Development and evaluation of the automated risk assessment system for multidrug-resistant organisms (autoRAS-MDRO).

BACKGROUND: A high proportion of infections acquired in hospitals are caused by multidrug-resistant organisms (MDROs). The priority in MDRO prevention is to detect high-risk patients and implement preventive intervention as soon as possible. AIM: To develop an automated risk assessment system for MDROs (autoRAS-MDRO) to screen for patients at MDRO infection risk and evaluate the predictive validity of the autoRAS-MDRO. METHODS: Data for 4200 variables were extracted from the electronic health records (EHRs) for constructing the MDRO risk-scoring algorithm, which was based on a logistic regression model. The autoRAS-MDRO was designed such that the MDRO risk classification (high, moderate, low risk) could be automatically displayed on the nursing Kardex screen in the EHRs system. For the development of the MDRO risk-scoring algorithm, 1000 patients with MDROs and 4000 patients without MDROs were selected; similarly, for the evaluation, 2173 and 8692 patients with and without MDROs, respectively, were selected. FINDINGS: The predictive validity of the autoRAS-MDRO was as follows: (i) at the 6-month evaluation: sensitivity, 81%; specificity, 79%; positive predictive value (PPV), 49%; negative predictive value (NPV), 94%; and Youden index, 0.60; (ii) at the 12-month evaluation: sensitivity 79%, specificity 78%, PPV 47%, NPV 94%, and Youden index, 0.57. CONCLUSION: The autoRAS-MDRO had moderate predictive validity. It could be useful in redirecting nurses' time and efforts required for MDRO risk assessment and implementation of infection control measures, and in reducing the incidence of MDRO infection in hospitals, thereby contributing to patient safety.

Quantitative Assessment of Neovascularization after Indirect Bypass Surgery: Color-Coded Digital Subtraction Angiography in Pediatric Moyamoya Disease.

BACKGROUND AND PURPOSE: For the postoperative follow-up in pediatric patients with Moyamoya disease, it is essential to evaluate the degree of neovascularization status. Our aim was to quantitatively assess the neovascularization status after bypass surgery in pediatric Moyamoya disease by using color-coded digital subtraction angiography. MATERIALS AND METHODS: Time-attenuation intensity curves were generated at ROIs corresponding to surgical flap sites from color-coded DSA images of the common carotid artery, internal carotid artery, and external carotid artery angiograms obtained pre- and postoperatively in 32 children with Moyamoya disease. Time-to-peak and area under the curve values were obtained. Postoperative changes in adjusted time-to-peak (ΔTTP) and ratios of adjusted area under the curve changes (ΔAUC ratio) of common carotid artery, ICA, and external carotid artery angiograms were compared across clinical and angiographic outcome groups. To analyze diagnostic performance, we categorized clinical outcomes into favorable and unfavorable groups. RESULTS: The ΔTTP at the common carotid artery increased among clinical and angiographic outcomes, in that order, with significant differences (P = .003 and .005, respectively). The ΔAUC ratio at the common carotid artery and external carotid artery also increased, in that order, among clinical and angiographic outcomes with a significant difference (all, P = .000). The ΔAUC ratio of ICA showed no significant difference among clinical and angiographic outcomes (P = .418 and .424, respectively). The ΔTTP for the common carotid artery of >1.27 seconds and the ΔAUC ratio of >33.5% for the common carotid artery and 504% for the external carotid artery are revealed as optimal cutoff values between favorable and unfavorable groups. CONCLUSIONS: Postoperative changes in quantitative values obtained with color-coded DSA software showed a significant correlation with outcome scores and can be used as objective parameters for predicting the outcome in pediatric Moyamoya disease, with an additional cutoff value calculated through the receiver operating characteristic curve.

Stopping clinical trials early for futility: retrospective analysis of several randomised clinical studies.

BACKGROUND: Many clinical trials show no overall benefit. We examined futility analyses applied to trials with different effect sizes. METHODS: Ten randomised cancer trials were retrospectively analysed; target sample size reached in all. The hazard ratio indicated no overall benefit (n=5), or moderate (n=4) or large (n=1) treatment effects. Futility analyses were applied after 25, 50 and 75% of events were observed, or patients were recruited. Outcomes were conditional power (CP), and time and cost savings. RESULTS: Futility analyses could stop some trials with no benefit, but not all. After observing 50% of the target number of events, 3 out of 5 trials with no benefit could be stopped early (low CP ≤ 15%). Trial duration for two studies could be reduced by 4-24 months, saving £44 000-231 000, but the third had already stopped recruiting, hence no savings were made. However, of concern was that 2 of the 4 trials with moderate treatment effects could be stopped early at some point, although they eventually showed worthwhile benefits. CONCLUSIONS: Careful application of futility can lead to future patients in a trial not being given an ineffective treatment, and should therefore be used more often. A secondary consideration is that it could shorten trial duration and reduce costs. However, studies with modest treatment effects could be inappropriately stopped early. Unless there is very good evidence for futility, it is often best to continue to the planned end.

New concept of CZT-based hand-held radioisotope identifier.

Radiation dose can be determined with the radiation dosimeter. Recently, hand-held radioisotope identifier is being developed by many researchers to measure the radiation dose and to determine the type of the radioisotope. New design concept of the radioisotope identifier is introduced in this work. In this design, one can measure the radiation dose and the type of the radioisotope, and one can also determine the direction where the radiation comes. The hand-held radioisotope identifier is based on cadmium zinc telluride (CZT) detector. The detection principle is from the change of the energy spectrum as the direction of the incident radiation is varied. EGSnrc Monte Carlo simulation is done to calculate the energy spectrum of the CZT detector, and the result is compared with the measured one. The energy spectra are calculated when the gamma-ray is incident on the detection at different directions. The simulation results show the change of the spectrum shape as the incident radiation comes from different directions. The calculation is also done with different radiation energies and detector sizes. A prototype radioisotope identifier is being developed at Korea Atomic Energy Research Institute (KAERI). This work would be helpful to develop next generation radiation dosimeter.

Lessons from an isocyanate tragedy.

This paper highlights the features of prevention of isocyanate-induced occupational asthma from various angles: the employer, the employee, as well as the occupational physician entrusted with the care of such occupationally-exposed group of workers. The difficulties posed by the variability of the presentation, not least because of the relatively long latency, as well as the sensitising nature of the hazard, are discussed.

Empirical Bayes approach to estimating the number of HIV-infected individuals in hidden and elusive populations.

In this paper we estimate the numbers of intravenous drug users (IVDUs) and commercial sex workers (CSWs) in Thailand infected with human immunodeficiency virus (HIV) who have not developed acquired immunodeficiency syndrome (AIDS) directly from the semi-annual HIV serosurveillance data of Thailand from June 1993 to June 1995. We propose a 'generalized removal model for open populations' for estimating HIV-infected population size within a hidden, elusive, and perhaps high-risk population group, for all sampling time when capture probabilities vary with time. We apply empirical Bayes methodology to the generalized removal model for open populations by using the Gibbs sampler, a Markov chain Monte Carlo method. No assumption on the size of the hidden population in question is needed to implement this procedure. The statistical method proposed here requires very little computing and only a minimum of two sets of serosurvey data to obtain an estimate, thereby providing a simple and viable option in epidemiological studies when either powerful computing facilities or abundant sampling data are lacking.

Carbon dioxide accumulation, walking performance, and metabolic cost in the NASA launch and entry suit.

BACKGROUND: In the event of an emergency on landing, Space Shuttle crewmembers while wearing the Launch and Entry Suit (LES) must stand, move to the hatch, exit the spacecraft with the helmet visor closed breathing 100% O2, and walk or run unassisted to a distance of 380 m upwind from the vehicle. The purpose of this study was to characterize the inspired CO2 and metabolic requirements during a simulated unaided egress from the Space Shuttle in healthy subjects wearing the LES. METHODS: As a simulation of a Shuttle landing with an unaided egress, 12 male subjects completed a 6-min seated pre-breathe with 100% O2 followed by a 2-min stand and 5-min walking at 1.56 m x s(-1) (5.6 km x h(-1), 3.5 mph) with the helmet visor closed. During walks with four different G-suit pressures (0.0, 0.5, 1.0, 1.5 psi; 3.4, 6.9, 10.3 kPa), inspired CO2 and walking time were measured. After a 10-min seated recovery, subjects repeated the 5-min walk with the same G-suit pressure and the helmet visor open for the measurement of metabolic rate (VO2). RESULTS: When G-suit inflation levels were 1.0 or 1.5 psi, only one-third of our subjects were able to complete the 5-min visor-closed walk after a 6-min pre-breathe. Inspired CO2 levels measured at the mouth were routinely greater than 4% (30 mmHg) during walking. The metabolic cost at the 1.5 psi G-suit inflation was over 135% of the metabolic cost at 0.0 psi inflation. CONCLUSION: During unaided egress, G-suit inflation pressures of 1.0 and 1.5 psi resulted in elevated CO2 in the LES helmet and increased metabolic cost of walking, both of which may impact unaided egress performance. Neither the LES, the LES helmet, nor the G-suit were designed for ambulation. Data from this investigation suggests that adapting flight equipment for uses other than those for which it was originally designed can result in unforeseen problems.

Recombinant human granulocyte colony-stimulating factor (filgrastim) following high-dose chemotherapy and peripheral blood progenitor cell rescue in high-grade non-Hodgkin's lymphoma: clinical benefits at no extra cost.

In order to evaluate the potential clinical and economic benefits of granulocyte colony-stimulating factor (G-CSF, filgrastim) following peripheral blood progenitor cells (PBPC) rescue after high-dose chemotherapy (HDCT), 23 consecutive patients aged less than 60 years with poor-prognosis, high-grade non-Hodgkin's lymphoma (NHL) were entered into a prospective randomized trial between May 1993 and September 1995. Patients were randomized to receive either PBPC alone (n = 12) or PBPC+G-CSF (n = 11) after HDCT with busulphan and cyclophosphamide. G-CSF (300 microg day[-1]) was given from day +5 until recovery of granulocyte count to greater than 1.0 x 10(9) l(-1) for 2 consecutive days. The mean time to achieve a granulocyte count > 0.5 x 10(9) l(-1) was significantly shorter in the G-CSF arm (9.7 vs 13.2 days; P<0.0001) as was the median duration of hospital stay (12 vs 15 days; P = 0.001). In addition the recovery periods (range 9-12 vs 11-17 days to achieve a count of 1.0 x 10(9) l[-1]) and hospital stays (range 11-14 vs 13-22 days) were significantly less variable in patients receiving G-CSF in whom the values clustered around the median. There were no statistically significant differences between the study arms in terms of days of fever, documented episodes of bacteraemia, antimicrobial drug usage and platelet/red cell transfusion requirements. Taking into account the costs of total occupied-bed days, drugs, growth factor usage and haematological support, the mean expenditure per inpatient stay was pound sterling 6500 (range pound sterling 5465-pound sterling 8101) in the G-CSF group compared with pound sterling 8316 (range pound sterling 5953-pound sterling 15,801) in the group not receiving G-CSF, with an observed mean saving of 1816 per patient (or 22% of the total cost) in the G-CSF group. This study suggests that after HDCT and PBPC rescue, the use of G-CSF leads to more rapid haematological recovery periods and is associated with a more predictable and shorter hospital stay. Furthermore, and despite the additional costs for G-CSF, these clinical benefits are not translated into increased health care expenditure.

Asian Americans: diverse and growing.

PIP: This bulletin analyzes the demographic, socioeconomic, and political characteristics of the Asian population in the US. During 1980-90, the Asian population doubled in size to 4% of total population. The Asian population is expected to double again in 20 years. The number and diversity of Asian ethnic groups has increased due to immigration. The proportion of Japanese, Chinese, and Filipino persons declined from 96% of Asians in 1970 to over 50% in 1997. Indians, Vietnamese, and Koreans outnumber Japanese ethnic groups in the US. Intermarriage is higher among US-born Asian Americans than foreign-born Asian Americans. Intermarriage is greater among female US-born Asian Americans than male US-born Asian Americans. The future size of the Asian population will depend upon how the children of these intermarriages identify themselves ethnically. Asians have advanced themselves educationally. In 1997, 42% of Asian Americans aged 25 years and older had a college or professional degree, compared to 26% of non-Hispanic Whites, 13% of Blacks, and 10% of Hispanics aged 25 years and older. Families with income below the poverty level, in 1996, amounted to 12.7% of Asians, compared to 26.4% of Hispanics, 26.1% of Blacks, and 6.5% of Whites. In 1990, over 43% of foreign born Asian Americans aged over 18 years were naturalized citizens, compared to 33% of all foreign-born residents. Asians have low rates of voter participation, but high rates of naturalization suggest greater political participation in the future. In Presidential 1996 elections, Asians tended to register as Republican, but voted Democratic.^ieng

Issues in research on women, international migration and labor.

"This paper discusses several themes that are useful in organizing research on women, migration, and work, and consists of four parts. It begins with a review of types of migration systems and highlights the importance of specifying migration systems when examining women migrants and work. The main theoretical approaches in migration and labor are discussed in the second part of the paper. This is followed by a section on several dimensions critical for research on women migrants. In particular, it shows that the effects of gender, race and ethnicity, social class, cohort, and history should be explicitly considered because the migration and labor market experiences of women migrants profoundly differ from that of men. The paper concludes with a discussion of some research and policy implications."

Health care costs in industry.

The costs of providing health care in industries must remain affordable and rational. While recognising that employers have a moral commitment to workers' health and welfare, it must also be realised that resources committed to this end are finite. Furthermore, if these resources are spent on the minority, then all the more, the interests of the majority must be defended, as ultimately, medical expenses must form part of the wage costs. Both demand and supply factors of health care must be tempered. The factors influencing demand include the abuse and inappropriate use of health services, unhealthy lifestyle factors, the ageing of the population and the threat of litigation, while the factors affecting supply include new technology, easy accessibility and the creation of demand by doctors. Cost containment strategies should include the collection and interpretation of data on health care costs, the rationing of services, and cost sharing. Cost sharing is one of the most persuasive means through which a sense of cost sensitivity on the part of the consumer can be achieved. This can, and should, be incorporated in whatever form of purchase plan that employers wish to implement.

The role of GABA-mediated inhibition in the rat ventral posterior medial thalamus. I. Assessment of receptive field changes following thalamic reticular nucleus lesions.

1. Changes in the receptive field (RF) properties of thalamic VPM neurons were assessed quantitatively using single-unit recording techniques following a selective excitotoxic lesion of the ipsilateral thalamic reticular nucleus (TRN). The response profiles to controlled deflections of the contralateral vibrissae were obtained from 97 VPM neurons in normal and 102 VPM neurons in TRN-lesioned animals. 2. Histological signs of TRN lesions were detectable in Nissl-stained sections as early as 20 h after the release of kainic acid into TRN. 3. The average RF size of VPM neurons in normal animals was 2.39 +/- 0.18 whiskers (mean +/- SE). Immediately after the lesion of TRN, the average RF size in VPM was enlarged significantly and remained expanded for as long as 1 mo after the destruction of TRN (7.64 +/- 0.47 whiskers, P < 0.001). 4. Subsequent lesions of trigeminal subnucleus interpolaris (SpVi) in TRN-lesioned animals produced a marked reduction in the RF size of VPM neurons. The average VPM RF size for TRN/SpVi lesioned animals was 2.14 +/- 0.64 whiskers. 5. The loss of inhibition from TRN increased the average response probability and magnitude to the center RF whisker by 38 and 34%, respectively. The response probability and magnitude of the surround RF whiskers increased by 64 and 69%, respectively. The average response latencies to the center and surround RF whiskers were significantly longer after the lesion of TRN; subsequent lesions of SpVi in TRN-lesioned cases reduced the average response latencies of VPM neurons to those seen in normal animals. 6. The RF of VPM neurons in both normal and TRN lesioned cases displayed a strong anterior-posterior ("row") preference. Immediately adjacent anterior-posterior whiskers were twice as likely to elicit a response in VPM than immediately adjacent dorsal-ventral whiskers. 7. VPM units were tested for a preferential response to whisker movement in one of four directions (up, down, backward, and forward). The majority of the neurons in both normal and TRN-lesioned cases showed direction-selective responses, mostly in the up direction. Thus gamma-aminobutyric acid (GABA)-mediated inhibition in rat VPM does not appear to be responsible for direction selectivity of VPM neurons. 8. Virtually all neurons in rat VPM after TRN lesions displayed responses that were sustained for the duration of the stimulus (25.5% in normal vs. 88.2% in TRN-lesioned cases). VPM units showing sustained (tonic) responses maintained a high rate of spontaneous activity and, on average, responded to 2-3 times more whiskers than phasically responding units.(ABSTRACT TRUNCATED AT 400 WORDS)

Female immigrants and labor in colonial Malaya: 1860-1947.

"The role of Chinese and Indian women as immigrants and workers in colonial Malaya is examined using data from censuses, immigration records, official reports and secondary sources. The article discusses the main types of work of female immigrants and their contribution to the economic development of colonial Malaya during the late nineteenth and early twentieth centuries in an attempt to redress the neglect of female immigrants' economic role in Malaya's history. Comparisons between male and female immigrants' labor and between Chinese and Indian immigrants, are drawn to highlight the different conditions of migration and labor for the different groups of immigrants."

A management science approach to contingency models of organizational structure.

This study demonstrates the applicability of a quantitative modeling approach, specifically goal programming, in operationalizing the relationship between environmental variables and specific organizational structural variables for optimal goal attainment. A goal programming model is developed to analyze and determine the optimal relationships for goal attainment.