Intermediate Priority Research Articles

Impact of Heart Transplant Allocation Change on Waitlist Mortality and Posttransplant Mortality in Patients With Left Ventricular Assist Devices.

In October 2018, the US heart transplant (HT) allocation system was revised giving patients with left ventricular assist device (LVAD) intermediate priority status. Few studies have examined the impact of this policy change on outcomes among patients with LVAD. We sought to determine how the allocation change impacted waitlist and posttransplant mortality in patients with LVAD. We retrospectively assessed the United Network for Organ Sharing registry for patients with LVAD who were listed for or underwent HT between October 2016 and October 2021. We evaluated waitlist mortality using competing risks analysis and a multivariable Fine-Gray model, and posttransplant mortality using Kaplan-Meier survival analysis and a multivariate proportional hazards model. We analyzed data from 3835 patients with LVAD listed for HT and 3486 patients with LVAD who underwent HT during the study period. Listing for HT preallocation change was significantly associated with an increased risk of waitlist mortality (Gray P=0.0058) compared with postallocation change. After adjustment for covariates, mortality differences by listing era were attenuated, but LVAD brand was significantly associated with waitlist mortality (HM3 versus HMII; hazard ratio, 0.38 [95% CI, 0.21-0.69]; P=0.002; HVAD versus HMII; hazard ratio, 0.79 [95% CI, 0.48-1.30]; P=0.36; overall P=0.004). In contrast, HT postallocation change was associated with increased posttransplant mortality (log-rank P=0.0172) compared with preallocation change. In a multivariable analysis, the association with posttransplant mortality between transplant eras was attenuated, but ischemic time (hazard ratio, 1.16 [95% CI, 1.07-1.26]; P<0.001) and status at time of HT (Status 1-3 versus 4; hazard ratio, 1.29 [95% CI, 1.04-1.61]; P=0.02) were significantly associated with posttransplant mortality. Among patients with LVAD, lower waitlist mortality postallocation change was likely driven by improved LVAD technology. Higher posttransplant mortality following the allocation change was largely attributable to longer ischemic times and patient acuity.

Translated article] Design of a panel of indicators for antibiotic stewardship programs in the Emergency Department

ObjectiveTo develop a panel of indicators to monitor antimicrobial stewardship programs activity in the emergency department. MethodsA multidisciplinary group consisting of experts in the management of infection in emergency departments and the implementation of antimicrobial stewardship programs (ASP) evaluated a proposal of indicators using a modified Delphi methodology. In the first round, each expert classified the relevance of each proposed indicators in two dimensions (healthcare impact and ease of implementation) and two attributes (prioritisation level and frequency). The second round was conducted based on the modified questionnaire according to the suggestions raised and new indicators suggested. Experts modified the prioritisation order and rated the new indicators in the same manner as in the first round. Results61 potential indicators divided into four groups were proposed: consumption indicators, microbiological indicators, process indicators, and outcome indicators. After analysing the scores and comments from the first round, 31 indicators were classified as high priority, 25 as intermediate priority, and 5 as low priority. Moreover, 18 new indicators were generated. Following the second round, all 61 initially proposed indicators were retained, and 18 new indicators were incorporated: 11 classified as high priority, 3 as intermediate priority, and 4 as low priority. ConclusionsThe experts agreed on a panel of ASP Indicators adapted to the emergency services prioritised by level of relevance. This is as a helpful tool for the development of these programs and will contribute to monitoring the appropriateness of the use of antimicrobials in these units.

Double J Stents and Reno-Ureteral Lithiasis: Dynamic Changes in Management during the COVID-19 Pandemic.

To provide an evidence-based review of the use of ureteral stents in managing reno-ureteral lithiasis during the COVID-19 pandemic. A literature search was conducted between 2020 and 2023 using the PubMed and SCOPUS databases. As a part of the search query, we entered "ureteral stents" OR "double J stent" AND "renal colic" OR "ureteral obstruction" OR "reno-ureteral lithiasis" AND "COVID-19 Pandemic" OR "SARS-CoV-2 infection". Patients with lithiasis should be categorized into low priority, intermediate priority, high priority, and emergency under the COVID-19 pandemic scenario to manage their delay and save resources, including healthcare professionals, beds, and ventilators. However, immediate interventions are necessary for individuals at risk of life-threatening septic complications. During the COVID-19 pandemic, the feasibility of conducting or resuming elective activity depended on local circumstances, the accessibility of beds and ventilators, and the execution of screening protocols. If lithiasis surgery is delayed, consequences and increased effort will be inevitable. It is possible that teleconsultation could help guide these patients and cut down on unnecessary visits and exposure. COVID-19 has shifted treatment options for urinary stones, with ureteral stents being a safe, efficient, and cost-effective option for managing urolithiasis. Decompression is essential in emergency situations, while ureteral stents reduce the risk of infection and hospital visits.

Diseño de un panel de indicadores para programas de optimización del uso de antimicrobianos en los Servicios de Urgencias

ObjectiveTo develop a panel of indicators to monitor antimicrobial stewardship programs activity in the emergency department. MethodsA multidisciplinary group consisting of experts in the management of infection in emergency departments and the implementation of antimicrobial stewardship programs (ASP) evaluated a proposal of indicators using a modified Delphi methodology. In the first round, each expert classified the relevance of each proposed indicators in two dimensions (healthcare impact and ease of implementation) and two attributes (prioritization level and frequency). The second round was conducted based on the modified questionnaire according to the suggestions raised and new indicators suggested. Experts modified the prioritization order and rated the new indicators in the same manner as in the first round. Results61 potential indicators divided into four groups were proposed: consumption indicators, microbiological indicators, process indicators, and outcome indicators. After analyzing the scores and comments from the first round, 31 indicators were classified as high priority, 25 as intermediate priority, and 5 as low priority. Moreover, 18 new indicators were generated. Following the second round, all 61 initially proposed indicators were retained, and 18 new indicators were incorporated: 11 classified as high priority, 3 as intermediate priority, and 4 as low priority. ConclusionsThe experts agreed on a panel of ASP indicators adapted to the emergency services prioritized by level of relevance. This is as a helpful tool for the development of these programs and will contribute to monitoring the appropriateness of the use of antimicrobials in these units.

Validation of a pre-established triage protocol for critically ill patients in a COVID-19 outbreak under resource scarcity: A retrospective multicenter cohort study.

In case of COVID-19 related scarcity of critical care resources, an early French triage algorithm categorized critically ill patients by probability of survival based on medical history and severity, with four priority levels for initiation or continuation of critical care: P1 -high priority, P2 -intermediate priority, P3 -not needed, P4 -not appropriate. This retrospective multi-center study aimed to assess its classification performance and its ability to help saving lives under capacity saturation. ICU patients admitted for severe COVID-19 without triage in spring 2020 were retrospectively included from three hospitals. Demographic data, medical history and severity items were collected. Priority levels were retrospectively allocated at ICU admission and on ICU day 7-10. Mortality rate, cumulative incidence of death and of alive ICU discharge, length of ICU stay and of mechanical ventilation were compared between priority levels. Calculated mortality and survival were compared between full simulated triage and no triage. 225 patients were included, aged 63.1±11.9 years. Median SAPS2 was 40 (IQR 29-49). At the end of follow-up, 61 (27%) had died, 26 were still in ICU, and 138 had been discharged. Following retrospective initial priority allocation, mortality rate was 53% among P4 patients (95CI 34-72%) versus 23% among all P1 to P3 patients (95CI 17-30%, chi-squared p = 5.2e-4). The cumulative incidence of death consistently increased in the order P3, P1, P2 and P4 both at admission (Gray's test p = 3.1e-5) and at reassessment (p = 8e-5), and conversely for that of alive ICU discharge. Reassessment strengthened consistency. Simulation under saturation showed that this two-step triage protocol could have saved 28 to 40 more lives than no triage. Although it cannot eliminate potentially avoidable deaths, this triage protocol proved able to adequately prioritize critical care for patients with highest probability of survival, hence to save more lives if applied.

Mapping an alien invasive shrub within conservation corridors using super-resolution satellite imagery

Alien invasive plant species are one of the main drivers of global biodiversity loss. Methods for monitoring the spread of alien invasive plants are needed to improve management and mitigate impact on local biodiversity. Recent advances in deep learning and image fusion holds great potential for mapping and managing alien invasive plants. One such method is super-resolution image reconstruction, where a neural network learns to downscale images from coarse to fine resolution. Within the commercial timber production landscape of KwaZulu-Natal, endangered grassland corridors are threatened by American bramble invasion, impacting plants, birds, arthropods, and soil restoration. Here we aim to improve our understanding of bramble invasion dynamics through using super-resolved satellite mosaics. Bramble was classified with very high accuracies (85%) from the super-resolved satellite mosaic, compared to other conventional satellite imagery with different spectral and spatial resolutions. Using landscape analyses, we identified plantation tree harvesting and prescribed burning to be major drivers increasing bramble cover within the landscape. Bramble cover was highest one year following plantation tree harvesting. Continuous prescribed burning positively influenced bramble. Bramble cover was also high close to streams, and under future invasion projections, bramble will severely impact Ensifera species alongside low priority grasshopper species habitat. Results also indicate that bramble has a significant negative impact on intermediate priority grasshoppers and plant species richness. For controlling bramble invasion within commercial timber production landscapes, we recommend the adoption rotational harvesting, as harvesting entire plantation blocks throughout the landscape will dramatically increase invasion potential of bramble. Current bramble removal programmes should prioritize riparian areas. Special attention is needed to control bramble one year after timber harvesting, as this is when bramble cover is highest. We show the benefits of using super-resolved mosaics to gain new insights into alien invasive species dynamics, while further development of this technique will aid in managing invasive alien plant species at local scales.

Assessment of a Crisis Standards of Care Scoring System for Resource Prioritization and Estimated Excess Mortality by Race, Ethnicity, and Socially Vulnerable Area During a Regional Surge in COVID-19

Crisis standards of care (CSOC) scores designed to allocate scarce resources during the COVID-19 pandemic could exacerbate racial disparities in health care. To analyze the association of a CSOC scoring system with resource prioritization and estimated excess mortality by race, ethnicity, and residence in a socially vulnerable area. This retrospective cohort analysis included adult patients in the intensive care unit during a regional COVID-19 surge from April 13 to May 22, 2020, at 6 hospitals in a health care network in greater Boston, Massachusetts. Participants were scored by acute severity of illness using the Sequential Organ Failure Assessment score and chronic severity of illness using comorbidity and life expectancy scores, and only participants with complete scores were included. The score was ordinal, with cutoff points suggested by the Massachusetts guidelines. Race, ethnicity, Social Vulnerability Index. The primary outcome was proportion of patients in the lowest priority score category stratified by self-reported race. Secondary outcomes were discrimination and calibration of the score overall and by race, ethnicity, and neighborhood Social Vulnerability Index. Projected excess deaths were modeled by race, using the priority scoring system and a random lottery. Of 608 patients in the intensive care unit during the study period, 498 had complete data and were included in the analysis; this population had a median (IQR) age of 67 (56-75) years, 191 (38.4%) female participants, 79 (15.9%) Black participants, and 225 patients (45.7%) with COVID-19. The area under the receiver operating characteristic curve for the priority score was 0.79 and was similar across racial groups. Black patients were more likely than others to be in the lowest priority group (12 [15.2%] vs 34 [8.1%]; P = .046). In an exploratory simulation model using the score for ventilator allocation, with only those in the highest priority group receiving ventilators, there were 43.9% excess deaths among Black patients (18 of 41 patients) and 28.6% (58 of 203 patients among all others (P = .05); when the highest and intermediate priority groups received ventilators, there were 4.9% (2 of 41 patients) excess deaths among Black patients and 3.0% (6 of 203) among all others (P = .53). A random lottery resulted in more excess deaths than the score. In this study, a CSOC priority score resulted in lower prioritization of Black patients to receive scarce resources. A model using a random lottery resulted in more estimated excess deaths overall without improving equity by race. CSOC policies must be evaluated for their potential association with racial disparities in health care.

Effectiveness of EUA colour Coding system in Urological Procedures during COVID-19: Experience at Institute of Kidney Diseases Peshawar Pakistan

Objective: To study effectiveness of EUA colour coding system in performing  urological procedures during COVID-19 Methodology: It is descriptive Study during three waves of COVID 19,  conducted  in Department of Urology  at Institute of Kidney Diseases Hayatabad Peshawar, Pakistan from March 24, 2020 till March 30, 2021. Total numbers of 3066 operated patients were included in the study. We followed the EUA guidelines of color coding for prioritization of surgical procedures. All the data of the patients and doctors were recorded on structured proforma and was analyzed on SPSS version 20. Results" Total numbers of 3066 surgeries were performed during three waves of COVID 19, that included 937 (30.5 %)) emergency Procedures with code black , 1272 (59.74%) high Priority labeled as code red, 636 (29.8%) as code yellow in intermediate priority and 221 (10.3%) as code green in. Regarding emergency surgeries code black, Obstructive uropathy remained high with 566 patients (60.4 %) patients, Pyonephrosis in 187(19.9%), Genito-urinary trauma in 93 (9.9%), miscellaneous in 91 (9.7%). The 1272 patients with high priority were dominated by Complicated Urolithiasis and High grade Urooncology. The preoperative nasopharyngeal PCR of 206 patients (22 %) in emergency procedures came positive for COVID-19. The rate of positive  seroconvesrion was recorded in  82(6%) in high and 9 (1.5%)in  intermediate priority and no seroconvesrion was recorded in code green . Conclusion:The EUA guidelines is a useful tool in prioritization of urological procedure.

A watershed moment: Analysis of sub-basins refocuses the geography of turtle conservation across the globe

Conservation planners use a variety of decision-making tools, many of which require identifying and prioritizing spatial units based on their biodiversity and levels of imperilment. Turtles are highly imperiled, but present schemes for determining global priority areas are focused mostly on broad regional scales. We conduct the first global evaluation of turtle biodiversity and imperilment at a sub-basin level to identify geographically smaller areas of high conservation value, and compare with these existing prioritizations. We employed two spatial analyses—bivariate maps and local indicator of spatial association (LISA)—to identify and prioritize sub-basin clusters based on multiple biodiversity and conservation metrics in addition to species richness. Most high-priority sub-basin clusters were located along tropical and subtropical coastlines. A new area of global significance for turtle conservation was identified in southwest India. Many sub-basins of the Indomalayan Realm were clustered as high or intermediate priority, with large clusters of high-priority sub-basins also in tropical Australasia. Other high and intermediate priority sub-basin clusters were found in the Afrotropical, Neotropical, and Nearctic realms, often in previously recognized turtle biodiversity hotspots. Many conservation-priority sub-basins with high turtle-species richness and endemism are in lowland and coastal areas where endemics (some from ancient lineages) are imperiled in association with a high human footprint. Our findings reiterate the global significance of Asia as a key area of chelonian conservation need, while identifying focal areas across the globe where the need for targeted turtle conservation is especially great.

Managing the delivery of quality cancer care during the COVID-19 pandemic in a small community cancer clinic.

45 Background: The global pandemic resulting from COVID-19 has resulted in over 400,000 deaths and nearly 7 million active cases at the time of writing this abstract (World Health Organization, 2020). This Public Health Emergency (PHE) represents an unprecedented challenge for oncologists and cancer patients alike. They are met with the challenge of providing uninterrupted care to cancer patients, a predicament that includes a balance between the use of immunosuppressive chemotherapy, it’s potential impact on contracting COVID-19 and the risk of cancer progression. Liang et al reported that cancer patients were not only at very high risk of contracting COVID -19, but also at a much higher risk of complications and death. Our medium sized oncology practice rapidly adapted to meet the challenge to continue to provide care. Methods: Employee and patient safety: Implement CDC recommendations in waiting room, infusion suites and supply of PPE. Categorize patients into priorities based on severity and need of treatment. Implement telehealth. Implement care in accordance to Cancer Patients Assessment and Treatment Priority Determination (top, intermediate and low priority)–Table. As a part of our initial strategy, we discussed the risk and balance of postponing chemotherapy or elective surgery for stable cancer patients during the first phase of closures. We also focused on more intensive surveillance in the older patient population or those with multiple high-risk comorbidities. For patients in complete remission on maintenance therapy, we balanced risk and benefit of stopping chemotherapy. In other patients, we considered the option of switching their chemotherapy regimen from IV to oral therapies, where clinically appropriate, to decrease the frequency of clinic visits and potential exposure. In cases where the option of non-immunosuppressive oral therapy is existed, we implemented the same. Results: Our clinic continues to provide uninterrupted care since the declaration of PHE. We saw a drop of 25% patient volume in March and 35% in April. However, with instant adaptation and implementation of CDC recommendations patient volume reached back to pre COVID 19 related emergency. None of our employees, their dependents nor any of our patients have contracted COVID-19 to date (according to DHEC feedback) at the time of writing. We had a total of 5082 patients visits (1261 chemo visits). Conclusions: By implementing the right steps and precautions, it is possible to provide continued care for and protect staff, physicians and patients. [Table: see text]

Prioritisation of ICU treatments for critically ill patients in a COVID-19 pandemic with scarce resources

BackgroundRelying on capacity increases and patient transfers to deal with the huge and continuous inflow of COVID-19 critically ill patients is a strategy limited by finite human and logistical resources. RationalePrioritising both critical care initiation and continuation is paramount to save the greatest number of lives. It enables to allocate scarce resources in priority to those with the highest probability of benefiting from them. It is fully ethical provided it relies on objective and widely shared criteria, thus preventing arbitrary decisions and guaranteeing equity. Prioritisation seeks to fairly allocate treatments, maximise saved lives, gain indirect life benefits from prioritising exposed healthcare and similar workers, give priority to those most penalised as a last resort, and apply similar prioritisation schemes to all patients. Prioritisation strategyPrioritisation schemes and their criteria are adjusted to the level of resource scarcity: strain (level A) or saturation (level B). Prioritisation yields a four level priority for initiation or continuation of critical care: P1–high priority, P2–intermediate priority, P3–not needed, P4–not appropriate. Prioritisation schemes take into account the patient's wishes, clinical frailty, pre-existing chronic condition, along with severity and evolution of acute condition. Initial priority level must be reassessed, at least after 48h once missing decision elements are available, at the typical turning point in the disease's natural history (ICU days 7 to 10 for COVID-19), and each time resource scarcity levels change. For treatments to be withheld or withdrawn, a collegial decision-making process and information of patient and/or next of kin are paramount. PerspectivePrioritisation strategy is bound to evolve with new knowledge and with changes within the epidemiological situation.

Impact Analysis of Flow Shaping in Ethernet-AVB/TSN and AFDX from Network Calculus and Simulation Perspective.

Ethernet-AVB/TSN (Audio Video Bridging/Time-Sensitive Networking) and AFDX (Avionics Full DupleX switched Ethernet) are switched Ethernet technologies, which are both candidates for real-time communication in the context of transportation systems. AFDX implements a fixed priority scheduling strategy with two priority levels. Ethernet-AVB/TSN supports a similar fixed priority scheduling with an additional Credit-Based Shaper (CBS) mechanism. Besides, TSN can support time-triggered scheduling strategy. One direct effect of CBS mechanism is to increase the delay of its flows while decreasing the delay of other priority ones. The former effect can be seen as the shaping restriction and the latter effect can be seen as the shaping benefit from CBS. The goal of this paper is to investigate the impact of CBS on different priority flows, especially on the intermediate priority ones, as well as the effect of CBS bandwidth allocation. It is based on a performance comparison of AVB/TSN and AFDX by simulation in an automotive case study. Furthermore, the shaping benefit is modeled based on integral operation from network calculus perspective. Combing with the analysis of shaping restriction and shaping benefit, some configuration suggestions on the setting of CBS bandwidth are given. Results show that the effect of CBS depends on flow loads and CBS configurations. A larger load of high priority flows in AVB tends to a better performance for the intermediate priority flows when compared with AFDX. Shaping benefit can be explained and calculated according to the changing from the permitted maximum burst.

A priority health index identifies the top six priority risk and related factors for non-communicable diseases in Brazilian cities.

BackgroundIn Brazil, 72% of all deaths in 2007 were attributable to non-communicable diseases (NCD). We used a risk and related factor based index to prioritize NCD prevention programs in the combined 26 capital cities and the federal district (i.e., Brasilia) of Brazil.MethodsWe used 2006–2011 data (adults) from census and Brazil's surveillance of 12 NCD risk factors and 74 disease group mortality. The risk and related factors were: smoking, physical inactivity, overweight-obesity, low fruits and vegetables intake, binge drinking, insufficient Pap smear screening (women aged 25 to 59 years), insufficient mammography screening (women aged 50 to 69 years), insufficient blood pressure screening, insufficient blood glucose screening, diagnosis of hypercholesterolemia, diagnosis of hypertension and diagnosis of diabetes. We generated six indicators: intervention reduction of the risk factor prevalence, intervention cost per person, prevalence of risk factor, deaths attributable to risk factor, risk factor prevalence trend and ratio of risk factor prevalence between people with and without a high school education. We transformed risk and related factor indicators into priority scores to compute a priority health index (PHI). We implemented sensitivity analysis of PHI by computing it with slightly altered formulas and altering values of indicators under the assumption of bias in their estimation. We ranked risk factors based on PHI values.ResultsWe found one intermediate (i.e., overweight-obesity) and six top risk and related factors priorities for NCD prevention in Brazil's large urban areas: diagnosed hypertension, physical inactivity, blood pressure screening, diagnosed hypercholesterolemia, smoking and binge drinking.ConclusionBrazil has already prioritized the six top priorities (i.e., hypertension, physical inactivity, blood pressure screening, hypercholesterolemia, smoking and binge drinking) and one intermediate priority (i.e., overweight-obesity) for NCD prevention identified in this report. Because effective interventions to reduce disease burden associated with each of the six priority risk factors are available, strategies based on these interventions need to be sustained in order to reduce NCD burden in Brazil. PHI can be used to track NCD prevention and health promotion actions at the local and national level in Brazil and in countries with similar public health surveillance systems.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-015-1787-1) contains supplementary material, which is available to authorized users.

Climate change and the distribution of neotropical red-bellied toads (Melanophryniscus, Anura, Amphibia): how to prioritize species and populations?

We used species distribution modeling to investigate the potential effects of climate change on 24 species of Neotropical anurans of the genus Melanophryniscus. These toads are small, have limited mobility, and a high percentage are endangered or present restricted geographical distributions. We looked at the changes in the size of suitable climatic regions and in the numbers of known occurrence sites within the distribution limits of all species. We used the MaxEnt algorithm to project current and future suitable climatic areas (a consensus of IPCC scenarios A2a and B2a for 2020 and 2080) for each species. 40% of the species may lose over 50% of their potential distribution area by 2080, whereas 28% of species may lose less than 10%. Four species had over 40% of the currently known occurrence sites outside the predicted 2080 areas. The effect of climate change (decrease in climatic suitable areas) did not differ according to the present distribution area, major habitat type or phylogenetic group of the studied species. We used the estimated decrease in specific suitable climatic range to set a conservation priority rank for Melanophryniscus species. Four species were set to high conservation priority: M. montevidensis, (100% of its original suitable range and all known occurrence points potentially lost by 2080), M. sp.2, M. cambaraensis, and M. tumifrons. Three species (M. spectabilis, M. stelzneri, and M. sp.3) were set between high to intermediate priority (more than 60% decrease in area predicted by 2080); nine species were ranked as intermediate priority, while eight species were ranked as low conservation priority. We suggest that monitoring and conservation actions should be focused primarily on those species and populations that are likely to lose the largest area of suitable climate and the largest number of known populations in the short-term.

A GOAL PROGRAMMING APPROACH TO GROUP DECISION MAKING WITH INCOMPLETE FUZZY AND INTERVAL PREFERENCE RELATIONS

In order to solve group decision making (GDM) problems where the preference relations are provided by decision makers with incomplete fuzzy and interval numbers, this paper develops a GDM approach on the basis of multiple objective optimization and goal programming methods. The proposed approach first analyzes the two types of preference relations and then builds their respective optimization models. Subsequently, an integrated programming model combining the two preference relations is developed to minimize the inconsistency among the decision makers' opinions. By solving the programming model, the ranking of alternatives or selection of the most desirable alternative can be obtained using the intermediate priority vector. Two numerical examples including incomplete fuzzy and interval preference relations are examined to illustrate and show the applicability of the proposed approach.

Motion constraint

In this paper, we propose a hybrid postural control approach taking advantage of data-driven and goal-oriented methods while overcoming their limitations. In particular, we take advantage of the latent space characterizing a given motion database. We introduce a motion constraint operating in the latent space to benefit from its much smaller dimension compared to the joint space. This allows its transparent integration into a Prioritized Inverse Kinematics framework. If its priority is high the constraint may restrict the solution to lie within the motion database space. We are more interested in the alternate case of an intermediate priority level that channels the postural control through a spatiotemporal pattern representative of the motion database while achieving a broader range of goals. We illustrate this concept with a sparse database of large range full-body reach motions.

Laparoscopy influences hiring practices within academic surgical departments

This study aimed to determine whether the increasing emphasis on minimally invasive surgery (MIS) influences hiring practices within academic surgical departments. A questionnaire was mailed to chairs of surgery departments and divisions of general surgery at the 16 Canadian academic institutions. Nonresponders were identified and contacted directly. The survey consisted of 34 questions, including Likert scales, single answers, and multiple-choice questions. Data were collected on demographics, perceptions of MIS, and recruitment/hiring. At the time of the survey, two department chair positions were vacant. A response rate of 87% (26/30) was obtained, with representation from 94% of departments (15/16). Of those surveyed, 88% intend to increase the importance of MIS at their institution within 5 years, and 87% intend to achieve this objective through new hirings. Networking (73%) and retention of recent graduates (89%) were cited most frequently as recruitment strategies. Strengthening the division, research, and education were considered important or extremely important by more than 90% of the respondents with respect to recruitment goals, whereas strengthening MIS was considered important or extremely important by 50%. Within 5 years, surgical departments intend to hire a median of four general surgeons, 50% of whom will have formal MIS training. In comparison, over the past 10 years, only 25% of new recruits had formal MIS training. More than 90% of the respondents considered formal MIS fellowship, MIS fellowship plus a second fellowship, and proctorship to be adequate training for performing advanced MIS, whereas traditional methods were considered inadequate. Lack of operative time and resource issues were considered most limiting in the hiring of new MIS surgeons. Minimally invasive surgery is growing in importance within academic surgical departments, but it remains an intermediate recruitment priority. Formal MIS training appears to be important in the recruiting of new surgeons, whereas traditional training methods are considered inadequate.

Spatial analysis for stratification of priority malaria control areas, Mato Grosso State, Brazil

The goal of this study was to stratify priority areas for malaria control in the State of Mato Grosso, Brazil, based on spatial analysis. The variables used were: Annual Parasite Index (API), Plasmodium falciparum/Plasmodium vivax ratio, population variation, number of families settled, and percent of deforested area. The Moran's I and Local Moran Test were applied, visualized with the Box Map and Moran Map, for 1986- 1991, 1992-1997, and 1998-2003. Box Map identified areas with high, low, and intermediate priority for control, and Moran Map identified municipalities with significant autocorrelation. In the high priority area, located in the North of Mato Grosso, malaria incidence decreased drastically despite the increase in the number of municipalities from the first to the last period. Other municipalities were added to the lower priority area, from the Southeast, Southwest, and Central-South of the State. The intermediate priority area was located along the border with neighboring States and municipalities classified as high and low priority. Spatial analysis showed the importance of the neighboring phenomenon between municipalities in defining priority areas, thus highlighting the technique's advantages for use in malaria control and surveillance.

Essential Features of a Surveillance System to Support the Prevention and Management of Heart Disease and Stroke

A strategic goal of the American Heart Association (AHA) is to reduce heart disease, stroke, and risk for both by 25%,1 and Healthy People 2010 (HP2010) established 4 national goals for heart disease and stroke prevention and management.2 However, the current health tracking systems (surveillance) in the United States cannot track progress toward these goals in a comprehensive and systematic manner. This article provides a brief overview of these goals, prevention and management strategies, and the role of surveillance in monitoring the impact of prevention and treatment efforts. It also provides a review of the existing surveillance system for monitoring progress toward preventing heart disease and stroke in the United States and recommendations for filling important gaps in that system. This information will serve as an important basis for advocacy to guide the development of a comprehensive surveillance system to support the current HP2010 and AHA goals and the likely future goal of eliminating the epidemic burden of heart disease and stroke. Recommendations are categorized as overarching (fundamental recommendations that cut across goal areas) or as goal-specific. They are further classified according to priority (P) (I for high priority and II for intermediate priority. No low-priority recommendations were made), staging (S) (I for early staging [1–2 years], II for intermediate staging [2–4 years], and III for later staging), and cost (C) ($ for items estimated to cost less than $10 million per year, $$ for estimates of $10 to $100 million, and $$$ for estimates exceeding $100 million). In addition, potential barriers to action are addressed. 1. A National Heart Disease and Stroke Surveillance unit should be established to produce annual reports on key indicators of progress in the prevention and management of heart disease and stroke. P I, S I, C $. 2. Cardiovascular disease (CVD), including cardiac arrests, …

Tradeoff and Sensitivity Analysis in Software Architecture Evaluation Using Analytic Hierarchy Process

Software architecture evaluation involves evaluating different architecture design alternatives against multiple quality-attributes. These attributes typically have intrinsic conflicts and must be considered simultaneously in order to reach a final design decision. AHP (Analytic Hierarchy Process), an important decision making technique, has been leveraged to resolve such conflicts. AHP can help provide an overall ranking of design alternatives. However it lacks the capability to explicitly identify the exact tradeoffs being made and the relative size of these tradeoffs. Moreover, the ranking produced can be sensitive such that the smallest change in intermediate priority weights can alter the final order of design alternatives. In this paper, we propose several in-depth analysis techniques applicable to AHP to identify critical tradeoffs and sensitive points in the decision process. We apply our method to an example of a real-world distributed architecture presented in the literature. The results are promising in that they make important decision consequences explicit in terms of key design tradeoffs and the architecture's capability to handle future quality attribute changes. These expose critical decisions which are otherwise too subtle to be detected in standard AHP results.