A fully Bayesian approach to inference for Coxian phase-type distributions with covariate dependent mean

Phase-type distributions represent the time to absorption for a finite state Markov chain in continuous time, generalising the exponential distribution and providing a flexible and useful modelling tool. We present a new reversible jump Markov chain Monte Carlo scheme for performing a fully Bayesian analysis of the popular Coxian subclass of phase-type models; the convenient Coxian representation involves fewer parameters than a more general phase-type model. The key novelty of our approach is that we model covariate dependence in the mean whilst using the Coxian phase-type model as a very general residual distribution. Such incorporation of covariates into the model has not previously been attempted in the Bayesian literature. A further novelty is that we also propose a reversible jump scheme for investigating structural changes to the model brought about by the introduction of Erlang phases. Our approach addresses more questions of inference than previous Bayesian treatments of this model and is automatic in nature. We analyse an example dataset comprising lengths of hospital stays of a sample of patients collected from two Australian hospitals to produce a model for a patient's expected length of stay which incorporates the effects of several covariates. This leads to interesting conclusions about what contributes to length of hospital stay with implications for hospital planning. We compare our results with an alternative classical analysis of these data.

Change to costs and lengths of stay in the emergency department and the Brisbane protocol: An observational study

- Objective To compare health service cost and length of stay between a traditional and an accelerated diagnostic approach to assess acute coronary syndromes (ACS) among patients who presented to the emergency department (ED) of a large tertiary hospital in Australia. - Design, setting and participants This historically controlled study analysed data collected from two independent patient cohorts presenting to the ED with potential ACS. The first cohort of 938 patients was recruited in 2008–2010, and these patients were assessed using the traditional diagnostic approach detailed in the national guideline. The second cohort of 921 patients was recruited in 2011–2013 and was assessed with the accelerated diagnostic approach named the Brisbane protocol. The Brisbane protocol applied early serial troponin testing for patients at 0 and 2 h after presentation to ED, in comparison with 0 and 6 h testing in traditional assessment process. The Brisbane protocol also defined a low-risk group of patients in whom no objective testing was performed. A decision tree model was used to compare the expected cost and length of stay in hospital between two approaches. Probabilistic sensitivity analysis was used to account for model uncertainty. - Results Compared with the traditional diagnostic approach, the Brisbane protocol was associated with reduced expected cost of $1229 (95% CI −$1266 to $5122) and reduced expected length of stay of 26 h (95% CI −14 to 136 h). The Brisbane protocol allowed physicians to discharge a higher proportion of low-risk and intermediate-risk patients from ED within 4 h (72% vs 51%). Results from sensitivity analysis suggested the Brisbane protocol had a high chance of being cost-saving and time-saving. - Conclusions This study provides some evidence of cost savings from a decision to adopt the Brisbane protocol. Benefits would arise for the hospital and for patients and their families.

Guidelines on artificial nutrition versus hydration in terminal cancer patients

Whether a terminally ill cancer patient should be actively fed or simply hydrated through subcutaneous or intravenous infusion of isotonic fluids is a matter of ongoing controversy among clinicians involved in the care of these patients. Under the auspices of the European Association for Palliative Care, a committee of experts developed guidelines to help clinicians make a reasonable decision on what type of nutritional support should be provided on a case-by-case basis. It was acknowledged that part of the controversy related to the definition of the terminal cancer patient, since this is a heterogeneous group of patients with different needs, expectations, and potential for a medical intervention. A major difficulty is the prediction of life expectancy and the patient's likely response to vigorous nutritional support. In an attempt to reach a decision on the type of treatment support (artificial nutrition vs. hydration) which would best meet the needs and expectations of the patient, we propose a three-step process: Step I: define the eight key elements necessary to reach a decision: Step II: make the decision; and Step III: reevaluate the patient and the proposed treatment at specified intervals. Step I involves assessing the patient concerning the following: 1) oncological/clinical condition; 2) symptoms; 3) expected length of survival; 4) hydration and nutritional status; 5) spontaneous or voluntary nutrient intake; 6) psychological profile; 7) gut function and potential route of administration; and 8) need for special services based on type of nutritional support prescribed. Step II involves the overall assessment of pros and cons, based on information determined in Step I, in order to reach an appropriate decision based on a well-defined end point (i.e. improvement of quality of life; maintaining patient survival; attaining rehydration). Step III involves the periodic reevaluation of the decision made in Step II based on the proposed goal and the attained result.

ALTERNATIVE SAMPLING STRATEGY FOR A RANDOM OPTIMIZATION ALGORITHM

Alternative sampling procedures are compared to the pure random search method. It is shown that the efficiency of the algorithm can be improved with respect to the expected number of steps to reach an epsilon-neighborhood of the optimal point.

Expression of the Yeast FRE Genes in Transgenic Tobacco

Two yeast genes, FRE1 and FRE2 (encoding Fe(III) reductases) were placed under the control of the cauliflower mosaic virus 35S promoter and introduced into tobacco (Nicotiana tabacum L.) via Agrobacterium tumefaciens-mediated transformation. Homozygous lines containing FRE1, FRE2, or FRE1 plus FRE2 were generated. Northern-blot analyses revealed mRNA of two different sizes in FRE1 lines, whereas all FRE2 lines had mRNA only of the expected length. Fe(III) reduction, chlorophyll contents, and Fe levels were determined in transgenic and control plants under Fe-sufficient and Fe-deficient conditions. In a normal growth environment, the highest root Fe(III) reduction, 4-fold higher than in controls, occurred in the double transformant (FRE1 + FRE2). Elevated Fe(III) reduction was also observed in all FRE2 and some FRE1 lines. The increased Fe(III) reduction occurred along the entire length of the roots and on shoot sections. FRE2 and double transformants were more tolerant to Fe deficiency in hydroponic culture, as shown by higher chlorophyll and Fe concentrations in younger leaves, whereas FRE1 transformants did not differ from the controls. Overall, the beneficial effects of FRE2 were consistent, suggesting that FRE2 may be used to improve Fe efficiency in crop plants.

Expected values for pedometer-determined physical activity in older populations

The purpose of this review is to update expected values for pedometer-determined physical activity in free-living healthy older populations. A search of the literature published since 2001 began with a keyword (pedometer, "step counter," "step activity monitor" or "accelerometer AND steps/day") search of PubMed, Cumulative Index to Nursing & Allied Health Literature (CINAHL), SportDiscus, and PsychInfo. An iterative process was then undertaken to abstract and verify studies of pedometer-determined physical activity (captured in terms of steps taken; distance only was not accepted) in free-living adult populations described as ≥ 50 years of age (studies that included samples which spanned this threshold were not included unless they provided at least some appropriately age-stratified data) and not specifically recruited based on any chronic disease or disability. We identified 28 studies representing at least 1,343 males and 3,098 females ranging in age from 50–94 years. Eighteen (or 64%) of the studies clearly identified using a Yamax pedometer model. Monitoring frames ranged from 3 days to 1 year; the modal length of time was 7 days (17 studies, or 61%). Mean pedometer-determined physical activity ranged from 2,015 steps/day to 8,938 steps/day. In those studies reporting such data, consistent patterns emerged: males generally took more steps/day than similarly aged females, steps/day decreased across study-specific age groupings, and BMI-defined normal weight individuals took more steps/day than overweight/obese older adults. The range of 2,000–9,000 steps/day likely reflects the true variability of physical activity behaviors in older populations. More explicit patterns, for example sex- and age-specific relationships, remain to be informed by future research endeavors.

How important is length? : mechanical testing and measurement of a cemented, polished, tapered femoral implant

Total hip arthroplasty (THA) has a proven clinical record for providing pain relief and return of function to patients with disabling arthritis. There are many successful options for femoral implant design and fixation. Cemented, polished, tapered femoral implants have been shown to have excellent results in national joint registries and long-term clinical series. These implants are usually 150mm long at their lateral aspect. Due to their length, these implants cannot always be offered to patients due to variations in femoral anatomy. Polished, tapered implants as short as 95mm exist, however their small proximal geometry (neck offset and body size) limit their use to smaller stature patients. There is a group of patients in which a shorter implant with a maintained proximal body size would be advantageous. There are also potential benefits to a shorter implant in standard patient populations such as reduced bone removal due to reduced reaming, favourable loading of the proximal femur, and the ability to revise into good proximal bone stock if required. These factors potentially make a shorter implant an option for all patient populations. The role of implant length in determining the stability of a cemented, polished, tapered femoral implant is not well defined by the literature. Before changes in implant design can be made, a better understanding of the role of each region in determining performance is required. The aim of the thesis was to describe how implant length affects the stability of a cemented, polished, tapered femoral implant. This has been determined through an extensive body of laboratory testing. The major findings are that for a given proximal body size, a reduction in implant length has no effect on the torsional stability of a polished, tapered design, while a small reduction in axial stability should be expected. These findings are important because the literature suggests that torsional stability is the major determinant of long-term clinical performance of a THA system. Furthermore, a polished, tapered design is known to be forgiving of cement-implant interface micromotion due to the favourable wear characteristics. Together these findings suggest that a shorter polished, tapered implant may be well tolerated. The effect of a change in implant length on the geometric characteristics of polished, tapered design were also determined and applied to the mechanical testing. Importantly, interface area does play a role in stability of the system; however it is the distribution of the interface and not the magnitude of the area that defines stability. Taper angle (at least in the range of angles seen in this work) was shown not to be a determinant of axial or torsional stability. A range of implants were tested, comparing variations in length, neck offset and indication (primary versus cement-in-cement revision). At their manufactured length, the 125mm implants were similar to their longer 150mm counterparts suggesting that they may be similarly well tolerated in the clinical environment. However, the slimmer cement-in-cement revision implant was shown to have a poorer mechanical performance, suggesting their use in higher demand patients may be hazardous. An implant length of 125mm has been shown to be quite stable and the results suggest that a further reduction to 100mm may be tolerated. However, further work is required. A shorter implant with maintained proximal body size would be useful for the group of patients who are unable to access the current standard length implants due to variations in femoral anatomy. Extending the findings further, the similar function with potential benefits of a shorter implant make their application to all patients appealing.

Survival models of community tenure and length of hospital stay for the seriously mentally ill : a 10-year perspective

Objective: To examine the effects of personal and community characteristics, specifically race and rurality, on lengths of state psychiatric hospital and community stays using maximum likelihood survival analysis with a special emphasis on change over a ten year period of time. Data Sources: We used the administrative data of the Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS) from 1982-1991 and the Area Resources File (ARF). Given these two sources, we constructed a history file for each individual who entered the state psychiatric system over the ten year period. Histories included demographic, treatment, and community characteristics. Study Design: We used a longitudinal, population-based design with maximum likelihood estimation of survival models. We presented a random effects model with unobserved heterogeneity that was independent of observed covariates. The key dependent variables were lengths of inpatient stay and subsequent length of community stay. Explanatory variables measured personal, diagnostic, and community characteristics, as well as controls for calendar time. Data Collection: This study used secondary, administrative, and health planning data. Principal Findings: African-American clients leave the community more quickly than whites. After controlling for other characteristics, however, race does not affect hospital length of stay. Rurality does not affect length of community stays once other personal and community characteristics are controlled for. However, people from rural areas have longer hospital stays even after controlling for personal and community characteristics. The effects of time are significantly smaller than expected. Diagnostic composition effects and a decrease in the rate of first inpatient admissions explain part of this reduced impact of time. We also find strong evidence for the existence of unobserved heterogeneity in both types of stays and adjust for this in our final models. Conclusions: Our results show that information on client characteristics available from inpatient stay records is useful in predicting not only the length of inpatient stay but also the length of the subsequent community stay. This information can be used to target increased discharge planning for those at risk of more rapid readmission to inpatient care. Correlation across observed and unobserved factors affecting length of stay has significant effects on the measurement of relationships between individual factors and lengths of stay. Thus, it is important to control for both observed and unobserved factors in estimation.

Effect of bond length on the behaviour of CFRP strengthened concrete-filled steel tubes under transverse impact

Concrete-filled steel tubular (CFST) columns have shown great potential as axial load carrying member and used widely in many mission critical infrastructures. However, attention is needed to strengthen these members where transverse impact force is expected to occur due to vehicle collisions. In this work, finite element (FE) model of carbon fibre reinforced polymer (CFRP) strengthened CFST columns are developed and the effect of CFRP bond length is investigated under transverse impact loading. Initially the numerical models have been validated by comparing impact test results from literature. The validated models are then used for detail parametric studies by varying the length of externally bonded CFRP composites. The parameters considered for this research are impact velocity, impact mass, CFRP modulus, adhesive type, and axial static loading. It has been observed that the effect of CFRP strengthening is consistent after an optimum effective bond length of CFRP wrapping. The effect of effective bond length has been studied for above parameters. The results show that, under combined axial static and transverse impact loads CFST columns can successfully prevent global buckling failure by strengthening only 34% of column length. Therefore, estimation of effective bond length is essential to utilise the CFRP composites cost effectively.

A2MoTiO7−x (Atriple bond; length as m-dashrare earth or Y): a new series of oxide pyrochlores prepared by topochemical reduction of A2MoTiO8 scheelites

A series of anion-deficient pyrochlore oxides of the formula A2MoTiO7−x (xless-than-or-equals, slant0.5), where Atriple bond; length as m-dashSm, Gd, Tb, Dy, Ho, Er, Lu and Y, has been prepared by reduction of A2MoTiO8 scheelites. The scheelite-to-pyrochlore conversion is reversible, indicating that the reaction is likely to be topochemical. The oxidation states of molybdenum and titanium are most probably Mo(III) and Ti(IV) for the limiting composition of the pyrochlores A2MoTiO6.5. The new pyrochlores are non-metallic and paramagnetic as expected.

Optimal control of arrivals to queues with delayed queue length information

We consider discrete-time versions of two classical problems in the optimal control of admission to a queueing system: i) optimal routing of arrivals to two parallel queues and ii) optimal acceptance/rejection of arrivals to a single queue. We extend the formulation of these problems to permit a k step delay in the observation of the queue lengths by the controller. For geometric inter-arrival times and geometric service times the problems are formulated as controlled Markov chains with expected total discounted cost as the minimization objective. For problem i) we show that when k = 1, the optimal policy is to allocate an arrival to the queue with the smaller expected queue length (JSEQ: Join the Shortest Expected Queue). We also show that for this problem, for k greater than or equal to 2, JSEQ is not optimal. For problem ii) we show that when k = 1, the optimal policy is a threshold policy. There are, however, two thresholds m(0) greater than or equal to m(1) > 0, such that mo is used when the previous action was to reject, and mi is used when the previous action was to accept.

Thermally Induced Demixing in an LCST Mixture in the Presence of Densely Grafted Nanoparticles: Tuning the Graft Chain Length To Induce Thermodynamic Miscibility

The demixing in an LCST mixture of PS/PVME (polystyrene/poly(vinyl methyl ether)) was probed here by melt rheology in the presence of gold nanoparticles which were densely coated with varying graft lengths of PS. The graft density for the gold nanoparticles coated with 3 kDa PS was ca. Sigma = 1.7 chains/nm(2), and that for 53 kDa PS was ca. Sigma = 1.2 chains/nm(2). The evolution of morphology, as the blends transit through the metastable and the unstable envelopes of the phase diagram, and the localization of the gold nanoparticles upon demixing were monitored using in situ hot-stage AFM and confocal Raman imaging. Interestingly, gold nanoparticles coated with 3 kDa polystyrene (PS(3 kDa)-g-nAu) were localized in the PVME phase, whereas gold nanoparticles coated with 53 kDa polystyrene (PS(53 kDa)-g-nAu) were localized in the PS phase of the blend. While the localization of PS(3 kDa)-g-nAu in the PVME phase can be expected to be of entropic origin due to expulsion from the PS phase as R-g,R-matrix chains > R-g,R-grafted chains (where R-g is the radius of gyration of the polymer chain), the localization of PS(53 kDa)-g-nAu in the PS phase is believed to be facilitated by favorable melt/graft interactions. The latter nanoparticles also delayed the demixing by 12 degrees C with respect to the neat mixture. The observed changes were addressed in context to enthalpic interactions between the grafted PS and the free PS, the entropic losses (deformational entropic losses on blending, translational entropic loss of the free PS, and the conformational entropic loss of the grafted PS), and the interface of the grafted and the free chains.