Comparing potentially avoidable hospitalization rates related to ambulatory care sensitive conditions in Switzerland: the need to refine the definition of health conditions and to adjust for population health status.

BACKGROUND: Regional rates of hospitalization for ambulatory care sensitive conditions (ACSC) are used to compare the availability and quality of ambulatory care but the risk adjustment for population health status is often minimal. The objectives of the study was to examine the impact of more extensive risk adjustment on regional comparisons and to investigate the relationship between various area-level factors and the properly adjusted rates. METHODS: Our study is an observational study based on routine data of 2 million anonymous insured in 26 Swiss cantons followed over one or two years. A binomial negative regression was modeled with increasingly detailed information on health status (age and gender only, inpatient diagnoses, outpatient conditions inferred from dispensed drugs and frequency of physician visits). Hospitalizations for ACSC were identified from principal diagnoses detecting 19 conditions, with an updated list of ICD-10 diagnostic codes. Co-morbidities and surgical procedures were used as exclusion criteria to improve the specificity of the detection of potentially avoidable hospitalizations. The impact of the adjustment approaches was measured by changes in the standardized ratios calculated with and without other data besides age and gender. RESULTS: 25% of cases identified by inpatient main diagnoses were removed by applying exclusion criteria. Cantonal ACSC hospitalizations rates varied from to 1.4 to 8.9 per 1,000 insured, per year. Morbidity inferred from diagnoses and drugs dramatically increased the predictive performance, the greatest effect found for conditions linked to an ACSC. More visits were associated with fewer PAH although very high users were at greater risk and subjects who had not consulted at negligible risk. By maximizing health status adjustment, two thirds of the cantons changed their adjusted ratio by more than 10 percent. Cantonal variations remained substantial but unexplained by supply or demand. CONCLUSION: Additional adjustment for health status is required when using ACSC to monitor ambulatory care. Drug-inferred morbidities are a promising approach.

Definition of key variables for the induction of optimal NY-ESO-1-specific T cells in HLA transgene mice.

An attractive treatment of cancer consists in inducing tumor-eradicating CD8(+) CTL specific for tumor-associated Ags, such as NY-ESO-1 (ESO), a strongly immunogenic cancer germ line gene-encoded tumor-associated Ag, widely expressed on diverse tumors. To establish optimal priming of ESO-specific CTL and to define critical vaccine variables and mechanisms, we used HLA-A2/DR1 H-2(-/-) transgenic mice and sequential immunization with immunodominant DR1- and A2-restricted ESO peptides. Immunization of mice first with the DR1-restricted ESO(123-137) peptide and subsequently with mature dendritic cells (DCs) presenting this and the A2-restriced ESO(157-165) epitope generated abundant, circulating, high-avidity primary and memory CD8(+) T cells that efficiently killed A2/ESO(157-165)(+) tumor cells. This prime boost regimen was superior to other vaccine regimes and required strong Th1 cell responses, copresentation of MHC class I and MHC class II peptides by the same DC, and resulted in upregulation of sphingosine 1-phosphate receptor 1, and thus egress of freshly primed CD8(+) T cells from the draining lymph nodes into circulation. This well-defined system allowed detailed mechanistic analysis, which revealed that 1) the Th1 cytokines IFN-gamma and IL-2 played key roles in CTL priming, namely by upregulating on naive CD8(+) T cells the chemokine receptor CCR5; 2) the inflammatory chemokines CCL4 (MIP-1beta) and CCL3 (MIP-1alpha) chemoattracted primed CD4(+) T cells to mature DCs and activated, naive CD8(+) T cells to DC-CD4 conjugates, respectively; and 3) blockade of these chemokines or their common receptor CCR5 ablated priming of CD8(+) T cells and upregulation of sphingosine 1-phosphate receptor 1. These findings provide new opportunities for improving T cell cancer vaccines.

Definition of linear color models in the RGB vector color space to detect red peaches in orchard images taken under natural illumination

This work proposes the detection of red peaches in orchard images based on the definition of different linear color models in the RGB vector color space. The classification and segmentation of the pixels of the image is then performed by comparing the color distance from each pixel to the different previously defined linear color models. The methodology proposed has been tested with images obtained in a real orchard under natural light. The peach variety in the orchard was the paraguayo (Prunus persica var. platycarpa) peach with red skin. The segmentation results showed that the area of the red peaches in the images was detected with an average error of 11.6%; 19.7% in the case of bright illumination; 8.2% in the case of low illumination; 8.6% for occlusion up to 33%; 12.2% in the case of occlusion between 34 and 66%; and 23% for occlusion above 66%. Finally, a methodology was proposed to estimate the diameter of the fruits based on an ellipsoidal fitting. A first diameter was obtained by using all the contour pixels and a second diameter was obtained by rejecting some pixels of the contour. This approach enables a rough estimate of the fruit occlusion percentage range by comparing the two diameter estimates.

Product Definition Process for Mobile Radio System Product

Työn tarkoituksena oli tutkia tuotteen määrittelyyn liittyvää kirjallisuutta ja perehtyä tuotteen määrittelytyön nykytilaan kohdeyrityksessä. Näihin molempiin perustuen muodostetaan prosessimalli tuotteen määrittelytyölle kohdeyrityksessä. Työssä käsitellään prosessijohtamisen pääperiaatteet sekä tuotteen määrittelyä koskevaa kirjallisuutta ja tutkimuksia. Koska kysessä oleva tuote on suurelta osalta ohjelmistotuote, ohjelmistojen suunnittelua, erityisesti ohjelmistovaatimusten hallintaa ja ohjelmistojen määrittelyä, on myös tarkasteltu työssä. Tuotteen määrittelyn haasteita on käsitelty yksityiskohtaisemmin, esimerkiksi dokumentointia, prosessin kulkua, vaatimusten epävakaisuutta sekä muutoksia. Kohdeyritys ja sen ongelmakohdat esitellään ja luodaan prosessimalli. Tämä malli esittelee seuraavat prosessit: raakavaatimusten hallinta -prosessin, roadmapping -prosessin, esisuunnittelu- ja spesifikaatioprosessin ja julkaisun suunnittelu -prosessin. Kaikki nämä ovat vaiheita ennen varsinaisen tuotekehitysprojektin aloittamista. Työssä esitellään myös kolmetasoinen dokumentaatiomalli.

Purchasing Process Performance Definition and Improvement in the Mechanical Wood Industry

Tämän tutkimuksen ensisijaisena tavoitteena oli määrittää Schauman Wood Oy:n ostoprosessin suorituskyvyn nykytila yrityksen Suomen yksiköissä. Nykytila-arviointi suoritettiin uusien ja käytössä olevien mittaustulosten avulla. Tutkimuksessa verrattiin kymmenen tuotantolaitoksen ostoprosesseja keskenään. Keskeinen tutkimusongelma oli ostoprosessin suorituseroja aikaansaavien tekijöiden selvittäminen eri yksiköissä. Tutkimuksen tavoitteena oli saavuttaa yhtenäisemmät toimintatavat yrityksessä sekä laajentaa konsernin osto-organisaation hyödyntämistä hankintatoimessa. Tavoitteena oli ostoprosessin virtaviivaistaminen ja tehokkaamman seurantajärjestelmän kehittäminen. Ostotoimintojen suorituskyvyn jatkuva parantaminen perustuu osittain uusien mittareiden avulla saatavaan informaatioon ja täsmällisempään seurantaan. Sisäistä benchmarkingia käytettiin työkaluna suorituskyky-eroavaisuuksien määrittelyssä. Tietoa erilaisista toimintatavoista kerättiin haastattelemalla yrityksen ostajia ja tehdaspalvelupäälliköitä eri tehdaspaikkakunnilla. Sisäisen benchmarkingin avulla määriteltiin toimintatapa eroavaisuudet sekä kehitettiin seurantakortti, jossa jokaista yksikköä verrataan parhaaseen ja eniten kehittyneeseen yksikköön. Työn tuloksina muodostui ehdotuksia ostotoiminnon uusiksi mittareiksi. Uudet mittarit ovat tehokkuusmittareita, jotka kuvaavat resurssien käytön tehokkuutta sekä auttavat seuraamaan ostoprosessin tilaa entistä paremmin. Uusien mittareiden tavoitteena on myös vähentää mittareiden manipulaatiomahdollisuutta. Työn ulkopuolelle rajattiin informaatioteknologiajärjestelmien tietotekninen osuus. Eräs yrityksen tuotantolaitoksista rajattiin myös työn ulkopuolelle, koska sen ostoprosessit ovat huomattavasti kehittymättömämpiä kuin Schauman Woodin muiden tehtaiden ostoprosessit. Kyseisen yksikön kehittämisen tulee lähteä aivan ruohonjuuritasolta. Tutkimuksen teoriaosuus on kerätty alan ammattikirjallisuudesta ja tutkimuksen aihetta käsittelevistä uudehkoista tieteellisistä alan artikkeleista. Teorian tarkoituksena on tukea empiiristä osuutta sekä antaa lukijalle uusia näkemyksiä ostotoiminnan monista mahdollisuuksista. Tutkimuksen tuloksia ovat nykytila-analyysi, ehdotukset uusista ostotoiminnan mittareista sekä ehdotus MRO-tuotteiden ulkoistamiskokeilusta. Yrityksen ostotoiminnan tulisi kehittyä operatiivisesta tasosta kohti strategisempaa oston tasoa. Johdon sitoutuminen hankintatoimen kehityshankkeisiin on erityisen tärkeää, lisäksi hankintatoimi tulisi nähdä strategisempana osa-alueena yrityksessä. Hankintatoimen kehittämisen avulla yrityksen kustannustehokkuutta voidaan lisätä merkittävästi.

A definition and classification of status epilepticus - Report of the ILAE Task Force on Classification of Status Epilepticus.

The Commission on Classification and Terminology and the Commission on Epidemiology of the International League Against Epilepsy (ILAE) have charged a Task Force to revise concepts, definition, and classification of status epilepticus (SE). The proposed new definition of SE is as follows: Status epilepticus is a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms, which lead to abnormally, prolonged seizures (after time point t1 ). It is a condition, which can have long-term consequences (after time point t2 ), including neuronal death, neuronal injury, and alteration of neuronal networks, depending on the type and duration of seizures. This definition is conceptual, with two operational dimensions: the first is the length of the seizure and the time point (t1 ) beyond which the seizure should be regarded as "continuous seizure activity." The second time point (t2 ) is the time of ongoing seizure activity after which there is a risk of long-term consequences. In the case of convulsive (tonic-clonic) SE, both time points (t1 at 5 min and t2 at 30 min) are based on animal experiments and clinical research. This evidence is incomplete, and there is furthermore considerable variation, so these time points should be considered as the best estimates currently available. Data are not yet available for other forms of SE, but as knowledge and understanding increase, time points can be defined for specific forms of SE based on scientific evidence and incorporated into the definition, without changing the underlying concepts. A new diagnostic classification system of SE is proposed, which will provide a framework for clinical diagnosis, investigation, and therapeutic approaches for each patient. There are four axes: (1) semiology; (2) etiology; (3) electroencephalography (EEG) correlates; and (4) age. Axis 1 (semiology) lists different forms of SE divided into those with prominent motor systems, those without prominent motor systems, and currently indeterminate conditions (such as acute confusional states with epileptiform EEG patterns). Axis 2 (etiology) is divided into subcategories of known and unknown causes. Axis 3 (EEG correlates) adopts the latest recommendations by consensus panels to use the following descriptors for the EEG: name of pattern, morphology, location, time-related features, modulation, and effect of intervention. Finally, axis 4 divides age groups into neonatal, infancy, childhood, adolescent and adulthood, and elderly.

Duration of untreated psychosis: Impact of the definition of treatment onset on its predictive value over three years of treatment.

BACKGROUND: While reduction of DUP (Duration of Untreated Psychosis) is a key goal in early intervention strategies, the predictive value of DUP on outcome has been questioned. We planned this study in order to explore the impact of three different definition of "treatment initiation" on the predictive value of DUP on outcome in an early psychosis sample. METHODS: 221 early psychosis patients aged 18-35 were followed-up prospectively over 36 months. DUP was measured using three definitions for treatment onset: Initiation of antipsychotic medication (DUP1); engagement in a specialized programme (DUP2) and combination of engagement in a specialized programme and adherence to medication (DUP3). RESULTS: 10% of patients never reached criteria for DUP3 and therefore were never adequately treated over the 36-month period of care. While DUP1 and DUP2 had a limited predictive value on outcome, DUP3, based on a more restrictive definition for treatment onset, was a better predictor of positive and negative symptoms, as well as functional outcome at 12, 24 and 36 months. Globally, DUP3 explained 2 to 5 times more of the variance than DUP1 and DUP2, with effect sizes falling in the medium range according to Cohen. CONCLUSIONS: The limited predictive value of DUP on outcome in previous studies may be linked to problems of definitions that do not take adherence to treatment into account. While they need replication, our results suggest effort to reduce DUP should continue and aim both at early detection and development of engagement strategies.

Définition et prise en charge de l'échec d'une première injection de toxine botulique Botox(®) 200 U pour hyperactivité détrusorienne neurogène : résultats de l'enquête DETOX [Definition of botulinum toxin failure in neurogenic detrusor overactivity: Preliminary results of the DETOX survey].

OBJECTIVE: There is currently no guideline regarding the management of neurogenic detrusor overactivity (NDO) refractory to intra-detrusor botulinum toxin injections. The primary objective of the present study was to find a consensus definition of failure of botulinum toxin intra-detrusor injections for NDO. The secondary objective was to report current trends in the managment of NDO refractory to botulinum toxin. METHODS: A survey was created, based on data drawn from current literature, and sent via e-mail to all the experts form the Group for research in neurourology in french language (GENULF) and from the comittee of neurourology of the French urological association (AFU). The experts who did not answer to the first e-mail were contacted again twice. Main results from the survey are presented and expressed as numbers and proportions. RESULTS: Out of the 42 experts contacted, 21 responded to the survey. Nineteen participants considered that the definition of failure should be a combination of clinical and urodynamics criteria. Among the urodynamics criteria, the persistence of a maximum detrusor pressure>40cm H2O was the most supported by the experts (18/21, 85%). According to the vast majority of participants (19/21, 90.5%), the impact of injections on urinary incontinence should be included in the definition of failure. Regarding the management, most experts considered that the first line treatment in case of failure of a first intra-detrusor injection of Botox(®) 200 U should be a repeat injection of Botox(®) at a higher dosage (300 U) (15/20, 75%), regardless of the presence or not of urodynamics risk factors of upper tract damage (16/20, 80%). CONCLUSION: This work has provided a first overview of the definition of failure of intra-detrusor injections of botulinum toxin in the management of NDO. For 90.5% of the experts involved, the definition of failure should be clinical and urodynamic and most participants (75%) considered that, in case of failure of a first injection of Botox(®) 200 U, repeat injection of Botox(®) 300 U should be the first line treatment. Level of proof 4.

La identidad en disputa. Conflictos alrededor de la construcción de la transexualidad

Como toda categoría identitaria, transexual tiene una definición normativa —en este caso, muy marcada por su origen médico—, hay unos agentes sociales que controlan su uso y existe un conflicto alrededor de los límites que abarca. En este artículo, analizamos cómo el conflicto por la delimitación de esta categoría se articula a nivel individual y colectivo. En base al análisis de entrevistas, grupos de discusión y mensajes en foros de Internet, se ha observado que hay un choque entre dos concepciones de la transexualidad. La primera defiende, desde postulados biologistas, que los criterios para entrar dentro de esta categoría son el cambio corporal y una identificación normativa con el género reivindicado. La segunda propone una interpretación más inclusiva y estratégica de la categoría. El choque entre estas dos concepciones permite entender el trasfondo de este debate aparentemente terminológico e invita a repensar la forma de entender la conexión entre el género y el cuerpo.

The institutional vs. the academic definition of the quality of work life. What is the focus of the European Commission?

In recent years, we have seen how the quality of work life has been focused and defined by the European Commission (EC). In our study we compare the EC definition with the academic one and try to see how close they are. We also analyse the possibility of applying the institutional definition to the Spanish case through the development of specific indicators. Our main conclusions are that QWL is increasingly important for policy makers. In addition, it is essential to have objective indicators and to conduct surveys in order to reliably measure QWL.

Management zones definition using soil chemical and physical attributes in a soybean area

Several equipments and methodologies have been developed to make available precision agriculture, especially considering the high cost of its implantation and sampling. An interesting possibility is to define management zones aim at dividing producing areas in smaller management zones that could be treated differently, serving as a source of recommendation and analysis. Thus, this trial used physical and chemical properties of soil and yield aiming at the generation of management zones in order to identify whether they can be used as recommendation and analysis. Management zones were generated by the Fuzzy C-Means algorithm and their evaluation was performed by calculating the reduction of variance and performing means tests. The division of the area into two management zones was considered appropriate for the present distinct averages of most soil properties and yield. The used methodology allowed the generation of management zones that can serve as source of recommendation and soil analysis; despite the relative efficiency has shown a reduced variance for all attributes in divisions in the three sub-regions, the ANOVA did not show significative differences among the management zones.

Spatial influence of physical and chemical parameters on management zone definition in apple orchards

ABSTRACT Precision agriculture adoption in Brazilian apple orchards is still incipient. This study aimed at evaluating the spatial variability of certain soil properties as soil density, soil penetration resistance, electrical conductivity, yield, and fruit quality in an apple orchard through digital mapping, as well as assessing the correlation between these factors by means of geostatistics, establishing management zones. Forty representative points were set within 2.5 hectares of apple orchard, wherein soil samples were collected and analyzed, besides measurements of fruit quality (Brix degree, size or diameter, pulp firmness and color) to generate an overall index quality. We concluded that the fruit quality indexes, when isolated, did not show strong spatial dependence, unlike the index of fruit quality (FQI), derived from a combination of these parameters, allowing orchard planning according to management zones based on quality.

Image analysis and definition of nuclear phenotypes

Some basic topics concerned with the extraction of textural and geometric information from cell nucleus images as well as description and characterization of chromatin supraorganization and consequent classification of nuclear phenotypes are presented.