Implementation and Operational Research: Risk Charts to Guide Targeted HIV-1 Viral Load Monitoring of ART: Development and Validation in Patients From Resource-Limited Settings.

BACKGROUND HIV-1 RNA viral load (VL) testing is recommended to monitor antiretroviral therapy (ART) but not available in many resource-limited settings. We developed and validated CD4-based risk charts to guide targeted VL testing. METHODS We modeled the probability of virologic failure up to 5 years of ART based on current and baseline CD4 counts, developed decision rules for targeted VL testing of 10%, 20%, or 40% of patients in 7 cohorts of patients starting ART in South Africa, and plotted cutoffs for VL testing on colour-coded risk charts. We assessed the accuracy of risk chart-guided VL testing to detect virologic failure in validation cohorts from South Africa, Zambia, and the Asia-Pacific. RESULTS In total, 31,450 adult patients were included in the derivation and 25,294 patients in the validation cohorts. Positive predictive values increased with the percentage of patients tested: from 79% (10% tested) to 98% (40% tested) in the South African cohort, from 64% to 93% in the Zambian cohort, and from 73% to 96% in the Asia-Pacific cohort. Corresponding increases in sensitivity were from 35% to 68% in South Africa, from 55% to 82% in Zambia, and from 37% to 71% in Asia-Pacific. The area under the receiver operating curve increased from 0.75 to 0.91 in South Africa, from 0.76 to 0.91 in Zambia, and from 0.77 to 0.92 in Asia-Pacific. CONCLUSIONS CD4-based risk charts with optimal cutoffs for targeted VL testing maybe useful to monitor ART in settings where VL capacity is limited.

The Effect of Incidental Consolidation on Management and Outcomes in COPD Exacerbations: Data from the European COPD Audit

OBJECTIVE There is controversy regarding the significance of radiological consolidation in the context of COPD exacerbation (eCOPD). While some studies into eCOPD exclude these cases, consolidation is a common feature of eCOPD admissions in real practice. This study aims to address the question of whether consolidation in eCOPD is a distinct clinical phenotype with implications for management decisions and outcomes. PATIENTS AND METHODS The European COPD Audit was carried out in 384 hospitals from 13 European countries between 2010 and 2011 to analyze guideline adherence in eCOPD. In this analysis, admissions were split according to the presence or not of consolidation on the admission chest radiograph. Groups were compared in terms of clinical and epidemiological features, existing treatment, clinical care utilized and mortality. RESULTS 14,111 cases were included comprising 2,714 (19.2%) with consolidation and 11,397 (80.8%) without. The risk of radiographic consolidation increased with age, female gender, cardiovascular diseases, having had two or more admissions in the previous year, and sputum color change. Previous treatment with inhaled steroids was not associated. Patients with radiographic consolidation were significantly more likely to receive antibiotics, oxygen and non-invasive ventilation during the admission and had a lower survival from admission to 90-day follow-up. CONCLUSIONS Patients admitted for COPD exacerbation who have radiological consolidation have a more severe illness course, are treated more intensively by clinicians and have a poorer prognosis. We recommend that these patients be considered a distinct subset in COPD exacerbation.

Air Force web-based preventive health assessement alcohol screening effectiveness using the Alcohol Use Disorders Identification Tool (AUDIT)

Alcohol consumption has a long-standing tradition in the United States Air Force (USAF). From squadron bars to officers and enlisted clubs, alcohol has been used in social settings to increase morale and also as a way to help decrease the stress of military operations. Surveys have demonstrated that the USAF has more than double the percentage of heavy drinkers than the US population. More than one-third of the Air Force reports binge drinking in the last month while only six percent of the nation reports the same consumption pattern.^ However, alcohol has a significant harmful health effect if consumed in excess. As part of an overall prevention and treatment program aimed at curbing the harmful effects of alcohol consumption, the USAF uses the Alcohol Use Disorder Identification Test (AUDIT) to screen for high-risk alcohol consumption patterns before alcohol disorder and disability occur. All Air Force active-duty members are required to complete a yearly Preventive Health Assessment questionnaire. Various health topics are included in this questionnaire including nutrition, exercise, tobacco use, family history, mental health and alcohol use. While this questionnaire has been available in a web-based format for several years, mandatory use was not implemented until 2009.^ Although the AUDIT was selected due to its effectiveness in assessing high-risk alcohol consumption in other populations, its effectiveness in the Air Force population had not been studied previously. In order to assess the sensitivity, specificity, and positive predictive value of this screening tool, the Air Force Web-based Preventive Health Assessment alcohol screening results were compared to whether any alcohol-related diagnosis was made from January 1, 2009 to March 31, 2010.^ While the AUDIT has previously been shown to have a high sensitivity and specificity, the Air Force screening values were 27.9% and 93.0% respectively. Positive predictive value was only 4.9%. With the screening statistics found, less than one-third of those having an alcohol disorder will be found with this screening tool and only 1 out of 20 Airmen who require further evaluation actually have an alcohol-related diagnosis.^

DEVELOPMENT AND IMPLEMENTATION OF A REMOTE AUDIT TOOL FOR HIGH DOSE RATE (HDR) 192IR BRACHYTHERAPY USING OPTICALLY STIMULATED LUMINESCENCE DOSIMETRY

This work aimed to create a mailable and OSLD-based phantom with accuracy suitable for RPC audits of HDR brachytherapy sources at institutions participating in NCI-funded cooperative clinical trials. An 8 × 8 × 10 cm3 prototype with two slots capable of holding nanoDot Al2O3:C OSL dosimeters (Landauer, Glenwood, IL) was designed and built. The phantom has a single channel capable of accepting all 192Ir HDR brachytherapy sources in current clinical use in the United States. Irradiations were performed with an 192Ir HDR source to determine correction factors for linearity with dose, dose rate, and the combined effect of irradiation energy and phantom construction. The uncertainties introduced by source positioning in the phantom and timer resolution limitations were also investigated. It was found that the linearity correction factor was where dose is in cGy, which differed from that determined by the RPC for the same batch of dosimeters under 60Co irradiation. There was no significant dose rate effect. Separate energy+block correction factors were determined for both models of 192Ir sources currently in clinical use and these vendor-specific correction factors differed by almost 2.6%. For Nucletron sources, this correction factor was 1.026±0.004 (99% Confidence Interval) and for Varian sources it was 1.000±0.007 (99% CI). Reasonable deviations in source positioning within the phantom and the limited resolution of the source timer had insignificant effects on the ability to measure dose. Overall measurement uncertainty of the system was estimated to be ±2.5% for both Nucletron and Varian source audits (95% CI). This uncertainty was sufficient to establish a ±5% acceptance criterion for source strength audits under a formal RPC audit program. Trial audits of eight participating institutions resulted in an average RPC-to-institution dose ratio of 1.000 with a standard deviation of 0.011.

Supply chain collaboration and responsiveness : a comparison between Thai automotive and electronics industries

This paper examines factors that promote firms to develop supply chain collaborations (SCC) with their partners and relationships between SCC and supply chain operational performances (SCOP), using a questionnaire survey on Thai automotive and electronics industries in 2012. This paper also carries out a comparative study on these questions between the electronics and automotive industries. Two-stage least squares (2SLS) regressions verifY that supplier evaluation and audit is a foundation for firms to share information and synchronize decision makings with their partners, and that such SCC are significantly related to SCOP indictors such as on-time delivery, fast procurement, and flexibility to customer need irrespective of industry type. On the other hand, competitive pressure motivates only electronics firms to develop sec in order to be more innovative.

Operational Modal Analysis on laminated glass beams

Laminated glass is a sandwich element consisting of two or more glass sheets, with one or more interlayers of polyvinyl butyral (PVB). The dynamic response of laminated glass beams and plates can be predicted using analytical or numerical models in which the glass and the PVB are usually modelled as linear-elastic and linear viscoelastic materials, respectively. In this work the dynamic behavior of laminated glass beams are predicted using a finite element model and the analytical model of Ross-Kerwin-Ungar. The numerical and analytical results are compared with those obtained by operational modal analysis performed at different temperatures.

An approach to operational modal analysis using the expectation maximization algorithm

This paper presents the Expectation Maximization algorithm (EM) applied to operational modal analysis of structures. The EM algorithm is a general-purpose method for maximum likelihood estimation (MLE) that in this work is used to estimate state space models. As it is well known, the MLE enjoys some optimal properties from a statistical point of view, which make it very attractive in practice. However, the EM algorithm has two main drawbacks: its slow convergence and the dependence of the solution on the initial values used. This paper proposes two different strategies to choose initial values for the EM algorithm when used for operational modal analysis: to begin with the parameters estimated by Stochastic Subspace Identification method (SSI) and to start using random points. The effectiveness of the proposed identification method has been evaluated through numerical simulation and measured vibration data in the context of a benchmark problem. Modal parameters (natural frequencies, damping ratios and mode shapes) of the benchmark structure have been estimated using SSI and the EM algorithm. On the whole, the results show that the application of the EM algorithm starting from the solution given by SSI is very useful to identify the vibration modes of a structure, discarding the spurious modes that appear in high order models and discovering other hidden modes. Similar results are obtained using random starting values, although this strategy allows us to analyze the solution of several starting points what overcome the dependence on the initial values used.

Modal contribution and state space order selection in operational modal analysis

The estimation of modal parameters of a structure from ambient measurements has attracted the attention of many researchers in the last years. The procedure is now well established and the use of state space models, stochastic system identification methods and stabilization diagrams allows to identify the modes of the structure. In this paper the contribution of each identified mode to the measured vibration is discussed. This modal contribution is computed using the Kalman filter and it is an indicator of the importance of the modes. Also the variation of the modal contribution with the order of the model is studied. This analysis suggests selecting the order for the state space model as the order that includes the modes with higher contribution. The order obtained using this method is compared to those obtained using other well known methods, like Akaike criteria for time series or the singular values of the weighted projection matrix in the Stochastic Subspace Identification method. Finally, both simulated and measured vibration data are used to show the practicability of the derived technique. Finally, it is important to remark that the method can be used with any identification method working in the state space model.

Performance of pressure control valves and flow meters precision in operational irrigation-water balance accuracy

In pressure irrigation-water distribution networks, pressure regulating devices for controlling the discharged flow rate by irrigation units are needed due to the variability of flow rate. In addition, applied water volume is used controlled operating the valve during a calculated time interval, and assuming constant flow rate. In general, a pressure regulating valve PRV is the commonly used pressure regulating device in a hydrant, which, also, executes the open and close function. A hydrant feeds several irrigation units, requiring a wide range in flow rate. In addition, some flow meters are also available, one as a component of the hydrant and the rest are placed downstream. Every land owner has one flow meter for each group of field plots downstream the hydrant. Its lecture could be used for refining the water balance but its accuracy must be taken into account. Ideal PRV performance would maintain a constant downstream pressure. However, the true performance depends on both upstream pressure and the discharged flow rate. The objective of this work is to asses the influence of the performance on the applied volume during the whole irrigation events in a year. The results of the study have been obtained introducing the flow rate into a PRV model. Variations on flow rate are simulated by taking into account the consequences of variations on climate conditions and also decisions in irrigation operation, such us duration and frequency application. The model comprises continuity, dynamic and energy equations of the components of the PRV.

Operational characterisation of a Micro-SME producing farmhouse cheese in the south of Venezuela

A piece of research is presented that was conducted on the Guayanes Farmhouse Telita Cheese Producers Network located in the Piar and Padre Chien rural municipalities of Bolivar state in Venezuela. Guayanes telita cheese is a regional dairy product. The producers are to be found in a rural area with a high potential for marketing the label in the Southern Common Market (MERCOSUR). This market is the focal point of the strategic importance of this study for the Region and the Country. The research is of a descriptive scope conducted in the field. A questionnaire based on good food production practice was used as a data gathering technique. The final sample comprised 30 production units. Statistical processing was performed with version 15.2 of the STATGRAPHICS Centurion computational tool. The results would appear to confirm previous studies that point to the existence of factors that prevent these Micro-SMEs from guaranteeing the food safety of the product. The results indicate that new lines of research need to be opened up. These are oriented towards formulating strategies for the continuous improvement of these micro-SMEs, including quality control indicators.