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.

Pitfalls of practicing cancer epidemiology in resource-limited settings: the case of survival and loss to follow-up after a diagnosis of Kaposi's sarcoma in five countries across sub-Saharan Africa.

BACKGROUND Survival after diagnosis is a fundamental concern in cancer epidemiology. In resource-rich settings, ambient clinical databases, municipal data and cancer registries make survival estimation in real-world populations relatively straightforward. In resource-poor settings, given the deficiencies in a variety of health-related data systems, it is less clear how well we can determine cancer survival from ambient data. METHODS We addressed this issue in sub-Saharan Africa for Kaposi's sarcoma (KS), a cancer for which incidence has exploded with the HIV epidemic but for which survival in the region may be changing with the recent advent of antiretroviral therapy (ART). From 33 primary care HIV Clinics in Kenya, Uganda, Malawi, Nigeria and Cameroon participating in the International Epidemiologic Databases to Evaluate AIDS (IeDEA) Consortia in 2009-2012, we identified 1328 adults with newly diagnosed KS. Patients were evaluated from KS diagnosis until death, transfer to another facility or database closure. RESULTS Nominally, 22% of patients were estimated to be dead by 2 years, but this estimate was clouded by 45% cumulative lost to follow-up with unknown vital status by 2 years. After adjustment for site and CD4 count, age <30 years and male sex were independently associated with becoming lost. CONCLUSIONS In this community-based sample of patients diagnosed with KS in sub-Saharan Africa, almost half became lost to follow-up by 2 years. This precluded accurate estimation of survival. Until we either generally strengthen data systems or implement cancer-specific enhancements (e.g., tracking of the lost) in the region, insights from cancer epidemiology will be limited.

Defining barriers in caring for seriously-ill children in a resource-limited setting: An observational study of 2 children's hospitals in Haiti

Background. According to the WHO 2007 country report, Haiti lags behind the Millennium Development Goal of reducing child mortality and maintains the highest under-5 mortality rate in the Western hemisphere. 3 Overall, few studies exist that seek to better grasp barriers in caring for a seriously ill child in a resource-limited setting and only a handful propose sustainable, effective interventions. ^ Objectives. The objectives of this study are to describe the prevalence of serious illnesses among children hospitalized at 2 children's hospitals in Port au Prince, to determine the barriers faced when caring for seriously ill children, and to report hospital outcomes of children admitted with serious illnesses. ^ Methods. Data were gathered from 2 major children's hospitals in Port au Prince, Haiti (Grace Children's Hospital [GCH] and Hopital d l'Universite d'Etat d'Haiti [HUEH]) using a triangulated approach of focus group discussions, physician questionnaires, and retrospective chart review. 23 pediatric physicians participated in focus group discussions and completed a self-administered questionnaire evaluating healthcare provider knowledge, self-efficacy, and perceived barriers relating to the care of seriously ill children in a resource-limited setting. A sample of 240 patient charts meeting eligibility criteria was abstracted for pertinent elements including sociodemographics, documentation, treatment strategies, and outcomes. Factors associated with mortality were analyzed using χ2 test and Fisher exact test [Minitab v.15]. ^ Results. The most common primary diagnoses at admission were gastroenteritis with moderate dehydration (35.5%), severe malnutrition (25.8%), and pneumonia (19.3%) for GCH, and severe malnutrition (32.6%), sepsis (24.7%), and severe respiratory distress (18%) for HUEH. Overall, 12.9% and 27% of seriously ill patients presented with shock to GCH and HUEH, respectively. ^ Shortage of necessary materials and equipment represented the most commonly reported limitation (18/23 respondents). According to chart data, 9.4% of children presenting with shock did not receive a fluid bolus, and only 8% of patients presenting with altered mental status or seizures received a glucose check. 65% of patients with meningitis did not receive a lumbar puncture due to lack of materials. ^ Hospital mortality rates did not differ by gender or by institution. Children who died were more likely to have a history of prematurity (OR 4.97 [95% CI 1.32-18.80]), an incomplete vaccination record (OR 4.05 [95% CI 1.68-9.74]), or a weight for age ≤3rd percentile (OR 6.1 [95% CI 2.49-14.93]. Case-fatality rates were significantly higher among those who presented with signs of shock compared with those who did not (23.1% vs. 10.7%, RR=2.16, p=0.03). Caregivers did not achieve shock reversal in 21% of patients and did not document shock reversal in 50% of patients. ^ Conclusions. Many challenges face those who seek to optimize care for seriously ill children in resource-limited settings. Specifically, in Haiti, qualitative and quantitative data suggest major issues with lack of supplies, pre-hospital factors, including malnutrition as a comorbidity, and early recognition and management of shock. A tailored intervention designed to address these issues is needed in order to prospectively evaluate improvements in child mortality in a high-risk population.^

Parameterization of the atmospheric boundary layer for offshore wind resource assessment with a limited length-scale k-ε model

The structure of the atmospheric boundary layer (ABL) is modelled with the limited- length-scale k-ε model of Apsley and Castro. Contrary to the standard k-ε model, the limited-length-scale k-ε model imposes a maximum mixing length which is derived from the boundary layer height, for neutral and unstable atmospheric situations, or by Monin-Obukhov length when the atmosphere is stably stratified. The model is first verified reproducing the famous Leipzig wind profile. Then the performance of the model is tested with measurements from FINO-1 platform using sonic anemometers to derive the appropriate maximum mixing length.

Competition and resource availability in an annual plant community dominated by an invasive species, Carrichtera annua (L. Aschers.), in South Australia

The last decade has seen spirited debates about how resource availability affect the intensity of competition. This paper examines the effect that a dominant introduced species, Carrichtera annua, has upon the winter annual community in the arid chenopod shrublands of South Australia. Manipulative field experiments were conducted to assess plant community response to changing below-ground resource levels and to the manipulation of the density of C. annua. Changes in the density of C. annua had little effect on the abundance of all other species in the guild. Nutrient addition produced an increase in the biomass of the most abundant native species, Crassula colorata. An analysis of the root distribution of the main species suggested that the areas of soil resource capture of C. annua and C. colorata are largely segregated. Our results suggest that intraspecific competition may be stronger than interspecific competition, controlling the species responses to increased resource availability. The results are consistent with a two-phase resource dynamics systems, with pulses of high resource availability triggering growth, followed by pulses of stress. Smaller plants were nutrient limited under natural field conditions, suggesting that stress experienced during long interpulse phases may override competitive effects after short pulse phases. The observed differences in root system structure will determine when plants of a different species are experiencing a pulse or an interpulse phase. We suggest that the limitations to plant recruitment and growth are the product of a complex interplay between the length and intensity of the pulse of resource availability, the duration and severity of the interpulse periods, and biological characters of the species.

A hybrid genetic algorithm for the multi-mode resource-constrained project scheduling

A construction project is a group of discernible tasks or activities that are conduct-ed in a coordinated effort to accomplish one or more objectives. Construction projects re-quire varying levels of cost, time and other resources. To plan and schedule a construction project, activities must be defined sufficiently. The level of detail determines the number of activities contained within the project plan and schedule. So, finding feasible schedules which efficiently use scarce resources is a challenging task within project management. In this context, the well-known Resource Constrained Project Scheduling Problem (RCPSP) has been studied during the last decades. In the RCPSP the activities of a project have to be scheduled such that the makespan of the project is minimized. So, the technological precedence constraints have to be observed as well as limitations of the renewable resources required to accomplish the activities. Once started, an activity may not be interrupted. This problem has been extended to a more realistic model, the multi-mode resource con-strained project scheduling problem (MRCPSP), where each activity can be performed in one out of several modes. Each mode of an activity represents an alternative way of combining different levels of resource requirements with a related duration. Each renewable resource has a limited availability for the entire project such as manpower and machines. This paper presents a hybrid genetic algorithm for the multi-mode resource-constrained pro-ject scheduling problem, in which multiple execution modes are available for each of the ac-tivities of the project. The objective function is the minimization of the construction project completion time. To solve the problem, is applied a two-level genetic algorithm, which makes use of two separate levels and extend the parameterized schedule generation scheme. It is evaluated the quality of the schedules and presents detailed comparative computational re-sults for the MRCPSP, which reveal that this approach is a competitive algorithm.

Multi-level SLA-driven resource management on Cloud Providers

Nowadays, service providers in the Cloud offer complex services ready to be used as it was a commodity like water or electricity to their customers with any other extra effort for them. However, providing these services implies a high management effort which requires a lot of human interaction. Furthermore, an efficient resource management mechanism considering only provider's resources is, though necessary, not enough, because the provider's profit is limited by the amount of resources it owns. Dynamically outsourcing resources to other providers in response to demand variation avoids this problem and makes the provider to get more profit. A key technology for achieving these goals is virtualization which facilitates provider's management and provides on-demand virtual environments, which are isolated and consolidated in order to achieve a better utilization of the provider's resources. Nevertheless, dealing with some virtualization capabilities implies an effort for the user in order to take benefit from them. In order to avoid this problem, we are contributing the research community with a virtualized environment manager which aims to provide virtual machines that fulfils with the user requirements. Another challenge is sharing resources among different federated Cloud providers while exploiting the features of virtualization in a new approach for facilitating providers' management. This project aims for reducing provider's costs and at the same time fulfilling the quality of service agreed with the customers while maximizing the provider's revenue. It considers resource management at several layers, namely locally to each node in the provider, among different nodes in the provider, and among different federated providers. This latter layer supports the novel capabilities of outsourcing when the local resources are not enough to fulfil the users demand, and offering resources to other providers when the local resources are underused.

Dried blood spots collected on filter paper: an international resource for the diagnosis and genetic characterization of human immunodeficiency virus Type-1

The collection of dried blood spots (DBS) on filter paper provides a powerful approach for the development of large-scale, population-based screening programs. DBS methods are particularly valuable in developing countries and isolated rural regions where resources are limited. Large numbers of field specimens can be economically collected and shipped to centralized reference laboratories for genetic and (or) serological analysis. Alternatively, the dried blood can be stored and used as an archival resource to rapidly establish the frequency and distribution of newly recognized mutations, confirm patient identity or track the origins and emergence of newly identified pathogens. In this report, we describe how PCR-based technologies are beginning to interface with international screening programmes for the diagnosis and genetic characterization of human immunodeficiency virus type 1 (HIV-1). In particular, we review recent progress using DBS specimens to resolve the HIV-1 infection status of neonates, monitor the genetic evolution of HIV-1 during early infancy and establish a sentinel surveillance system for the systematic monitoring of HIV-1 genetic variation in Asia.

Tree-based message diffusion for managing replicated data in unreliable and resource-constrained peer-to-peer environment

Abstract This thesis proposes a set of adaptive broadcast solutions and an adaptive data replication solution to support the deployment of P2P applications. P2P applications are an emerging type of distributed applications that are running on top of P2P networks. Typical P2P applications are video streaming, file sharing, etc. While interesting because they are fully distributed, P2P applications suffer from several deployment problems, due to the nature of the environment on which they perform. Indeed, defining an application on top of a P2P network often means defining an application where peers contribute resources in exchange for their ability to use the P2P application. For example, in P2P file sharing application, while the user is downloading some file, the P2P application is in parallel serving that file to other users. Such peers could have limited hardware resources, e.g., CPU, bandwidth and memory or the end-user could decide to limit the resources it dedicates to the P2P application a priori. In addition, a P2P network is typically emerged into an unreliable environment, where communication links and processes are subject to message losses and crashes, respectively. To support P2P applications, this thesis proposes a set of services that address some underlying constraints related to the nature of P2P networks. The proposed services include a set of adaptive broadcast solutions and an adaptive data replication solution that can be used as the basis of several P2P applications. Our data replication solution permits to increase availability and to reduce the communication overhead. The broadcast solutions aim, at providing a communication substrate encapsulating one of the key communication paradigms used by P2P applications: broadcast. Our broadcast solutions typically aim at offering reliability and scalability to some upper layer, be it an end-to-end P2P application or another system-level layer, such as a data replication layer. Our contributions are organized in a protocol stack made of three layers. In each layer, we propose a set of adaptive protocols that address specific constraints imposed by the environment. Each protocol is evaluated through a set of simulations. The adaptiveness aspect of our solutions relies on the fact that they take into account the constraints of the underlying system in a proactive manner. To model these constraints, we define an environment approximation algorithm allowing us to obtain an approximated view about the system or part of it. This approximated view includes the topology and the components reliability expressed in probabilistic terms. To adapt to the underlying system constraints, the proposed broadcast solutions route messages through tree overlays permitting to maximize the broadcast reliability. Here, the broadcast reliability is expressed as a function of the selected paths reliability and of the use of available resources. These resources are modeled in terms of quotas of messages translating the receiving and sending capacities at each node. To allow a deployment in a large-scale system, we take into account the available memory at processes by limiting the view they have to maintain about the system. Using this partial view, we propose three scalable broadcast algorithms, which are based on a propagation overlay that tends to the global tree overlay and adapts to some constraints of the underlying system. At a higher level, this thesis also proposes a data replication solution that is adaptive both in terms of replica placement and in terms of request routing. At the routing level, this solution takes the unreliability of the environment into account, in order to maximize reliable delivery of requests. At the replica placement level, the dynamically changing origin and frequency of read/write requests are analyzed, in order to define a set of replica that minimizes communication cost.

Iowa's People: a resource for extension educators, June 1989

Statistics about people and their families interest community planners, social scientists, Extension educators, and others because the family is the fundamental social institution in our society. The purpose of this publication is to bring together in one reference many statistics about people in Iowa counties that have been published separately elsewhere. Most of the data presented are limited to only one year. This cross-sectional view is similar to a photograph that shows only one point in time. At an earlier or later time it might appear differently. Although the statistics reported in the various tables and figures represent different years, the data presented were the most recent available at the time this publication was prepared.

Prepupal Building Behavior in Drosophila melanogaster and Its Evolution under Resource and Time Constraints.

Structures built by animals are a widespread and ecologically important 'extended phenotype'. While its taxonomic diversity has been well described, factors affecting short-term evolution of building behavior within a species have received little experimental attention. Here we describe how, given the opportunity, wandering Drosophila melanogaster larvae often build long tunnels in agar substrates and embed their pupae within them. These embedded larvae are characterized by a longer egg-to-pupariation developmental time than larvae that pupate on the surface. Assuming that such building behaviors are likely to be energetically costly and/or time consuming, we hypothesized that they should evolve to be less pronounced under resource or time limitation. In accord with this prediction, larvae from populations evolved for 160 generations under a regime that combines larval malnutrition with limited developmental time dug shorter tunnels than larvae from control unselected populations. However, the proportion of larvae that embedded before pupation did not differ between the malnutrition-adapted and control populations, suggesting that tunnel length and likelihood of embedding before pupation are controlled by different genetic loci. The behaviors exhibited by wandering larvae of Drosophila melanogaster prior to pupation offer a model system to study evolution of animal building behaviors because the tunneling and embedding phenotypes are simple, facultative and highly variable.

Trophic resource partitioning and competition between the two sibling bat species Myotis myotis and Myotis blythii

1. Niche theory predicts that the stable coexistence of species within a guild should be associated, if resources are limited, with a mechanism of resource partitioning. Using extensive data on diets, the present study attempts: (i) to test the hypothesis that, in sympatry, the interspecific overlap between the trophic niches of the sibling bat species Myotis myotis and M. blythii-which coexist intimately in their roosts-is effectively lower than the two intraspecific overlaps; (ii) to assess the role played by interspecific competition in resource partitioning through the study of trophic niche displacement between several sympatric and allopatric populations. 2. Diets were determined by the analysis of faecal samples collected in the field from individual bats captured in various geographical areas. Trophic niche overlaps were calculated monthly for all possible intraspecific and interspecific pairs of individuals from sympatric populations. Niche breadth was estimated from: (i) every faecal sample; (ii) all the faecal samples collected per month in a given population (geographical area). 3. In every population, the bulk of the diets of M. myotis and M. blythii consisted of, respectively, terrestrial (e.g. carabid beetles) and grass-dwelling (mostly bush crickets) prey. All intraspecific trophic niche overlaps were significantly greater than the interspecific one, except in Switzerland in May when both species exploited mass concentrations of cockchafers, a non-limiting food source. This clearcut partitioning of resources may allow the stable, intimate coexistence observed under sympatric conditions. 4. Relative proportions of ground-and grass-dwelling prey, as well as niche breadths (either individual or population), did not differ significantly between sympatry and allopatry, showing that, under allopatric conditions, niche expansion does not take place. This suggests that active interspecific competition is not the underlying mechanism responsible for the niche partitioning which is currently observed between M. myotis and M. blythii.

Success of service-intensive manufacturing firms - resource-based view

The main objective of this study is to examine the relationships between resources, competitive advantage and firm success. The study focuses, on one hand, on the financial performance of service-intensive manufac-turing firms against competitors with a lower service intensity and, on the other hand, on the resources as drivers for competitive advantage and success. The purpose of the theoretical part is to link the study in the field of the strategy research. The empirical part of the study is based on the quantitative analyses of the survey data collected from 50 major suppliers of industrial machinery and transportation equipment in Europe and North America. Results indicate that service-intensive manufacturing firms have performed better and their performance has been more stable vis-à-vis their peers. The main resources that differentiate service-intensive manufacturing firms from their non-service intensive competitors are service strategy and service-oriented top management. The analyses on the VRIO resources produced only a limited amount of information and solely service-centred culture appeared to be a rent generating resource.

Benefits and challenges of Enterprise Resource Planning for Pakistani SMEs

Enterprise resource planning (ERP) software is used to combine all the functions happening inside the organization with the help of one software. All the data is centralized which makes it easy to manage information for all participants. The literature on ERP is studied thoroughly the whole process of adoption till the implementation and final evaluations. But studies that focus on small and medium sized enterprises are limited in number when compared to the large scale enterprises. In case of Pakistan, research is very limited. In this thesis, the author tries to analyze the current status of SMEs usage of ERP system. The benefits obtained and challenges faced by SMEs of Pakistan are studied. Framework presented by Shang and Seddon (2000) is used to understand the benefits obtained by the SMEs in Pakistan. This is a comprehensive framework that classifies the benefits obtained by the ERP adoption, into five categories: operational benefits, managerial benefits, Strategic benefits, IT benefits, and Organizational benefits. The results show that SMEs of Pakistan are also getting many benefits after adoption of ERP. Most of the firms had implemented SAP software. Operational benefits were mentioned by all the firms. The most important benefits were report generation, quick access to critical information, better product and cost planning. Respondents also mentioned that they had reduced corruption as a result of ERP implementation. It is also an important benefit considering high corruption rate in Pakistan. Along with benefits, challenges faced by Pakistani SMEs included infrastructure problems like electricity, difficulties with integration of one module with other module, costs of adoption and lack of skilled ERP consultants. Further studies in this regard can be conducted on cloud based ERP which is fast growing all around the world.

Modernizing human resource management : the importance of values-based leadership in the Canadian federal public service /

Over the past several decades, many theories have been advanced as to why efforts to reform the public service have met with only limited success. Clearly, the role of leadership with respect to reform must be examined, since successful organizational leaders should be extremely accomplished in the promotion and protection of the values that underlie decision-making. The issue of effective leadership is particularly significant for the future of the public service of Canada. Large numbers of public servants in the executive ranks are due to retire within the next five years. Given their central role, it is vital that there be enough dedicated and committed public servants to staff future vacancies. It is also essential that future public service leaders possess the competencies and values associated with a world-class public service and, a new type of public organization. Related to this point is the importance of people-management skills. People management in the public service is an issue that has historically faced - and will continue to face - major challenges with respect to recruiting and retaining the leaders it requires for its continued success. It is imperative that the public service not only be revitalized and be seen as an employer of choice, but also that the process by which it accomplishes this goal - the practice of human resource management - be modernized. To achieve the flexibility needed to remain effective, the public service requires the kind ofleadership that supports new public service values such as innovation and which emphasizes a "people- first" approach. This thesis examines the kind of public service leadership needed to modernize the human resource management regime in the federal public service. A historical examination of public service values is presented to help determine the values that are important for public service leaders with respect to modernizing human resource management. Since replenishing the 2 ranks of public service leaders is crucial to ensure the quality of service to Canadians, leadership that supports career planning will be a major focus of this paper. In addition, this thesis demonstrates that while traditional public service values continue to endure, innovative leaders must effectively reconcile new public service values with traditional values in order to increase the possibilities for successful reform as well as achieve business objectives. Much of the thesis is devoted to explaining the crucial role of post-bureaucratic leadership to successful reform. One of the major findings of the thesis is that leaders who demonstrate a blending of new public service values and traditional values are critical to creating effective employment relationships, which are key to modernizing human resource management in the federal public service. It will be apparent that public service leaders must ensure that an appropriate accountability framework is in place before embarking on reform. However, leaders who support new public service values such as innovation and empowerment and who emphasize the importance of people are essential to successful reform.