Impact of the availability of an influenza virus rapid antigen test on diagnostic decision making in a pediatric emergency department

OBJECTIVES: Fever is one of the most commonly seen symptoms in the pediatric emergency department. The objective of this study was to observe how the rapid testing for influenza virus impacts on the management of children with fever. METHODS: We performed a review of our pediatric emergency department records during the 2008/2009 annual influenza season. The BinaxNow Influenza A+B test was performed on patients with the following criteria: age 1.0 to 16.0 years, fever greater than 38.5 °C, fever of less than 96 hours' duration after the onset of clinical illness, clinical signs compatible with acute influenza, and nontoxic appearance. Additional laboratory tests were performed at the treating physician's discretion. RESULTS: The influenza rapid antigen test was performed in 192 children. One hundred nine (57%) were influenza positive, with the largest fraction (101 patients) positive for influenza A. The age distribution did not differ between children with negative and positive test results (mean, 5.3 vs. 5.1 years, not statistically significant). A larger number of diagnostic tests were performed in the group of influenza-negative patients. Twice as many complete blood counts, C-reactive protein determinations, lumbar punctures, and urinalyses were ordered in the latter group. CONCLUSIONS: Rapid diagnosis of influenza in the pediatric emergency department affects the management of febrile children as the confirmation of influenza virus infection decreases additional diagnostic tests ordered.

Contrast-enhanced 3-D MRA in decision making for carotid endarterectomy: a 6-year experience

BACKGROUND: Systematic need for angiography in diagnosis of carotid artery stenosis and indication of surgical therapy is still debated. Noninvasive imaging techniques such as MR angiography (MRA) or CT angiography (CTA) offer an alternative to digital subtraction angiography (DSA) and are increasingly used in clinical practice. In this study, we present the radiological characteristics and clinical results of a series of patients operated on the basis of combined ultrasonography (US)/MRA. METHODS: This observational study included all the patients consecutively operated for a carotid stenosis in our Department from October 1998 to December 2004. The applied MRA protocol had previously been established in a large correlation study with DSA. DSA was used only in case of discordance between US and MRA. The preoperative radiological information furnished by MRA was compared with intraoperative findings. The outcome of the operation was assessed according to ECST criteria. RESULTS: Among 327 patients, preoperative MRA was performed in 278 (85%), DSA in 44 (13.5%) and CT angiography in 5 (1.5%). Most of DSA studies were performed as emergency for preparation of endovascular therapy or for reasons other than carotid stenosis. Eleven additional DSA (3.3%) complemented US/MRA, mostly because diverging diagnosis of subocclusion of ICA. No direct morbidity or intraoperative difficulty was related to preoperative MRA. Combined mortality/major morbidity rate was 0.9% (3 patients) and minor morbidity rate 5.5% (18 patients). CONCLUSIONS: This observational study describes a well-established practice of carotid surgery and supports the exclusive use of non invasive diagnostic imaging for indicating and deciding the operation.

Assessment of low-flow, low-gradient, severe aortic stenosis: an invasive evaluation is required for decision making.

Low-flow, low-gradient severe aortic stenosis (AS) is characterised by a small aortic valve area (AVA) and low mean gradient (MG) secondary to a low cardiac output and may occur in patients with either a preserved or reduced left ventricular ejection fraction (LVEF). Symptomatic patients presenting with low-flow, low-gradient severe AS have a dismal prognosis independent of baseline LVEF if managed conservatively and should therefore undergo aortic valve replacement if feasible. Transthoracic echocardiography (TTE) is the first-line investigation for the assessment of AS haemodynamic severity. However, when confronted with guideline-discordant AVA (small) and MG (low) values, there are several reasons other than severe AS combined with a low cardiac output which may lead to such a situation, including erroneous measurements, small body size, inherent inconsistencies in the guidelines' criteria, prolonged ejection time and aortic pseudostenosis. The distinction between these various entities poses a diagnostic challenge. However, it is important to make a distinction because each has very different implications in terms of risk stratification and therapeutic management. In such instances, cardiac catheterisation forms an integral part of the work-up of these patients in order to confirm or refute the echocardiographic findings to guide management decisions appropriately.

Environmental sustainability and the human element: Decision making in National Cancer Institute-designated cancer centers and Practice Greenhealth subscribing institutions

Background. Various aspects of sustainability have taken root in the hospital environment; however, decisions to pursue sustainable practices within the framework of a master plan are not fully developed in National Cancer Institute (NCI) -designated cancer centers and subscribing institutions to the Practice Greenhealth (PGH) listserv.^ Methods. This cross sectional study was designed to identify the organizational characteristics each study group pursed to implement sustainability practices, describe the barriers they encountered and reasons behind their choices for undertaking certain sustainability practices. A web-based questionnaire was pilot tested, and then sent out to 64 NCI-designated cancer centers and 1638 subscribing institutions to the PGH listserv.^ Results. Complete responses were received from 39 NCI-designated cancer centers and 58 subscribing institutions to the PGH listserv. NCI-designated cancer centers reported greater progress in integrating sustainability criteria into design and construction projects than hospitals of institutions subscribing to the PHG listserv (p-value = <0.05). Statistically significant differences were also identified between these two study groups in undertaking work life options, conducting energy usage assessments, developing energy conservation and optimization plans, implementing solid waste and hazardous waste minimization programs, using energy efficient vehicles and reporting sustainability progress to external stakeholders. NCI-designated cancer centers were further along in implementing these programs (p-value = <0.05). In comparing the self-identified NCI-designated cancer centers to centers that indicated they were both and NCI and PGH, the later had made greater progress in using their collective buying power to pursue sustainable purchasing practices within the medical community (p-value = <0.05). In both study groups, recycling programs were well developed.^ Conclusions. Employee involvement was viewed as the most important reason for both study groups to pursue recycling initiatives and incorporated environmental criteria into purchasing decisions. A written sustainability commitment did not readily translate into a high percentage that had developed a sustainability master plan. Coordination of sustainability programs through a designated sustainability professional was not being undertaken by a large number of institutions within each study group. This may be due to the current economic downturn or management's attention to the emerging health care legislation being debated in congress. ^ Lifecycle assessments, an element of a carbon footprint, are seen as emerging areas of opportunity for health care institutions that can be used to evaluate the total lifecycle costs of products and services.^

A review of economic analysis in the vaccination program; decision making and governance: Adivisory Committee on Immunization Practices (ACIP)

The Advisory Committee on Immunization Practices (ACIP) develops written recommendations for the routine administration of vaccines to children and adults in the U.S. civilian population. The ACIP is the only entity in the federal government that makes such recommendations. ACIP elaborates on selection of its members and rules out concerns regarding its integrity, but fails to provide information about the importance of economic analysis in vaccine selection. ACIP recommendations can have large health and economic consequences. Emphasis on economic evaluation in health is a likely response to severe pressures of the federal and state health budget. This study describes the economic aspects considered by the ACIP while sanctioning a vaccine, and reviews the economic evaluations (our economic data) provided for vaccine deliberations. A five year study period from 2004 to 2009 is adopted. Publicly available data from ACIP web database is used. Drummond et al. (2005) checklist serves as a guide to assess the quality of economic evaluations presented. Drummond et al.'s checklist is a comprehensive hence it is unrealistic to expect every ACIP deliberation to meet all of their criteria. For practical purposes we have selected seven criteria that we judge to be significant criteria provided by Drummond et al. Twenty-four data points were obtained in a five year period. Our results show that out of the total twenty-four data point‘s (economic evaluations) only five data points received a score of six; that is six items on the list of seven were met. None of the data points received a perfect score of seven. Seven of the twenty-four data points received a score of five. A minimum of a two score was received by only one of the economic analyses. The type of economic evaluation along with the model criteria and ICER/QALY criteria met at 0.875 (87.5%). These three criteria were met at the highest rate among the seven criteria studied. Our study findings demonstrate that the perspective criteria met at 0.583 (58.3%) followed by source and sensitivity analysis criteria both tied at 0.541 (54.1%). The discount factor was met at 0.250 (25.0%).^ Economic analysis is not a novel concept to the ACIP. It has been practiced and presented at these meetings on a regular basis for more than five years. ACIP‘s stated goal is to utilize good quality epidemiologic, clinical and economic analyses to help policy makers choose among alternatives presented and thus achieve a better informed decision. As seen in our study the economic analyses over the years are inconsistent. The large variability coupled with lack of a standardized format may compromise the utility of the economic information for decision-making. While making recommendations, the ACIP takes into account all available information about a vaccine. Thus it is vital that standardized high quality economic information is provided at the ACIP meetings. Our study may provide a call for the ACIP to further investigate deficiencies within the system and thereby to improve economic evaluation data presented. ^

The analytic hierarchy process to support decision-making processes in infrastructure projects with social impact

There is an increasing awareness among all kinds of organisations (in business,government and civil society) about the benefits of jointly working with stakeholders to satisfy both their goals and the social demands placed upon them. This is particularly the case within corporate social responsibility (CSR) frameworks. In this regard, multi-criteria tools for decision-making like the analytic hierarchy process (AHP) described in the paper can be useful for the building relationships with stakeholders. Since these tools can reveal decision-maker’s preferences, the integration of opinions from various stakeholders in the decision-making process may result in better and more innovative solutions with significant shared value. This paper is based on ongoing research to assess the feasibility of an AHP-based model to support CSR decisions in large infrastructure projects carried out by Red Electrica de España, the sole transmission agent and operator of the Spanishelectricity system.

Decision-Making Mechanism to Organize the Agenda of a Guide-Robot

One of the major challenges in evolutionary robotics is constituted by the need of the robot being able to make decisions on its own, in accordance with the multiple tasks programmed, optimizing its timings and power. In this paper, we present a new automatic decision making mechanism for a robot guide that allows the robot to make the best choice in order to reach its aims, performing its tasks in an optimal way. The election of which is the best alternative is based on a series of criteria and restrictions of the tasks to perform. The software developed in the project has been verified on the tour-guide robot Urbano. The most important aspect of this proposal is that the design uses learning as the means to optimize the quality in the decision making. The modeling of the quality index of the best choice to perform is made using fuzzy logic and it represents the beliefs of the robot, which continue to evolve in order to match the "external reality”. This fuzzy system is used to select the most appropriate set of tasks to perform during the day. With this tool, the tour guide-robot prepares its agenda daily, which satisfies the objectives and restrictions, and it identifies the best task to perform at each moment. This work is part of the ARABOT project of the Intelligent Control Research Group at the Universidad Politécnica de Madrid to create "awareness" in a robot guide.

Veto values in Group Decision Making within MAUT: aggregating complete rankings derived from dominance intensity measures

We consider a groupdecision-making problem within multi-attribute utility theory, in which the relative importance of decisionmakers (DMs) is known and their preferences are represented by means of an additive function. We allow DMs to provide veto values for the attribute under consideration and build veto and adjust functions that are incorporated into the additive model. Veto functions check whether alternative performances are within the respective veto intervals, making the overall utility of the alternative equal to 0, where as adjust functions reduce the utilty of the alternative performance to match the preferences of other DMs. Dominance measuring methods are used to account for imprecise information in the decision-making scenario and to derive a ranking of alternatives for each DM. Specifically, ordinal information about the relative importance of criteria is provided by each DM. Finally, an extension of Kemeny's method is used to aggregate the alternative rankings from the DMs accounting for the irrelative importance.

Proceso metodológico para optimizar la toma de decisiones en el proyecto de envolventes arquitectónicas multicapa = Methodological process for the optimization of the decision making in multilayer building envelope projects

La presente tesis doctoral se enmarca dentro del concepto de la sistematización del conocimiento en arquitectura, más concretamente en el campo de las construcciones arquitectónicas y la toma de decisiones en la fase de proyecto de envolventes arquitectónicas multicapa. Por tanto, el objetivo principal es el establecimiento de las bases para una toma de decisiones informadas durante el proyecto de una envolvente multicapa con el fin de colaborar en su optimización. Del mismo modo que la historia de la arquitectura está relacionada con la historia de la innovación en construcción, la construcción está sujeta a cambios como respuesta a los fracasos anteriores. En base a esto, se identifica la toma de decisiones en la fase de proyecto como el estadio inicial para establecer un punto estratégico de reflexión y de control sobre los procesos constructivos. La presente investigación, conceptualmente, define los parámetros intervinientes en el proyecto de envolventes arquitectónicas multicapa a partir de una clasificación y sistematización de todos los componentes (elementos, unidades y sistemas constructivos) utilizados en las fachadas multicapa. Dicha sistematización se materializa en una hoja matriz de datos en la que, dentro de una organización a modo de árbol, se puede acceder a la consulta de cada componente y de su caracterización. Dicha matriz permite la incorporación futura de cualquier componente o sistema nuevo que aparezca en el mercado, relacionándolo con aquellos con los que comparta ubicación, tipo de material, etc. Con base en esa matriz de datos, se diseña la sistematización de la toma de decisiones en la fase de proyecto de una envolvente arquitectónica, en concreto, en el caso de una fachada. Operativamente, el resultado se presenta como una herramienta que permite al arquitecto o proyectista reflexionar y seleccionar el sistema constructivo más adecuado, al enfrentarse con las distintas decisiones o elecciones posibles. La herramienta se basa en las elecciones iniciales tomadas por el proyectista y se estructura, a continuación y sucesivamente, en distintas aproximaciones, criterios, subcriterios y posibilidades que responden a los distintos avances en la definición del sistema constructivo. Se proponen una serie de fichas operativas de comprobación que informan sobre el estadio de decisión y de definición de proyecto alcanzados en cada caso. Asimismo, el sistema permite la conexión con otros sistemas de revisión de proyectos para fomentar la reflexión sobre la normalización de los riesgos asociados tanto al proprio sistema como a su proceso constructivo y comportamiento futuros. La herramienta proporciona un sistema de ayuda para ser utilizado en el proceso de toma de decisiones en la fase de diseño de una fachada multicapa, minimizando la arbitrariedad y ofreciendo una cualificación previa a la cuantificación que supondrá la elaboración del detalle constructivo y de su medición en las sucesivas fases del proyecto. Al mismo tiempo, la sistematización de dicha toma de decisiones en la fase del proyecto puede constituirse como un sistema de comprobación en las diferentes fases del proceso de decisión proyectual y de definición de la envolvente de un edificio. ABSTRACT The central issue of this doctoral Thesis is founded on the framework of the concept of the systematization of knowledge in architecture, in particular, in respect of the field of building construction and the decision making in the design stage of multilayer building envelope projects. Therefore, the main objective is to establish the bases for knowledgeable decision making during a multilayer building envelope design process, in order to collaborate with its optimization. Just as the history of architecture is connected to the history of innovation in construction, construction itself is subject to changes as a response to previous failures. On this basis, the decisions made during the project design phase are identified as the initial state to establish an strategic point for reflection and control, referred to the constructive processes. Conceptually, this research defines the parameters involving the multilayer building envelope projects, on the basis of a classification and systematization for all the components (elements, constructive units and constructive systems) used in multilayer façades. The mentioned systematization is materialized into a data matrix sheet in which, following a tree‐like organization, the access to every single component and its characterization is possible. The above data matrix allows the future inclusion of any new component or system that may appear in the construction market. That new component or system can be put into a relationship with another, which it shares location, type of material,… with. Based on the data matrix, the systematization of the decision making process for a building envelope design stage is designed, more particularly in the case of a façade. Putting this into practice, it is represented as a tool which allows the architect or the designer, to reflect and to select the appropriate building system when facing the different elections or the different options. The tool is based on the initial elections taken by the designer. Then and successively, it is shaped on the form of different operative steps, criteria, sub‐criteria and possibilities which respond to a different progress in the definition of the building construction system. In order to inform about the stage of the decision and the definition reached by the project in every particular case, a range of operative sheets are proposed. Additionally, the system allows the connection with other reviewing methods for building projects. The aim of this last possibility is to encourage the reflection on standardization of the associated risks to the building system itself and its future performance. The tool provides a helping system to be used during the decision making process for a multilayer façade design. It minimizes the arbitrariness and offers a qualification previous to the quantification that will be done with the development of the construction details and their bill of quantities, that in subsequent project stages will be executed. At the same time, the systematization of the mentioned decision making during the design phase, can be found as a checking system in the different stages of the decision making design process and in the different stages of the building envelope definition.

Collaborative decision-making processes for maintaining biodiversity: Two Australian case studies

There have been many models developed by scientists to assist decision-makers in making socio-economic and environmental decisions. It is now recognised that there is a shift in the dominant paradigm to making decisions with stakeholders, rather than making decisions for stakeholders. Our paper investigates two case studies where group model building has been undertaken for maintaining biodiversity in Australia. The first case study focuses on preservation and management of green spaces and biodiversity in metropolitan Melbourne under the umbrella of the Melbourne 2030 planning strategy. A geographical information system is used to collate a number of spatial datasets encompassing a range of cultural and natural assets data layers including: existing open spaces, waterways, threatened fauna and flora, ecological vegetation covers, registered cultural heritage sites, and existing land parcel zoning. Group model building is incorporated into the study through eliciting weightings and ratings of importance for each datasets from urban planners to formulate different urban green system scenarios. The second case study focuses on modelling ecoregions from spatial datasets for the state of Queensland. The modelling combines collaborative expert knowledge and a vast amount of environmental data to build biogeographical classifications of regions. An information elicitation process is used to capture expert knowledge of ecoregions as geographical descriptions, and to transform this into prior probability distributions that characterise regions in terms of environmental variables. This prior information is combined with measured data on the environmental variables within a Bayesian modelling technique to produce the final classified regions. We describe how linked views between descriptive information, mapping and statistical plots are used to decide upon representative regions that satisfy a number of criteria for biodiversity and conservation. This paper discusses the advantages and problems encountered when undertaking group model building. Future research will extend the group model building approach to include interested individuals and community groups.

Planning and decision-making for energy recovery from waste at the sub-regional level

This research project has developed a novel decision support system using Geographical Information Systems and Multi Criteria Decision Analysis and used it to develop and evaluate energy-from-waste policy options. The system was validated by applying it to the UK administrative areas of Cornwall and Warwickshire. Different strategies have been defined by the size and number of the facilities, as well as the technology chosen. Using sensitivity on the results from the decision support system, it was found that key decision criteria included those affected by cost, energy efficiency, transport impacts and air/dioxin emissions. The conclusions of this work are that distributed small-scale energy-from-waste facilities score most highly overall and that scale is more important than technology design in determining overall policy impact. This project makes its primary contribution to energy-from-waste planning by its development of a Decision Support System that can be used to assist waste disposal authorities to identify preferred energy-from-waste options that have been tailored specifically to the socio-geographic characteristics of their jurisdictional areas. The project also highlights the potential of energy-from-waste policies that are seldom given enough attention to in the UK, namely those of a smaller-scale and distributed nature that often have technology designed specifically to cater for this market.

A decision support system for supplier selection and order allocation in stochastic, multi-stakeholder and multi-criteria environments

Integrated supplier selection and order allocation is an important decision for both designing and operating supply chains. This decision is often influenced by the concerned stakeholders, suppliers, plant operators and customers in different tiers. As firms continue to seek competitive advantage through supply chain design and operations they aim to create optimized supply chains. This calls for on one hand consideration of multiple conflicting criteria and on the other hand consideration of uncertainties of demand and supply. Although there are studies on supplier selection using advanced mathematical models to cover a stochastic approach, multiple criteria decision making techniques and multiple stakeholder requirements separately, according to authors' knowledge there is no work that integrates these three aspects in a common framework. This paper proposes an integrated method for dealing with such problems using a combined Analytic Hierarchy Process-Quality Function Deployment (AHP-QFD) and chance constrained optimization algorithm approach that selects appropriate suppliers and allocates orders optimally between them. The effectiveness of the proposed decision support system has been demonstrated through application and validation in the bioenergy industry.

Több szempontú részvételi döntések a fenntarthatósági értékelésekben. A legnépszerűbb módszerek összehasonlítása = Participatory multi-criteria decision analysis. A comparison of methodologies

A fenntarthatóság értékelése definíciószerűen többdimenziós probléma. A megfelelő alternatíva, forgatókönyv, eljárás stb. kiválasztásakor ugyanis a döntéshozóknak egyszerre kell figyelembe venniük környezetvédelmi, gazdasági és társadalmi szempontokat. Az ilyen döntéseket alátámaszthatják a több szempontú döntéshozatali modellek. A tanulmány a több szempontú döntési eljárások közül a legfontosabb hétnek az alkalmazhatóságát vizsgálja részvételi körülmények között. Az utóbbi évek e témában publikált esettanulmányainak áttekintésével megállapítható, hogy egyik módszer sem uralja a többit, azok különböző feltételek mellett eltérő sikerrel használhatók. Ennek ellenére a különböző módszerek kombinációjával végrehajthatunk olyan eljárásokat, amelyekkel az egyes módszerek előnyeit még jobban kiaknázhatjuk. ________ Measuring and comparing the sustainability of certain actions, scenarios, technologies, etc. is by definition a multidimensional problem. Decision-makers must consider environmental, economic and social aspects when choosing an alternative course of action. Such decisions can be aided by multi-criteria decision analysis (MCDA). This paper investigates seven different MCDA methodologies: MAU, the Analytic Hierarchic Process (AHP), the ELECTRE, PROMETHEE, REGIME, and NAIADE methods, and "Ideal and reference point" approaches). It is based on a series of reports in which over 30 real-world case studies focusing on participatory MCDA were reviewed. It is stressed, however, that there is no "best" choice in the list of MCDA techniques. Some methods fit certain decision problems better than others. Nonetheless, some complementary benefits of the different techniques can be exploited by combining these methodologies.