Funding the utilization of community health workers in Texas

Community health workers (CHWs) are volunteers or paid members of communities that perform outreach, patient assistance, health education, and assist in navigation of healthcare system amongst other duties. The utilization of CHWs in hospital and community setting provides health benefits to their communities while reducing cost to the overall healthcare system. ^ The general population of Texas lacks adequate access to primary care. An important indicator of such a crisis is excessive usage of emergency department services in Texas, especially by the large minority population within the state. Also, unmanaged chronic diseases have been shown to be correlated with the excessive usage of emergency services. According to a recent survey of 25 Houston metropolitan area hospitals, almost 54% of the ER visits could have been resolved in primary care settings. A Galveston based study also indicated that the ER usage was higher amongst African-Americans and Latinos. Meanwhile, 28.5% of the total ER visits were made by Latinos from the surrounding areas (Begley et al., 2007). There is substantial evidence present which indicates enormous cost-savings that CHWs have produced in Texas and nationwide through reduction in unnecessary ER visits along with better management of chronic diseases (Fedder et al, 2003). ^ This paper provides an analysis regarding the need and importance for sustainable and stable sources of funding for Community health workers (CHWs) in Texas utilizing Kingdon's model of Agenda Setting as framework. The policy analysis is also aimed at reporting on the policy process and actions taken by Children at Risk to address this critical issue. Children at Risk, a Houston based advocacy organization, has created a legislative proposal that calls on the Texas Health and Human Commission to apply for a Medicaid §§1115 waiver to provide sustainable sources of funding for CHWs, Rep. John Zerwas sponsored HB 2244 bill and it was filed on March 3, 2011. The bill would affect the use of CHWs in Texas in two ways: 1) through the establishment and operation of a program designed to train and educate CHWs 2) by creating a statewide training and certification advisory committee. The advisory committee is required in the bill to submit recommendations for providing sustainable funding and employment for CHWs. The HB 2244 failed to move out of the House Public Health committee. However, HB2244 was amended into HB 2610 introduced by Representative Guillen. The House Bill 2610 is geared towards establishing a community-based navigator program in order to assist individuals applying for public assistance through the Internet. The House Bill 2610 was signed by the Governor and will be effective September 1, 2011.^

Radiomics of NSCLC: Quantitative CT Image Feature Characterization and Tumor Shrinkage Prediction

Radiomics is the high-throughput extraction and analysis of quantitative image features. For non-small cell lung cancer (NSCLC) patients, radiomics can be applied to standard of care computed tomography (CT) images to improve tumor diagnosis, staging, and response assessment. The first objective of this work was to show that CT image features extracted from pre-treatment NSCLC tumors could be used to predict tumor shrinkage in response to therapy. This is important since tumor shrinkage is an important cancer treatment endpoint that is correlated with probability of disease progression and overall survival. Accurate prediction of tumor shrinkage could also lead to individually customized treatment plans. To accomplish this objective, 64 stage NSCLC patients with similar treatments were all imaged using the same CT scanner and protocol. Quantitative image features were extracted and principal component regression with simulated annealing subset selection was used to predict shrinkage. Cross validation and permutation tests were used to validate the results. The optimal model gave a strong correlation between the observed and predicted shrinkages with . The second objective of this work was to identify sets of NSCLC CT image features that are reproducible, non-redundant, and informative across multiple machines. Feature sets with these qualities are needed for NSCLC radiomics models to be robust to machine variation and spurious correlation. To accomplish this objective, test-retest CT image pairs were obtained from 56 NSCLC patients imaged on three CT machines from two institutions. For each machine, quantitative image features with concordance correlation coefficient values greater than 0.90 were considered reproducible. Multi-machine reproducible feature sets were created by taking the intersection of individual machine reproducible feature sets. Redundant features were removed through hierarchical clustering. The findings showed that image feature reproducibility and redundancy depended on both the CT machine and the CT image type (average cine 4D-CT imaging vs. end-exhale cine 4D-CT imaging vs. helical inspiratory breath-hold 3D CT). For each image type, a set of cross-machine reproducible, non-redundant, and informative image features was identified. Compared to end-exhale 4D-CT and breath-hold 3D-CT, average 4D-CT derived image features showed superior multi-machine reproducibility and are the best candidates for clinical correlation.

Understanding and Characterizing Shared Decision-Making and Behavioral Intent in Medical Uncertainty

Applying Theoretical Constructs to Address Medical Uncertainty Situations involving medical reasoning usually include some level of medical uncertainty. Despite the identification of shared decision-making (SDM) as an effective technique, it has been observed that the likelihood of physicians and patients engaging in shared decision making is lower in those situations where it is most needed; specifically in circumstances of medical uncertainty. Having identified shared decision making as an effective, yet often a neglected approach to resolving a lack of information exchange in situations involving medical uncertainty, the next step is to determine the way(s) in which SDM can be integrated and the supplemental processes that may facilitate its integration. SDM involves unique types of communication and relationships between patients and physicians. Therefore, it is necessary to further understand and incorporate human behavioral elements - in particular, behavioral intent - in order to successfully identify and realize the potential benefits of SDM. This paper discusses the background and potential interaction between the theories of shared decision-making, medical uncertainty, and behavioral intent. Identifying Shared Decision-Making Elements in Medical Encounters Dealing with Uncertainty A recent summary of the state of medical knowledge in the U.S. reported that nearly half (47%) of all treatments were of unknown effectiveness, and an additional 7% involved an uncertain tradeoff between benefits and harms. Shared decision-making (SDM) was identified as an effective technique for managing uncertainty when two or more parties were involved. In order to understand which of the elements of SDM are used most frequently and effectively, it is necessary to identify these key elements, and understand how these elements related to each other and the SDM process. The elements identified through the course of the present research were selected from basic principles of the SDM model and the “Data, Information, Knowledge, Wisdom” (DIKW) Hierarchy. The goal of this ethnographic research was to identify which common elements of shared decision-making patients are most often observed applying in the medical encounter. The results of the present study facilitated the understanding of which elements patients were more likely to exhibit during a primary care medical encounter, as well as determining variables of interest leading to more successful shared decision-making practices between patients and their physicians. Understanding Behavioral Intent to Participate in Shared Decision-Making in Medically Uncertain Situations Objective: This article describes the process undertaken to identify and validate behavioral and normative beliefs and behavioral intent of men between the ages of 45-70 with regard to participating in shared decision-making in medically uncertain situations. This article also discusses the preliminary results of the aforementioned processes and explores potential future uses of this information which may facilitate greater understanding, efficiency and effectiveness of doctor-patient consultations.Design: Qualitative Study using deductive content analysisSetting: Individual semi-structure patient interviews were conducted until data saturation was reached. Researchers read the transcripts and developed a list of codes.Subjects: 25 subjects drawn from the Philadelphia community.Measurements: Qualitative indicators were developed to measure respondents’ experiences and beliefs related to behavioral intent to participate in shared decision-making during medical uncertainty. Subjects were also asked to complete the Krantz Health Opinion Survey as a method of triangulation.Results: Several factors were repeatedly described by respondents as being essential to participate in shared decision-making in medical uncertainty. These factors included past experience with medical uncertainty, an individual’s personality, and the relationship between the patient and his physician.Conclusions: The findings of this study led to the development of a category framework that helped understand an individual’s needs and motivational factors in their intent to participate in shared decision-making. The three main categories include 1) an individual’s representation of medically uncertainty, 2) how the individual copes with medical uncertainty, and 3) the individual’s behavioral intent to seek information and participate in shared decision-making during times of medically uncertain situations.

Attitudes and other barriers to the utilization of clinical research findings by American physicians: A systematic review

Background: The Institute of Medicine estimates that only a maximum of 25% of clinical research findings are incorporated into practice by physicians. To improve clinical practice, efforts have been made to promote evidence-based medicine and the use of clinical guidelines. Despite these efforts, the gap between research and clinical practice remains wide.^ Objective: To systematically review the literature describing the factors which influence the use of clinical research recommendations by American physicians.^ Hypothesis: Barriers exist in the application of clinical research into clinical practice, and are multifactorial. The establishment of the Clinical and Translational Awards (CTSA; special federal grants awarded to selected institutions to support clinical and translational research) has reduced the effect of these barriers and improved the process of clinical research translation into practice among American physicians.^ Aims: Identify barriers and facilitators of the use of research findings in clinical practice by American physicians. Contrast studies published six years before and after the creation of the CTSA.^ Methods: The sources of data include published literature from Medline, PubMed and PsycINFO. Selected studies must be qualitative, a survey of American clinicians, based on evidence-based medicine practice, clinical guidelines or treatment pathways. Systematic reviews and reports were excluded, as well as studies with less than 100 respondents.^ Results: In total, 1036 abstracts were reviewed; 115 full text potential articles were identified and reviewed, and a total of 31 studies met all criteria for inclusion in the final review.^ Conclusions: The barriers against the application of clinical research findings, in the forms of clinical guidelines, evidence-based medicine guides and clinical pathways, can be divided broadly into physician barriers, practice/system barriers and patient barriers. Physician barriers are the most common barriers, especially the lack of familiarity with guidelines and the lack of time. Of the factors which improve the use of research based guidelines, physician factors such as younger age, lower duration of clinical practice, specialty training, and practice in large group Health Maintenance Organization (HMO) settings with fewer patients seen were the most commonly cited.^

Comparison of machine learning approaches and statistical methods for estimation of airborne chemical exposures

Accurate quantitative estimation of exposure using retrospective data has been one of the most challenging tasks in the exposure assessment field. To improve these estimates, some models have been developed using published exposure databases with their corresponding exposure determinants. These models are designed to be applied to reported exposure determinants obtained from study subjects or exposure levels assigned by an industrial hygienist, so quantitative exposure estimates can be obtained. ^ In an effort to improve the prediction accuracy and generalizability of these models, and taking into account that the limitations encountered in previous studies might be due to limitations in the applicability of traditional statistical methods and concepts, the use of computer science- derived data analysis methods, predominantly machine learning approaches, were proposed and explored in this study. ^ The goal of this study was to develop a set of models using decision trees/ensemble and neural networks methods to predict occupational outcomes based on literature-derived databases, and compare, using cross-validation and data splitting techniques, the resulting prediction capacity to that of traditional regression models. Two cases were addressed: the categorical case, where the exposure level was measured as an exposure rating following the American Industrial Hygiene Association guidelines and the continuous case, where the result of the exposure is expressed as a concentration value. Previously developed literature-based exposure databases for 1,1,1 trichloroethane, methylene dichloride and, trichloroethylene were used. ^ When compared to regression estimations, results showed better accuracy of decision trees/ensemble techniques for the categorical case while neural networks were better for estimation of continuous exposure values. Overrepresentation of classes and overfitting were the main causes for poor neural network performance and accuracy. Estimations based on literature-based databases using machine learning techniques might provide an advantage when they are applied to other methodologies that combine `expert inputs' with current exposure measurements, like the Bayesian Decision Analysis tool. The use of machine learning techniques to more accurately estimate exposures from literature-based exposure databases might represent the starting point for the independence from the expert judgment.^

Grain-size analysis and geochemistry of sediment core GeoB13602-1

Grain-size, terrigenous element and rock magnetic remanence data of Quaternary marine sediments retrieved at the NW African continental margin off Gambia (gravity core GeoB 13602-1, 13°32.71' N, 17°50.96'W) were jointly analyzed by end-member (EM) unmixing methods to distinguish and budget past terrigenous fluxes. We compare and cross-validate the identified single-parameter EM systems and develop a numerical strategy to calculate associated multi-parameter EM properties. One aeolian and two fluvial EMs were found. The aeolian EM is much coarser than the fluvial EMs and is associated with a lower goethite/hematite ratio, a higher relative concentration of magnetite and lower Al/Si and Fe/K ratios. Accumulation rates and grain sizes of the fluvial sediment appear to be primarily constrained by shore distance (i.e., sea-level fluctuations) and to a lesser extent by changes in hinterland precipitation. High dust fluxes occurred during the Last Glacial Maximum (LGM) and during Heinrich Stadials (HS) while the fluvial input remained unchanged. Our approach reveals that the LGM dust fluxes were ~7 times higher than today's. However, by far the highest dust accumulation occurred during HS 1 (~300 g m**-2 yr** -1), when dust fluxes were ~80 fold higher than today. Such numbers have not yet been reported for NW Africa, and emphasize strikingly different environmental conditions during HSs. They suggest that deflation rate and areal extent of HSs dust sources were much larger due to retreating vegetation covers. Beyond its regional and temporal scope, this study develops new, in principle, generally applicable strategies for multi-method end-member interpretation, validation and flux budgeting calibration.

Lithology, biostratigraphy, and geochemistry of the Black Sea sediments, DSDP Leg 42 (pt. 2) data

The monograph presents results of deep-sea drilling in the Black Sea carried out in 1975. Detailed lithological, biostratigraphic and geochemical studies of Miocene-Holocene sediments have been carried out by specialists from institutes of the USSR Academy of Sciences, Moscow State University and other organizations. Drilling results are compared with geophysical data. Geological history of the Black Sea basin is considered as well.

Sulfur contents and S, C and O isotopic compositions in serpentinized peridotites at ODP Site 153-920

The opaque mineralogy and the contents and isotope compositions of sulfur in serpentinized peridotites from the MARK (Mid-Atlantic Ridge, Kane Fracture Zone) area were examined to understand the conditions of serpentinization and evaluate this process as a sink for seawater sulfur. The serpentinites contain a sulfur-rich secondary mineral assemblage and have high sulfur contents (up to 1 wt.%) and elevated d34S_sulfide (3.7 to 12.7?). Geochemical reaction modeling indicates that seawater-peridotite interaction at 300 to 400°C alone cannot account for both the high sulfur contents and high d34S_sulfide. These require a multistage reaction with leaching of sulfide from subjacent gabbro during higher temperature (~400°C) reactions with seawater and subsequent deposition of sulfide during serpentinization of peridotite at ~300°C. Serpentinization produces highly reducing conditions and significant amounts of H2 and results in the partial reduction of seawater carbonate to methane. The latter is documented by formation of carbonate veins enriched in 13C (up to 4.5?) at temperatures above 250°C. Although different processes produce variable sulfur isotope effects in other oceanic serpentinites, sulfur is consistently added to abyssal peridotites during serpentinization. Data for serpentinites drilled and dredged from oceanic crust and from ophiolites indicate that oceanic peridotites are a sink for up to 0.4 to 6.0 mln ton seawater S per year. This is comparable to sulfur exchange that occurs in hydrothermal systems in mafic oceanic crust at midocean ridges and on ridge flanks and amounts to 2 to 30% of the riverine sulfate source and sedimentary sulfide sink in the oceans. The high concentrations and modified isotope compositions of sulfur in serpentinites could be important for mantle metasomatism during subduction of crust generated at slow spreading rates.

Methanol and ethanol analysis in marine sediment pore water

Low-molecular-weight (LMW) alcohols are produced during the microbial degradation of organic matter from precursors such as lignin, pectin, and carbohydrates. The biogeochemical behavior of these alcohols in marine sediment is poorly constrained but potentially central to carbon cycling. Little is known about LMW alcohols in sediment pore waters because of their low concentrations and high water miscibility, both of which pose substantial analytical challenges. In this study, three alternative methods were adapted for the analysis of trace amounts of methanol and ethanol in small volumes of saline pore waters: direct aqueous injection (DAI), solid-phase microextraction (SPME), and purge and trap (P&T) in combination with gas chromatography (GC) coupled to either a flame ionization detector (FID) or a mass spectrometer (MS). Key modifications included the desalination of samples prior to DAI, the use of a threaded midget bubbler to purge small-volume samples under heated conditions and the addition of salt during P&T. All three methods were validated for LMW alcohol analysis, and the lowest detection limit (60 nM and 40 nM for methanol and ethanol, respectively) was achieved with the P&T technique. With these methods, ambient concentrations of volatile alcohols were determined for the first time in marine sediment pore waters of the Black Sea and the Gulf of Mexico. A strong correlation between the two compounds was observed and tentatively interpreted as being controlled by similar sources and sinks at the examined stations.

Mercury species concentrations near Casey station, Antarctica and along the SR3 CASO-GEOTRACES transect

We present here the first mercury speciation study in the water column of the Southern Ocean, using a high-resolution south-to-north section (27 stations from 65.50°S to 44.00°S) with up to 15 depths (0-4440 m) between Antarctica and Tasmania (Australia) along the 140°E meridian. In addition, in order to explore the role of sea ice in Hg cycling, a study of mercury speciation in the 'snow-sea ice-seawater' continuum was conducted at a coastal site, near the Australian Casey station (66.40°S; 101.14°E). In the open ocean waters, total Hg (Hg(T)) concentrations varied from 0.63 to 2.76 pmol/L with 'transient-type' vertical profiles and a latitudinal distribution suggesting an atmospheric mercury source south of the Southern Polar Front (SPF) and a surface removal north of the Subantartic Front (SAF). Slightly higher mean Hg(T) concentrations (1.35 ± 0.39 pmol/L) were measured in Antarctic Bottom Water (AABW) compared to Antarctic Intermediate water (AAIW) (1.15 ± 0.22 pmol/L). Labile Hg (Hg(R)) concentrations varied from 0.01 to 2.28 pmol/L, with a distribution showing that the Hg(T) enrichment south of the SPF consisted mainly of Hg(R) (67 ± 23%), whereas, in contrast, the percentage was half that in surface waters north of PFZ (33 ± 23%). Methylated mercury species (MeHg(T)) concentrations ranged from 0.02 to 0.86 pmol/L. All vertical MeHg(T) profiles exhibited roughly the same pattern, with low concentrations observed in the surface layer and increasing concentrations with depth up to an intermediate depth maximum. As for Hg(T), low mean MeHg(T) concentrations were associated with AAIW, and higher ones with AABW. The maximum of MeHg(T) concentration at each station was systematically observed within the oxygen minimum zone, with a statistically significant MeHg(T) vs Apparent Oxygen Utilization (AOU) relationship (p <0.001). The proportion of Hg(T) as methylated species was lower than 5% in the surface waters, around 50% in deep waters below 1000 m, reaching a maximum of 78% south of the SPF. At Casey coastal station Hg(T) and Hg(R) concentrations found in the 'snow-sea ice-seawater' continuum were one order of magnitude higher than those measured in open ocean waters. The distribution of Hg(T) there suggests an atmospheric Hg deposition with snow and a fractionation process during sea ice formation, which excludes Hg from the ice with a parallel Hg enrichment of brine, probably concurring with the Hg enrichment of AABW observed in the open ocean waters. Contrastingly, MeHg(T) concentrations in the sea ice environment were in the same range as in the open ocean waters, remaining below 0.45 pmol/L. The MeHg(T) vertical profile through the continuum suggests different sources, including atmosphere, seawater and methylation in basal ice. Whereas Hg(T) concentrations in the water samples collected between the Antarctic continent and Tasmania are comparable to recent measurements made in the other parts of the World Ocean (e.g., Soerensen et al., 2010; doi:10.1021/es903839n), the Hg species distribution suggests distinct features in the Southern Ocean Hg cycle: (i) a net atmospheric Hg deposition on surface water near the ice edge, (ii) the Hg enrichment in brine during sea ice formation, and (iii) a net methylation of Hg south of the SPF.

Global LAI uncertainty and relative uncertainty datasets derived from a Triple Collocation Error Model (TCEM)

Uncertainty information for global leaf area index (LAI) products is important for global modeling studies but usually difficult to systematically obtain at a global scale. Here, we present a new method that cross-validates existing global LAI products and produces consistent uncertainty information. The method is based on a triple collocation error model (TCEM) that assumes errors among LAI products are not correlated. Global monthly absolute and relative uncertainties, in 0.05° spatial resolutions, were generated for MODIS, CYCLOPES, and GLOBCARBON LAI products, with reasonable agreement in terms of spatial patterns and biome types. CYCLOPES shows the lowest absolute and relative uncertainties, followed by GLOBCARBON and MODIS. Grasses, crops, shrubs, and savannas usually have lower uncertainties than forests in association with the relatively larger forest LAI. With their densely vegetated canopies, tropical regions exhibit the highest absolute uncertainties but the lowest relative uncertainties, the latter of which tend to increase with higher latitudes. The estimated uncertainties of CYCLOPES generally meet the quality requirements (± 0.5) proposed by the Global Climate Observing System (GCOS), whereas for MODIS and GLOBCARBON only non-forest biome types have met the requirement. Nevertheless, none of the products seems to be within a relative uncertainty requirements of 20%. Further independent validation and comparative studies are expected to provide a fair assessment of uncertainties derived from TCEM. Overall, the proposed TCEM is straightforward and could be automated for the systematic processing of real time remote sensing observations to provide theoretical uncertainty information for a wider range of land products.

Geochemistry of igneous rocks recovered from a transect across the Mariana Trough, arc, fore-arc, and trench, at DSDP Leg 60 Holes and DM17

Major and trace element analyses are presented for 110 samples from the DSDP Leg 60 basement cores drilled along a transect across the Mariana Trough, arc, fore-arc, and Trench at about 18°N. The igneous rocks forming breccias at Site 453 in the west Mariana Trough include plutonic cumulates and basalts with calc-alkaline affinities. Basalts recovered from Sites 454 and 456 in the Mariana Trough include types with compositions similar to normal MORB and types with calc-alkaline affinities within a single hole. At Site 454 the basalts show a complete compositional transition between normal MORB and calc-alkaline basalts. These basalts may be the result of mixing of the two magma types in small sub-crustal magma reservoirs or assimilation of calc-alkaline, arc-derived vitric tuffs by normal MORB magmas during eruption or intrusion. A basaltic andesite clast in the breccia recovered from Site 457 on the active Mariana arc and samples dredged from a seamount in the Mariana arc are calc-alkaline and similar in composition to the basalts recovered from the Mariana Trough and West Mariana Ridge. Primitive island arc tholeiites were recovered from all four sites (Sites 458-461) drilled on the fore-arc and arc-side wall of the trench. These basalts form a coherent compositional group distinct from the Mariana arc, West Mariana arc, and Mariana Trough calc-alkaline lavas, indicating temporal (and perhaps spatial?) chemical variations in the arc magmas erupted along the transect. Much of the 209 meters of basement cored at Site 458 consists of endiopside- and bronzite-bearing, Mg-rich andesites with compositions related to boninites. These andesites have the very low Ti, Zr, Ti/Zr, P, and rare-earthelement contents characteristic of boninites, although they are slightly light-rare-earth-depleted and have lower MgO, Cr, Ni, and higher CaO and Al2O3 contents than those reported for typical boninites. The large variations in chemistry observed in the lavas recovered from this transect suggest that diverse mantle source compositions and complex petrogenetic process are involved in forming crustal rocks at this intra-oceanic active plate margin.

Composition of particulate lipids in the intermediate zone between the Kara and Laptev Seas

Chemical group composition of particulate lipids from the intermediate zone between the Kara and Laptev Seas is studied by thin-layer chromatography with flame ionization detection (IATROSCAN TH-10). Hydrocarbons and complex polar lipids similar to those found in the previously studied southeastern area of the Kara Sea are basic components of particulate lipids. High content of triglycerides in the upper layers of the water mass north of the Severnaya Zemlya Islands is a characteristic feature of group composition of particulate lipids. Distribution of triglycerides correlates with localization of the ice cover boundary and complies with process of phytoplankton blooming in the ice edge zone. Distribution of lipid concentration depends on water stratification in the intermediate zone between the Kara and Laptev Seas.

Structural Changes and Formation of Rusta-shahr in Post-Revolutionary Rural Society in Iran

The following paper is based on the author's two-year research and fieldwork in Iran and examines the process of political and social changes since the Iranian Revolution of 1979 and the subsequent impact of the Iran-Iraq War of 1980-88. This paper focuses on the transition of traditional, small villages into rusta-shahr or small rural cities and the first and second nation-wide elections of shoura or councils which were the first steps toward self-government. The author is guardedly optimistic regarding this democratic process but warns of possible future social unrest if changes are not more "balanced" between cities and rural areas and if the employment needs of the burgeoning younger generation are not met, political and social consequences may be catastrophic.

FDI inflows and outflows, intellectual property rights, and productivity growth

Using panel data of 57 countries during the period of 1995-2012, this study investigates the impact of intellectual property rights (IPR) processes on productivity growth. The IPR processes are decomposed into three stages, innovation process, commercialization process, and IPR protection process. Our results suggest that better IPR protection is directly associated with productivity improvement only in developed economies. In addition, the contribution of IPR processes on growth through foreign direct investment (FDI) appears to be very limited. Only FDI inflows in developed countries which help to create a better innovative capability lead to a higher growth. And in connection with FDI outflows, only IPR protection and commercialization processes are proven to improve productivity in the case of developing countries, particularly when the country acts as the investing country.