Survey of VFC provider knowledge of catch-up regimens and contraindications to vaccination in Houston, Texas

In 2004, Houston had one of the lowest childhood immunization levels among major metropolitan cities in the United States at 65% for the 4:3:1:3:3 vaccination series. Delays in the receipt of scheduled vaccinations may be related to missed opportunities due to health care provider lack of knowledge about catch-up regimens and contraindications for pediatric vaccination. The objectives of this study are to identify, measure, and report on VFC provider-practice characteristics, knowledge of catch-up regimens and contraindications, and use of Reminder recall (R/R) and moved or gone elsewhere (MOGE) practices among providers with high (>80%) and low (<70%) immunization coverage among 19-35 month old children. The sampling frame consists of 187 Vaccines for Children (VFC) providers with 2004 clinic assessment software application (CASA) scores. Data were collected by personal interview with each participating practice provider. Only ten VFC providers were successful at maximizing vaccinations for every vignette and no provider administered the maximum possible number of vaccinations at visit 2 for all six vignettes. Both coverage groups administered polio conjugate vaccine (PCV), haemophilus influenza type b (Hib), and diphtheria, tetanus and acellular pertussis (DTaP) most frequently and omitted most frequently varicella zoster vaccine (VZV) and measles, mumps, and rubella (MMR) vaccine. ^

Federally regulated institutional review boards: The aspects of a "model" IRB---Is the current system in need of a tune up or complete overhaul?

Institutional Review Boards (IRBs) are the primary gatekeepers for the protection of ethical standards of federally regulated research on human subjects in this country. This paper focuses on what general, broad measures that may be instituted or enhanced to exemplify a "model IRB". This is done by examining the current regulatory standards of federally regulated IRBs, not private or commercial boards, and how many of those standards have been found either inadequate or not generally understood or followed. The analysis includes suggestions on how to bring about changes in order to make the IRB process more efficient, less subject to litigation, and create standardized educational protocols for members. The paper also considers how to include better oversight for multi-center research, increased centralization of IRBs, utilization of Data Safety Monitoring Boards when necessary, payment for research protocol review, voluntary accreditation, and the institution of evaluation/quality assurance programs. ^ This is a policy study utilizing secondary analysis of publicly available data. Therefore, the research for this paper focuses on scholarly medical/legal journals, web information from the Department of Health and Human Services, Federal Drug Administration, and the Office of the Inspector General, Accreditation Programs, law review articles, and current regulations applicable to the relevant portions of the paper. ^ Two issues are found to be consistently cited by the literature as major concerns. One is a need for basic, standardized educational requirements across all IRBs and its members, and secondly, much stricter and more informed management of continuing research. There is no federally regulated formal education system currently in place for IRB members, except for certain NIH-based trials. Also, IRBs are not keeping up with research once a study has begun, and although regulated to do so, it does not appear to be a great priority. This is the area most in danger of increased litigation. Other issues such as voluntary accreditation and outcomes evaluation are slowing gaining steam as the processes are becoming more available and more sought after, such as JCAHO accrediting of hospitals. ^ Adopting the principles discussed in this paper should promote better use of a local IRBs time, money, and expertise for protecting the vulnerable population in their care. Without further improvements to the system, there is concern that private and commercial IRBs will attempt to create a monopoly on much of the clinical research in the future as they are not as heavily regulated and can therefore offer companies quicker and more convenient reviews. IRBs need to consider the advantages of charging for their unique and important services as a cost of doing business. More importantly, there must be a minimum standard of education for all IRB members in the area of the ethical standards of human research and a greater emphasis placed on the follow-up of ongoing research as this is the most critical time for study participants and may soon lead to the largest area for litigation. Additionally, there should be a centralized IRB for multi-site trials or a study website with important information affecting the trial in real time. There needs to be development of standards and metrics to assess the performance of the IRBs for quality assurance and outcome evaluations. The boards should not be content to run the business of human subjects' research without determining how well that function is actually being carried out. It is important that federally regulated IRBs provide excellence in human research and promote those values most important to the public at large.^

Follow-up care after a health fair screening in three Houston neighborhoods in 2008

Background. Each year thousands of people participate in mass health screenings for diabetes and hypertension, but little is known about whether or not those who receive higher than normal screening results obtain the recommended follow-up medical care, or what barriers they perceive to doing so. ^ Methods. Study participants were recruited from attendees at three health fairs in low-income neighborhoods in Houston, Texas Potential participants had higher than normal blood pressure (> 90/140 mgHg) or blood glucose readings (100 mm/dL fasting or 140 mm/dL random). Study participants were called at one, two, and three months and asked if they had obtained follow-up medical care; those who had not yet obtained follow-up care were asked to identify barriers. Using a modified Aday-Andersen model of health service access, the independent variables were individual and community characteristics and self-perceived need. The dependent variable was obtaining follow-up care, with barriers to care a secondary outcome. ^ Results. Eighty-two study participants completed the initial questionnaire and 59 participants completed the study protocol. Forty-eight participants (59% under an intent to treat analysis, 81% of those completing the study protocol) obtained follow-up care. Those who completed the initial questionnaire and who reported a regular source of care were significantly more likely to obtain follow-up care. For those who completed the study protocol the relationship between having a regular source of care and obtaining follow-up care approached but did not reach significance. For those who completed the initial questionnaire, self-described health status, when examined as a binary variable (good, very good, excellent, or poor, fair, not sure) was associated with obtaining follow-up care for those who rated their health as poor, fair, or not sure. While the group who completed the study protocol did not reach statistical significance, the same relationship between self-described health status of poor, fair, or not sure and obtaining follow-up care was present. The participants who completed the study protocol and described their blood pressure as OK or a little high were statistically more likely to get follow-up care than those who described it as high or very high. All those on oral medications for hypertension (12/12) and diabetes (4/4) who were told to obtain follow-up care did so; however, the small sample size allows this correlation to be of statistical significance only for those treating hypertension. ^ The variables significantly associated with obtaining follow-up care were having a regular source of care, self-described health status of poor, fair, or not sure, self-described blood pressure of OK or a little high, and taking medication for blood pressure. ^ At the follow-up telephone calls, 34 participants identified barriers to care; cost was a significant barrier reported by 16 participants, and 10 reported that they didn’t have time because they were working long hours after Hurricane Ike. ^ The study included the offer of access assistance: information about nearby safety-net providers, a visit to or information from the Health Information Center at their Neighborhood Center location, or information from Project Safety Net (a searchable web site for safety net providers). Access assistance was offered at the health fairs and then again at follow-up telephone calls to those who had not yet obtained follow-up care. Of the 48 participants who reported obtaining follow-up care, 26 said they had made use of the access assistance to do so. The use of access assistance was associated with being Hispanic, not having health insurance or a regular source of care, and speaking Spanish. It was also associated with being worried about blood glucose. ^ Conclusion. Access assistance, as a community enabling characteristic, may be useful in aiding low-income people in obtaining medical care. ^

THE RELATIONSHIP BETWEEN DEGREE OF BLOOD PRESSURE REDUCTION AND MORTALITY AMONG HYPERTENSIVES IN THE HYPERTENSION DETECTION AND FOLLOW-UP PROGRAM

The relationship between degree of diastolic blood pressure (DBP) reduction and mortality was examined among hypertensives, ages 30-69, in the Hypertension Detection and Follow-up Program (HDFP). The HDFP was a multi-center community-based trial, which followed 10,940 hypertensive participants for five years. One-year survival was required for inclusion in this investigation since the one-year annual visit was the first occasion where change in blood pressure could be measured on all participants. During the subsequent four years of follow-up on 10,052 participants, 568 deaths occurred. For levels of change in DBP and for categories of variables related to mortality, the crude mortality rate was calculated. Time-dependent life tables were also calculated so as to utilize available blood pressure data over time. In addition, the Cox life table regression model, extended to take into account both time-constant and time-dependent covariates, was used to examine the relationship change in blood pressure over time and mortality.^ The results of the time-dependent life table and time-dependent Cox life table regression analyses supported the existence of a quadratic function which modeled the relationship between DBP reduction and mortality, even after adjusting for other risk factors. The minimum mortality hazard ratio, based on a particular model, occurred at a DBP reduction of 22.6 mm Hg (standard error = 10.6) in the whole population and 8.5 mm Hg (standard error = 4.6) in the baseline DBP stratum 90-104. After this reduction, there was a small increase in the risk of death. There was not evidence of the quadratic function after fitting the same model using systolic blood pressure. Methodologic issues involved in studying a particular degree of blood pressure reduction were considered. The confidence interval around the change corresponding to the minimum hazard ratio was wide and the obtained blood pressure level should not be interpreted as a goal for treatment. Blood pressure reduction was attributed, not only to pharmacologic therapy, but also to regression to the mean, and to other unknown factors unrelated to treatment. Therefore, the surprising results of this study do not provide direct implications for treatment, but strongly suggest replication in other populations. ^

Sacred vocation program follow up evaluation at the Baylor healthcare system

Background: The Sacred Vocation Program (SVP) (Amick B, Karff S., 2003) helps workers find meaning, spirituality, and see their job as a sacred vocation. The SVP is based on Participatory Action Research (PAR) (Minkler & Wallerstein, 1997; Parker & Wall, 1998). This study aims to evaluate the SVP implemented at the Baylor Healthcare System, Dallas-Fort Worth. ^ Methods: The study design is a qualitative design. We used data from study participants who have participated in focus groups. During these focus groups specific questions and probes regarding the effectiveness of the SVP have been asked. We analyzed the focus groups and derived themes. ^ Results: Results of this study demonstrate SVP helps graduates feel valued and important. The SVP has improved meaningful work for employees and improved a sense of belonging for participants. The program has also increased participant spirituality. The coping techniques developed during a SVP class helps participants deal with stressful situations. The SVP faces challenges of implementation fidelity, poor communication, program viability in tough economic times and implementation of phase II. Another sustainability challenge for SVP is the perception of the program being a religious one versus a spiritual program. ^ Conclusion: Several aspects of the SVP work. The phase I of SVP is successful in improving meaningful work and a sense of belonging for participants. The coping techniques help participants deal with difficult work situations. The SVP can increase effectiveness through improvements in implementation fidelity, communication and leadership commitment. ^

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.^

Figures and related data of a review of the "Global and Russian energy outlook up to 2040"

The Global and Russian Energy Outlook up to 2040, prepared by the Energy Research Institute of the Russian Academy of Sciences and the Analytical Center for the Government of the Russian Federation, analyses the long-term changes in the main energy markets and thereby identifies the threats to the Russian economy and energy sector. Research has shown that shifts in the global energy sector, especially in hydrocarbon markets (primarily the development of technologies for shale oil and gas extraction), will result in a slowdown of Russia's economy by one percentage point each year on average due to a decrease in energy exports comparison with the official projections. Owing to the lack of development of an institutional framework, an outdated tax system, low competition and low investment efficiency, Russia will be the most sensitive to fluctuations in global hydrocarbon markets among all major energy market players within the forecast period.

An investigation of the performance of a new Mechanical thrombectomy device using Bond Graph modelling: application to the extraction of blood clots in the middle cerebral artery

A number of thrombectomy devices using a variety of methods have now been developed to facilitate clot removal. We present research involving one such experimental device recently developed in the UK, called a ‘GP’ Thrombus Aspiration Device (GPTAD). This device has the potential to bring about the extraction of a thrombus. Although the device is at a relatively early stage of development, the results look encouraging. In this work, we present an analysis and modeling of the GPTAD by means of the bond graph technique; it seems to be a highly effective method of simulating the device under a variety of conditions. Such modeling is useful in optimizing the GPTAD and predicting the result of clot extraction. The aim of this simulation model is to obtain the minimum pressure necessary to extract the clot and to verify that both the pressure and the time required to complete the clot extraction are realistic for use in clinical situations, and are consistent with any experimentally obtained data. We therefore consider aspects of rheology and mechanics in our modeling.

Design and evaluation of acceleration strategies for speeding up the development of dialog applications

In this paper, we describe a complete development platform that features different innovative acceleration strategies, not included in any other current platform, that simplify and speed up the definition of the different elements required to design a spoken dialog service. The proposed accelerations are mainly based on using the information from the backend database schema and contents, as well as cumulative information produced throughout the different steps in the design. Thanks to these accelerations, the interaction between the designer and the platform is improved, and in most cases the design is reduced to simple confirmations of the “proposals” that the platform dynamically provides at each step. In addition, the platform provides several other accelerations such as configurable templates that can be used to define the different tasks in the service or the dialogs to obtain or show information to the user, automatic proposals for the best way to request slot contents from the user (i.e. using mixed-initiative forms or directed forms), an assistant that offers the set of more probable actions required to complete the definition of the different tasks in the application, or another assistant for solving specific modality details such as confirmations of user answers or how to present them the lists of retrieved results after querying the backend database. Additionally, the platform also allows the creation of speech grammars and prompts, database access functions, and the possibility of using mixed initiative and over-answering dialogs. In the paper we also describe in detail each assistant in the platform, emphasizing the different kind of methodologies followed to facilitate the design process at each one. Finally, we describe the results obtained in both a subjective and an objective evaluation with different designers that confirm the viability, usefulness, and functionality of the proposed accelerations. Thanks to the accelerations, the design time is reduced in more than 56% and the number of keystrokes by 84%.

Bond Modelling of prestressed concrete during the prestressing force release

This paper presents an analytical model for simulating the bond between steel and concrete, in precast prestressed concrete elements, during the prestressing force release. The model establishes a relationship between bond stress, steel and concrete stress and slip in such concrete structures. This relationship allows us to evaluate the bond stress in the transmission zone, where bond stress is not constant, along the whole prestressing force release process. The model is validated with the results of a series of tests and is extended to evaluate the transmission length. This capability has been checked by comparing the transmission length predicted by the model and one measured experimentally in a series of tests.

Non-linear gain - look-up table based approach for modeling a family of DC to DC converters based on transient response analysis

The purpose of this work is to propose a structure for simulating power systems using behavioral models of nonlinear DC to DC converters implemented through a look-up table of gains. This structure is specially designed for converters whose output impedance depends on the load current level, e.g. quasi-resonant converters. The proposed model is a generic one whose parameters can be obtained by direct measuring the transient response at different operating points. It also includes optional functionalities for modeling converters with current limitation and current sharing in paralleling characteristics. The pusposed structured also allows including aditional characteristics of the DC to DC converter as the efficency as a function of the input voltage and the output current or overvoltage and undervoltage protections. In addition, this proposed model is valid for overdamped and underdamped situations.

Multi-criteria selection of structural adhesives to bond ABS parts obtained by rapid prototyping

One of the most used methods in rapidprototyping is Fused Deposition Modeling (FDM), which provides components with a reasonable strength in plastic materials such as ABS and has a low environmental impact. However, the FDM process exhibits low levels of surface finishing, difficulty in getting complex and/or small geometries and low consistency in “slim” elements of the parts. Furthermore, “cantilever” elements need large material structures to be supported. The solution of these deficiencies requires a comprehensive review of the three-dimensional part design to enhance advantages and performances of FDM and reduce their constraints. As a key feature of this redesign a novel method of construction by assembling parts with structuraladhesive joints is proposed. These adhesive joints should be designed specifically to fit the plastic substrate and the FDM manufacturing technology. To achieve this, the most suitable structuraladhesiveselection is firstly required. Therefore, the present work analyzes five different families of adhesives (cyanoacrylate, polyurethane, epoxy, acrylic and silicone), and, by means of the application of technical multi-criteria decision analysis based on the analytic hierarchy process (AHP), to select the structuraladhesive that better conjugates mechanical benefits and adaptation to the FDM manufacturing process

Bond modelling of prestressed concrete during the prestressing force release

This paper presents an analytical model for simulating the bond between steel and concrete, in precast prestressed concrete elements, during the prestressing force release. The model establishes a relationship between bond stress, steel and concrete stress and slip in such concrete structures. This relationship allows us to evaluate the bond stress in the transmission zone, where bond stress is not constant, along the whole prestressing force release process. The model is validated with the results of a series of tests, considering different steel indentation depths and concrete covers and is extended to evaluate the transmission length. This capability has been checked by comparing the transmission length predicted by the model and one measured experimentally in two series of tests.

Softening-up mannan-rich cell walls

The softening and degradation of the cell wall (CW), often mannan enriched, is involved in several processes during development of higher plants, such as meristematic growth, fruit ripening, programmed cell death, and endosperm rupture upon germination. Mannans are also the predominant hemicellulosic CW polymers in many genera of green algae. The endosperm CWs of dry seeds often contain mannan polymers, sometimes in the form of galactomannans (Gal-mannans). The endo-beta-mannanases (MANs) that catalyse the random hydrolysis of the beta-linkage in the mannan backbone are one of the main hydrolytic enzymes involved in the loosening and remodelling of CWs. In germinating seeds, the softening of the endosperm seed CWs facilitates the emergence of the elongating radicle. Hydrolysis and mobilization of endosperm Gal-mannans by MANs also provides a source of nutrients for early seedling growth, since Gal-mannan, besides its structural role, serves as a storage polysaccharide. Therefore, the role of mannans and of their hydrolytic enzymes is decisive in the life cycle of seeds. This review updates and discusses the significance of mannans and MANs in seeds and explores the increasing biotechnological potential of MAN enzymes.