Pathways to care in subjects at high risk for psychotic disorders — A European perspective

Evidence-based decisions on indicated prevention in early psychosis require large-scale studies on the pathways to care in high-risk subjects. EPOS (The European Prediction of Psychosis Study), a prospective multi-center, naturalistic field study in four European countries (Finland, Germany, The Netherlands and England), was designed to acquire accurate knowledge about pathways to care and delay in obtaining specialized high risk care. Our high risk sample (n=233) reported on average 2.9 help-seeking contacts, with an average delay between onset of relevant problems to initial help-seeking contact of 72.6 weeks, and between initial help-seeking contact and reaching specialized high risk care of 110.9 weeks. This resulted in a total estimated duration of an unrecognized risk for psychosis of 3 ½ years. Across EPOS EU regions, about 90% of care pathway contacts were within professional health care sectors. Between EPOS regions, differences in the pathways parameters including early detection and health-care systems were often very pronounced. High-risk participants who later made transition to a full psychotic disorder had significantly longer delays between initial help-seeking and receiving appropriate interventions. Our study underlines the need for regionally adapted implementation of early detection and intervention programs within respective mental health and health care networks, including enhancing public awareness of early psychosis.

Prevalence and risk factors of late presentation for HIV diagnosis and care in a tertiary referral centre in Switzerland.

QUESTIONS UNDER STUDY We sought to identify reasons for late human immunodeficiency virus (HIV) testing or late presentation for care. METHODS A structured chart review was performed to obtain data on test- and health-seeking behaviour of patients presenting late with CD4 cell counts below 350 cells/µl or with acquired immunodeficiency syndrome (AIDS), at the Zurich centre of the Swiss HIV Cohort Study between January 2009 and December 2011. Logistic regression analyses were used to compare demographic characteristics of persons presenting late with not late presenters. RESULTS Of 281 patients, 45% presented late, 48% were chronically HIV-infected non-late presenters, and an additional 7% fulfilled the <350 CD4 cells/µl criterion for late presentation but a chart review revealed that lymphopenia was caused by acute HIV infection. Among the late presenters, 60% were first tested HIV positive in a private practice. More than half of the tests (60%) were suggested by a physician, only 7% following a specific risk situation. The majority (88%) of patients entered medical care within 1 month of testing HIV positive. Risk factors for late presentation were older age (odds ratio [OR] for ≥50 vs <30 years: 3.16, p = 0.017), Asian versus Caucasian ethnicity (OR 3.5, p = 0.021). Compared with men who have sex with men (MSM) without stable partnership, MSM in a stable partnership appeared less likely to present late (OR 0.50, p = 0.034), whereas heterosexual men in a stable partnership had a 2.72-fold increased odds to present late (p = 0.049). CONCLUSIONS The frequency of late testing could be reduced by promoting awareness, particularly among older individuals and heterosexual men in stable partnerships.

Observed management practices in relation to the risk of infection with paratuberculosis and to the spread of Mycobacterium avium subsp. paratuberculosis in Swiss dairy and beef herds

Abstract BACKGROUND: Many studies have been conducted to define risk factors for the transmission of bovine paratuberculosis, mostly in countries with large herds. Little is known about the epidemiology in infected Swiss herds and risk factors important for transmission in smaller herds. Therefore, the presence of known factors which might favor the spread of paratuberculosis and could be related to the prevalence at animal level of fecal shedding of Mycobacterium avium subsp. paratuberculosis were assessed in 17 infected herds (10 dairy, 7 beef). Additionally, the level of knowledge of herd managers about the disease was assessed. In a case-control study with 4 matched negative control herds per infected herd, the association of potential risk factors with the infection status of the herd was investigated. RESULTS: Exposure of the young stock to feces of older animals was frequently observed in infected and in control herds. The farmers' knowledge about paratuberculosis was very limited, even in infected herds. An overall prevalence at animal level of fecal shedding of Mycobacterium avium subsp. paratuberculosis of 6.1% was found in infected herds, whereby shedders younger than 2 years of age were found in 46.2% of the herds where the young stock was available for testing. Several factors related to contamination of the heifer area with cows' feces and the management of the calving area were found to be significantly associated with the within-herd prevalence. Animal purchase was associated with a positive herd infection status (OR = 7.25, p = 0.004). CONCLUSIONS: Numerous risk factors favoring the spread of Mycobacterium avium subsp. paratuberculosis from adult animals to the young stock were observed in infected Swiss dairy and beef herds, which may be amenable to improvement in order to control the disease. Important factors were contamination of the heifer and the calving area, which were associated with higher within-herd prevalence of fecal shedding. The awareness of farmers of paratuberculosis was very low, even in infected herds. Animal purchase in a herd was significantly associated with the probability of a herd to be infected and is thus the most important factor for the control of the spread of disease between farms.

Genotype-specific risk factors for Staphylococcus aureus in Swiss dairy herds with an elevated yield-corrected herd somatic cell count

Bovine mastitis is a frequent problem in Swiss dairy herds. One of the main pathogens causing significant economic loss is Staphylococcus aureus. Various Staph. aureus genotypes with different biological properties have been described. Genotype B (GTB) of Staph. aureus was identified as the most contagious and one of the most prevalent strains in Switzerland. The aim of this study was to identify risk factors associated with the herd-level presence of Staph. aureus GTB and Staph. aureus non-GTB in Swiss dairy herds with an elevated yield-corrected herd somatic cell count (YCHSCC). One hundred dairy herds with a mean YCHSCC between 200,000 and 300,000cells/mL in 2010 were recruited and each farm was visited once during milking. A standardized protocol investigating demography, mastitis management, cow husbandry, milking system, and milking routine was completed during the visit. A bulk tank milk (BTM) sample was analyzed by real-time PCR for the presence of Staph. aureus GTB to classify the herds into 2 groups: Staph. aureus GTB-positive and Staph. aureus GTB-negative. Moreover, quarter milk samples were aseptically collected for bacteriological culture from cows with a somatic cell count ≥150,000cells/mL on the last test-day before the visit. The culture results allowed us to allocate the Staph. aureus GTB-negative farms to Staph. aureus non-GTB and Staph. aureus-free groups. Multivariable multinomial logistic regression models were built to identify risk factors associated with the herd-level presence of Staph. aureus GTB and Staph. aureus non-GTB. The prevalence of Staph. aureus GTB herds was 16% (n=16), whereas that of Staph. aureus non-GTB herds was 38% (n=38). Herds that sent lactating cows to seasonal communal pastures had significantly higher odds of being infected with Staph. aureus GTB (odds ratio: 10.2, 95% CI: 1.9-56.6), compared with herds without communal pasturing. Herds that purchased heifers had significantly higher odds of being infected with Staph. aureus GTB (rather than Staph. aureus non-GTB) compared with herds without purchase of heifers. Furthermore, herds that did not use udder ointment as supportive therapy for acute mastitis had significantly higher odds of being infected with Staph. aureus GTB (odds ratio: 8.5, 95% CI: 1.6-58.4) or Staph. aureus non-GTB (odds ratio: 6.1, 95% CI: 1.3-27.8) than herds that used udder ointment occasionally or regularly. Herds in which the milker performed unrelated activities during milking had significantly higher odds of being infected with Staph. aureus GTB (rather than Staph. aureus non-GTB) compared with herds in which the milker did not perform unrelated activities at milking. Awareness of 4 potential risk factors identified in this study guides implementation of intervention strategies to improve udder health in both Staph. aureus GTB and Staph. aureus non-GTB herds.

Duration of unspecific prodromal and clinical high risk states, and early help-seeking in first-admission psychosis patients

PURPOSE Prevention of psychosis requires both presence of clinical high risk (CHR) criteria and early help-seeking. Previous retrospective studies of the duration of untreated illness (i.e. prodrome plus psychosis) did not distinguish between prodromal states with and without CHR symptoms. Therefore, we examined the occurrence of CHR symptoms and first help-seeking, thereby considering effects of age at illness-onset. METHODS Adult patients first admitted for psychosis (n = 126) were retrospectively assessed for early course of illness and characteristics of first help-seeking. RESULTS One-hundred and nine patients reported a prodrome, 58 with CHR symptoms. In patients with an early illness-onset before age 18 (n = 45), duration of both illness and psychosis were elongated, and CHR symptoms more frequent (68.9 vs. 33.3 %) compared to those with adult illness-onset. Only 29 patients reported help-seeking in the prodrome; this was mainly self-initiated, especially in patients with an early illness-onset. After the onset of first psychotic symptoms, help-seeking was mainly initiated by others. State- and age-independently, mental health professionals were the main first point-of-call (54.0 %). CONCLUSIONS Adult first-admission psychosis patients with an early, insidious onset of symptoms before age 18 were more likely to recall CHR symptoms as part of their prodrome. According to current psychosis-risk criteria, these CHR symptoms, in principle, would have allowed the early detection of psychosis. Furthermore, compared to patients with an adult illness-onset, patients with an early illness-onset were also more likely to seek help on their own account. Thus, future awareness strategies to improve CHR detection might be primarily related to young persons and self-perceived subtle symptoms.

Evaluation of a pilot diabetes educational intervention using the American Diabetes Association's Risk Assessment form with the patrons of The Health Museum, Houston Texas

Diabetes Mellitus is not a disease, but a group of diseases. Common to all types of diabetes is high levels of blood glucose produced from a variety of causes. In 2006, the American Diabetes Association ranked diabetes as the fifth leading cause of death in the United States. The complications and consequences are serious and include nephropathy, retinopathy, neuropathy, heart disease, amputations, pregnancy complications, sexual dysfunction, biochemical imbalances, susceptibility and sensitivity to many other diseases and in some cases death. ^ The serious nature of diabetes mellitus and its complications has compelled researchers to devise new strategies to reach population segments at high risk. Various avenues of outreach have been attempted. This pilot program is not unique in using a health museum as a point of outreach. However health museums have not been a major source of interventions, either. Little information was available regarding health museum visitor demographics, visitation patterns, companion status and museum trust levels prior to this pilot intervention. This visitor information will improve planning for further interventions and studies. ^ This thesis also examined prevalence data in a temporal context, the populations at risk for diabetes, the collecting agencies, and other relevant collected data. The prevalence of diabetes has been rapidly increasing. The increase is partially explained by refinement of the definition of diabetes as the etiology has become better understood. Increasing obesity and sedentary lifestyles have contributed to the increase, as well as the burdensome increase on minority populations. ^ Treatment options are complex and have had limited effectiveness. This would lead one to conclude that prevention and early diagnosis are preferable. However, the general public has insufficient awareness and education regarding diabetes symptoms and the serious risks and complications the disease can cause. Reaching high risk, high prevalence, populations is challenging for any intervention. During its “free family Thursdays” The Health Museum (Houston, Texas) has attracted a variety of ethnic patrons; similar to the Houston and Harris County demographics. This research project explored the effectiveness of a pilot diabetes educational intervention in a health museum setting where people chose to visit. ^

Psychosocial predictors of HIV testing behaviors among high risk heterosexuals

Though a lot of progress has been made in the treatment, prevention, and in increasing the knowledge and awareness of HIV/AIDS, the CDC reports that over 21% of the people infected with HIV are unaware of their HIV serostatus. Thirty-one percent of people infected with HIV are diagnosed late in the disease progression, often too late to prevent the transmission or the progression of HIV to AIDS. CDC has set a goal to increase by the year 2010, the number of people aware of the HIV serostatus by 5%. ^ This study examined the association between decision-making and risk-taking (assessed using the decision-making confidence and risk-taking scales of the Texas Christian University Self Rating Form) and HIV testing behaviors within a population of heterosexuals at risk for HIV infections living in Harris County, Texas (N=923). Data used in the study was obtained during the first cycle of the National HIV Behavioral Surveillance among heterosexuals at risk for HIV infection (NHBS-HET1), conducted from October, 2006 to June, 2007. Eighty percent of the study population reported testing for HIV at some point in their lives. The results showed that individuals who scored high (>3.3) on the decision-making confidence scale of the TCU/SRF were more likely to be tested for HIV when compared to those who scored low on the scale (OR= 2.02, 95% CI= 1.44–2.84), and that individuals who score low on the risk-taking scale of the TCU/SRF were more likely to have been tested for HIV when compared to those who scored high on the scale (OR= 1.65, 95% CI= 1.2–2.31). Several demographic factors were also assessed for their association with HIV testing behaviors. Only sex was found to be associated with HIV testing. ^ The findings suggest that risk-taking and decision-making are predictors of HIV testing behaviors such as prior HIV testing within heterosexuals living in high-risk areas of Houston, Texas, and that intervention designed to improve the risk-taking and decision-making attributes of this population might improve HIV testing within this population.^

Planning and implementation efficacy as a determinant of health risk communication outcomes: Case studies of the U.S. Public Health Service (PHS)

This study was conducted under the auspices of the Subcommittee on Risk Communication and Education of the Committee to Coordinate Environmental Health and Related Programs (CCEHRP) to determine how Public Health Service (PHS) agencies are communicating information about health risk, what factors contributed to effective communication efforts, and what specific principles, strategies, and practices best promote more effective health risk communication outcomes.^ Member agencies of the Subcommittee submitted examples of health risk communication activities or decisions they perceived to be effective and some examples of cases they thought had not been as effective as desired. Of the 10 case studies received, 7 were submitted as examples of effective health risk communication, and 3, as examples of less effective communication.^ Information contained in the 10 case studies describing the respective agencies' health risk communication strategies and practices was compared with EPA's Seven Cardinal Rules of Risk Communication, since similar rules were not found in any PHS agency. EPA's rules are: (1) Accept and involve the public as a legitimate partner. (2) Plan carefully and evaluate your efforts. (3) Listen to the public's specific concerns. (4) Be honest, frank, and open. (5) Coordinate and collaborate with other credible sources. (6) Meet the needs of the media. (7) Speak clearly and with compassion.^ On the basis of case studies analysis, the Subcommittee, in their attempts to design and implement effective health risk communication campaigns, identified a number of areas for improvement among the agencies. First, PHS agencies should consider developing a focus specific to health risk communication (i.e., office or specialty resource). Second, create a set of generally accepted practices and guidelines for effective implementation and evaluation of PHS health risk communication activities and products. Third, organize interagency initiatives aimed at increasing awareness and visibility of health risk communication issues and trends within and between PHS agencies.^ PHS agencies identified some specific implementation strategies the CCEHRP might consider pursuing to address the major recommendations. Implementation strategies common to PHS agencies emerged in the following five areas: (1) program development, (2) building partnerships, (3) developing training, (4) expanding information technologies, and (5) conducting research and evaluation. ^

Assessing the Environmental Protection Agency's guidelines for cumulative risk assessment: Are they suitable for state agencies and EPA regional offices?

In the field of health risk analysis, cumulative risk assessment (CRA) is a necessary, although undeniably more complex approach to understanding the mixture of stressors, whether chemical or psychosocial, that exist in our environment, in all the pathways through which the chemicals may evolve—air, soil, or water, as well as the accumulation of these exposures over time. Related, or attached to the developing awareness of scientists understanding this mix of combined health effects is the burgeoning of the environmental justice movement, in which educated community advocates and even affected community members have called attention to evidence of a higher pollution burden in minority and/or lower SES communities. The intention of this paper is to 1) examine the development and understanding of CRA, primarily by the U.S. Environmental Protection Agency; 2) to assess several states agencies and some EPA regional offices' interpretation of CRA, again based primarily on EPA guidance, and 3) to analyze how CRA might be refined in its implementation—giving some cues as to how the EPA may more effectively interact with communities interested in CRA.^

Increasing awareness of colorectal cancer screening through targeted exam room based video messages

Colorectal cancer (CRC) is the third largest cause of cancer death in the United States. While the disease burden is high, there are proven methods to screen for CRC and detect it at a stage that is amenable to cure. Patients with low health literacy have difficulty navigating the health care system and are at increased risk to not receive preventive care services such as colorectal cancer screening (CRCS). To address this need, an exam-room based video was developed to be played for patients in the privacy of the exam room, while they are waiting to be seen by their medical provider. In roughly 2 minutes, the video informs the patient about CRC and CRCS and how they can successfully complete CRCS. One of the key barriers to completing CRCS is the need to increase patients' knowledge and improve attitudes surrounding CRCS. This study examines the impact of the video on patients' knowledge and attitudes about CRC and CRCS in a medically underserved patient population in Houston, Texas. ^ Sixty-one patients presenting for routine medical care were enrolled in the study. Depending on their randomization, the patients either received routine information about CRC and CRCS or they watched the video. We found that the patients who did watch the video did have improvements in their knowledge and improved attitudes about CRC and CRCS. Future studies will be needed to examine whether the video improves the patients' completion of CRCS.^

Dengue transmission risk maps of the continental United States

Dengue fever is a strictly human and non-human primate disease characterized by a high fever, thrombocytopenia, retro-orbital pain, and severe joint and muscle pain. Over 40% of the world population is at risk. Recent re-emergence of dengue outbreaks in Texas and Florida following the re-introduction of competent Aedes mosquito vectors in the United States have raised growing concerns about the potential for increased occurrences of dengue fever outbreaks throughout the southern United States. Current deficiencies in vector control, active surveillance and awareness among medical practitioners may contribute to a delay in recognizing and controlling a dengue virus outbreak. Previous studies have shown links between low-income census tracts, high population density, and dengue fever within the United States. Areas of low-income and high population density that correlate with the distribution of Aedes mosquitoes result in higher potential for outbreaks. In this retrospective ecologic study, nine maps were generated to model U.S. census tracts’ potential to sustain dengue virus transmission if the virus was introduced into the area. Variables in the model included presence of a competent vector in the county and census tract percent poverty and population density. Thirty states, 1,188 counties, and 34,705 census tracts were included in the analysis. Among counties with Aedes mosquito infestation, the census tracts were ranked high, medium, and low risk potential for sustained transmission of the virus. High risk census tracts were identified as areas having the vector, ≥20% poverty, and ≥500 persons per square mile. Census tracts with either ≥20% poverty or ≥500 persons per square mile and have the vector present are considered moderate risk. Census tracts that have the vector present but have <20% poverty and <500 persons per square mile are considered low risk. Furthermore, counties were characterized as moderate risk if 50% or more of the census tracts in that county were rated high or moderate risk, and high risk if 25% or greater were rated high risk. Extreme risk counties, which were primarily concentrated in Texas and Mississippi, were considered having 50% or greater of the census tracts ranked as high risk. Mapping of geographic areas with potential to sustain dengue virus transmission will support surveillance efforts and assist medical personnel in recognizing potential cases. ^

Methodologies for Collision Risk Computation = Metodologías para Cálculo de Riesgo de Colisión

Esta tesis aborda metodologías para el cálculo de riesgo de colisión de satélites. La minimización del riesgo de colisión se debe abordar desde dos puntos de vista distintos. Desde el punto de vista operacional, es necesario filtrar los objetos que pueden presentar un encuentro entre todos los objetos que comparten el espacio con un satélite operacional. Puesto que las órbitas, del objeto operacional y del objeto envuelto en la colisión, no se conocen perfectamente, la geometría del encuentro y el riesgo de colisión deben ser evaluados. De acuerdo con dicha geometría o riesgo, una maniobra evasiva puede ser necesaria para evitar la colisión. Dichas maniobras implican un consumo de combustible que impacta en la capacidad de mantenimiento orbital y por tanto de la visa útil del satélite. Por tanto, el combustible necesario a lo largo de la vida útil de un satélite debe ser estimado en fase de diseño de la misión para una correcta definición de su vida útil, especialmente para satélites orbitando en regímenes orbitales muy poblados. Los dos aspectos, diseño de misión y aspectos operacionales en relación con el riesgo de colisión están abordados en esta tesis y se resumen en la Figura 3. En relación con los aspectos relacionados con el diseño de misión (parte inferior de la figura), es necesario evaluar estadísticamente las características de de la población espacial y las teorías que permiten calcular el número medio de eventos encontrados por una misión y su capacidad de reducir riesgo de colisión. Estos dos aspectos definen los procedimientos más apropiados para reducir el riesgo de colisión en fase operacional. Este aspecto es abordado, comenzando por la teoría descrita en [Sánchez-Ortiz, 2006]T.14 e implementada por el autor de esta tesis en la herramienta ARES [Sánchez-Ortiz, 2004b]T.15 proporcionada por ESA para la evaluación de estrategias de evitación de colisión. Esta teoría es extendida en esta tesis para considerar las características de los datos orbitales disponibles en las fases operacionales de un satélite (sección 4.3.3). Además, esta teoría se ha extendido para considerar riesgo máximo de colisión cuando la incertidumbre de las órbitas de objetos catalogados no es conocida (como se da el caso para los TLE), y en el caso de querer sólo considerar riesgo de colisión catastrófico (sección 4.3.2.3). Dichas mejoras se han incluido en la nueva versión de ARES [Domínguez-González and Sánchez-Ortiz, 2012b]T.12 puesta a disposición a través de [SDUP,2014]R.60. En fase operacional, los catálogos que proporcionan datos orbitales de los objetos espaciales, son procesados rutinariamente, para identificar posibles encuentros que se analizan en base a algoritmos de cálculo de riesgo de colisión para proponer maniobras de evasión. Actualmente existe una única fuente de datos públicos, el catálogo TLE (de sus siglas en inglés, Two Line Elements). Además, el Joint Space Operation Center (JSpOC) Americano proporciona mensajes con alertas de colisión (CSM) cuando el sistema de vigilancia americano identifica un posible encuentro. En función de los datos usados en fase operacional (TLE o CSM), la estrategia de evitación puede ser diferente debido a las características de dicha información. Es preciso conocer las principales características de los datos disponibles (respecto a la precisión de los datos orbitales) para estimar los posibles eventos de colisión encontrados por un satélite a lo largo de su vida útil. En caso de los TLE, cuya precisión orbital no es proporcionada, la información de precisión orbital derivada de un análisis estadístico se puede usar también en el proceso operacional así como en el diseño de la misión. En caso de utilizar CSM como base de las operaciones de evitación de colisiones, se conoce la precisión orbital de los dos objetos involucrados. Estas características se han analizado en detalle, evaluando estadísticamente las características de ambos tipos de datos. Una vez concluido dicho análisis, se ha analizado el impacto de utilizar TLE o CSM en las operaciones del satélite (sección 5.1). Este análisis se ha publicado en una revista especializada [Sánchez-Ortiz, 2015b]T.3. En dicho análisis, se proporcionan recomendaciones para distintas misiones (tamaño del satélite y régimen orbital) en relación con las estrategias de evitación de colisión para reducir el riesgo de colisión de manera significativa. Por ejemplo, en el caso de un satélite en órbita heliosíncrona en régimen orbital LEO, el valor típico del ACPL que se usa de manera extendida es 10-4. Este valor no es adecuado cuando los esquemas de evitación de colisión se realizan sobre datos TLE. En este caso, la capacidad de reducción de riesgo es prácticamente nula (debido a las grandes incertidumbres de los datos TLE) incluso para tiempos cortos de predicción. Para conseguir una reducción significativa del riesgo, sería necesario usar un ACPL en torno a 10-6 o inferior, produciendo unas 10 alarmas al año por satélite (considerando predicciones a un día) o 100 alarmas al año (con predicciones a tres días). Por tanto, la principal conclusión es la falta de idoneidad de los datos TLE para el cálculo de eventos de colisión. Al contrario, usando los datos CSM, debido a su mejor precisión orbital, se puede obtener una reducción significativa del riesgo con ACPL en torno a 10-4 (considerando 3 días de predicción). Incluso 5 días de predicción pueden ser considerados con ACPL en torno a 10-5. Incluso tiempos de predicción más largos se pueden usar (7 días) con reducción del 90% del riesgo y unas 5 alarmas al año (en caso de predicciones de 5 días, el número de maniobras se mantiene en unas 2 al año). La dinámica en GEO es diferente al caso LEO y hace que el crecimiento de las incertidumbres orbitales con el tiempo de propagación sea menor. Por el contrario, las incertidumbres derivadas de la determinación orbital son peores que en LEO por las diferencias en las capacidades de observación de uno y otro régimen orbital. Además, se debe considerar que los tiempos de predicción considerados para LEO pueden no ser apropiados para el caso de un satélite GEO (puesto que tiene un periodo orbital mayor). En este caso usando datos TLE, una reducción significativa del riesgo sólo se consigue con valores pequeños de ACPL, produciendo una alarma por año cuando los eventos de colisión se predicen a un día vista (tiempo muy corto para implementar maniobras de evitación de colisión).Valores más adecuados de ACPL se encuentran entre 5•10-8 y 10-7, muy por debajo de los valores usados en las operaciones actuales de la mayoría de las misiones GEO (de nuevo, no se recomienda en este régimen orbital basar las estrategias de evitación de colisión en TLE). Los datos CSM permiten una reducción de riesgo apropiada con ACPL entre 10-5 y 10-4 con tiempos de predicción cortos y medios (10-5 se recomienda para predicciones a 5 o 7 días). El número de maniobras realizadas sería una en 10 años de misión. Se debe notar que estos cálculos están realizados para un satélite de unos 2 metros de radio. En el futuro, otros sistemas de vigilancia espacial (como el programa SSA de la ESA), proporcionarán catálogos adicionales de objetos espaciales con el objetivo de reducir el riesgo de colisión de los satélites. Para definir dichos sistemas de vigilancia, es necesario identificar las prestaciones del catalogo en función de la reducción de riesgo que se pretende conseguir. Las características del catálogo que afectan principalmente a dicha capacidad son la cobertura (número de objetos incluidos en el catalogo, limitado principalmente por el tamaño mínimo de los objetos en función de las limitaciones de los sensores utilizados) y la precisión de los datos orbitales (derivada de las prestaciones de los sensores en relación con la precisión de las medidas y la capacidad de re-observación de los objetos). El resultado de dicho análisis (sección 5.2) se ha publicado en una revista especializada [Sánchez-Ortiz, 2015a]T.2. Este análisis no estaba inicialmente previsto durante la tesis, y permite mostrar como la teoría descrita en esta tesis, inicialmente definida para facilitar el diseño de misiones (parte superior de la figura 1) se ha extendido y se puede aplicar para otros propósitos como el dimensionado de un sistema de vigilancia espacial (parte inferior de la figura 1). La principal diferencia de los dos análisis se basa en considerar las capacidades de catalogación (precisión y tamaño de objetos observados) como una variable a modificar en el caso de un diseño de un sistema de vigilancia), siendo fijas en el caso de un diseño de misión. En el caso de las salidas generadas en el análisis, todos los aspectos calculados en un análisis estadístico de riesgo de colisión son importantes para diseño de misión (con el objetivo de calcular la estrategia de evitación y la cantidad de combustible a utilizar), mientras que en el caso de un diseño de un sistema de vigilancia, los aspectos más importantes son el número de maniobras y falsas alarmas (fiabilidad del sistema) y la capacidad de reducción de riesgo (efectividad del sistema). Adicionalmente, un sistema de vigilancia espacial debe ser caracterizado por su capacidad de evitar colisiones catastróficas (evitando así in incremento dramático de la población de basura espacial), mientras que el diseño de una misión debe considerar todo tipo de encuentros, puesto que un operador está interesado en evitar tanto las colisiones catastróficas como las letales. Del análisis de las prestaciones (tamaño de objetos a catalogar y precisión orbital) requeridas a un sistema de vigilancia espacial se concluye que ambos aspectos han de ser fijados de manera diferente para los distintos regímenes orbitales. En el caso de LEO se hace necesario observar objetos de hasta 5cm de radio, mientras que en GEO se rebaja este requisito hasta los 100 cm para cubrir las colisiones catastróficas. La razón principal para esta diferencia viene de las diferentes velocidades relativas entre los objetos en ambos regímenes orbitales. En relación con la precisión orbital, ésta ha de ser muy buena en LEO para poder reducir el número de falsas alarmas, mientras que en regímenes orbitales más altos se pueden considerar precisiones medias. En relación con los aspectos operaciones de la determinación de riesgo de colisión, existen varios algoritmos de cálculo de riesgo entre dos objetos espaciales. La Figura 2 proporciona un resumen de los casos en cuanto a algoritmos de cálculo de riesgo de colisión y como se abordan en esta tesis. Normalmente se consideran objetos esféricos para simplificar el cálculo de riesgo (caso A). Este caso está ampliamente abordado en la literatura y no se analiza en detalle en esta tesis. Un caso de ejemplo se proporciona en la sección 4.2. Considerar la forma real de los objetos (caso B) permite calcular el riesgo de una manera más precisa. Un nuevo algoritmo es definido en esta tesis para calcular el riesgo de colisión cuando al menos uno de los objetos se considera complejo (sección 4.4.2). Dicho algoritmo permite calcular el riesgo de colisión para objetos formados por un conjunto de cajas, y se ha presentado en varias conferencias internacionales. Para evaluar las prestaciones de dicho algoritmo, sus resultados se han comparado con un análisis de Monte Carlo que se ha definido para considerar colisiones entre cajas de manera adecuada (sección 4.1.2.3), pues la búsqueda de colisiones simples aplicables para objetos esféricos no es aplicable a este caso. Este análisis de Monte Carlo se considera la verdad a la hora de calcular los resultados del algoritmos, dicha comparativa se presenta en la sección 4.4.4. En el caso de satélites que no se pueden considerar esféricos, el uso de un modelo de la geometría del satélite permite descartar eventos que no son colisiones reales o estimar con mayor precisión el riesgo asociado a un evento. El uso de estos algoritmos con geometrías complejas es más relevante para objetos de dimensiones grandes debido a las prestaciones de precisión orbital actuales. En el futuro, si los sistemas de vigilancia mejoran y las órbitas son conocidas con mayor precisión, la importancia de considerar la geometría real de los satélites será cada vez más relevante. La sección 5.4 presenta un ejemplo para un sistema de grandes dimensiones (satélite con un tether). Adicionalmente, si los dos objetos involucrados en la colisión tienen velocidad relativa baja (y geometría simple, Caso C en la Figura 2), la mayor parte de los algoritmos no son aplicables requiriendo implementaciones dedicadas para este caso particular. En esta tesis, uno de estos algoritmos presentado en la literatura [Patera, 2001]R.26 se ha analizado para determinar su idoneidad en distintos tipos de eventos (sección 4.5). La evaluación frete a un análisis de Monte Carlo se proporciona en la sección 4.5.2. Tras este análisis, se ha considerado adecuado para abordar las colisiones de baja velocidad. En particular, se ha concluido que el uso de algoritmos dedicados para baja velocidad son necesarios en función del tamaño del volumen de colisión proyectado en el plano de encuentro (B-plane) y del tamaño de la incertidumbre asociada al vector posición entre los dos objetos. Para incertidumbres grandes, estos algoritmos se hacen más necesarios pues la duración del intervalo en que los elipsoides de error de los dos objetos pueden intersecar es mayor. Dicho algoritmo se ha probado integrando el algoritmo de colisión para objetos con geometrías complejas. El resultado de dicho análisis muestra que este algoritmo puede ser extendido fácilmente para considerar diferentes tipos de algoritmos de cálculo de riesgo de colisión (sección 4.5.3). Ambos algoritmos, junto con el método Monte Carlo para geometrías complejas, se han implementado en la herramienta operacional de la ESA CORAM, que es utilizada para evaluar el riesgo de colisión en las actividades rutinarias de los satélites operados por ESA [Sánchez-Ortiz, 2013a]T.11. Este hecho muestra el interés y relevancia de los algoritmos desarrollados para la mejora de las operaciones de los satélites. Dichos algoritmos han sido presentados en varias conferencias internacionales [Sánchez-Ortiz, 2013b]T.9, [Pulido, 2014]T.7,[Grande-Olalla, 2013]T.10, [Pulido, 2014]T.5, [Sánchez-Ortiz, 2015c]T.1. ABSTRACT This document addresses methodologies for computation of the collision risk of a satellite. Two different approaches need to be considered for collision risk minimisation. On an operational basis, it is needed to perform a sieve of possible objects approaching the satellite, among all objects sharing the space with an operational satellite. As the orbits of both, satellite and the eventual collider, are not perfectly known but only estimated, the miss-encounter geometry and the actual risk of collision shall be evaluated. In the basis of the encounter geometry or the risk, an eventual manoeuvre may be required to avoid the conjunction. Those manoeuvres will be associated to a reduction in the fuel for the mission orbit maintenance, and thus, may reduce the satellite operational lifetime. Thus, avoidance manoeuvre fuel budget shall be estimated, at mission design phase, for a better estimation of mission lifetime, especially for those satellites orbiting in very populated orbital regimes. These two aspects, mission design and operational collision risk aspects, are summarised in Figure 3, and covered along this thesis. Bottom part of the figure identifies the aspects to be consider for the mission design phase (statistical characterisation of the space object population data and theory computing the mean number of events and risk reduction capability) which will define the most appropriate collision avoidance approach at mission operational phase. This part is covered in this work by starting from the theory described in [Sánchez-Ortiz, 2006]T.14 and implemented by this author in ARES tool [Sánchez-Ortiz, 2004b]T.15 provided by ESA for evaluation of collision avoidance approaches. This methodology has been now extended to account for the particular features of the available data sets in operational environment (section 4.3.3). Additionally, the formulation has been extended to allow evaluating risk computation approached when orbital uncertainty is not available (like the TLE case) and when only catastrophic collisions are subject to study (section 4.3.2.3). These improvements to the theory have been included in the new version of ESA ARES tool [Domínguez-González and Sánchez-Ortiz, 2012b]T.12 and available through [SDUP,2014]R.60. At the operation phase, the real catalogue data will be processed on a routine basis, with adequate collision risk computation algorithms to propose conjunction avoidance manoeuvre optimised for every event. The optimisation of manoeuvres in an operational basis is not approached along this document. Currently, American Two Line Element (TLE) catalogue is the only public source of data providing orbits of objects in space to identify eventual conjunction events. Additionally, Conjunction Summary Message (CSM) is provided by Joint Space Operation Center (JSpOC) when the American system identifies a possible collision among satellites and debris. Depending on the data used for collision avoidance evaluation, the conjunction avoidance approach may be different. The main features of currently available data need to be analysed (in regards to accuracy) in order to perform estimation of eventual encounters to be found along the mission lifetime. In the case of TLE, as these data is not provided with accuracy information, operational collision avoidance may be also based on statistical accuracy information as the one used in the mission design approach. This is not the case for CSM data, which includes the state vector and orbital accuracy of the two involved objects. This aspect has been analysed in detail and is depicted in the document, evaluating in statistical way the characteristics of both data sets in regards to the main aspects related to collision avoidance. Once the analysis of data set was completed, investigations on the impact of those features in the most convenient avoidance approaches have been addressed (section 5.1). This analysis is published in a peer-reviewed journal [Sánchez-Ortiz, 2015b]T.3. The analysis provides recommendations for different mission types (satellite size and orbital regime) in regards to the most appropriate collision avoidance approach for relevant risk reduction. The risk reduction capability is very much dependent on the accuracy of the catalogue utilized to identify eventual collisions. Approaches based on CSM data are recommended against the TLE based approach. Some approaches based on the maximum risk associated to envisaged encounters are demonstrated to report a very large number of events, which makes the approach not suitable for operational activities. Accepted Collision Probability Levels are recommended for the definition of the avoidance strategies for different mission types. For example for the case of a LEO satellite in the Sun-synchronous regime, the typically used ACPL value of 10-4 is not a suitable value for collision avoidance schemes based on TLE data. In this case the risk reduction capacity is almost null (due to the large uncertainties associated to TLE data sets, even for short time-to-event values). For significant reduction of risk when using TLE data, ACPL on the order of 10-6 (or lower) seems to be required, producing about 10 warnings per year and mission (if one-day ahead events are considered) or 100 warnings per year (for three-days ahead estimations). Thus, the main conclusion from these results is the lack of feasibility of TLE for a proper collision avoidance approach. On the contrary, for CSM data, and due to the better accuracy of the orbital information when compared with TLE, ACPL on the order of 10-4 allows to significantly reduce the risk. This is true for events estimated up to 3 days ahead. Even 5 days ahead events can be considered, but ACPL values down to 10-5 should be considered in such case. Even larger prediction times can be considered (7 days) for risk reduction about 90%, at the cost of larger number of warnings up to 5 events per year, when 5 days prediction allows to keep the manoeuvre rate in 2 manoeuvres per year. Dynamics of the GEO orbits is different to that in LEO, impacting on a lower increase of orbits uncertainty along time. On the contrary, uncertainties at short prediction times at this orbital regime are larger than those at LEO due to the differences in observation capabilities. Additionally, it has to be accounted that short prediction times feasible at LEO may not be appropriate for a GEO mission due to the orbital period being much larger at this regime. In the case of TLE data sets, significant reduction of risk is only achieved for small ACPL values, producing about a warning event per year if warnings are raised one day in advance to the event (too short for any reaction to be considered). Suitable ACPL values would lay in between 5•10-8 and 10-7, well below the normal values used in current operations for most of the GEO missions (TLE-based strategies for collision avoidance at this regime are not recommended). On the contrary, CSM data allows a good reduction of risk with ACPL in between 10-5 and 10-4 for short and medium prediction times. 10-5 is recommended for prediction times of five or seven days. The number of events raised for a suitable warning time of seven days would be about one in a 10-year mission. It must be noted, that these results are associated to a 2 m radius spacecraft, impact of the satellite size are also analysed within the thesis. In the future, other Space Situational Awareness Systems (SSA, ESA program) may provide additional catalogues of objects in space with the aim of reducing the risk. It is needed to investigate which are the required performances of those catalogues for allowing such risk reduction. The main performance aspects are coverage (objects included in the catalogue, mainly limited by a minimum object size derived from sensor performances) and the accuracy of the orbital data to accurately evaluate the conjunctions (derived from sensor performance in regards to object observation frequency and accuracy). The results of these investigations (section 5.2) are published in a peer-reviewed journal [Sánchez-Ortiz, 2015a]T.2. This aspect was not initially foreseen as objective of the thesis, but it shows how the theory described in the thesis, initially defined for mission design in regards to avoidance manoeuvre fuel allocation (upper part of figure 1), is extended and serves for additional purposes as dimensioning a Space Surveillance and Tracking (SST) system (bottom part of figure below). The main difference between the two approaches is the consideration of the catalogue features as part of the theory which are not modified (for the satellite mission design case) instead of being an input for the analysis (in the case of the SST design). In regards to the outputs, all the features computed by the statistical conjunction analysis are of importance for mission design (with the objective of proper global avoidance strategy definition and fuel allocation), whereas for the case of SST design, the most relevant aspects are the manoeuvre and false alarm rates (defining a reliable system) and the Risk Reduction capability (driving the effectiveness of the system). In regards to the methodology for computing the risk, the SST system shall be driven by the capacity of providing the means to avoid catastrophic conjunction events (avoiding the dramatic increase of the population), whereas the satellite mission design should consider all type of encounters, as the operator is interested on avoiding both lethal and catastrophic collisions. From the analysis of the SST features (object coverage and orbital uncertainty) for a reliable system, it is concluded that those two characteristics are to be imposed differently for the different orbital regimes, as the population level is different depending on the orbit type. Coverage values range from 5 cm for very populated LEO regime up to 100 cm in the case of GEO region. The difference on this requirement derives mainly from the relative velocity of the encounters at those regimes. Regarding the orbital knowledge of the catalogues, very accurate information is required for objects in the LEO region in order to limit the number of false alarms, whereas intermediate orbital accuracy can be considered for higher orbital regimes. In regards to the operational collision avoidance approaches, several collision risk algorithms are used for evaluation of collision risk of two pair of objects. Figure 2 provides a summary of the different collision risk algorithm cases and indicates how they are covered along this document. The typical case with high relative velocity is well covered in literature for the case of spherical objects (case A), with a large number of available algorithms, that are not analysed in detailed in this work. Only a sample case is provided in section 4.2. If complex geometries are considered (Case B), a more realistic risk evaluation can be computed. New approach for the evaluation of risk in the case of complex geometries is presented in this thesis (section 4.4.2), and it has been presented in several international conferences. The developed algorithm allows evaluating the risk for complex objects formed by a set of boxes. A dedicated Monte Carlo method has also been described (section 4.1.2.3) and implemented to allow the evaluation of the actual collisions among a large number of simulation shots. This Monte Carlo runs are considered the truth for comparison of the algorithm results (section 4.4.4). For spacecrafts that cannot be considered as spheres, the consideration of the real geometry of the objects may allow to discard events which are not real conjunctions, or estimate with larger reliability the risk associated to the event. This is of particular importance for the case of large spacecrafts as the uncertainty in positions of actual catalogues does not reach small values to make a difference for the case of objects below meter size. As the tracking systems improve and the orbits of catalogued objects are known more precisely, the importance of considering actual shapes of the objects will become more relevant. The particular case of a very large system (as a tethered satellite) is analysed in section 5.4. Additionally, if the two colliding objects have low relative velocity (and simple geometries, case C in figure above), the most common collision risk algorithms fail and adequate theories need to be applied. In this document, a low relative velocity algorithm presented in the literature [Patera, 2001]R.26 is described and evaluated (section 4.5). Evaluation through comparison with Monte Carlo approach is provided in section 4.5.2. The main conclusion of this analysis is the suitability of this algorithm for the most common encounter characteristics, and thus it is selected as adequate for collision risk estimation. Its performances are evaluated in order to characterise when it can be safely used for a large variety of encounter characteristics. In particular, it is found that the need of using dedicated algorithms depend on both the size of collision volume in the B-plane and the miss-distance uncertainty. For large uncertainties, the need of such algorithms is more relevant since for small uncertainties the encounter duration where the covariance ellipsoids intersect is smaller. Additionally, its application for the case of complex satellite geometries is assessed (case D in figure above) by integrating the developed algorithm in this thesis with Patera’s formulation for low relative velocity encounters. The results of this analysis show that the algorithm can be easily extended for collision risk estimation process suitable for complex geometry objects (section 4.5.3). The two algorithms, together with the Monte Carlo method, have been implemented in the operational tool CORAM for ESA which is used for the evaluation of collision risk of ESA operated missions, [Sánchez-Ortiz, 2013a]T.11. This fact shows the interest and relevance of the developed algorithms for improvement of satellite operations. The algorithms have been presented in several international conferences, [Sánchez-Ortiz, 2013b]T.9, [Pulido, 2014]T.7,[Grande-Olalla, 2013]T.10, [Pulido, 2014]T.5, [Sánchez-Ortiz, 2015c]T.1.

Expert Approaches to Mental Toughness Development in the High Risk Sport of Diving

Research focusing on mental toughness development and high risk sport is limited to one examination of elite gymnasts' perceptions. Coaches have acknowledged that mental toughness is important to performance success, while admitting they do not know effective development strategies. The aim of the current research is to address both these concerns by employing a grounded theory approach to ascertain elite diving coaches perceptions of mental toughness development and what mental toughness is. Seven diving coaches volunteered and were interviewed for an average of 49 minutes. They all coached an athlete that participated either in the world championships or Olympic games since 2008. Participants reported that mental toughness was the ability of a diver to perform a movement in a crucial moment that requires focus, extending beyond their comfort zone, overcoming fear, and never giving up. Mentaltoughness may not be the appropriate term due to its lack of multicultural sensitivity. Participants felt that dealing with adversity was something divers would have to constantly process. Mental toughness can be developed by the coach, the environment, or individual athlete. Unique attributes specific to divers were an awareness of self and a distinct level of knowing what the athlete was going to do. More research needs to be conducted to determine if these concepts can be generalized to other high risk sports. Future research could help establish a valid quantitative measure of mental toughness development.

In-House Risk

Over the last thirty years or so, as the number of in-house counsel rose and their role increased in scope and prominence, increased attention has been given the various challenges these lawyers face under the ABA Model Rules of Professional Conduct, from figuring out who is the client the in-house lawyer represents, to navigating conflicts of interest, maintaining independence, and engaging in a multijurisdictional practice of law. Less attention, to date, has been given to business risk assessment, perhaps in part because that function appears to be part of in-house counsel’s role as a business person rather than as a lawyer. Overlooking the role of in-house counsel in assessing risk, however, is a risky proposition, because risk assessment constitutes for some in-house counsel a significant aspect of their role, a role that in turn informs and shapes how in-house counsel perform other more overtly legal tasks. For example, wearing her hat as General Counsel, a lawyer for the entity-client may opine and explain issues of compliance with the law. Wearing her hat as the Chief Legal Officer, however, the same lawyer may now be called upon as a member of business management to participate in the decision whether to comply with the law. After outlining some of the traditional challenges faced by in-house counsel under the Rules, this short essay explores risk assessment by in-house counsel and its impact on their role and function under the Rules. It argues that the key to in-house lawyers’ successful navigation of multiple roles, and, in particular, to their effective assessment of business risk is keen awareness of the various hats they are called upon to wear. Navigating these various roles may not be easy for lawyers, whose training and habits of mind often teach them to zoom in on legal risks to the exclusion of business risks. Indeed, law schools continue to teach law students “to think like a lawyer” and law firms, the historical breeding grounds for in-house counsel positions, in a world of increased specialization master the narrower contemplation of legal questions. Yet the present and future of in-house counsel practice demand of its practitioners the careful and gradual coming to terms, buildup and mastery of business risk analysis skills, alongside the cultivation of traditional legal risk analysis tools.

Should I share this? : support awareness of social sharing practice that might compromise online privacy and reputation

Thesis (Master's)--University of Washington, 2016-06