Long Term Follow-up of Morbidity and Quality of Life Associated with Isolated Gastroschisis

Gastroschisis is a birth defect in which an opening in the abdominal wall allows herniation of the viscera. Prenatal counseling regarding gastroschisis typically discusses that, although these infants often endure a difficult neonatal course, they experience few long-term complications. However, information regarding long-term outcomes is based on limited studies that lack specificity. Therefore, we aimed to study the long-term morbidity and quality of life in children born with gastroschisis in a large and diverse population drawn from the Texas Birth Defects Registry (TBDR). Study packets with informed consent, a questionnaire, and the Pediatric Quality of Life Inventory Generic Core Scale 4.0 (PedsQL 4.0) in English and Spanish were mailed to 1,112 parents of children born with isolated gastroschisis in Texas between 1999 and 2008 via the TBDR. Information was abstracted from the TBDR for 58 mothers of children with gastroschisis who returned study materials. Three hundred fifty five packets were returned to sender, giving a response rate of 7.7%. Children born with gastroschisis had quality of life scores that were not significantly different than expected (p = 0.981). However, factors such as having a learning disability (p = 0.001) and missing school due to gastrointestinal issues (p = 0.020) were found to significantly decrease quality of life. Overall, children with gastroschisis had a significantly increased risk for learning disabilities regardless of whether they were preterm (p = 0.021) or full term (p = 0.021). Additionally, there appeared to be an increased risk for auditory impairment in Caucasian children (p < 0.0005). Therefore, while overall long-term quality of life is not significantly altered for children born with gastroschisis, the previously unreported increased risk for learning disabilities and possible association with hearing impairment are important findings that should be conveyed to prospective parents.

Trastuzumab use and risk of congestive heart failure in older breast cancer patients

Trastuzumab is a humanized-monoclonal antibody, developed specifically for HER2-neu over-expressed breast cancer patients. Although highly effective and well tolerated, it was reported associated with Congestive Heart Failure (CHF) in clinical trial settings (up to 27%). This leaves a gap where, Trastuzumab-related CHF rate in general population, especially older breast cancer patients with long term treatment of Trastuzumab remains unknown. This thesis examined the rates and risk factors associated with Trastuzumab-related CHF in a large population of older breast cancer patients. A retrospective cohort study using the existing Surveillance, Epidemiology and End Results (SEER) and Medicare linked de-identified database was performed. Breast cancer patients ≥ 66 years old, stage I-IV, diagnosed in 1998-2007, fully covered by Medicare but no HMO within 1-year before and after first diagnosis month, received 1st chemotherapy no earlier than 30 days prior to diagnosis were selected as study cohort. The primary outcome of this study is a diagnosis of CHF after starting chemotherapy but none CHF claims on or before cancer diagnosis date. ICD-9 and HCPCS codes were used to pool the claims for Trastuzumab use, chemotherapy, comorbidities and CHF claims. Statistical analysis including comparison of characteristics, Kaplan-Meier survival estimates of CHF rates for long term follow up, and Multivariable Cox regression model using Trastuzumab as a time-dependent variable were performed. Out of 17,684 selected cohort, 2,037 (12%) received Trastuzumab. Among them, 35% (714 out of 2037) were diagnosed with CHF, compared to 31% (4784 of 15647) of CHF rate in other chemotherapy recipients (p<.0001). After 10 years of follow-up, 65% of Trastuzumab users developed CHF, compared to 47% in their counterparts. After adjusting for patient demographic, tumor and clinical characteristics, older breast cancer patients who used Trastuzumab showed a significantly higher risk in developing CHF than other chemotherapy recipients (HR 1.69, 95% CI 1.54 - 1.85). And this risk is increased along with the increment of age (p-value < .0001). Among Trastuzumab users, these covariates also significantly increased the risk of CHF: older age, stage IV, Non-Hispanic black race, unmarried, comorbidities, Anthracyclin use, Taxane use, and lower educational level. It is concluded that, Trastuzumab users in older breast cancer patients had 69% higher risk in developing CHF than non-Trastuzumab users, much higher than the 27% increase reported in younger clinical trial patients. Older age, Non-Hispanic black race, unmarried, comorbidity, combined use with Anthracycline or Taxane also significantly increase the risk of CHF development in older patients treated with Trastuzumab. ^

Fasting blood glucose and 8-year mortality in the hypertension detection follow-up program population

This study analyzed the relationship between fasting blood glucose (FBG) and 8-year mortality in the Hypertension Detection Follow-up Program (HDFP) population. Fasting blood glucose (FBG) was examined both as a continuous variable and by specified FBG strata: Normal (FBG 60–100 mg/dL), Impaired (FBG ≥100 and ≤125 mg/dL), and Diabetic (FBG>125 mg/dL or pre-existing diabetes) subgroups. The relationship between type 2 diabetes was examined with all-cause mortality. This thesis described and compared the characteristics of fasting blood glucose strata by recognized glucose cut-points; described the mortality rates in the various fasting blood glucose strata using Kaplan-Meier mortality curves, and compared the mortality risk of various strata using Cox Regression analysis. Overall, mortality was significantly greater among Referred Care (RC) participants compared to Stepped Care (SC) {HR = 1.17; 95% CI (1.052,1.309); p-value = 0.004}, as reported by the HDFP investigators in 1979. Compared with SC participants, the RC mortality rate was significantly higher for the Normal FBG group {HR = 1.18; 95% CI (1.029,1.363); p-value = 0.019} and the Impaired FBG group, {HR = 1.34; 95% CI (1.036,1.734); p-value = 0.026,}. However, for the diabetic group, 8-year mortality did not differ significantly between the RC and SC groups after adjusting for race, gender, age, smoking status among Diabetic individuals {HR = 1.03; 95% CI (0.816,1.303); p-value = 0.798}. This latter finding is possibly due to a lack of a treatment difference of hypertension among Diabetic participants in both RC and SC groups. The largest difference in mortality between RC and SC was in the Impaired subgroup, suggesting that hypertensive patients with FBG between 100 and 125 mg/dL would benefit from aggressive antihypertensive therapy.^

Role of obesity, weight gain, physical activity, and polymorphisms in the mTOR pathway and the risk of renal cell carcinoma

The interplay between obesity, physical activity, weight gain and genetic variants in mTOR pathway have not been studied in renal cell carcinoma (RCC). We examined the associations between obesity, weight gain, physical activity and RCC risk. We also analyzed whether genetic variants in the mTOR pathway could modify the association. Incident renal cell carcinoma cases and healthy controls were recruited from the University of Texas MD Anderson Cancer Center in Houston, Texas. Cases and controls were frequency-matched by age (±5 years), ethnicity, sex, and county of residence. Epidemiologic data were collected via in-person interview. A total of 577 cases and 593 healthy controls (all white) were included. One hundred ninety-two (192) SNPs from 22 genes were available and their genotyping data were extracted from previous genome-wide association studies. Logistic regression and regression spline were performed to obtain odds ratios. Obesity at age 20, 40, and 3 years prior to diagnosis/recruitment, and moderate and large weight gain from age 20 to 40 were each significantly associated with increased RCC risk. Low physical activity was associated with a 4.08-fold (95% CI: 2.92-5.70) increased risk. Five single nucleotide polymorphisms (SNPs) were significantly associated with RCC risk and their cumulative effect increased the risk by up to 72% (95% CI: 1.20-2.46). Strata specific effects for weight change and genotyping cumulative groups were observed. However, no interaction was suggested by our study. In conclusion, energy balance related risk factors and genetic variants in the mTOR pathway may jointly influence susceptibility to RCC. ^

Is H. pylori infection associated with diarrhea in a cohort of 3- to 8-year-old Colombian children?

The Estudio Comunitario sobre la Salud del Niño cohort study followed 326 3- to 8-year-old Colombian children for 4 years to observe the natural history of Helicobacter pylori infection and identify risk factors for acquisition, recurrence and persistence. Acute H. pylori infection during childhood may predispose to other enteric infections and therefore increase the risk of diarrheal disease. This dissertation aimed to estimate the effect of H. pylori infection on the occurrence of diarrhea and parasitic co-infections. The analysis used Generalized Estimating Equations to obtain odds ratios to estimate relative risks for diarrhea and the Zhang-Yu algorithm to estimate relative risks for on parasitic infections. Andersen-Gill models were used to estimate rate ratios for the effect of H. pylori status on the recurrence of parasitic infections. H. pylori status was classified for the entire follow-up duration in 1 of 3 categories: persistently positive, intermittently positive, and persistently negative. Multivariable models included child’s sex, age, symptoms, medication use, and socio-environmental factors. H. pylori infection was weakly and imprecisely associated with diarrheal disease, which occurred at an unexpectedly low frequency in this study. Persistently H. pylori-positive children had a somewhat higher incidence of reported diarrhea than intermittently positive or persistently negative children. Stratified analysis revealed that the presence of specific helminthes modified the effect of persistent H. pylori infection on diarrhea. The incidence of any parasitic infections was higher in children with persistent H. pylori infection relative to those with intermittent or persistently negative status, but this association did not hold when adjusted for the full set of selected covariates. The effects of H. pylori persistent status were similar for the occurrence or recurrence of Giardia duodenalis, Entamoeba histolytica, and Ascaris lumbricoides. These results show that H. pylori frequently co-exists with other parasites in Andean children and suggest that intermittently H. pylori–positive children might be at a lower risk of parasitic infections than persistently positive children. The relationship of H. pylori infection, helminthic infection and diarrheal disease should be further explored in studies that devote more intensive resources to accurate ascertainment of diarrhea.^

Developing the follow-up schedules for women with breast cancer

Background: The follow-up care for women with breast cancer requires an understanding of disease recurrence patterns and the follow-up visit schedule should be determined according to the times when the recurrence are most likely to occur, so that preventive measure can be taken to avoid or minimize the recurrence. Objective: To model breast cancer recurrence through stochastic process with an aim to generate a hazard function for determining a follow-up schedule. Methods: We modeled the process of disease progression as the time transformed Weiner process and the first-hitting-time was used as an approximation of the true failure time. The women's "recurrence-free survival time" or a "not having the recurrence event" is modeled by the time it takes Weiner process to cross a threshold value which represents a woman experiences breast cancer recurrence event. We explored threshold regression model which takes account of covariates that contributed to the prognosis of breast cancer following development of the first-hitting time model. Using real data from SEER-Medicare, we proposed models of follow-up visits schedule on the basis of constant probability of disease recurrence between consecutive visits. Results: We demonstrated that the threshold regression based on first-hitting-time modeling approach can provide useful predictive information about breast cancer recurrence. Our results suggest the surveillance and follow-up schedule can be determined for women based on their prognostic factors such as tumor stage and others. Women with early stage of disease may be seen less frequently for follow-up visits than those women with locally advanced stages. Our results from SEER-Medicare data support the idea of risk-controlled follow-up strategies for groups of women. Conclusion: The methodology we proposed in this study allows one to determine individual follow-up scheduling based on a parametric hazard function that incorporates known prognostic factors.^

Journeying Beyond the Balcony to the Block Party and Up to 50,000 Feet: Disparities in Children’s Health and Healthcare

Invited Commentary on “Observations from the Balcony: Directions for Pediatric Health Disparities Research and Policy".

Risk factors for surgical site infections among patients undergoing major colon surgery in the United States 2007-2009

Background: Surgical site infections (SSIs) after abdominal surgeries account for approximately 26% of all reported SSIs. The Center for Disease Control and Prevention (CDC) defines 3 types of SSIs: superficial incisional, deep incisional, and organ/space. Preventing SSIs has become a national focus. This dissertation assesses several associations with the individual types of SSI in patients that have undergone colon surgery. ^ Methods: Data for this dissertation was obtained from the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP); major colon surgeries were identified in the database that occurred between the time period of 2007 and 2009. NSQIP data includes more than 50 preoperative and 30 intraoperative factors; 40 collected postoperative occurrences are based on a follow-up period of 30 days from surgery. Initially, four individual logistic regressions were modeled to compare the associations between risk factors and each of the SSI groups: superficial, deep, organ/space and a composite of any single SSI. A second analysis used polytomous regression to assess simultaneously the associations between risk factors and the different types of SSIs, as well as, formally test the different effect estimates of 13 common risk factors for SSIs. The final analysis explored the association between venous thromboembolism (VTEs) and the different types of SSIs and risk factors. ^ Results: A total of 59,365 colon surgeries were included in the study. Overall, 13% of colon cases developed a single type of SSI; 8% of these were superficial SSIs, 1.4% was deep SSIs, and 3.8% were organ/space SSIs. The first article identifies the unique set of risk factors associated with each of the 4 SSI models. Distinct risk factors for superficial SSIs included factors, such as alcohol, chronic obstructive pulmonary disease, dyspnea and diabetes. Organ/space SSIs were uniquely associated with disseminated cancer, preoperative dialysis, preoperative radiation treatment, bleeding disorder and prior surgery. Risk factors that were significant in all models had different effect estimates. The second article assesses 13 common SSI risk factors simultaneously across the 3 different types of SSIs using polytomous regression. Then each risk factor was formally tested for the effect heterogeneity exhibited. If the test was significant the final model would allow for the effect estimations for that risk factor to vary across each type of SSI; if the test was not significant, the effect estimate would remain constant across the types of SSIs using the aggregate SSI value. The third article explored the relationship of venous thromboembolism (VTE) and the individual types of SSIs and risk factors. The overall incidence of VTEs after the 59,365 colon cases was 2.4%. All 3 types of SSIs and several risk factors were independently associated with the development of VTEs. ^ Conclusions: Risk factors associated with each type of SSI were different in patients that have undergone colon surgery. Each model had a unique cluster of risk factors. Several risk factors, including increased BMI, duration of surgery, wound class, and laparoscopic approach, were significant across all 4 models but no statistical inferences can be made about their different effect estimates. These results suggest that aggregating SSIs may misattribute and hide true associations with risk factors. Using polytomous regression to assess multiple risk factors with the multiple types of SSI, this study was able to identify several risk factors that had significant effect heterogeneity across the 3 types of SSI challenging the use of aggregate SSI outcomes. The third article recognizes the strong association between VTEs and the 3 types of SSIs. Clinicians understand the difference between superficial, deep and organ/space SSIs. Our results indicate that they should be considered individually in future studies.^

The Risk of Using the Q Heterogeneity Estimator for Software Engineering Experiments

All meta-analyses should include a heterogeneity analysis. Even so, it is not easy to decide whether a set of studies are homogeneous or heterogeneous because of the low statistical power of the statistics used (usually the Q test). Objective: Determine a set of rules enabling SE researchers to find out, based on the characteristics of the experiments to be aggregated, whether or not it is feasible to accurately detect heterogeneity. Method: Evaluate the statistical power of heterogeneity detection methods using a Monte Carlo simulation process. Results: The Q test is not powerful when the meta-analysis contains up to a total of about 200 experimental subjects and the effect size difference is less than 1. Conclusions: The Q test cannot be used as a decision-making criterion for meta-analysis in small sample settings like SE. Random effects models should be used instead of fixed effects models. Caution should be exercised when applying Q test-mediated decomposition into subgroups.

Evolution and treatment of vitamin B12 deficiency as a risk factor for (cognitive and functional) neurodegenerative diseases in institutionalized elderly = Evolución y tratamiento de la deficiencia de vitamina B12 como factor de riesgo de enfermedades neurodegenerativas (cognitivas y funcionales) en las personas mayores institucionalizadas.

Prevalence of vitamin B12 deficiency is very common in elderly people and can reach values as high as 40.5% of the population. It can be the result of the interaction among several factors. Vitamin B12 deficiencies have been associated with neurological, cognitive deterioration, haematological abnormalities and cardiovascular diseases that have an important influence on the health of the elderly and their quality of life. It is necessary to approach the problems arisen from the lack of data relative to them. The main objective of this thesis was to analyse the evolution of vitamin B12 status and related parameters, lipid and haematological profiles and their relationship to health risk factors, and to functional and cognitive status over one year and to determine the effect of an oral supplementation of 500 μg of cyanocobalamin for a short period of 28 days. An additional objective was to analyze the possible effects of medicine intakes on vitamin B status. Three studies were performed: a) a one year longitudinal follow-up with four measure points; b) an intervention study providing an oral liquid supplement of 500 μg of cyanocobalamin for a 28 days period; and c) analysis of the possible effect of medication intake on vitamin B status using the ATC classification of medicines. The participants for these studies were recruited from nursing homes for the elderly in the Region of Madrid. Sixty elders (mean age 84 _ 7y, 19 men and 41 women) were recruited for Study I and 64 elders (mean age 82 _ 7y, 24 men and 40 women) for Study II. For Study III, baseline data from the initially recruited participants of the first two studies were used. An informed consent was obtained from all participants or their mentors. The studies were approved by the Ethical Committee of the University of Granada. Blood samples were obtained at each examination date and were analyzed for serum cobalamin, holoTC, serum and RBC folate and total homocysteine according to laboratory standard procedures. The haematological parameters analyzed were haematocrit, haemoglobin and MCV. For the lipid profile TG, total cholesterol, LDL- and HDLcholesterol were analyzed. Anthropometric measures (BMI, skinfolds [triceps and subscapular], waist girth and waist to hip ratio), functional tests (hand grip, arm and leg strength tests, static balance) and MMSE were obtained or administered by trained personal. The vitamin B12 supplement of Study II was administered with breakfast and the medication intake was taken from the residents’ anamnesis. Data were analyzed by parametric and non-parametric statistics depending on the obtained data. Comparisons were done using the appropriate ANOVAs or non-parametric tests. Pearsons’ partial correlations with the variable “time” as control were used to define the association of the analyzed parameters. XIII The results showed that: A) Over one year, in relationship to vitamin B status, serum cobalamin decreased, serum folate and mean corpuscular volumen increased significantly and total homocysteine concentrations were stable. Regarding blood lipid profile, triglycerides increased and HDL-cholesterol decreased significantly. Regarding selected anthropometric measurements, waist circumference increased significantly. No significant changes were observed for the rest of parameters. B) Prevalence of hyperhomocysteinemia was high in the elderly studied, ranging from 60% to 90 % over the year depending on the cut-off used for the classification. LDL-cholesterol values were high, especially among women, and showed a tendency to increase over the year. Results of the balance test showed a deficiency and a tendency to decrease; this indicates that the population studied is at high risk for falls. Lower extremity muscular function was deficient and showed a tendency to decrease. A highly significant relationship was observed between the skinfold of the triceps and blood lipid profile. C) Low cobalamin concentrations correlated significantly with low MMSE scores in the elderly studied. No correlations were observed between vitamin B12 status and functional parameters. D) Regarding vitamin B12 status, holo-transcobalamin seems to be more sensitive for diagnosis; 5-10% of the elderly had a deficiency using serum cobalamin as a criterion, and 45-52% had a deficiency when using serum holotranscobalamin as a criterion. E) 500 μg of cyanocobalamin administered orally during 28 days significantly improved vitamin B12 status and significantly decreased total homocysteine concentrations in institutionalized elderly. No effect of the intervention was observed on functional and cognitive parameters. F) The relative change (%) of improvement of vitamin B12 status was higher when using serum holo-transcobalamin as a criterion than serum cobalamin. G) Antiaenemic drug intake normalized cobalamin, urologic drugs and corticosteroids serum folate, and psychoanaleptics holo-transcobalamin levels. Drugs treating pulmonary obstruction increased total homocysteine concentration significantly. H) The daily mean drug intake was 5.1. Fiftynine percent of the elderly took medication belonging to 5 or more different ATC groups. The most prevalent were psycholeptic (53%), antiacid (53%) and antithrombotic (47%) drugs.

Environmental risk assessment in open pit blasting operations: compliance with ISO 31010:2010

All activities of an organization involve risks that should be managed. The risk management process aids decision making by taking account of uncertainty and the possibility of future events or circumstances (intended or unintended) and their effects on agreed objectives. With that idea, new ISO Standard has been drawn up. ISO 31010 has been recently issued which provides a structured process that identifies how objectives may be affected, and analyses the risk in term of consequences and their probabilities before deciding on whether further treatment is required. In this lecture, that ISO Standard has been adapted to Open Pit Blasting Operations, focusing in Environmental effects which can be managed properly. Technique used is Fault Tree Analysis (FTA), which is applied in all possible scenarios, providing to Blasting Professionals the tools to identify, analyze and manage environmental effects in blasting operations. Also this lecture can help to minimize each effect, studying each case. This paper also can be useful to Project Managers and Occupational Health and Safety Departments (OH&S) because blasting operations can be evaluated and compared one to each other to determine the risks that should be managed in different case studies. The environmental effects studied are: ground vibrations, flyrock and air overpressure (airblast). Sometimes, blasting operations are carried out near populated areas where environmental effects may impose several limitations on the use of explosives. In those cases, where these factors approach certain limits, National Standards and Regulations have to be applied.

A telematics solution for the remote follow-up of malnourished children in underserved areas

The identification of malnourished children living under extreme poverty conditions in isolated areas is crucial to trigger urgent interventions like supplementary or therapeutic feeding. This work aims to strengthen the task of following-up malnourished maternal-child population in rural areas of developing countries like Nicaragua. The solution facilitates low-cost health nutritional remote monitoring to support rural communities at the point of care. Thus, the system allows medical staff to communicate with brigades, who transmit anthropometric measurements, such as weight and height of the children, from communities which are sited about 12 km. far away. A hybrid WiMAX/WiFi architecture was deployed to provide affordable communications between the isolated communities and the health center. Furthermore, a free PBX software and an open information system, installed at the health center, support WiFi based mobile communications and information management to support the care needs of maternal-child population at risk.

A methodology proposal to obtain operational parameter forecasts and operational risk assessment in container terminals

Las terminales de contenedores son sistemas complejos en los que un elevado número de actores económicos interactúan para ofrecer servicios de alta calidad bajo una estricta planificación y objetivos económicos. Las conocidas como "terminales de nueva generación" están diseñadas para prestar servicio a los mega-buques, que requieren tasas de productividad que alcanzan los 300 movimientos/ hora. Estas terminales han de satisfacer altos estándares dado que la competitividad entre terminales es elevada. Asegurar la fiabilidad de las planificaciones del atraque es clave para atraer clientes, así como reducir al mínimo el tiempo que el buque permanece en el puerto. La planificación de las operaciones es más compleja que antaño, y las tolerancias para posibles errores, menores. En este contexto, las interrupciones operativas deben reducirse al mínimo. Las principales causas de dichas perturbaciones operacionales, y por lo tanto de incertidumbre, se identifican y caracterizan en esta investigación. Existen una serie de factores que al interactuar con la infraestructura y/o las operaciones desencadenan modos de fallo o parada operativa. Los primeros pueden derivar no solo en retrasos en el servicio sino que además puede tener efectos colaterales sobre la reputación de la terminal, o incluso gasto de tiempo de gestión, todo lo cual supone un impacto para la terminal. En el futuro inmediato, la monitorización de las variables operativas presenta gran potencial de cara a mejorar cualitativamente la gestión de las operaciones y los modelos de planificación de las terminales, cuyo nivel de automatización va en aumento. La combinación del criterio experto con instrumentos que proporcionen datos a corto y largo plazo es fundamental para el desarrollo de herramientas que ayuden en la toma de decisiones, ya que de este modo estarán adaptadas a las auténticas condiciones climáticas y operativas que existen en cada emplazamiento. Para el corto plazo se propone una metodología con la que obtener predicciones de parámetros operativos en terminales de contenedores. Adicionalmente se ha desarrollado un caso de estudio en el que se aplica el modelo propuesto para obtener predicciones de la productividad del buque. Este trabajo se ha basado íntegramente en datos proporcionados por una terminal semi-automatizada española. Por otro lado, se analiza cómo gestionar, evaluar y mitigar el efecto de las interrupciones operativas a largo plazo a través de la evaluación del riesgo, una forma interesante de evaluar el effecto que eventos inciertos pero probables pueden generar sobre la productividad a largo plazo de la terminal. Además se propone una definición de riesgo operativo junto con una discusión de los términos que representan con mayor fidelidad la naturaleza de las actividades y finalmente, se proporcionan directrices para gestionar los resultados obtenidos. Container terminals are complex systems where a large number of factors and stakeholders interact to provide high-quality services under rigid planning schedules and economic objectives. The socalled next generation terminals are conceived to serve the new mega-vessels, which are demanding productivity rates up to 300 moves/hour. These terminals need to satisfy high standards because competition among terminals is fierce. Ensuring reliability in berth scheduling is key to attract clients, as well as to reduce at a minimum the time that vessels stay the port. Because of the aforementioned, operations planning is becoming more complex, and the tolerances for errors are smaller. In this context, operational disturbances must be reduced at a minimum. The main sources of operational disruptions and thus, of uncertainty, are identified and characterized in this study. External drivers interact with the infrastructure and/or the activities resulting in failure or stoppage modes. The later may derive not only in operational delays but in collateral and reputation damage or loss of time (especially management times), all what implies an impact for the terminal. In the near future, the monitoring of operational variables has great potential to make a qualitative improvement in the operations management and planning models of terminals that use increasing levels of automation. The combination of expert criteria with instruments that provide short- and long-run data is fundamental for the development of tools to guide decision-making, since they will be adapted to the real climatic and operational conditions that exist on site. For the short-term a method to obtain operational parameter forecasts in container terminals. To this end, a case study is presented, in which forecasts of vessel performance are obtained. This research has been entirely been based on data gathered from a semi-automated container terminal from Spain. In the other hand it is analyzed how to manage, evaluate and mitigate disruptions in the long-term by means of the risk assessment, an interesting approach to evaluate the effect of uncertain but likely events on the long-term throughput of the terminal. In addition, a definition for operational risk evaluation in port facilities is proposed along with a discussion of the terms that better represent the nature of the activities involved and finally, guidelines to manage the results obtained are provided.

Methodologies for Collision Risk Computation = Metodologías para Cálculo de Riesgo de Colisión

Esta tesis aborda metodologías para el cálculo de riesgo de colisión de satélites. La minimización del riesgo de colisión se debe abordar desde dos puntos de vista distintos. Desde el punto de vista operacional, es necesario filtrar los objetos que pueden presentar un encuentro entre todos los objetos que comparten el espacio con un satélite operacional. Puesto que las órbitas, del objeto operacional y del objeto envuelto en la colisión, no se conocen perfectamente, la geometría del encuentro y el riesgo de colisión deben ser evaluados. De acuerdo con dicha geometría o riesgo, una maniobra evasiva puede ser necesaria para evitar la colisión. Dichas maniobras implican un consumo de combustible que impacta en la capacidad de mantenimiento orbital y por tanto de la visa útil del satélite. Por tanto, el combustible necesario a lo largo de la vida útil de un satélite debe ser estimado en fase de diseño de la misión para una correcta definición de su vida útil, especialmente para satélites orbitando en regímenes orbitales muy poblados. Los dos aspectos, diseño de misión y aspectos operacionales en relación con el riesgo de colisión están abordados en esta tesis y se resumen en la Figura 3. En relación con los aspectos relacionados con el diseño de misión (parte inferior de la figura), es necesario evaluar estadísticamente las características de de la población espacial y las teorías que permiten calcular el número medio de eventos encontrados por una misión y su capacidad de reducir riesgo de colisión. Estos dos aspectos definen los procedimientos más apropiados para reducir el riesgo de colisión en fase operacional. Este aspecto es abordado, comenzando por la teoría descrita en [Sánchez-Ortiz, 2006]T.14 e implementada por el autor de esta tesis en la herramienta ARES [Sánchez-Ortiz, 2004b]T.15 proporcionada por ESA para la evaluación de estrategias de evitación de colisión. Esta teoría es extendida en esta tesis para considerar las características de los datos orbitales disponibles en las fases operacionales de un satélite (sección 4.3.3). Además, esta teoría se ha extendido para considerar riesgo máximo de colisión cuando la incertidumbre de las órbitas de objetos catalogados no es conocida (como se da el caso para los TLE), y en el caso de querer sólo considerar riesgo de colisión catastrófico (sección 4.3.2.3). Dichas mejoras se han incluido en la nueva versión de ARES [Domínguez-González and Sánchez-Ortiz, 2012b]T.12 puesta a disposición a través de [SDUP,2014]R.60. En fase operacional, los catálogos que proporcionan datos orbitales de los objetos espaciales, son procesados rutinariamente, para identificar posibles encuentros que se analizan en base a algoritmos de cálculo de riesgo de colisión para proponer maniobras de evasión. Actualmente existe una única fuente de datos públicos, el catálogo TLE (de sus siglas en inglés, Two Line Elements). Además, el Joint Space Operation Center (JSpOC) Americano proporciona mensajes con alertas de colisión (CSM) cuando el sistema de vigilancia americano identifica un posible encuentro. En función de los datos usados en fase operacional (TLE o CSM), la estrategia de evitación puede ser diferente debido a las características de dicha información. Es preciso conocer las principales características de los datos disponibles (respecto a la precisión de los datos orbitales) para estimar los posibles eventos de colisión encontrados por un satélite a lo largo de su vida útil. En caso de los TLE, cuya precisión orbital no es proporcionada, la información de precisión orbital derivada de un análisis estadístico se puede usar también en el proceso operacional así como en el diseño de la misión. En caso de utilizar CSM como base de las operaciones de evitación de colisiones, se conoce la precisión orbital de los dos objetos involucrados. Estas características se han analizado en detalle, evaluando estadísticamente las características de ambos tipos de datos. Una vez concluido dicho análisis, se ha analizado el impacto de utilizar TLE o CSM en las operaciones del satélite (sección 5.1). Este análisis se ha publicado en una revista especializada [Sánchez-Ortiz, 2015b]T.3. En dicho análisis, se proporcionan recomendaciones para distintas misiones (tamaño del satélite y régimen orbital) en relación con las estrategias de evitación de colisión para reducir el riesgo de colisión de manera significativa. Por ejemplo, en el caso de un satélite en órbita heliosíncrona en régimen orbital LEO, el valor típico del ACPL que se usa de manera extendida es 10-4. Este valor no es adecuado cuando los esquemas de evitación de colisión se realizan sobre datos TLE. En este caso, la capacidad de reducción de riesgo es prácticamente nula (debido a las grandes incertidumbres de los datos TLE) incluso para tiempos cortos de predicción. Para conseguir una reducción significativa del riesgo, sería necesario usar un ACPL en torno a 10-6 o inferior, produciendo unas 10 alarmas al año por satélite (considerando predicciones a un día) o 100 alarmas al año (con predicciones a tres días). Por tanto, la principal conclusión es la falta de idoneidad de los datos TLE para el cálculo de eventos de colisión. Al contrario, usando los datos CSM, debido a su mejor precisión orbital, se puede obtener una reducción significativa del riesgo con ACPL en torno a 10-4 (considerando 3 días de predicción). Incluso 5 días de predicción pueden ser considerados con ACPL en torno a 10-5. Incluso tiempos de predicción más largos se pueden usar (7 días) con reducción del 90% del riesgo y unas 5 alarmas al año (en caso de predicciones de 5 días, el número de maniobras se mantiene en unas 2 al año). La dinámica en GEO es diferente al caso LEO y hace que el crecimiento de las incertidumbres orbitales con el tiempo de propagación sea menor. Por el contrario, las incertidumbres derivadas de la determinación orbital son peores que en LEO por las diferencias en las capacidades de observación de uno y otro régimen orbital. Además, se debe considerar que los tiempos de predicción considerados para LEO pueden no ser apropiados para el caso de un satélite GEO (puesto que tiene un periodo orbital mayor). En este caso usando datos TLE, una reducción significativa del riesgo sólo se consigue con valores pequeños de ACPL, produciendo una alarma por año cuando los eventos de colisión se predicen a un día vista (tiempo muy corto para implementar maniobras de evitación de colisión).Valores más adecuados de ACPL se encuentran entre 5•10-8 y 10-7, muy por debajo de los valores usados en las operaciones actuales de la mayoría de las misiones GEO (de nuevo, no se recomienda en este régimen orbital basar las estrategias de evitación de colisión en TLE). Los datos CSM permiten una reducción de riesgo apropiada con ACPL entre 10-5 y 10-4 con tiempos de predicción cortos y medios (10-5 se recomienda para predicciones a 5 o 7 días). El número de maniobras realizadas sería una en 10 años de misión. Se debe notar que estos cálculos están realizados para un satélite de unos 2 metros de radio. En el futuro, otros sistemas de vigilancia espacial (como el programa SSA de la ESA), proporcionarán catálogos adicionales de objetos espaciales con el objetivo de reducir el riesgo de colisión de los satélites. Para definir dichos sistemas de vigilancia, es necesario identificar las prestaciones del catalogo en función de la reducción de riesgo que se pretende conseguir. Las características del catálogo que afectan principalmente a dicha capacidad son la cobertura (número de objetos incluidos en el catalogo, limitado principalmente por el tamaño mínimo de los objetos en función de las limitaciones de los sensores utilizados) y la precisión de los datos orbitales (derivada de las prestaciones de los sensores en relación con la precisión de las medidas y la capacidad de re-observación de los objetos). El resultado de dicho análisis (sección 5.2) se ha publicado en una revista especializada [Sánchez-Ortiz, 2015a]T.2. Este análisis no estaba inicialmente previsto durante la tesis, y permite mostrar como la teoría descrita en esta tesis, inicialmente definida para facilitar el diseño de misiones (parte superior de la figura 1) se ha extendido y se puede aplicar para otros propósitos como el dimensionado de un sistema de vigilancia espacial (parte inferior de la figura 1). La principal diferencia de los dos análisis se basa en considerar las capacidades de catalogación (precisión y tamaño de objetos observados) como una variable a modificar en el caso de un diseño de un sistema de vigilancia), siendo fijas en el caso de un diseño de misión. En el caso de las salidas generadas en el análisis, todos los aspectos calculados en un análisis estadístico de riesgo de colisión son importantes para diseño de misión (con el objetivo de calcular la estrategia de evitación y la cantidad de combustible a utilizar), mientras que en el caso de un diseño de un sistema de vigilancia, los aspectos más importantes son el número de maniobras y falsas alarmas (fiabilidad del sistema) y la capacidad de reducción de riesgo (efectividad del sistema). Adicionalmente, un sistema de vigilancia espacial debe ser caracterizado por su capacidad de evitar colisiones catastróficas (evitando así in incremento dramático de la población de basura espacial), mientras que el diseño de una misión debe considerar todo tipo de encuentros, puesto que un operador está interesado en evitar tanto las colisiones catastróficas como las letales. Del análisis de las prestaciones (tamaño de objetos a catalogar y precisión orbital) requeridas a un sistema de vigilancia espacial se concluye que ambos aspectos han de ser fijados de manera diferente para los distintos regímenes orbitales. En el caso de LEO se hace necesario observar objetos de hasta 5cm de radio, mientras que en GEO se rebaja este requisito hasta los 100 cm para cubrir las colisiones catastróficas. La razón principal para esta diferencia viene de las diferentes velocidades relativas entre los objetos en ambos regímenes orbitales. En relación con la precisión orbital, ésta ha de ser muy buena en LEO para poder reducir el número de falsas alarmas, mientras que en regímenes orbitales más altos se pueden considerar precisiones medias. En relación con los aspectos operaciones de la determinación de riesgo de colisión, existen varios algoritmos de cálculo de riesgo entre dos objetos espaciales. La Figura 2 proporciona un resumen de los casos en cuanto a algoritmos de cálculo de riesgo de colisión y como se abordan en esta tesis. Normalmente se consideran objetos esféricos para simplificar el cálculo de riesgo (caso A). Este caso está ampliamente abordado en la literatura y no se analiza en detalle en esta tesis. Un caso de ejemplo se proporciona en la sección 4.2. Considerar la forma real de los objetos (caso B) permite calcular el riesgo de una manera más precisa. Un nuevo algoritmo es definido en esta tesis para calcular el riesgo de colisión cuando al menos uno de los objetos se considera complejo (sección 4.4.2). Dicho algoritmo permite calcular el riesgo de colisión para objetos formados por un conjunto de cajas, y se ha presentado en varias conferencias internacionales. Para evaluar las prestaciones de dicho algoritmo, sus resultados se han comparado con un análisis de Monte Carlo que se ha definido para considerar colisiones entre cajas de manera adecuada (sección 4.1.2.3), pues la búsqueda de colisiones simples aplicables para objetos esféricos no es aplicable a este caso. Este análisis de Monte Carlo se considera la verdad a la hora de calcular los resultados del algoritmos, dicha comparativa se presenta en la sección 4.4.4. En el caso de satélites que no se pueden considerar esféricos, el uso de un modelo de la geometría del satélite permite descartar eventos que no son colisiones reales o estimar con mayor precisión el riesgo asociado a un evento. El uso de estos algoritmos con geometrías complejas es más relevante para objetos de dimensiones grandes debido a las prestaciones de precisión orbital actuales. En el futuro, si los sistemas de vigilancia mejoran y las órbitas son conocidas con mayor precisión, la importancia de considerar la geometría real de los satélites será cada vez más relevante. La sección 5.4 presenta un ejemplo para un sistema de grandes dimensiones (satélite con un tether). Adicionalmente, si los dos objetos involucrados en la colisión tienen velocidad relativa baja (y geometría simple, Caso C en la Figura 2), la mayor parte de los algoritmos no son aplicables requiriendo implementaciones dedicadas para este caso particular. En esta tesis, uno de estos algoritmos presentado en la literatura [Patera, 2001]R.26 se ha analizado para determinar su idoneidad en distintos tipos de eventos (sección 4.5). La evaluación frete a un análisis de Monte Carlo se proporciona en la sección 4.5.2. Tras este análisis, se ha considerado adecuado para abordar las colisiones de baja velocidad. En particular, se ha concluido que el uso de algoritmos dedicados para baja velocidad son necesarios en función del tamaño del volumen de colisión proyectado en el plano de encuentro (B-plane) y del tamaño de la incertidumbre asociada al vector posición entre los dos objetos. Para incertidumbres grandes, estos algoritmos se hacen más necesarios pues la duración del intervalo en que los elipsoides de error de los dos objetos pueden intersecar es mayor. Dicho algoritmo se ha probado integrando el algoritmo de colisión para objetos con geometrías complejas. El resultado de dicho análisis muestra que este algoritmo puede ser extendido fácilmente para considerar diferentes tipos de algoritmos de cálculo de riesgo de colisión (sección 4.5.3). Ambos algoritmos, junto con el método Monte Carlo para geometrías complejas, se han implementado en la herramienta operacional de la ESA CORAM, que es utilizada para evaluar el riesgo de colisión en las actividades rutinarias de los satélites operados por ESA [Sánchez-Ortiz, 2013a]T.11. Este hecho muestra el interés y relevancia de los algoritmos desarrollados para la mejora de las operaciones de los satélites. Dichos algoritmos han sido presentados en varias conferencias internacionales [Sánchez-Ortiz, 2013b]T.9, [Pulido, 2014]T.7,[Grande-Olalla, 2013]T.10, [Pulido, 2014]T.5, [Sánchez-Ortiz, 2015c]T.1. ABSTRACT This document addresses methodologies for computation of the collision risk of a satellite. Two different approaches need to be considered for collision risk minimisation. On an operational basis, it is needed to perform a sieve of possible objects approaching the satellite, among all objects sharing the space with an operational satellite. As the orbits of both, satellite and the eventual collider, are not perfectly known but only estimated, the miss-encounter geometry and the actual risk of collision shall be evaluated. In the basis of the encounter geometry or the risk, an eventual manoeuvre may be required to avoid the conjunction. Those manoeuvres will be associated to a reduction in the fuel for the mission orbit maintenance, and thus, may reduce the satellite operational lifetime. Thus, avoidance manoeuvre fuel budget shall be estimated, at mission design phase, for a better estimation of mission lifetime, especially for those satellites orbiting in very populated orbital regimes. These two aspects, mission design and operational collision risk aspects, are summarised in Figure 3, and covered along this thesis. Bottom part of the figure identifies the aspects to be consider for the mission design phase (statistical characterisation of the space object population data and theory computing the mean number of events and risk reduction capability) which will define the most appropriate collision avoidance approach at mission operational phase. This part is covered in this work by starting from the theory described in [Sánchez-Ortiz, 2006]T.14 and implemented by this author in ARES tool [Sánchez-Ortiz, 2004b]T.15 provided by ESA for evaluation of collision avoidance approaches. This methodology has been now extended to account for the particular features of the available data sets in operational environment (section 4.3.3). Additionally, the formulation has been extended to allow evaluating risk computation approached when orbital uncertainty is not available (like the TLE case) and when only catastrophic collisions are subject to study (section 4.3.2.3). These improvements to the theory have been included in the new version of ESA ARES tool [Domínguez-González and Sánchez-Ortiz, 2012b]T.12 and available through [SDUP,2014]R.60. At the operation phase, the real catalogue data will be processed on a routine basis, with adequate collision risk computation algorithms to propose conjunction avoidance manoeuvre optimised for every event. The optimisation of manoeuvres in an operational basis is not approached along this document. Currently, American Two Line Element (TLE) catalogue is the only public source of data providing orbits of objects in space to identify eventual conjunction events. Additionally, Conjunction Summary Message (CSM) is provided by Joint Space Operation Center (JSpOC) when the American system identifies a possible collision among satellites and debris. Depending on the data used for collision avoidance evaluation, the conjunction avoidance approach may be different. The main features of currently available data need to be analysed (in regards to accuracy) in order to perform estimation of eventual encounters to be found along the mission lifetime. In the case of TLE, as these data is not provided with accuracy information, operational collision avoidance may be also based on statistical accuracy information as the one used in the mission design approach. This is not the case for CSM data, which includes the state vector and orbital accuracy of the two involved objects. This aspect has been analysed in detail and is depicted in the document, evaluating in statistical way the characteristics of both data sets in regards to the main aspects related to collision avoidance. Once the analysis of data set was completed, investigations on the impact of those features in the most convenient avoidance approaches have been addressed (section 5.1). This analysis is published in a peer-reviewed journal [Sánchez-Ortiz, 2015b]T.3. The analysis provides recommendations for different mission types (satellite size and orbital regime) in regards to the most appropriate collision avoidance approach for relevant risk reduction. The risk reduction capability is very much dependent on the accuracy of the catalogue utilized to identify eventual collisions. Approaches based on CSM data are recommended against the TLE based approach. Some approaches based on the maximum risk associated to envisaged encounters are demonstrated to report a very large number of events, which makes the approach not suitable for operational activities. Accepted Collision Probability Levels are recommended for the definition of the avoidance strategies for different mission types. For example for the case of a LEO satellite in the Sun-synchronous regime, the typically used ACPL value of 10-4 is not a suitable value for collision avoidance schemes based on TLE data. In this case the risk reduction capacity is almost null (due to the large uncertainties associated to TLE data sets, even for short time-to-event values). For significant reduction of risk when using TLE data, ACPL on the order of 10-6 (or lower) seems to be required, producing about 10 warnings per year and mission (if one-day ahead events are considered) or 100 warnings per year (for three-days ahead estimations). Thus, the main conclusion from these results is the lack of feasibility of TLE for a proper collision avoidance approach. On the contrary, for CSM data, and due to the better accuracy of the orbital information when compared with TLE, ACPL on the order of 10-4 allows to significantly reduce the risk. This is true for events estimated up to 3 days ahead. Even 5 days ahead events can be considered, but ACPL values down to 10-5 should be considered in such case. Even larger prediction times can be considered (7 days) for risk reduction about 90%, at the cost of larger number of warnings up to 5 events per year, when 5 days prediction allows to keep the manoeuvre rate in 2 manoeuvres per year. Dynamics of the GEO orbits is different to that in LEO, impacting on a lower increase of orbits uncertainty along time. On the contrary, uncertainties at short prediction times at this orbital regime are larger than those at LEO due to the differences in observation capabilities. Additionally, it has to be accounted that short prediction times feasible at LEO may not be appropriate for a GEO mission due to the orbital period being much larger at this regime. In the case of TLE data sets, significant reduction of risk is only achieved for small ACPL values, producing about a warning event per year if warnings are raised one day in advance to the event (too short for any reaction to be considered). Suitable ACPL values would lay in between 5•10-8 and 10-7, well below the normal values used in current operations for most of the GEO missions (TLE-based strategies for collision avoidance at this regime are not recommended). On the contrary, CSM data allows a good reduction of risk with ACPL in between 10-5 and 10-4 for short and medium prediction times. 10-5 is recommended for prediction times of five or seven days. The number of events raised for a suitable warning time of seven days would be about one in a 10-year mission. It must be noted, that these results are associated to a 2 m radius spacecraft, impact of the satellite size are also analysed within the thesis. In the future, other Space Situational Awareness Systems (SSA, ESA program) may provide additional catalogues of objects in space with the aim of reducing the risk. It is needed to investigate which are the required performances of those catalogues for allowing such risk reduction. The main performance aspects are coverage (objects included in the catalogue, mainly limited by a minimum object size derived from sensor performances) and the accuracy of the orbital data to accurately evaluate the conjunctions (derived from sensor performance in regards to object observation frequency and accuracy). The results of these investigations (section 5.2) are published in a peer-reviewed journal [Sánchez-Ortiz, 2015a]T.2. This aspect was not initially foreseen as objective of the thesis, but it shows how the theory described in the thesis, initially defined for mission design in regards to avoidance manoeuvre fuel allocation (upper part of figure 1), is extended and serves for additional purposes as dimensioning a Space Surveillance and Tracking (SST) system (bottom part of figure below). The main difference between the two approaches is the consideration of the catalogue features as part of the theory which are not modified (for the satellite mission design case) instead of being an input for the analysis (in the case of the SST design). In regards to the outputs, all the features computed by the statistical conjunction analysis are of importance for mission design (with the objective of proper global avoidance strategy definition and fuel allocation), whereas for the case of SST design, the most relevant aspects are the manoeuvre and false alarm rates (defining a reliable system) and the Risk Reduction capability (driving the effectiveness of the system). In regards to the methodology for computing the risk, the SST system shall be driven by the capacity of providing the means to avoid catastrophic conjunction events (avoiding the dramatic increase of the population), whereas the satellite mission design should consider all type of encounters, as the operator is interested on avoiding both lethal and catastrophic collisions. From the analysis of the SST features (object coverage and orbital uncertainty) for a reliable system, it is concluded that those two characteristics are to be imposed differently for the different orbital regimes, as the population level is different depending on the orbit type. Coverage values range from 5 cm for very populated LEO regime up to 100 cm in the case of GEO region. The difference on this requirement derives mainly from the relative velocity of the encounters at those regimes. Regarding the orbital knowledge of the catalogues, very accurate information is required for objects in the LEO region in order to limit the number of false alarms, whereas intermediate orbital accuracy can be considered for higher orbital regimes. In regards to the operational collision avoidance approaches, several collision risk algorithms are used for evaluation of collision risk of two pair of objects. Figure 2 provides a summary of the different collision risk algorithm cases and indicates how they are covered along this document. The typical case with high relative velocity is well covered in literature for the case of spherical objects (case A), with a large number of available algorithms, that are not analysed in detailed in this work. Only a sample case is provided in section 4.2. If complex geometries are considered (Case B), a more realistic risk evaluation can be computed. New approach for the evaluation of risk in the case of complex geometries is presented in this thesis (section 4.4.2), and it has been presented in several international conferences. The developed algorithm allows evaluating the risk for complex objects formed by a set of boxes. A dedicated Monte Carlo method has also been described (section 4.1.2.3) and implemented to allow the evaluation of the actual collisions among a large number of simulation shots. This Monte Carlo runs are considered the truth for comparison of the algorithm results (section 4.4.4). For spacecrafts that cannot be considered as spheres, the consideration of the real geometry of the objects may allow to discard events which are not real conjunctions, or estimate with larger reliability the risk associated to the event. This is of particular importance for the case of large spacecrafts as the uncertainty in positions of actual catalogues does not reach small values to make a difference for the case of objects below meter size. As the tracking systems improve and the orbits of catalogued objects are known more precisely, the importance of considering actual shapes of the objects will become more relevant. The particular case of a very large system (as a tethered satellite) is analysed in section 5.4. Additionally, if the two colliding objects have low relative velocity (and simple geometries, case C in figure above), the most common collision risk algorithms fail and adequate theories need to be applied. In this document, a low relative velocity algorithm presented in the literature [Patera, 2001]R.26 is described and evaluated (section 4.5). Evaluation through comparison with Monte Carlo approach is provided in section 4.5.2. The main conclusion of this analysis is the suitability of this algorithm for the most common encounter characteristics, and thus it is selected as adequate for collision risk estimation. Its performances are evaluated in order to characterise when it can be safely used for a large variety of encounter characteristics. In particular, it is found that the need of using dedicated algorithms depend on both the size of collision volume in the B-plane and the miss-distance uncertainty. For large uncertainties, the need of such algorithms is more relevant since for small uncertainties the encounter duration where the covariance ellipsoids intersect is smaller. Additionally, its application for the case of complex satellite geometries is assessed (case D in figure above) by integrating the developed algorithm in this thesis with Patera’s formulation for low relative velocity encounters. The results of this analysis show that the algorithm can be easily extended for collision risk estimation process suitable for complex geometry objects (section 4.5.3). The two algorithms, together with the Monte Carlo method, have been implemented in the operational tool CORAM for ESA which is used for the evaluation of collision risk of ESA operated missions, [Sánchez-Ortiz, 2013a]T.11. This fact shows the interest and relevance of the developed algorithms for improvement of satellite operations. The algorithms have been presented in several international conferences, [Sánchez-Ortiz, 2013b]T.9, [Pulido, 2014]T.7,[Grande-Olalla, 2013]T.10, [Pulido, 2014]T.5, [Sánchez-Ortiz, 2015c]T.1.

Survival in treated hypertension: follow up study after two decades

Objective: To compare survival and cause specific mortality in hypertensive men with non-hypertensive men derived from the same random population, and to study mortality and morbidity from cardiovascular diseases in the hypertensive men in relation to effects on cardiovascular risk factors during 22-23 years of follow up.