Intensive care unit utilization among patients with cancer at the end of life

Over the last 2 decades, survival rates in critically ill cancer patients have improved. Despite the increase in survival, the intensive care unit (ICU) continues to be a location where end-of-life care takes place. More than 20% of deaths in the United States occur after admission to an ICU, and as baby boomers reach the seventh and eighth decades of their lives, the volume of patients in the ICU is predicted to rise. The aim of this study was to evaluate intensive care unit utilization among patients with cancer who were at the end of life. End of life was defined using decedent and high-risk cohort study designs. The decedent study evaluated characteristics and ICU utilization during the terminal hospital stay among patients who died at The University of Texas MD Anderson Cancer Center during 2003-2007. The high-risk cohort study evaluated characteristics and ICU utilization during the index hospital stay among patients admitted to MD Anderson during 2003-2007 with a high risk of in-hospital mortality. Factors associated with higher ICU utilization in the decedent study included non-local residence, hematologic and non-metastatic solid tumor malignancies, malignancy diagnosed within 2 months, and elective admission to surgical or pediatric services. Having a palliative care consultation on admission was associated with dying in the hospital without ICU services. In the cohort of patients with high risk of in-hospital mortality, patients who went to the ICU were more likely to be younger, male, with newly diagnosed non-metastatic solid tumor or hematologic malignancy, and admitted from the emergency center to one of the surgical services. A palliative care consultation on admission was associated with a decreased likelihood of having an ICU stay. There were no differences in ethnicity, marital status, comorbidities, or insurance status between patients who did and did not utilize ICU services. Inpatient mortality probability models developed for the general population are inadequate in predicting in-hospital mortality for patients with cancer. The following characteristics that differed between the decedent study and high-risk cohort study can be considered in future research to predict risk of in-hospital mortality for patients with cancer: ethnicity, type and stage of malignancy, time since diagnosis, and having advance directives. Identifying those at risk can precipitate discussions in advance to ensure care remains appropriate and in accordance with the wishes of the patient and family.^

An autonomic framework for enhancing the quality of data grid services

Data grid services have been used to deal with the increasing needs of applications in terms of data volume and throughput. The large scale, heterogeneity and dynamism of grid environments often make management and tuning of these data services very complex. Furthermore, current high-performance I/O approaches are characterized by their high complexity and specific features that usually require specialized administrator skills. Autonomic computing can help manage this complexity. The present paper describes an autonomic subsystem intended to provide self-management features aimed at efficiently reducing the I/O problem in a grid environment, thereby enhancing the quality of service (QoS) of data access and storage services in the grid. Our proposal takes into account that data produced in an I/O system is not usually immediately required. Therefore, performance improvements are related not only to current but also to any future I/O access, as the actual data access usually occurs later on. Nevertheless, the exact time of the next I/O operations is unknown. Thus, our approach proposes a long-term prediction designed to forecast the future workload of grid components. This enables the autonomic subsystem to determine the optimal data placement to improve both current and future I/O operations.

The dicode workbench: A flexible framework for the integration of information and web services

Aiming to address requirements concerning integration of services in the context of ?big data?, this paper presents an innovative approach that (i) ensures a flexible, adaptable and scalable information and computation infrastructure, and (ii) exploits the competences of stakeholders and information workers to meaningfully confront information management issues such as information characterization, classification and interpretation, thus incorporating the underlying collective intelligence. Our approach pays much attention to the issues of usability and ease-of-use, not requiring any particular programming expertise from the end users. We report on a series of technical issues concerning the desired flexibility of the proposed integration framework and we provide related recommendations to developers of such solutions. Evaluation results are also discussed.

A component library to improve the reusability in the development of converged services

The evolution of communications networks to Next Generation Networks (NGN) has encouraged the development of new services. Nowadays, several technologies are being integrated into telecommunications services in order to provide new functionalities, resulting in what are known as converged services. The objective is to adapt the behavior of the services to the necessities of different users, generating customized services. Some of the main technologies involved in their development are those related to the Web. But due to this type of services implies the combination of different technologies, their development is a very complex process that has to be improved to reduce the time and cost required, with the aim of promoting the success of such services. This paper proposes to apply software reuse through the utilization of a component library and presents one focused on ECharts for SIP Servlets (E4SS). It is a framework, based on the SIP Servlet specification, which uses finite state machines for the definition of converged communications services. Also, to promote the use of the library, a methodology is proposed in order to facilitate the integration between the library operations and the software development cycle.

Self-rated health and hospital services use in the Spanish National Health System: a longitudinal study

Background: Self-rated health is a subjective measure that has been related to indicators such as mortality, morbidity, functional capacity, and the use of health services. In Spain, there are few longitudinal studies associating self-rated health with hospital services use. The purpose of this study is to analyze the association between self-rated health and socioeconomic, demographic, and health variables, and the use of hospital services among the general population in the Region of Valencia, Spain. Methods: Longitudinal study of 5,275 adults who were included in the 2005 Region of Valencia Health Survey and linked to the Minimum Hospital Data Set between 2006 and 2009. Logistic regression models were used to calculate the odds ratios between use of hospital services and self-rated health, sex, age, educational level, employment status, income, country of birth, chronic conditions, disability and previous use of hospital services. Results: By the end of a 4-year follow-up period, 1,184 participants (22.4 %) had used hospital services. Use of hospital services was associated with poor self-rated health among both men and women. In men, it was also associated with unemployment, low income, and the presence of a chronic disease. In women, it was associated with low educational level, the presence of a disability, previous hospital services use, and the presence of chronic disease. Interactions were detected between self-rated health and chronic disease in men and between self-rated health and educational level in women. Conclusions: Self-rated health acts as a predictor of hospital services use. Various health and socioeconomic variables provide additional predictive capacity. Interactions were detected between self-rated health and other variables that may reflect different complex predictive models, by gender.

The Case Law of the ECJ concerning the Free Provision of Services : 2000 - 2005. Research Papers in Law, 2/2006

Introduction. The present overview covers the period starting from 2000 until the end of 2005.1 This is the follow-up to our overview covering the 1995-1999 period.2 The first striking feature of the present contribution is that it has to deal with almost 3,5 times as many cases as the previous one. Hence, the ECJ has gone from deciding 40 cases in the five year period between 1995- 1999 to deciding over 140 cases based on Art 49 between 2000-2005. This confirms, beyond any doubt, the tendency already observed in our previous overview, that a “third generation” case law on services is being developed at a very rapid pace by the ECJ. This third generation case law is based on the idea that Article 49 EC is not limited to striking down discriminatory measures but extends to the elimination of all hindrances to the free provision of services. This idea was first expressed in the Tourist Guide cases, the Greek and Dutch TV cases and most importantly in the Säger case.3 It has been confirmed ever since. As was to be expected, this broad brush approach of the Court’s has led to an ever-increasing amount of litigation reaching Luxemburg. It is clear that, if indicators were used to weight the importance of the Court’s case law during the relevant period, services would score much higher than goods, both from a quantitative and from a qualitative perspective.4 Hence, contrary to the previous overview, this one cannot deal in detail with any of the judgments delivered during the reference period. The aim of the present contribution is restricted to presenting the basic trends of the Court’s case law in the field of services Therefore, the analysis follows a fundamentally horizontal approach, fleetingly considering the facts of individual cases, with a view to identifying the conceptual premises of the Court’s approach to the free movement of services. Nonetheless, the substantial solutions adopted by the Court in some key topics, such as concession contracts, healthcare services, posted workers and gambling, are also presented as case studies. In this regard, the analysis is organized in four sections. First we explore the (ever expanding) scope of the freedom to provide services (Section 2), then we go on to identify the nature of the violations and of justifications thereto (Section 3), before carrying out some case studies to concretely illustrate the above (Section 4). Then, for the sake of completeness, we try to deduce the general principles running through the totality of the relevant case law (Section 5). Inevitably, some concluding remarks follow (Section 6).5

Legal Aspects in Establishing the Internal Market for services. Research Papers in Law, 6/2007

Introduction. The internal market for services is one of the objectives set by the founding fathers of the EC back in 1957. It is only in the last ten-fifteen years, however, that this aspect of the internal market has seriously attracted the attention of the EC legislature and judiciary.1 With the exception of some sector-specific directives dating back in the late ‘80s, it is only with the deregulation of network industries, the development of electronic communications and the spread of financial services, in the ‘90s that substantial bits of legislation got adopted in the field of services. Similarly, the European Court of Justice (ECJ, the Court) left the principles established in Van Binsbergen back in 1973, hibernate for a long time before fully applying them in Säger and constantly thereafter.2 Ever since, the Court’s case law in this field has grown so important that it has become the compulsory starting point for any study concerning the (horizontal) regulation of the internal market in services. The limits inherent to negative integration and to the casuistic approach pursued by judiciary decisions have prompted the need for a general legislative text to be adopted for services in the internal market. This text, however, hotly debated both at the political and at the legal level, has ended up in little more than a complex restatement of the Court’s case law. It may be, however, that this ‘little more’ is not that little. In view of the ever expanding application of the Treaty rules on services, promoted by the ECJ (para. 1),3 the Directive certainly appears to be a limited regulatory attempt (para. 2). This, however, does not mean that the Directive is a toothless, or useless regulatory instrument (conclusion: para. 3).

Analysing the Contribution of Business Services to European Economic Growth. Bruges European Economic Research (BEER) Papers 9/February 2007

The sector business services contributes directly and indirectly to aggregate economic growth in Europe. The direct contribution comes from the sector’s own dynamism. Though the business-services industry appears to be characterised by strong cyclical volatility, there was also a strong structural growth. Business services actually generated more than half of total net employment growth in the European Union since the second half of the 1990s. Apart from this direct growth contribution, the sector also contributed in an indirect way to economic growth by generating knowledge and productivity spill-overs for other industries. The knowledge role of business services is reflected in its employment characteristics. The business-services industry created spill-overs in three ways: original innovations, knowledge diffusion, and the reduction of human capital indivisibilities at firm level. The share of knowledge-intensive business services in the intermediate inputs of the total economy has risen sharply in the last decade. Firm-level scale diseconomies with regard to knowledge and skill inputs are reduced by external deliveries of such inputs, thereby exploiting positive external scale economies. The process goes along with an increasingly complex social division of labour between economic sectors. The European business-services industry itself is characterised by a relatively weak productivity growth. Does this contribute to growth stagnation tendencies à la the socalled “Baumol disease”? The paper argues that there is no reason to expect this as long as the productivity and growth spill-overs from business services to other sectors are large enough. Finally, the paper concludes by suggesting several policy elements that could boost the role of business services in European economic growth. This might to achieve some of the ambitious Lisbon goals with respect to employment, productivity and innovation.

The Digital Market for Local Services: A one-night stand for workers? An example from the on-demand economy. CEPS Special Report, No. 133/April 2016

This case study provides a snapshot of the dynamics in the digital market for locally provided personal services. Based on a case study for a Belgium platform with 14,113 identified workers and 9,459 posted tasks, the findings suggest that the current intermediation is inefficient. Only a limited share of the tasks posted on the platform are being completed, whereas the characteristics of the not-completed tasks are fairly limited. Moreover, just a small share of the workers participating in the platform is actually performing the completed tasks. Their average earnings per hour are in most cases above the minimum wage and even above the median wage in the offline market. At the present time, however, the limited earnings for individual workers prevent this mode of working from becoming an alternative to a conventional job. In addition to the standard determinants of workers’ earnings (e.g. gender, age, occupation, etc.), the characteristics and evaluation mechanism of the platform have a large influence on the distribution of tasks and earnings.

Reflections on the preferential liberalization of services trade

This paper takes stock of the forces that lie behind the recent rise of preferential agreements in services trade. Its initial focus is with a number of distinguishing features of services trade that set it apart from trade in goods and shapes trade liberalization and rule-making approaches in the services field. The paper then documents the nature, modal, and sectoral incidence of the trade and investment preferences spawned by preferential trade agreements (PTAs) in services. It does so with a view to addressing the question of how preferential the preferential treatment of services trade is. Finally, the paper addresses a number of considerations arising from attempts to multilateralize preferential access and rule-making in services trade.

Dysfunction of respiratory muscles in critically ill patients on the intensive care unit.

Muscular weakness and muscle wasting may often be observed in critically ill patients on intensive care units (ICUs) and may present as failure to wean from mechanical ventilation. Importantly, mounting data demonstrate that mechanical ventilation itself may induce progressive dysfunction of the main respiratory muscle, i.e. the diaphragm. The respective condition was termed 'ventilator-induced diaphragmatic dysfunction' (VIDD) and should be distinguished from peripheral muscular weakness as observed in 'ICU-acquired weakness (ICU-AW)'. Interestingly, VIDD and ICU-AW may often be observed in critically ill patients with, e.g. severe sepsis or septic shock, and recent data demonstrate that the pathophysiology of these conditions may overlap. VIDD may mainly be characterized on a histopathological level as disuse muscular atrophy, and data demonstrate increased proteolysis and decreased protein synthesis as important underlying pathomechanisms. However, atrophy alone does not explain the observed loss of muscular force. When, e.g. isolated muscle strips are examined and force is normalized for cross-sectional fibre area, the loss is disproportionally larger than would be expected by atrophy alone. Nevertheless, although the exact molecular pathways for the induction of proteolytic systems remain incompletely understood, data now suggest that VIDD may also be triggered by mechanisms including decreased diaphragmatic blood flow or increased oxidative stress. Here we provide a concise review on the available literature on respiratory muscle weakness and VIDD in the critically ill. Potential underlying pathomechanisms will be discussed before the background of current diagnostic options. Furthermore, we will elucidate and speculate on potential novel future therapeutic avenues.

The new Soviet legislature : Committee on Defense and State Security : report of the Committee on Armed Services, House of Representatives, One Hundred First Congress, second session.

"The attached report was prepared ... by Dr. Mark Lowenthal ..."--p. iv.

Annual report of the physician in charge of the Oxford Retreat, for the year ending ...

Latest issue consulted: 13th (1895).

ORS, the Office of Research Services : supporting national health and research /

Mode of access: Internet.

Statistical tables, demographic and psychiatric characteristics of patients of outpatient psychiatric clinics in the United States.

Cover title: Outpatient psychiatric clinics, special statistical report, 1961.