De-freezing frozen patient management.

OBJECTIVE: To compare the effectiveness of two methods in encouraging the consideration of a leap from one patient management routine to another: (i) real-time review of the facts by an external medical team (ii) implementation of the 're-thinking-protocol' ('de-Freezing') by both treating and external medical teams. DESIGN: Students accompanied doctors, nurses and patients as non-interrupting observers. When an obvious gap between the expected and actual findings occurred, it was discussed four times: by two teams (treating team, external medical team) in two discussion modes (real-time review, de-Freezing-questionnaire). The students then recorded if a leap was considered for each discussion. SETTING: The study was conducted in the emergency department of the Baruch Padeh Medical Centre, Poriya, Israel. PARTICIPANTS: All patients were included during times when both medical teams (treating, external) were present. INTERVENTION(S): During 14 periods of 5-7 h each, 459 patients were sampled. In 183 patients, 200 gaps were discovered. RESULTS: The external team considered a leap 76 times, compared with 47 by the treating team (P < 0.001). Using the de-Freezing-protocol, the treating team considered a leap 133 times. Interestingly, even the external team benefited from the de-Freezing protocol and considered a leap 140 times (NS compared to the treating team). CONCLUSIONS: While the importance of timely leaping from one patient management routine to another is emphasized in the training of physicians, medical teams too often fail to do so. The de-Freezing-protocol inexpensively encourages the consideration of a leap beyond what is evoked by the involvement of an external team. The protocol is applicable to all medical processes and should be incorporated into medical practice and education.

Efficacy of oral methotrexate in paediatric Crohn's disease: a multicentre propensity score study.

BACKGROUND: Oral methotrexate (MTX) administration avoids weekly injections, reduces costs and may improve quality of life of patients with Crohn's disease (CD), especially children. Routes of administration have never been systematically compared in CD. We aimed to compare effectiveness and safety of orally (PO) versus subcutaneously (SC) administered MTX in paediatric CD. METHODS: 226 children with CD treated with oral or subcutaneous MTX were included in a multicentre, retrospective 1-year cohort study (62% boys, mean age 13.8±2.8 years, 88% previous thiopurines). 38 (17%) were initially commenced on oral, 98 (43%) started subcutaneous and switched to oral and 90 (40%) were treated with subcutaneous only. Matching and 'doubly robust' weighted regression models were based on the propensity score method, controlling for confounding-by-indication bias. 11/23 pretreatment variables were different between the groups, but the propensity score modelling successfully balanced the treatment groups. RESULTS: 76 children (34%) had sustained steroid-free remission with a difference that did not reach significance between the PO and the SC groups (weighted OR=1.72 (95% CI 0.5 to 5.9); p=0.52). There were no differences in need for treatment escalation (p=0.24), elevated liver enzymes (p=0.59) or nausea (p=0.85). Height velocity was lower in the PO group (p=0.006) and time to remission was delayed in the PO group (p=0.036; Fleming (0, 1) test). CONCLUSIONS: In this largest paediatric CD cohort to date, SC administered MTX was superior to PO, but only in some of the outcomes and with a modest effect size. Therefore, it may be reasonable to consider switching children in complete remission treated with subcutaneous MTX to the oral route with close monitoring of inflammatory markers and growth.

Establishment of fetal biometric charts using quantile regression analysis.

OBJECTIVES: Fetal growth evaluation is an essential component of pregnancy surveillance. There have been several methods used to construct growth charts. The conventional charts used in current daily practice are based on small numbers and traditional statistical methods. The purpose of this study was to improve fetal biometric charts based on a much larger number of observations with an alternative statistical method: quantile regression analysis. A comparison between the charts is presented. METHODS: During the 12 years of study, 17,708 sonographic examinations of pregnant women from the north of Israel, between 12 and 42 weeks of pregnancy, were performed. Fetal measurements were obtained by several operators using various equipment and included head circumference, abdominal circumference, and femur length. RESULTS: Growth charts were established based on these measurements. CONCLUSIONS: In this study, we constructed biometric growth charts using a large cohort of pregnant women. These charts offer the advantages of specific estimated regression parameters for each specified percentile, thus better defining the normal range. We suggest using these new charts in routine daily obstetric practice.

Further Insight and Additional Inference Methods for Polynomial Regression Applied to the Analysis of Congruence.

In their seminal paper, Edwards and Parry (1993) presented the polynomial regression as a better alternative to applying difference score in the study of congruence. While this method is increasingly applied in congruence research, its complexity relative to other methods for assessing congruence (e.g., difference score methods) was one of the main claims against its use. The objective of this work is to gain additional insight into the use of polynomial regression in the area of social and behavioral sciences. First, we elaborate on the meaning and the inference based on the coefficients obtained by applying polynomial regression and explain the mathematical terms that are used to describe response surfaces. Then, we introduce additional inference methods and illustrate their application on a real life example from the area of supportive exchanges, using data collected by the Smithers Institute at Cornell University (supported by the National Institute on Alcohol Abuse and Alcoholism). Our work is aimed to provide a guide to researchers who apply polynomial regression in order to assess the effect of congruence between two constructs and enable better understanding and interpretation of the results obtained.

An examination of billboard impacts on crashes on a suburban highway: Comparing three periods-Billboards present, removed, and restored.

Objective: Advertisement billboards on roadsides distract drivers from driving tasks and may increase the risk of crashes. Yet, empirical evidence on the direct impact of advertisement signs on crashes is scarce. The Ayalon Highway in Israel is a suburban highway crossing the greater Tel Aviv-Yafo metropolitan area. Following debates in parliament, advertising billboards were removed from the road in 2008 and restored mid-2009. This study examined the impact of advertising billboards on crashes while considering 2 interventions: Removing (or covering) existing billboards and their subsequent restoration.Method: Three periods of billboard presence were defined: Period 0, when billboards were visible; period 1, when billboards were removed; and period 2, when billboards became visible again. Crash changes associated with each intervention were estimated by comparing period 1 vs. period 0 and period 2 vs. period 1, respectively, and by comparing vs. control groups. Negative-binomial regression models were fitted to the monthly crash counts, while controlling for time period, site group (treatment or control), and seasonal effect.Results: Removing the billboards was associated with a decrease of 30 to 40% in injury crashes and restoring the billboards was associated with an increase of 40 to 50% in injury crashes. The crash changes were consistent across various analyses. The estimated decrease in crash numbers during the removal period was up to 100 damage-only crashes and 50 injury crashes per year, and the estimated increase in crashes after billboard restoration was up to 120 damage-only crashes and 30 injury crashes a year.Conclusion: The study provided empirical evidence on the positive safety impact of removing billboard advertising from the roadsides of a suburban highway and of the negative safety impact of billboard restoration. The stronger impact values found in the study, compared to previous research, may be related to the high frequency of conspicuous billboards along the road and to complicated traffic conditions on the road-a heavily traveled route with a high density of interchanges-that might strengthen the negative impact of driver distraction due to advertising billboards.

The influence of shoulder characteristics on the safety level of two-lane roads: A case-study.

Constructing proper shoulders may improve road safety on two-lane roads. Previous research reported crash reductions following shoulder widening. This study aimed to examine the relationship between shoulder characteristics and crash occurrences on two-lane rural roads in Israel. The study database combined information on crash numbers, traffic volumes and road infrastructure characteristics of 3594 road sections. To examine a relationship between shoulder characteristics and crashes, given other road characteristics, two types of statistical models were developed: case-control and negative-binomial regression models, for several crash types. We found that the impacts of shoulder width and other road characteristics on crashes were generally consistent across various models and crash types, where a non-monotonous link between the shoulder width and crashes was typically observed. For various crash types, the models showed an increase in crash risk with an initial extension of the total shoulder, up to 2.2 m, and a consequent decrease in crashes with a further shoulder widening, over 2.2 m, by 2-6% and 1-4%, respectively, for each 0.1 m of shoulder extension. An increase in the width of unpaved shoulders, over 0.9 m, was associated with increased crash risk, in injury and total crashes, by 5% for each 0.1 m of shoulder extension. Lowest crash risks were found for total shoulder widths of about 3 m or more, but also for narrow total shoulders, below 1 m. Conversely, medium total shoulders, of 1.8-2.4 m in width, and unpaved shoulders of over 1 m, were associated with an increase in crash risk and, hence, are not recommended for use. The tools developed in the study may assist in decision-making during the design stages of a new road or upgrading existing road sections, on two-lane local roads.

Firefighters, critical incidents, and drinking to cope: the adequacy of unit-level performance resources as a source of vulnerability and protection.

The authors investigated the moderating role of unit-level performance resources on the distress-mediated relationship between the intensity of involvement in workplace critical incidents and problematic drinking behavior (i.e., drinking to cope). Building on recent developments in hierarchical linear modeling, the authors tested a cross-level, moderated-mediation model using data from 1,481 firefighters in 144 companies. The findings indicate that (a) there is a significant, distress-mediated association between intensity of involvement in such incidents and drinking to cope, which varies by company (i.e., unit), and (b) the adequacy of unit-level performance resources explains much of this cross-unit variance and attenuates both individual-level mediation stages (i.e., intensity of involvement in critical incidents 3 distress, and distress 3 drinking to cope). Implications regarding the role of unit resources adequacy as a vulnerability factor in stressor-strain relations are discussed.

Exploring safety impacts of pedestrian-crossing configurations at signalized junctions on urban roads with public transport routes.

This study explored the impacts of pedestrian-crossing configurations and other design features, on accident occurrences at signalized junctions situated on central public transport routes (PTRs) of urban arterials. Statistical tests and negative-binomial regression models were applied to identify factors affecting accidents and to examine accident numbers of the PTR junctions as opposed to comparison-sites. At the PTR junctions, a consistent impact of pedestrian-crossing configurations on accidents was found, where a gradated-crossing with mixed-shifting is the least safe. Four-legged junctions tend to higher accident numbers relative to the three-legged junctions. PTR junctions are characterized by higher accident numbers, related to comparison-sites, when controlling for other design characteristics. The study findings may assist in selecting preferable design solutions while planning PTR.

Central tendency and matched difference approaches for assessing interrater agreement.

In Study 1 of this two-part investigation, we present a "central tendency approach" and procedures for assessing overall interrater agreement across multiple groups. We define parameters for mean group agreement and construct bootstrapped confidence intervals around the mean population parameters for rWG, AD, and ICC(1). In Study 2, we extend assessments of overall interrater agreement by developing a "matched difference approach" and procedures for assessing real versus pseudo agreement in a sample of groups. Here, we use random group resampling and the matched difference between assessments of the respective rWG, AD, and ICC(1) values for actual and pseudo groups, with the establishment of bootstrapped confidence intervals around such differences. In both studies, we employ simulated and real data to demonstrate the accuracy and practical utility of the new procedures for assessing agreement with respect to groups. Notably, to generate simulated data for Studies 1 and 2, we developed a new underlying model for multilevel data and procedure for data generation, and we discuss its potential utility for enhancing research in group-level studies. Moreover, we discuss, relative to current practices, how and why the new inference procedures provide information about mean interrater agreement in the population, which can improve data aggregation decisions and interpretations of findings from group-level studies. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Assisting upon entry: Helping type and approach as moderators of how role conflict affects newcomer resource drain.

We extend recent research on the costs and benefits of helping to help providers by asking whether and under what conditions newcomer help giving may amplify or mitigate the role-conflict-based resource drain such individuals may experience in the context of their initial socialization. Drawing from conservation of resources (COR) theory, we propose that whether providing assistance to peers enhances or weakens newcomer help providers' resilience to such conflict-based resource drain (i.e., exhaustion) depends on both the type of help given (instrumental vs. emotional) and the orientation (more vs. less empowering) that newcomers adopt when providing it. We test our propositions on the basis of time-lagged data collected from newly hired call center representatives at the end of their first and sixth months on the job. Results largely support our predictions, with instrumental assistance mitigating, and emotional assistance exacerbating, the role-conflict-based resource drain experienced by newcomer help providers. Moreover, these amplifying effects of emotional help provision on the conflict-exhaustion relationship are largely eliminated among those newcomer help providers reporting a more empowering approach to help provision. (PsycINFO Database Record

Statistical significance criteria for the rWG and average deviation interrater agreement indices.

Despite the widespread use of interrater agreement statistics for multilevel modeling and other types of research, the existing guidelines for inferring the statistical significance of interrater agreement are quite limited. They are largely relevant only under conditions that numerous researchers have argued rarely exist. Here we address this problem by generating guidelines for inferring statistical significance under a number of conditions via a computer simulation. As a set, these guidelines cover many of the conditions researchers commonly face. We discuss how researchers can use the guidelines presented to more reasonably infer the statistical significance of interrater agreement relative to using the limited guidelines available in the extant literature.

Development of road safety performance indicators for trauma management in Europe.

Trauma management (TM) covers two types of medical treatment: the initial one provided by Emergency Medical Services (EMS) and a further one provided by permanent medical facilities. There is a consensus in the professional literature that to reduce the severity and the number of road crash victims, the TM system should provide rapid and adequate initial care of injury, combined with sufficient further treatment at a hospital or trauma centre. Recognizing the important role of TM for reducing road crash injury outcome, it was decided, within the EU funded SafetyNet project, to develop road safety performance indicators (SPIs) which would characterize the level of TM systems' performance in European countries and enable country comparisons. The concept of TM SPIs was developed based on a literature study of performance indicators in TM, a survey of available practices in Europe and data availability examinations. A set of TM SPIs was introduced including 14 indicators which characterize five issues such as: availability of EMS stations; availability and composition of EMS medical staff; availability and composition of EMS transportation units; characteristics of the EMS response time, and availability of trauma beds in permanent medical facilities. Basic information on the TM systems was collected in close cooperation with the national expert group. A dataset with TM SPIs for 21 countries was created. It was demonstrated that the countries can be compared using selected TM SPIs. Moreover, a more general comparison of the TM systems' performance in the countries is possible, using multiple ranking and statistical weighting techniques. By both methods, final estimates were received enabling the recognition of groups of countries with similar levels of the TM system's performance. The results of various trials were consistent as to the recognition of countries with high or low level of the TM systems' performance, where in grouping countries with intermediate levels of the TM system's performance some differences were observed. The SafetyNet project's practice demonstrated that data collection for estimating TM SPIs is not an easy task but is realizable for the majority of countries. The TM SPIs' message is currently limited to the availability of trauma care services. Further development of the TM SPIs should focus on characteristics of actual treatment supplied, based on combined police and medical road crash related databases.

Detection of subclinical keratoconus using an automated decision tree classification.

PURPOSE: To develop a method for automatizing the detection of subclinical keratoconus based on a tree classification. DESIGN: Retrospective case-control study. METHODS: setting: University Hospital of Bordeaux. participants: A total of 372 eyes of 197 patients were enrolled: 177 normal eyes of 95 subjects, 47 eyes of 47 patients with forme fruste keratoconus, and 148 eyes of 102 patients with keratoconus. observation procedure: All eyes were imaged with a dual Scheimpflug analyzer. Fifty-five parameters derived from anterior and posterior corneal measurements were analyzed for each eye and a machine learning algorithm, the classification and regression tree, was used to classify the eyes into the 3 above-mentioned conditions. main outcome measures: The performance of the machine learning algorithm for classifying eye conditions was evaluated, and the curvature, elevation, pachymetric, and wavefront parameters were analyzed in each group and compared. RESULTS: The discriminating rules generated with the automated decision tree classifier allowed for discrimination between normal and keratoconus with 100% sensitivity and 99.5% specificity, and between normal and forme fruste keratoconus with 93.6% sensitivity and 97.2% specificity. The algorithm selected as the most discriminant variables parameters related to posterior surface asymmetry and thickness spatial distribution. CONCLUSION: The machine learning classifier showed very good performance for discriminating between normal corneas and forme fruste keratoconus and provided a tool that is closer to an automated medical reasoning. This might help in the surgical decision before refractive surgery by providing a good sensitivity in detecting ectasia-susceptible corneas.

Screening for sleep disordered breathing among applicants for a professional driver's license.

OBJECTIVES: Individuals with sleep disordered breathing (SDB) are at high risk for falling asleep while driving. The aim of this study was to identify variables that would predict SDB among healthy young applicants for a professional driver's license. METHOD: A total of 301 applicants for a driver's license completed self-administered questionnaires. Sleep was recorded for one night with the Watch peripheral arterial tone-100. To identify possible predictors of SDB (Respiratory Disturbance Index >15), we employed new statistical methods. RESULTS: The following items were identified as significant predictors of SDB: body mass index, age, Mini Sleep Questionnaire, smoking, father snoring, afternoon nap-taking, and falling asleep while traveling as a passenger. Moderate or severe SDB was prevalent in at least 25% of the applicants. CONCLUSION: New statistical methods revealed that a combination of questions related to sleep habits, complaints, and demographic data predicted most of the clinically significant SDB.