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A variety of physical interventions have been used to improve reactive balance in older adults.To summarize the effectiveness of active treatment approaches to improve reactive postural responses in community-dwelling older adults.Systematic review guided by PRISMA guidelines.A literature search included the databases PubMed, OVID, CINAHL, ClinicalTrials.gov, OTseeker, and PEDro up to December 2017. Randomized controlled trials that evaluated quantitative measures of reactive postural responses in healthy adults following participation in an active physical training program were included.Of 4,481 studies initially identified, 11 randomized controlled trials covering 313 participants were selected for analysis. Study designs were heterogeneous, preventing a quantitative analysis. Nine of the 11 studies reported improvements in reactive postural responses.Several clinically feasible training methods have the potential to improve reactive postural responses in older adults; however, conclusions on the efficacy of treatment methods are limited because of numerous methodological issues and heterogeneity in outcomes and intervention procedures.

Structure-preserving algorithms for solving conservative PDEs with added linear dissipation are generalized to systems with time-dependent damping/driving terms. This study is motivated by several PDE models of physical phenomena, such as Korteweg-de Vries, Klein-Gordon, Schr\"{o}dinger, and Camassa-Holm equations, all with damping/driving terms and time-dependent coefficients. Since key features of the PDEs under consideration are described by local conservation laws, which are independent of the boundary conditions, the proposed (second-order in time) discretizations are developed with the intent of preserving those local conservation laws. The methods are respectively applied to a damped-driven nonlinear Schr\"{o}dinger equation and a damped Camassa-Holm equation. Numerical experiments illustrate the structure-preserving properties of the methods, as well as favorable results over other competitive schemes., Comment: 17 pages, 3 figures

For many pharmaceutical engineers the validation and operation of heating, ventilating, and air conditioning (HVAC) systems serving their manufacturing areas can be a vexing problem. This chapter introduces some practical information that help the HVAC engineer design a reliable, properly performing air handling system. The construction cost for HVAC systems serving aseptic spaces is considerable. Costs in the range of $120.00 to $180.00 per square foot or more for state-of-the-art systems are common; thus, the need to hold these costs in check is mandatory. The successful design and construction of HVAC systems for cleanroom control requires a greater attention to detail and quality than normally exists for a standard commercial building. Positive pressurization of clean rooms with respect to adjacent spaces is a "must" as stated in the Aseptic Guideline. Cleanroom HVAC systems are by nature high noise generators. The resultant noise can be quite objectionable and should be attenuated.

Tree symmetry is crucial to the investigation of evolutionary processes, particularly adaptive radiation. Testing a phylogeny for asymmetry requires a null model; the most accepted to date is the Markov (random branching) model, which assumes that speciation is instantaneous and that all species have an equal and independent chance of speciation. Such assumptions result in a high probability of asymmetric trees (which makes tests of asymmetry weak) and may be unrealistic. Subsequent modification of this model incorporated parameters conforming to diversification by peripheral-isolates speciation, producing trees that were more symmetric than those generated under the Markov model. Our reanalysis of these data, and remodeling with a greater number of replicates, shows that differences between the original Markov and modified models may have been exaggerated: different measures show that initial increases in tree symmetry under peripheral-isolates speciation are transient; symmetry on small scales actually decreases when the process of speciation requires a significant fraction of the average time between speciation events. The peripheral-isolates mode of speciation is compared with a vicariant mode, which shows steadily increasing symmetry on all scales. In cases where vicariant speciation has been common, use of a vicariant-based null model in tests of phylogenetic asymmetry is appropriate and will provide greater statistical power.

Introduction Limited research has been conducted on the impact of deployment-related trauma exposure on post-traumatic stress symptoms in military medical personnel. This study evaluated the association between exposure to both combat experiences and medical duty stressors and post-traumatic stress symptoms in deployed military medical personnel. Materials and Methods U.S. military medical personnel (N = 1,138; 51% male) deployed to Iraq between 2004 and 2011 were surveyed about their exposure to combat stressors, healthcare stressors, and symptoms of post-traumatic stress disorder (PTSD). All participants were volunteers, and the surveys were completed anonymously approximately halfway into their deployment. The Combat Experiences Scale was used as a measure of exposure to and impact of various combat-related stressors such as being attacked or ambushed, being shot at, and knowing someone seriously injured or killed. The Military Healthcare Stressor Scale (MHSS) was modeled after the Combat Experiences Scale and developed for this study to assess the impact of combat-related healthcare stressors such as exposure to patients with traumatic amputations, gaping wounds, and severe burns. The Post-traumatic Stress Disorder Checklist-Military Version (PCL-M) was used to measure the symptoms of PTSD. Results Eighteen percent of the military medical personnel reported exposure to combat experiences that had a significant impact on them. In contrast, more than three times as many medical personnel (67%) reported exposure to medical-specific stressors that had a significant impact on them. Statistically significant differences were found in self-reported exposure to healthcare stressors based on military grade, education level, and gender. Approximately 10% of the deployed medical personnel screened positive for PTSD. Approximately 5% of the sample were positive for PTSD according to a stringent definition of caseness (at least moderate scores on requisite Diagnostic and Statistical Manual for Mental Disorders criteria and a total PCL-M score ≥ 50). Both the MHSS scores (r(1,127) = 0.49, p < 0.0001) and the Combat Experiences Scale scores (r(1,127) = 0.34, p < 0.0001) were significantly associated with PCL-M scores. However, the MHSS scores had statistically larger associations with PCL-M scores than the Combat Experiences Scale scores (z = 5.57, p < 0.0001). The same was true for both the minimum criteria for scoring positive for PTSD (z = 3.83, p < 0.0001) and the strict criteria PTSD (z = 1.95, p = 0.05). Conclusions The U.S. military has provided significant investments for the funding of research on the prevention and treatment of combat-related PTSD, and military medical personnel may benefit from many of these treatment programs. Although exposure to combat stressors places all service members at risk of developing PTSD, military medical personnel are also exposed to many significant, high-magnitude medical stressors. The present study shows that medical stressors appear to be more impactful on military medical personnel than combat stressors, with approximately 5-10% of deployed medical personnel appearing to be at risk for clinically significant levels of PTSD.

The edgewise interactions of anions with phenylalanine (Phe) aromatic rings in proteins, known as anion-quadrupole interactions, have been well studied. However, the anion-quadrupole interactions of the tyrosine (Tyr) and tryptophan (Trp) rings have been less well studied, probably because these have been considered weaker than interactions of anions hydrogen bonded to Trp/Tyr side chains. Distinguishing such hydrogen bonding interactions, we comprehensively surveyed the edgewise interactions of certain anions (aspartate, glutamate, and phosphate) with Trp, Tyr, and Phe rings in high-resolution, nonredundant protein single chains and interfaces (protein-protein, DNA/RNA-protein, and membrane-protein). Trp/Tyr anion-quadrupole interactions are common, with Trp showing the highest propensity and average interaction energy for this type of interaction. The energy of an anion-quadrupole interaction (-15.0 to 0.0 kcal/mol, based on quantum mechanical calculations) depends not only on the interaction geometry but also on the ring atom. The phosphate anions at DNA/RNA-protein interfaces interact with aromatic residues with energies comparable to that of aspartate/glutamate anion-quadrupole interactions. At DNA-protein interfaces, the frequency of aromatic ring participation in anion-quadrupole interactions is comparable to that of positive charge participation in salt bridges, suggesting an underappreciated role for anion-quadrupole interactions at DNA-protein (or membrane-protein) interfaces. Although less frequent than salt bridges in single-chain proteins, we observed highly conserved anion-quadrupole interactions in the structures of remote homologues, and evolutionary covariance-based residue contact score predictions suggest that conserved anion-quadrupole interacting pairs, like salt bridges, contribute to polypeptide folding, stability, and recognition.

Cutaneous malignancy is the most common cancer worldwide and has been estimated to account for approximately one million new cases each year in the United States alone. Basal cell carcinoma makes up the overwhelming majority of these cases, accounting for 80%. The remainder is made up by squamous cell carcinoma, melanoma, and Merkel cell carcinoma. Approximately 80–90% of these malignancies appear on sun-exposed areas of the head and neck, and the auricle is estimated to be involved at an incidence of 5–10%.

A large nondurable goods manufacturing firm introduced a value-based insurance design health benefit program for comprehensive diabetes care with six diabetes-related service types subject to a copayment waiver: laboratory tests, physician office visits, diabetes supplies, diabetes medications, antihypertensive (blood pressure) medications, and cholesterol-lowering medications. We evaluated the impact of this natural experiment compared to a matched comparison group drawn from firms with similar composition and baseline trends. We examined the difference-in-differences impact of the program on diabetes-related services, utilization and all-cause spending. In the first year, adherence to oral diabetes medications was 15.0% higher relative to the matched comparison group (p 0.10). Our analysis suggests that a comprehensive diabetes care program with patient incentives can improve care without increasing direct health plan costs.

Under the dependent coverage expansion (DCE) provision of health reform adult children up to 26 years of age whose parents have employer-sponsored or individual health insurance are eligible for insurance under their parents’ health plan. Using a difference-in-differences approach and the 2008–2014 Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases we examined the impact of the DCE on hospital services use. In analyses of individuals age

Photometric stereo is a method that seeks to reconstruct the normal vectors of an object from a set of images of the object illuminated under different light sources. While effective in some situations, classical photometric stereo relies on a diffuse surface model that cannot handle objects with complex reflectance patterns, and it is sensitive to non-idealities in the images. In this work, we propose a novel approach to photometric stereo that relies on dictionary learning to produce robust normal vector reconstructions. Specifically, we develop two formulations for applying dictionary learning to photometric stereo. We propose a model that applies dictionary learning to regularize and reconstruct the normal vectors from the images under the classic Lambertian reflectance model. We then generalize this model to explicitly model non-Lambertian objects. We investigate both approaches through extensive experimentation on synthetic and real benchmark datasets and observe state-of-the-art performance compared to existing robust photometric stereo methods., To appear in IEEE Transactions on Computational Imaging

Sparsity-based techniques have yielded promising results for dynamic MRI (dMRI) reconstruction. Data-driven methods involving dictionary learning have become increasingly popular, but they involve expensive computation and memory requirements. We propose a framework for online or time-sequential data-driven reconstruction of dynamic MRI sequences from k-t space measurements recorded by one or more receive coils. The spatiotemporal patches of the underlying image sequence are modeled as sparse in a DIctioNary with lOw-ranK AToms (DINO-KAT), and the proposed method estimates the dictionary, sparse coefficients, and images sequentially and efficiently from the time series of MRI measurements. Our experiments demonstrate the promising performance of our schemes for online dMRI reconstruction from limited data.

OBJECTIVES/SPECIFIC AIMS: The goal for this project is to determine the feasibility of using a novel multi-photon fiber-coupled microscope to aid surgeons in localizing STN during surgeries. In order to accomplish this goal, we needed to identify the source of a strong autofluorescent signal in the STN and determine whether we could use image classification methods to automatically distinguish STN from surrounding brain regions. METHODS/STUDY POPULATION: We acquired 3 cadaveric brains from the University of Colorado Anschutz Medical Campus, Department of Pathology. Two of these brains were non-PD controls whereas 1 was diagnosed with PD. We dissected a 10 square centimeter region of midbrain surrounding STN, then prepared this tissue for slicing on a vibratome or cryostat. Samples were immuno-labeled for various cellular markers for identification, or left unlabeled in order to observe the autofluorescence for image classification. RESULTS/ANTICIPATED RESULTS: The border of STN is clearly visible based on the density of a strong autofluorescent signal. The autofluorescent signal is visible using 2-photon (850–1040 nm excitation) and conventional confocal microscopy (488–647 nm excitation). We were also able to visualize blood vessels with second harmonic generation. The autofluorescent signal is quenched by high concentrations of Sudan-black B (0.5%–5%), and is primarily localized in microtubule-associated protein-2 (MAP2)+ cells, indicating that it is likely lipofuscin accumulation in neurons. Smaller lipofuscin particles also accumulate in microglia, identified based on ionized calcium binding adopter 1 (Iba1)+ labeling. We anticipate that colocalization analysis will confirm these qualitative observations. Using 2-photon images of the endogenous autofluorescent signal in these samples, we trained a logistic regression-based image classifier using features derived from gray-level co-occurrence matrices. Preliminary testing indicates that our classifier performed well, with a mean accuracy of 0.89 (standard deviation of 0.11) and a Cohen’s Kappa value of 0.76 (standard deviation of 0.24). We are currently using coherent anti-Stokes Raman scattering and third harmonic imaging to identify different features of myelin that can be used to distinguish between these regions and expect similar results. DISCUSSION/SIGNIFICANCE OF IMPACT: Traditional methods for localizing STN during DBS surgery include the use of stereotactic coordinates and multi-electrode recording (MER) during implantation. MERs are incredibly useful in DBS surgeries, but require penetration of brain structures in order to infer location. Using multi-photon microscopy techniques to aid identification of STN during DBS surgeries offers a number of advantages over traditional methods. For example, blood vessels can be clearly identified with second harmonic generation, something that is not possible with MER. Multi-photon microscopy also allows visualization deep into tissue without actually penetrating it. This ability to look within a depth of field is useful for detection of STN borders based on autofluorescent cell density. When combined with traditional stereotactic information, our preliminary image classification methods are a fast, reliable way to provide surgeons with extra information concerning their location in the midbrain. We anticipate that future advancements and refinements to our image classifier will only increase accuracy and the potential applications and value. In summary, these preliminary data support the feasibility of multi-photon microscopy to aid in the identification of target brain regions during DBS surgeries. The techniques described here complement and enhance current stereotactic and electrophysiological methods for DBS surgeries.

Introduction Angiotropic lymphoma is a rare large B-cell lymphoma involving the intravascular compartment without local tissue or vessel wall infiltration. Case report A 48-year-old male presented with 8 months of progressive paraparesis and bowel and bladder incontinence. Initial cerebrospinal fluid analysis showed high protein, lymphocytic pleocytosis, high IgG synthesis, but no oligoclonal bands. Brain imaging at presentation was unrevealing. Electromyography revealed evidence of bilateral lumbosacral radiculoplexopathy [R>L]. A trial of intravenous solumedrol resulted in significant improvement in weakness. He had multiple hospital admissions for worsening lower extremity weakness, altered mental status, and new-onset upper extremity weakness. Magnetic resonance imaging of the spine revealed abnormal hyperintense T2 signal at T7-T8 level. Visual-evoked potentials revealed significant slowing of conduction in both optic nerves. Repeat electromyography showed a moderate to severe motor axonal polyneuropathy with secondary demyelination in the upper and lower extremities. A working diagnosis of encephalomyeloradiculoneuritis was made because of signs of polyradiculopathy, peripheral neuropathy and myelopathy. Patient had 3 trials of intravenous solumedrol with transient improvement in symptoms. The magnetic resonance imaging brain on his sixth hospital admission revealed multiple areas of restricted diffusion throughout the brain parenchyma. The patient underwent a right frontal lobe biopsy, which showed large CD-20 neoplastic lymphocytes within small arteries, veins, and capillaries with no extension to surrounding brain parenchyma. The findings were consistent with intravascular large B-cell lymphoma. Conclusion Angiotropic lymphoma is a rare disease with frequent involvement of central nervous system and skin that can present with neurological involvement of both the peripheral and central nervous system.

Numerical methods for solving linearly damped Hamiltonian systems are constructed using the popular Stormer---Verlet and implicit midpoint methods. Each method is shown to preserve dissipation of symplecticity and dissipation of angular momentum of an N-body system with pairwise distance dependent interactions. Necessary and sufficient conditions for second order accuracy are derived. Analysis for linear equations gives explicit relationships between the damping parameter and the step size to reveal when the methods are most advantageous; essentially, the damping rate of the numerical solution is exactly preserved under these conditions. The methods are applied to several model problems, both ODEs and PDEs. Additional structure preservation is discovered for the discretized PDEs, in one case dissipation in total linear momentum and in another dissipation in mass are preserved by the methods. The numerical results, along with comparisons to standard Runge---Kutta methods and another structure-preserving method, demonstrate the usefulness and strengths of the methods.

Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.

In this article, we present a compressive sensing based framework for generalized linear model regression that employs a two-component noise model and convex optimization techniques to simultaneously detect outliers and determine optimally sparse representations of noisy data from arbitrary sets of basis functions. We then extend our model to include model order reduction capabilities that can uncover inherent sparsity in regression coefficients and achieve simple, superior fits. Second, we use the mixed l2/l1 norm to develop another model that can efficiently uncover block-sparsity in regression coefficients. By performing model order reduction over all independent variables and basis functions, our algorithms successfully deemphasize the effect of independent variables that become uncorrelated with dependent variables. This desirable property has various applications in real-time anomaly detection, such as faulty sensor detection and sensor jamming in wireless sensor networks. After developing our frame...

Summary: Many fundamental questions in evolutionary biology entail estimating rates of lineage diversification (speciation–extinction) that are modeled using birth–death branching processes. We leverage recent advances in branching-process theory to develop a flexible Bayesian framework for specifying diversification models—where rates are constant, vary continuously, or change episodically through time—and implement numerical methods to estimate parameters of these models from molecular phylogenies, even when species sampling is incomplete. We enable both statistical inference and efficient simulation under these models. We also provide robust methods for comparing the relative and absolute fit of competing branching-process models to a given tree, thereby providing rigorous tests of biological hypotheses regarding patterns and processes of lineage diversification. Availability and implementation: The source code for TESS is freely available at http://cran.r-project.org/web/packages/TESS/. Contact: Sebastian.Hoehna@gmail.com

This paper introduces a novel approach to robust surface reconstruction from photometric stereo normal vector maps that is particularly well-suited for reconstructing surfaces from noisy gradients. Specifically, we propose an adaptive dictionary learning based approach that attempts to simultaneously integrate the gradient fields while sparsely representing the spatial patches of the reconstructed surface in an adaptive dictionary domain. We show that our formulation learns the underlying structure of the surface, effectively acting as an adaptive regularizer that enforces a smoothness constraint on the reconstructed surface. Our method is general and may be coupled with many existing approaches in the literature to improve the integrity of the reconstructed surfaces. We demonstrate the performance of our method on synthetic data as well as real photometric stereo data and evaluate its robustness to noise., ICIP 2017

Trend analyses of opioid-related inpatient stays depend on the availability of comparable data over time. In October 2015, the US transitioned diagnosis coding from International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to ICD-10-CM, increasing from ∼14,000 to 68,000 codes. This study examines how trend analyses of inpatient stays involving opioid diagnoses were affected by the transition to ICD-10-CM.Data are from Healthcare Cost and Utilization Project State Inpatient Databases for 14 states in 2015-2016, representing 26% of acute care inpatient discharges in the US.We examined changes in the number of opioid-related stays before, during, and after the transition to ICD-10-CM using quarterly ICD-9-CM data from 2015 and quarterly ICD-10-CM data from the fourth quarter of 2015 and the first 3 quarters of 2016.Overall, stays involving any opioid-related diagnosis increased by 14.1% during the ICD transition-which was preceded by a much lower 5.0% average quarterly increase before the transition and followed by a 3.5% average increase after the transition. In stratified analysis, stays involving adverse effects of opioids in therapeutic use showed the largest increase (63.2%) during the transition, whereas stays involving abuse and poisoning diagnoses decreased by 21.1% and 12.4%, respectively.The sharp increase in opioid-related stays overall during the transition to ICD-10-CM may indicate that the new classification system is capturing stays that were missed by ICD-9-CM data. Estimates of stays involving other diagnoses may also be affected, and analysts should assess potential discontinuities in trends across the ICD transition.

Sparsity-based techniques have been popular for reconstructing images and videos from limited or corrupted measurements. Methods such as dictionary or transform learning have been demonstrated to be useful in applications such as denoising, inpainting, and medical image reconstruction. In this work, we propose a new framework for online or sequential adaptive reconstruction of dynamic image sequences from linear (typically undersampled) measurements. In particular, the spatiotemporal patches of the underlying dynamic image sequence are assumed to be sparse in a DIctioNary with lOw-ranK AToms (DINO-KAT), and the dictionary model and images are simultaneously and sequentially estimated from streaming measurements. The proposed online algorithm involves efficient memory usage and simple and efficient updates of the low-rank atoms, sparse coefficients, and images. Our numerical experiments show the usefulness of the proposed scheme in inverse problem settings such as video reconstruction or inpainting from limited and noisy pixels.

Photometric stereo is a method for estimating the normal vectors of an object from images of the object under varying lighting conditions. Motivated by several recent works that extend photometric stereo to more general objects and lighting conditions, we study a new robust approach to photometric stereo that utilizes dictionary learning. Specifically, we propose and analyze two approaches to adaptive dictionary regularization for the photometric stereo problem. First, we propose an image preprocessing step that utilizes an adaptive dictionary learning model to remove noise and other non-idealities from the image dataset before estimating the normal vectors. We also propose an alternative model where we directly apply the adaptive dictionary regularization to the normal vectors themselves during estimation. We study the practical performance of both methods through extensive simulations, which demonstrate the state-of-the-art performance of both methods in the presence of noise., Comment: ICIP 2017

Objective To estimate the effects of 2014 Medicaid expansions on inpatient outcomes. Data Sources Health Care Cost and Utilization Project State Inpatient Databases, 2011–2014; population and unemployment estimates. Study Design Retrospective study estimating effects of Medicaid expansions using difference-in-differences regression. Outcomes included total admissions, referral-sensitive surgical and preventable admissions, length of stay, cost, and patient illness severity. Findings In 2014 quarter four, compared with nonexpansion states, Medicaid admissions increased (28.5 percent, p = .006), and uninsured and private admissions decreased (–55.1 percent, p = .001, and –6.6 percent, p = .052), whereas all-payer admissions showed little change. Uninsured expansion effects were negative for preventable admissions (−24.4 percent, p = .068), length of stay (–9.3 percent, p = .039), total cost (−9.2 percent, p = .128), and illness severity (−4.5 percent, p = .397). Significant positive expansion effects were found for Medicaid referral-sensitive surgeries (11.8 percent, p = .021) and patient illness severity (2.3 percent, p = .015). Private and all-payer expansion effects for outcomes other than admission volume were small and mainly nonsignificant (p > .05). Conclusion Medicaid expansions did not change all-payer admission volumes, but they were associated with increased Medicaid and decreased uninsured volumes. Results suggest those previously uninsured with greater needs for inpatient services were most likely to gain coverage. Compositional changes in uninsured and Medicaid admissions may be due to selection.

Foot-and-mouth disease (FMD) is, arguably, the animal disease with the most devastating global economic impact owing in part, to the severe trade restrictions imposed upon affected countries and regions. South Asia is one of the regions where widespread lineages of the FMDV virus (FMDV) have emerged. Here, we performed an integrative phylogenetic analysis of all FMDV serotypes (A, O and Asia-1) circulating in southern Asia, including viral sequences collected until 2013. Our results describe the occurrence of FMD caused by different serotypes and lineages, focusing in the cycles where a specific lineage predominates within a region for a protracted period and then are rapidly or progressively replaced by an emergent or re-emergent strain that is introduced from an adjacent region. Transmission between the two main regions in southern Asia (the Indian subcontinent and the region comprised by Afghanistan, Iran and Pakistan) has been limited. Results of time divergence estimation of lineages that currently circulate in this region indicate that the most recent common ancestor of endemic lineages are: 1992 [1989-1995] for lineage O/PanAsia; 1997 [1995-1999] for PanAsia2; 2001 [1998-2004] for O/Ind2001; 2001 [2000-2002] for A/Iran-05; 1990 [1988-1991] for A/G-18 (G-VII); 2003 [2000-2006] for Asia-1 Sindh08 and 2002 [1999-2004] for Asia-1 G-VIII. We estimated the mean of the overall substitution rate of the VP1 coding region (substitution/site/year) for serotype O (5.95 × 10-3 ), serotype A (1.19 × 10-2 ) and serotype Asia-1 (3.08 × 10-3 ). The potential factors driving the lineage turnover are discussed. Our results provide insights into the ecological and evolutionary factors driving the emergence of FMDV.

We extend the literature on comorbidity measurement by developing 2 indices, based on the Elixhauser Comorbidity measures, designed to predict 2 frequently reported health outcomes: in-hospital mortality and 30-day readmission in administrative data. The Elixhauser measures are commonly used in research as an adjustment factor to control for severity of illness.We used a large analysis file built from all-payer hospital administrative data in the Healthcare Cost and Utilization Project State Inpatient Databases from 18 states in 2011 and 2012.The final models were derived with bootstrapped replications of backward stepwise logistic regressions on each outcome. Odds ratios and index weights were generated for each Elixhauser comorbidity to create a single index score per record for mortality and readmissions. Model validation was conducted with c-statistics.Our index scores performed as well as using all 29 Elixhauser comorbidity variables separately. The c-statistic for our index scores without inclusion of other covariates was 0.777 (95% confidence interval, 0.776-0.778) for the mortality index and 0.634 (95% confidence interval, 0.633-0.634) for the readmissions index. The indices were stable across multiple subsamples defined by demographic characteristics or clinical condition. The addition of other commonly used covariates (age, sex, expected payer) improved discrimination modestly.These indices are effective methods to incorporate the influence of comorbid conditions in models designed to assess the risk of in-hospital mortality and readmission using administrative data with limited clinical information, especially when small samples sizes are an issue.

Postoperative use of anticoagulation after free tissue transfer in head and neck ablative procedures is common practice, but a clear protocol has not been well established. The outcome measures including total flap failure, thrombosis, and hematoma formation for different anticoagulation regimens in free tissue transfer in the head and neck were reviewed.PubMed, Ovid, and Cochrane databases were examined for patients who underwent free tissue transfer following head and neck ablative procedures.Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were utilized to identify English-language studies reporting anticoagulation regimens following free tissue transfer in head and neck ablative procedures. Outcomes included total flap failure, thrombosis, and hematoma formation. Two independent reviewers assessed the quality of the articles by using the Methodological Index for Non-Randomized Studies.A total of 368 articles were identified. An additional 36 articles were identified through screening of reference lists. Twenty-one of these studies met final inclusion criteria for qualitative analysis. Outcome data on total flap failure, thrombosis, and hematoma formation were extracted and analyzed for comparison against all anticoagulation regimens. Total flap failure, thrombosis, and hematoma formation rates were 4.4%, 4.5%, and 2.2%, respectively. Individual study rates ranged from 0.0% to 10.7%, 0.0% to 10.4%, and 0.6% to 7.2%, respectively.There is not adequate evidence to develop a standardized anticoagulation protocol for head and neck free flap procedures. Comparable flap complications were reported between all the employed anticoagulation methods studied, though significant variability in study design among articles existed. Prospective, randomized studies are warranted to determine the optimal postoperative anticoagulation regimen following free tissue transfer of the head and neck. Laryngoscope, 128:412-421, 2018.

Modern unipolar hip hemiarthroplasty, commonly used for displaced femoral neck fracture, is now modular, with both a variable length cobalt-chromium adapter-sleeve and large femoral head. Patients with these modular components may develop symptomatic trunnion corrosion, with elevated serum metal levels. We report the case of an 82-year-old woman, 5.5 years after a modular unipolar hip hemiarthroplasty, who presented with a 4-month history of hip pain and limp. Evaluation showed elevated serum cobalt and chromium levels and an acetabular cyst. At revision, fluid, tissue, and gross inspection were consistent with trunnion corrosion. The hip was revised with a ceramic head and dual mobility acetabular component, with a good result at 1 year. The designs of commercially available, modern unipolar hip hemiarthroplasty prostheses are reviewed. Keywords: MACC, corrosion, ALTR, unipolar, hemiarthroplasty, trunnion

This work presents a novel approach for robust PCA with total variation regularization for foreground-background separation and denoising on noisy, moving camera video. Our proposed algorithm registers the raw (possibly corrupted) frames of a video and then jointly processes the registered frames to produce a decomposition of the scene into a low-rank background component that captures the static components of the scene, a smooth foreground component that captures the dynamic components of the scene, and a sparse component that can isolate corruptions and other non-idealities. Unlike existing methods, our proposed algorithm produces a panoramic low-rank component that spans the entire field of view, automatically stitching together corrupted data from partially overlapping scenes. The low-rank portion of our robust PCA model is based on a recently discovered optimal low-rank matrix estimator (OptShrink) that requires no parameter tuning. We demonstrate the performance of our algorithm on both static and moving camera videos corrupted by noise and outliers.

An analytic model was developed to predict the failure strength of pin loaded composite joints using a two-dimensional analysis. The characteristic dimensions, which define the characteristic curve, were obtained by stress analyses associated with no bearing and tensile tests on laminates with and without a hole. The available experimental data in the literature was then used to evaluate the joints’ strength. There was a good agreement between the experimental data and the computed joints’ strength. Additionally, the failure mode that characterizes the failure condition depends on the orientations of the laminas that constitute the laminate used for joint construction.

The death of a child in the emergency department (ED) is one of the most challenging problems facing ED clinicians. This revised technical report and accompanying policy statement reaffirm principles of patient- and family-centered care. Recent literature is examined regarding family presence, termination of resuscitation, bereavement responsibilities of ED clinicians, support of child fatality review efforts, and other issues inherent in caring for the patient, family, and staff when a child dies in the ED. Appendices are provided that offer an approach to bereavement activities in the ED, carrying out forensic responsibilities while providing compassionate care, communicating the news of the death of a child in the acute setting, providing a closing ritual at the time of terminating resuscitation efforts, and managing the child with a terminal condition who presents near death in the ED.

This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable.

Background The prevalence of diabetes mellitus (DM), chronic kidney disease (CKD), hemodialysis (HD), and renal transplantation (RT) is increasing. This study assessed postoperative complications among diabetic patients with CKD, HD, or post-RT after total hip arthroplasty (THA). Methods Four cohorts were created using a nationwide database: DM&THA, DM&CKD&THA, DM&HD&THA, and DM&RT&THA. Cohorts were matched to a control group by age and gender. Thirty-day medical complications and 90-day and 2-year surgical complications were evaluated. Results All 30-day complications were higher in each cohort. Ninety-day and 2-year surgical complications in the DM&HD&THA cohort were increased compared to the DM&RT&THA cohort. Remarkably, no increased risk of periprosthetic joint infection, periprosthetic fracture, or revision was noted post-THA in the DM&RT&THA cohort. Conclusion Diabetic patients with worsening kidney function are associated with increased post-THA complications. Postsurgical risks decline following RT. Diabetic patients with kidney failure may want to undergo RT prior to THA to optimize surgical outcomes.

Copyright © 2016 by the American Academy of Pediatrics. Transitions of care (ToCs), also referred to as handoffs or sign-outs, occur when the responsibility for a patient's care transfers from 1 health care provider to another. Transitions are common in the acute care setting and have been noted to be vulnerable events with opportunities for error. Health care is taking ideas from other high-risk industries, such as aerospace and nuclear power, to create models of structured transition processes. Although little literature currently exists to establish 1 model as superior, multiorganizational consensus groups agree that standardization is warranted and that additional work is needed to establish characteristics of ToCs that are associated with clinical or practice outcomes. The rationale for structuring ToCs, specifically those related to the care of children in the emergency setting, and a description of identified strategies are presented, along with resources for educating health care providers on ToCs. Recommendations for development, education, and implementation of transition models are included.

We consider the robust PCA problem of recovering a low-rank matrix corrupted by Gaussian noise and large elementlevel outliers. Motivated by the sparse estimation literature, we consider outlier rejection schemes that apply hard or soft thresholding, respectively, to the elements of the data matrix to efficiently estimate the sparse component and then apply an SVD on the residual matrix to estimate the underlying low-rank component. We analyze the performance of the low-rank matrix thus estimated by comparing the asymptotic accuracy of the recovered subspace to that of an oracle estimator that replaces the a priori known outlier-corrupted entries of the data matrix with zeros and then applies an SVD to estimate the low-rank component. Our analysis reveals that, in the “not-too-sparse” outlier regime, both hard and soft thresholding asymptotically attain oracle performance. However, in the dense outlier regime, while hard thresholding again achieves oracle performance, soft thresholding does not and the estimated subspace is asymptotically orthogonal to the true underlying subspace. We validate our theoretical predictions with numerical simulations.

Sparsity-based techniques have been popular in many applications in signal and image processing. In particular, the data-driven adaptation of sparse signal models such as the synthesis model has shown promise in applications. However, dictionary learning problems are typically nonconvex and NP-hard, and the usual alternating minimization approaches for learning are often expensive and lack convergence guarantees. In this work, we investigate efficient methods for learning structured synthesis dictionaries. In particular, we model the atoms (columns) of the dictionary, after reshaping, as low-rank. We propose a block coordinate descent algorithm for our dictionary learning model that involves efficient optimal updates. We also provide a convergence analysis of the proposed method for a highly nonconvex problem. Our numerical experiments show the usefulness of our schemes in inverse problem settings, such as in dynamic MRI and inpainting.

Objective The National Surgical Quality Improvement Program (NSQIP) calculator was created to improve outcomes and guide cost-effective care in surgery. Patients with head and neck cancer (HNC) undergo ablative and free flap reconstructive surgery with prolonged postoperative courses. Methods A case series with chart review was performed on 50 consecutive patients with HNC undergoing ablative and reconstructive free flap surgery from October 2014 to March 2016 at a tertiary care center. Comorbidities and intraoperative and postoperative variables were collected. Predicted length of stay was tabulated with the NSQIP calculator. Results Thirty-five patients (70%) were male. The mean (SD) age was 67.2 (13.4) years. The mean (SD) length of stay (LOS) was 13.5 (10.3) days. The mean (SD) NSQIP-predicted LOS was 10.3 (2.2) days ( P = .027). Discussion The NSQIP calculator may be an inadequate predictor for LOS in patients with HNC undergoing free flap surgery. Additional study is necessary to determine the accuracy of this tool in this patient population. Implications for Practice: Head and neck surgeons performing free flap reconstructive surgery following tumor ablation may find that the NSQIP risk calculator underestimates the LOS in this population.

Introduction The primary objective of this study was to describe the demographic, clinical, and attrition characteristics of active duty U.S. military service members who were aeromedically evacuated from Iraq and Afghanistan theaters with a psychiatric condition as the primary diagnosis. The study links the U.S. Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) data with the Defense Manpower Data Center (DMDC) to conduct an examination of the long-term occupational impact of psychiatric aeromedical evacuations on military separations and discharges. Materials and methods Retrospective analyses were conducted on the demographic, clinical, and attrition information of active duty service members (N = 7,023) who received a psychiatric aeromedical evacuation from Iraq or Afghanistan between 2001 and 2013 using TRAC2ES data. Additionally, TRAC2ES database was compared with DMDC data to analyze personal and service demographics, aeromedical evacuation information, and reasons for military separation with the entire 2013 active duty force. Chi-square tests of independence and standardized residuals were used to identify cells with observed frequencies or proportions significantly different than expected by chance. Additionally, OR were calculated to provide context about the nature of any significant relationships. Results Compared with the active duty comparison sample, those with a psychiatric aeromedical evacuation tended to be younger, female, white, divorced or widowed, and less educated. They were also more likely to be junior enlisted service members in the Army serving in a Combat Arms military occupational specialty. The primary psychiatric conditions related to the aeromedical evacuation were depressive disorders (25%), adjustment disorders (18%), post-traumatic stress disorder (9%), bipolar disorders (6%), and anxiety disorders (6%). Approximately, 3% were evacuated for suicidal ideation and associated behaviors. Individuals who received a psychiatric aeromedical evacuation were almost four times as likely (53%) to have been subsequently separated from active duty at the time of the data analysis compared with other active duty service members (14%). The current study also found that peaks in the number of aeromedical evacuations coincided with significant combat operational events. These peaks almost always preceded or followed a significant operational event. An unexpected finding of the present study was that movement classification code was not predictive of subsequent reasons for separation from the military. Thus, the degree of clinical supervision and restraint of a service member during psychiatric aeromedical evacuation from deployment proved to be unrelated to subsequent service outcome. Conclusions Psychiatric conditions are one of the leading reasons for the aeromedical evacuation of active duty military personnel from the military combat theater. For many active duty military personnel, a psychiatric aeromedical evacuation from a combat theater is the start of a military career-ending event that results in separation from active duty. This finding has important clinical and operational implications for the evaluation and treatment of psychiatric conditions during military deployments. Whenever possible, deployed military behavioral health providers should attempt to treat psychiatric patients in theater to help them remain in theater to complete their operational deployments. Improved understanding of the factors related to psychiatric aeromedical evacuations will provide important clinical and policy implications for future conflicts.

Evolutionary biologists have long been fascinated by the extreme differences in species numbers across branches of the Tree of Life. This has motivated the development of statistical methods for detecting shifts in the rate of lineage diversification across the branches of phylogenic trees. One of the most frequently used methods, MEDUSA, explores a set of diversification-rate models, where each model assigns branches of the phylogeny to a set of diversification-rate categories. Each model is first fit to the data, and the Akaike information criterion (AIC) is then used to identify the optimal diversification model. Surprisingly, the statistical behavior of this popular method is uncharacterized, which is a concern in light of: (1) the poor performance of the AIC as a means of choosing among models in other phylogenetic contexts; (2) the ad hoc algorithm used to visit diversification models, and; (3) errors that we reveal in the likelihood function used to fit diversification models to the phylogenetic data. Here, we perform an extensive simulation study demonstrating that MEDUSA (1) has a high false-discovery rate (on average, spurious diversification-rate shifts are identified [Formula: see text] of the time), and (2) provides biased estimates of diversification-rate parameters. Understanding the statistical behavior of MEDUSA is critical both to empirical researchers-in order to clarify whether these methods can make reliable inferences from empirical datasets-and to theoretical biologists-in order to clarify the specific problems that need to be solved in order to develop more reliable approaches for detecting shifts in the rate of lineage diversification. [Akaike information criterion; extinction; lineage-specific diversification rates; phylogenetic model selection; speciation.].

Unlike lymphadenectomy at other sites, there is no discrete lymph node count defining an adequate neck dissection. The purpose of this study was to determine the minimum lymph node yield (LNY) of an elective level I-III neck dissection required to reliably capture any positive nodes present in these nodal basins.Retrospective single-institution analysis.All patients with the diagnosis of head and neck squamous cell carcinoma who underwent elective level I-III neck dissection between 2004 and 2015 at our institution were analyzed. Preoperatively, patients had no clinical or radiographic evidence of lymphadenopathy. Patients with unknown number of lymph nodes on pathology report were excluded. Age, gender, race, history of radiation, tumor subsite, stage, surgeon, LNY, and number of positive nodes were recorded; bilateral neck dissections were reported separately.One hundred eighteen level I-III neck dissections met criteria and were included in the study. Mean LNY was 21.15, and metastatic disease was present in 24.5% of cases, with 8.4% of cases being N2. The highest portion of positive lymph nodes was present in the group with 18 to 24 lymph nodes (36%), which was significantly higher than the group with18 (14.89%) (P = .044).Although there is no accepted minimum for LNY in level I-III neck dissection, at least 18 nodes may be considered an adequate LNY. Such a yield reliably allows for capture of occult disease within these nodal basins.4. Laryngoscope, 127:2070-2073, 2017.

Anti-bullying policies and interventions are the main approach addressing bullying behaviours in Australian schools. However, the evidence supporting these approaches is inconsistent and its theoretical underpinning may be problematic. The current study examined the effects of a martial arts based psycho-social intervention on participants&rsquo, ratings of resilience and self-efficacy, delivered as a randomised controlled trial to 283 secondary school students. Results found a consistent pattern for strengths-based wellbeing outcomes. All measures relating to resilience and self-efficacy improved for the intervention group, whereas results declined for the control group. These findings suggest that a martial arts based psycho-social intervention may be an efficacious method of improving wellbeing outcomes including resilience and self-efficacy. The study proposes utilising alternatives to the anti-bullying approach and that interventions should be aimed towards helping individuals develop strengths and cope more effectively, which has specific relevance to bullying and more generalised importance to positive mental health.

A second-order difference equation with boundary conditions at infinity is solved, and solutions are analysed in terms of problem parameters. The equation describes stationary pulse solutions of differential-difference equations with a nonlinearity known as McKean's caricature of the cubic. The method of solution reduces the nonlinear problem to a linear inhomogeneous problem under certain conditions. The most important feature of the problem is that coefficients of the difference terms are allowed to vary on a finite interval, leading to changes in solution shapes, as well as changes in parameter values that are acceptable for generating solutions to the problem. Formulas for multiple-pulse solutions are derived, while 1-pulse solutions are considered in detail, and the range of parameter values that allow for the existence of stationary pulses is determined. Numerical methods applied to a spatially discrete FitzHugh–Nagumo equation demonstrate the solution stability and the relationship between the exis...

Acute kidney injury is common in critically ill children, and renal replacement therapies provide a life-saving therapy to a subset of these children. However, there is no Food and Drug Administration-approved device to provide pediatric continuous renal replacement therapy (CRRT). Consequently, clinicians adapt approved adult CRRT devices for use in children because of lack of safer alternatives. Complications occur using adult CRRT devices in children because of inaccurate fluid balance (FB) between the volumes of ultrafiltrate (UF) removed and replacement fluid (RF) delivered. We demonstrate the design and validation of a pediatric fluid management system for obtaining accurate instantaneous and cumulative FB. Fluid transport was achieved via multiple novel pulsatile diaphragm pumps. The conservation of volume principle leveraging the physical property of fluid incompressibility along with mechanical coupling via a crankshaft was used for FB. Accuracy testing was conducted in vitro for 8 hour long continuous operation of the coupled UF and RF pumps. The mean cumulative FB error was

Brain metastasis of breast cancer profoundly affects the cognitive and sensory functions as well as morbidity of patients, and the 1 year survival rate among these patients remains less than 20%. However, the pathological mechanism of brain metastasis is as yet poorly understood. In this report, we found that metastatic breast tumour cells in the brain highly expressed IL-1β which then ‘activated’ surrounding astrocytes. This activation significantly augmented the expression of JAG1 in the astrocytes, and the direct interaction of the reactivated astrocytes and cancer stem-like cells (CSCs) significantly stimulated Notch signalling in CSCs. We also found that the activated Notch signalling in CSCs up-regulated HES5 followed by promoting self-renewal of CSCs. Furthermore, we have shown that the blood-brain barrier permeable Notch inhibitor, Compound E, can significantly suppress the brain metastasis in vivo. These results represent a novel paradigm for the understanding of how metastatic breast CSCs re-establish their niche for their self-renewal in a totally different microenvironment, which opens a new avenue to identify a novel and specific target for the brain metastatic disease.

The β-tropomyosin gene encodes a component of the sarcomeric thin filament. Rod-shaped dimers of tropomyosin regulate actin-myosin interactions and β-tropomyosin mutations have been associated with nemaline myopathy, cap myopathy, Escobar syndrome and distal arthrogryposis types 1A and 2B. In this study, we expand the allelic spectrum of β-tropomyosin-related myopathies through the identification of a novel β-tropomyosin mutation in two clinical contexts not previously associated with β-tropomyosin. The first clinical phenotype is core-rod myopathy, with a β-tropomyosin mutation uncovered by whole exome sequencing in a family with autosomal dominant distal myopathy and muscle biopsy features of both minicores and nemaline rods. The second phenotype, observed in four unrelated families, is autosomal dominant trismus-pseudocamptodactyly syndrome (distal arthrogryposis type 7; previously associated exclusively with myosin heavy chain 8 mutations). In all four families, the mutation identified was a novel 3-bp in-frame deletion (c.20_22del) that results in deletion of a conserved lysine at the seventh amino acid position (p.K7del). This is the first mutation identified in the extreme N-terminus of β-tropomyosin. To understand the potential pathogenic mechanism(s) underlying this mutation, we performed both computational analysis and in vivo modelling. Our theoretical model predicts that the mutation disrupts the N-terminus of the α-helices of dimeric β-tropomyosin, a change predicted to alter protein-protein binding between β-tropomyosin and other molecules and to disturb head-to-tail polymerization of β-tropomyosin dimers. To create an in vivo model, we expressed wild-type or p.K7del β-tropomyosin in the developing zebrafish. p.K7del β-tropomyosin fails to localize properly within the thin filament compartment and its expression alters sarcomere length, suggesting that the mutation interferes with head-to-tail β-tropomyosin polymerization and with overall sarcomeric structure. We describe a novel β-tropomyosin mutation, two clinical-histopathological phenotypes not previously associated with β-tropomyosin and pathogenic data from the first animal model of β-tropomyosin-related myopathies.

Conformal conservation laws are defined and derived for a class of multi-symplectic equations with added dissipation. In particular, the conservation laws of energy and momentum are considered, along with those that arise from linear symmetries. Numerical methods that preserve these conformal conservation laws are presented in detail, providing a framework for proving a numerical method exactly preserves the dissipative properties considered. The conformal methods are compared analytically and numerically to standard conservative methods, which includes a thorough inspection of numerical solution behavior for linear equations. Damped Klein-Gordon and sine-Gordon equations, and a damped nonlinear Schrodinger equation, are used as examples to demonstrate the results.

Bayesian analysis of macroevolutionary mixtures (BAMM) has recently taken the study of lineage diversification by storm. BAMM estimates the diversification-rate parameters (speciation and extinction) for every branch of a study phylogeny and infers the number and location of diversification-rate shifts across branches of a tree. Our evaluation of BAMM reveals two major theoretical errors: (i) the likelihood function (which estimates the model parameters from the data) is incorrect, and (ii) the compound Poisson process prior model (which describes the prior distribution of diversification-rate shifts across branches) is incoherent. Using simulation, we demonstrate that these theoretical issues cause statistical pathologies; posterior estimates of the number of diversification-rate shifts are strongly influenced by the assumed prior, and estimates of diversification-rate parameters are unreliable. Moreover, the inability to correctly compute the likelihood or to correctly specify the prior for rate-variable trees precludes the use of Bayesian approaches for testing hypotheses regarding the number and location of diversification-rate shifts using BAMM.

To describe changes in adults with persistent symptoms and disability following a concussion after completing a supervised home exercise vestibular rehabilitation (VR) program combined with aerobic training.Participants included 14 consecutive individuals referred for VR within the context of a comprehensive concussion center. Outcome measures were administered at initial evaluation, 3 mos, and 6 mos. Outcome measures included: Rivermead Post-Concussion Questionnaire symptom (RPQ-3) and function (RPQ-13) subcategories, Dizziness Handicap Inventory (DHI), Activities-specific Balance Confidence Scale (ABC), functional gait assessment (FGA), return to work/study (RTW), and return to activity (RTA).At 6 months, all clinical outcome measures were found to be statistically significant or approaching statistical significance: RPQ-3 (p0.001), RPQ-13 (p0.004), DHI (p0.001), ABC (p0.007), FGA (p0.001). For return to meaningful activity, associations between time of measure and both RTW (p0.019) and RTA (p0.001) were found to be statistically significant or approach statistical significance.Following 6 months of participation in a supervised home exercise VR program with aerobic training, significant improvements were observed in participants' report of concussion-related symptoms, function, and return to meaningful activities.