The Effects of Advanced Practice Nurses (APNs) as Intensivists in a Surgical Intensive Care Unit (SICU) on Patient Outcomes, Healthcare Charges, and APN Intensivist Services in the SICU

Intensive Care Units (ICUs) account for over 10 percent of all US hospital beds, have over 4.4 million patient admissions yearly, approximately 360,000 deaths, and account for close to 30% of acute care hospital costs. The need for critical care services has increased due to an aging population and medical advances that extend life. The result is efforts to improve patient outcomes, optimize financial performance, and implement models of ICU care that enhance quality of care and reduce health care costs. This retrospective chart review study examined the dose effect of APN Intensivists in a surgical intensive care unit (SICU) on differences in patient outcomes, healthcare charges, SICU length of stay, charges for APN intensivist services, and frequency of APNs special initiatives when the SICU was staffed by differing levels of APN Intensivist staffing over four time periods (T1-T4) between 2009 and 2011. The sample consisted of 816 randomly selected (204 per T1-T4) patient chart data. Study findings indicated reported ventilator associated pneumonia (VAP) rates, ventilator days, catheter days and catheter associated urinary tract infection (CAUTI) rates increased at T4 (when there was the lowest number of APN Intensivists), and there was increased pressure ulcer incidence in first two quarters of T4. There was no statistically significant difference in post-surgical glycemic control (M = 142.84, SD= 40.00), t (223) = 1.40, p = .17, and no statistically significant difference in the SICU length of stay among the time-periods (M= 3.27, SD = 3.32), t (202) = 1.02, p= .31. Charges for APN services increased over the 4 time periods from $11,268 at T1 to $51,727 at T4 when a system to capture APN billing was put into place. The number of new APN initiatives declined in T4 as the number of APN Intensivists declined. Study results suggest a dose effect of APN Intensivists on important patient health outcomes and on the number of APNs initiatives to prevent health complications in the SICU.

(Table S1) Radiocarbon dates of organic matter from Lena Delta ice wedges

Relative to the past 2,000 years, the Arctic region has warmed significantly over the past few decades. However, the evolution of Arctic temperatures during the rest of the Holocene is less clear. Proxy reconstructions, suggest a long-term cooling trend throughout the mid- to late Holocene, whereas climate model simulations show only minor changes or even warming. Here we present a record of the oxygen isotope composition of permafrost ice wedges from the Lena River Delta in the Siberian Arctic. The isotope values, which reflect winter season temperatures, became progressively more enriched over the past 7,000 years, reaching unprecedented levels in the past five decades. This warming trend during the mid- to late Holocene is in opposition to the cooling seen in other proxy records. However, most of these existing proxy records are biased towards summer temperatures. We argue that the opposing trends are related to the seasonally different orbital forcing over this interval. Furthermore, our reconstructed trend as well as the recent maximum are consistent with the greenhouse gas forcing and climate model simulations, thus reconciling differing estimates of Arctic and northern high-latitude temperature evolution during the Holocene.

Geochemistry of ODP Leg 135 igneous rock samples

Ocean Drilling Program Leg 135 provided igneous rock cores from six sites drilled on a transect across the Lau Basin between the Lau Ridge remnant arc and the modem spreading ridges of the Central and Eastern Lau Spreading Centers. The drill cores sampled crust from the earliest stage of backarc extension (latest Miocene time, about 6 Ma), and younger crust (late Pliocene, about 3.8-2 Ma, and middle Pleistocene, about 0.64-0.8 Ma). Nearly all of the igneous samples are from tholeiitic basalt flows; many of them are interbedded with arc-composition volcaniclastic sediments. Rock compositions range from olivine-plagioclase-clinopyroxene basalt, with up to 8% MgO, to oceanic andesites with less than 3.2% MgO and silica contents as high as 56%. The oldest rocks recovered are close in composition to rocks formed at the modern Central and Eastern Lau Spreading Centers and have MORB-like characteristics. Generation of the oldest units was coeval with arc-tholeiitic volcanism on the Lau Ridge less than 100 km to the west. The arc and backarc melts came from different mantle sources. At three sites near the center of the basin, the crust is arc-tholeiitic basalt, two-pyroxene basaltic-andesite, and two-pyroxene andesite. These rocks have many similarities to modem Tofua Arc lavas yet they were drilled within 70 km of the MORB-like Eastern Lau Spreading Center. Estimates of the minimum age for these arc-like rocks indicate that they are late Pliocene (about 2 Ma). These ages overlap the age of the nearby Eastern Lau Spreading Center. The heterogeneous crust of the Lau Basin carries many of the signatures of supra-subduction zone (SSZ) melts but also has a distinct MORB-like component. Mixing between SSZ and MORB mantle sources may explain the variations and the spatial distribution of magma types.

Granulometry, geochemistry, amino acids, radiocarbon ages and paleomagnetics of samples from Heidemann Valley

A Pliocene (2.6-3.5 Ma) age is determined from glacial sediments studied in a 20m long, 4 m deep trench excavated in Heidemann Valley, Vestfold Hills, East Antarctica. The age determination is based on a combined study of amino acid racemization, diatoms, foraminifera, and magnetic polarity, and supports earlier estimates of the age of the sedimentary section; all are beyond 14C range. Four till units are recognized and documented, and 16 subunits are identified. All are ascribed to deposition during a Late Pliocene glaciation that was probably the last time the entire Vestfold Hills was covered by an enlarged East Antarctic Ice Sheet (EAIS). Evidence for other more recent glacial events of the 'Vestfold Glaciation' may have been due to lateral expansion of the Sorsdal Glacier and limited expansion of the icesheet margin during the Last Glacial Maximum rather than a major expansion of the EAIS. The deposit appears to correlate with a marine deposition event recorded in Ocean Drilling Program Site 1166 in Prydz Bay, possibly with the Bardin Bluffs Formation of the Prince Charles Mountains and with part of the time represented in the ANDRILL AND-1B core in the Ross Sea.

Size-partitioned phytoplankton carbon concentrations retrieved from ocean color data, links to data in netCDF format

Owing to their important roles in biogeochemical cycles, phytoplankton functional types (PFTs) have been the aim of an increasing number of ocean color algorithms. Yet, none of the existing methods are based on phytoplankton carbon (C) biomass, which is a fundamental biogeochemical and ecological variable and the "unit of accounting" in Earth system models. We present a novel bio-optical algorithm to retrieve size-partitioned phytoplankton carbon from ocean color satellite data. The algorithm is based on existing methods to estimate particle volume from a power-law particle size distribution (PSD). Volume is converted to carbon concentrations using a compilation of allometric relationships. We quantify absolute and fractional biomass in three PFTs based on size - picophytoplankton (0.5-2 µm in diameter), nanophytoplankton (2-20 µm) and microphytoplankton (20-50 µm). The mean spatial distributions of total phytoplankton C biomass and individual PFTs, derived from global SeaWiFS monthly ocean color data, are consistent with current understanding of oceanic ecosystems, i.e., oligotrophic regions are characterized by low biomass and dominance of picoplankton, whereas eutrophic regions have high biomass to which nanoplankton and microplankton contribute relatively larger fractions. Global climatological, spatially integrated phytoplankton carbon biomass standing stock estimates using our PSD-based approach yield - 0.25 Gt of C, consistent with analogous estimates from two other ocean color algorithms and several state-of-the-art Earth system models. Satisfactory in situ closure observed between PSD and POC measurements lends support to the theoretical basis of the PSD-based algorithm. Uncertainty budget analyses indicate that absolute carbon concentration uncertainties are driven by the PSD parameter No which determines particle number concentration to first order, while uncertainties in PFTs' fractional contributions to total C biomass are mostly due to the allometric coefficients. The C algorithm presented here, which is not empirically constrained a priori, partitions biomass in size classes and introduces improvement over the assumptions of the other approaches. However, the range of phytoplankton C biomass spatial variability globally is larger than estimated by any other models considered here, which suggests an empirical correction to the No parameter is needed, based on PSD validation statistics. These corrected absolute carbon biomass concentrations validate well against in situ POC observations.

Distribution of diatom species as abundance estimates from vertical multinet hauls from 150 m water depth in the Indian Ocean

During the Indian Ocean Expedition of R/V METEOR phytoplankton samples were taken with a multiple closing net (Multinet) at 103 stations. In this material the diatoms were investigated. In all 247 taxa could be identified which belong to 242 species and 5 varieties of formae of 80 genera. Of these 1 variety, 15 pecies, and 3 genera are newly described. New combinations were made for 18 species, and a number of old combinations was reinstated.

Analytical results of 19 amino acid analyses from Unit 3.1 of sediment core CRP-1 (Table 1)

Amino acid-based geochronological analyses were carried out on fossil mollusc shell and foraminifera from Unit 3.1, Cape Roberts Project core CRP-1. Ratios of D-alloIsoleucine to L-Isoleucine (D/L) were measured from 19 fossil samples using cation exchange High Performance Liquid Chromatography (HPLC) methods. Preliminary interpretation of these results suggest that Unit 3.1 contains carbonate fossils having multiple ages. The interpreted ages have a bimodal distribution between ~220 Ka (Quaternary) and ~2.4 Ma (Pliocene). However, these results lack a comprehensive regional and taxonomic context for amino acid studies in Antarctica and therefore should be regarded as preliminary age estimates of fossil shell ages.

Conventional and 40Ar/39Ar K-Ar ages of volcanic rocks at DSDP Leg 55 Holes

Conventional K-Ar, 40Ar/39Ar total fusion, and 40Ar/39Ar incremental heating data on hawaiite and tholeiitic basalt samples from Ojin (Site 430), alkalic basalt samples from Nintoku (Site 432), and alkalic and tholeiitic basalt samples from Suiko (Site 433) seamounts in the Emperor Seamount chain give the following best ages for these volcanoes: Ojin = 55.2 ± 0.7 m.y., Nintoku = 56.2 ± 0.6 m.y., and Suiko = 64.7 ± 1.1 m.y. These new data bring to 27 the number of dated volcanoes in the Hawaiian-Emperor volcanic chain. The new dates prove that the age progression from Kilauea Volcano on Hawaii (0 m.y.) through the Hawaiian-Emperor bend (- 43 m.y.) to Koko Seamount (48.1 m.y.) in the southernmost Emperor Seamounts continues more than halfway up the Emperor chain to Suiko Seamount. The age versus distance data for the Hawaiian-Emperor chain are consistent with the kinematic hot-spot hypothesis, which predicts that the volcanoes are progressively older west and north away from the active volcanoes of Kilauea and Mauna Loa. The data are consistent with an average volcanic propagation velocity of either 8 cm/year from Suiko to Kilauea or of 6 cm/year from Suiko to Midway followed by a velocity of 9 cm/year from Midway to Kilauea, but it appears that the change in direction that formed the Hawaiian- Emperor bend probably was not accompanied by a major change in velocity.

Labor Scheduling Using NPV Estimates of the Marginal Benefit of Additional Labor Capacity

An extensive literature exists on the problems of daily (shift) and weekly (tour) labor scheduling. In representing requirements for employees in these problems, researchers have used formulations based either on the model of Dantzig (1954) or on the model of Keith (1979). We show that both formulations have weakness in environments where management knows, or can attempt to identify, how different levels of customer service affect profits. These weaknesses results in lower-than-necessary profits. This paper presents a New Formulation of the daily and weekly Labor Scheduling Problems (NFLSP) designed to overcome the limitations of earlier models. NFLSP incorporates information on how changing the number of employees working in each planning period affects profits. NFLP uses this information during the development of the schedule to identify the number of employees who, ideally, should be working in each period. In an extensive simulation of 1,152 service environments, NFLSP outperformed the formulations of Dantzig (1954) and Keith (1979) at a level of significance of 0.001. Assuming year-round operations and an hourly wage, including benefits, of $6.00, NFLSP's schedules were $96,046 (2.2%) and $24,648 (0.6%) more profitable, on average, than schedules developed using the formulations of Danzig (1954) and Keith (1979), respectively. Although the average percentage gain over Keith's model was fairly small, it could be much larger in some real cases with different parameters. In 73 and 100 percent of the cases we simulated NFLSP yielded a higher profit than the models of Keith (1979) and Danzig (1954), respectively.

Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980-2015 : the Global Burden of Disease Study 2015

Background Timely assessment of the burden of HIV/AIDS is essential for policy setting and programme evaluation. In this report from the Global Burden of Disease Study 2015 (GBD 2015), we provide national estimates of levels and trends of HIV/AIDS incidence, prevalence, coverage of antiretroviral therapy (ART), and mortality for 195 countries and territories from 1980 to 2015. Methods For countries without high-quality vital registration data, we estimated prevalence and incidence with data from antenatal care clinics and population-based seroprevalence surveys, and with assumptions by age and sex on initial CD4 distribution at infection, CD4 progression rates (probability of progression from higher to lower CD4 cell-count category), on and off antiretroviral therapy (ART) mortality, and mortality from all other causes. Our estimation strategy links the GBD 2015 assessment of all-cause mortality and estimation of incidence and prevalence so that for each draw from the uncertainty distribution all assumptions used in each step are internally consistent. We estimated incidence, prevalence, and death with GBD versions of the Estimation and Projection Package (EPP) and Spectrum software originally developed by the Joint United Nations Programme on HIV/AIDS (UNAIDS). We used an open-source version of EPP and recoded Spectrum for speed, and used updated assumptions from systematic reviews of the literature and GBD demographic data. For countries with high-quality vital registration data, we developed the cohort incidence bias adjustment model to estimate HIV incidence and prevalence largely from the number of deaths caused by HIV recorded in cause-of-death statistics. We corrected these statistics for garbage coding and HIV misclassifi cation. Findings Global HIV incidence reached its peak in 1997, at 3·3 million new infections (95% uncertainty interval [UI] 3·1–3·4 million). Annual incidence has stayed relatively constant at about 2·6 million per year (range 2·5–2·8 million) since 2005, after a period of fast decline between 1997 and 2005. The number of people living with HIV/AIDS has been steadily increasing and reached 38·8 million (95% UI 37·6–40·4 million) in 2015. At the same time, HIV/AIDS mortality has been declining at a steady pace, from a peak of 1·8 million deaths (95% UI 1·7–1·9 million) in 2005, to 1·2 million deaths (1·1–1·3 million) in 2015. We recorded substantial heterogeneity in the levels and trends of HIV/AIDS across countries. Although many countries have experienced decreases in HIV/AIDS mortality and in annual new infections, other countries have had slowdowns or increases in rates of change in annual new infections. Interpretation Scale-up of ART and prevention of mother-to-child transmission has been one of the great successes of global health in the past two decades. However, in the past decade, progress in reducing new infections has been slow, development assistance for health devoted to HIV has stagnated, and resources for health in low-income countries have grown slowly. Achievement of the new ambitious goals for HIV enshrined in Sustainable Development Goal 3 and the 90-90-90 UNAIDS targets will be challenging, and will need continued eff orts from governments and international agencies in the next 15 years to end AIDS by 2030.

Estimates of Total Fuel Consumption in Transporting Grain from Iowa to Major Grain-Importing Countries by Alternative Modes and Routes, 1985

This study measured fuel consumption in transporting grain from Iowa origins to Japan and Amsterdam by alternative routes and modes of transport and applied these data to construct equations for fuel consumption from Iowa origins to alternative final destinations. Some of the results are as follows: (1) The metered tractor-trailer truck averaged 186.6 gross ton-miles per gallon and 90.5 net ton-miles per gallon when loaded 50% of total miles. (2) The 1983 fuel consumption of seven trucks taken from company records was 82.4 net ton-miles per gallon at 67.5% loaded miles and 68.6 net ton-miles per gallon at 50% loaded miles. (3) Unit grain trains from Iowa to West Coast ports averaged 437.0 net ton-miles per gallon whereas unit grain trains from Iowa to New Orleans averaged 640.1 net ton-miles per gallon--a 46% advantage for the New Orleans trips. (4) Average barge fuel consumption on the Mississippi River from Iowa to New Orleans export grain elevators was 544.5 net ton-miles per gallon, with a 35% backhaul rate. (5) Ocean vessel net ton-miles per gallon varies widely by size of ship and backhaul percentage. With no backhaul, the average net ton-miles per gallon were as follows: for 30,000 dwt ship, 574.8 net ton-miles per gallon; for 50,000 dwt ship, 701.9; for 70,000 dwt ship, 835.1; and for 100,000 dwt ship, 1,043.4. (6) The most fuel efficient route and modal combination to transport grain from Iowa to Japan depends on the size of ocean vessel, the percentage of backhaul, and the origin of the grain. Alternative routes and modal combinations in shipping grain to Japan are ranked in descending order of fuel efficiencies.

The Effect of Water Consumption on Schoolchildren's Fine Motor Skills, Cognitive Function and Mood

Previous research has suggested that dehydration may have a negative effect on some aspects of mood, cognitive performance and motor skills (Benton, 2011). Furthermore, a large proportion of children arrive at school in a dehydrated state (Baron, Courbebaisse, Lepicard, & Friedlander, 2015). The present work investigated whether supplementing children with water may, as a consequence of reducing dehydration, improve their cognitive performance and motor skills. In studies 1, 2, 3 and 5, it was found that tasks that predominantly tested motor skills, were improved in children who had a drink, compared to those who did not. Furthermore, study 3 showed that this effect was moderated by hydration status. One theoretical explanation for the poorer performance of dehydrated children is that they may lack the neurological resources to sustain their effort and thus performance does not improve over time. In support of this, these studies showed that, when re-hydrated, performance on these tasks improves to the level of non-dehydrated children. Study 2 showed that the number of errors increased in a StopSignal task in children that had high self-rated levels of thirst, compared to low levels: and hydration status did not moderate this effect. A possible explanation for the increased number of errors in children with high self-rated thirst is that the thirst sensation diverts attention away from the task, causing task performance to deteriorate. In study 4, it was observed that there was a large variation in intra-individual and inter-individual hydration scores throughout the day, which was not related to volume drank or levels of thirst. Further studies should use imaging techniques to study brain activity during dehydration and rehydration, and during periods of high thirst, to help to further elucidate the mechanism underlying the negative effect of dehydration on motor performance, and the effect of self-rated thirst on attention.

Critère de validation croisée pour le choix des modèles des petits domaines au niveau des unités

Ce mémoire s’intéresse à l’étude du critère de validation croisée pour le choix des modèles relatifs aux petits domaines. L’étude est limitée aux modèles de petits domaines au niveau des unités. Le modèle de base des petits domaines est introduit par Battese, Harter et Fuller en 1988. C’est un modèle de régression linéaire mixte avec une ordonnée à l’origine aléatoire. Il se compose d’un certain nombre de paramètres : le paramètre β de la partie fixe, la composante aléatoire et les variances relatives à l’erreur résiduelle. Le modèle de Battese et al. est utilisé pour prédire, lors d’une enquête, la moyenne d’une variable d’intérêt y dans chaque petit domaine en utilisant une variable auxiliaire administrative x connue sur toute la population. La méthode d’estimation consiste à utiliser une distribution normale, pour modéliser la composante résiduelle du modèle. La considération d’une dépendance résiduelle générale, c’est-à-dire autre que la loi normale donne une méthodologie plus flexible. Cette généralisation conduit à une nouvelle classe de modèles échangeables. En effet, la généralisation se situe au niveau de la modélisation de la dépendance résiduelle qui peut être soit normale (c’est le cas du modèle de Battese et al.) ou non-normale. L’objectif est de déterminer les paramètres propres aux petits domaines avec le plus de précision possible. Cet enjeu est lié au choix de la bonne dépendance résiduelle à utiliser dans le modèle. Le critère de validation croisée sera étudié à cet effet.

New tools for cognitive and motor rehabilitation: development and clinical validation

Nervous system disorders are associated with cognitive and motor deficits, and are responsible for the highest disability rates and global burden of disease. Their recovery paths are vulnerable and dependent on the effective combination of plastic brain tissue properties, with complex, lengthy and expensive neurorehabilitation programs. This work explores two lines of research, envisioning sustainable solutions to improve treatment of cognitive and motor deficits. Both projects were developed in parallel and shared a new sensible approach, where low-cost technologies were integrated with common clinical operative procedures. The aim was to achieve more intensive treatments under specialized monitoring, improve clinical decision-making and increase access to healthcare. The first project (articles I – III) concerned the development and evaluation of a web-based cognitive training platform (COGWEB), suitable for intensive use, either at home or at institutions, and across a wide spectrum of ages and diseases that impair cognitive functioning. It was tested for usability in a memory clinic setting and implemented in a collaborative network, comprising 41 centers and 60 professionals. An adherence and intensity study revealed a compliance of 82.8% at six months and an average of six hours/week of continued online cognitive training activities. The second project (articles IV – VI) was designed to create and validate an intelligent rehabilitation device to administer proprioceptive stimuli on the hemiparetic side of stroke patients while performing ambulatory movement characterization (SWORD). Targeted vibratory stimulation was found to be well tolerated and an automatic motor characterization system retrieved results comparable to the first items of the Wolf Motor Function Test. The global system was tested in a randomized placebo controlled trial to assess its impact on a common motor rehabilitation task in a relevant clinical environment (early post-stroke). The number of correct movements on a hand-to-mouth task was increased by an average of 7.2/minute while the probability to perform an error decreased from 1:3 to 1:9. Neurorehabilitation and neuroplasticity are shifting to more neuroscience driven approaches. Simultaneously, their final utility for patients and society is largely dependent on the development of more effective technologies that facilitate the dissemination of knowledge produced during the process. The results attained through this work represent a step forward in that direction. Their impact on the quality of rehabilitation services and public health is discussed according to clinical, technological and organizational perspectives. Such a process of thinking and oriented speculation has led to the debate of subsequent hypotheses, already being explored in novel research paths.

Um mar de histórias num grupo de três anos

Relatório de estágio apresentado à Escola Superior de Educação de Paula Frassinetti para obtenção do grau de Mestre em Educação Pré-escolar