A multiplicative model for standardizing vital rates without using external standards

Standardization is a common method for adjusting confounding factors when comparing two or more exposure category to assess excess risk. Arbitrary choice of standard population in standardization introduces selection bias due to healthy worker effect. Small sample in specific groups also poses problems in estimating relative risk and the statistical significance is problematic. As an alternative, statistical models were proposed to overcome such limitations and find adjusted rates. In this dissertation, a multiplicative model is considered to address the issues related to standardized index namely: Standardized Mortality Ratio (SMR) and Comparative Mortality Factor (CMF). The model provides an alternative to conventional standardized technique. Maximum likelihood estimates of parameters of the model are used to construct an index similar to the SMR for estimating relative risk of exposure groups under comparison. Parametric Bootstrap resampling method is used to evaluate the goodness of fit of the model, behavior of estimated parameters and variability in relative risk on generated sample. The model provides an alternative to both direct and indirect standardization method. ^

HEALTH MAINTENANCE ORGANIZATION ENVIRONMENT: AN EMPIRICAL STUDY OF THE RELATIONSHIP OF EXTERNAL CONTEXT AND PERFORMANCE

The research project is an extension of a series of administrative science and health care research projects evaluating the influence of external context, organizational strategy, and organizational structure upon organizational success or performance. The research will rely on the assumption that there is not one single best approach to the management of organizations (the contingency theory). As organizational effectiveness is dependent on an appropriate mix of factors, organizations may be equally effective based on differing combinations of factors. The external context of the organization is expected to influence internal organizational strategy and structure and in turn the internal measures affect performance (discriminant theory). The research considers the relationship of external context and organization performance.^ The unit of study for the research will be the health maintenance organization (HMO); an organization the accepts in exchange for a fixed, advance capitation payment, contractual responsibility to assure the delivery of a stated range of health sevices to a voluntary enrolled population. With the current Federal resurgence of interest in the Health Maintenance Organization (HMO) as a major component in the health care system, attention must be directed at maximizing development of HMOs from the limited resources available. Increased skills are needed in both Federal and private evaluation of HMO feasibility in order to prevent resource investment and in projects that will fail while concurrently identifying potentially successful projects that will not be considered using current standards.^ The research considers 192 factors measuring contextual milieu (social, educational, economic, legal, demographic, health and technological factors). Through intercorrelation and principle components data reduction techniques this was reduced to 12 variables. Two measures of HMO performance were identified, they are (1) HMO status (operational or defunct), and (2) a principle components factor score considering eight measures of performance. The relationship between HMO context and performance was analysed using correlation and stepwise multiple regression methods. In each case it has been concluded that the external contextual variables are not predictive of success or failure of study Health Maintenance Organizations. This suggests that performance of an HMO may rely on internal organizational factors. These findings have policy implications as contextual measures are used as a major determinant in HMO feasibility analysis, and as a factor in the allocation of limited Federal funds. ^

External validation study of a clinical prediction rule for ambulation outcomes after traumatic spinal cord injury

The main objective of this study was to determine the external validity of a clinical prediction rule developed by the European Multicenter Study on Human Spinal Cord Injury (EM-SCI) to predict the ambulation outcomes 12 months after traumatic spinal cord injury. Data from the North American Clinical Trials Network (NACTN) data registry with approximately 500 SCI cases were used for this validity study. The predictive accuracy of the EM-SCI prognostic model was evaluated using calibration and discrimination based on 231 NACTN cases. The area under the receiver-operating-characteristics curve (ROC) curve was 0.927 (95% CI 0.894 – 0.959) for the EM-SCI model when applied to NACTN population. This is lower than the AUC of 0.956 (95% CI 0.936 – 0.976) reported for the EM-SCI population, but suggests that the EM-SCI clinical prediction rule distinguished well between those patients in the NACTN population who were able to achieve independent ambulation and those who did not achieve independent ambulation. The calibration curve suggests that higher the prediction score is, the better the probability of walking with the best prediction for AIS D patients. In conclusion, the EM-SCI clinical prediction rule was determined to be generalizable to the adult NACTN SCI population.^

UNDERSTANDING NURSE CREATED COGNITIVE ARTIFACTS: PERSONALLY-CREATED-COGNITIVE-ARTIFACTS AS EXTERNAL REPRESENTATIONS OF DISTRIBUTED COGNITION

Manuscript 1: “Conceptual Analysis: Externalizing Nursing Knowledge” We use concept analysis to establish that the report tool nurses prepare, carry, reference, amend, and use as a temporary data repository are examples of cognitive artifacts. This tool, integrally woven throughout the work and practice of nurses, is important to cognition and clinical decision-making. Establishing the tool as a cognitive artifact will support new dimensions of study. Such studies can characterize how this report tool supports cognition, internal representation of knowledge and skills, and external representation of knowledge of the nurse. Manuscript 2: “Research Methods: Exploring Cognitive Work” The purpose of this paper is to describe a complex, cross-sectional, multi-method approach to study of personal cognitive artifacts in the clinical environment. The complex data arrays present in these cognitive artifacts warrant the use of multiple methods of data collection. Use of a less robust research design may result in an incomplete understanding of the meaning, value, content, and relationships between personal cognitive artifacts in the clinical environment and the cognitive work of the user. Manuscript 3: “Making the Cognitive Work of Registered Nurses Visible” Purpose: Knowledge representations and structures are created and used by registered nurses to guide patient care. Understanding is limited regarding how these knowledge representations, or cognitive artifacts, contribute to working memory, prioritization, organization, cognition, and decision-making. The purpose of this study was to identify and characterize the role a specific cognitive artifact knowledge representation and structure as it contributed to the cognitive work of the registered nurse. Methods: Data collection was completed, using qualitative research methods, by shadowing and interviewing 25 registered nurses. Data analysis employed triangulation and iterative analytic processes. Results: Nurse cognitive artifacts support recall, data evaluation, decision-making, organization, and prioritization. These cognitive artifacts demonstrated spatial, longitudinal, chronologic, visual, and personal cues to support the cognitive work of nurses. Conclusions: Nurse cognitive artifacts are an important adjunct to the cognitive work of nurses, and directly support patient care. Nurses need to be able to configure their cognitive artifact in ways that are meaningful and support their internal knowledge representations.

External assessment of myocardial glucose metabolism with $\sp{18}$F-2 -deoxy-2 -fluoro-D-glucose

Despite the popularity of the positron emitting glucose analog, ($\sp{18}$F) -2-deoxy-2-fluoro-D-glucose (2FDG), for the noninvasive "metabolic imaging" of organs with positron emission tomography (PET), the physiological basis for the tracer has not been tested, and the potential of 2FDG for the rapid kinetic analysis of altered glucose metabolism in the intact heart has not been fully exploited. We, therefore, developed a quantitative method to characterize metabolic changes of myocardial glucose metabolism noninvasively and with high temporal resolution.^ The first objective of the work was to provide direct evidence that the initial steps in the metabolism of 2FDG are the same as for glucose and that 2FDG is retained by the tissue in proportion to the rate of glucose utilization. The second objective was to characterize the kinetic changes in myocardial glucose transport and phosphorylation in response to changes in work load, competing substrates, acute ischemia and reperfusion, and the addition of insulin. To assess changes in myocardial glucose metabolism isolated working rat hearts were perfused with glucose and 2FDG. Tissue uptake of 2FDG and the input function were measured on-line by external detection. The steady state rate of 2FDG phosphorylation was determined by graphical analysis of 2FDG time-activity curves.^ The rate of 2FDG uptake was linear with time and the tracer was retained in its phosphorylated form. Tissue accumulation of 2FDG decreased within seconds with a reduction in work load, in the presence of competing substrates, and during reperfusion after global ischemia. Thus, most interventions known to alter glucose metabolism induced rapid parallel changes in 2FDG uptake. By contrast, insulin caused a significant increase in 2FDG accumulation only in hearts from fasted animals when perfused at a sub-physiological work load. The mechanism for this phenomenon is not known but may be related to the existence of two different glucose transporter systems and/or glycogen metabolism in the myocardial cell.^ It is concluded that (1) 2FDG traces glucose uptake and phosphorylation in the isolated working rat heart; and (2) early and transient kinetic changes in glucose metabolism can be monitored with high temporal resolution with 2FDG and a simple positron coincidence counting system. The new method has revealed transients of myocardial glucose metabolism, which would have remained unnoticed with conventional methods. These transients are not only important for the interpretation of glucose metabolic PET scans, but also provide insights into mechanisms of glucose transport and phosphorylation in heart muscle. ^

Global cooling during the Eocene Oligocene Transition

About 34 million years ago, Earth's climate shifted from a relatively ice-free world to one with glacial conditions on Antarctica characterized by substantial ice sheets. How Earth's temperature changed during this climate transition remains poorly understood, and evidence for Northern Hemisphere polar ice is controversial. Here, we report proxy records of sea surface temperatures from multiple ocean localities and show that the high-latitude temperature decrease was substantial and heterogeneous. High-latitude (45 degrees to 70 degrees in both hemispheres) temperatures before the climate transition were ~20°C and cooled an average of ~5°C. Our results, combined with ocean and ice-sheet model simulations and benthic oxygen isotope records, indicate that Northern Hemisphere glaciation was not required to accommodate the magnitude of continental ice growth during this time.

(Table 3) Run conditions and phase relations and proportions during cooling rate experiments on ODP Interval 163-989B-10R-7,55-59

Equilibrium melting and controlled cooling experiments were undertaken to constrain the crystallization and cooling histories of tholeiitic basalts recovered by the Ocean Drilling Program drilling of Site 989 on the Southeast Greenland continental margin. Isothermal experiments conducted at 1 atm. and at the fayalite-magnetite-quartz buffer using lava sample Section 163-989B-10R-7 yielded the equilibrium appearance sequence with decreasing temperature: olivine at 1184 ± 2ºC; plagioclase at 1177ºC ± 5ºC; augite at 1167 ± 5ºC; and pigeonite at 1113 ± 12ºC. In controlled cooling experiments using the same starting composition and cooling rates between 10ºC/hr and 2000ºC/hr, we find a significant temperature delay in the crystallization of olivine, plagioclase, and augite (relative to the equilibrium appearance temperature); pigeonite does not form under any dynamic crystallization conditions. Olivine exhibits the largest suppression in appearance temperature (e.g., 30º for 10ºC/hr and >190º at 100ºC/hr), while plagioclase shows the smallest (~10ºC at 10ºC/hr; 30ºC at 100ºC/hr, and ~80ºC at 1000ºC/hr). These results are in marked contrast to those obtained on lunar basalts, which generally show a large suppression of plagioclase crystallization and modest suppression of olivine crystallization with an increased cooling rate. The results we report agree well with the petrography of lavas recovered from Site 989. Furthermore, the textural analysis of run products, representing a large range of cooling rates and quench temperatures (1150ºC to 1000ºC), provide a framework for evaluating cooling conditions necessary for glass formation, rates of plagioclase growth, and kinetic factors governing plagioclase growth morphology. Specifically, we use these insights to interpret the textural and mineralogical features of the unusual compound flow recovered at Site 989. We concluded from the analysis that this flow most likely records multiple breakouts from a distal tube at an abrupt break in slope, possibly a fault scarp, resulting in the formation of a lava fan delta. This interpretation implies that normal faulting of the oldest lava sequences (lower and, possibly, middle series) preceded eruption of Site 989 lavas.

Constraints on the magnitude and patterns of ocean cooling at the Last Glacial Maximum - Supplementary material

Observation-based reconstructions of sea surface temperature from relatively stable periods in the past, such as the Last Glacial Maximum, represent an important means of constraining climate sensitivity and evaluating model simulations. The first quantitative global reconstruction of sea surface temperatures during the Last Glacial Maximum was developed by the Climate Long-Range Investigation, Mapping and Prediction (CLIMAP) project in the 1970s and 1980s. Since that time, several shortcomings of that earlier effort have become apparent. Here we present an updated synthesis of sea surface temperatures during the Last Glacial Maximum, rigorously defined as the period between 23 and 19 thousand years before present, from the Multiproxy Approach for the Reconstruction of the Glacial Ocean Surface (MARGO) project. We integrate microfossil and geochemical reconstructions of surface temperatures and include assessments of the reliability of individual records. Our reconstruction reveals the presence of large longitudinal gradients in sea surface temperature in all of the ocean basins, in contrast to the simulations of the Last Glacial Maximum climate available at present.

Onset of long-term cooling of Greenland near the Eocene-Oligocene boundary as revealed by branched tetraether lipids

The Eocene-Oligocene (E-O) boundary interval is considered to be one of the major transitions in Earth's climate, witnessing the first major expansion of the East Antarctic Ice Sheet. However, the extent of the associated climatic cooling, especially for high northern latitude continental landmasses, is poorly constrained. In this study we reconstruct the first mean annual air temperature (MAAT) for the Greenland landmass during the late Eocene and early Oligocene by applying a new proxy based on the distribution of branched tetraether lipids derived from soil bacteria preserved in a marine sediment core from the Greenland Basin. The temperature estimates are compared with a composite continental temperature record based on bio-climatic analysis of pollen assemblages. Both proxies reveal comparable late Eocene MAATs of ~13-15 °C and a gradual long-term cooling of ~3-5 °C starting near the E-O boundary. These data are in agreement with other MAAT reconstructions from northern midlatitude continents and suggest a general cooling of the Northern Hemisphere during the E-O transition.

Response of marine palynomorphs to Neogene climate cooling in the Iceland Sea, ODP Hole 151-907A

The present study on ODP Leg 151 Hole 907A combines a detailed analysis of marine palynomorphs (dinoflagellate cysts, prasinophytes, and acritarchs) and a low-resolution alkenone-based sea-surface temperature (SST) record for the interval between 14.5 and 2.5 Ma, and allows to investigate the relationship between palynomorph assemblages and the paleoenvironmental evolution of the Iceland Sea. A high marine productivity is indicated in the Middle Miocene, and palynomorphs and SSTs both mirror the subsequent long-term Neogene climate deterioration. The diverse Middle Miocene palynomorph assemblages clearly diminish towards the impoverished assemblages of the Late Pliocene; parallel with a somewhat gradual decrease of SSTs being as high as 20 °C at ~13.5 Ma to around 8 °C at ~3 Ma. Superimposed, palynomorph assemblages not only reflect Middle to Late Miocene climate variability partly coinciding with the short-lived global Miocene isotope events (Mi-events), but also the initiation of a proto-thermohaline circulation across the Middle Miocene Climate Transition, which led to increased meridionality in the Nordic Seas. Last occurrences of species cluster during three events in the Late Miocene to Early Pliocene and are ascribed to the progressive strengthening and freshening of the proto-East Greenland Current towards modern conditions. A significant high latitude cooling between 6.5 and 6 Ma is depicted by the supraregional "Decahedrella event" coeval with lowest Miocene productivity and a SST decline. In the Early Pliocene, a transient warming is accompanied by surface water stratification and increased productivity that likely reflects a high latitude response to the global biogenic bloom. The succeeding crash in palynomorph accumulation, and a subsequent interval virtually barren of marine palynomorphs may be attributed to enhanced bottom water oxygenation and substantial sea ice cover, and indicates that conditions seriously affecting marine productivity in the Iceland Sea were already established well before the marked expansion of the Greenland Ice Sheet at 3.3 Ma.

Estimation of cooling of lavas from Serocki volcano

A dynamic crystallization study was undertaken to provide a framework for linking the textural variations observed in the Hole 648B lavas with the size and morphology of cooling units inferred from drilling and submersible observation. The textures produced in cooling rate experiments carried out using a Serocki lava (ALV-1690-20) are comparable to the groundmass textural characteristics of lavas from Serocki volcano. The results of the dynamic crystallization study provide a quantitative link between texture, cooling rate, and eruption temperature. The maximum half-width of cooling units estimated from textural characteristics is on the order of 3 m, a value consistent with constraints from drilling and submersible observation. Textural characteristics indicate that the temperature from which cooling began was slightly above the liquidus. The relation between cooling rate and texture are also tested on a drill core sample of basalt of similar composition from a 9-m-thick flow in DSDP Hole 396B.

Table 3: Reproductive viability of Hemichloris antarctica after cycles of cooling und warming

Laboratory experiments show that undercooling to about -5°C occurs in colonized Beacon sandstones of the Ross Desert, Antarctica. High-frequency temperature oscillations between 5°C and -5°C or -10°C (which occur in nature on the rock surface) did not damage Hemichloris antarctica. In a cryomicroscope, H. antarctica appeared to be undamaged after slow or rapid cooling to -50°C. l4CO2 incorporation after freezing to -20°C was unaffected in H. antarctica or in Trebouxia sp. but slightly depressed in Stichococcus sp. (isolated from a less extreme Antarctic habitat). These results suggest that the freezing regime in the Antarctic desert is not injurious to endolithic algae. It is likely that the freezing-point depression inside the rock makes available liquid water for metabolic activity at subzero temperatures. Freezing may occur more frequently on the rock surface and contribute to the abiotic nature of the surface.