Ultra-early intravenous stroke thrombolysis: do all patients benefit similarly?

BACKGROUND AND PURPOSE We previously reported increased benefit and reduced mortality after ultra-early stroke thrombolysis in a single center. We now explored in a large multicenter cohort whether extra benefit of treatment within 90 minutes from symptom onset is uniform across predefined stroke severity subgroups, as compared with later thrombolysis. METHODS Prospectively collected data of consecutive ischemic stroke patients who received i.v. thrombolysis in 10 European stroke centers were merged. Logistic regression tested association between treatment delays, as well as excellent 3-month outcome (modified Rankin scale, 0-1), and mortality. The association was tested separately in tertiles of baseline National Institutes of Health Stroke Scale. RESULTS In the whole cohort (n=6856), shorter onset-to-treatment time as a continuous variable was significantly associated with excellent outcome (P<0.001). Every fifth patient had onset-to-treatment time≤90 minutes, and these patients had lower frequency of intracranial hemorrhage. After adjusting for age, sex, admission glucose level, and year of treatment, onset-to-treatment time≤90 minutes was associated with excellent outcome in patients with National Institutes of Health Stroke Scale 7 to 12 (odds ratio, 1.37; 95% confidence interval, 1.11-1.70; P=0.004), but not in patients with baseline National Institutes of Health Stroke Scale>12 (odds ratio, 1.00; 95% confidence interval, 0.76-1.32; P=0.99) and baseline National Institutes of Health Stroke Scale 0 to 6 (odds ratio, 1.04; 95% confidence interval, 0.78-1.39; P=0.80). In the latter, however, an independent association (odds ratio, 1.51; 95% confidence interval, 1.14-2.01; P<0.01) was found when considering modified Rankin scale 0 as outcome (to overcome the possible ceiling effect from spontaneous better prognosis of patients with mild symptoms). Ultra-early treatment was not associated with mortality. CONCLUSIONS I.v. thrombolysis within 90 minutes is, compared with later thrombolysis, strongly and independently associated with excellent outcome in patients with moderate and mild stroke severity.

Clinical benefit response in pancreatic cancer trials revisited.

OBJECTIVES Clinical benefit response (CBR), based on changes in pain, Karnofsky performance status, and weight, is an established palliative endpoint in trials for advanced gastrointestinal cancer. We investigated whether CBR is associated with survival, and whether CBR reflects a wide-enough range of domains to adequately capture patients' perception. METHODS CBR was prospectively evaluated in an international phase III chemotherapy trial in patients with advanced pancreatic cancer (n = 311) in parallel with patient-reported outcomes (PROs). RESULTS The median time to treatment failure was 3.4 months (range: 0-6). The majority of the CBRs (n = 39) were noted in patients who received chemotherapy for at least 5 months. Patients with CBR (n = 62) had longer survival than non-responders (n = 182) (hazard ratio = 0.69; 95% confidence interval: 0.51-0.94; p = 0.013). CBR was predicted with a sensitivity and specificity of 77-80% by various combinations of 3 mainly physical PROs. A comparison between the duration of CBR (n = 62, median = 8 months, range = 4-31) and clinically meaningful improvements in the PROs (n = 100-116; medians = 9-11 months, range = 4-24) showed similar intervals. CONCLUSION CBR is associated with survival and mainly reflects physical domains. Within phase III chemotherapy trials for advanced gastrointestinal cancer, CBR can be replaced by a PRO evaluation, without losing substantial information but gaining complementary information.

Physician adoption of a practice guideline: Effect on the cost of medical care for adult patients with diabetes

In the demanding environment of healthcare reform, reduction of unwanted physician practice variation is promoted, often through evidence-based guidelines. Guidelines represent innovations that direct change(s) in physician practice; however, compliance has been disappointing. Numerous studies have analyzed guideline development and dissemination, while few have evaluated the consequences of guideline adoption. The primary purpose of this study was to explore and analyze the relationship between physician adoption of the glycated hemoglobin test guideline for management of adult patients with diabetes, and the cost of medical care. The study also examined six personal and organizational characteristics of physicians and their association with innovativeness, or adoption of the guideline. ^ Cost was represented by approved charges from a managed care claims database. Total cost, and diabetes and related complications cost, first were compared for all patients of adopter physicians with those of non-adopter physicians. Then, data were analyzed controlling for disease severity based on insulin dependency, and for high cost cases. There was no statistically significant difference in any of eight cost categories analyzed. This study represented a twelve-month period, and did not reflect cost associated with future complications known to result from inadequate management of glycemia. Guideline compliance did not increase annual cost, which, combined with the future benefit of glycemic control, lends support to the cost effectiveness of the guideline in the long term. Physician adoption of the guideline was recommended to reduce the future personal and economic burden of this chronic disease. ^ Only half of physicians studied had adopted the glycated hemoglobin test guideline for at least 75% of their diabetic patients. No statistically significant relationship was found between any physician characteristic and guideline adoption. Instead, it was likely that the innovation-decision process and guideline dissemination methods were most influential. ^ A multidisciplinary, multi-faceted approach, including interventions for each stage of the innovation-decision process, was proposed to diffuse practice guidelines more effectively. Further, it was recommended that Organized Delivery Systems expand existing administrative databases to include clinical information, decision support systems, and reminder mechanisms, to promote and support physician compliance with this and other evidence-based guidelines. ^

A PROPOSED SAMPLE-BASED TECHNIQUE TO ESTIMATE THE STANDARDIZED MORTALITY RATIO

Evaluation of a series of deaths due to a particular disease is a frequently requested task in occupational epidemiology. There are several techniques available to determine whether a series represents an occupational health problem. Each of these techniques, however, is subject to certain limitations including cost, applicability to a given situation, feasibility relative to available resources, or potential for bias. In light of these problems, a technique was developed to estimate the standardized mortality ratio at a greatly reduced cost. The technique is demonstrated by its application in the investigation of brain cancer among employees of a large chemical company. ^

Towards data-aware cost-driven adaptation for service orchestrations.

Several activities in service oriented computing, such as automatic composition, monitoring, and adaptation, can benefit from knowing properties of a given service composition before executing them. Among these properties we will focus on those related to execution cost and resource usage, in a wide sense, as they can be linked to QoS characteristics. In order to attain more accuracy, we formulate execution costs / resource usage as functions on input data (or appropriate abstractions thereof) and show how these functions can be used to make better, more informed decisions when performing composition, adaptation, and proactive monitoring. We present an approach to, on one hand, synthesizing these functions in an automatic fashion from the definition of the different orchestrations taking part in a system and, on the other hand, to effectively using them to reduce the overall costs of non-trivial service-based systems featuring sensitivity to data and possibility of failure. We validate our approach by means of simulations of scenarios needing runtime selection of services and adaptation due to service failure. A number of rebinding strategies, including the use of cost functions, are compared.

Low-cost retrofitting solutions for RC frames using masonry infill panels

A large number of reinforced concrete (RC) frame structures built in earthquake-prone areas such as Haiti are vulnerable to strong ground motions. Structures in developing countries need low-cost seismic retrofit solutions to reduce their vulnerability. This paper investigates the feasibility of using masonry infill walls to reduce deformations and damage caused by strong ground motions in brittle and weak RC frames designed only for gravity loads. A numerical experiment was conducted in which several idealized prototypes representing RC frame structures of school buildings damaged during the Port-au-Prince earthquake (Haiti, 2010) were strengthened by adding elements representing masonry infill walls arranged in different configurations. Each configuration was characterized by the ratio Rm of the area of walls in the direction of the ground motion (in plan) installed in each story to the total floor area. The numerical representations of these idealized RC frame structures with different values of Rm were (hypothetically) subjected to three major earthquakes with peak ground accelerations of approximately 0.5g. The results of the non-linear dynamic response analyses were summarized in tentative relationships between Rm and four parameters commonly used to characterize the seismic response of structures: interstory drift, Park and Ang indexes of damage, and total amount of energy dissipated by the main frame. It was found that Rm=4% is a reasonable minimum design value for seismic retrofitting purposes in cases in which available resources are not sufficient to afford conventional retrofit measures.

Towards cost reduction in concentrating solar power: innovative design for an efficient fresnel based solar field

Energía termosolar (de concentración) es uno de los nombres que hacen referencia en español al término inglés “concentrating solar power”. Se trata de una tecnología basada en la captura de la potencia térmica de la radiación solar, de forma que permita alcanzar temperaturas capaces de alimentar un ciclo termodinámico convencional (o avanzado); el futuro de esta tecnología depende principalmente de su capacidad para concentrar la radiación solar de manera eficiente y económica. La presente tesis está orientada hacia la resolución de ciertos problemas importantes relacionados con este objetivo. La mencionada necesidad de reducir costes en la concentración de radiación solar directa, asegurando el objetivo termodinámico de calentar un fluido hasta una determinada temperatura, es de vital importancia. Los colectores lineales Fresnel han sido identificados en la literatura científica como una tecnología con gran potencial para alcanzar esta reducción de costes. Dicha tecnología ha sido seleccionada por numerosas razones, entre las que destacan su gran libertad de diseño y su actual estado inmaduro. Con el objetivo de responder a este desafío se desarrollado un detallado estudio de las propiedades ópticas de los colectores lineales Fresnel, para lo cual se han utilizado métodos analíticos y numéricos de manera combinada. En primer lugar, se han usado unos modelos para la predicción de la localización y la irradiación normal directa del sol junto a unas relaciones analíticas desarrolladas para estudiar el efecto de múltiples variables de diseño en la energía incidente sobre los espejos. Del mismo modo, se han obtenido analíticamente los errores debidos al llamado “off-axis aberration”, a la apertura de los rayos reflejados en los espejos y a las sombras y bloqueos entre espejos. Esto ha permitido la comparación de diferentes formas de espejo –planos, circulares o parabólicos–, así como el diseño preliminar de la localización y anchura de los espejos y receptor sin necesidad de costosos métodos numéricos. En segundo lugar, se ha desarrollado un modelo de trazado de rayos de Monte Carlo con el objetivo de comprobar la validez del estudio analítico, pero sobre todo porque este no es preciso en el estudio de la reflexión en espejos. El código desarrollado está específicamente ideado para colectores lineales Fresnel, lo que ha permitido la reducción del tiempo de cálculo en varios órdenes de magnitud en comparación con un programa comercial más general. Esto justifica el desarrollo de un nuevo código en lugar de la compra de una licencia de otro programa. El modelo ha sido usado primeramente para comparar la intensidad de flujo térmico y rendimiento de colectores Fresnel, con y sin reflector secundario, con los colectores cilíndrico parabólicos. Finalmente, la conjunción de los resultados obtenidos en el estudio analítico con el programa numérico ha sido usada para optimizar el campo solar para diferentes orientaciones –Norte-Sur y Este-Oeste–, diferentes localizaciones –Almería y Aswan–, diferentes inclinaciones hacia el Trópico –desde 0 deg hasta 32 deg– y diferentes mínimos de intensidad del flujo en el centro del receptor –10 kW/m2 y 25 kW/m2–. La presente tesis ha conducido a importantes descubrimientos que deben ser considerados a la hora de diseñar un campo solar Fresnel. En primer lugar, los espejos utilizados no deben ser plano, sino cilíndricos o parabólicos, ya que los espejos curvos implican mayores concentraciones y rendimiento. Por otro lado, se ha llegado a la conclusión de que la orientación Este-Oeste es más propicia para localizaciones con altas latitudes, como Almería, mientras que en zonas más cercanas a los trópicos como Aswan los campos Norte-Sur conducen a mayores rendimientos. Es de destacar que la orientación Este-Oeste requiere aproximadamente la mitad de espejos que los campos Norte-Sur, puediendo estar inclinados hacia los Trópicos para mejorar el rendimiento, y que alcanzan parecidos valores de intensidad térmica en el receptor todos los días a mediodía. Sin embargo, los campos con orientación Norte-Sur permiten un flujo más constante a lo largo de un día. Por último, ha sido demostrado que el uso de diseños pre-optimizados analíticamente, con anchura de espejos y espaciado entre espejos variables a lo ancho del campo, pueden implicar aumentos de la energía generada por metro cuadrado de espejos de hasta el 6%. El rendimiento óptico anual de los colectores cilíndrico parabólicos es 23 % mayor que el rendimiento de los campos Fresnel en Almería, mientras que la diferencia es de solo 9 % en Aswan. Ello implica que, para alcanzar el mismo precio de electricidad que la tecnología de referencia, la reducción de costes de instalación por metro cuadrado de espejo debe estar entre el 10 % y el 25 %, y que los colectores lineales Fresnel tienen más posibilidades de ser desarrollados en zonas de bajas latitudes. Como consecuencia de los estudios desarrollados en esta tesis se ha patentado un sistema de almacenamiento que tiene en cuenta la variación del flujo térmico en el receptor a lo largo del día, especialmente para campos con orientación Este-Oeste. Este invento permitiría el aprovechamiento de la energía incidente durante más parte del año, aumentando de manera apreciable los rendimientos óptico y térmico. Abstract Concentrating solar power is the common name of a technology based on capturing the thermal power of solar radiation, in a suitable way to reach temperatures able to activate a conventional (or advanced) thermodynamic cycle to generate electricity; this quest mainly depends on our ability to concentrate solar radiation in a cheap and efficient way. The present thesis is focused to highlight and help solving some of the important issues related to this problem. The need of reducing costs in concentrating the direct solar radiation, but without jeopardizing the thermodynamic objective of heating a fluid up to the required temperature, is of prime importance. Linear Fresnel collectors have been identified in the scientific literature as a technology with high potential to reach this cost reduction. This technology has been selected because of a number of reasons, particularly the degrees of freedom of this type of concentrating configuration and its current immature state. In order to respond to this challenge, a very detailed exercise has been carried out on the optical properties of linear Fresnel collectors. This has been done combining analytic and numerical methods. First, the effect of the design variables on the ratio of energy impinging onto the reflecting surface has been studied using analytically developed equations, together with models that predict the location and direct normal irradiance of the sun at any moment. Similarly, errors due to off-axis aberration, to the aperture of the reflected energy beam and to shading and blocking effects have been obtained analytically. This has allowed the comparison of different shapes of mirrors –flat, cylindrical or parabolic–, as well as a preliminary optimization of the location and width of mirrors and receiver with no need of time-consuming numerical models. Second, in order to prove the validity of the analytic results, but also due to the fact that the study of the reflection process is not precise enough when using analytic equations, a Monte Carlo Ray Trace model has been developed. The developed code is designed specifically for linear Fresnel collectors, which has reduced the computing time by several orders of magnitude compared to a wider commercial software. This justifies the development of the new code. The model has been first used to compare radiation flux intensities and efficiencies of linear Fresnel collectors, both multitube receiver and secondary reflector receiver technologies, with parabolic trough collectors. Finally, the results obtained in the analytic study together with the numeric model have used in order to optimize the solar field for different orientations –North-South and East-West–, different locations –Almería and Aswan–, different tilts of the field towards the Tropic –from 0 deg to 32 deg– and different flux intensity minimum requirements –10 kW/m2 and 25 kW/m2. This thesis work has led to several important findings that should be considered in the design of Fresnel solar fields. First, flat mirrors should not be used in any case, as cylindrical and parabolic mirrors lead to higher flux intensities and efficiencies. Second, it has been concluded that, in locations relatively far from the Tropics such as Almería, East-West embodiments are more efficient, while in Aswan North- South orientation leads to a higher annual efficiency. It must be noted that East-West oriented solar fields require approximately half the number of mirrors than NS oriented fields, can be tilted towards the Equator in order to increase the efficiency and attain similar values of flux intensity at the receiver every day at midday. On the other hand, in NS embodiments the flux intensity is more even during each single day. Finally, it has been proved that the use of analytic designs with variable shift between mirrors and variable width of mirrors across the field can lead to improvements in the electricity generated per reflecting surface square meter up to 6%. The annual optical efficiency of parabolic troughs has been found to be 23% higher than the efficiency of Fresnel fields in Almería, but it is only around 9% higher in Aswan. This implies that, in order to attain the same levelized cost of electricity than parabolic troughs, the required reduction of installation costs per mirror square meter is in the range of 10-25%. Also, it is concluded that linear Fresnel collectors are more suitable for low latitude areas. As a consequence of the studies carried out in this thesis, an innovative storage system has been patented. This system takes into account the variation of the flux intensity along the day, especially for East-West oriented solar fields. As a result, the invention would allow to exploit the impinging radiation along longer time every day, increasing appreciably the optical and thermal efficiencies.

The impact of the internet on the pricing strategies of the European low cost airlines

This study seeks to analyse the price determination of low cost airlines in Europe and the effect that Internet has on this strategy. The outcomes obtained reveal that both users and companies benefit from the use of ICTs in the purchase and sale of airline tickets: the Internet allows consumers to increase their bargaining power comparing different airlines and choosing the most competitive flight, while companies can easily check the behaviour of users to adapt their pricing strategies using internal information. More than 2500 flights of the largest European low cost airlines have been used to carry out the study. The study revealed that the most significant variables for understanding pricing strategies were the number of rivals, the behaviour of the demand and the associated costs. The results indicated that consumers should buy their tickets before 25 days prior to departure.

The Impact of BIM on the Distribution of Cost and Return on Investment in UK Construction Projects

It has been widely documented that when Building Information Modelling (BIM) is used, there is a shift in effort to the design phase. Little investigation into the impact of this shift in effort has been done and how it impacts on costs. It can be difficult to justify the increased expenditure on BIM in a market that is heavily driven by costs. There are currently studies attempting to quantify the return on investment (ROI) for BIM for which these returns can be seen to balance out the shift in efforts and costs to the design phase. The studies however quantify the ROI based on the individual stakeholder’s investment without consideration for the impact that the use of BIM from their project partners may have on their own profitability. In this study, a questionnaire investigated opinions and experience of construction professionals, representing clients, consultants, designers and contractors, to determine fluctuations in costs by their magnitude and when they occur. These factors were examined more closely by interviewing senior members representing each of the stakeholder categories and comparing their experience in using BIM within environments where their project partners were also using BIM and when they were not. This determined the differences in how the use and the investment in BIM impacts on others and how costs are redistributed. This redistribution is not just through time but also between stakeholders and categories of costs. Some of these cost fluctuations and how the cost of BIM is currently financed are also highlighted in several case studies. The results show that the current distribution of costs set for traditional 2D delivery is hindering the potential success of BIM. There is also evidence that stakeholders who don’t use BIM may benefit financially from the BIM use of others and that collaborative BIM is significantly different to the use of ‘lonely’ BIM in terms of benefits and profitability.

How much does EU citizenship cost? The Maltese citizenship-for-sale affair: A breakthrough for sincere cooperation in citizenship of the union? CEPS Liberty and Security in Europe No. 64, April/2014

How much does European citizenship cost in the EU? This was the question that has raised so much controversy over the Maltese citizenship-for-sale programme. The outright selling of Maltese nationality to rich foreigners led to unprecedented responses by the European Parliament and European Commission. This paper examines the affair and its relevance for current and future configurations of citizenship of the EU. It studies the extent to which member states are still free to lay down the grounds for the acquisition and loss of nationality without any EU supervision and accountability. It provides a comparative overview of member state schemes and the exact price for buying citizenship and a residency permit in the EU. It is argued that the EU’s intervention on the Maltese citizenship-for-sale affair constitutes a legal precedent for assessing the lawfulness of passport-for-sale or golden migration programmes in other EU member states. The affair has also revealed the increasing relevance of a set of European and international legal principles limiting member states’ discretion over citizenship matters and providing a supranational constellation of accountability venues scrutinising the impact of their decisions over citizenship of the Union. The Maltese citizenship-for-sale affair has placed at the forefront the EU general principle of sincere cooperation in nationality matters. Member states’ actions in the citizenship domain cannot negatively affect in substance the concept and freedoms of European citizenship. That notwithstanding, the European institutions’ insistence on the need for Maltese nationality law to require a ‘genuine link’ in the form of an effective residence criteria for any rich applicants to benefit from the fast-track naturalisation poses a fundamental dilemma from the angle of Union citizenship: what is this genuine link really about? And what is precisely ‘habitual’, ‘effective’ or ‘functional’ residence? It is argued that by supporting the ‘real connections’ as the most relevant standard, the European institutions may be paradoxically fuelling nationalistic misuses by member states of the ‘genuine link’ as a way to justify restrictive integration policies on the acquisition of nationality.

Past, present and future safety benefit assessment methods.

Mode of access: Internet.

Cost-Effectiveness Analysis of Adaptive Monitoring Strategies for Depression Treatment

Thesis (Master's)--University of Washington, 2016-06

Design determines 70% of cost? A review of implications for design evaluation

This paper disputes the fact that product design determines 70% of costs and the implications that follow for design evaluation tools. Using the idea of decision chains, it is argued that such tools need to consider more of the downstream business activities and should take into account the current and future state of the business rather than some idealized view of it. To illustrate the argument, a series of experiments using an enterprise simulator are described that show the benefit from the application of a more holistic 'design for' technique. Design For the Existing Environment.

A fuzzy levelised energy cost method for renewable energy technology assessment

Renewable energy project development is highly complex and success is by no means guaranteed. Decisions are often made with approximate or uncertain information yet the current methods employed by decision-makers do not necessarily accommodate this. Levelised energy costs (LEC) are one such commonly applied measure utilised within the energy industry to assess the viability of potential projects and inform policy. The research proposes a method for achieving this by enhancing the traditional discounting LEC measure with fuzzy set theory. Furthermore, the research develops the fuzzy LEC (F-LEC) methodology to incorporate the cost of financing a project from debt and equity sources. Applied to an example bioenergy project, the research demonstrates the benefit of incorporating fuzziness for project viability, optimal capital structure and key variable sensitivity analysis decision-making. The proposed method contributes by incorporating uncertain and approximate information to the widely utilised LEC measure and by being applicable to a wide range of energy project viability decisions. © 2013 Elsevier Ltd. All rights reserved.

Improving the cost-effectiveness of photographic screening for diabetic macular oedema:a prospective, multi-centre, UK study

Background/aims: Retinal screening programmes in England and Scotland have similar photographic grading schemes for background (non-proliferative) and proliferative diabetic retinopathy, but diverge over maculopathy. We looked for the most cost-effective method of identifying diabetic macular oedema from retinal photographs including the role of automated grading and optical coherence tomography, a technology that directly visualises oedema. Methods: Patients from seven UK centres were recruited. The following features in at least one eye were required for enrolment: microaneurysms/dot haemorrhages or blot haemorrhages within one disc diameter, or exudates within one or two disc diameters of the centre of the macula. Subjects had optical coherence tomography and digital photography. Manual and automated grading schemes were evaluated. Costs and QALYs were modelled using microsimulation techniques. Results: 3540 patients were recruited, 3170 were analysed. For diabetic macular oedema, England's scheme had a sensitivity of 72.6% and specificity of 66.8%; Scotland 's had a sensitivity of 59.5% and specificity of 79.0%. When applying a ceiling ratio of £30 000 per quality adjusted life years (QALY) gained, Scotland's scheme was preferred. Assuming automated grading could be implemented without increasing grading costs, automation produced a greater number of QALYS for a lower cost than England's scheme, but was not cost effective, at the study's operating point, compared with Scotland's. The addition of optical coherence tomography, to each scheme, resulted in cost savings without reducing health benefits. Conclusions: Retinal screening programmes in the UK should reconsider the screening pathway to make best use of existing and new technologies.