Use of stress echocardiography to predict mortality in patients with diabetes and known or suspected coronary artery disease

OBJECTIVE - This study sought to determine whether stress echocardiography using exercise (when feasible) or dobutamine echo could be used to predict mortality in patients with diabetes. RESEARCH DESIGN AND METHODS - Stress echo was performed in 937 patients with diabetes (aged 59 +/- 13 years, 529 men) for symptom evaluation (42%) and follow-up of known coronary artery disease (CAD) (58%). Stress echocardiography using exercise was performed in 333 patients able to exercise maximally, and dobutamine echo using a standard dobutamine stress was used in 604 patients. Patients were followed for less than or equal to9 years (mean 3.9 +/- 2.3) for all-cause mortality. RESULTS - Normal studies were obtained in 567 (60%) patients; 29% had resting left ventricular (LV) dysfunction, and 25% had ischemia. Abnormalities were confined to one territory in 183 (20%) patients and to multiple territories in 187 (20%) patients. Death (in 275 [29%] patients) was predicted by referral for pharmacologic stress (hazard ratio [HR] 3.94, P < 0.0001), ischemia (1.77, P <0.0001), age (1.02, P = 0.002), and heart failure (1.54, P = 0.01). The risk of death in patients With a normal scan was 4% per year, and this was associated with age and selection for pharmacologic stress testing. In stepwise models replicating the sequence of clinical evaluation, the predictive power of independent clinical predictors (age, selection for pharmacologic stress, previous infarction, and heart failure; model chi(2) = 104.8) was significantly enhanced by addition of stress echo data (model chi(2) = 122.9). CONCLUSIONS - The results of stress echo are independent predictors of death in diabetic patients with known or suspected CAD.. Ischemia adds risk that is incremental to clinical risks and LV dysfunction.

Prediction of outcomes in hypertensive patients with suspected coronary disease

Stress echocardiography has been shown to improve the diagnosis of coronary artery disease in the presence of hypertension, but its value in prognostic evaluation is unclear. We sought to determine whether stress echocardiography could be used to predict mortality in 2363 patients with hypertension, who were followed for up to 10 years (mean 4.0+/-1.8) for death and revascularization. Stress echocardiograms were normal in 1483 patients (63%), 16% had resting left ventricular (LV) dysfunction alone, and 21% had ischemia. Abnormalities were confined to one territory in 489 patients (21%) and to multiple territories in 365 patients (15%). Cardiac death was less frequent among the patients able to exercise than among those undergoing dobutamine echocardiography (4% versus 7%, P<0.001). The risk of death in patients with a negative stress echocardiogram was <1% per year. Ischemia identified by stress echocardiography was an independent predictor of mortality in those able to exercise (hazard ratio 2.21, 95% confidence intervals 1.10 to 4.43, P=0.0001) as well as those undergoing dobutamine echo (hazard ratio 2.39, 95% confidence intervals 1.53 to 3.75, P=0.0001); other predictors were age, heart failure, resting LV dysfunction, and the Duke treadmill score. In stepwise models replicating the sequence of clinical evaluation, the results of stress echocardiography added prognostic power to models based on clinical and stress-testing variables. Thus, the results of stress echocardiography are an independent predictor of cardiac death in hypertensive patients with known or suspected coronary artery disease, incremental to clinical risks and exercise results.

Observations of foehn onset in the Southern Alps, New Zealand

Local scale windfield and air mass characteristics during the onset of two foehn wind events in an alpine hydro-catchment are presented. Grounding of the topographically modified foehn was found to be dependent on daytime surface heating and topographic channelling of flow. The foehn front was observed to advance down-valley until the valley widened significantly. The foehn wind appeared to decouple from the surface downstream of the accelerated flow associated with the valley constriction. and to be lifted above local thermally generated circulations including a lake breeze. Towards evening. the foehn front retreated up valley in response to reduced surface heating and the intrusion into the study area of a deep and cool air mass associated with a regional scale mountain-plain circulation. Differences in the local windfield observed during both case study events reflect the importance of different thermal and dynamic forcings on airflow in complex terrain. These are the result of variation in surface energy exchanges, channelling and blocking of airflow. Observations presented here have both theoretical and applied implications with regard to forecasting foehn onset, wind hazard management, recreational activities and air quality management in alpine settings.

Assessing the self-heating behaviour of Callide coal using a 2-metre column

A 2-m, adiabatic column has been successfully refurbished and recommissioned for coal self-heating research at The University of Queensland. Subbituminous coal from the Callide Coalfields reached thermal runaway in just under 19 days from a starting temperature of 20-22 degreesC. The coal was loaded as two layers, with an R-70 index of 2.73 degreesC h(-1) and 5.90 degreesC h(-1) for the upper layer and lower layer respectively. Initially, a hotspot developed in the upper layer between 120 and 140 cm from the air inlet due to moisture adsorption. After 7 days, self-heating in the lower half of the column began to take over, consistent with the higher R-70 index of this coal. The location of the final hotspot was approximately 60 cm from the air inlet. Further tests on Australian coals, with the column, will enable a better understanding of coal self-heating under conditions closely resembling mining, transport and storage of coal. The results from the column will also provide industry with the information needed to manage the coal self-heating hazard. (C) 2002 Elsevier Science Ltd. All rights reserved.

Binder treatment and lubricant system for aluminium P/M

Organic binders are used in premixes for powder metallurgy applications to prevent dusting and segregation. This is a particular problem for aluminium powder metallurgy because the dust is a potential safety hazard. The binder must also burn out completely at low temperatures in an inert environment and not react with the metal powders. It is demonstrated that cellulose acetate, polyvinyl acetate and polyvinyl alcohol are effective dedusting agents but they react with the metal powders during sintering and decrease the sintered density. Paraffin wan is an effect dedusting agent that provided die wall lubricity, does not interfere with sintering and increases tensile strength and ductility.

Simulation of the load-unload response ratio and critical sensitivity in the lattice solid model

The Load-Unload Response Ratio (LURR) method is an intermediate-term earthquake prediction approach that has shown considerable promise. It involves calculating the ratio of a specified energy release measure during loading and unloading where loading and unloading periods are determined from the earth tide induced perturbations in the Coulomb Failure Stress on optimally oriented faults. In the lead-up to large earthquakes, high LURR values are frequently observed a few months or years prior to the event. These signals may have a similar origin to the observed accelerating seismic moment release (AMR) prior to many large earthquakes or may be due to critical sensitivity of the crust when a large earthquake is imminent. As a first step towards studying the underlying physical mechanism for the LURR observations, numerical studies are conducted using the particle based lattice solid model (LSM) to determine whether LURR observations can be reproduced. The model is initialized as a heterogeneous 2-D block made up of random-sized particles bonded by elastic-brittle links. The system is subjected to uniaxial compression from rigid driving plates on the upper and lower edges of the model. Experiments are conducted using both strain and stress control to load the plates. A sinusoidal stress perturbation is added to the gradual compressional loading to simulate loading and unloading cycles and LURR is calculated. The results reproduce signals similar to those observed in earthquake prediction practice with a high LURR value followed by a sudden drop prior to macroscopic failure of the sample. The results suggest that LURR provides a good predictor for catastrophic failure in elastic-brittle systems and motivate further research to study the underlying physical mechanisms and statistical properties of high LURR values. The results provide encouragement for earthquake prediction research and the use of advanced simulation models to probe the physics of earthquakes.

An EM-based Semi-Parametric Mixture Model Approach to the Regression Analysis of Competing-Risks Data

We consider a mixture model approach to the regression analysis of competing-risks data. Attention is focused on inference concerning the effects of factors on both the probability of occurrence and the hazard rate conditional on each of the failure types. These two quantities are specified in the mixture model using the logistic model and the proportional hazards model, respectively. We propose a semi-parametric mixture method to estimate the logistic and regression coefficients jointly, whereby the component-baseline hazard functions are completely unspecified. Estimation is based on maximum likelihood on the basis of the full likelihood, implemented via an expectation-conditional maximization (ECM) algorithm. Simulation studies are performed to compare the performance of the proposed semi-parametric method with a fully parametric mixture approach. The results show that when the component-baseline hazard is monotonic increasing, the semi-parametric and fully parametric mixture approaches are comparable for mildly and moderately censored samples. When the component-baseline hazard is not monotonic increasing, the semi-parametric method consistently provides less biased estimates than a fully parametric approach and is comparable in efficiency in the estimation of the parameters for all levels of censoring. The methods are illustrated using a real data set of prostate cancer patients treated with different dosages of the drug diethylstilbestrol. Copyright (C) 2003 John Wiley Sons, Ltd.

A modified Weibull distribution

A new lifetime distribution capable of modeling a bathtub-shaped hazard-rate function is proposed. The proposed model is derived as a limiting case of the Beta Integrated Model and has both the Weibull distribution and Type I extreme value distribution as special cases. The model can be considered as another useful 3-parameter generalization of the Weibull distribution. An advantage of the model is that the model parameters can be estimated easily based on a Weibull probability paper (WPP) plot that serves as a tool for model identification. Model characterization based on the WPP plot is studied. A numerical example is provided and comparison with another Weibull extension, the exponentiated Weibull, is also discussed. The proposed model compares well with other competing models to fit data that exhibits a bathtub-shaped hazard-rate function.

Estimates of global and regional potential health gains from reducing multiple major risk factors

Background Estimates of the disease burden due to multiple risk factors can show the potential gain from combined preventive measures. But few such investigations have been attempted, and none on a global scale. Our aim was to estimate the potential health benefits from removal of multiple major risk factors. Methods We assessed the burden of disease and injury attributable to the joint effects of 20 selected leading risk factors in 14 epidemiological subregions of the world. We estimated population attributable fractions, defined as the proportional reduction in disease or mortality that would occur if exposure to a risk factor were reduced to an alternative level, from data for risk factor prevalence and hazard size. For every disease, we estimated joint population attributable fractions, for multiple risk factors, by age and sex, from the direct contributions of individual risk factors. To obtain the direct hazards, we reviewed publications and re-analysed cohort data to account for that part of hazard that is mediated through other risks. Results Globally, an estimated 47% of premature deaths and 39% of total disease burden in 2000 resulted from the joint effects of the risk factors considered. These risks caused a substantial proportion of important diseases, including diarrhoea (92%-94%), lower respiratory infections (55-62%), lung cancer (72%), chronic obstructive pulmonary disease (60%), ischaemic heart disease (83-89%), and stroke (70-76%). Removal of these risks would have increased global healthy life expectancy by 9.3 years (17%) ranging from 4.4 years (6%) in the developed countries of the western Pacific to 16.1 years (43%) in parts of sub-Saharan Africa. Interpretation Removal of major risk factors would not only increase healthy life expectancy in every region, but also reduce some of the differences between regions, The potential for disease prevention and health gain from tackling major known risks simultaneously would be substantial.

Dietary influences on survival after ovarian cancer

We evaluated the effects of various food groups and micronutrients in the diet on survival among women who originally participated in a population-based case-control study of ovarian cancer conducted across 3 Australian states between 1990 and 1993. This analysis included 609 women with invasive epithelial ovarian cancer, primarily because there was negligible mortality in women with borderline tumors. The women's usual diet was assessed using a validated food frequency questionnaire. Deaths in the cohort were identified using state-based cancer registries and the Australian National Death Index (NDI). Crude 5-year survival probabilities were estimated using the Kaplan-Meier technique, and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were obtained from Cox regression models. After adjusting for important confounding factors, a survival advantage was observed for those who reported higher intake of vegetables in general (HR = 0.75, 95% CI = 0.57-0.99, p-value trend 0.01 for the highest third, compared to the lowest third), and cruciferous vegetables in particular (HR = 0.75, 95% CI = 0.57-0.98, p-value trend 0.03), and among women in the upper third of intake of vitamin E (HR = 0.76, 95% CI = 0.58-1.01, p-value trend 0.04). Inverse associations were also seen with protein (p-value trend 0.09), red meat (p-value trend 0.06) and white meat (p-value trend 0.07), and modest positive trends (maximum 30% excess) with lactose (p-value trend 0.04), calcium and dairy products. Although much remains to be learned about the influence of nutritional factors after a diagnosis of ovarian cancer, our study suggests the possibility that a diet high in vegetable intake may help improve survival. (C) 2003 Wiley-Liss, Inc.

Sonar de varredura lateral e sísmica de alta resolução aplicados no estudo de ecofácies na baía de Vitória-ES

Levantamentos geofísicos de alta resolução e amostragem de sedimentos de fundo foram realizados na Baía de Vitória tendo como objetivo mapear o fundo marinho acusticamente. A análise integrada de registros de sonar de varredura lateral e sísmica rasa permitiu o reconhecimento de 4 ecofácies distintas. A ecofácies Tipo 1 está associada a fundos sem penetração do sinal acústico e com sonogramas de alta intensidade de retorno do sinal e dunas subaquosas, onde areias são predominantes. A ecofácies Tipo 2 ocorre comumente em fundos areno-lamosos que apresentam alta penetração do sinal acústico e baixa intensidade do sinal nos sonogramas. A ecofácies Tipo 3 é caracterizada por uma penetração transparente do sinal até encontrar um refletor de alta amplitude e sem penetração, sendo típica de fundos lamosos. A ecofácies Tipo 4 está diretamente associada a fundos rochosos. A análise da distribuição destas ecofácies permite a interpretação dos principais processos sedimentares que atuam ao longo da baía.

Survival Analysis Employed in Predicting Corporate Failure: A Forecasting Model Proposal

In face of the current economic and financial environment, predicting corporate bankruptcy is arguably a phenomenon of increasing interest to investors, creditors, borrowing firms, and governments alike. Within the strand of literature focused on bankruptcy forecasting we can find diverse types of research employing a wide variety of techniques, but only a few researchers have used survival analysis for the examination of this issue. We propose a model for the prediction of corporate bankruptcy based on survival analysis, a technique which stands on its own merits. In this research, the hazard rate is the probability of ‘‘bankruptcy’’ as of time t, conditional upon having survived until time t. Many hazard models are applied in a context where the running of time naturally affects the hazard rate. The model employed in this paper uses the time of survival or the hazard risk as dependent variable, considering the unsuccessful companies as censured observations.

Impact of a 1755-like tsunami in Huelva, Spain

Coastal areas are highly exposed to natural hazards associated with the sea. In all cases where there is historical evidence for devastating tsunamis, as is the case of the southern coasts of the Iberian Peninsula, there is a need for quantitative hazard tsunami assessment to support spatial planning. Also, local authorities must be able to act towards the population protection in a preemptive way, to inform 'what to do' and 'where to go' and in an alarm, to make people aware of the incoming danger. With this in mind, we investigated the inundation extent, run-up and water depths, of a 1755-like event on the region of Huelva, located on the Spanish southwestern coast, one of the regions that was affected in the past by several high energy events, as proved by historical documents and sedimentological data. Modelling was made with a slightly modified version of the COMCOT (Cornell Multi-grid Coupled Tsunami Model) code. Sensitivity tests were performed for a single source in order to understand the relevance and influence of the source parameters in the inundation extent and the fundamental impact parameters. We show that a 1755-like event will have a dramatic impact in a large area close to Huelva inundating an area between 82 and 92 km(2) and reaching maximum run-up around 5 m. In this sense our results show that small variations on the characteristics of the tsunami source are not too significant for the impact assessment. We show that the maximum flow depth and the maximum run-up increase with the average slip on the source, while the strike of the fault is not a critical factor as Huelva is significantly far away from the potential sources identified up to now. We also show that the maximum flow depth within the inundated area is very dependent on the tidal level, while maximum run-up is less affected, as a consequence of the complex morphology of the area.

Exposure assessment: the influence of environmental monitoring methodology

Exposure assessment is an important step of risk assessment process and has evolved more quickly than perhaps any aspect of the four-step risk paradigm (hazard identification, exposure assessment, dose-response analysis, and risk characterization). Nevertheless, some epidemiological studies have associated adverse health effects to a chemical exposure with an inadequate or absent exposure quantification. In addition to the metric used, the truly representation of exposure by measurements depends on: the strategy of sampling, random collection of measurements, and similarity between the measured and unmeasured exposure groups. Two environmental monitoring methodologies for formaldehyde occupational exposure were used to assess the influence of metric selection in exposure assessment and, consequently, in risk assessment process.

Projecto de execução de fundações e estruturas de uma ponte em betão armado pré-esforçado

Este Trabalho refere-se ao Projecto de Execução de Fundações e Estruturas de uma Ponte Rodoviária em betão armado pré-esforçado, realizado no âmbito do Trabalho Final de Mestrado em Engenharia Civil – Especialização em Estruturas, do Instituto Superior de Engenharia de Lisboa. O Projecto de Execução é composto de Peças Escritas e Peças Desenhadas. Nas Peças Escritas estão incluídos: Memória Justificativa e Descritiva; Cálculos Justificativos e Anexos. A ponte é composta por dois tabuleiros paralelos com 10,28m de largura cada um e afastados entre si de 0,10m. A obra é constituída de 8 tramos; os tramos correntes com 31m de comprimento e os tramos extremos com 25 e 20m de comprimento, perfazendo um comprimento total de 231m. A obra foi parcialmente isolada dos sismos pela introdução, em todos os pilares, de aparelhos de apoio de elevado amortecimento sísmico do tipo HDRB (High Damping Rubber Bearings). Encontram-se particularmente discriminadas e detalhadas neste projecto as seguintes situações: - Cálculo do Pré-esforço e respectivas perdas; - Acção das sobrecargas rodoviárias; - Diferença de comportamento da obra na entrada em serviço e no longo prazo; - Análise sísmica e do isolamento sísmico; - Estudo dos efeitos diferidos: retracção e fluência. Tendo as abordagens de cálculo e as verificações de segurança seguido a regulamentação nacional em vigor, nomeadamente RSA e REBAP, foi no entanto feita uma aproximação às regras do “Capacity Design” previstas no EC8, em que se privilegia a actuação do projectista sobre o comportamento da estrutura, procurando uma resposta não linear da mesma, visando garantir que: - A rotura não ocorrerá nos elementos de fundação; - Nos pilares a dissipação de energia se faz através de rótulas plásticas, evitando-se roturas associadas a esforços transversos. A aplicação destas regras neste Projecto demonstrou haver um agravamento substancial na definição dos esforços a que devem resistir alguns dos componentes da estrutura, designadamente os pilares e as fundações, originando soluções de secções de betão e armaduras bem mais exigentes do que aqueles que resultariam da simples verificação de segurança, pela comparação entre esforços actuante e esforços resistentes “secção a secção”, imposta pela actual regulamentação nacional.