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Patients with submassive pulmonary embolism (PE) are vulnerable to sudden deterioration, recurrent PE, and progression to pulmonary hypertension and chronic right ventricular (RV) dysfunction. Previous studies have suggested a clinical benefit of using ultrasound-assisted catheter-directed thrombolysis (USCDT) to invasively manage patients with submassive PE. However, there is sparse data comparing the clinical outcomes of these patients when treated with USCDT versus anticoagulation (AC) alone. We sought to compare the outcomes of USCDT versus AC alone in the management of submassive PE.192 consecutive patients who underwent USCDT for submassive PE between January 2013 and February 2019 were identified. ICD9/ICD10 codes were used to detect 2554 patients diagnosed with PE who did not undergo thrombolysis. Propensity matching identified 192 patients with acute PE treated with AC alone. Clinical outcomes were compared between the two groups. Baseline demographics, laboratory values, and pulmonary embolism severity index scores were similar between the two cohorts.There was a significant reduction in mean systolic pulmonary artery pressure (sPAP) in the USCDT group compared to the AC group (∆11 vs ∆3.9 mmHg, p 0.001). There was significant improvement in proportion of RV dysfunction in all patients, but the difference was larger in the USCDT group (∆43.3% vs ∆17.3%, p 0.001). Patients who underwent USCDT had lower 30-day (4.3% vs 10.5%, p = 0.03), 90-day (5.5% vs 12.4%, p = 0.03), and 1-year mortality (6.2% vs 14.2%, p = 0.03).In patients with acute submassive PE, USCDT was associated with improved 30-day, 90-day, and 1 year mortality as compared to AC alone. USCDT also improved RV function and reduced sPAP to a greater degree than AC alone. Further studies are needed to verify these results in both short- and long-term outcomes.

We estimate a narrative factor pricing model from news text of The Wall Street Journal. Our empirical method integrates topic modeling (LDA), latent factor analysis (IPCA), and variable selection (group lasso). Narrative factors achieve higher out-of-sample Sharpe ratios and smaller pricing errors than standard characteristic-based factor models and predict future investment opportunities in a manner consistent with the ICAPM. We derive an interpretation of the estimated risk factors from narratives in the underlying article text. Authors have furnished an Internet Appendix, which is available on the Oxford University Press Web site next to the link to the final published paper online

Introduction Outcomes in colorectal cancer treatment are historically worse in Black people and residents of rural areas. Purported reasons include factors such as systemic racism, poverty, lack of access to care, and social determinants of health. We sought to determine whether outcomes worsened when race and rural residence intersected. Methods The National Cancer Database was queried for individuals with stage II–III colorectal cancer (2004-2018). To examine the intersectionality of race/rurality on outcomes, race (Black/White) and rurality (based on county) were combined into a single variable. Main outcome of interest was 5-year survival. Cox hazard regression analysis was performed to determine variables independently associating with survival. Control variables included age at diagnosis, sex, race, Charlson-Deyo score, insurance status, stage, and facility type. Results Of 463 948 patients, 5717 were Black-Rural, 50 742 were Black-Urban, 72 241 were White-Rural, and 33 5271 were White-Urban. Five-year mortality rate was 31.6%. Univariate Kaplan-Meier survival analysis demonstrated race-rurality was associated with overall survival ( P < .001), with White-Urban having the greatest mean survival length (47.9 months) and Black-Rural with the lowest (46.7 months). Multivariable analysis found that Black-Rural (1.26, 95% confidence interval [1.20-1.32]), Black-Urban (1.16, [1.16-1.18]), and White-Rural (HR: 1.05; (1.04-1.07) had increased mortality when compared to White-Urban individuals ( P < .001). Conclusion Although White-Rural individuals fared worse than White-Urban, Black individuals fared worst of all, with the poorest outcomes observed in Black individuals in rural areas. This suggests that both Black race and rurality negatively affect survival, and act synergistically to further worsen outcomes.

Purpose The purpose of this report is to describe the activities of critical care and ambulatory care pharmacists in a multidisciplinary transitions-of-care (TOC) service for critically ill patients with pulmonary arterial hypertension (PAH) receiving PAH medications. Summary Initiation of medications for treatment of PAH involves complex medication access steps. In the ambulatory care setting, multidisciplinary teams often have a process for completing these steps to ensure access to PAH medications. Patients with PAH are frequently admitted to an intensive care unit (ICU), and their home PAH medications are continued and/or new medications are initiated in the ICU setting. Inpatient multidisciplinary teams are often unfamiliar with the medication access steps unique to PAH medications. The coordination and completion of medication access steps in the inpatient setting is critical to ensure access to medications at discharge and prevent delays in care. A PAH-specific TOC bundle for patients prescribed a PAH medication who are admitted to the ICU was developed by a multidisciplinary team at an academic teaching hospital. The service involves a critical care pharmacist completing a PAH medication history, assessing for PAH medication access barriers, and referring patients to an ambulatory care pharmacist for postdischarge telephone follow-up. In collaboration with the PAH multidisciplinary team, a standardized workflow to be initiated by the critical care pharmacist was developed to streamline completion of PAH medication access steps. Within 3 days of hospital discharge, the ambulatory care pharmacist calls referred patients to ensure access to PAH medications, provide disease state and medication education, and request that the patient schedule a follow-up office visit to take place within 14 days of discharge. Conclusion Collaboration by a PAH multidisciplinary team, critical care pharmacist, and ambulatory care pharmacist can improve TOC related to PAH medication access for patients with PAH. The PAH TOC bundle serves as a model that may be transferable to other health centers.

Pulmonary arterial hypertension has evolved from a fatal disease with few treatment options to a chronic condition with improved survival. This improvement is possible through development of effective therapies as well as the expansion of risk stratification scores to assist clinical decision making. Despite improved disease control, quality of life, and overall prognosis, many challenges remain. The treatment itself is burdensome, with significant impact on quality of life. Many patients with pulmonary arterial hypertension still present with advanced, often end-stage disease. Increased use of mechanical circulatory support and catheter-based interventions have expanded use of extracorporeal life support and right ventricle assist devices. For these reasons as well as the long-term relationships pulmonary hypertension physicians have with patients and their families, navigating the course of the illness in a considered, proactive way is essential. Understanding individual goals and revisiting them as they change over time requires comfort with the conversation itself. There are many barriers and challenges to having effective, compassionate conversations in the clinical setting with time constraints being the most often cited. Compressed visits are necessarily focused on the clinical aspects, therapy and medication adherence and tolerance. Clinicians are sometimes wary of diminishing hope in the face of ongoing treatment. Having sufficient experience and comfort with these discussions can be empowering. In this paper, we discuss the challenges involved and propose a framework to assist in incorporating these discussions into clinical care.

Introduction Previous studies have shown that sleep disordered breathing (SDB) is common in patients with Interstitial Lung Disease (ILD), and oximetry is often used for screening prior to further diagnostic testing. Current guidelines recommend polysomnography (PSG) for diagnosis of SDB in patients with significant pulmonary disease, however, home sleep apnea tests (HSAT) are increasingly used in clinical practice for a variety of reasons despite lack of evidence regarding accuracy in this population. In this study, we evaluate the correlation between screening oximetry, a commercial brand HSAT (WatchPAT®) and PSG to examine the diagnostic accuracy of this HSAT technology in patients with ILD. Methods The institution electronic medical record was screened for patients with a diagnosis code for ILD who underwent screening oximetry followed by PSG or HSAT using peripheral arterial tonometry from July 1, 2012 to present. Clinical review confirmed presence of ILD according to American Thoracic Society guidelines. Among the respective cohorts, Paired Wilcoxon Test was used to compare the oximetry 4% oxygen desaturation index (ODI) to the HSAT ODI and PSG apnea-hypopnea index (AHI) as well as percent time spent below oxyhemoglobin saturation of 89%. Spearman correlation was used to correlate the oximetry ODI and parameters of SDB on HSAT and PSG. Results Data was analyzed for 25 patients who had undergone oximetry/HSAT and for 25 patients who had undergone oximetry/PSG. Oximetry ODI showed no significant difference from PSG AHI (p = 0.2635) or between HSAT ODI (p = 0.0755), and no difference was seen in hypoxic time between oximetry and PSG (p = 0.9789). Hypoxic time on HSAT was significantly longer than that on oximetry (p < 0.001). Using HSAT ODI as the standard, HSAT AHI and respiratory disturbance index (RDI) showed rs of 0.9638 and 0.8913 respectively, while oximetry ODI was 0.3893. Compared to PSG AHI, the PSG RDI and oximetry ODI rs were 0.9759 and 0.7407 respectively. Conclusion Among patients with ILD, screening oximetry appears to correlate more strongly with indices of SDB and hypoxic time on PSG rather than HSAT. Further studies are warranted to evaluate efficacy of additional HSAT testing modalities in this patient population. Support (If Any)

Objectives: Outcomes following isolated hip arthroscopy for patients with dysplasia have been unfavorable, results have included iatrogenic instability and conversion to total hip arthroplasty (THA) at a young age. However, patients with borderline dysplasia have portended more favorable results at short and medium term follow-up. The purpose of this study was to assess long term outcomes after hip arthroscopy for femoroacetabular impingement (FAI) in borderline dysplasia (BD) patients (LCEA, 18°-25°) compared to a control cohort of nondysplastic patients (LCEA, 25°-40°). Methods: Between March 2009 and July 2012, a BD group of 33 patients (38 hips) was identified. An age- and sex-matched control group of 83 patients (96 hips) was also identified. Patient-reported outcome scores, including the modified Harris Hip Score (mHHS), the Hip Outcome Score–Activities of Daily Living (HOS-ADL) and Sport-Specific Subscale (HOS-SSS), and the International Hip Outcome Tool (iHOT-33), were collected preoperatively and subsequently at an average of 9.6 years post-operatively. Results: The mean LCEA and Tönnis angle was 22.4° ± 2.02° and 6.2° ± 3.23° in the BD group and 31.7° ± 3.52° and 2.42° ± 3.02° in the control group, respectively ( P Conclusions: Durable outcomes (>9 years) with low revision rates can be expected after isolated hip arthroscopy that includes cam resection, labral refixation and capsular closure in BD patients with equivalent outcomes to a nondysplastic cohort.

Industrial automation, especially within the manufacturing environment, is reliant on accurate control of robotic manipulators; for this reason, Inverse Kinematic (IK) control is desired. This paper outlines some key differences between forward and inverse kinematic control, and the derivation complexity of such, for Serial Kinematic Manipulators (SKM's) versus Parallel Kinematic Manipulators (PKM's). The IK of a single quasi-serial manipulator was derived, and subsequently validated using the physical model and an Arduino script. The workspace of this same mechanism was determined via an empirical method, and compared to an analytically derived workspace using MATLAB. Finally, a two-quasi-serial PKM was proposed and described.

We propose and implement a procedure to dynamically hedge climate change risk. We extract innovations from climate news series that we construct through textual analysis of newspapers. We then use a mimicking portfolio approach to build climate change hedge portfolios. We discipline the exercise by using third-party ESG scores of firms to model their climate risk exposures. We show that this approach yields parsimonious and industry-balanced portfolios that perform well in hedging innovations in climate news both in sample and out of sample. We discuss multiple directions for future research on financial approaches to managing climate risk.

This paper outlines techniques to effectively simulate the powertrain of an electric vehicle at different levels of abstraction, with simulation goals ranging from overall efficiency and thermal analysis over hours of driving cycles, down to the nanosecond details of the inverter switching characteristics and losses. Such techniques can be leveraged to optimize motor and inverter controls, to verify power quality (THD and losses), and to simulate faults. Central to this powertrain design, a high fidelity PMSM motor model produced with an FEA solver includes spatial harmonics, flux saturation and frequency dependent iron losses. The use of virtual prototyping at different levels of abstraction offers several benefits. It permits design of a state of the art control methodology for PMSM motor drives, to verify performance over long drive cycles, as well as stability over the entire torque-speed range. Control algorithm aside, the traction motor’s 3-phase drive inverter stage is an intricate component of the PMSM motor control system. Design engineers need access to a robust virtual prototype environment to implement detailed electronic configurations to verify PWM switching strategies and performance. Regenerative braking energy capture and control through the smart traction drive to charge the Lithium-ion battery pack can be also tested and fault conditions easily and safely applied. Moreover, in this study, both aging and adverse temperature effects can be applied to the battery pack and impacts to drivetrain range performance can be observed for any selected drive cycle. As hardware prototypes are usually not available at the early validation design phase, simulation is the only choice for confident confirmation of the traction drive concept. The simulation model of the traction motor system coupled with Lithium-ion battery pack is the executable specification recognized as the virtual prototype.

We perform a comparative analysis of machine learning methods for the canonical problem of empirical asset pricing: measuring asset risk premiums. We demonstrate large economic gains to investors using machine learning forecasts, in some cases doubling the performance of leading regression-based strategies from the literature. We identify the best-performing methods (trees and neural networks) and trace their predictive gains to allowing nonlinear predictor interactions missed by other methods. All methods agree on the same set of dominant predictive signals, a set that includes variations on momentum, liquidity, and volatility. Authors have furnished an Internet Appendix, which is available on the Oxford University Press Web site next to the link to the final published paper online.

We propose a new measure of time-varying tail risk that is directly estimable from the cross-section of returns. We exploit firm-level price crashes every month to identify common fluctuations in tail risk among individual stocks. Our tail measure is significantly correlated with tail risk measures extracted from S&P 500 index options and negatively predicts real economic activity. We show that tail risk has strong predictive power for aggregate market returns. Cross-sectionally, stocks with high loadings on past tail risk earn an annual three-factor alpha 5.4% higher than stocks with low tail risk loadings. We explore potential mechanisms giving rise to these asset pricing facts.

The purpose of this paper is to review the requirements of the law that are relevant to nuclear risk assessment at UK nuclear licensed sites. The relevant Acts of Parliament, Statutory Instruments and Approved Codes of Practice are reviewed for nuclear risk assessment requirements. Relevant requirements are drawn together and grouped in appropriate categories. The issue of nuclear risk assessment depth is considered. Definitions and interpretations of key legal words and phrases are discussed.

On July 20, 2004, the Securities and Exchange Commission (SEC) published for comment proposed rules under the Investment Advisers Act of 1940 (the Act), which would require many non‐U.S. hedge fund advisers to be registered with the SEC. The proposed rules would require non‐U.S. investment advisers to look through their hedge funds (U.S. and non‐U.S. funds) to count all U.S. investors therein as clients for purposes of the Section 203(b)(3) “private adviser” exemption. The SEC stated in the proposing release that it did not intend the proposed rules to change current policy of substantially limiting the extraterritorial application of the Act to dealings between a registered non‐U.S. investment adviser and its non‐U.S. clients. However, there remains some ambiguity as to the application of this policy, which has been developed over the past 12 years through a series of no‐action letters. In addition, notwithstanding the SEC’s statement in the proposing release, the proposed rules could be read as changing current SEC policy in a couple of respects. This article explains those issues.