Immutable Factors Research Articles

Derivation of a nomogram to estimate probability of revisit in at-risk older adults discharged from the emergency department

Estimation of the risk of revisit to the emergency department (ED) soon after discharge in the older population may assist discharge planning and targeting of post discharge intervention in high risk patients. In this study we sought to derive a risk prediction calculator for this purpose. In a prospective observational study in two tertiary ED, we conducted a comprehensive assessment of people aged 65 and over, and followed them for a minimum of 28days post discharge. Cox proportional hazard models relating any unplanned ED revisit in the follow up period to observed risk factors were used to compute a probability nomogram. From 1,439 patients, 189 (13.1%) had at least one unplanned revisit within 28days. Revisit probability was weighted towards chronic and difficult to modify risk factors such as depression, malignancy and cognitive impairment. We conclude that the risk of revisit post discharge is calculable using a probability nomogram. However, revisit is largely related to immutable factors reflecting chronic illness burden, and does not necessarily reflect poor ED care during the initial index presentation.

The Evaluator’s Role in Recommending Program Closure

Evaluators face challenges when programs consistently fail to meet expectations for performance or improvement and consequently, evaluators may recommend that closing a program is the most prudent course of action. However, the evaluation literature provides little guidance regarding when an evaluator might recommend program closure. Given evaluators’ ethical responsibilities to the public good coupled with the inadequacy of methods currently used to justify program closure, we posit the development of a heuristic model designed to identify the point at which a program might be recommended for closure. The heuristic model depends on whether implementation factors are under the control of program administrators (i.e., flexible factors) or out of their control (i.e., immutable factors) and are potentially moderated by facilitating or inhibitory characteristics (e.g., political advocacy, community need, length of time in operation, performance quality). By delineating whether a poorly functioning program could be substantially improved, evaluators should not consider recommendation for or support of a program closure a personal or professional defeat, but rather an opportunity to exercise their professional responsibility to the evaluation profession and the public good. Caveats regarding the political context of an evaluation and the information required to make heuristic judgments about program closure are also discussed.

Nonmelanoma Skin and Mucosal Cancers After Hematopoietic Cell Transplantation

To evaluate the incidence of and risk factors for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) in survivors of hematopoietic cell transplantation (HCT). The impact of patient-, disease-, treatment-, and toxicity-related factors on risk of BCC and SCC was determined in a retrospective cohort study of 4,810 patients who received allogeneic HCT and who survived for at least 100 days. Among allogeneic HCT recipients, 237 developed at least one skin or mucosal cancer (BCC, n = 158; SCC, n = 95). Twenty-year cumulative incidences of BCC and SCC were 6.5% and 3.4%, respectively. Total-body irradiation was a significant risk factor for BCC (P = .003), most strongly among patients younger than 18 years old at HCT (P = .02, interaction). Light-skinned patients had an increased risk of BCC (P = .01). Acute graft-versus-host disease (GVHD) increased the risk of SCC (P = .02), whereas chronic GVHD increased the risk of both BCC (P = .01) and SCC (P < .001). This analysis suggests that immutable factors, such as age and complexion, have a significant impact on BCC and SCC. However, specific treatment (radiotherapy) and transplantation complications (GVHD) may modify that risk. These additional risk factors suggest the contribution of immunologic mechanism DNA and tissue repair in the development of BCC and SCC. We confirm previous reports that exposure to ionizing radiation increases the risk of BCC but not SCC. Survivors of HCT should be monitored for the development of BCC and SCC and use preventive strategies.

Rethinking Realism with a Constructivist Twist

Theories of International Cooperation and the Primacy of Anarchy: Explaining U.S. International Monetary Policy-Making after Bretton Woods. By Jennifer Sterling-Folker. Albany: State University of New York Press, 2002. 308 pp., $75.50 cloth (ISBN: 0-7914-5207-7), $25.95 paper (ISBN: 0-7914-5208-5). Jennifer Sterling-Folker's Theories of International Cooperation and the Primacy of Anarchy proposes a bold rethinking of realism. The book argues that realism has substantial explanatory potential, despite its limitations. Sterling-Folker then suggests how these limitations can be usefully addressed by synthesizing realism with constructivist elements. Finally, she uses this “realist-constructivist” theory to explain US international monetary policy after Bretton Woods—a period that Sterling-Folker argues is inadequately explained by liberal theories of international cooperation and interdependence. Given the current debate in the field regarding realism's continued explanatory relevance as a paradigm, as well as the debates between neoliberal institutionalists and constructivists regarding the nature of international institutions, Theories of International Cooperation and the Primacy of Anarchy is timely and should be of interest to students of international relations and international political economy—whether they be advanced undergraduates, graduate students, or professionals. Furthermore, the book has a breadth of theoretical vision that is quite admirable. However, Sterling-Folker's critique of liberal theories of cooperation is not always satisfying, and her exposition of “realist-constructivist” theory raises more questions than it answers. As if to answer the question that Jeffrey Legro and Andrew Moravcsik (1999) posed: “Is Anybody Still a Realist?,” Sterling-Folker argues in chapter 3 that realism is not only analytically coherent, but it also has analytical applicability beyond systemic factors. Her claim is that anarchy, in neoclassical realist thought, is an immutable factor that provides incentives for groups to form and to compete with each other. In essence, groups form because they …

Modifiable barriers to adherence to inhaled steroids among adults with asthma: It's not just black and white

Background: Sociobehavioral factors influence adherence to inhaled corticosteroid (ICS) in adults with asthma and warrant exploration as explanations of apparent racial disparities in adherence. Objective: The purposes of this study were to identify barriers to adherence, potentially modifiable by healthcare providers, in a group of African Americans and non–African Americans and to test modifiable barriers as explanations of racial-ethnic differences in adherence. Methods: We conducted a cohort study of 85 adults (mean age, 47 ± 15 years; 61 [72%] female; 55 [65%] African American) with moderate or severe persistent asthma to determine modifiable sociobehavioral predictors of adherence. These were knowledge of the function of ICS, patient-perceived adequacy of communication with the provider, social support, attitude (perception of risks/benefits of ICS), depression, and self-efficacy. Adherence was calculated from electronic monitoring data as the mean of the number of doses recorded per 12 hours divided by the number prescribed, truncated at 100%. Past adherence, baseline severity of symptoms, and sociodemographics were treated as fixed confounders in ordinal logistic modeling. Results: Adherence was 60% ± 30%. In bivariate analyses, favorable attitude to ICS (P = .01) was associated with better adherence. Of immutable predictors, African American race-ethnicity (P = .001), lower educational achievement (P = .01), lower household income (P = .002), and more baseline symptoms (P = .003) were associated with poorer adherence. In multivariable analysis, controlling for immutable predictors, favorable attitude was associated with adherence. Favorable attitude was associated with greater adherence in African Americans and non–African Americans. Controlling for immutable factors, the race-adherence relationship was not mediated by the mutable factors, but economic factors (income and insurance) were mediators. Conclusion: Attitude is strongly related to adherence but does not mediate the effect of race-ethnicity. (J Allergy Clin Immunol 2003;111:1219-26.)

Outpatient management of “low-risk” nonvariceal upper GI hemorrhage. Are we ready to put evidence into practice?

Outpatient management of “low-risk” nonvariceal upper GI hemorrhage. Are we ready to put evidence into practice?

Independent and Interactive Effects of Apolipoprotein E Phenotype and Cardiorespiratory Fitness on Plasma Lipids

PURPOSE: To examine whether the association Apolipoprotein E (Apo E) phenotype with plasma lipids is influenced by physical fitness level. Also, to explore the interactive and independent relative contributions of Apo E phenotype, fitness (or physical activity), and other modifiable factors to variation in plasma low density lipoprotein (LDL-C) and high density lipoprotein (HDL-C) levels at baseline and over a seven-year follow-up. METHODS: Physical fitness (duration of a graded treadmill test), Apo E phenotype, plasma LDL-C and HDL-C, and covariates were measured at baseline and seven years later in a bi-racial cohort of young adults, aged 18–30 years at baseline in 1985–86 N = 3629 , from the Coronary Artery Risk Development In Young Adults (CARDIA) study. RESULTS: Fitness did not influence the associations of Apo E and LDL-C or HDL-C. The independent effects of several modifiable variables (changes in Keys' score, smoking, oral contraceptive use, education, body weight, alcohol intake, and fitness), when combined, contributed considerably more than Apo E to the variance in LDL-C changes (6.74% or 8.71% for combined modifiable variables vs. 1.27% or 0.90% for ApoE, in women or men, respectively) and HDL-C changes (13.11% or 12.66% for combined modifiable variables vs. 0.12% or 0.02% for ApoE, in women or men, respectively). The pattern of findings was similar when self-reported physical activity was substituted for fitness. CONCLUSIONS: Changes in modifiable factors, including fitness, may be stronger correlates of changes in LDL-C and HDL-C over time than the immutable factor, Apo E phenotype.

Prostate cancer: how much do we know and how do we know it?

We use data from the Massachusetts Male Aging Study to approximate the total current knowledge about prostate cancer and to evaluate the relative contributions of various risk factors. The sum total of current knowledge is assessed using the area under the receiver operating characteristic curve (AUROC) and by the Hosmer-Lemeshow statistic in a logistic regression model that includes 30 risk factors identified in the literature that are available in the data set. Relative contributions are measured using the adjusted generalized R2 (AR2). To measure relative contributions, we group risk factors with similar etiology and then remove groups and compare the AR2 attained without each group to the AR2 with all variables included. The overall model fits adequately. The A UROC is 0.788, relatively far from its default value of 0.5, and the Hosmer-Lemeshow statistic has a p value of 0.926. We conclude that, while some knowledge about prostate cancer has been accumulated, there are still more risk factors yet unsuspected. The relative importance analysis shows that immutable factors (i.e. age, genotype) contribute 42%, dietary factors 30%, other lifestyle factors 15%, and endocrinological factors 11%. We recommend that age and other unchanging factors should be the primary focus of screening and risk evaluation and that future interventions should center on nutritional behavior.

International Trade Conflict in High Technology Sectors: The Japanese Satellite Example

INTERNATIONAL TRADE CONFLICT IN HIGH TECHNOLOGY SECTORS: THE JAPANESE SATELLITE EXAMPLE Glenn H. Reynoldst I. INTRODUCTION Commerce in high technology items has been a source of international trade friction for some time.' Arguments address- ing the friction have frequently focused on the feasibility of an activist or strategic policy in this field 2 and the constructive re- sponses of other trading nations to the development of such poli- cies. 3 Of late, two particular industry sectors have received t Associate Professor of Law, University of Tennessee. J.D., Yale Law School, 1985; B.A., University of Tennessee, 1982. Professor Reynolds chairs the policy committee of the National Space Society, and the International Space Law committee of the American Bar Association, and is the author (with Robert P. Merges) of OUTER SPACE: PROBLEMS OF LAW AND POLICY (Westview Press, 2d ed. 1994). This article is based on prepared testimony presented to the United States Senate Finance Committee, Subcommittee on International Trade, in June 1993 and on comments submitted to the United States Trade Representative's office in July 1989. 1 would like to thank my research assistant, Brannon Denning, for his usual excellent work. 1. See, e.g., THOMAS HOWELL ET AL., THE MICROELECTRONICS RACE: THE IMPACT OF GOVERNMENT POLICY ON INTERNATIONAL COMPETITION (1988); RICH- ARD NELSON, HIGH TECHNOLOGY POLICIES: A FIVE NATION COMPARISON (1984); LAURA D'ANDREA TYSON, WHO's BASHING WHOM? TRADE CONFLICT IN HIGH TECHNOLOGY INDUSTRIES (1993); Glenn H. Reynolds, United States Telecommuni- cations Trade Policy: Critique and Suggestions, 58 TENN. L. REV. 573 (1991). 2. Traditional analysis of international trade matters has generally turned on questions of comparative advantage. See ROBERT GILPIN, THE POLITICAL ECON- OMY OF INTERNATIONAL RELATIONS 22 (1987). The assumption was that some na- tions, because of relatively immutable factors, such as climate and natural resources, would have an advantage in producing particular commodities over others. Since the causes of such an advantage were fixed, governmental policies might do harm, but could not do much good. Id. at 173-75. More recently, however, an increasing number of nations have proven capable of creating their own comparative advan- tage through technological, economic, and regulatory approaches designed to foster international competitiveness. Theories that purport to explain the success of these approaches generally refer to them as strategic trade policies, and thus are known as strategic trade theories. See generally Reynolds, supra note 1, at 594-98 (dis- cussing strategic trade theories). 3. For a summary of this debate, see Reynolds, supra note 1, at 586-98.

Introduction

Ideas about the role of education in national development have changed greatly during the last thirty years. Before the mid-twentieth century, Westerners thought education had little to offer the underdeveloped world, especially the colonized regions of Africa and South Asia. They saw little prospect for modernization because underdevelopment was attributed to immutable factors like climate and race. Colonial education was directed towards preparing a small indigenous elite to become clerks and junior civil servants in local bureaucracies.