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This paper presents the implementation of simulated annealing (SA) method, an artificial intelligence technique, to solve the optimization problem known as the school bus routing problem (SBRP). A specific challenge in all artificial intelligence optimization techniques is the selection of appropriate value parameters. One contribution of this paper is the implementation of a design of experiments technique to provide statistical support for parameter selection. The SBRP is formulated as a 0–1 integer linear programming model, where the objective function is to minimize the total cost. Because this problem is combinatorial in nature, it is not possible to find exact solutions in an adequate time, calling for the use of an artificial intelligence optimization technique. The proposed technique is SA due to its modeling flexibility and processing speed. To demonstrate the performance of the proposed algorithm, several experiments with real instances were carried out, showing that the metaheuristic algorithm performs better in quality and time than the classic routing method.

This paper proposes a mixed-integer linear programming (MILP) model that is implemented based on a rolling horizon scheme to solve an aggregate production planning decision problem of a manufacturing company that produces snacks in Monterrey, Mexico. The demand of the company is characterized by trends and seasonality. The proposed solution is evaluated by means of computational experiments to determine the relation between demand uncertainty and flexibility of a production system. A 2k factorial experimental design and a multivariate regression were performed. Results show forecast bias and length of frozen period in the rolling horizon have a strong effect on total profit. The safety stock level was also found to be a significant factor, depending on the level of bias.

The current universally challenging SARS-COV-2 pandemic has transcended all the social, logical, economic, and mortal boundaries regarding global operations. Although myriad global societies tried to address this issue, most of the employed efforts seem superficial and failed to deal with the problem, especially in the healthcare sector. On the other hand, the Internet of Things (IoT) has enabled healthcare system for both better understanding of the patient's condition and appropriate monitoring in a remote fashion. However, there has always been a gap for utilizing this approach on the healthcare system especially in agitated condition of the pandemics. Therefore, in this study, we develop two innovative approaches to design a relief supply chain network is by using IoT to address multiple suspected cases during a pandemic like the SARS-COV-2 outbreak. The first approach (prioritizing approach) minimizes the maximum ambulances response time, while the second approach (allocating approach) minimizes the total critical response time. Each approach is validated and investigated utilizing several test problems and a real case in Iran as well. A set of efficient meta-heuristics and hybrid ones is developed to optimize the proposed models. The proposed approaches have shown their versatility in various harsh SARS-COV-2 pandemic situations being dealt with by managers. Finally, we compare the two proposed approaches in terms of response time and route optimization using a real case study in Iran. Implementing the proposed IoT-based methodology in three consecutive weeks, the results showed 35.54% decrease in the number of confirmed cases.

Reporting healthcare quality has become an important factor in healthcare delivery. Prior research has shown that patient-consumers do not frequently use information on websites reporting physician quality to guide their choice of physicians. Our aim is to understand the contextual and personal characteristics that influence patient-consumers’ decisions to trust or ignore information sources about healthcare quality. We use data from Finding Quality Doctors: How Americans Evaluate Provider Quality in the US, 2014, to examine factors that explain trust in sources reporting healthcare quality provided by physicians. Using factor analysis, 3 overarching information sources were identified: (1) employers and healthcare providers; (2) user advocacy sources; and (3) insurance companies and government. We use multiple regression analysis to understand the factors that impact trust in these 3 information sources. Our study found that contrary to previous findings, health status was not a significant factor that affects trust in sources reporting care quality data. Also, age was the only factor that significantly correlated with trusting information from all 3 sources. Specifically, younger adults trusted information from all sources compared to older adults. Furthermore, political affiliation, employment status, income, and area of residence correlated with trusting care quality information from either companies and government agencies or family and social network sources. Results suggest that individual and contextual characteristics are significant factors in trusting information sources regardless of health status and these should be taken into consideration by those promoting public reporting of healthcare quality information.

Purpose In spite of progress in understanding the importance of social support for health outcomes in Persons Living with HIV (PLWH), more remains to be known about mechanisms of support most beneficial at each stage of HIV treatment. In this study, we use a qualitative analytic approach to investigate the forms and sources of social support deemed most integral to the diagnosis, care engagement, and medication adherence behaviors of a diverse sample of PLWH in a mostly rural health district in the Southeastern United States. Methods In-depth interviews (N = 18) were collected during the qualitative phase of a larger mixed methods needs assessment for the Northeast Georgia Health District. A deductive-inductive analysis of participant narratives revealed variation in the perceived importance of particular forms and sources of social support during the initial versus advanced stages of HIV care. Findings PLWH identified the emotional, informational, and appraisal support provided by family as especially critical for emotional stability, coping, and care linkage during the initial stages of diagnosis and treatment. However, once in care, PLWH emphasized informational and instrumental forms of support from care providers and appraisal support from peers as key influences in care engagement and retention behaviors. Conclusion Increased understanding of the social support mechanisms that contribute to the HIV treatment behaviors of PLWH can fill knowledge gaps in research and inform the efforts of health care providers seeking to leverage various aspects of the social support toward improving the care retention, health, and wellness outcomes of PLWH.

Background: Stroke can result in disabling impairments, affecting functional mobility, balance, and gait. Individualized in-patient rehabilitation interventions improve balance and gait in patients with stroke. Rhythmic pairing of personally-selected music with rehabilitation interventions can be a practical form of personalized therapy that could improve functional outcomes. Objective: To describe an in-patient rehabilitation intervention that rhythmically paired patient-selected music with rehabilitative interventions for a patient with acute stroke. Case Description: The patient was a 48-year old male who sustained a right thalamic hemorrhagic stroke eight days prior to admittance to the in-patient rehabilitation facility. The Berg Balance Scale (BBS) (Balance), Performance Oriented Mobility Assessment-Gait portion (POMA-G) (Gait), and Functional Independence Measure® (FIM) Motor were completed on Day 1, Day 4, and Day 16 (Discharge) during the patient's in-patient rehabilitation stay. Outcomes: From intake to discharge, balance, gait and functional mobility significantly increased by 35, 9, and 31 points, respectively. Likewise, the patient reported positive attitudes toward the novel intervention. Conclusion: Incorporating patient-selected music with in-patient physical rehabilitation may be a feasible intervention for patients with acute stroke. Further research with an adequate sample size that randomly assigns patients to music and control conditions is necessary to confirm the promising findings from this case report.

BACKGROUND: Challenges persist regarding how to integrate computing effectively into the exam room, while maintaining patient-centered care. PURPOSE: Our objective was to evaluate a new exam room design with respect to the computing layout, which included a wall-mounted monitor for ease of (re)-positioning. METHODS: In a lab-based experiment, 28 providers used prototypes of the new and older “legacy” outpatient exam room layouts in a within-subject comparison using simulated patient encounters. We measured efficiency, errors, workload, patient-centeredness (proportion of time the provider was focused on the patient), amount of screen sharing with the patient, workflow integration, and provider situation awareness. RESULTS: There were no statistically significant differences between the exam room layouts for efficiency, errors, or time spent focused on the patient. However, when using the new layout providers spent 75% more time in screen sharing activities with the patient, had 31% lower workload, and gave higher ratings for situation awareness (14%) and workflow integration (17%). CONCLUSIONS: Providers seemed to be unwilling to compromise their focus on the patient when the computer was in a fixed position in the corner of the room and, as a result, experienced greater workload, lower situation awareness, and poorer workflow integration when using the old “legacy” layout. A thoughtful design of the exam room with respect to the computing may positively impact providers’ workload, situation awareness, time spent in screen sharing activities, and workflow integration.

We address a logistics districting problem faced by a parcel company whose operations consist of picking up and delivering packages over a service region. The districting process aims to find a partition of the service region into delivery and collection zones that may be served by a single vehicle that departs from a central depot. Criteria to be optimized are to balance workload content among the districts and to create districts of compact shape. A solution approach based on a hybrid procedure that combines elements of GRASP and Tabu Search (TS) is proposed to solve large-scale instances. Numerical experimentation is performed considering different instance sizes and types. Results show that the proposed solution approach is able to solve large-scale instances in reasonable computational times with good quality of the solutions obtained. To determine the quality of the solutions, results are compared with CPLEX solutions and with the current real solution to highlight the benefits of the proposed approach. Conclusions and recommendations for further research are provided. © 2017 Rosa G. González-Ramírez et al.

A continuous flow extracorporeal ventricular assist device (VAD) was modified to support functionally univentricular infants and children awaiting heart transplantation. A centrifugal VAD, designed to flow from 1.5 to 8 L/min, was used as a bridge-to-transplant in four patients with functionally univentricular circulation. A variable restrictive recirculation shunt permitted lower flow ranges in small patients. In hypoxic patients, an oxygenator was incorporated into the circuit. From 2012 to 2015, the modified VAD was placed in four patients with Glenn physiology. Age ranged from 0.97 to 6.98 years (median = 2.2 yrs). Body surface area ranged from 0.41 to 0.84 m2 (median = 0.54 m2 ). One patient was on extracorporeal membrane oxygenation prior to VAD. A recirculation shunt was used in three patients. Three patients required temporary use of an oxygenator for 4, 10, and 27 days. Median time on the VAD was 32.3 days (range = 23-43 days). A decrease in the cavopulmonary pressure was noted in all patients, as was a fall in the B-type natriuretic peptide. Three patients survived transplant and were discharged at 28-82 days post-transplantation. One patient died after 35 days of support. Two patients experienced major bleeding events. Two patients experienced cerebrovascular accidents, one major and one minor. The centrifugal VAD successfully supported palliated functionally univentricular patients awaiting heart transplantation. The modified recirculation shunt facilitated the successful support of patients in whom optimal flows were substantially lower than that recommended by the manufacturer. The continuous-flow VAD effectively decompressed the cavopulmonary system. The design allowed placement of an in-line oxygenator in hypoxic patients. Further investigation is required to decrease the thromboembolic events, and associated morbidity, in patients supported with this device.

Objectives Chronic kidney disease (CKD) almost universally occurs in individuals with other medical problems. However, few studies have described CKD-related multimorbidity using a framework that identifies chronic conditions as concordant (having overlap in treatment goals) versus discordant (having opposing treatment recommendations) and unrelated (having no overlap, but contributing to complexity via different resource requirements). Design Retrospective cohort. Setting Veterans Affairs (VA) Medical Centers. Participants VA patients (n = 821,334) ages 18–100 years with at least one outpatient visit and incident CKD defined as an estimated glomerular filtration rate

Design of personnel teams has been studied from diverse perspectives; the most common are the people and systems requirements perspectives. All these point of view are linked, which is the reason why it is necessary to study them simultaneously. Considering this gap, a decision making model is developed based on factors, models, and requirements mentioned in the literature. The model is applied to a real case. The findings indicate that the Personnel Behavior Based Lean model (PBBL) can be converted into a decision making model for the selection of team members. The study is focused not only on the individual candidates’ knowledge, skills, and aptitudes, but also on how the model considers the company requirements, conflicts, and the importance of each person to the project.

El manejo eficiente de carga es un elemento clave para un puerto marítimo pueda competir y proveer adecuados niveles de servicio a sus usuarios. El desempeño de un puerto depende del tiempo de permanencia de la nave, que está condicionado por la eficiencia en las operaciones de carga y descarga de las naves. En el patio, los contenedores son almacenados temporalmente para ser cargados a la nave o despachados a los usuarios externos con un alto impacto en los tiempos de atención de las naves. Este artículo propone una política para stacking de contenedores, considerando las características particulares de un terminal de contenedores en Chile. Para medir el desempeño de este procedimiento, se propone una cota superior para el número de despejes de un contenedor en función de la capacidad de los bloques. Se presentan resultados numéricos en comparación con la cota superior, mostrando un buen desempeño del procedimiento propuesto. Efficient cargo handling is a key element for a maritime port to compete and provide good service levels to its users. The performance of a port is related to ship-turnaround, which is conditioned by the ships loading and unloading operational efficiency. At the yard, containers are temporarily stacked in order to later either load them onto a ship or dispatch them to external users. Stacking has a strong impact on ships’ service times. This paper proposes a container stacking policy, considering the particular characteristics of a container terminal in Chile. In order to measure the performance of the procedure, an upper bound for the number of re-handles of containers is estimated as a function of the block’s capacity. Numerical results are provided in comparison to an upper bound, and a good performance by the proposed procedure is demonstrated.

The Department of Veterans Affairs (VA) has developed a new exam room design standard that is intended to facilitate a greater degree of patient centeredness. This new design includes a wall-mounted monitor on an armature system and a moveable table workspace. To date, however, this design has not been formally evaluated in a field setting. We conducted observations and interviews with primary care providers and their patients from three locations within the Phoenix VA Health Care System, in a pilot study comparing the new exam room design standard with the older legacy exam rooms. When using the new exam room layout, providers spent a greater proportion of time focused on the patient, spent more time in screen-sharing activities with the patient, and had a higher degree of self-reported situation awareness. However, the legacy exam rooms were perceived as better facilitating workflow integration. Provider and patient debrief interviews were supportive of the new exam room design. Overall, our field study results suggest that the new exam room design does contribute to a greater degree of patient centeredness, though more thorough evaluations are required to support these preliminary results.

As today’s world is rapidly trending to man-made or anthropogenic alternative energy while the total energy being utilized is increased, it is important to understand what happens to the energy generated and dissipated. The new energy conversions are mainly for electricity and for heating, cooling, lighting or chemical and metallurgical processes, all of which create thermal wastes, which are independent of the fuel or alternative energy. Present correlations will become obsolete in explaining atmospheric temperature variations when more and more renewable energy is used to create electricity, which in turn will continue the thermal emissions into the future, leaving only a small fraction as converted non-thermal stored energy. This is being addressed by a convective model in this paper that discusses the effect of thermal waste storage in the atmosphere – which leads to climatic change due to excess precipitation. The model shows that evapotranspiration changes play a major role in the atmospheric air mass constrained climate change. The extent of global mean temperature increase is a function of global population which increases thermal wastes or a function of sinusoidal variances in solar influx as noted by several scientists; the excess precipitation computations will fit any of the global mean temperature assumptions – from small to large increases.

Radio frequency identification (RFID) is a technology most commonly used for the tracking and identification of objects. Optimally implementing RFID is challenging, especially in supply chain management where the use of passive tags is more common. Challenges in RFID implementation include, costs, standardization, privacy, performance, reliability and a need for greater collaboration. Systems integration will be expensive too in most current systems. Due to the nature of RF communications, many RFID systems involve multiple readers. Therefore, determining the number and position of reader antennas has a significant effect on success of the deployment. In this paper, we propose two optimization models and a GRASP metaheuristic that consider the effect of the orientation of antennas, the type of material to identify, and the interference from obstacles in a three-dimensional warehouse. The solution gives the minimal number of readers along with their positions for 100 % coverage of the tagged items.

Radio frequency identification (RFID) is a technology with numerous benefits in applications where objects have to be identified automatically. However, cost, fragile tags, collision and reading errors are some of issues to be concerned with in an RFID implementation. Mainly, this paper proposes a method for tag identification and a method for the selection of the binary codes to program on the tags in order to facilitate the identification process. For the identification method a heuristic based on Hamming distance is developed where the basic idea is to utilize the information obtained in consecutive read attempts to help identify a tag. For the selection method three models based on Hamming distance are also developed which strive to find the set with the greatest dissimilarity among the codes. Computer simulations are performed to verify the validity of the proposed methods.

The purpose of this project was to improve dysphagia-screening processes in a tertiary Veterans Affairs Medical Center. The dysphagia-screening tool was redesigned on the basis of frontline clinician feedback, clinical guidelines, user satisfaction, and multidisciplinary expertise. The revised tool triggered a speech-language consult for positive screens and demonstrated higher scores in user satisfaction and task efficiency. Systems redesign processes were effective for redesigning the tool and implementing practice changes with clinicians involved in dysphagia screening.

The purpose of this study was to investigate how patients' self-rated health status (SRHS) is associated with their attribute reaction integration process and, in turn, their overall ratings of hospitals. We collected patient satisfaction data from 70 hospitals by means of a patient satisfaction questionnaire. The sample included patients who were 18 years or older and discharged from the hospital from July 1, 2011, through June 30, 2012. Data for 36,528 patients were available for analysis. We conducted multiple linear regression analysis with patients' SRHS and interaction effects with nursing care, physician care, staff care, and room, while controlling for age, gender, race, and education. Study findings showed an association between SRHS levels and the patient's overall rating of the hospital; they also revealed interaction effects with nursing care, physician care, and staff care variables in the model. The statistically significant interaction effects indicate that for patients whose SRHS was less than excellent, physician care became more important and nursing care and staff care became less important compared with patients whose SRHS was excellent. When we consider the nature of medical care, this transition seems reasonable. We also found that it is reasonable to categorize patients into two groups: those whose SRHS is excellent and those whose SRHS is less than excellent (i.e., very good, good, fair, or poor). As the study findings show, these two groups of patients combined their attribute reactions differently.

Summary We determined the effect of a multifaceted stroke telerehabilitation (STeleR) intervention on falls-related self-efficacy and satisfaction with care. We conducted a prospective, randomized, multisite, single-blinded trial in 52 veterans from three Veterans Affairs Medical Centers. Participants who experienced a stroke in the past 24 months were randomized to the STeleR intervention or usual care. Participants in the intervention arm were administered an exit interview to gather specific patient satisfaction data three months after their final outcome measure. The STeleR intervention consisted of three home visits, five telephone calls, and an in-home messaging device provided over three months to instruct patients in functionally based exercises and adaptive strategies. The outcome measures included Falls Efficacy Scale to measure fall-related self-efficacy and a Stroke-Specific Patient Satisfaction with Care (SSPSC) scale, a measure separated into two subscales (satisfaction with home care and satisfaction with hospital care) was employed to measure the participants’ satisfaction. At six months, compared with the usual care group, the STeleR group showed statistically significant improvements in one of the two SSPSC scales (satisfaction with hospital care, p = .029) and approached significance in the second SSPSC scale (satisfaction with home care, p = .077). There were no improvements in fall-related self-efficacy. Core concepts identified were: (a) beneficial impact of the trained assistant; (b) exercises helpful; (c) home use of technology. The STeleR intervention improved satisfaction with care, especially as it relates to care following their experience from the hospital. With the limited resources available for in-home rehabilitation for stroke survivors, STeleR (and especially its exercise components) can be a useful complement to traditional post-stroke rehabilitation.

Organic agriculture is using natural materials such as degrading plant matter to replenish soils. This includes use of naturally degraded plant components such as peat, humus and weathered brown coals. Another important natural organic matter which has not been applied in agriculture thus far has been the black coal, Here we show that reversing the coal formation reaction by combined hydro-oxidation principles of biochemical engineering in natural conversion methods in an accelerated fashion. The modified coal soil additive can convert arid lands into farm lands for the future to sustain the population growth. In addition, the development of this new use of black coal will revive economically deprived areas from phasing out coal in the USA and Europe. This will show how the Stored energy in coal can be made renewable in helping plant growth under the soil to facilitate above ground photosynthesis.

Radio frequency identification (RFID) plays an important role in warehouse management. Unfortunately, the normal work environment in warehouses has electromagnetic interferences that cause reading failures. Failures can also be caused by other circumstances, such as collision between reading attempts, tag type, and hardware problems. Rather than propose a hardware-based approach, we propose a method based on information processing. We propose the points assignment (PA) method for the identification of multiple RFID tags based on the Hamming distances. The basic idea is to use all the readings, even if they contain errors. The method allows groups of tags to be identified in high-interference environments, where other methods have great difficulty for achieving error-free readings. The performance of the proposed method is compared with two other methods, showing that the PA achieves zero errors with fewer readings, and that it has more consistent performance as interference increases.

During export ship loading operations, it is often necessary to perform relocation movements with containers that interfere with access to the desired container in the ship loading sequence. This paper presents a real-time heuristic procedure for the container relocation problem employing reachstacker vehicles as container handling equipment. The proposed heuristic searches for good relocation coordinates within a set of nearby bays. The heuristic has a parameter that determines how far from the original bay a container may be relocated. The tradeoff between reducing relocation movements and limiting vehicle travel distances is examined and the performance of the heuristic is compared with a common practice in the smaller container terminals in Chile and Mexico. Finally, a mathematical model for the container relocation problem is presented. © 2015 Roberto Guerra-Olivares et al.

Context: Health care environments have been changing rapidly, and one of the changes is to emphasize patient satisfaction. However, most studies assume that all patients integrate their health care attribute reactions in the same way to arrive at their satisfaction. Objective: The objective of this study is to investigate how patients’ experience of pain influences their attribute reaction integration process and their overall rating of the hospital. Design: Patient satisfaction data were collected using a mailed questionnaire. Multiple linear regression analyses with a dichotomous (yes/no) pain variable and its interaction effects with nursing care, physician care, staff care, and hospital room were conducted with control variables. Main Outcome Measures: The pain variable was statistically significant and also revealed interaction effects with the physician care and the staff care variables in the model. Patients who needed medicine for pain showed lower overall rating of the hospitals than patients who did not need medicine. Results: The statistically significant interaction effects indicate that for patients who needed medicine for pain, staff care becomes more important and physician care becomes less important compared to patients who do not need medicine for pain. All 4 attributes (nursing care, physician care, staff care, and hospital room) are not equally influential. Conclusion: Implementing policies and procedures related to these interaction effects would lead to the most efficient and effective improvement outcomes. These findings suggest that future policies should be modified to enhance nursing and staff care to provide more direct care for patients with pain.

Importance The causal direction and magnitude of the association between telomere length and incidence of cancer and non-neoplastic diseases is uncertain owing to the susceptibility of observational studies to confounding and reverse causation. Objective To conduct a Mendelian randomization study, using germline genetic variants as instrumental variables, to appraise the causal relevance of telomere length for risk of cancer and non-neoplastic diseases. Data Sources Genomewide association studies (GWAS) published up to January 15, 2015. Study Selection GWAS of noncommunicable diseases that assayed germline genetic variation and did not select cohort or control participants on the basis of preexisting diseases. Of 163 GWAS of noncommunicable diseases identified, summary data from 103 were available. Data Extraction and Synthesis Summary association statistics for single nucleotide polymorphisms (SNPs) that are strongly associated with telomere length in the general population. Main Outcomes and Measures Odds ratios (ORs) and 95%confidence intervals (CIs) for disease per standard deviation (SD) higher telomere length due to germline genetic variation. Results Summary data were available for 35 cancers and 48 non-neoplastic diseases, corresponding to 420 081 cases (median cases, 2526 per disease) and 1 093 105 controls (median, 6789 per disease). Increased telomere length due to germline genetic variation was generally associated with increased risk for site-specific cancers. The strongest associations (ORs [95%CIs] per 1-SD change in genetically increased telomere length) were observed for glioma, 5.27 (3.15-8.81); serous low-malignant-potential ovarian cancer, 4.35 (2.39-7.94); lung adenocarcinoma, 3.19 (2.40-4.22); neuroblastoma, 2.98 (1.92-4.62); bladder cancer, 2.19 (1.32-3.66); melanoma, 1.87 (1.55-2.26); testicular cancer, 1.76 (1.02-3.04); kidney cancer, 1.55 (1.08-2.23); and endometrial cancer, 1.31 (1.07-1.61). Associations were stronger for rarer cancers and at tissue sites with lower rates of stem cell division. There was generally little evidence of association between genetically increased telomere length and risk of psychiatric, autoimmune, inflammatory, diabetic, and other non-neoplastic diseases, except for coronary heart disease (OR, 0.78 [95%CI, 0.67-0.90]), abdominal aortic aneurysm (OR, 0.63 [95%CI, 0.49-0.81]), celiac disease (OR, 0.42 [95%CI, 0.28-0.61]) and interstitial lung disease (OR, 0.09 [95%CI, 0.05-0.15]). Conclusions and Relevance It is likely that longer telomeres increase risk for several cancers but reduce risk for some non-neoplastic diseases, including cardiovascular diseases.

The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating the use of telemedicine in cardiovascular and stroke care and to provide consensus policy suggestions. We evaluate the effectiveness of telehealth in advancing healthcare quality, identify legal and regulatory barriers that impede telehealth adoption or delivery, propose steps to overcome these barriers, and identify areas for future research to ensure that telehealth continues to enhance the quality of cardiovascular and stroke care. The result of these efforts is designed to promote telehealth models that ensure better patient access to high-quality cardiovascular and stroke care while striving for optimal protection of patient safety and privacy.

Purpose The development of pediatric ventricular assist device (VAD) circuits with lower flow ranges for infants and small children is ongoing. We present our results with modifying a readily available adult VAD to support the pediatric population. Description The TandemHeart VAD (CardiacAssist, Pittsburgh, PA) circuit was modified to include a variable restrictive recirculation shunt to permit lower flow ranges in small pediatric patients. Evaluation Initial benchtop flow rates and pressures were studied. Hemolysis trials were performed using whole bovine blood to compare plasma-free hemoglobin levels between modified and unmodified VAD circuits. The modified VAD was surgically implanted in 7 piglets (6 to 14 kg) and which supported them for 4 hours. Levels of hemolysis did not increase and full hemodynamic support was achieved. The modified TandemHeart VAD with a recirculation shunt was subsequently implanted in 2 pediatric patients who were bridged to transplant successfully. Conclusions Because of its simplicity, availability, low prime volume, greater patient flow range, and lower cost, the modified TandemHeart VAD with a recirculation shunt should be considered as an alternative to extracorporeal membrane oxygenation and other pulsatile VADs in children.

Extractive metallurgy has used free or combined sulfur as both the raw material and the energy material in carrying out economical manufacture of several metals in millions of tons per year quantities over the past century. This has controlled carbon emissions in an unintentional fashion and out of necessity as the ores in many cases have been sulfides to start with. And the benefits of heat generation by the sulfides reacting with oxygen in the process steps have avoided the use of carbon as a fuel in providing the reaction temperatures. In this article, we will show the inherent benefits of “thiometallurgy,” which uses sulfur in the extraction of metals in alleviating CO2 and water vapor–greenhouse gas (GHG) emissions, as well as its ability to provide a cost-effective energy material solution. Such solutions are not only applicable to existing base metal production but, as the authors will show, also are applicable to newer processes in the production of other metals and chemicals, such as alkaline earth metals, titanium, and to an extent aluminum in an indirect fashion. Iron ores can also be treated with thiometallurgy to meet the ULCOS criterion of ultra-low carbon dioxide steel being studied in Europe. The concept of generating “thiopower” as an alternative energy approach is also introduced by the authors.

In this article we propose a collaborative logistics framework for a Port Logistics Chain (PLC) based on the principles of Supply Chain Management (SCM) that rely on stakeholders integration and collaboration, providing a reference model for the inland coordination of the PLC. A comprehensive literature review was conducted, analyzing several cases in which SCM practices have been implemented as well as studies related to port development, governance, coordination and best practices associated. This background information was used to identify current gaps in logistics management practices and potential scopes of intervention within the PLC to suggest a redesign process and configure new structures under a collaborative scheme, following the guidelines of SCM.

This paper presents (1) a novel capacitated model for supply chain network design which considers manufacturing, distribution, and quality costs (named SCND-COQ model) and (2) five combinatorial optimization methods, based on nonlinear optimization, heuristic, and metaheuristic approaches, which are used to solve realistic instances of practical size. The SCND-COQ model is a mixed-integer nonlinear problem which can be used at a strategic planning level to design a supply chain network that maximizes the total profit subject to meeting an overall quality level of the final product at minimum costs. The SCND-COQ model computes the quality-related costs for the whole supply chain network considering the interdependencies among business entities. The effectiveness of the proposed solution approaches is shown using numerical experiments. These methods allow solving more realistic (capacitated) supply chain network design problems including quality-related costs (inspections, rework, opportunity costs, and others) within a reasonable computational time. © 2014 Krystel K. Castillo-Villar et al.

Purpose Differences in stroke care quality for patients in rural and urban locations have been suggested, but whether differences exist across Veteran Administration Medical Centers (VAMCs) is unknown. This study examines whether rural-urban disparities exist in inpatient quality among veterans with acute ischemic stroke. Methods In this retrospective study, inpatient stroke care quality was assessed in a national sample of veterans with acute ischemic stroke using 14 quality indicators (QIs). Rural-Urban Commuting Areas codes defined each VAMC's rural-urban status. A hierarchical linear model assessed the rural-urban differences across the 14 QIs, adjusting for patient and facility characteristics, and clustering within VAMCs. Findings Among 128 VAMCs, 18 (14.1%) were classified as rural VAMCs and admitted 284 (7.3%) of the 3,889 ischemic stroke patients. Rural VAMCs had statistically significantly lower unadjusted rates on 6 QIs: Deep vein thrombosis (DVT) prophylaxis, antithrombotic at discharge, antithrombotic at day 2, lipid management, smoking cessation counseling, and National Institutes of Health Stroke Scale completion, but they had higher rates of stroke education, functional assessment, and fall risk assessment. After adjustment, differences in 2 QIs remained significant—patients treated in rural VAMCs were less likely to receive DVT prophylaxis, but more likely to have documented functional assessment. Conclusions After adjustment for key demographic, clinical, and facility-level characteristics, there does not appear to be a systematic difference in inpatient stroke quality between rural and urban VAMCs. Future research should seek to understand the few differences in care found that could serve as targets for future quality improvement interventions.

Challenges adapting to continuous positive airway pressure (CPAP) therapy are largely unexplored in patients with stroke or transient ischemic attack. This study, nested within a randomized controlled trial of CPAP use, employed qualitative methods to explore challenges and motivators related to CPAP at two time points: prior to initiating therapy and at a 1-month follow up. Emergent thematic analysis, an inductive, qualitative approach, revealed variations in how patients experienced and adapted to CPAP across five phases: (a) interpreting the sleep apnea diagnosis, (b) contemplating CPAP therapy, (c) trying CPAP therapy, (d) making mid-course adjustments, and (e) experiencing benefits from CPAP therapy. Patients all had mild to moderate sleep apnea, and frequently did not experience sleep apnea symptoms. A salient motivator for adhering to CPAP therapy for these patients was the desire to reduce the risk of subsequent cerebrovascular events. Self-determination theory guided the interpretation of results.

Pain is the most common physical symptom in primary care, accounting for an enormous burden in terms of patient suffering, quality of life, work and social disability, and health care and societal costs. Although collaborative care interventions are well-established for conditions such as depression, fewer systems-based interventions have been tested for chronic pain. This paper describes the study design and baseline characteristics of the enrolled sample for the Stepped Care to Optimize Pain care Effectiveness (SCOPE) study, a randomized clinical effectiveness trial conducted in five primary care clinics. SCOPE has enrolled 250 primary care veterans with persistent (3 months or longer) musculoskeletal pain of moderate severity and randomized them to either the stepped care intervention or usual care control group. Using a telemedicine collaborative care approach, the intervention couples automated symptom monitoring with a telephone-based, nurse care manager/physician pain specialist team to treat pain. The goal is to optimize analgesic management using a stepped care approach to drug selection, symptom monitoring, dose adjustment, and switching or adding medications. All subjects undergo comprehensive outcome assessments at baseline, 1, 3, 6 and 12 months by interviewers blinded to treatment group. The primary outcome is pain severity/disability, and secondary outcomes include pain beliefs and behaviors, psychological functioning, health-related quality of life and treatment satisfaction. Innovations of SCOPE include optimized analgesic management (including a stepped care approach, opioid risk stratification, and criteria-based medication adjustment), automated monitoring, and centralized care management that can cover multiple primary care practices.

Despite many advances in stroke care treatment, there is substantial room for improvement in quality of care for stroke patients. In an attempt to disseminate up-to-date quality information and evidence-based best practices of stroke care, the Veterans Health Administration (VHA)and the VHA Stroke QUERI implemented an innovative web-based toolkit tailored for providers and program planners interested in improving stroke care quality. This study evaluated the VA Stroke QUERI Toolkit to determine its most useful aspects and those that require improvement. In-depth qualitative interviews (n = 48) were conducted with a geographically dispersed sample of clinicians and program planners throughout the VHA system. Findings suggest the Stroke QUERI toolkit was perceived as an effective, efficient and user-friendly site but knowledge of the toolkit continues to be initiated and shared mainly through individuals and small groups. To achieve greater impact a comprehensive set of strategies designed to encourage broader uptake is required.

Introduction: Preventable hospitalizations are responsible for increasing the cost of health care and reflect ineffectiveness of the health services in the primary care setting. The objective of this study was to assess expenditure for hospitalizations and utilize expenditure differentials to determine factors associated with ambulatory care - sensitive conditions (ACSCs) hospitalizations. Methods: A cross-sectional study of hospitalizations among Medicaid enrollees in comprehensive managed care plans in 2009 was conducted. A total of 25 581 patients were included in the analysis. Expenditures on hospitalizations were examined at the 50th, 75th, 90th, and 95th expenditure percentiles both at the bivariate level and in the logistic regression model to determine the impact of differing expenditure on ACSC hospitalizations. Results: Compared with patients without ACSC admissions, a larger proportion of patients with ACSC hospitalizations required advanced treatment or died on admission. Overall mean expenditures were higher for the ACSC group than for non-ACSC group (US$18 070 vs US$14 452). Whites and blacks had higher expenditures for ACSC hospitalization than Hispanics at all expenditure percentiles. Patient’s age remained a consistent predictor of ACSC hospitalization across all expenditure percentiles. Patients with ACSC were less likely to have a procedure on admission; however, the likelihood decreased as expenditure percentiles increased. At the median expenditure, blacks and Hispanics were more likely than other race/ethnic groups to have ACSC hospitalizations (odds ratio [OR]: 1.307, 95% confidence interval [CI]: 1.013-1.686 and OR 1.252, 95% CI: 1.060-1.479, respectively). Conclusion: Future review of delivery and monitoring of services at the primary care setting should include managed care plans in order to enhance access and overall quality of care for optimal utilization of the resources.

Purpose The primary aim of this chapter is to explore stigmatization, stress, and coping among adolescent mothers and to identify positive coping mechanisms that not only resist stigmatization but also generate positive affect. Methodology/approach Fifty-two pregnant and parenting adolescents in an urban county in the Midwestern United States were recruited to participate. A journaling tool was developed and used to allow participants to express their thoughts and concerns in a real-time, reflexive manner. Data were coded at different “nodes” or themes. Concepts, such as stigma, stress, strength, and empowerment were operationalized into key words and “themes” based on previous published literature. Key phrases were used to code the journaling data. Findings Adolescent mothers used positive reappraisal of life circumstances to create a positive self-image and resist the stress of stigma and parenting. Overcoming stereotypes and success in parenting were reappraised as “strength,” which allowed the young women to feel empowered in their caregiving role. Research implications/limitations The chapter also contributes to the sociological literature on positive coping responses to stigma and stress. Indeed, very few studies have employed the sociological imagination of pregnant and parenting adolescents by describing not only their lives but also seeking their understanding and explaining their lives sociologically. This chapter also has direct implications for several health care providers, including nurses and social workers. For example, nurses and social workers are a vital part of the healthcare team for pregnant and parenting adolescents, and they often serve as the link between the adolescent, her family and significant others, and healthcare and social service agencies. Originality/value This chapter described the mechanisms that adolescent mothers use to cope with stress with a focus on how caregiving generates positive affect through the voices of these young mothers themselves. This chapter contributed to the sociological literature on stress and coping. In particular, our findings were also in line with the work of sociologist Antonovsky’s Sense of Coherence concept. SOC is a global measure that indicates the availability of, and willingness to use, adaptive coping resources as a key variable in maintaining health.

In 1939, Dow Chemical had advertisements discussing the use of magnesium for trains, following their successful use of Dowmetal truck bodies in 1935. Despite the fact that the concept of using magnesium (Mg) alloys in trains has existed for at least 75 years, their remains significant challenges in alloy development and forming technologies before commercial application will find mass application.

We examine how distance to a Veterans Health Administration (VHA) facility, patient hometown classification (e.g., small rural town), and service-connected disability are associated with veterans' utilization of radiation therapy services across the VHA and Medicare. In 2008, 45,914 dually-enrolled veteran patients received radiation therapy. Over 3-quarters (35,513) of the patients received radiation therapy from the Medicare program. Younger age, male gender, shorter distance to a VHA facility, and VHA priority or disability status increased the odds of utilizing the VHA. However, veterans residing in urban areas were less likely to utilize the VHA. Urban dwelling patients' utilization of Medicare instead of the VHA suggests a complex decision that incorporates geographic access to VHA services, financial implications of veteran priority status, and the potential availability of multiple sources of radiation therapy in competitive urban markets.

In order to create user-centered design information to guide the development of personal health records (PHRs), 24 patients participated in usability assessments of VA's MyHealtheVet program. Observational videos and efficiency measures were collected among users performing four PHR scenarios: registration and log-in, prescription refill, tracking health, and searching for health information. Twenty-five percent of users successfully completed registration. Individuals preferred prescription numbers over names, sometimes due to privacy concerns. Only efficiency in prescription refills was significantly better than target values. Users wanted to print their information to share with their doctors, and questioned the value of MyHealtheVet search functions over existing online health information. In summary, PHR registration must balance simplicity and security, usability tests guide how PHRs can tailor functions to individual preferences, PHRs add value to users' data by making information more accessible and understandable, and healthcare organizations should build trust for PHR health content.