Comparative Benchmarking Research Articles

Revising the stochastic iterative ensemble smoother

Abstract. Ensemble randomized maximum likelihood (EnRML) is an iterative (stochastic) ensemble smoother, used for large and nonlinear inverse problems, such as history matching and data assimilation. Its current formulation is overly complicated and has issues with computational costs, noise, and covariance localization, even causing some practitioners to omit crucial prior information. This paper resolves these difficulties and streamlines the algorithm without changing its output. These simplifications are achieved through the careful treatment of the linearizations and subspaces. For example, it is shown (a) how ensemble linearizations relate to average sensitivity and (b) that the ensemble does not lose rank during updates. The paper also draws significantly on the theory of the (deterministic) iterative ensemble Kalman smoother (IEnKS). Comparative benchmarks are obtained with the Lorenz 96 model with these two smoothers and the ensemble smoother using multiple data assimilation (ES-MDA).

Turbulence Coherence Within Canonical and Realistic Aeolian Dune-Field Roughness Sublayers

Large-eddy simulation has been used to study the formation and spatial nature of inertia-dominated turbulent flows responding to aeolian sand dunes. The former is recovered from simulations initialized with a Reynolds-averaged flow, without any small-scale features, which highlights the emergence of salient structures within the dune-field roughness sublayer (RSL). The latter is based upon computation of integral lengths. In the interest of generality, these exercises are based upon flow over canonical dune geometries—which serve as a comparative benchmark—and flow over a section of the White Sands National Monument aeolian dune field in southern New Mexico. These cases, thus, capture a vast range of complexity. In both applications, we report the emergence of mixing-layer-like processes—as per results for other canopy flows—although the distinct geometric nature of the dunes shows the prevalence of a persistent interdune roller, which is aligned most closely with the streamwise direction. In order to demonstrate underlying similarities in the processes occuring above idealized and natural dune fields, we normalize the integral lengths by characteristic length scales: vorticity thickness, attached-eddy-hypothesis mixing length, and dissipation length. This exercise reveals a distinct growth and collapse pattern that is robust across all considered dune arrangements. Herein, ‘growth’ refers to the stage of downflow thickening of vortices produced via vortex shedding off the upflow dune; growth is regulated by the lesser of the distance to the wall or distance to the upflow dune, where the latter marks the beginning of the ‘collapse’ stage. Both are compliant with the notion of wall-attached eddies. In the RSL, we demonstrate that the integral lengths exhibit an optimal collapse when normalized by vorticity thickness, while inertial layer scaling is attained as close as one dune height above the top of the dune canopy. These results help to establish dune-field RSL dynamics within the broader context of canopy turbulence, which is important given the relatively greater efforts devoted to flows over vegetative canopies and urban environments.

A Long, Unnerving Road: Malpractice Claims Involving the Surgical Management of Thyroid and Parathyroid Disease.

Given their profound emotional, physical, and financial toll on patients and surgeons, we studied the characteristics, costs, and contributing factors of thyroid and parathyroid surgical malpractice claims. Using the Controlled Risk Insurance Company Strategies' Comparative Benchmarking System database, representing ~30% of all US paid and unpaid malpractice claims, 5384 claims filed against general surgeons and otolaryngologists from 1995-2015 were reviewed to isolate claims involving the surgical management of thyroid and parathyroid disease. These claims were studied, and multivariable regression analysis was performed to identify factors associated with plaintiff payout. One hundred twenty-eight thyroid and parathyroid surgical malpractice claims were isolated. The median time from alleged harm event to closure of a malpractice case was 39months. The most common associated complications were bilateral recurrent laryngeal nerve (RLN) injury (n = 23) and hematoma (n = 18). Complications led to death in 18 cases. Patient payout occurred in 33% of claims (n = 42), and the median cost per claim was $277,913 (IQR $87,343-$783,663). On multivariable analysis, bilateral RLN injury was predictive of patient payout (OR 3.58, p = 0.03), while procedure, death, and surgeon specialty were not. Though rare, malpractice claims related to thyroid and parathyroid surgery are costly, time-consuming, and reveal opportunities for early surgeon-patient resolution after poor outcomes.

Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database.

Background Misdiagnosis of dangerous cerebrovascular disease is a substantial public health problem. We sought to identify and describe breakdowns in the diagnostic process among patients with ischemic stroke to facilitate future improvements in diagnostic accuracy. Methods We performed a retrospective, descriptive study of medical malpractice claims housed in the Controlled Risk Insurance Company (CRICO) Strategies Comparative Benchmarking System (CBS) database from 1/1/2006 to 1/1/2016 involving ischemic stroke patients. Baseline claimant demographics, clinical setting, primary allegation category, and outcomes were abstracted. Among cases with a primary diagnosis-related allegation, we detail presenting symptoms and diagnostic breakdowns using CRICO's proprietary taxonomy. Results A total of 478 claims met inclusion criteria; 235 (49.2%) with diagnostic error. Diagnostic errors originated in the emergency department (ED) in 46.4% (n = 109) of cases, outpatient clinic in 27.7% (n = 65), and inpatient setting in 25.1% (n = 59). Across care-settings, the most frequent process breakdown was in the initial patient-provider encounter [76.2% (n = 179 cases)]. Failure to assess, communicate, and respond to ongoing symptoms was the component of the patient-provider encounter most frequently identified as a source of misdiagnosis in the ED. Exclusively non-traditional presenting symptoms occurred in 35.7% (n = 84), mixed traditional and non-traditional symptoms in 30.6% (n = 72), and exclusively traditional in 23.8% (n = 56) of diagnostic error cases. Conclusions Among ischemic stroke patients, breakdowns in the initial patient-provider encounter were the most frequent source of diagnostic error. Targeted interventions should focus on the initial diagnostic encounter, particularly for ischemic stroke patients with atypical symptoms.

A Contemporary Medicolegal Analysis of Injury Related to Peripheral Nerve Blocks

Background: Closed malpractice claims can provide insight into low-frequency adverse events in many areas of perioperative and chronic pain care. Over the last decade, there have been changes in surgical and regional anesthetic practice, likely impacting adverse event patterns. Given the wide variability and low frequency of complications associated with peripheral nerve blocks, the study of closed malpractice claims offers an opportunity to examine adverse events, and the patient, technical, and provider factors that led to the claim. Knowledge gained from examination of closed claims has already resulted in multiple improvements in processes of care and patient safety. Objectives: An investigation of the factors that contributed to medicolegal claims against anesthesia providers related to peripheral nerve blocks. Study Design: Retrospective analysis. Setting: Inpatient and outpatient surgery facilities. Methods: The Comparative Benchmarking System database is a medical liability database that contains more than 400,000 malpractice claims from more than 400 academic and communitybased institutions accounting for over 30% of malpractice claims in the United States. The present investigation reviewed all (n = 113) available closed malpractice claims related to regional anesthesia (RA) in surgical patients closed between 2006 and 2016, and investigated factors that may have contributed to patient injury, including type of nerve block, type of surgery, nerves injured, resulting neurologic deficits, and potential factors contributing to the injury. Results: Our data analyzed 62 claims related to RA and showed that most closed claims were classified as permanent minor injuries. The greatest number of claims were for brachial plexus injuries associated with interscalene blocks performed for shoulder or rotator cuff repairs. Femoral and sciatic nerve blocks with resulting lower extremity injuries were the most common nerve blocks resulting in payment. The largest contributing factor to these injuries was noted to be “Technical Knowledge/Performance” of the regionalist followed by “Pre-existing Injury/Radiculopathy.” Symptom onset from these claims was most likely to be delayed with the leading initial presenting symptom being paresthesia. Limitations: It is difficult to establish cause-effect relationship, and the small sample size limits the ability to detect clinical differences and associations with specific comorbidities or techniques. There was also limited information related to regional anesthetic techniques and medications used that would have helped explore further relationships between the procedure and cause for litigation. Conclusions: There remains significant room for risk reduction in regional anesthetic practice. Patterns based on the analysis of closed claims show that interscalene blocks are the most common peripheral nerve block resulting in litigation, even when compared with other blocks involving the brachial plexus. Furthermore, patients with existing nerve injury/radiculopathy may also warrant alternative techniques or greater emphasis during informed consent on the increased risk of injury. As most of the presenting symptoms associated with claims are delayed, an opportunity for improvement in postregional care may be better communication with patients following discharge to discuss their postoperative recovery. Key words: Regional, pain, anesthesia, complications, closed claims, liability, nerve, block, injury

Serious misdiagnosis-related harms in malpractice claims: The "Big Three" - vascular events, infections, and cancers.

Background Diagnostic errors cause substantial preventable harm, but national estimates vary widely from 40,000 to 4 million annually. This cross-sectional analysis of a large medical malpractice claims database was the first phase of a three-phase project to estimate the US burden of serious misdiagnosis-related harms. Methods We sought to identify diseases accounting for the majority of serious misdiagnosis-related harms (morbidity/mortality). Diagnostic error cases were identified from Controlled Risk Insurance Company (CRICO)'s Comparative Benchmarking System (CBS) database (2006-2015), representing 28.7% of all US malpractice claims. Diseases were grouped according to the Agency for Healthcare Research and Quality (AHRQ) Clinical Classifications Software (CCS) that aggregates the International Classification of Diseases diagnostic codes into clinically sensible groupings. We analyzed vascular events, infections, and cancers (the "Big Three"), including frequency, severity, and settings. High-severity (serious) harms were defined by scores of 6-9 (serious, permanent disability, or death) on the National Association of Insurance Commissioners (NAIC) Severity of Injury Scale. Results From 55,377 closed claims, we analyzed 11,592 diagnostic error cases [median age 49, interquartile range (IQR) 36-60; 51.7% female]. These included 7379 with high-severity harms (53.0% death). The Big Three diseases accounted for 74.1% of high-severity cases (vascular events 22.8%, infections 13.5%, and cancers 37.8%). In aggregate, the top five from each category (n = 15 diseases) accounted for 47.1% of high-severity cases. The most frequent disease in each category, respectively, was stroke, sepsis, and lung cancer. Causes were disproportionately clinical judgment factors (85.7%) across categories (range 82.0-88.8%). Conclusions The Big Three diseases account for about three-fourths of serious misdiagnosis-related harms. Initial efforts to improve diagnosis should focus on vascular events, infections, and cancers.

A Contemporary Medicolegal Analysis of Outpatient Interventional Pain Procedures: 2009-2016.

Closed malpractice claim studies allow a review of rare but often severe complications, yielding useful insight into improving patient safety and decreasing practitioner liability. This retrospective observational study of pain medicine malpractice claims utilizes the Controlled Risk Insurance Company Comparative Benchmarking System database, which contains nearly 400,000 malpractice claims drawn from >400 academic and community medical centers. The Controlled Risk Insurance Company Comparative Benchmarking System database was queried for January 1, 2009 through December 31, 2016, for cases with pain medicine as the primary service. Cases involving outpatient interventional pain management were identified. Controlled Risk Insurance Company-coded data fields and the narrative summaries were reviewed by the study authors. A total of 126 closed claims were identified. Forty-one claims resulted in payments to the plaintiffs, with a median payment of $175,000 (range, $2600-$2,950,000). Lumbar interlaminar epidural steroid injections were the most common procedures associated with claims (n = 34), followed by cervical interlaminar epidural steroid injections (n = 31) and trigger point injections (n = 13). The most common alleged injuring events were an improper performance of a procedure (n = 38); alleged nonsterile technique (n = 17); unintentional dural puncture (n = 13); needle misdirected to the spinal cord (n = 11); and needle misdirected to the lung (n = 10). The most common alleged outcomes were worsening pain (n = 26); spinal cord infarct (n = 16); epidural hematoma (n = 9); soft-tissue infection (n = 9); postdural puncture headache (n = 9); and pneumothorax (n = 9). According to the Controlled Risk Insurance Company proprietary contributing factor system, perceived deficits in technical skill were present in 83% of claims. Epidural steroid injections are among the most commonly performed interventional pain procedures and, while a familiar procedure to pain management practitioners, may result in significant neurological injury. Trigger point injections, while generally considered safe, may result in pneumothorax or injury to other deep structures. Ultimately, the efforts to minimize practitioner liability and patient harm, like the claims themselves, will be multifactorial. Best outcomes will likely come from continued robust training in procedural skills, attention paid to published best practice recommendations, documentation that includes an inclusive consent discussion, and thoughtful patient selection. Limitations for this study are that closed claim data do not cover all complications that occur and skew toward more severe complications. In addition, the data from Controlled Risk Insurance Company Comparative Benchmarking System cannot be independently verified.

1290-P: Achieving and Sustaining Inpatient Glycemic Goals by Employing Targeted Strategies that Include Daily Surveillance and Real-Time Communication

Background: Approximately 30% of inpatient admissions require glycemic management at our 680 bed academic hospital. The Inpatient Diabetes (DM) Program created internal glycemic goals, employed targeted strategies to meet and sustain these goals, and began participation in a national database for comparative benchmarking. Purpose: The purpose of the Inpatient Diabetes Program is to lead evidence-based diabetes care to achieve glycemic outcomes for hospitalized patients. Method: The DM Program uses targeted strategies to meet glycemic outcomes, including daily surveillance, real-time communication with providers, maximization of the Electronic Health Record (EHR), provision of varied educational formats, and empowerment of front line staff in decision making. Daily real-time communication occurs with the prescribing provider (e.g., resident/advanced practice provider and the attending provider regarding recurrent hypoglycemia and persistent hyperglycemia. Follow-up surveillance is completed to evaluate if there was a treatment change. Maximization of the EHR has facilitated standardization of care with the creation of order sets, reports and real-time surveillance. Staff education is provided using various platforms including focused courses, a DM share-point site, videos, and a DM newsletter. Results/Outcomes: The rate of hyperglycemia (BG >180 mg/dL) has decreased in the previous 3 years from 25% to 20% for point of care glucose values, without an increase in hypoglycemia. The hypoglycemia rate has consistently remained at 2% with a severe hypoglycemia rate of 0.1%. Day weighted mean BGs in both critical care and non-critical care meet the national benchmark targets. Implications for Practice: Using targeted interventions that are “active” strategies like frequent surveillance and real-time communication helps achieve inpatient glucose goals. Disclosure E.L. Thompson: None. B. Everhart: None.

A Contemporary Analysis of Medicolegal Issues in Obstetric Anesthesia Between 2005 and 2015.

Detailed reviews of closed malpractice claims have provided insights into the most common events resulting in litigation and helped improve anesthesia care. In the past 10 years, there have been multiple safety advancements in the practice of obstetric anesthesia. We investigated the relationship among contributing factors, patient injuries, and legal outcome by analyzing a contemporary cohort of closed malpractice claims where obstetric anesthesiology was the principal defendant. The Controlled Risk Insurance Company (CRICO) is the captive medical liability insurer of the Harvard Medical Institutions that, in collaboration with other insurance companies and health care entities, contributes to the Comparative Benchmark System database for research purposes. We reviewed all (N = 106) closed malpractice cases related to obstetric anesthesia between 2005 and 2015 and compared the following classes of injury: maternal death and brain injury, neonatal death and brain injury, maternal nerve injury, and maternal major and minor injury. In addition, settled claims were compared to the cases that did not receive payment. χ, analysis of variance, Student t test, and Kruskal-Wallis tests were used for comparison between the different classes of injury. The largest number of claims, 54.7%, involved maternal nerve injury; 77.6% of these claims did not receive any indemnity payment. Cases involving maternal death or brain injury comprised 15.1% of all cases and were more likely to receive payment, especially in the high range (P = .02). The most common causes of maternal death or brain injury were high neuraxial blocks, embolic events, and failed intubation. Claims for maternal major and minor injury were least likely to receive payment (P = .02) and were most commonly (34.8%) associated with only emotional injury. Compared to the dropped/denied/dismissed claims, settled claims more frequently involved general anesthesia (P = .03), were associated with delays in care (P = .005), and took longer to resolve (3.2 vs 1.3 years; P < .0001). Obstetric anesthesia remains an area of significant malpractice liability. Opportunities for practice improvement in the area of severe maternal injury include timely recognition of high neuraxial block, availability of adequate resuscitative resources, and the use of advanced airway management techniques. Anesthesiologists should avoid delays in maternal care, establish clear communication, and follow their institutional policy regarding neonatal resuscitation. Prevention of maternal neurological injury should be directed toward performing neuraxial techniques at the lowest lumbar spine level possible and prevention/recognition of retained neuraxial devices.

Grey Wolf Optimizer Driven design space exploration: A novel framework for multi-objective trade-off in architectural synthesis

Abstract Initiating Design Space Exploration (DSE) procedure during architectural synthesis is a highly intricate and tedious process. It involves optimal arrangement of resource utilizations within a design search space to resolve conflicting objectives of power-performance as well as area occupied by different types of resources. To arrive at an arrangement with minimum completion time among all of the permuted arrangements is a Non-Polynomial-hard problem. The problem becomes acute when it involves multi-objectives, as in the case of DSE for ensuring reliable power-performance-area trade-off of application specific processors. Many heuristic algorithms are being considered to derive an optimal solution for this multi-objective DSE procedure. A comprehensive mapping process and reliable solution evaluation approach called Grey Wolf Optimizer Driven DSE (GWO-DSE) is proposed in this article. The contributions of the article are as follows: i) Introduction of a novel GWO-DSE methodology for power-performance-area trade-off ii) Unique solution evaluation methodology called Utility Coefficients and Utility Ranking iii) Unique fitness evaluation function Grey wolf optimizer iv) Comparative benchmarks using digital filter transfer functions v) Substantial improvement in solution arrival within search space (average > 51%) and reduction in exploration time (>89%) when compared to recent DSE approaches for the tested benchmarks.

A medicolegal analysis of positioning-related perioperative peripheral nerve injuries occurring between 1996 and 2015

Study objectiveTo provide an analysis of closed malpractice claims brought against anesthesiologists for positioning-related perioperative nerve injury (PRPNI). DesignIn this retrospective study, we analyzed closed claims data from the Controlled Risk Insurance Company (CRICO) Comparative Benchmarking System (CBS) database. SettingClosed claims involving nerve injuries that occurred between January 1, 1996 and December 31, 2015 in all surgical settings, provided the alleged damaging event occurred under general anesthesia. PatientsPatient ages ranged from 23 to 94. Patients underwent a variety of surgical procedures. Severity of nerve injury ranged from “Insignificant” to “Grave” according to the NAIC Severity of Injury Code. InterventionsNone. MeasurementsPatient age and gender, alleged nerve injury type and severity, operating surgical specialty, contributing factors to the alleged nerve injury, and case outcome. Some of these data were drawn directly from coded variables in the CBS database, and some were gathered by the authors from CRICO-encoded narrative case summaries. Main resultsSeventy-five claims were determined to represent PRPNI. Ninety-two percent of all PRPNI claims involved practitioner technical knowledge/performance. Of all the recorded nerve injuries in this series, 56% involved brachial plexus injuries, and supine patient positioning represented 55% of brachial plexus claims. Settlement payments were made in 33% of claims, and the average payment for all cases was $46,269. Twenty-four percent of PRPNI claims were found to be temporary, while 76% were permanent. ConclusionsPRPNI is multifactorial, and stems both from practitioner errors as well as from patient comorbidities and pre-existing neuropathies. Supine positioning can increase PRPNI risk. There are likely still causes of PRPNI of which we are not yet aware, given that despite concerted efforts towards positioning and padding interventions, injuries such as those described in this study still occur.

Medical Malpractice Involving Pulmonary/Critical Care Physicians

Medical malpractice data can be leveraged to understand specialty-specific risk. Malpractice claims were examined from the Comparative Benchmarking System (2007-2016), a national database containing > 30%of claims data in the United States. Claims were identified with either internal medicine or pulmonary/critical care (PCC) physicians as the primary provider involved in the harm. Claim characteristics were compared according to specialty and care setting (inpatient vsoutpatient), and multiple regression analysis was performed to predict claim payment. Claims involving PCC physicians differed from those involving internal medicine physicians in terms of harm severity, allegation, final diagnosis, procedure involvement, payment rate, and contributing factors. The majority of claims involving PCC physicians resulted from inpatient care (63%), of which only 26%occurred delivering intensive care. Eighty-one percent were from harm events that resulted in death/permanent injury. The most common diagnosis was laceration during a procedure for inpatient claims (6%) and lung cancer for outpatient claims (28%). Thirty-one percent of claims overall involved procedures. Although only 26%were paid, the median indemnity per paid claim of $285,769 ranked PCC as the twelfth highest of 69 specialties. The two variables associated with indemnity payment were outpatient care (OR, 1.70; 95%CI, 1.01-2.86) and temporary harm (OR, 0.36; 95%CI, 0.15-0.87). Malpractice claims involving PCC physicians were distinct from claims involving internal medicine physicians. Although only one-quarter of claims was paid, the indemnity per claim was high among specialties. Specialty-specific prevention strategies must be developed to mitigate both patient harm and provider malpractice risk.

What Have We Learned From Malpractice Claims Involving the Surgical Management of Benign Biliary Disease?: A 128 Million Dollar Question.

We aimed to study the contributing factors and costs of malpractice claims involving the surgical management of benign biliary disease given the emotional, physical, and financial toll of these claims on patients, providers, and the healthcare system. Cholecystectomy complications carry significant morbidity and rank among the leading sources of surgical malpractice claims. Using the CRICO Strategies' Comparative Benchmarking System database, representing approximately 30% of all paid and unpaid malpractice claims in the United States, 4081 closed claims filed against general surgeons from 1995 to 2015 were reviewed to isolate 745 cholecystectomy-related claims. A multivariable model was used to determine factors associated with claim outcome. The most common associated complications included bile duct injury (n = 397), bowel perforation (n = 96), and hemorrhage (n = 78). Bile duct injuries were recognized intraoperatively only 19% of the time and required biliary reconstruction surgery 77% of the time. The total cost for all claims over the study period was over $128 M and the median time from event to case close was over 3 years. 40% of claims resulted in patient payout; of these, most claims were settled out of court and the median cost per claim was $264,650. For the 60% of claims not resulting in patient payout, most cases were denied, dropped, or dismissed, yet still averaged over $15,000 per claim in legal and administrative fees. On multivariable analysis, bile duct injury, bowel perforation, and high clinical severity were associated with patient payout, while a resident or fellow being named in a claim was negatively associated with patient payout (P < 0.05). Cholecystectomy-related claims are costly and time-consuming. Strategies that reduce the risk and aid in recognition of cholecystectomy complications, as well as advance support of patients and families after poor outcomes, may improve clinical care and reduce claim burden.

Excessive Pricing by Dominant Firms, Private Litigation, and the Existence of Alternative Products

The aim of this paper is to discuss two issues concerning the antitrust prohibition of excessive pricing by dominant firms. The first is private enforcement of the prohibition and the second is the case where consumers can purchase alternative products inferior to the dominant firm’s product. With regard to private suits, the paper discusses several issues that may arise in private litigation, including the tools that civil courts have to cope with such litigation and the case where the excessive price was charged for a product that was not sold directly to the end consumer. The paper elaborates further regarding determination of a “competitive price” or “more competitive price” that can be compared with the price charged by the dominant firm and discusses the virtues of comparative (rather than cost-based) benchmarks, and in particular a retrospective competitive benchmark, which compares the price the dominant firm has charged before and after entry. It then proposes to cope with concerns about accounting manipulations when a reliable comparative benchmark does not exist and the court has to revert to a cost-based benchmark, and proposes limitations on the way dominant firms should be allowed to allocate costs that are common to producing the product in question and other products. In relation to the case where consumers can purchase alternative products instead of the dominant firm’s product that has been priced excessively, the paper shows why this scenario should not serve as a defense for the dominant firm, neither when the alternative products are sold for similar (excessive) prices nor when they are sold for lower prices. The paper also shows why it would be bad policy to restrict liability for excessive pricing to the case of essential products.

A contemporary medicolegal claims analysis of injuries related to neuraxial anesthesia between 2007 and 2016

Study objectiveTo provide a contemporary medicolegal analysis of claims brought against anesthesia providers in the United States related to neuraxial blocks for surgery and obstetrics. DesignIn this retrospective analysis, we analyzed closed claims data from the Controlled Risk Insurance Company (CRICO) Comparative Benchmarking System (CBS) database between 2007 and 2016. SettingClosed claims from inpatient and outpatient settings related to neuraxial anesthesia for surgical procedures and obstetrics. PatientsForty-five claims were identified for analysis. These patients underwent a variety of surgical procedures, included both children and adults, and with ages ranging from 6 to 82. InterventionsPatients receiving neuraxial anesthesia (spinals, epidurals) for surgery or obstetrics. MeasurementsData collected includes patient demographics, alleged injury type/severity, surgical specialty, likely contributors to the alleged damaging event, and case outcome. Some of the data were drawn directly from coded variables in the CRICO database, and some were gathered from narrative case summaries. Main resultsSettlement payments were made in 20% of claims. Reported adverse outcomes ranged from temporary minor to permanent major injuries. Most closed claims were classified as permanent minor injuries. The greatest number of claims involved residual weakness and radiculopathy resulting from epidurals. The largest contributing factor to these injuries was noted to be “Technical Knowledge/Performance” of the anesthesia provider followed by “Missing or Documentation Error.” Over half of the claims arose from obstetric patients (31%) and patients undergoing orthopedic surgery (27%). ConclusionsPatients with pre-existing radiculopathy or comorbidities may warrant more thorough informed consent about the increased risk of injury. Additionally, prompt follow-up, monitoring, and documentation of post-operative symptoms, such as weakness or radiculopathy, are crucial for improving patient safety and satisfaction. More timely communication with the patient and the surgical team regarding residual neurologic symptoms is important for earlier diagnosis of injury.

ChronoSphere: a graph-based EMF model repository for IT landscape models

IT Landscape models are representing the real-world IT infrastructure of a company. They include hardware assets such as physical servers and storage media, as well as virtual components like clusters, virtual machines and applications. These models are a critical source of information in numerous tasks, including planning, error detection and impact analysis. The responsible stakeholders often struggle to keep such a large and densely connected model up-to-date due to its inherent size and complexity, as well as due to the lack of proper tool support. Even though modeling techniques are very suitable for this domain, existing tools do not offer the required features, scalability or flexibility. In order to solve these challenges and meet the requirements that arise from this application domain, we combine domain-driven modeling concepts with scalable graph-based repository technology and a custom language for model-level queries. We analyze in detail how we synthesized these requirements from the application domain and how they relate to the features of our repository. We discuss the architecture of our solution which comprises the entire data management stack, including transactions, queries, versioned persistence and metamodel evolution. Finally, we evaluate our approach in a case study where our open-source repository implementation is employed in a production environment in an industrial context, as well as in a comparative benchmark with an existing state-of-the-art solution.

Dynamic Compression Garments for Sensory Processing Disorder Treatment Using Integrated Active Materials

Many medical conditions, including sensory processing disorder (SPD), employ compression therapy as a form of treatment. SPD patients often wear weighted or elastic vests to produce compression on the body, which have been shown to have a calming effect on the wearer. Recent advances in compression garment technology incorporate active materials to produce dynamic, low bulk compression garments that can be remotely controlled. In this study, an active compression vest using shape memory alloy (SMA) spring actuators was developed to produce up to 52.5 mmHg compression on a child's torso for SPD applications. The vest prototype incorporated 16 SMA spring actuators (1.25 mm diameter, spring index = 3) that constrict when heated, producing large forces and displacements that can be controlled via an applied current. When power was applied (up to 43.8 W), the prototype vest generated increasing magnitudes of pressure (up to 37.6 mmHg, spatially averaged across the front of the torso) on a representative child-sized form. The average pressure generated was measured up to 71.6% of the modeled pressure, and spatial pressure nonuniformities were observed that can be traced to specific garment architectural features. Although there is no consistent standard in magnitude or distribution of applied force in compression therapy garments, it is clear from comparative benchmarks that the compression produced by this garment exceeds the demands of the target application. This study demonstrates the viability of SMA-based compression garments as an enabling technology for enhancing SPD (and other compression-based) treatment.

Population skills as an indicator of European countries' competitiveness in the modern economy

Human capital and population skills are main drivers of economic growth and national competitiveness in modern economy. The paper investigates current state and development potential of selected European countries in field of population skills competitiveness. Particular attention is paid to this issue in relation to Balkan countries. The aim is to identify factors of population skills that are critical for competitiveness of Balkan countries and which have to be improved in future. The analysis is based on data published by World Economic Forum in the Global Competitiveness Report 2018. The research has been done by applying comparative analysis and benchmarking method. The research findings indicate that level of population skills competitiveness of Balkan countries lags significantly behind top European countries. This study contributes to skills and human capital literature and it could have practical implications in formulating development policy of population skills in European countries.

H-CNN: Spatial Hashing Based CNN for 3D Shape Analysis.

We present a novel spatial hashing based data structure to facilitate 3D shape analysis using convolutional neural networks (CNNs). Our method builds hierarchical hash tables for an input model under different resolutions that leverage the sparse occupancy of 3D shape boundary. Based on this data structure, we design two efficient GPU algorithms namely hash2col and col2hash so that the CNN operations like convolution and pooling can be efficiently parallelized. The perfect spatial hashing is employed as our spatial hashing scheme, which is not only free of hash collision but also nearly minimal so that our data structure is almost of the same size as the raw input. Compared with existing 3D CNN methods, our data structure significantly reduces the memory footprint during the CNN training. As the input geometry features are more compactly packed, CNN operations also run faster with our data structure. The experiment shows that, under the same network structure, our method yields comparable or better benchmark results compared with the state-of-the-art while it has only one-third memory consumption when under high resolutions (i.e., 2563).

Overview and Evaluation of Recent Methods for Statistical Inference of Gene Regulatory Networks from Time Series Data.

A challenging problem in systems biology is the reconstruction of gene regulatory networks from postgenomic data. A variety of reverse engineering methods from machine learning and computational statistics have been proposed in the literature. However, deciding on the best method to adopt for a particular application or data set might be a confusing task. The present chapter provides a broad overview of state-of-the-art methods with an emphasis on conceptual understanding rather than a deluge of mathematical details, and the pros and cons of the various approaches are discussed. Guidance on practical applications with pointers to publicly available software implementations are included. The chapter concludes with a comprehensive comparative benchmark study on simulated data and a real-work application taken from the current plant systems biology.