Surgical safety and hospital volume across a wide range of interventions

OBJECTIVES:: For certain major operations, inpatient mortality risk is lower in high-volume hospitals than those in low-volume hospitals. Extending the analysis to a broader range of interventions and outcomes is necessary before adopting policies based on minimum volume thresholds. METHODS:: Using the United States 2004 Nationwide Inpatient Sample, we assessed the effect of intervention-specific and overall hospital volume on surgical complications, potentially avoidable reoperations, and deaths across 1.4 million interventions in 353 hospitals. Outcome variations across hospitals were analyzed through a 3-level hierarchical logistic regression model (patients, surgical interventions, and hospitals), which took into account interventions on multiple organs, 144 intervention categories, and structural hospital characteristics. Discriminative performance and calibration were good. RESULTS:: Hospitals with more experience in a given intervention had similar reoperation rates but lower mortality and complication rates: odds ratio per volume deciles 0.93 and 0.97. However, the benefit was limited to heart surgery and a small number of other operations. Risks were higher for hospitals that performed more interventions overall: odds ratio per 1000 for each event was approximately 1.02. Even after adjustment for specific volume, mortality varied substantially across both high- and low-volume hospitals. CONCLUSION:: Although the link between specific volume and certain inpatient outcomes suggests that specialization might help improve surgical safety, the variable magnitude of this link and the heterogeneity of hospital effect do not support the systematic use of volume-based referrals. It may be more efficient to monitor risk-adjusted postoperative outcomes and to investigate facilities with worse than expected outcomes.

High-precision dating and origin of synsedimentary volcanism in the Late Carboniferous Salvan-Dorenaz basin (Aiguilles-Rouges Massif, Western Alps)

Late Variscan volcanic activity is documented in the Late Carboniferous Salvan-Dorenaz sedimentary basin and in the neighboring basement units of the Aiguilles-Rouges and Mont-Blanc crystalline massifs (Western Alps). Precise U/Pb isotopic dating, zircon morphology and geochemical analyses indicate that volcanism occurred during short-lived pulses and that coexisting crustal and mantle sources were involved in the production of melts. Volcanic and subvolcanic products were emplaced along major N-S to NNE-SSW transtensional fracture zones, similar to the ones that governed intense basement exhumation and that favored the formation and filling of the Late Carboniferous Salvan-Dorenaz continental basin. In the Aiguilles-Rouges massif, dacitic flows outcropping at the base of the Salvan-Dorenaz basin erupted at 308 +/- 3 Ma; they represent the surface equivalent of the nearby Vallorcine peraluminous granite and associated rhyolitic dykes (311 +/- 17 Ma). In the Mont Blanc massif, calc-alkaline rhyolitic dykes were emplaced simultaneously (307 +/- 2 Ma) at shallow crustal levels, but they derive from deeper magma sources denoting enhanced mantellic activity. Recently identified tuffs and volcaniclastic layers embedded at different levels of the Salvan-Dorenaz stratigraphic record testify a 295 +3/-4 Ma old episode of highly explosive volcanism from distant volcanic centers, possibly located in the Aar-Gotthard massifs (Central Alps). Their zircon typology is highly heterogeneous. documenting wall-rock contamination of the melts and/or admixture of crustal sediments, whereas consistent subpopulations point to high-temperature magmas of deep-seated origin and alkaline affinity. The dated volcanic layers from the Salvan-Dorenaz basin set the beginning of the detrital sedimentation at 308 +/- 3 Ma and constrain the deposition of 1.5-1.7 km thick of elastic sediments within a time span of 10-15 Ma. These results infer minimum, long-term subsidence rates during basin evolution in the order of >0.1 mm/a, while in the surrounding basement units estimated exhumation rates are in the range of 1 mm/a. All dated rocks contain inherited zircon populations about 350, 450 or 600 Ma old.

Inferring ultraviolet anatomical exposure patterns while distinguishing the relative contribution of radiation components

Exposure to solar ultraviolet (UV) radiation is the main causative factor for skin cancer. UV exposure depends on environmental and individual factors, but individual exposure data remain scarce. UV irradiance is monitored via different techniques including ground measurements and satellite observations. However it is difficult to translate such observations into human UV exposure or dose because of confounding factors (shape of the exposed surface, shading, behavior, etc.) A collaboration between public health institutions, a meteorological office and an institute specialized in computing techniques developed a model predicting the dose and distribution of UV exposure on the basis of ground irradiation and morphological data. Standard 3D computer graphics techniques were adapted to develop this tool, which estimates solar exposure of a virtual manikin depicted as a triangle mesh surface. The amount of solar energy received by various body locations is computed for direct, diffuse and reflected radiation separately. The radiation components are deduced from corresponding measurements of UV irradiance, and the related UV dose received by each triangle of the virtual manikin is computed accounting for shading by other body parts and eventual protection measures. The model was verified with dosimetric measurements (n=54) in field conditions using a foam manikin as surrogate for an exposed individual. Dosimetric results were compared to the model predictions. The model predicted exposure to solar UV adequately. The symmetric mean absolute percentage error was 13%. Half of the predictions were within 17% range of the measurements. This model allows assessing outdoor occupational and recreational UV exposures, without necessitating time-consuming individual dosimetry, with numerous potential uses in skin cancer prevention and research. Using this tool, we investigated solar UV exposure patterns with respect to the relative contribution of the direct, diffuse and reflected radiation. We assessed exposure doses for various body parts and exposure scenarios of a standing individual (static and dynamic postures). As input, the model used erythemally-weighted ground irradiance data measured in 2009 at Payerne, Switzerland. A year-round daily exposure (8 am to 5 pm) without protection was assumed. For most anatomical sites, mean daily doses were high (typically 6.2-14.6 SED) and exceeded recommended exposure values. Direct exposure was important during specific periods (e.g. midday during summer), but contributed moderately to the annual dose, ranging from 15 to 24% for vertical and horizontal body parts, respectively. Diffuse irradiation explained about 80% of the cumulative annual exposure dose. Acute diffuse exposures were also obtained for cloudy summer days. The importance of diffuse UV radiation should not be underestimated when advocating preventive measures. Messages focused on avoiding acute direct exposures may be of limited efficiency to prevent skin cancers associated with chronic exposure (e.g., squamous cell carcinomas).

Subjectively adapted high capacity lossless image data hiding based on prediction errors

This article reports on a lossless data hiding scheme for digital images where the data hiding capacity is either determined by minimum acceptable subjective quality or by the demanded capacity. In the proposed method data is hidden within the image prediction errors, where the most well-known prediction algorithms such as the median edge detector (MED), gradient adjacent prediction (GAP) and Jiang prediction are tested for this purpose. In this method, first the histogram of the prediction errors of images are computed and then based on the required capacity or desired image quality, the prediction error values of frequencies larger than this capacity are shifted. The empty space created by such a shift is used for embedding the data. Experimental results show distinct superiority of the image prediction error histogram over the conventional image histogram itself, due to much narrower spectrum of the former over the latter. We have also devised an adaptive method for hiding data, where subjective quality is traded for data hiding capacity. Here the positive and negative error values are chosen such that the sum of their frequencies on the histogram is just above the given capacity or above a certain quality.

Secure Dynamic MANET On-demand (SEDYMO) Routing Protocol

This paper describes the state of the art of secure ad hoc routing protocols and presents SEDYMO, a mechanism to secure a dynamic multihop ad hoc routing protocol. The proposed solution defeats internal and external attacks usinga trustworthiness model based on a distributed certification authority. Digital signatures and hash chains are used to ensure the correctness of the protocol. The protocol is compared with other alternatives in terms of security strength, energy efficiency and time delay. Both computational and transmission costs are considered and it is shown that the secure protocol overhead is not a critical factor compared to the high network interface cost.

A high-resolution anatomical atlas of the transcriptome in the mouse embryo.

Ascertaining when and where genes are expressed is of crucial importance to understanding or predicting the physiological role of genes and proteins and how they interact to form the complex networks that underlie organ development and function. It is, therefore, crucial to determine on a genome-wide level, the spatio-temporal gene expression profiles at cellular resolution. This information is provided by colorimetric RNA in situ hybridization that can elucidate expression of genes in their native context and does so at cellular resolution. We generated what is to our knowledge the first genome-wide transcriptome atlas by RNA in situ hybridization of an entire mammalian organism, the developing mouse at embryonic day 14.5. This digital transcriptome atlas, the Eurexpress atlas (http://www.eurexpress.org), consists of a searchable database of annotated images that can be interactively viewed. We generated anatomy-based expression profiles for over 18,000 coding genes and over 400 microRNAs. We identified 1,002 tissue-specific genes that are a source of novel tissue-specific markers for 37 different anatomical structures. The quality and the resolution of the data revealed novel molecular domains for several developing structures, such as the telencephalon, a novel organization for the hypothalamus, and insight on the Wnt network involved in renal epithelial differentiation during kidney development. The digital transcriptome atlas is a powerful resource to determine co-expression of genes, to identify cell populations and lineages, and to identify functional associations between genes relevant to development and disease.

In vivo Structural Imaging of the Cerebellum, the Contribution of Ultra-High Fields.

This review covers some of the contributions to date from cerebellar imaging studies performed at ultra-high magnetic fields. A short overview of the general advantages and drawbacks of the use of such high field systems for imaging is given. One of the biggest advantages of imaging at high magnetic fields is the improved spatial resolution, achievable thanks to the increased available signal-to-noise ratio. This high spatial resolution better matches the dimensions of the cerebellar substructures, allowing a better definition of such structures in the images. The implications of the use of high field systems is discussed for several imaging sequences and image contrast mechanisms. This review covers studies which were performed in vivo in both rodents and humans, with a special focus on studies that were directed towards the observation of the different cerebellar layers.

Linear and nonlinear terrain deformation maps from a reduced set of interferometric SAR images

In this paper, an advanced technique for the generation of deformation maps using synthetic aperture radar (SAR) data is presented. The algorithm estimates the linear and nonlinear components of the displacement, the error of the digital elevation model (DEM) used to cancel the topographic terms, and the atmospheric artifacts from a reduced set of low spatial resolution interferograms. The pixel candidates are selected from those presenting a good coherence level in the whole set of interferograms and the resulting nonuniform mesh tessellated with the Delauney triangulation to establish connections among them. The linear component of movement and DEM error are estimated adjusting a linear model to the data only on the connections. Later on, this information, once unwrapped to retrieve the absolute values, is used to calculate the nonlinear component of movement and atmospheric artifacts with alternate filtering techniques in both the temporal and spatial domains. The method presents high flexibility with respect to the required number of images and the baselines length. However, better results are obtained with large datasets of short baseline interferograms. The technique has been tested with European Remote Sensing SAR data from an area of Catalonia (Spain) and validated with on-field precise leveling measurements.

Multiple introductions boosted genetic diversity in the invasive range of black cherry (Prunus serotina; Rosaceae).

BACKGROUND AND AIMS: Black cherry (Prunus serotina) is a North American tree that is rapidly invading European forests. This species was introduced first as an ornamental plant, then it was massively planted by foresters in many countries, but its origins and the process of invasion remain poorly documented. Based on a genetic survey of both native and invasive ranges, the invasion history of black cherry was investigated by identifying putative source populations and then assessing the importance of multiple introductions on the maintenance of gene diversity. METHODS: Genetic variability and structure of 23 populations from the invasive range and 22 populations from the native range were analysed using eight nuclear microsatellite loci and five chloroplast DNA regions. KEY RESULTS: Chloroplast DNA diversity suggests there were multiple introductions from a single geographic region (the north-eastern United States). A low reduction of genetic diversity was observed in the invasive range for both nuclear and plastid genomes. High propagule pressure including both the size and number of introductions shaped the genetic structure in Europe and boosted genetic diversity. Populations from Denmark, The Netherlands, Belgium and Germany showed high genetic diversity and low differentiation among populations, supporting the hypothesis that numerous introduction events, including multiple individuals and exchanges between sites, have taken place during two centuries of plantation. CONCLUSIONS: This study postulates that the invasive black cherry has originated from east of the Appalachian Mountains (mainly the Allegheny plateau) and its invasiveness in north-western Europe is mainly due to multiple introductions containing high numbers of individuals.

Effect of Shielding Gases in Laser Welding of Aluminium Alloys

High reflectivity to laser light, alloying element evaporation during high power laser welding makes aluminium alloys highly susceptibility to weld defects such as porosity, cracking and undercutting. The dynamic behaviour of the keyhole, due to fluctuating plasma above the keyhole and the vaporization ofthe alloying elements with in the keyhole, is the key problem to be solved for the improvement of the weld quality and stabilization of the keyhole dynamics isperhaps the single most important development that can broaden the application of laser welding of aluminium alloys. In laser welding, the shielding gas is commonly used to stabilize the welding process, to improve the welded joint features and to protect the welded seam from oxidation. The chemicalcomposition of the shielding gas is a key factor in achieving the final qualityof the welded joints. Wide range of shielding gases varying from the pure gasesto complex mixtures based on helium, argon, nitrogen and carbon dioxide are commercially available. These gas mixtures should be considered in terms of their suitability during laser welding of aluminium alloys to produce quality welds. The main objective of the present work is to study the effect of the shielding gascomposition during laser welding of aluminium alloys. Aluminium alloy A15754 was welded using 3kW Nd-YAG laser (continuous wave mode). The alloy samples were butt welded with different shielding gases (pure and mixture of gases) so that high quality welds with high joint efficiencies could be produced. It was observed that the chemical composition of the gases influenced the final weld quality and properties. In general, the mixture gases, in correct proportions, enabled better utilisation of the properties of the mixing gases, stabilized the welding process and produced better weld quality compared to the pure shielding gases.

Three-Dimensional (3D) Microarchitecture Correlations with 2D Projection Image Gray-Level Variations Assessed by Trabecular Bone Score Using High-Resolution Computed Tomographic Acquisitions: Effects of Resolution and Noise.

The aim of the present study is to determine the level of correlation between the 3-dimensional (3D) characteristics of trabecular bone microarchitecture, as evaluated using microcomputed tomography (μCT) reconstruction, and trabecular bone score (TBS), as evaluated using 2D projection images directly derived from 3D μCT reconstruction (TBSμCT). Moreover, we have evaluated the effects of image degradation (resolution and noise) and X-ray energy of projection on these correlations. Thirty human cadaveric vertebrae were acquired on a microscanner at an isotropic resolution of 93μm. The 3D microarchitecture parameters were obtained using MicroView (GE Healthcare, Wauwatosa, MI). The 2D projections of these 3D models were generated using the Beer-Lambert law at different X-ray energies. Degradation of image resolution was simulated (from 93 to 1488μm). Relationships between 3D microarchitecture parameters and TBSμCT at different resolutions were evaluated using linear regression analysis. Significant correlations were observed between TBSμCT and 3D microarchitecture parameters, regardless of the resolution. Correlations were detected that were strongly to intermediately positive for connectivity density (0.711≤r(2)≤0.752) and trabecular number (0.584≤r(2)≤0.648) and negative for trabecular space (-0.407 ≤r(2)≤-0.491), up to a pixel size of 1023μm. In addition, TBSμCT values were strongly correlated between each other (0.77≤r(2)≤0.96). Study results show that the correlations between TBSμCT at 93μm and 3D microarchitecture parameters are weakly impacted by the degradation of image resolution and the presence of noise.

Patterns of neurovascular compression in patients with classic trigeminal neuralgia: A high-resolution MRI-based study.

PURPOSE: To describe the anatomical characteristics and patterns of neurovascular compression in patients suffering classic trigeminal neuralgia (CTN), using high-resolution magnetic resonance imaging (MRI). MATERIALS AND METHODS: The analysis of the anatomy of the trigeminal nerve, brain stem and the vascular structures related to this nerve was made in 100 consecutive patients treated with a Gamma Knife radiosurgery for CTN between December 1999 and September 2004. MRI studies (T1, T1 enhanced and T2-SPIR) with axial, coronal and sagital simultaneous visualization were dynamically assessed using the software GammaPlan?. Three-dimensional reconstructions were also developed in some representative cases. RESULTS: In 93 patients (93%), there were one or several vascular structures in contact, either, with the trigeminal nerve, or close to its origin in the pons. The superior cerebellar artery was involved in 71 cases (76%). Other vessels identified were the antero-inferior cerebellar artery, the basilar artery, the vertebral artery, and some venous structures. Vascular compression was found anywhere along the trigeminal nerve. The mean distance between the nerve compression and the origin of the nerve in the brainstem was 3.76±2.9mm (range 0-9.8mm). In 39 patients (42%), the vascular compression was located proximally and in 42 (45%) the compression was located distally. Nerve dislocation or distortion by the vessel was observed in 30 cases (32%). CONCLUSIONS: The findings of this study are similar to those reported in surgical and autopsy series. This non-invasive MRI-based approach could be useful for diagnostic and therapeutic decisions in CTN, and it could help to understand its pathogenesis.

Development of a hepatocyte hollow fiber bioreactor for the study of contrast agents by magnetic resonance imaging

Thanks to the continuous progress made in recent years, medical imaging has become an important tool in the diagnosis of various pathologies. In particular, magnetic resonance imaging (MRI) permits to obtain images with a remarkably high resolution without the use of ionizing radiation and is consequently widely applied for a broad range of conditions in all parts of the body. Contrast agents are used in MRI to improve tissue discrimination. Different categories of contrast agents are clinically available, the most widely used being gadolinium chelates. One can distinguish between extracellular gadolinium chelates such as Gd-DTPA, and hepatobiliary gadolinium chelates such as Gd-BOPTA. The latter are able to enter hepatocytes from where they are partially excreted into the bile to an extent dependent on the contrast agent and animal species. Due to this property, hepatobiliary contrast agents are particularly interesting for the MRI of the liver. Actually, a change in signal intensity can result from a change in transport functions signaling the presence of impaired hepatocytes, e.g. in the case of focal (like cancer) or diffuse (like cirrhosis) liver diseases. Although the excretion mechanism into the bile is well known, the uptake mechanisms of hepatobiliary contrast agents into hepatocytes are still not completely understood and several hypotheses have been proposed. As a good knowledge of these transport mechanisms is required to allow an efficient diagnosis by MRI of the functional state of the liver, more fundamental research is needed and an efficient MRI compatible in vitro model would be an asset. So far, most data concerning these transport mechanisms have been obtained by MRI with in vivo models or by a method of detection other than MRI with cellular or sub-cellular models. Actually, no in vitro model is currently available for the study and quantification of contrast agents by MRI notably because high cellular densities are needed to allow detection, and no metallic devices can be used inside the magnet room, which is incompatible with most tissue or cell cultures that require controlled temperature and oxygenation. The aim of this thesis is thus to develop an MRI compatible in vitro cellular model to study the transport of hepatobiliary contrast agents, in particular Gd-BOPTA, into hepatocytes directly by MRI. A better understanding of this transport and especially of its modification in case of hepatic disorder could permit in a second step to extrapolate this knowledge to humans and to use the kinetics of hepatobiliary contrast agents as a tool for the diagnosis of hepatic diseases.

A novel procedure for establishing clinching parameters for high strength steel sheet

The building industry has a particular interest in using clinching as a joining method for frame constructions of light-frame housing. Normally many clinch joints are required in joining of frames.In order to maximise the strength of the complete assembly, each clinch joint must be as sound as possible. Experimental testing is the main means of optimising a particular clinch joint. This includes shear strength testing and visual observation of joint cross-sections. The manufacturers of clinching equipment normally perform such experimental trials. Finite element analysis can also be used to optimise the tool geometry and the process parameter, X, which represents the thickness of the base of the joint. However, such procedures require dedicated software, a skilled operator, and test specimens in order to verify the finite element model. In addition, when using current technology several hours' computing time may be necessary. The objective of the study was to develop a simple calculation procedure for rapidly establishing an optimum value for the parameter X for a given tool combination. It should be possible to use the procedure on a daily basis, without stringent demands on the skill of the operator or the equipment. It is also desirable that the procedure would significantly decrease thenumber of shear strength tests required for verification. The experimental workinvolved tests in order to obtain an understanding of the behaviour of the sheets during clinching. The most notable observation concerned the stage of the process in which the upper sheet was initially bent, after which the deformation mechanism changed to shearing and elongation. The amount of deformation was measured relative to the original location of the upper sheet, and characterised as the C-measure. By understanding in detail the behaviour of the upper sheet, it waspossible to estimate a bending line function for the surface of the upper sheet. A procedure was developed, which makes it possible to estimate the process parameter X for each tool combination with a fixed die. The procedure is based on equating the volume of material on the punch side with the volume of the die. Detailed information concerning the behaviour of material on the punch side is required, assuming that the volume of die does not change during the process. The procedure was applied to shear strength testing of a sample material. The sample material was continuously hot-dip zinc-coated high-strength constructional steel,with a nominal thickness of 1.0 mm. The minimum Rp0.2 proof stress was 637 N/mm2. Such material has not yet been used extensively in light-frame housing, and little has been published on clinching of the material. The performance of the material is therefore of particular interest. Companies that use clinching on a daily basis stand to gain the greatest benefit from the procedure. By understanding the behaviour of sheets in different cases, it is possible to use data at an early stage for adjusting and optimising the process. In particular, the functionality of common tools can be increased since it is possible to characterise the complete range of existing tools. The study increases and broadens the amount ofbasic information concerning the clinching process. New approaches and points of view are presented and used for generating new knowledge.

Improving Dynamic Characteristics of Open-loop Controlled Log Crane

The improvement of the dynamics of flexible manipulators like log cranes often requires advanced control methods. This thesis discusses the vibration problems in the cranes used in commercial forestry machines. Two control methods, adaptive filtering and semi-active damping, are presented. The adaptive filter uses a part of the lowest natural frequency of the crane as a filtering frequency. The payload estimation algorithm, filtering of control signal and algorithm for calculation of the lowest natural frequency of the crane are presented. The semi-active damping method is basedon pressure feedback. The pressure vibration, scaled with suitable gain, is added to the control signal of the valve of the lift cylinder to suppress vibrations. The adaptive filter cuts off high frequency impulses coming from the operatorand semi-active damping suppresses the crane?s oscillation, which is often caused by some external disturbance. In field tests performed on the crane, a correctly tuned (25 % tuning) adaptive filter reduced pressure vibration by 14-17 % and semi-active damping correspondingly by 21-43%. Applying of these methods require auxiliary transducers, installed in specific points in the crane, and electronically controlled directional control valves.