Quality of life and application of the transtheoretical model to diabetes self -management behaviors in older adults with type 2 diabetes

One in five adults 65 years and older has diabetes. Coping with diabetes is a lifelong task, and much of the responsibility for managing the disease falls upon the individual. Reports of non-adherence to recommended treatments are high. Understanding the additive impact of diabetes on quality of life issues is important. The purpose of this study was to investigate the quality of life and diabetes self-management behaviors in ethnically diverse older adults with type 2 diabetes. The SF-12v2 was used to measure physical and mental health quality of life. Scores were compared to general, age sub-groups, and diabetes-specific norms. The Transtheoretical Model (TTM) was applied to assess perceived versus actual behavior for three diabetes self-management tasks: dietary management, medication management, and blood glucose self-monitoring. Dietary intake and hemoglobin A1c values were measured as outcome variables. Utilizing a cross-sectional research design, participants were recruited from Elderly Nutrition Program congregate meal sites (n = 148, mean age 75). ^ Results showed that mean scores of the SF-12v2 were significantly lower in the study sample than the general norms for physical health (p < .001), mental health (p < .01), age sub-group norms (p < .05), and diabetes-specific norms for physical health (p < .001). A multiple regression analysis found that adherence to an exercise plan was significantly associated with better physical health (p < .001). Transtheoretical Model multiple regression analyses explained 68% of the variance for % Kcal from fat, 41% for fiber, 70% for % Kcal from carbohydrate, and 7% for hemoglobin A 1c values. Significant associations were found between TTM stage of change and dietary fiber intake (p < .01). Other significant associations related to diet included gender (p < .01), ethnicity (p < .05), employment (p < .05), type of insurance (p < .05), adherence to an exercise plan (p < .05), number of doctor visits/year ( p < .01), and physical health (p < .05). Significant associations were found between hemoglobin A1c values and age ( p < .05), being non-Hispanic Black (p < .01), income (p < .01), and eye problems (p < .05). ^ The study highlights the importance of the beneficial effects of exercise on quality of life issues. Furthermore, application of the Transtheoretical Model in conjunction with an assessment of dietary intake may be valuable in helping individuals make lifestyle changes. ^

Effect of the Supplemental Nutrition Assistance Program (SNAP) and nutrition education on nutrition and health outcomes of HIV+ individuals

Factors associated with and barriers to participation in Supplemental Nutrition Assistance Program (SNAP) and the effect participation has on food security, nutrition status, disease status and quality of life was investigated in a cross-sectional study including 175 HIV infected individuals. In addition, the effect of a targeted nutrition education on nutrition knowledge, readiness to dietary behavior change, nutrition status, disease status and quality of life was also investigated among a subset of the population (N = 45) in a randomized clinical control trial. ^ SNAP participation rate was 70.3%, similar to the State of Florida and national participation rates. SNAP participation was positively and independently associated with being born in the US (P < 0.001), having monthly income less than $1000 (P = 0.006), and receiving antiretroviral treatment (P < 0.001). Participation barriers include denial of participation by program, recent incarceration, living in a shelter where participation is not allowed and unawareness of eligibility status. In regression analyses, SNAP participation was not significantly associated with improved food security, nutrition status, disease status and health related quality of life (HRQOL). Over half (56%) of the population experienced food insecurity and had inadequate intakes of half of the nutrients assessed. Illicit drug, alcohol and cigarette use were high in this population (31%, 55% and 63% respectively), and affected food security, nutrients intake, disease status and HRQOL. The nutrition education intervention resulted in a trend towards improvements nutrition knowledge, self-efficacy, and readiness to change without impacting nutrition status, disease state and quality of life. ^ Food insecurity and other nutrition related issues, with implications for treatment, management and cost of HIV disease, continue to plague infected individuals living in poverty. More resources, including food and nutrition programs, specifically targeted towards this population are needed to address these issues.^

Hospitality Graduate Students’ Program Choice Decisions: Implications for Faculty and Administrators

Despite rapid growth in the quality and volume of hospitality graduate research and education in recent years, little information is available in the extant body of literature about the program choices of hospitality management graduate students, information that is crucial for program administrators and faculty in their attempts to attract the most promising students to their programs. This paper reports on a study among graduate students in U.S, hospitality management programs designed to understand why they chose to pursue their degrees at their programs of choice. Given the large numbers of international students presently enrolled, the study additionally looked into why international hospitality management students chose to leave their home countries and why they decided to pursue a graduate degree in the U.S. Based on the findings, implications for hospitality administrators and faculty in the U.S. and abroad are discussed and directions for future research are presented.

Pressure ulcers and nutritional deficits in elderly long-term care patients : effects of a comprehensive nutritional program on pressure ulcer healing, length of hospital stay and charges to patients

The elderly are at the highest risk of developing pressure ulcers that result in prolonged hospitalization, high health care costs, increased mortality, and decreased quality of life. The burden of pressure ulcers will intensify because of a rapidly increasing elderly population in the United States (US). Poor nutrition is a major predictor of pressure ulcer formation. The purpose of this study was to examine the effects of a comprehensive, interdisciplinary nutritional protocol on: 1) pressure ulcer wound healing 2) length of hospital stays, and 3) charges for pressure ulcer management. Using a pre-intervention/post intervention quasi-experimental design the study sample was composed of 100 patients 60 years or older, admitted with or acquiring a pressure ulcer. A pre-intervention group (n= 50) received routine pressure ulcer care (standard diet, dressing changes, and equipment). A post-intervention group received routine care plus an interdisciplinary nutrition intervention (physical therapy, speech therapy, occupational therapy, added protein and calories to the diet). Research questions were analyzed using descriptive statistics, frequencies, Chi-Square Tests, and T-tests. Findings indicated that the comprehensive, interdisciplinary nutritional protocol had a significant effect on the rate of wound healing in Week3 and Week4, total hospital length of stay (pre-intervention M= 43.2 days, SD=31.70 versus M=31.77, SD=12.02 post-intervention), and pressure ulcer length of stay (pre-intervention 25.28 days, SD5.60 versus 18.40 days, SD 5.27 post-intervention). Although there was no significant difference in total charges for the pre-intervention group ($727,245.00) compared to the post-intervention group ($702,065.00), charges for speech (m=$5885.12, SD=$332.55), pre albumin (m=$808.52,SD= $332.55), and albumin($278 .88, SD=55.00) were higher in the pre-intervention group and charges for PT ($5721.26, SD$3655.24) and OT($2544 .64, SD=1712.863) were higher in the post-intervention group. Study findings indicate that this comprehensive nutritional intervention was effective in improving pressure ulcer wound healing, decreasing both hospital length of stay for treatment of pressure ulcer and total hospital length of stay while showing no significant additional charges for treatment of pressure ulcers.

Reaganomics and its effects on pricing and participation in the regular paying sector of the National School Lunch Program in Dade County public high schools

Problem: This research proposes to examine the effects of Reaganomics on pricing and participation in the regular paying sector of the National School Lunch Program in Dade County Public High Schools. Subproblems: The first subproblem is to examine the effects of Reaganomics on pricing in the regular paying sector of the National School Lunch Program in Dade County Public High Schools. The second subproblem is to examine the effects of Reaganomics on participation in the regular paying sector of the National School Lunch Program in Dade County Public High Schools. Hypotheses: The first hypothesis is that Reaganomics has resulted in price increases to the regular paying sector of the National School Lunch Program in Dade County Public High Schools. The second hypothesis is that Reaganomics has decreased the percentage of the regular paying sector participating in the National School Lunch Program in Dade County Public High Schools.

Land Use and Climate Change Impacts on the Hydrology of the Upper Mara River Basin, Kenya: Results of a Modeling Study to Support Better Resource Management

Some of the most valued natural and cultural landscapes on Earth lie in river basins that are poorly gauged and have incomplete historical climate and runoff records. The Mara River Basin of East Africa is such a basin. It hosts the internationally renowned Mara-Serengeti landscape as well as a rich mixture of indigenous cultures. The Mara River is the sole source of surface water to the landscape during the dry season and periods of drought. During recent years, the flow of the Mara River has become increasingly erratic, especially in the upper reaches, and resource managers are hampered by a lack of understanding of the relative influence of different sources of flow alteration. Uncertainties about the impacts of future climate change compound the challenges. We applied the Soil Water Assessment Tool (SWAT) to investigate the response of the headwater hydrology of the Mara River to scenarios of continued land use change and projected climate change. Under the data-scarce conditions of the basin, model performance was improved using satellite-based estimated rainfall data, which may also improve the usefulness of runoff models in other parts of East Africa. The results of the analysis indicate that any further conversion of forests to agriculture and grassland in the basin headwaters is likely to reduce dry season flows and increase peak flows, leading to greater water scarcity at critical times of the year and exacerbating erosion on hillslopes. Most climate change projections for the region call for modest and seasonally variable increases in precipitation (5–10 %) accompanied by increases in temperature (2.5–3.5 °C). Simulated runoff responses to climate change scenarios were non-linear and suggest the basin is highly vulnerable under low (−3 %) and high (+25 %) extremes of projected precipitation changes, but under median projections (+7 %) there is little impact on annual water yields or mean discharge. Modest increases in precipitation are partitioned largely to increased evapotranspiration. Overall, model results support the existing efforts of Mara water resource managers to protect headwater forests and indicate that additional emphasis should be placed on improving land management practices that enhance infiltration and aquifer recharge as part of a wider program of climate change adaptation.

Mobile Clinics & Bundled Healthcare: An Exploration of Patient Perceptions of the SughaVazhvu Approach to Chronic Care Management

As the burden of non-communicable diseases increases worldwide, it is imperative that health systems adopt delivery approaches that will enable them to provide accessible, high-quality, and low-cost care to patients that need consistent management of their lifelong conditions. This is especially true in low- and middle-income country settings, such as India, where the disease burden is high and the health sector resources to address it are limited. The subscription-based, managed care model that SughaVazhvu Healthcare—a non-profit social enterprise operating in rural Thanjavur, Tamil Nadu—has deployed demonstrates potential for ensuring continuity of care among chronic care patients in resource-strained areas. However, its effectiveness and sustainability will depend on its ability to positively impact patient health status and patient satisfaction with the care management they are receiving. Therefore, this study is not only a program appraisal to aid operational quality improvement of the SughaVazhvu Healthcare model, but also an attempt to identify the factors that affect patient satisfaction among individuals with chronic conditions actively availing services.

Neurosurgical Needs and Assets Assessment of Public Hospitals in Uganda: An Eevaluation of Mulago Hospital to Inform Neurosurgical Program Planning at Mbarara

Background: Since 2007, there has been an ongoing collaboration between Duke University and Mulago National Referral Hospital (NRH) in Kampala, Uganda to increase surgical capacity. This program is prepared to expand to other sites within Uganda to improve neurosurgery outside of Kampala as well. This study assessed the existing progress at Mulago NRH and the neurosurgical needs and assets at two potential sites for expansion. Methods: Three public hospitals were visited to assess needs and assets: Mulago NRH, Mbarara Regional Referral Hospital (RRH), and Gulu RRH. At each site, a surgical capacity tool was administered and healthcare workers were interviewed about perceived needs and assets. A total of 39 interviews were conducted between the three sites. Thematic analysis of the interviews was conducted to identify the reported needs and assets at each hospital. Results: Some improvements are needed to the Duke-Mulago Collaboration model prior to expansion; minor changes to the neurosurgery residency program as well as the method for supply donation and training provided during neurosurgery camps need to examined. Neurosurgery can be implemented at Mbarara RRH currently but the hospital needs a biomedical equipment technician on staff immediately. Gulu RRH is not well positioned for Neurosurgery until there is a CT Scanner somewhere in the Northern Region of Uganda or at the hospital. Conclusions: Neurosurgery is already present in Uganda on a small scale and needs rapid expansion to meet patient needs. This progression is possible with prudent allocation of resources on strategic equipment purchases, human resources including clinical staff and biomedical staff, and changes to the supply chain management system.

Building a Rockfall Database Using Remote Sensing: Techniques for Hazard Management in Canadian Rail Corridors

The section of CN railway between Vancouver and Kamloops runs along the base of many hazardous slopes, including the White Canyon, which is located just outside the town of Lytton, BC. The slope has a history of frequent rockfall activity, which presents a hazard to the railway below. Rockfall inventories can be used to understand the frequency-magnitude relationship of events on hazardous slopes, however it can be difficult to consistently and accurately identify rockfall source zones and volumes on large slopes with frequent activity, leaving many inventories incomplete. We have studied this slope as a part of the Canadian Railway Ground Hazard Research Program and have collected remote sensing data, including terrestrial laser scanning (TLS), photographs, and photogrammetry data since 2012, and used change detection to identify rockfalls on the slope. The objective of this thesis is to use a subset of this data to understand how rockfalls identified from TLS data could be used to understand the frequency-magnitude relationship of rockfalls on the slope. This includes incorporating both new and existing methods to develop a semi-automated workflow to extract rockfall events from the TLS data. We show that these methods can be used to identify events as small as 0.01 m3 and that the duration between scans can have an effect on the frequency-magnitude relationship of the rockfalls. We also show that by incorporating photogrammetry data into our analysis, we can create a 3D geological model of the slope and use this to classify rockfalls by lithology, to further understand the rockfall failure patterns. When relating the rockfall activity to triggering factors, we found that the amount of precipitation occurring over the winter has an effect on the overall rockfall frequency for the remainder of the year. These results can provide the railways with a more complete inventory of events compared to records created through track inspection, or rockfall monitoring systems that are installed on the slope. In addition, we can use the database to understand the spatial and temporal distribution of events. The results can also be used as an input to rockfall modelling programs.

IMPROVING THE PERFORMANCE OF DATABASE-CENTRIC APPLICATIONS THROUGH PROGRAM ANALYSIS

Modern software applications are becoming more dependent on database management systems (DBMSs). DBMSs are usually used as black boxes by software developers. For example, Object-Relational Mapping (ORM) is one of the most popular database abstraction approaches that developers use nowadays. Using ORM, objects in Object-Oriented languages are mapped to records in the database, and object manipulations are automatically translated to SQL queries. As a result of such conceptual abstraction, developers do not need deep knowledge of databases; however, all too often this abstraction leads to inefficient and incorrect database access code. Thus, this thesis proposes a series of approaches to improve the performance of database-centric software applications that are implemented using ORM. Our approaches focus on troubleshooting and detecting inefficient (i.e., performance problems) database accesses in the source code, and we rank the detected problems based on their severity. We first conduct an empirical study on the maintenance of ORM code in both open source and industrial applications. We find that ORM performance-related configurations are rarely tuned in practice, and there is a need for tools that can help improve/tune the performance of ORM-based applications. Thus, we propose approaches along two dimensions to help developers improve the performance of ORM-based applications: 1) helping developers write more performant ORM code; and 2) helping developers configure ORM configurations. To provide tooling support to developers, we first propose static analysis approaches to detect performance anti-patterns in the source code. We automatically rank the detected anti-pattern instances according to their performance impacts. Our study finds that by resolving the detected anti-patterns, the application performance can be improved by 34% on average. We then discuss our experience and lessons learned when integrating our anti-pattern detection tool into industrial practice. We hope our experience can help improve the industrial adoption of future research tools. However, as static analysis approaches are prone to false positives and lack runtime information, we also propose dynamic analysis approaches to further help developers improve the performance of their database access code. We propose automated approaches to detect redundant data access anti-patterns in the database access code, and our study finds that resolving such redundant data access anti-patterns can improve application performance by an average of 17%. Finally, we propose an automated approach to tune performance-related ORM configurations using both static and dynamic analysis. Our study shows that our approach can help improve application throughput by 27--138%. Through our case studies on real-world applications, we show that all of our proposed approaches can provide valuable support to developers and help improve application performance significantly.

A quality control program for mutation detection in KIT and PDGFRA in gastrointestinal stromal tumours.

BACKGROUND: Although most gastrointestinal stromal tumours (GIST) carry oncogenic mutations in KIT exons 9, 11, 13 and 17, or in platelet-derived growth factor receptor alpha (PDGFRA) exons 12, 14 and 18, around 10% of GIST are free of these mutations. Genotyping and accurate detection of KIT/PDGFRA mutations in GIST are becoming increasingly useful for clinicians in the management of the disease. METHOD: To evaluate and improve laboratory practice in GIST mutation detection, we developed a mutational screening quality control program. Eleven laboratories were enrolled in this program and 50 DNA samples were analysed, each of them by four different laboratories, giving 200 mutational reports. RESULTS: In total, eight mutations were not detected by at least one laboratory. One false positive result was reported in one sample. Thus, the mean global rate of error with clinical implication based on 200 reports was 4.5%. Concerning specific polymorphisms detection, the rate varied from 0 to 100%, depending on the laboratory. The way mutations were reported was very heterogeneous, and some errors were detected. CONCLUSION: This study demonstrated that such a program was necessary for laboratories to improve the quality of the analysis, because an error rate of 4.5% may have clinical consequences for the patient.

Evaluation, Selection and Planning the Implementation of a Pavement Management Optimization Model: Optimization Recommendations, 1994

This document briefly summarizes the pavement management activities under the existing Iowa Department of Transportation (DOT) Pavement Management System. The second part of the document provides projected increase in use due to the implementation of the Iowa DOT Pavement Management Optimization System. All estimates of existing time devoted to the Pavement Management System and project increases in time requirements are estimates made by the appropriate Iowa DOT office director or function manager. Included is the new Pavement Management Optimization Structure for the three main offices which will work most closely with the Pavement Management Optimization System (Materials, Design, and Program Management).

Iowa Motor Vehicle Fuel Reduction Program, 1989

This report documents the results of a three million dollar traffic signal improvement demonstration program, known as the Iowa Motor Vehicle Fuel Reduction Program (the program). The program was funded with the use of oil overcharge funds and administered by the Iowa Departments of Natural Resources and Transportation. The objective of the program was to provide restitution to overcharged motorists by improving the efficiency of traffic signals. More efficient traffic signals reduce fuel consumption, delay, travel time, and automobile pollution while improving traffic safety. The program demonstrated the effectiveness of improving traffic signals and resulted in a 14.20-to-1 benefit-to-cost ratio.