COMPARISON OF THE ORGANIZATIONAL STRUCTURES AND EFFECTIVENESS OF THE INVESTOR-OWNED AND VOLUNTARY MULTIHOSPITAL SECTORS

Objectives. The central objective of this study was to systematically examine the internal structure of multihospital systems, determining the management principles used and the performance levels achieved in medical care and administrative areas.^ The Universe. The study universe consisted of short-term general American hospitals owned and operated by multihospital corporations. Corporations compared were the investor-owned (for-profit) and the voluntary multihospital systems. The individual hospital was the unit of analysis for the study.^ Theoretical Considerations. The contingency theory, using selected aspects of the classical and human relations schools of thought, seemed well suited to describe multihospital organization and was used in this research.^ The Study Hypotheses. The main null hypotheses generated were that there are no significant differences between the voluntary and the investor-owned multihospital sectors in their (1) hospital structures and (2) patient care and administrative performance levels.^ The Sample. A stratified random sample of 212 hospitals owned by multihospital systems was selected to equally represent the two study sectors. Of the sampled hospitals approached, 90.1% responded.^ The Analysis. Sixteen scales were constructed in conjunction with 16 structural variables developed from the major questions and sub-items of the questionnaire. This was followed by analysis of an additional 7 structural and 24 effectiveness (performance) measures, using frequency distributions. Finally, summary statistics and statistical testing for each variable and sub-items were completed and recorded in 38 tables.^ Study Findings. While it has been argued that there are great differences between the two sectors, this study found that with a few exceptions the null hypotheses of no difference in organizational and operational characteristics of non-profit and for-profit hospitals was accepted. However, there were several significant differences found in the structural variables: functional specialization, and autonomy were significantly higher in the voluntary sector. Only centralization was significantly different in the investor owned. Among the effectiveness measures, occupancy rate, cost of data processing, total manhours worked, F.T.E. ratios, and personnel per occupied bed were significantly higher in the voluntary sector. The findings indicated that both voluntary and for-profit systems were converging toward a common hierarchical corporate management approach. Factors of size and management style may be better descriptors to characterize a specific multihospital group than its profit or nonprofit status. (Abstract shortened with permission of author.) ^

Does prior receipt of a rifamycin antibiotic increase the risk of acquiring an infection due to a rifamycin-resistant strain of Clostridium difficile?

Objectives. To examine the association between prior rifamycin exposure and later development of C. difficile infection (CDI) caused by a rifamycin-resistant strain of C. difficile , and to compare patient characteristics between rifamycin-resistant strains of C. difficile infection and rifamycin-susceptible strains of C. difficile infection. ^ Methods. A case-control study was performed in a large university-affiliated hospital in Houston, Texas. Study subjects were patients with C. difficile infection acquired at the hospital with culture-positive isolates of C. difficile with which in vitro rifaximin and rifampin susceptibility has been tested. Prior use of rifamycin, demographic and clinical characteristics was compared between case and control groups using univariate statistics. ^ Results. A total of 49 C. difficile strains met the study inclusion criteria for rifamycin-resistant case isolates, and a total of 98 rifamycin-susceptible C. difficile strains were matched to case isolates. Of 49 case isolates, 12 (4%) were resistant to rifampin alone, 12 (4%) were resistant to rifaximin alone, and 25 (9%) were resistant to both rifampin and rifaximin. There was no significant association between prior rifamycin use and rifamycin-resistant CDI. Cases and controls did not differ according to demographic characteristics, length of hospital stay, known risk factors of CDI, type of CDI-onset, and pre-infection medical co-morbidities. Our results on 37 rifaximin-resistant isolates (MIC ≥32 &mgr;g/ml) showed more than half of isolates had a rifaximin MIC ≥256 &mgr;g/ml, and out of these isolates, 19 isolates had MICs ≥1024 &mgr;g/ml. ^ Conclusions. Using a large series of rifamycin-non-susceptible isolates, no patient characteristics were independently associated with rifamycin-resistant CDI. This data suggests that factors beyond previous use of rifamycin antibiotics are primary risk factors for rifamycin-resistant C. difficile. ^

A systematic review of telemedicine interventions for type 2 diabetes patients

Telemedicine is the use of telecommunications to support health care services and it incorporates a wide range of technology and devices. This systematic review seeks to determine which types of telemedicine technologies have been the most effective at improving the major health factors of subjects with type 2 diabetes. The major health factors identified were blood glucose, systolic and diastolic blood pressure, LDL cholesterol, weight, BMI, triglyceride levels, and waist circumference. A literature search was performed using peer reviewed, scholarly articles focused on the health outcomes of type 2 diabetes patients served by various telemedicine interventions. A total of 15 articles met the search criteria and were then analyzed to determine the significant health outcomes of each telemedicine interventions for type 2 diabetes patients. Results showed that telemedicine interventions using videoconferencing technology resulted in significant improvements in five health factor outcomes (total body weight, BMI, blood glucose, LDL cholesterol, and blood pressure), while telemedicine interventions using web applications and health monitors/modems only produced significant improvements in blood glucose. Future research should focus on examining the costs and benefits of videoconferencing and other telemedicine technologies for type 2 diabetes patients.^

WORKLOAD AND PERFORMANCE FACTORS ASSOCIATED WITH MULTIMEDIA JOB AIDS FOR COMMUNITY HEALTH WORKERS

This dissertation focuses on factors of multimedia job aids that modify workload, protocol adherence and clinical errors in community health workers. Literature shows that community health workers performance is not acceptable even with support of paper job aids. There are cognitive theories that try to explain reasons why the performance of community health workers is poor regardless of the access to paper based-job aid. Based on cognitive science and multimedia design theories an intervention was designed to compare alternative representations for the information contained on paper job aids and the capability of this new designed job aids to enhance community health workers performance. The dissertation is divided in 5 main parts: 1. identification and description of the problem, 2. a methodological approach to create and evaluate an intervention, 3. Presentation of results of the intervention evaluation, 4. Discussion of findings and 5. Conclusions

Retrospective analysis of Methicillin-Resistant Staphylococcus Aureus (MRSA) skin and Soft-Tissue Infections (SSTI) in a university hospital emergency department (ED)

Study Objective: Identify the most frequent risk factors of Community Acquired-MRSA (CA-MRSA) Skin and Soft-tissue Infections (SSTIs) using a case series of patients and characterize them by age, race/ethnicity, gender, abscess location, druguse and intravenous drug-user (IVDU), underlying medical conditions, homelessness, treatment resistance, sepsis, those whose last healthcare visit was within the last 12 months, and describe the susceptibility pattern from this central Texas population that have come into the University Medical Center Brackenridge (UMCB) Emergency Department (ED). ^ Methods: This study was a retrospective case-series medical record review involving a convenience sample of patients in 2007 from an urban public hospital's ED in Texas that had a SSTI that tested positive for MRSA. All positive MRSA cultures underwent susceptibility testing to determine antibiotic resistance. The demographic and clinical variables that were independently associated with MRSA were determined by univariate and multivariate analysis using logistic regression to calculate odds ratios (OR), 95% confidence intervals, and significance (p≤ 0.05). ^ Results: In 2007, there were 857 positive MRSA cultures. The demographics were: males 60% and females 40%, with the average age of 36.2 (std. dev. =13) the study population consisted of non-Hispanic white (42%), Hispanics (38%), and non-Hispanic black (18.8%). Possible risk factors addressed included using recreational drugs (not including IVDU) (27%) homelessness (13%), diabetes status (12.6%) or having an infectious disease, and IVDU (10%). The most frequent abscess location was the leg (26.6%), followed by the arm and torso (both 13.7%). Eighty-three percent of patients had one prominent susceptibility pattern that had a susceptibility rate for the following antibiotics: trimethoprim/sulfamethoxazole (TMP-SMX) and vancomycin had 100%, gentamicin 99%, clindamycin 96%, tetracycline 96%, and erythromycin 56%. ^ Conclusion: The ED is becoming an important area for disease transmission between the sterile hospital environment and the outside environment. As always, it is important to further research in the ED in an effort to better understand MRSA transmission and antibiotic resistance, as well as to keep surveillance for the introduction of new opportunistic pathogens into the population. ^

Risk factors for inflammatory breast cancer

Background: Inflammatory breast cancer (IBC) is rare and accounts for 2.5% of all invasive breast cancers. The 5-year survival rates are significantly lower than for other types of breast cancer, highlighting the significance of cancer prevention in IBC. The comprehensive multi-disciplinary team Morgan Welch Inflammatory Breast Cancer Research Program and Clinic at University of Texas MD Anderson Cancer Center treats the largest number of Inflammatory Breast patients in a single center. Because of this unique center, large patient resources, and good medical and epidemiological records, we were able to conduct the largest single center case-control and case-case study on IBC. Methods: We identified 246 patients diagnosed with IBC and 397 cancer free patients seen at the Dan L Duncan Cancer Prevention Clinic. Breast cancer reproductive risk factors and lifestyle risk factors were compared between tumor subtypes of IBC patients (Estrogen Receptor positive (ER+) and/or Progesterone Receptor positive (PR+), Human Epidermal Growth Factor 2 positive (HER2+)), and (ER -/PR-/HER2-)) and cancer free controls. Results: Breastfeeding was the only significant risk factor (p<0.01) between tumor subtypes in IBC patients. In the case-control study that included all IBC patients and cancer free patients the descriptive statistics indicate significant difference in BMI, history of smoking, number of children, age of first pregnancy, any breastfeeding and total time breastfeeding (p<0.05). No differences were found in the frequency of other breast cancer risk factors. Conclusion: The associations determined between cancer free controls and IBC patients have identified previously unknown risk factors for IBC. The risk factors identified by the case control study suggest BMI, history of smoking, and the protective effect of breastfeeding as potential modifiable risk factors that can be used to decrease the incidence of IBC. Impact: These results highlight the importance of evaluating epidemiologic risk factors of IBC, which could lead to the identification of distinct etiologic pathways that could be targeted for prevention.^

AN EVALUATION OF THE CONSISTENCY OF IMRT PATIENT-SPECIFIC QA TECHNIQUES

To ensure the integrity of an intensity modulated radiation therapy (IMRT) treatment, each plan must be validated through a measurement-based quality assurance (QA) procedure, known as patient specific IMRT QA. Many methods of measurement and analysis have evolved for this QA. There is not a standard among clinical institutions, and many devices and action levels are used. Since the acceptance criteria determines if the dosimetric tools’ output passes the patient plan, it is important to see how these parameters influence the performance of the QA device. While analyzing the results of IMRT QA, it is important to understand the variability in the measurements. Due to the different form factors of the many QA methods, this reproducibility can be device dependent. These questions of patient-specific IMRT QA reproducibility and performance were investigated across five dosimeter systems: a helical diode array, radiographic film, ion chamber, diode array (AP field-by-field, AP composite, and rotational composite), and an in-house designed multiple ion chamber phantom. The reproducibility was gauged for each device by comparing the coefficients of variation (CV) across six patient plans. The performance of each device was determined by comparing each one’s ability to accurately label a plan as acceptable or unacceptable compared to a gold standard. All methods demonstrated a CV of less than 4%. Film proved to have the highest variability in QA measurement, likely due to the high level of user involvement in the readout and analysis. This is further shown by how the setup contributed more variation than the readout and analysis for all of the methods, except film. When evaluated for ability to correctly label acceptable and unacceptable plans, two distinct performance groups emerged with the helical diode array, AP composite diode array, film, and ion chamber in the better group; and the rotational composite and AP field-by-field diode array in the poorer group. Additionally, optimal threshold cutoffs were determined for each of the dosimetry systems. These findings, combined with practical considerations for factors such as labor and cost, can aid a clinic in its choice of an effective and safe patient-specific IMRT QA implementation.

The number and timing of time -dependent covariate measurements for the Cox regression model

The problem of analyzing data with updated measurements in the time-dependent proportional hazards model arises frequently in practice. One available option is to reduce the number of intervals (or updated measurements) to be included in the Cox regression model. We empirically investigated the bias of the estimator of the time-dependent covariate while varying the effect of failure rate, sample size, true values of the parameters and the number of intervals. We also evaluated how often a time-dependent covariate needs to be collected and assessed the effect of sample size and failure rate on the power of testing a time-dependent effect.^ A time-dependent proportional hazards model with two binary covariates was considered. The time axis was partitioned into k intervals. The baseline hazard was assumed to be 1 so that the failure times were exponentially distributed in the ith interval. A type II censoring model was adopted to characterize the failure rate. The factors of interest were sample size (500, 1000), type II censoring with failure rates of 0.05, 0.10, and 0.20, and three values for each of the non-time-dependent and time-dependent covariates (1/4,1/2,3/4).^ The mean of the bias of the estimator of the coefficient of the time-dependent covariate decreased as sample size and number of intervals increased whereas the mean of the bias increased as failure rate and true values of the covariates increased. The mean of the bias of the estimator of the coefficient was smallest when all of the updated measurements were used in the model compared with two models that used selected measurements of the time-dependent covariate. For the model that included all the measurements, the coverage rates of the estimator of the coefficient of the time-dependent covariate was in most cases 90% or more except when the failure rate was high (0.20). The power associated with testing a time-dependent effect was highest when all of the measurements of the time-dependent covariate were used. An example from the Systolic Hypertension in the Elderly Program Cooperative Research Group is presented. ^

Composition of sedimentary rocks from the Mountainous Crimea and the Northwestern Caucasus

Detailed data obtained on chemistry of sedimentary rocks from the Mountainous Crimea and the Northwestern Caucasus that were dated at the Cenomanian/Turonian boundary and formed during Oceanic Anoxic Event 2 make it possible to calculate dissolved oxygen concentration in bottom waters of the sedimentation basin. Enrichment factors of trace elements in black shales are revised and an explanation is suggested for genesis of the rocks with regard for unusual climatic changes.

Abundance of mesozooplankton in the western part of the Black Sea in 1995 during the Cooperative Marine Science Program for the Black Sea (CoMSBlack)

The "CoMSBlack-95" dataset is based on samples collected in the summer of 1995. The whole dataset is composed of 81 samples (28 stations) with data of zooplankton species composition, abundance and biomass. Samples were collected in discrete layers 0-10, 0-20, 0-50, 10-25, 25-50, 50-100 and from bottom up to the surface at depths depending on water column stratification and the thermocline depth. Zooplankton samples were collected with vertical closing Juday net,diameter - 36 cm, mesh size 150 µm. Tows were performed from surface down to bottom meters depths in discrete layers. Samples were preserved by a 4% formaldehyde sea water buffered solution. Sampling volume was estimated by multiplying the mouth area with the wire length. Mesozooplankton abundance: The collected material was analysed using the method of Domov (1959). Samples were brought to volume of 25-30 ml depending upon zooplankton density and mixed intensively until all organisms were distributed randomly in the sample volume. After that 5 ml of sample was taken and poured in the counting chamber which is a rectangle form for taxomomic identification and count. Large (> 1 mm body length) and not abundant species were calculated in whole sample. Counting and measuring of organisms were made in the Dimov chamber under the stereomicroscope to the lowest taxon possible. Taxonomic identification was done at the Institute of Oceanology by Asen Konsulov and Lyudmila Kamburska using the relevant taxonomic literature (Mordukhay-Boltovskoy, F.D. (Ed.). 1968, 1969,1972). Taxon-specific abundance: The collected material was analysed using the method of Domov (1959). Samples were brought to volume of 25-30 ml depending upon zooplankton density and mixed intensively until all organisms were distributed randomly in the sample volume. After that 5 ml of sample was taken and poured in the counting chamber which is a rectangle form for taxomomic identification and count. Copepods and Cladoceras were identified and enumerated; the other mesozooplankters were identified and enumerated at higher taxonomic level (commonly named as mesozooplankton groups). Large (> 1 mm body length) and not abundant species were calculated in whole sample. Counting and measuring of organisms were made in the Dimov chamber under the stereomicroscope to the lowest taxon possible. Taxonomic identification was done at the Institute of Oceanology by Asen Konsulov and Lyudmila Kamburska using the relevant taxonomic literature (Mordukhay-Boltovskoy, F.D. (Ed.). 1968, 1969,1972).

(Table 4) Mesozoolpankton abundance and biomass and relative percentage of key zooplankton groups along the Bulgarian coast, Black Sea

Results of studies during Project of an international expedition onboard R/V Vladimir Parshin in September-October 2005 are presented. Intensive development of Bacillariophyceae and Dynophyceae was recorded in coastal waters of Bulgaria, Turkey, and in the Danube River delta during period of investigations. Increase in algae population was accompanied by rising of chlorophyll a concentration up to 2.0-5.5 µg/l. In the deep water region it did not exceed 0.5 µg/l. Phytoplankton growth rate in the surface water layer varied from 0.1 to 1.0 1/day. This parameter and NO2+NO3 concentration, as well as the silicon concentration were correlative, as was described by the Michaelis-Menten equation. Phytoplankton growth was affected by basic nutrients. Zooplankton grazing varied from 0.10 to 0.69 1/day and average values in different regions varied by 1.5 times. Microalgae size range is one of major factors of grazing regulation. Rate of phytoplankton consumption was decreasing with increasing the largest diatom Pseudosolenia calcar-avis impact on total biomass of nano- and microphytoplankton.

Radiochemical analyses and contents of organic carbon and CaCO3 in equatorial Pacific Ocean sediments

Uranium series nuclide concentrations have been measured on sediments from five box cores from an equatorial Pacific transect. 230Thexcess activities show discontinuities at the Holocene-glacial boundary as dated by 14C. The glacial sedimentation rates determined by 230Th and 14C are 2.5-3.0 cm/kyr. The Holocene rates from 230Th are much lower than those dated by 14C (1.9-2.3 cm/kyr) because of carbonate dissolution. 230Th sedimentation fluxes exceed water column supply by factors of 1.2-1.8 in the Holocene and 1.8-3.0 in the glacial sections. A number of models have been applied to calculate carbonate dissolution rates. The results show that carbonate dissolution rates in the Holocene (in g/cm**2 kyr) equal 1.5 * 10**-3 exp (1.4D) where D is water depth in kilometers. A point-by- point estimation of sediment fluxes through time show that clay accumulation rates in the area have been near constant at 0.1-0.2 g/cm**2 kyr over the past 20 kyr whereas carbonate accumulation rates have decreased dramatically from 0.6-1.0 g/cm**2 kyr in the glacial sections of the cores to 0.2-0.6 g/cm**2 kyr in the Holocene. The errors caused by the uncertainties in the age of the termination of the last glacial period have been investigated and results show that a range of 11-14 kyr leads to an error upper limit of about 30% in the estimation of CaCO3 dissolution rates. The response time of CaCO3 and 230Thex concentrations in the mixed layer of sediments due to an impulse of change in CaCO3 dissolution rate has also been discussed, showing that the observed changes in carbonate dissolution may be explained in terms of a single or a continuous change, depending upon the thickness of the mixed layer.

Sedimentology and stable isotope record of DSDP Hole 68-503B

Samples from the upper portion of a cyclic pelagic carbonate sediment sequence in Deep-Sea Drilling Project (DSDP) hole 503B (4.0°N, 95.6°W) are the first group to be analyzed for paleoceanographic and paleoclimatic proxy-indicators of ice volume, deep ocean and surface water circulation, and atmospheric circulation in order to resolve the complex origin of the cyclicity. Temporal resolution is taken from the delta18O time scale, most other parameters are calculated in terms of their mass flux to the seafloor. CaCO3 percent in the sediments fluctuates in the well-known Pacific pattern and is higher during glacial times. The fluxes of opal and organic carbon have patterns similar to each other and show a variability of a factor of 2.5 to 4. The longer organic carbon record shows flux maxima during both glacial and interglacial times. The accumulation patterns of both opal and organic carbon suggest that the variability in surface water productivity and/or seafloor preservation of those materials is not simply correlated to glacial or interglacial periods. Eolian dust fluxes are greater during interglacial periods by factors of 2 to 5, indicating that eolian source regions in central and northern South America were more arid during interglacial periods. The record of eolian grain size provides a semiquantitative estimation of the intensity of the transporting winds. The eolian data suggest more intense atmospheric circulation during interglacial periods, opposite to the anticipated results. We interpret this observation as recording the southerly shift of the intertropical convergence zone to the latitude of hole 503B during glaciations.

Cadmium and lead in sea ice and seawater of the Amur Bay, Sea of Japan

Distribution of Cd and Pb in sea ice and in under-ice water of the Amur Bay at the end of February 1998 is considered. The metals were determined by technique of inversion voltammetry. Contribution of Cd and Pb from atmospheric precipitation and from under-ice water to sea ice examined is discussed. On the basis of analysis of vertical distribution in ice, atmospheric fluxes supplying metals to the aquatic area of the bay are estimated at 100 and 2000 µg/m**2/year for Cd and Pb, respectively. Concentrations of Cd and Pb found in middle and lower parts of ice cores allow to suggest that their accumulation relative to main ions of seawater occurs in the ice. Estimated enrichment factors of Cd and Pb in sea ice relative to seawate are ~9 and ~5. A possible mechanism of relative metal accumulation in sea ice is considered.

Chemical composition of ocean-floor basalts and separated magnetites DSDP Legs 37, 45 and 46

Titanomagnetites separated from 15 different rock samples (including ocean-floor basalts from DSDP Legs 37, 45 and 46) were analyzed together with whole-rock samples by instrumental neutron-activation analysis for Sc, Cr, Co, Zn, Hf, Ta, Th and the REE La, Ce, Nd, Sm, Eu, Gd, Tb, Dy, Tm, Yb and Lu. In titanomagnetities from ocean-floor basalts and some other rocks, REE are enriched with respect to the whole-rock composition by factors of between 1.5 and 3 for light REE and between 1.0 and 1.9 for heavy REE; that is, REE with larger ionic radii are preferentially incorporated into the magnetite lattice. Three magnetite samples are REE depleted. Their whole-rock samples contain P in appreciable amounts, so apatite, an important REE-accumulating mineral, could have captured REE to some extent. All titanomagnetites show a marked negative Eu anomaly, this is most probably caused by discrimination of Eu(2+) from the magnetite lattice. Co, Zn, Hf and Ta are significantly enriched in magnetites. The distribution behaviour of Sc and Cr is masked chiefly by the crystallization of clinopyroxene and therefore is not easy to estimate. Ulvöspinel contents of about 70% for the titanomagnetites from ocean-floor basalts were estimated from qualitative microprobe analysis. Ulvöspinel contents of all other samples varied in a wide range from 20% to about 90%. No correlation could be observed between this and the REE contents of the magnetites. Ilmenite exsolution lamellae could only be observed in titanomagnetites from a doleritic basalt from Leg 45.