C-reactive protein predicts mortality in patients referred for coronary angiography and symptoms of heart failure with preserved ejection fraction

AIMS Heart failure with preserved ejection fraction (HFpEF) has a different pathophysiological background compared to heart failure with reduced ejection fraction (HFrEF). Tailored risk prediction in this separate heart failure group with a high mortality rate is of major importance. Inflammation may play an important role in the pathogenesis of HFpEF because of its significant contribution to myocardial fibrosis. We therefore aimed to assess the predictive value of C-reactive protein (CRP) in patients with HFpEF. METHODS AND RESULTS Plasma levels of CRP were determined in 459 patients with HFpEF in the LUdwigshafen Risk and Cardiovascular Health (LURIC) study using a high-sensitivity assay. During a median follow-up of 9.7 years 40% of these patients died. CRP predicted all-cause mortality with an adjusted hazard ratio (HR) of 1.20 [95% confidence interval (CI) 1.02-1.40, P = 0.018] and cardiovascular mortality with a HR of 1.32 (95% CI 1.08-1.62, P = 0.005) per increase of one standard deviation. CRP was a significantly stronger mortality predictor in HFpEF patients than in a control group of 522 HFrEF patients (for interaction, P = 0.015). Furthermore, CRP added prognostic value to N-terminal pro B-type natriuretic peptide (Nt-proBNP): the lowest 5-year mortality rate of 6.8% was observed for patients in the lowest tertile of Nt-proBNP as well as CRP. The mortality risk peaked in the group combining the highest values of Nt-proBNP and CRP with a 5-year rate of 36.5%. CONCLUSION It was found that CRP was an independent and strong predictor of mortality in HFpEF. This observation may reflect immunological processes with an adverse impact on the course of HFpEF.

Positive affect moderates the effect of negative affect on cardiovascular disease-related hospitalizations and all-cause mortality after cardiac rehabilitation

BACKGROUND Little is known as to whether negative emotions adversely impact the prognosis of patients who undergo cardiac rehabilitation. We prospectively investigated the predictive value of state negative affect (NA) assessed at discharge from cardiac rehabilitation for prognosis and the moderating role of positive affect (PA) on the effect of NA on outcomes. METHODS A total of 564 cardiac patients (62.49 ± 11.51) completed a comprehensive three-month outpatient cardiac rehabilitation program, filling in the Global Mood Scale (GMS) at discharge. The combined endpoint was cardiovascular disease (CVD)-related hospitalizations plus all-cause mortality at follow-up. Cox regression models estimated the predictive value of NA, as well as the moderating influence of PA on outcomes. Survival models were adjusted for sociodemographic factors, traditional cardiovascular risk factors, and severity of disease. RESULTS During a mean follow-up period of 3.4 years, 71 patients were hospitalized for a CVD-related event and 15 patients died. NA score (range 0-20) was a significant and independent predictor (hazard ratio (HR) 1.091, 95% confidence interval (CI) 1.012-1.175; p = 0.023) with a three-point higher level in NA increasing the relative risk by 9.1%. Furthermore, PA interacted significantly with NA (p < 0.001). The relative risk of poor prognosis with NA was increased in patients with low PA (p = 0.012) but remained unchanged in combination with high PA (p = 0.12). CONCLUSION The combination of NA with low PA was particularly predictive of poor prognosis. Whether reduction of NA and increase of PA, particularly in those with high NA, improves outcome needs to be tested.

Multiple imputation for missing continuous and dichotomous data: The effects of patterns of missingness and variable correlations on type I error with small samples

The purpose of this study is to investigate the effects of predictor variable correlations and patterns of missingness with dichotomous and/or continuous data in small samples when missing data is multiply imputed. Missing data of predictor variables is multiply imputed under three different multivariate models: the multivariate normal model for continuous data, the multinomial model for dichotomous data and the general location model for mixed dichotomous and continuous data. Subsequent to the multiple imputation process, Type I error rates of the regression coefficients obtained with logistic regression analysis are estimated under various conditions of correlation structure, sample size, type of data and patterns of missing data. The distributional properties of average mean, variance and correlations among the predictor variables are assessed after the multiple imputation process. ^ For continuous predictor data under the multivariate normal model, Type I error rates are generally within the nominal values with samples of size n = 100. Smaller samples of size n = 50 resulted in more conservative estimates (i.e., lower than the nominal value). Correlation and variance estimates of the original data are retained after multiple imputation with less than 50% missing continuous predictor data. For dichotomous predictor data under the multinomial model, Type I error rates are generally conservative, which in part is due to the sparseness of the data. The correlation structure for the predictor variables is not well retained on multiply-imputed data from small samples with more than 50% missing data with this model. For mixed continuous and dichotomous predictor data, the results are similar to those found under the multivariate normal model for continuous data and under the multinomial model for dichotomous data. With all data types, a fully-observed variable included with variables subject to missingness in the multiple imputation process and subsequent statistical analysis provided liberal (larger than nominal values) Type I error rates under a specific pattern of missing data. It is suggested that future studies focus on the effects of multiple imputation in multivariate settings with more realistic data characteristics and a variety of multivariate analyses, assessing both Type I error and power. ^

Racial/ethnic disparities in colorectal cancer screening and survival in a large nationwide population-based cohort

Background. Colorectal cancer (CRC) is the third most commonly diagnosed cancer (excluding skin cancer) in both men and women in the United States, with an estimated 148,810 new cases and 49,960 deaths in 2008 (1). Racial/ethnic disparities have been reported across the CRC care continuum. Studies have documented racial/ethnic disparities in CRC screening (2-9), but only a few studies have looked at these differences in CRC screening over time (9-11). No studies have compared these trends in a population with CRC and without cancer. Additionally, although there is evidence suggesting that hospital factors (e.g. teaching hospital status and NCI designation) are associated with CRC survival (12-16), no studies have sought to explain the racial/ethnic differences in survival by looking at differences in socio-demographics, tumor characteristics, screening, co-morbidities, treatment, as well as hospital characteristics. ^ Objectives and Methods. The overall goals of this dissertation were to describe the patterns and trends of racial/ethnic disparities in CRC screening (i.e. fecal occult blood test (FOBT), sigmoidoscopy (SIG) and colonoscopy (COL)) and to determine if racial/ethnic disparities in CRC survival are explained by differences in socio-demographic, tumor characteristics, screening, co-morbidities, treatment, and hospital factors. These goals were accomplished in a two-paper format.^ In Paper 1, "Racial/Ethnic Disparities and Trends in Colorectal Cancer Screening in Medicare Beneficiaries with Colorectal Cancer and without Cancer in SEER Areas, 1992-2002", the study population consisted of 50,186 Medicare beneficiaries diagnosed with CRC from 1992 to 2002 and 62,917 Medicare beneficiaries without cancer during the same time period. Both cohorts were aged 67 to 89 years and resided in 16 Surveillance, Epidemiology and End Results (SEER) regions of the United States. Screening procedures between 6 months and 3 years prior to the date of diagnosis for CRC patients and prior to the index date for persons without cancer were identified in Medicare claims. The crude and age-gender-adjusted percentages and odds ratios of receiving FOBT, SIG, or COL were calculated. Multivariable logistic regression was used to assess race/ethnicity on the odds of receiving CRC screening over time.^ Paper 2, "Racial/Ethnic Disparities in Colorectal Cancer Survival: To what extent are racial/ethnic disparities in survival explained by racial differences in socio-demographics, screening, co-morbidities, treatment, tumor or hospital characteristics", included a cohort of 50,186 Medicare beneficiaries diagnosed with CRC from 1992 to 2002 and residing in 16 SEER regions of the United States which were identified in the SEER-Medicare linked database. Survival was estimated using the Kaplan-Meier method. Cox proportional hazard modeling was used to estimate hazard ratios (HR) of mortality and 95% confidence intervals (95% CI).^ Results. The screening analysis demonstrated racial/ethnic disparities in screening over time among the cohort without cancer. From 1992 to 1995, Blacks and Hispanics were less likely than Whites to receive FOBT (OR=0.75, 95% CI: 0.65-0.87; OR=0.50, 95% CI: 0.34-0.72, respectively) but their odds of screening increased from 2000 to 2002 (OR=0.79, 95% CI: 0.72-0.85; OR=0.67, 95% CI: 0.54-0.75, respectively). Blacks and Hispanics were less likely than Whites to receive SIG from 1992 to 1995 (OR=0.75, 95% CI: 0.57-0.98; OR=0.29, 95% CI: 0.12-0.71, respectively), but their odds of screening increased from 2000 to 2002 (OR=0.79, 95% CI: 0.68-0.93; OR=0.50, 95% CI: 0.35-0.72, respectively).^ The survival analysis showed that Blacks had worse CRC-specific survival than Whites (HR: 1.33, 95% CI: 1.23-1.44), but this was reduced for stages I-III disease after full adjustment for socio-demographic, tumor characteristics, screening, co-morbidities, treatment and hospital characteristics (aHR=1.24, 95% CI: 1.14-1.35). Socioeconomic status, tumor characteristics, treatment and co-morbidities contributed to the reduction in hazard ratios between Blacks and Whites with stage I-III disease. Asians had better survival than Whites before (HR: 0.73, 95% CI: 0.64-0.82) and after (aHR: 0.80, 95% CI: 0.70-0.92) adjusting for all predictors for stage I-III disease. For stage IV, both Asians and Hispanics had better survival than Whites, and after full adjustment, survival improved (aHR=0.73, 95% CI: 0.63-0.84; aHR=0.74, 95% CI: 0.61-0.92, respectively).^ Conclusion. Screening disparities remain between Blacks and Whites, and Hispanics and Whites, but have decreased in recent years. Future studies should explore other factors that may contribute to screening disparities, such as physician recommendations and language/cultural barriers in this and younger populations.^ There were substantial racial/ethnic differences in CRC survival among older Whites, Blacks, Asians and Hispanics. Co-morbidities, SES, tumor characteristics, treatment and other predictor variables contributed to, but did not fully explain the CRC survival differences between Blacks and Whites. Future research should examine the role of quality of care, particularly the benefit of treatment and post-treatment surveillance, in racial disparities in survival.^

The asymptotic distribution of canonical correlations and vectors in higher-order cointegrated models

The study of the large-sample distribution of the canonical correlations and variates in cointegrated models is extended from the first-order autoregression model to autoregression of any (finite) order. The cointegrated process considered here is nonstationary in some dimensions and stationary in some other directions, but the first difference (the “error-correction form”) is stationary. The asymptotic distribution of the canonical correlations between the first differences and the predictor variables as well as the corresponding canonical variables is obtained under the assumption that the process is Gaussian. The method of analysis is similar to that used for the first-order process.

The Relationship between Adolescent Social Network Structure and Perceptions of School Climate

Thesis (Ph.D.)--University of Washington, 2016-06

Putting teeth into the developmental origins hypothesis: A longitudinal study of early childhood malnutrition, enamel hypoplasia and adolescent health in Amazonian Bolivia

Thesis (Ph.D.)--University of Washington, 2016-06

Adolescents' intentions to smoke as a predictor of smoking

Background. Adolescents' intentions to smoke are generally regarded as a valid and reliable predictor of subsequent smoking. This association is largely based on research with adults and needs a more detailed analysis for adolescents. Methods. Data on intentions and smoking status were collected as part of a longitudinal, birth-cohort study when the study members were 9, 11, 13, 15, 18, and 21 years of age. Results. The results showed that intention to smoke only had an important predictive power in the subgroup of previous nonsmokers. Among those already smoking (on a monthly basis or greater), previous level of smoking was a more important predictor of future behavior than intention to smoke. In addition, the effect of positive intention to smoke was nonlinear over age and had the greatest effect at age 15. Conclusion. The results indicated that in adolescence, measurement of intentions to smoke or not smoke cannot be assumed to be a general predictor of behavior at a later age for all groups of adolescents. (C) 2004 The Institute For Cancer Prevention and Elsevier Inc. All rights reserved.

Development and evaluation of a youth mental health community awareness campaign - The Compass Strategy

Background: Early detection and treatment of mental disorders in adolescents and young adults can lead to better health outcomes. Mental health literacy is a key to early recognition and help seeking. Whilst a number of population health initiatives have attempted to improve mental health literacy, none to date have specifically targeted young people nor have they applied the rigorous standards of population health models now accepted as best practice in other health areas. This paper describes the outcomes from the application of a health promotion model to the development, implementation and evaluation of a community awareness campaign designed to improve mental health literacy and early help seeking amongst young people. Method: The Compass Strategy was implemented in the western metropolitan Melbourne and Barwon regions of Victoria, Australia. The Precede-Proceed Model guided the population assessment, campaign strategy development and evaluation. The campaign included the use of multimedia, a website, and an information telephone service. Multiple levels of evaluation were conducted. This included a cross-sectional telephone survey of mental health literacy undertaken before and after 14 months of the campaign using a quasi-experimental design. Randomly selected independent samples of 600 young people aged 12 - 25 years from the experimental region and another 600 from a comparison region were interviewed at each time point. A series of binary logistic regression analyses were used to measure the association between a range of campaign outcome variables and the predictor variables of region and time. Results: The program was judged to have an impact on the following variables, as indicated by significant region-by-time interaction effects ( p < 0.05): awareness of mental health campaigns, self-identified depression, help for depression sought in the previous year, correct estimate of prevalence of mental health problems, increased awareness of suicide risk, and a reduction in perceived barriers to help seeking. These effects may be underestimated because media distribution error resulted in a small amount of print material leaking into the comparison region. Conclusion: We believe this is the first study to apply the rigorous standards of a health promotion model including the use of a control region to a mental health population intervention. The program achieved many of its aims despite the relatively short duration and moderate intensity of the campaign.

Effects of syllabic complexity in predicting accuracy of repetition and direction of errors in patients with articulatory and phonological difficulties

The purpose of this paper is to demonstrate the existence of a strong and significant effect of complexity in aphasia independent from other variables including length. Complexity was found to be a strong and significant predictor of accurate repetition in a group of 13 Italian aphasic patients when it was entered in a regression equation either simultaneously or after a large number of other variables. Significant effects were found both when complexity was measured in terms of number of complex onsets (as in a recent paper by Nickels & Howard, 2004) and when it was measured in a more comprehensive way. Significant complexity effects were also found with matched lists contrasting simple and complex words and in analyses of errors. Effects of complexity, however, were restricted to patients with articulatory difficulties. Reasons for this association and for the lack of significant results in Nickels and Howard (2004) are discussed. © 2005 Psychology Press Ltd.

A study of business user based information systems development, and modelling success factors

This thesis describes research into business user involvement in the information systems application building process. The main interest of this research is in establishing and testing techniques to quantify the relationships between identified success factors and the outcome effectiveness of 'business user development' (BUD). The availability of a mechanism to measure the levels of the success factors, and quantifiably relate them to outcome effectiveness, is important in that it provides an organisation with the capability to predict and monitor effects on BUD outcome effectiveness. This is particularly important in an era where BUD levels have risen dramatically, user centred information systems development benefits are recognised as significant, and awareness of the risks of uncontrolled BUD activity is becoming more widespread. This research targets the measurement and prediction of BUD success factors and implementation effectiveness for particular business users. A questionnaire instrument and analysis technique has been tested and developed which constitutes a tool for predicting and monitoring BUD outcome effectiveness, and is based on the BUDES (Business User Development Effectiveness and Scope) research model - which is introduced and described in this thesis. The questionnaire instrument is designed for completion by 'business users' - the target community being more explicitly defined as 'people who primarily have a business role within an organisation'. The instrument, named BUD ESP (Business User Development Effectiveness and Scope Predictor), can readily be used with survey participants, and has been shown to give meaningful and representative results.

Modelling of induction motors for system faults and transient stability studies

The research carried out in this thesis was mainly concerned with the effects of large induction motors and their transient performance in power systems. Computer packages using the three phase co-ordinate frame of reference were developed to simulate the induction motor transient performance. A technique using matrix algebra was developed to allow extension of the three phase co-ordinate method to analyse asymmetrical and symmetrical faults on both sides of the three phase delta-star transformer which is usually required when connecting large induction motors to the supply system. System simulation, applying these two techniques, was used to study the transient stability of a power system. The response of a typical system, loaded with a group of large induction motors, two three-phase delta-star transformers, a synchronous generator and an infinite system was analysed. The computer software developed to study this system has the advantage that different types of fault at different locations can be studied by simple changes in input data. The research also involved investigating the possibility of using different integrating routines such as Runge-Kutta-Gill, RungeKutta-Fehlberg and the Predictor-Corrector methods. The investigation enables the reduction of computation time, which is necessary when solving the induction motor equations expressed in terms of the three phase variables. The outcome of this investigation was utilised in analysing an introductory model (containing only minimal control action) of an isolated system having a significant induction motor load compared to the size of the generator energising the system.

Do left and right asymmetries of hemispheric preference interact with attention to predict local and global performance in applied tasks?

Many cognitive neuroscience studies show that the ability to attend to and identify global or local information is lateralised between the two hemispheres in the human brain; the left hemisphere is biased towards the local level, whereas the right hemisphere is biased towards the global level. Results of two studies show attention-focused people with a right ear preference (biased towards the left hemisphere) are better at local tasks, whereas people with a left ear preference (biased towards the right hemisphere) are better at more global tasks. In a third study we determined if right hemisphere-biased followers who attend to global stimuli are likely to have a stronger relationship between attention and globally based supervisor ratings of performance. Results provide evidence in support of this hypothesis. Our research supports our model and suggests that the interaction between attention and lateral preference is an important and novel predictor of work-related outcomes. © 2012 Copyright Psychology Press Ltd.

Tree Island Response to Fire and Flooding in the Short-Hydroperiod Marl Prairie Grasslands of the Florida Everglades

Within the marl prairie grasslands of the Florida Everglades, USA, the combined effects of fire and flooding usually lead to very significant changes in tree island structure and composition. Depending on fire severity and post-fire hydroperiod, these effects vary spatially and temporally throughout the landscape, creating a patchy post-fire mosaic of tree islands with different successional states. Through the use of the Normalized Difference Vegetation Index (NDVI) and three predictor variables (marsh water table elevation at the time of fire, post-fire hydroperiod, and tree island size), along with logistic regression analysis, we examined the probability of tree island burning and recovering following the Mustang Corner Fire (May to June 2008) in Everglades National Park. Our data show that hydrologic conditions during and after fire, which are under varying degrees of management control, can lead to tree island contraction or loss. More specifically, the elevation of the marsh water table at the time of the fire appears to be the most important parameter determining the severity of fire in marl prairie tree islands. Furthermore, in the post-fire recovery phase, both tree island size and hydroperiod during the first year after the fire played important roles in determining the probability of tree island recovery, contraction, or loss.

Turning conflict into coexistence: cross-cutting ties and institutions in the agro-pastoral borderlands of Lake Naivasha basin, Kenya

The Maasai/Kikuyu agro-pastoral borderlands of Maiella and Enoosupukia, located in the hinterlands of Lake Naivasha’s agro-industrial hub, are particularly notorious in the history of ethnicised violence in the Kenya’s Rift Valley. In October 1993, an organised assault perpetrated by hundreds of Maasai vigilantes, with the assistance of game wardens and administration police, killed more than 20 farmers of Kikuyu descent. Consequently, thousands of migrant farmers were violently evicted from Enoosupukia at the instigation of leading local politicians. Nowadays, however, intercommunity relations are surprisingly peaceful and the cooperative use of natural resources is the rule rather than the exception. There seems to be a form of reorganization. Violence seems to be contained and the local economy has since recovered. This does not mean that there is no conflict, but people seem to have the facility to solve them peacefully. How did formerly violent conflicts develop into peaceful relations? How did competition turn into cooperation, facilitating changing land use? This dissertation explores the value of cross-cutting ties and local institutions in peaceful relationships and the non-violent resolution of conflicts across previously violently contested community boundaries. It mainly relies on ethnographic data collected between 2014 and 2015. The discussion therefore builds on several theoretical approaches in anthropology and the social sciences – that is, violent conflicts, cross-cutting ties and conflicting loyalties, joking relationships, peace and nonviolence, and institutions, in order to understand shared spaces that are experiencing fairly rapid social and economic changes, and characterised by conflict and coexistence. In the researched communities, cross-cutting ties and the split allegiances associated with them result from intermarriages, land transactions, trade, and friendship. By institutions, I refer to local peace committees, an attempt to standardise an aspect of customary law, and Nyumba Kumi, a strategy of anchoring community policing at the household level. In 2010, the state “implanted” these grassroots-level institutions and conferred on them the rights to handle specific conflicts and to prevent crime. I argue that the studied groups utilise diverse networks of relationships as adaptive responses to landlessness, poverty, and socio-political dynamics at the local level. Material and non-material exchanges and transfers accompany these social and economic ties and networks. In addition to being instrumental in nurturing a cohesive social fabric, I argue that such alliances could be thought of as strategies of appropriation of resources in the frontiers – areas that are considered to have immense agricultural potential and to be conducive to economic enterprise. Consequently, these areas are continuously changed and shaped through immigration, population growth, and agricultural intensification. However, cross-cutting ties and intergroup alliances may not necessarily prevent the occurrence or escalation of conflicts. Nevertheless, disputes and conflicts, which form part of the social order in the studied area, create the opportunities for locally contextualised systems of peace and non-violence that inculcate the values of cooperation, coexistence, and restraint from violence. Although the neo-traditional institutions (local peace committees and Nyumba Kumi) face massive complexities and lack the capacity to handle serious conflicts, their application of informal constraints in dispute resolution provides room for some optimism. Notably, the formation of ties and alliances between the studied groups, and the use of local norms and values to resolve disputes, are not new phenomena – they are reminiscent of historical patterns. Their persistence, particularly in the context of Kenya, indicates a form of historical continuity, which remains rather “undisturbed” despite the prevalence of ethnicised political economies. Indeed, the formation of alliances, which are driven by mutual pursuit of commodities (livestock, rental land, and agricultural produce), markets, and diversification, tends to override other identities. While the major thrust of social science literature in East Africa has focused on the search for root causes of violence, very little has been said about the conditions and practices of cooperation and non-violent conflict resolution. In addition, situations where prior violence turned into peaceful interaction have attracted little attention, though the analysis of such transitional phases holds the promise of contributing to applicable knowledge on conflict resolution. This study is part of a larger multidisciplinary project, “Resilience in East African Landscapes” (REAL), which is a Marie Curie Actions Innovative Training Networks (ITN) project. The principal focus of this multidisciplinary project is to study past, present, and future thresholds and sustainable trajectories in human-landscape interactions in East Africa over the last millennia. While other individual projects focus on long-term ecosystem dynamics and societal interactions, my project examines human-landscape interactions in the present and the very recent past (i.e. the period in which events and processes were witnessed or can still be recalled by today’s population). The transition from conflict to coexistence and from competition to cooperative use of previously violently contested land resources is understood here as enhancing adaptation in the face of social-political, economic, environmental, and climatic changes. This dissertation is therefore a contribution to new modes of resilience in human-landscape interactions after a collapse situation.