Social and medical vulnerability factors of frequent users at the emergency department: a case-control study

BACKGROUND: Up to 5% of patients presenting to the emergency department (ED) four or more times within a 12 month period represent 21% of total ED visits. In this study we sought to characterize social and medical vulnerability factors of ED frequent users (FUs) and to explore if these factors hold simultaneously. METHODS: We performed a case-control study at Lausanne University Hospital, Switzerland. Patients over 18 years presenting to the ED at least once within the study period (April 2008 toMarch 2009) were included. FUs were defined as patients with four or more ED visits within the previous 12 months. Outcome data were extracted from medical records of the first ED attendance within the study period. Outcomes included basic demographics and social variables, ED admission diagnosis, somatic and psychiatric days hospitalized over 12 months, and having a primary care physician.We calculated the percentage of FUs and non-FUs having at least one social and one medical vulnerability factor. The four chosen social factors included: unemployed and/or dependence on government welfare, institutionalized and/or without fixed residence, either separated, divorced or widowed, and under guardianship. The fourmedical vulnerability factors were: ≥6 somatic days hospitalized, ≥1 psychiatric days hospitalized, ≥5 clinical departments used (all three factors measured over 12 months), and ED admission diagnosis of alcohol and/or drug abuse. Univariate and multivariate logistical regression analyses allowed comparison of two JGIM ABSTRACTS S391 random samples of 354 FUs and 354 non-FUs (statistical power 0.9, alpha 0.05 for all outcomes except gender, country of birth, and insurance type). RESULTS: FUs accounted for 7.7% of ED patients and 24.9% of ED visits. Univariate logistic regression showed that FUs were older (mean age 49.8 vs. 45.2 yrs, p=0.003),more often separated and/or divorced (17.5%vs. 13.9%, p=0.029) or widowed (13.8% vs. 8.8%, p=0.029), and either unemployed or dependent on government welfare (31.3% vs. 13.3%, p<0.001), compared to non-FUs. FUs cumulated more days hospitalized over 12 months (mean number of somatic days per patient 1.0 vs. 0.3, p<0.001; mean number of psychiatric days per patient 0.12 vs. 0.03, p<0.001). The two groups were similar regarding gender distribution (females 51.7% vs. 48.3%). The multivariate linear regression model was based on the six most significant factors identified by univariate analysis The model showed that FUs had more social problems, as they were more likely to be institutionalized or not have a fixed residence (OR 4.62; 95% CI, 1.65 to 12.93), and to be unemployed or dependent on government welfare (OR 2.03; 95% CI, 1.31 to 3.14) compared to non-FUs. FUs were more likely to need medical care, as indicated by involvement of≥5 clinical departments over 12 months (OR 6.2; 95%CI, 3.74 to 10.15), having an ED admission diagnosis of substance abuse (OR 3.23; 95% CI, 1.23 to 8.46) and having a primary care physician (OR 1.70;95%CI, 1.13 to 2.56); however, they were less likely to present with an admission diagnosis of injury (OR 0.64; 95% CI, 0.40 to 1.00) compared to non-FUs. FUs were more likely to combine at least one social with one medical vulnerability factor (38.4% vs. 12.1%, OR 7.74; 95% CI 5.03 to 11.93). CONCLUSIONS: FUs were more likely than non-FUs to have social and medical vulnerability factors and to have multiple factors in combination.

The continuous wavelet transform as a maximum entropy solution of the corresponding inverse problem

The continuous wavelet transform is obtained as a maximumentropy solution of the corresponding inverse problem. It is well knownthat although a signal can be reconstructed from its wavelet transform,the expansion is not unique due to the redundancy of continuous wavelets.Hence, the inverse problem has no unique solution. If we want to recognizeone solution as "optimal", then an appropriate decision criterion hasto be adopted. We show here that the continuous wavelet transform is an"optimal" solution in a maximum entropy sense.

Second-order parameter estimation

This work provides a general framework for the design of second-order blind estimators without adopting anyapproximation about the observation statistics or the a prioridistribution of the parameters. The proposed solution is obtainedminimizing the estimator variance subject to some constraints onthe estimator bias. The resulting optimal estimator is found todepend on the observation fourth-order moments that can be calculatedanalytically from the known signal model. Unfortunately,in most cases, the performance of this estimator is severely limitedby the residual bias inherent to nonlinear estimation problems.To overcome this limitation, the second-order minimum varianceunbiased estimator is deduced from the general solution by assumingaccurate prior information on the vector of parameters.This small-error approximation is adopted to design iterativeestimators or trackers. It is shown that the associated varianceconstitutes the lower bound for the variance of any unbiasedestimator based on the sample covariance matrix.The paper formulation is then applied to track the angle-of-arrival(AoA) of multiple digitally-modulated sources by means ofa uniform linear array. The optimal second-order tracker is comparedwith the classical maximum likelihood (ML) blind methodsthat are shown to be quadratic in the observed data as well. Simulationshave confirmed that the discrete nature of the transmittedsymbols can be exploited to improve considerably the discriminationof near sources in medium-to-high SNR scenarios.

Common snook fed in alternate and continuous regimens with diet supplemented with Bacillus subtilis probiotic

The objective of this work was to evaluate the addition of Bacillus subtilis probiotic to the feed of common snook (Centropomus undecimalis) fingerlings, in alternate and continuous regimens. Six hundred and sixty fish, with average length of 5.90±0.88 cm and weight of 1.92±0.28 g, were stocked in 12 cages of 1.0 m3, with 55 fish each. The experimental design was completely randomized, with three treatments and four replicates. The treatments consisted of diet with the addition of probiotic, provided in alternate regimen for 7 days and in continuous regimen; besides a control without probiotic in the feed. Zootechnical performance, body composition, immune response, and blood parameters were evaluated. No significant differences were observed in zootechnical performance indexes and in body composition of fish treated with probiotic, when compared to the control. Fish from the alternate regimen showed an increment in respiratory burst and a lower total erythrocyte count than fish from the continuous regimen and the control. Fish from the continuous regimen did not differ from those of the control. The addition of Bacillus subtilis does not increase growth rates of common snook fingerlings; however, it has an immunostimulant action when supplied in alternate regimen.

Genetic control of iron concentration in Mesoamerican and Andean common bean seeds

The objective of this work was to evaluate the main differences in the genetic control of the iron concentration in Mesoamerican and Andean common bean seeds, in early generations, and to select recombinants with a high iron concentration in the seeds. F1, F1 reciprocal, F2, F2 reciprocal, and backcross (BC11 and BC12) generations were produced by crosses between Mesoamerican (CNFP 10104 x CHC 01-175) and Andean (Cal 96 x Hooter) inbred lines. The expression of significant maternal effect was observed for the Mesoamerican gene pool. Iron concentration was higher in the seed coat of Mesoamerican common bean seeds (54.61 to 67.92%) and in the embryo of Andean common bean seeds (69.40 to 73.44%). High broad-sense heritability was obtained for iron concentration in Mesoamerican and Andean common bean seeds. Gains with the selection of higher magnitude, from 20.39 to 24.58%, are expected in Mesoamerican common bean seeds. Iron concentration in common bean seeds showed a continuous distribution in F2, which is characteristic of quantitative inheritance in Mesoamerican and Andean common bean seeds. Recombinants with high iron concentration in seeds can be selected in both Mesoamerican and Andean common bean hybrids.

Jatkuvavaletun teräksen leikkaussuunnitelman optimointi

Teollisuuden tuotannon eri prosessien optimointi on hyvin ajankohtainen aihe. Monet ohjausjärjestelmät ovat ajalta, jolloin tietokoneiden laskentateho oli hyvin vaatimaton nykyisiin verrattuna. Työssä esitetään tuotantoprosessi, joka sisältää teräksen leikkaussuunnitelman muodostamisongelman. Valuprosessi on yksi teräksen valmistuksen välivaiheita. Siinä sopivaan laatuun saatettu sula teräs valetaan linjastoon, jossa se jähmettyy ja leikataan aihioiksi. Myöhemmissä vaiheissa teräsaihioista muokataan pienempiä kokonaisuuksia, tehtaan lopputuotteita. Jatkuvavaletut aihiot voidaan leikata tilauskannasta riippuen monella eri tavalla. Tätä varten tarvitaan leikkaussuunnitelma, jonka muodostamiseksi on ratkaistava sekalukuoptimointiongelma. Sekalukuoptimointiongelmat ovat optimoinnin haastavin muoto. Niitä on tutkittu yksinkertaisempiin optimointiongelmiin nähden vähän. Nykyisten tietokoneiden laskentateho on kuitenkin mahdollistanut raskaampien ja monimutkaisempien optimointialgoritmien käytön ja kehittämisen. Työssä on käytetty ja esitetty eräs stokastisen optimoinnin menetelmä, differentiaalievoluutioalgoritmi. Tässä työssä esitetään teräksen leikkausoptimointialgoritmi. Kehitetty optimointimenetelmä toimii dynaamisesti tehdasympäristössä käyttäjien määrittelemien parametrien mukaisesti. Työ on osa Syncron Tech Oy:n Ovako Bar Oy Ab:lle toimittamaa ohjausjärjestelmää.

Stage fright: its experience as a problem and coping with it.

PURPOSE AND METHOD: This questionnaire survey of 190 university music students assessed negative feelings of music performance anxiety (MPA) before performing, the experience of stage fright as a problem, and how closely they are associated with each other. The study further investigated whether the experience of stage fright as a problem and negative feelings of MPA predict the coping behavior of the music students. Rarely addressed coping issues were assessed, i.e., self-perceived effectiveness of different coping strategies, knowledge of possible risks and acceptance of substance-based coping strategies, and need for more support.RESULTS: The results show that one-third of the students experienced stage fright as a problem and that this was only moderately correlated with negative feelings of MPA. The experience of stage fright as a problem significantly predicted the frequency of use and the acceptance of medication as a coping strategy. Breathing exercises and self-control techniques were rated as effective as medication. Finally, students expressed a strong need to receive more support (65%) and more information (84%) concerning stage fright.CONCLUSION: Stage fright was experienced as a problem and perceived as having negative career consequences by a considerable percentage of the surveyed students. In addition to a desire for more help and support, the students expressed an openness and willingness to seriously discuss and address the topic of stage fright. This provides a necessary and promising basis for optimal career preparation and, hence, an opportunity to prevent occupational problems in professional musicians. [Authors]

Disposition of valganciclovir during continuous renal replacement therapy in two lung transplant recipients.

OBJECTIVES: To determine whether valganciclovir 450 mg every 48 h for cytomegalovirus (CMV) prophylaxis provides appropriate ganciclovir exposure in solid organ transplant recipients during continuous renal replacement therapy (CRRT). PATIENTS AND METHODS: Ganciclovir pharmacokinetics was intensively studied in two lung transplant recipients under valganciclovir 450 mg every 48 h over one dosing interval. In vitro experiments using blank whole blood spiked with ganciclovir further investigated exchanges between plasma and erythrocytes. RESULTS: Ganciclovir disposition was characterized by apparent total body clearance of 3.3 and 5.8 L/h, terminal half-life of 16.9 and 14.1 h, and apparent volume of distribution of 60.3 and 104.9 L in Patients 1 and 2, respectively. The observed sieving coefficient was 1.05 and 0.96, and the haemofiltration clearance was 3.3 and 3.1 L/h. In vitro experiments confirmed rapid efflux of ganciclovir from red blood cells into plasma, increasing the apparent efficacy of haemofiltration. CONCLUSIONS: A valganciclovir dosage of 450 mg every 48 h appears adequate for patients under CRRT requiring prophylaxis for CMV infection, providing concentration levels in the range reported for 900 mg once daily dosing outside renal failure.

Superjumborullien rullauksen hallinta

UPM-Kymmene Oyj:n Jämsänkosken PK6:n ongelmana ovat olleet ajoittaiset pohjakatkot suurilla rullilla. Diplomityön tavoitteena oli parantaa superjumborullien rullauksen hallintaa Jagenbergin rakentamalla VariTop keskiörullaimella. Kirjallisuusosassa selvitettiin rullanmuodostumista ja erilaisia rullausteorioita. Samalla käytiin läpi paperin rullautuvuuteen vaikuttavia tekijöitä, rullausperäisten vikojen muodostumisen syitä sekä pehmeän rullaussylinterin etuja verrattuna kovaan sylinteriin. Kokeellisessa osassa suoritettiin koeajoja tuotannon pituusleikkurilla. Näistä kokeista saatujen tulosten perusteella leikkurin ajoreseptit päivitettiin vastaamaanoptimaalisinta rullarakennetta. Pehmeän rullaussylinterin etuja verrattuna kovaan rullaussylinteriin selvitettiin koeajoissa Voithin koeleikkurilla Saksan Krefeldissä. Tuloksista selvisi, että samalla ajoreseptillä rullattaessa pehmeä sylinteri antoi valmiille rullalle suuremman kovuuden. Myös paperissa olevien profiilivirheiden vaikutukset lievenivät käytettäessä pehmeää rullaussylinteriä. Istukoiden luistamisesta johtuvaa hylsyjen sisäpinnan jauhautumista on ilmennyt suurilla jumborullilla. Tämä johtuu todennäköisimmin kasvaneesta rasituksesta hylsyn sisäpinnalla, mikä on seurausta rullien kasvusta. Ratkaisuina tälle ongelmalle on mahdollinen istukan pidentäminen sekä välyksen pienentäminen istukan ja hylsyn välissä. Myös hylsyjen toimintaa testattiin rullauksessa jahuomattiin niiden täyttävän toimittajien antamat laatuarvot. Lepo- ja liikekitkalla tiedetään olevan suuri merkitys rullausperäisten vikojenmuodostumiseen. Eri lajeista lähetettiin paperinäytteitä UPM-Kymmene Oyj:n Lappeenrannan tutkimuskeskukseen kitkojen määrittämiseksi. Tulosten perusteella havaittiin luettelolajilla lepo- ja liikekitkassa merkittävä ero. Standardi SC lajilla ero oli selvästi pienempi kuin luettelolajilla. Tämä saattaa olla yksi syy luettelolajeilla ilmeneviin pohjaongelmiin.

Analysis of Active Magnet Bearing Control Software

Problems of the designing active magnet bearingcontrol are developed. The estimation controller are designed and applied to a rigid rotor. The mathematical model of the active magnet bearing controller is developed. This mathematical model is realized on a DSP. The results of this realization are analyzed. The conclusions about the digital signal processing are made.

Clinically relevant quality measures for risk factor control in primary care: a retrospective cohort study.

BACKGROUND: Assessment of the proportion of patients with well controlled cardiovascular risk factors underestimates the proportion of patients receiving high quality of care. Evaluating whether physicians respond appropriately to poor risk factor control gives a different picture of quality of care. We assessed physician response to control cardiovascular risk factors, as well as markers of potential overtreatment in Switzerland, a country with universal healthcare coverage but without systematic quality monitoring, annual report cards on quality of care or financial incentives to improve quality. METHODS: We performed a retrospective cohort study of 1002 randomly selected patients aged 50-80 years from four university primary care settings in Switzerland. For hypertension, dyslipidemia and diabetes mellitus, we first measured proportions in control, then assessed therapy modifications among those in poor control. "Appropriate clinical action" was defined as a therapy modification or return to control without therapy modification within 12 months among patients with baseline poor control. Potential overtreatment of these conditions was defined as intensive treatment among low-risk patients with optimal target values. RESULTS: 20% of patients with hypertension, 41% with dyslipidemia and 36% with diabetes mellitus were in control at baseline. When appropriate clinical action in response to poor control was integrated into measuring quality of care, 52 to 55% had appropriate quality of care. Over 12 months, therapy of 61% of patients with baseline poor control was modified for hypertension, 33% for dyslipidemia, and 85% for diabetes mellitus. Increases in number of drug classes (28-51%) and in drug doses (10-61%) were the most common therapy modifications. Patients with target organ damage and higher baseline values were more likely to have appropriate clinical action. We found low rates of potential overtreatment with 2% for hypertension, 3% for diabetes mellitus and 3-6% for dyslipidemia. CONCLUSIONS: In primary care, evaluating whether physicians respond appropriately to poor risk factor control, in addition to assessing proportions in control, provide a broader view of the quality of care than relying solely on measures of proportions in control. Such measures could be more clinically relevant and acceptable to physicians than simply reporting levels of control.

Continuous positive airway pressure causes lung injury in a model of sepsis.

Continuous positive airway pressure, aimed at preventing pulmonary atelectasis, has been used for decades to reduce lung injury in critically ill patients. In neonatal practice, it is increasingly used worldwide as a primary form of respiratory support due to its low cost and because it reduces the need for endotracheal intubation and conventional mechanical ventilation. We studied the anesthetized in vivo rat and determined the optimal circuit design for delivery of continuous positive airway pressure. We investigated the effects of continuous positive airway pressure following lipopolysaccharide administration in the anesthetized rat. Whereas neither continuous positive airway pressure nor lipopolysaccharide alone caused lung injury, continuous positive airway pressure applied following intravenous lipopolysaccharide resulted in increased microvascular permeability, elevated cytokine protein and mRNA production, and impaired static compliance. A dose-response relationship was demonstrated whereby higher levels of continuous positive airway pressure (up to 6 cmH(2)O) caused greater lung injury. Lung injury was attenuated by pretreatment with dexamethasone. These data demonstrate that despite optimal circuit design, continuous positive airway pressure causes significant lung injury (proportional to the airway pressure) in the setting of circulating lipopolysaccharide. Although we would currently avoid direct extrapolation of these findings to clinical practice, we believe that in the context of increasing clinical use, these data are grounds for concern and warrant further investigation.

Acute ischemic cerebrovascular events on antiplatelet therapy: what is the optimal prevention strategy?

Even though patients who develop ischemic stroke despite taking antiplatelet drugs represent a considerable proportion of stroke hospital admissions, there is a paucity of data from investigational studies regarding the most suitable therapeutic intervention. There have been no clinical trials to test whether increasing the dose or switching antiplatelet agents reduces the risk for subsequent events. Certain issues have to be considered in patients managed for a first or recurrent stroke while receiving antiplatelet agents. Therapeutic failure may be due to either poor adherence to treatment, associated co-morbid conditions and diminished antiplatelet effects (resistance to treatment). A diagnostic work up is warranted to identify the etiology and underlying mechanism of stroke, thereby guiding further management. Risk factors (including hypertension, dyslipidemia and diabetes) should be treated according to current guidelines. Aspirin or aspirin plus clopidogrel may be used in the acute and early phase of ischemic stroke, whereas in the long-term, antiplatelet treatment should be continued with aspirin, aspirin/extended release dipyridamole or clopidogrel monotherapy taking into account tolerance, safety, adherence and cost issues. Secondary measures to educate patients about stroke, the importance of adherence to medication, behavioral modification relating to tobacco use, physical activity, alcohol consumption and diet to control excess weight should also be implemented.

Ruin problems under IBNR Dynamics

In this paper, we consider a discrete-time risk process allowing for delay in claim settlement, which introduces a certain type of dependence in the process. From martingale theory, an expression for the ultimate ruin probability is obtained, and Lundberg-type inequalities are derived. The impact of delay in claim settlement is then investigated. To this end, a convex order comparison of the aggregate claim amounts is performed with the corresponding non-delayed risk model, and numerical simulations are carried out with Belgian market data.

Particle transport method for convection-diffusion-reaction problems

Convective transport, both pure and combined with diffusion and reaction, can be observed in a wide range of physical and industrial applications, such as heat and mass transfer, crystal growth or biomechanics. The numerical approximation of this class of problemscan present substantial difficulties clue to regions of high gradients (steep fronts) of the solution, where generation of spurious oscillations or smearing should be precluded. This work is devoted to the development of an efficient numerical technique to deal with pure linear convection and convection-dominated problems in the frame-work of convection-diffusion-reaction systems. The particle transport method, developed in this study, is based on using rneshless numerical particles which carry out the solution along the characteristics defining the convective transport. The resolution of steep fronts of the solution is controlled by a special spacial adaptivity procedure. The serni-Lagrangian particle transport method uses an Eulerian fixed grid to represent the solution. In the case of convection-diffusion-reaction problems, the method is combined with diffusion and reaction solvers within an operator splitting approach. To transfer the solution from the particle set onto the grid, a fast monotone projection technique is designed. Our numerical results confirm that the method has a spacial accuracy of the second order and can be faster than typical grid-based methods of the same order; for pure linear convection problems the method demonstrates optimal linear complexity. The method works on structured and unstructured meshes, demonstrating a high-resolution property in the regions of steep fronts of the solution. Moreover, the particle transport method can be successfully used for the numerical simulation of the real-life problems in, for example, chemical engineering.