Treatment intensification and risk factor control: toward more clinically relevant quality measures.

BACKGROUND: Intensification of pharmacotherapy in persons with poorly controlled chronic conditions has been proposed as a clinically meaningful process measure of quality. OBJECTIVE: To validate measures of treatment intensification by evaluating their associations with subsequent control in hypertension, hyperlipidemia, and diabetes mellitus across 35 medical facility populations in Kaiser Permanente, Northern California. DESIGN: Hierarchical analyses of associations of improvements in facility-level treatment intensification rates from 2001 to 2003 with patient-level risk factor levels at the end of 2003. PATIENTS: Members (515,072 and 626,130; age >20 years) with hypertension, hyperlipidemia, and/or diabetes mellitus in 2001 and 2003, respectively. MEASUREMENTS: Treatment intensification for each risk factor defined as an increase in number of drug classes prescribed, of dosage for at least 1 drug, or switching to a drug from another class within 3 months of observed poor risk factor control. RESULTS: Facility-level improvements in treatment intensification rates between 2001 and 2003 were strongly associated with greater likelihood of being in control at the end of 2003 (P < or = 0.05 for each risk factor) after adjustment for patient- and facility-level covariates. Compared with facility rankings based solely on control, addition of percentages of poorly controlled patients who received treatment intensification changed 2003 rankings substantially: 14%, 51%, and 29% of the facilities changed ranks by 5 or more positions for hypertension, hyperlipidemia, and diabetes, respectively. CONCLUSIONS: Treatment intensification is tightly linked to improved control. Thus, it deserves consideration as a process measure for motivating quality improvement and possibly for measuring clinical performance.

Correcting Interdevice Bias of Horizontal White-to-White and Sulcus-to-Sulcus Measures Used for Implantable Collamer Lens Sizing.

PURPOSE: To assess the agreement and repeatability of horizontal white-to-white (WTW) and horizontal sulcus-to-sulcus (STS) diameter measurements and use these data in combination with available literature to correct for interdevice bias in preoperative implantable collamer lens (ICL) size selection. DESIGN: Interinstrument reliability and bias assessment study. METHODS: A total of 107 eyes from 56 patients assessed for ICL implantation at our institution were included in the study. This was a consecutive series of all patients with suitable available data. The agreement and bias between WTW (measured with the Pentacam and BioGraph devices) and STS (measured with the HiScan device) were estimated. RESULTS: The mean spherical equivalent was -8.93 ± 5.69 diopters. The BioGraph measures of WTW were wider than those taken with the Pentacam (bias = 0.26 mm, P < .01), and both horizontal WTW measures were wider than the horizontal STS measures (bias >0.91 mm, P < .01). The repeatability (Sr) of STS measured with the HiScan was 0.39 mm, which was significantly reduced (Sr = 0.15 mm) when the average of 2 measures was used. Agreement between the horizontal WTW measures and horizontal STS estimates when bias was accounted for was г = 0.54 with the Pentacam and г = 0.64 with the BioGraph. CONCLUSIONS: Large interdevice bias was observed for WTW and STS measures. STS measures demonstrated poor repeatability, but the average of repeated measures significantly improved repeatability. In order to conform to the US Food and Drug Administration's accepted guidelines for ICL sizing, clinicians should be aware of and account for the inconsistencies between devices.

黃赤道距度表Huang chi dao ju du biao.Table des degrés de distance entre l'écliptique et l'équateur.

Comparer aussi, Cat. imp., liv. 106, f. 21 (Xin fa suan shu, 100 livres).Publiée par ordre impérial avant 1644, par Xu Guang qi et le P. Terenz (1576-1630).

Bird depredation of grapes in Niagara vineyards : a novel approach to identifying spatial and temporal trends /

Although local grape growers view bird depredation as a significant economic issue, the most recent research on the problem in the Niagara Peninsula is three decades old. Peer-reviewed publications on the subject are rare, and researchers have struggled to develop bird-damage assessment techniques useful for facilitating management programmes. I used a variation of Stevenson and Virgo's (1971) visual estimation procedure to quantify spatial and temporal trends in bird damage to grapes within single vineyard plots at two locations near St. Catharines, Ontario. I present a novel approach to managing the rank-data from visual estimates, which is unprecedented in its sensitivity to spatial trends in bird damage. I also review its valid use in comparative statistical analysis. Spatial trends in 3 out of 4 study plots confirmed a priori predictions about localisation in bird damage based on optimal foraging from a central location (staging area). Damage to grape clusters was: (1) greater near the edges of vineyard plots and decreased with distance towards the center, (2) greater in areas adjacent to staging areas for birds, and (3) vertically stratified, with upper-tier clusters sustaining more damage than lower-tier clusters. From a management perspective, this predictive approach provides vineyard owners with the ability to identify the portions of plots likely to be most susceptible to bird damage, and thus the opportunity to focus deterrent measures in these areas. Other management considerations at Henry of Pelham were: (1) wind damage to ice-wine Riesling and Vidal was much higher than bird damage, (2) plastic netting with narrow mesh provided more effective protection agsiinst birds than nylon netting with wider mesh, and (3) no trends in relative susceptibility of varietals by colour (red vs green) were evident.

Effects of isometric elbow flexion on electromyographic spike analysis

The main objective of this research was to examine the relationship between surface electromyographic (SEMG) spike activity and force. The secondary objective was to determine to what extent subcutaneous tissue impacts the high frequency component of the signal, as well as, examining the relationship between measures of SEMG spike shape and their traditional time and frequency analogues. A total of96 participants (46 males and 50 females) ranging in age (18-35 years), generated three 5-second isometric step contractions at each force level of 40, 60, 80, and 100 percent of maximal voluntary contraction (MVC). The presentation of the contractions was balanced across subjects. The right arm of the subject was positioned in the sagittal plane, with the shoulder and elbow flexed to 90 degrees. The elbow rested on a support in a neutral position (mid pronation/mid supination) and placed within a wrist cuff, fastened below the styloid process. The wrist cuff was attached to a load cell (JR3 Inc., Woodland, CA) recording the force produced. Biceps brachii activity was monitored with a pair of Ag/AgCI recording electrodes (Grass F-E9, Astro-Med Inc., West Warwick, RI) placed in a bipolar configuration, with an interelectrode distance (lED) of 2cm distal to the motor point. Data analysis was performed on a I second window of data in the middle of the 5-second contraction. The results indicated that all spike shape measures exhibited significant (p < 0.01) differences as force increase~ from 40 to 100% MVC. The spike shape measures suggest that increased motor unit (MU) recruitment was responsible for increasing force up to 80% MVC. The results suggested that further increases in force relied on MU III synchronization. The results also revealed that the subcutaneous tissue (skin fold thickness) had no relationship (r = 0.02; P > 0.05) with the mean number of peaks per spike (MNPPS), which was the high frequency component of the signal. Mean spike amplitude (MSA) and mean spike frequency (MSF) were highly correlated with their traditional measures root mean square (RMS) and mean power frequency (MPF), respectively (r = 0.99; r = 0.97; P < 0.01).

Anaerobic performance in ice hockey : the effect of skate blade radius of hollow

The purpose of the study was to investigate the effect of skate blade radius of hollow (ROH) on anaerobic performance, specifically during the acceleration and stopping phases of an on-ice skating test. Fifteen, male Junior B hockey players (mean age 19 y ± 1.46) were recruited to participate. On-icc testing required each participant to complete an on-ice anaerobic performance test [Reed Repeat Skate (RRS)) on three separate days. During each on-ice test, the participant's skate blades were sharpened to one of three, randomly assigned, ROH values (0.63 cm, 1.27 cm, 1.90 cm). Performance times were recorded during each RRS and used to calculate anaerobic variables [anaerobic power (W), anaerobic capacity (W), and fatigue index (s, %)). Each RRS was video recorded for the purpose of motion analysis. Video footage was imported into Peak Motus™ to measure kinematic variables of the acceleration and stopping phases. The specific variables calculated from the acceleration phase were: average velocity over 6 m (m/s), average stride length (m), and mean stride rate (strides/s). The specific variables calculated from the stopping phase were: velocity at initiation of stopping (rn/s), stopping distance (m), stopping time (s). A repeated measures ANOV A was used to assess differences in mean performance and kinematic variables across the three selected hollows. Further analysis was conducted to assess differences in trial by trial performance and kinematic variables for all hollows. The primary findings of the study suggested that skate blade ROH can have a significant effect on kinematic variables, namely stride length and stride rate during the acceleration phase and stopping distance and stopping time during the stopping phase of an on-ice anaerobic performance test. During the acceleration phase, no significant difdifferences were found in SR and SL across the three selected hollows. Mean SR on the 1.27 cm hollow was significantly slower than both the 0.63 cm and 1.90 cm hollows and SL was significantly longer when skating on the 1.27 cm hollow in comparison to the 1.90 cm hollow. During the stopping phase, stopping distance on the 0.63 cm hollow (4.12 m ± 0.14) was significantly shorter than both the 1.27 cm hollow (4.43 m ± 0.08) (p < 0.05) and the 1.90 cm ho])ow (4.35 m ± 0.12) (p < 0.05). Mean ST was also significantly shorter when stopping on the 0.63 cm hollow then both the 1.27 cm and 1.90 cm hollows. Trial by trial results clearly illustrated the affect of fatigue on kinematic variables; AV, SR, IV decreased from trial 1 to 6. There was no significant effect on anaerobic performance variables during the RRS. Altering the skate blade ROH has a significant and practical affect on accelerating and stopping performance will be discussed in this paper.

Assessing evaluative measures for Internet-based courseware

Although there is a consensus in th~ literature on the many uses of the Internet in education, as well as the unique features of the Internet for presenting facts and information, there is no consensus on a standardized method for evaluating Internetbased courseware. Educators rarely have the opportunity to participate in the development of Internet-based courseware, yet they are encouraged to use the technology in their learning environments. This creates a need for summative evaluation methods for Internet-based health courseware. The purpose ofthis study was to assess evaluative measures for Internet-based courseware. Specifically, two entities were evaluated within the study: a) the outcome of the Internet-based courseware, and b) the Internet-based courseware itself. To this end, the Web site www.bodymatters.com was evaluated using two different approaches by two different cohorts. The first approach was a performance appraisal by a group of endusers. A positive, statistically significant change in the students performance was observed due to the intervention ofthe Web site. The second approach was a productoriented evaluation ofthe Web site with the use of a criterion-based checklist and an open-ended comments section. The findings indicate that a summative, criterion-based evaluation is best completed by a multidisciplinary team. The findi~gs also indicated that the two different cohorts reported different product-oriented appraisals of the Web site. The current research confirmed previous research that found that experts returning a poor evaluation of a Web site did not have a relationship to whether or not the end-users performance improved due to the intervention of the Web site.

Comparison of two measures of PSI electron transport in winter rye

The number of P700 (the reaction centre of Photosystem I) converted to P700+, in winter rye, was determined by measuring the absorbance change at 820nm . It was found, with a single turnover flash, that thylakoids isolated from cold grown plants have a 50% greater number of P700 oxidized than thylakoids isolated from warm grown plants. Incubation of thylakoids in the dark at 35 C did not change the number of P700 oxidized. The conversion of P700 to P700+ with a single flash can be compared to a steady state rate of electron transport using a Clark electrode. The results for P700 oxidation using the absorbance change at 820 nm measure effects within the PSI complex whereas the results obtained from a Clark electrode measures steady state electron transport between the cytochrome blf complex and the PSI complex. In contrast to the results for P700 oxidation it was shown, using a Clark electrode, that both thylakoids from cold grown plants and thylakoids incubated at in the dark 35 C exhibited 50% higher rates of electron transport than thylakoids from warm grown plants. The correlation between the higher rate of steady state PSI electron transport observed in thylakoids isolated from cold grown winter rye and number of active PSI reaction centres localizes the site of the increase to the PSI reaction centre. In contrast the lack of correlation after incubation at 35 C indicates the increase in the rate of light saturated electron transport in thylakoids isolated from cold grown plants and thylakoids incubated in the dark at 35 C occur by different mechanisms.

Elementary computer-mediated online distance education : identification of criteria for successful implementation and practice

This study had three purposes related to the effective implem,entation and practice of computer-mediated online distance education (C-MODE) at the elementary level: (a) To identify a preliminary framework of criteria 'or guidelines for effective implementation and practice, (b) to identify areas ofC-MODE for which criteria or guidelines of effectiveness have not yet been developed, and (c) to develop an implementation and practice criteria questionnaire based on a review of the distance education literature, and to use the questionnaire in an exploratory survey of elementary C-MODE practitioners. Using the survey instrument, the beliefs and attitudes of 16 elementary C'- MODE practitioners about what constitutes effective implementation and practice principles were investigated. Respondents, who included both administrators and instructors, provided information about themselves and the program in which they worked. They rated 101 individual criteria statenlents on a 5 point Likert scale with a \. point range that included the values: 1 (Strongly Disagree), 2 (Disagree), 3 (Neutral or Undecided), 4 (Agree), 5 (Strongly Agree). Respondents also provided qualitative data by commenting on the individual statements, or suggesting other statements they considered important. Eighty-two different statements or guidelines related to the successful implementation and practice of computer-mediated online education at the elementary level were endorsed. Response to a small number of statements differed significantly by gender and years of experience. A new area for investigation, namely, the role ofparents, which has received little attention in the online distance education literature, emerged from the findings. The study also identified a number of other areas within an elementary context where additional research is necessary. These included: (a) differences in the factors that determine learning in a distance education setting and traditional settings, (b) elementary students' ability to function in an online setting, (c) the role and workload of instructors, (d) the importance of effective, timely communication with students and parents, and (e) the use of a variety of media.

Male reproductive competition in the field crickets : gryllus veletis and G. pennsylvanicus

Sexual behavior in the field crickets, Gryllus veletis and G. pennsylvanicus , was studied in outdoor arenas (12 m2) at high and low levels of population density in 1983 and 1984. Crickets were weighed, individually marked, and observed from 2200 until 0800 hrs for at least 9 continuous nights. Calling was measured at 5 min intervals, and movement and matings were recorded hourly. Continuous 24 hr observations were also conducted,·and occurrences of aggressive and courtship songs were noted. The timing of males searching, calling, courting, and fighting for females should coincide with female movement and mating patterns. For most samples female movement and matings occurred at night in the 24 hr observations and were randomly distributed with time for both species in the 10 hr observations. Male movement for G. veletis high density only was enhanced at night in the 24 hr observations, however, males called more at night in both species at high and low densities. Male movement was randomly distributed with time in the 10 hr observations, and calling increased at dawn for the G. pennsylvanicus 1984 high density sample, but was randomly distributed in other samples. Most courtship and aggression songs in the 24 hr observations were too infrequent for statistical testing and generally did not coincide with matings. Assuming residual reproductive value, and costs attached to a male trait in terms of future reproductive success decline with age, males should behave in more costly ways with age; by calling and moving more with age. Consequently, mating rates should increase with age. Female behavior may not change with age. G. veletis , females moved more with age at both low density samples, however, crickets moved less with age at high density. G. pennsylvanicus females moved more with age in the 1984 low density sample, whereas crickets moved less with age in the 1983 high density sample. For both species males in the 1984 high density samples called less with age. For G. pennsylvanicus in 1983 calling and mating rates increased with age. Mating rates decreased with age for G. veletis males in the high density sample. Aging may not affect cricket behavior. As population density increases fewer calling sites become available, costs of territoriality increase, and matings resulting from non-calling behavior should increase. For both species the amount of calling and in G. veletis the distance travelled per night was not different between densities. G. pennsylvanicus males and females moved more at low density. At the same deneity levels there were no differences in calling, mating, and, movement rates in G. veletis , however, G. pennsylvanicus males moved more at high density in 1983 than 1984. There was a positive relationship between calling and mating for the G. pennsylvanicus low density sample only, and selection was acting directly to increase calling. For both species no relationships between movement and mating success was found, however, the selection gradient on movement in the G. veletis high density population was significant. The intensity of selection was not significant and was probably due to the inverse relationship between displacement and weight. Larger males should call more, mate more, and move less than smaller males. There were no correlations between calling and individual weight, and an inverse correlation between movement and size in the G. veletis high density population only. In G. pennsylvanicus , there was a positive correlation between individual weight and mating, but, some correlate of weight was under counter selection pressure and-prevented significance of the intensity of selection. In contrast, there was an inverse correlation in the G.·veletis low density B sample. Both measures of selection intensities were significant and showed that weight only was under selection pressures. An inverse correlation between calling and movement was found for G. veletis at low density only. Because males are territorial, females are predicted to move more than males, however, if movement is a mode of male-male reproductive competition then males may move more than females. G. pennsylvanicus males moved more than females in all samples, however, G. veletis males and females moved similar distances at all densities. The variation in relative mating success explained by calling scores, movement, and weight for both species and all samples were not significant In addition, for both species and all samples the intensity of selection never equalled the opportunity for selection.

Temporal variation in the coral reefs of the east coast of the inner gulf of Thailand

A series of permanent line transects established on fourteen reefs on the eastern seaboard of the Gulf of Thailand were monitored through a three-year period (1995- 1998) using a video transect method. Hierarchical cluster analysis shows three distinctive reef community types dominated by 1) Porites, 2) Acropora and 3) zoantharians. The reefs are developed under naturally turbid conditions and relatively low salinity due to the proximity of four major river outlets located in the uppermost area of the gulf. The number of Acroporid species on the reefs is positively correlated with distance from the major flver outlets. Eighty-seven species of scleractinian coral were found on the transects. Over the three-year period, the comparison of 1995-97-98 matched stations using Repeated Measures ANOV A reveals no significant time-dependent change in percent area cover of reef components except for an overall significant reduction in the faviid coral component. In the 1997-98 matched station comparison, statistical tests reveal significant increases in both Acropora and Porites components that translated into an overall increase in total living coral cover. These findings indicate that the overall environmental conditions have been favorable for coral growth. Outcompetition of massive corals by faster growing corals on several reefs also indicates conditions favorable for reef expansion. Growth of newlyformed Porites colonies over primary rock substrate and dead coral skeleton was presumably responsible for its rapid increase. Although these reefs are in an area of rapid industrialization and population growth, resultant anthropogenic effects have not yet stopped active coral accretion.

The condition of Niagara Falls, and the measures needed to preserve them : eight letters published in the New York Evening post, the New York tribune, and the Boston daily advertiser, during the summer of 1882 /

Appendix: Extracts from Harper's weekly, New York herald, New York tribune and the Nation.

The effects of upper extremity functional electrically stimulated (FES) exercise training on upper limb function in individuals with tetraplegia

Functional Electrically Stimulated (FES) ami cycle ergometry is a relatively new technique for exercise in individuals with impairments of the upper limbs. The purpose of this study was to determine the effects of 12 weeks of FES arm cycle ergometry on upper limb function and cardiovascular fitness in individuals with tetraplegia. F!ve subjects (4M/1F; mean age 43.8 ± 15.4 years) with a spinal cord injury of the cervical spine (C3- C7; ASIA B-D) participated in 12 weeks of3 times per week FES arm cycle ergometry training. Exercise performance measures (time to fatigue, distance to fatigue, work rate) were taken at baseline, 6 weeks, and following 12 weeks of training. Cardiovascular measures (MAP, resting HR, average and peak HR during exercise, cardiovascular efficiency) and self reported upper limb function (as determined by the CUE, sf-QIF, SCI-SET questionnaires) were taken at baseline and following 12 weeks of training. Increases were found in time to fatigue (84.4%), distance to fatigue (111.7%), and work rate (51.3%). These changes were non-significant. There was a significant decrease in MAP (91.1 ± 13.9 vs. 87.7 ± 14.7 mmHg) following 12 weeks ofFES arm cycle ergometry. There was no significant change in resting HR or average and peak HR during exercise. Cardiovascular efficiency showed an increase following the 12 weeks ofFES training (142.9%), which was non-significant. There were no significant changes in the measures of upper limb function and spasticity. Overall, FES arm cycle ergometry is an effective method of cardiovascular exercise for individuals with tetraplegia, as evidenced by a significant decrease in MAP, however it is unclear whether 12 weeks of thrice weekly FES arm cycle ergometry may effectively improve upper limb function in all individuals with a cervical SCI.

Role of family eating practices on daily nutrient intakes, dietary patterns and measures of body composition in peri-adolescents

Although family eating practices (FEPs) playa role in the formation of eating practices in children, there is a lack of evidence regarding the role of FEPs on obesity (DB) risk. The purpose of this thesis was to assess the role of child, mother 'and father eating practices (CEPs; MEPS; FaEPs) on nutrient intakes, dietary patterns and body composition. Data were collected on approximately 2,400 peri-adolescents (s250 with complete covariate data). Dietary patterns were assessed using scores that reflected how closely participants followed DASH and Health Canada (HC) recommendations. In girls, poor CEPs, MEPs and FaEPs were associated with increased BMI and risk of overweight and poor dietary patterns according to DASH, and DASH and HC, respectively. In boys, poor CEPs and FaEPs were associated with increased monounsaturated and trans fat, and Vitamin C intakes, respectively. These findings suggest FEPs are associated with DB risk, particularly in girls.