die Zuverlässigkeit der in der forensischen Genetik aktuell eingesetzten STR-Systeme jedoch noch nicht erreicht werden. Die Rolle des neuen Verfahrens wird damit nicht in einer Ablösung der etablierten Methoden, sondern in einer Ergänzung zur Lösung spezieller Probleme wie z.B. der Untersuchung stark degradierter DNA-Spuren zu finden sein.

E-ToF-Messungen mit kalorimetrischen Tieftemperatur-Detektoren zur Bestimmung spezischer Energieverluste und zur Massenidentifikation niederenergetischer Schwerionen

Kalorimetrische Tieftemperatur-Detektoren (Calorimetric Low Temperature Detectors, CLTDs) wurden erstmals in Messungen zur Bestimmung des spezifischen Energieverlustes (dE/dx) niederenergetischer Schwerionen beim Durchgang durch Materie eingesetzt. Die Messungen wurden im Energiebereich unterhalb des Bragg-Peaks, mit 0.1 - 1.4 MeV/u 238U-Ionen in Kohlenstoff und Gold sowie mit 0.05 - 1.0 MeV/u 131Xe-Ionen in Kohlenstoff, Nickel und Gold, durchgeführt. Die Kombination der CLTDs mit einem Flugzeitdetektor ermöglichte dabei, kontinuierliche dE/dx-Kurven über größere Energiebereiche hinweg simultan zu bestimmen. Im Vergleich zu herkömmlichen Meßsystemen, die Ionisationsdetektoren zur Energiemessung verwenden, erlaubten die höhere Energieauflösung und -linearität der CLTDs eine Verringerung der Kalibrierungsfehler sowie eine Erweiterung des zugänglichen Energiebereiches der dE/dx-Messungen in Richtung niedriger Energien. Die gewonnen Daten können zur Anpassung theoretischer und semi-empirischer Modelle und somit zu einer Erhöhung der Präzision bei der Vorhersage spezifischer Energieverluste schwerer Ionen beitragen. Neben der experimentellen Bestimmung neuer Daten wurden das alternative Detektionsprinzip der CLTDs, die Vorteile dieser Detektoren bezüglich Energieauflösung und -linearität sowie der modulare Aufbau des CLTD-Arrays aus mehreren Einzeldetektoren genutzt, um diese Art von Messung auf potentielle systematische Unsicherheiten zu untersuchen. Unter anderem wurden hierbei unerwartete Channeling-Effekte beim Durchgang der Ionen durch dünne polykristalline Absorberfolien beobachtet. Die koinzidenten Energie- und Flugzeitmessungen (E-ToF) wurden weiterhin genutzt, um das Auflösungsvermögen des Detektor-Systems bei der direkten in-flight Massenbestimmung langsamer und sehr schwerer Ionen zu bestimmen. Durch die exzellente Energieauflösung der CLTDs konnten hierbei Massenauflösungen von Delta-m(FWHM) = 1.3 - 2.5 u für 0.1 - 0.6 MeV/u 238U-Ionen erreicht werden. In einer E-ToF-Messung mit Ionisationsdetektoren sind solche Werte in diesem Energie- und Massenbereich aufgrund der Limitierung der Energieauflösung durch statistische Schwankungen von Verlustprozessen beim Teilchennachweis nicht erreichbar.

Systematic review of medication safety assessment methods

Purpose The accuracy, efficiency, and efficacy of four commonly recommended medication safety assessment methodologies were systematically reviewed. Methods Medical literature databases were systematically searched for any comparative study conducted between January 2000 and October 2009 in which at least two of the four methodologies—incident report review, direct observation, chart review, and trigger tool—were compared with one another. Any study that compared two or more methodologies for quantitative accuracy (adequacy of the assessment of medication errors and adverse drug events) efficiency (effort and cost), and efficacy and that provided numerical data was included in the analysis. Results Twenty-eight studies were included in this review. Of these, 22 compared two of the methodologies, and 6 compared three methods. Direct observation identified the greatest number of reports of drug-related problems (DRPs), while incident report review identified the fewest. However, incident report review generally showed a higher specificity compared to the other methods and most effectively captured severe DRPs. In contrast, the sensitivity of incident report review was lower when compared with trigger tool. While trigger tool was the least labor-intensive of the four methodologies, incident report review appeared to be the least expensive, but only when linked with concomitant automated reporting systems and targeted follow-up. Conclusion All four medication safety assessment techniques—incident report review, chart review, direct observation, and trigger tool—have different strengths and weaknesses. Overlap between different methods in identifying DRPs is minimal. While trigger tool appeared to be the most effective and labor-efficient method, incident report review best identified high-severity DRPs.

Patient safety--who cares?

Medical errors and adverse events are a serious threat to patients worldwide. In recent years methodologically sound studies have demonstrated that interventions exist, can be implemented and can have sustainable, measurable positive effects on patient safety. Nonetheless, system-wide progress and adoption of safety practices is slow and evidence of improvements on the organisational and systems level is scarce and ambiguous. This paper reports on the Swiss Patient Safety Conference in 2011 and addresses emerging issues for patient safety and future challenges.

[Patients as vigilant partners - patient involvement in patient safety]

Patients can contribute to the improvement in patient safety. They are usually vigilant observers of the care they receive and can provide information about adverse events and safety-related processes. In addition, they can help to prevent errors by active engagement in safety. This potential for involvement in error prevention is increasingly acknowledged internationally. Educational material has been developed and can be used to instruct and motivate patients to monitor care for failures and errors and communicate their observations towards health care workers. Preliminary research suggests that this approach can be successful in improving patient safety.

Algorithms for spacecraft formation flying navigation based on wireless positioning system measurements

Spacecraft formation flying navigation continues to receive a great deal of interest. The research presented in this dissertation focuses on developing methods for estimating spacecraft absolute and relative positions, assuming measurements of only relative positions using wireless sensors. The implementation of the extended Kalman filter to the spacecraft formation navigation problem results in high estimation errors and instabilities in state estimation at times. This is due tp the high nonlinearities in the system dynamic model. Several approaches are attempted in this dissertation aiming at increasing the estimation stability and improving the estimation accuracy. A differential geometric filter is implemented for spacecraft positions estimation. The differential geometric filter avoids the linearization step (which is always carried out in the extended Kalman filter) through a mathematical transformation that converts the nonlinear system into a linear system. A linear estimator is designed in the linear domain, and then transformed back to the physical domain. This approach demonstrated better estimation stability for spacecraft formation positions estimation, as detailed in this dissertation. The constrained Kalman filter is also implemented for spacecraft formation flying absolute positions estimation. The orbital motion of a spacecraft is characterized by two range extrema (perigee and apogee). At the extremum, the rate of change of a spacecraft’s range vanishes. This motion constraint can be used to improve the position estimation accuracy. The application of the constrained Kalman filter at only two points in the orbit causes filter instability. Two variables are introduced into the constrained Kalman filter to maintain the stability and improve the estimation accuracy. An extended Kalman filter is implemented as a benchmark for comparison with the constrained Kalman filter. Simulation results show that the constrained Kalman filter provides better estimation accuracy as compared with the extended Kalman filter. A Weighted Measurement Fusion Kalman Filter (WMFKF) is proposed in this dissertation. In wireless localizing sensors, a measurement error is proportional to the distance of the signal travels and sensor noise. In this proposed Weighted Measurement Fusion Kalman Filter, the signal traveling time delay is not modeled; however, each measurement is weighted based on the measured signal travel distance. The obtained estimation performance is compared to the standard Kalman filter in two scenarios. The first scenario assumes using a wireless local positioning system in a GPS denied environment. The second scenario assumes the availability of both the wireless local positioning system and GPS measurements. The simulation results show that the WMFKF has similar accuracy performance as the standard Kalman Filter (KF) in the GPS denied environment. However, the WMFKF maintains the position estimation error within its expected error boundary when the WLPS detection range limit is above 30km. In addition, the WMFKF has a better accuracy and stability performance when GPS is available. Also, the computational cost analysis shows that the WMFKF has less computational cost than the standard KF, and the WMFKF has higher ellipsoid error probable percentage than the standard Measurement Fusion method. A method to determine the relative attitudes between three spacecraft is developed. The method requires four direction measurements between the three spacecraft. The simulation results and covariance analysis show that the method’s error falls within a three sigma boundary without exhibiting any singularity issues. A study of the accuracy of the proposed method with respect to the shape of the spacecraft formation is also presented.

VuLF – Entwicklung eines Versuchsstandes zur Fehlerminimierung durch Fahrzeuganalyse

Fahrerlose Transportsysteme (FTS) kommen in der Intralogistik immer mehr zum Einsatz. Dabei wer-den neue Anforderungen an die FTS gestellt, die bisherige Aufgaben weit übersteigen. Der Transport von schweren Lasten und die Fahrt mehrere FTS in einer Formation sind dabei nur der Anfang einer Menge zukünftiger Einsatzgebiete. Große Probleme stellen dabei Schlupf und Verschleiß dar, die bisher noch kaum erforscht sind, welche die Performance der Fahrzeuge jedoch stark beeinträchtigen. Um diese Fehlerquellen besser verstehen zu können, wurde ein Versuchsstand entwickelt, mit dessen Hilfe Einzelfahrten aber auch Formationsfahrten in Bezug auf Schlupf und Verschleiß besser untersucht werden können. Dabei kann ein sehr breites Spektrum an Fahrzeugarten abgedeckt werden, da Parameter wie Lenksysteme oder Bereifung variabel gewählt werden können.

[Second victim : Critical incident stress management in clinical medicine]

BACKGROUND Critical incidents in clinical medicine can have far-reaching consequences on patient health. In cases of severe medical errors they can seriously harm the patient or even lead to death. The involvement in such an event can result in a stress reaction, a so-called acute posttraumatic stress disorder in the healthcare provider, the so-called second victim of an adverse event. Psychological distress may not only have a long lasting impact on quality of life of the physician or caregiver involved but it may also affect the ability to provide safe patient care in the aftermath of adverse events. METHODS A literature review was performed to obtain information on care giver responses to medical errors and to determine possible supportive strategies to mitigate negative consequences of an adverse event on the second victim. An internet search and a search in Medline/Pubmed for scientific studies were conducted using the key words "second victim, "medical error", "critical incident stress management" (CISM) and "critical incident stress reporting system" (CIRS). Sources from academic medical societies and public institutions which offer crisis management programs where analyzed. The data were sorted by main categories and relevance for hospitals. Analysis was carried out using descriptive measures. RESULTS In disaster medicine and aviation navigation services the implementation of a CISM program is an efficient intervention to help staff to recover after a traumatic event and to return to normal functioning and behavior. Several other concepts for a clinical crisis management plan were identified. CONCLUSIONS The integration of CISM and CISM-related programs in a clinical setting may provide efficient support in an acute crisis and may help the caregiver to deal effectively with future error events and employee safety.

Finite element analysis for prediction of bone strength

Article preview View full access options BoneKEy Reports | Review Print Email Share/bookmark Finite element analysis for prediction of bone strength Philippe K Zysset, Enrico Dall'Ara, Peter Varga & Dieter H Pahr Affiliations Corresponding author BoneKEy Reports (2013) 2, Article number: 386 (2013) doi:10.1038/bonekey.2013.120 Received 03 January 2013 Accepted 25 June 2013 Published online 07 August 2013 Article tools Citation Reprints Rights & permissions Abstract Abstract• References• Author information Finite element (FE) analysis has been applied for the past 40 years to simulate the mechanical behavior of bone. Although several validation studies have been performed on specific anatomical sites and load cases, this study aims to review the predictability of human bone strength at the three major osteoporotic fracture sites quantified in recently completed in vitro studies at our former institute. Specifically, the performance of FE analysis based on clinical computer tomography (QCT) is compared with the ones of the current densitometric standards, bone mineral content, bone mineral density (BMD) and areal BMD (aBMD). Clinical fractures were produced in monotonic axial compression of the distal radii, vertebral sections and in side loading of the proximal femora. QCT-based FE models of the three bones were developed to simulate as closely as possible the boundary conditions of each experiment. For all sites, the FE methodology exhibited the lowest errors and the highest correlations in predicting the experimental bone strength. Likely due to the improved CT image resolution, the quality of the FE prediction in the peripheral skeleton using high-resolution peripheral CT was superior to that in the axial skeleton with whole-body QCT. Because of its projective and scalar nature, the performance of aBMD in predicting bone strength depended on loading mode and was significantly inferior to FE in axial compression of radial or vertebral sections but not significantly inferior to FE in side loading of the femur. Considering the cumulated evidence from the published validation studies, it is concluded that FE models provide the most reliable surrogates of bone strength at any of the three fracture sites.

Ecological validity of virtual reality daily living activities screening for early dementia: longitudinal study

Background: Dementia is a multifaceted disorder that impairs cognitive functions, such as memory, language, and executive functions necessary to plan, organize, and prioritize tasks required for goal-directed behaviors. In most cases, individuals with dementia experience difficulties interacting with physical and social environments. The purpose of this study was to establish ecological validity and initial construct validity of a fire evacuation Virtual Reality Day-Out Task (VR-DOT) environment based on performance profiles as a screening tool for early dementia. Objective: The objectives were (1) to examine the relationships among the performances of 3 groups of participants in the VR-DOT and traditional neuropsychological tests employed to assess executive functions, and (2) to compare the performance of participants with mild Alzheimer’s-type dementia (AD) to those with amnestic single-domain mild cognitive impairment (MCI) and healthy controls in the VR-DOT and traditional neuropsychological tests used to assess executive functions. We hypothesized that the 2 cognitively impaired groups would have distinct performance profiles and show significantly impaired independent functioning in ADL compared to the healthy controls. Methods: The study population included 3 groups: 72 healthy control elderly participants, 65 amnestic MCI participants, and 68 mild AD participants. A natural user interface framework based on a fire evacuation VR-DOT environment was used for assessing physical and cognitive abilities of seniors over 3 years. VR-DOT focuses on the subtle errors and patterns in performing everyday activities and has the advantage of not depending on a subjective rating of an individual person. We further assessed functional capacity by both neuropsychological tests (including measures of attention, memory, working memory, executive functions, language, and depression). We also evaluated performance in finger tapping, grip strength, stride length, gait speed, and chair stands separately and while performing VR-DOTs in order to correlate performance in these measures with VR-DOTs because performance while navigating a virtual environment is a valid and reliable indicator of cognitive decline in elderly persons. Results: The mild AD group was more impaired than the amnestic MCI group, and both were more impaired than healthy controls. The novel VR-DOT functional index correlated strongly with standard cognitive and functional measurements, such as mini-mental state examination (MMSE; rho=0.26, P=.01) and Bristol Activities of Daily Living (ADL) scale scores (rho=0.32, P=.001). Conclusions: Functional impairment is a defining characteristic of predementia and is partly dependent on the degree of cognitive impairment. The novel virtual reality measures of functional ability seem more sensitive to functional impairment than qualitative measures in predementia, thus accurately differentiating from healthy controls. We conclude that VR-DOT is an effective tool for discriminating predementia and mild AD from controls by detecting differences in terms of errors, omissions, and perseverations while measuring ADL functional ability.

Distributed sensor failure detection in sensor networks

We investigate the problem of distributed sensors' failure detection in networks with a small number of defective sensors, whose measurements differ significantly from the neighbor measurements. We build on the sparse nature of the binary sensor failure signals to propose a novel distributed detection algorithm based on gossip mechanisms and on Group Testing (GT), where the latter has been used so far in centralized detection problems. The new distributed GT algorithm estimates the set of scattered defective sensors with a low complexity distance decoder from a small number of linearly independent binary messages exchanged by the sensors. We first consider networks with one defective sensor and determine the minimal number of linearly independent messages needed for its detection with high probability. We then extend our study to the multiple defective sensors detection by modifying appropriately the message exchange protocol and the decoding procedure. We show that, for small and medium sized networks, the number of messages required for successful detection is actually smaller than the minimal number computed theoretically. Finally, simulations demonstrate that the proposed method outperforms methods based on random walks in terms of both detection performance and convergence rate.

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.

Sustained attention in children with two etiologies of early hydrocephalus.

Several studies have shown that children with spina bifida meningomyelocele (SBM) and hydrocephalus have attention problems on parent ratings and difficulties in stimulus orienting associated with a posterior brain attention system. Less is known about response control and inhibition associated with an anterior brain attention system. Using the Gordon Vigilance Task (Gordon, 1983), we studied error rate, reaction time, and performance over time for sustained attention, a key anterior attention function, in 101 children with SBM, 17 with aqueductal stenosis (AS; another condition involving congenital hydrocephalus), and 40 typically developing controls (NC). In SBM, we investigated the relation between cognitive attention and parent ratings of inattention and hyperactivity and explored the impact of medical variables. Children with SBM did not differ from AS or NC groups on measures of sustained attention, but they committed more errors and responded more slowly. Approximately one-third of the SBM group had attention symptoms, although parent attention ratings were not associated with task performance. Hydrocephalus does not account for the attention profile of children with SBM, which also reflects the distinctive brain dysmorphologies associated with this condition.

Eye Movement Measures of Cognitive Control in Children with Tourette Syndrome

Tourette Syndrome begins in childhood and is characterized by uncontrollable repetitive actions like neck craning or hopping and noises such as sniffing or chirping. Worst in early adolescence, these tics wax and wane in severity and occur in bouts unpredictably, often drawing unwanted attention from bystanders. Making matters worse, over half of children with Tourette Syndrome also suffer from comorbid, or concurrent, disorders such as attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). These disorders introduce anxious thoughts, impulsivity, inattention, and mood variability that further disrupt children with Tourette Syndrome from focusing and performing well at school and home. Thus, deficits in the cognitive control functions of response inhibition, response generation, and working memory have long been ascribed to Tourette Syndrome. Yet, without considering the effect of medication, age, and comorbidity, this is a premature attribution. This study used an infrared eye tracking camera and various computer tasks requiring eye movement responses to evaluate response inhibition, response generation, and working memory in Tourette Syndrome. This study, the first to control for medication, age, and comorbidity, enrolled 39 unmedicated children with Tourette Syndrome and 29 typically developing peers aged 10-16 years who completed reflexive and voluntary eye movement tasks and diagnostic rating scales to assess symptom severities of Tourette Syndrome, ADHD, and OCD. Children with Tourette Syndrome and comorbid ADHD and/or OCD, but not children with Tourette Syndrome only, took longer to respond and made more errors and distracted eye movements compared to typically-developing children, displaying cognitive control deficits. However, increasing symptom severities of Tourette Syndrome, ADHD, and OCD correlated with one another. Thus, cognitive control deficits were not specific to Tourette Syndrome patients with comorbid conditions, but rather increase with increasing tic severity, suggesting that a majority of Tourette Syndrome patients, regardless of a clinical diagnosis of ADHD and/or OCD, have symptoms of cognitive control deficits at some level. Therefore, clinicians should evaluate and counsel all families of children with Tourette Syndrome, with or without currently diagnosed ADHD and/or OCD, about the functional ramifications of comorbid symptoms and that they may wax and wane with tic severity.