System-level Measures Research Articles

Label-free GaN HEMT-based biosensing platform for interferon-γ detection

Intracranial injury such as traumatic brain injury is caused by sudden injury to the brain from external mechanical force causing health loss and disability worldwide. The work reports the design and development of a GaN HEMT-based biosensor and system for the detection of IFN-γ for non-invasive detection of TBI. The developed platform can detect and differentiate IFN-γ with a peak sensitivity of 109.08 μA/pg/ml, high specificity, and good reproducibility. The platform offers good linearity with an LOD and LOQ of 6.82 fg/ml and 20.68 fg/ml respectively. The antibody-antigen binding has been confirmed with electrical and FTIR measurement techniques. A comparative analysis of system-level detection with on-chip measurement for validating the proposed readout interface shows a good match and thus confirms the system's suitability for the detection of IFN-γ in clinically relevant concentration ranges. The system level and on-chip measurement show a similar sensitivity of 21.59 μA/pg/ml and 19.05 μA/pg/ml respectively. The proposed platform offers a highly stable biofunctionalization protocol with high specificity and selectivity. Thus, the platform has a good potential for point-of-care system development suitable for on-field and clinical applications.

Early Identification of Patients at Risk of Cabazitaxel-induced Severe Neutropenia

BackgroundCabazitaxel frequently causes severe neutropenia. A higher cabazitaxel systemic exposure is related to a lower nadir absolute neutrophil count (ANC). ObjectiveTo describe the effect of cabazitaxel systemic exposure on ANC by a population pharmacokinetic/pharmacodynamic (POP-PK/PD) model, and to identify patients at risk of severe neutropenia early in their treatment course using a PK threshold. Design, setting, and participantsData from five clinical studies were pooled to develop a POP-PK/PD model using NONMEM, linking both patient characteristics and cabazitaxel systemic exposure directly to ANC. Outcome measurements and statistical analysisA PK threshold, predictive of severe neutropenia (grade ≥3), was determined using a receiver operating characteristic curve. Results and limitationsNinety-six patients were included with a total of 1726 PK samples and 1081 ANCs. The POP-PK/PD model described both cabazitaxel PK and ANC accurately. A cabazitaxel plasma concentration of >4.96 ng/ml at 6 h after the start of infusion was found to be predictive of severe neutropenia, with a sensitivity of 76% and a specificity of 65%. ConclusionsEarly cabazitaxel plasma levels are predictive of severe neutropenia. Implementation of the proposed PK threshold results in early identification of almost 76% of all severe neutropenias. If prospectively validated, patients at risk could benefit from prophylactic administration of granulocyte colony stimulating factors, preventing severe neutropenia in an early phase of treatment. Implementation of this threshold permits a less restricted use of the 25 mg/m2 dose, potentially increasing the therapeutic benefit. Patient summaryTreatment with cabazitaxel chemotherapy often causes neutropenia, leading to susceptibility to infections, which might be life threatening. We found that a systemic cabazitaxel concentration above 4.96 ng/ml 6 h after the start of infusion is predictive of the occurrence of severe neutropenia. Measurement of systemic cabazitaxel levels provides clinicians with the opportunity to prophylactically stimulate neutrophil growth.

Awakening and Breathing Coordination: A Mixed-Methods Analysis of Determinants of Implementation.

Rationale: Routine spontaneous awakening and breathing trial coordination (SAT/SBT) improves outcomes for mechanically ventilated patients, but adherence varies. Understanding barriers to and facilitators of consistent daily use of SAT/SBT (implementation determinants) can guide the development of implementation strategies to increase adherence to these evidence-based interventions. Objectives: We conducted an explanatory, sequential mixed-methods study to measure variation in the routine daily use of SAT/SBT and to identify implementation determinants that might explain variation in SAT/SBT use across 15 intensive care units (ICUs) in urban and rural locations within an integrated, community-based health system. Methods: We described the patient population and measured adherence to daily use of coordinated SAT/SBT from January to June 2021, selecting four sites with varied adherence levels for semistructured field interviews. We conducted key informant interviews with critical care nurses, respiratory therapists, and physicians/advanced practice clinicians (n = 55) from these four sites between October and December 2021 and performed content analysis to identify implementation determinants of SAT/SBT use. Results: The 15 sites had 1,901 ICU admissions receiving invasive mechanical ventilation (IMV) for ⩾24 hours during the measurement period. The mean IMV patient age was 58 years, and the median IMV duration was 5.3 days (interquartile range, 2.5-11.9). Coordinated SAT/SBT adherence (within 2 h) was estimated at 21% systemwide (site range, 9-68%). ICU clinicians were generally familiar with SAT/SBT but varied in their knowledge and beliefs about what constituted an evidence-based SAT/SBT. Clinicians reported that SAT/SBT coordination was difficult in the context of existing ICU workflows, and existing protocols did not explicitly define how coordination should be performed. The lack of an agreed-upon system-level measure for tracking daily use of SAT/SBT led to uncertainty regarding what constituted adherence. The effects of the COVID-19 pandemic increased clinician workloads, impacting performance. Conclusions: Coordinated SAT/SBT adherence varied substantially across 15 ICUs within an integrated, community-based health system. Implementation strategies that address barriers identified by this study, including knowledge deficits, challenges regarding workflow coordination, and the lack of performance measurement, should be tested in future hybrid implementation-effectiveness trials to increase adherence to daily use of coordinated SAT/SBT and minimize harm related to the prolonged use of mechanical ventilation and sedation.

Cortical microstructural gradients capture memory network reorganization in temporal lobe epilepsy.

Temporal lobe epilepsy (TLE), one of the most common pharmaco-resistant epilepsies, is associated with pathology of paralimbic brain regions, particularly in the mesiotemporal lobe. Cognitive dysfunction in TLE is frequent, and particularly affects episodic memory. Crucially, these difficulties challenge the quality of life of patients, sometimes more than seizures, underscoring the need to assess neural processes of cognitive dysfunction in TLE to improve patient management. Our work harnessed a novel conceptual and analytical approach to assess spatial gradients of microstructural differentiation between cortical areas based on high-resolution MRI analysis. Gradients track region-to-region variations in intracortical lamination and myeloarchitecture, serving as a system-level measure of structural and functional reorganization. Comparing cortex-wide microstructural gradients between 21 patients and 35 healthy controls, we observed a reorganization of this gradient in TLE driven by reduced microstructural differentiation between paralimbic cortices and the remaining cortex with marked abnormalities in ipsilateral temporopolar and dorsolateral prefrontal regions. Findings were replicated in an independent cohort. Using an independent post-mortem dataset, we observed that in vivo findings reflected topographical variations in cortical cytoarchitecture. We indeed found that macroscale changes in microstructural differentiation in TLE reflected increased similarity of paralimbic and primary sensory/motor regions. Disease-related transcriptomics could furthermore show specificity of our findings to TLE over other common epilepsy syndromes. Finally, microstructural dedifferentiation was associated with cognitive network reorganization seen during an episodic memory functional MRI paradigm and correlated with interindividual differences in task accuracy. Collectively, our findings showing a pattern of reduced microarchitectural differentiation between paralimbic regions and the remaining cortex provide a structurally-grounded explanation for large-scale functional network reorganization and cognitive dysfunction characteristic of TLE.

Development of a Common Data Model for a Multisite and Multiyear Study of Virtual Visit Implementation: A Case Study.

In multisite studies, a common data model (CDM) standardizes dataset organization, variable definitions, and variable code structures and can support distributed data processing. We describe the development of a CDM for a study of virtual visit implementation in 3 Kaiser Permanente (KP) regions. We conducted several scoping reviews to inform our study's CDM design: (1) virtual visit mode, implementation timing, and scope (targeted clinical conditions and departments); and (2) extant sources of electronic health record data to specify study measures. Our study covered the period from 2017 through June 2021. Integrity of the CDM was assessed by a chart review of random samples of virtual and in-person visits, overall and by specific conditions of interest (neck or back pain, urinary tract infection, major depression). The scoping reviews identified a need to address differences in virtual visit programs across the 3 KP regionsto harmonize measurement specifications for our research analyses. The final CDM contained patient-level, provider-level, and system-level measures on 7,476,604 person-years for KP members aged 19 years and above. Utilization included 2,966,112 virtual visits (synchronous chats, telephone visits, video visits) and 10,004,195 in-person visits. Chart review indicated the CDM correctly identified visit mode on>96% (n=444) of visits, and presenting diagnosis on >91% (n=482) of visits. Upfront design and implementation of CDMs may be resource intensive. Once implemented, CDMs, like the one we developed for our study, provide downstream programming and analytic efficiencies by harmonizing, in a consistent framework, otherwise idiosyncratic temporal and study site differences in source data.

Wildfire Burn Severity Affects Postfire Shifts in Evapotranspiration in Subalpine Forests

Highlights After wildfire, actual evapotranspiration (ETa) in four subalpine areas decreased proportionally to burn severity. High-severity burn areas maintained the highest ETa before fire and the lowest ETa after fire. After fire, ETa decreased more in areas that had higher prefire ETa. ETa was a useful system-level measure of susceptibility to fire and impact after fire. Abstract. The ecohydrologic response to fire is complex, with devastating consequences for source-water hydrology. Postfire canopy structure, leaf area, infiltration, and soil-water storage all may act to reduce evapotranspiration (ET), a key hydrologic variable and indicator of ecohydrologic function. This study explored the use of 30-m resolution Landsat-based SSEBop-model estimates of actual ET (ETa) to assess the effects of fire in the Upper Rio Grande Basin (2002 Million Fire, CO; 1996 Hondo Fire, NM; 2002 Montoya Fire, NM; 2000 Cerro Grande Fire, NM). SSEBop ETa data from 1985-2019 were analyzed to better understand postfire response and recovery in several sub-alpine burned areas. Results show step reductions in ETa after fire across all burn severities in all four fire areas. Prior to the fire, ETa was generally higher in high-severity burn areas, indicative of higher fuel loads, although high variability indicated the influence of additional factors. All areas had a greater response (decreased ETa) to fire in high-severity areas and a lesser response as burn severity decreased. The decrease in ETa after high-severity fire ranged from 42% to 63%, compared to the decrease after low-severity fire, which ranged from 24% to 44%. None of the four burn areas demonstrated postfire ETa recovery after 17 to 23 years. This study demonstrates the clear utility for remote-sensing ETa estimates as a system-level measure of susceptibility to fire, impact of fire, and, potentially, recovery after fire. However, additional research is needed to account for the covariate effects of other fuel, topographic, weather, and climate factors. Keywords: Ecohydrology, Postfire recovery, Remote sensing, Upper Rio Grande Basin.

Microgravity two-phase flow research in the context of vapor compression cycle experiments on parabolic flights

Research on two-phase channel flow in microgravity has extensively investigated flow regimes, pressure drop, and heat transfer during evaporation and condensation processes over several decades. This literature has been primarily motivated by the goal of enabling future space applications for two-phase thermal management systems, among them vapor compression refrigeration cycles. However, relative to the number of two-phase channel flow experiments, research on vapor compression cycles in microgravity has been almost non-existent. This paper reviews two-phase flow research and compares key outcomes with those from system-level measurements obtained from recent testing of a vapor compression cycle at varying inclination angles and on parabolic flights. Previous two-phase channel flow experiments have resulted in several microgravity-specific flow regime maps and have also generally found reduced condensation heat transfer coefficients in microgravity as compared to normal gravity. The flow pattern map of Jayawardena et al. (1997) and generally reduced condensation heat transfer are confirmed by the vapor compression cycle experiments. Regarding evaporation heat transfer coefficients and friction factors, there is not a consensus in the literature on the effects of microgravity in two-phase channel flows. Similarly, the system-level experiments do not show repeatable increases or decreases for those parameters. Lastly, the dependence of system-level behavior on orientation with respect to gravity was tested by performing dynamic inclination experiments, where the inclination angle was changed every 2 min by a 90-degree increment. These tests reveal an increased relative dependence of the vapor compression cycle to orientation with decreasing mass fluxes, in line with two-phase channel flow research that has generally shown that increasing the flow inertia acts to mitigate various flow instabilities and dependence on orientation. However, inclination testing with longer locking times per angle showed a constant relative dependence of the vapor compression cycle to orientation changes.

A 5.8 GHz π-Stub Decoupling Network for Receiving Antenna Arrays in Microwave Wireless Power Transmission

In this paper, a 5.8 GHz π-stub decoupling network is proposed to improve the performance of a receiving antenna array (RAA) in microwave wireless power transmission (MWPT) systems. A set of general design formulas was derived for determining the electric parameters of the required π-stubs. To validate the new technique, a π-stub decoupling network was combined with RAAs. The simulated and measured results show that the performance of the RAA is greatly improved by loading the π-stub decoupling network. In addition, a miniaturized MWPT system was built. System-level measurements indicate that the novel decoupling network enhances the receiving power of the RAA by up to 36.4%. An extended application also shows the scalability and effectiveness of the network, implying its huge potential in large-scale receiving arrays.

Prioritizing measures to assess performance of drug treatment services: a Delphi process with funders, treatment providers and service-users.

While many studies have examined outcome measurement as part of clinical trials and routine outcome collection at the person-level in alcohol and other drug (AOD) treatment services, there has been limited attention to measures required to assess performance at the service-level. In Australia, non-government services are primarily funded by government using public funds; however, there is no standardized approach to performance measurement. This study sought to establish a finite list of performance measures that represented consensus between funders, treatment providers and service-users. A three-round Delphi process was undertaken with (i) funders of treatment (n = 10), (ii) treatment providers (n = 10) and (iii) treatment service-users (n = 10). Participants were asked to rate a range of measures on a 10-point Likert scale on how important they were to be included in contracts with funders. Measures with a median score > 7 and agreement among participants above 70% were the criteria for inclusion in the final set of measures. Qualitative data in the form of text responses provided by participants for their ratings in rounds 1 and 2 were also analysed. Participants rated 93 measures in round 1, which reduced to 78 measures in round 2 and 32 measures in round 3. Fifteen service-level measures and two system-level measures met criteria for inclusion in the final set of performance measures. The final set of measures cover a range of measurement types: outcomes (n = 5), access (n = 3), structural (n = 3), experience (n = 2), input (n = 2), process (n = 1) and output (n = 1). In Australia, performance measures for alcohol and other drug treatment services that represent a consensus among service-users, providers and funders focus upon demonstrating accountability for public funds, improving services and communicating key measures of success to future service-users and the broader community.

Design and Implementation of a Quasi Nondiffraction Beam for Microwave Power Transmission Application

In this letter, a quasi nondiffraction beam is designed and implemented for microwave power transmission (MPT) application. To generate a quasi nondiffraction beam, a new formula is derived to calculate the phase distribution on the metasurface (MS), and a phase shifting unit with 360° transmission phase coverage and transmission amplitude better than −3 dB is designed to achieve desired phase. The simulated and measured results demonstrate that a quasi nondiffraction beam can be generated by the proposed MS. In order to prove that the quasi-nondiffraction beam can be used for microwave power transfer, a miniaturized MPT system is built and measured. The system-level measurement results indicate that the proposed transmitting antenna helps the receiving terminal to harvest more power and improves the power transmission efficiency of the system.

Are serum progesterone measurements truly representative for the identification of an adequate luteal phase in hormonal replacement therapy frozen embryo transfers?

Progesterone (P4) is crucial for the achievement and maintenance of a pregnancy and with rising numbers of frozen embryo transfers (FETs) performed worldwide, the search for the 'optimal' P4 levels in HRT FET cycles became a focus of research. Certainly, measurement of systemic P4 levels is an easy applicable tool and P4 levels, considered as being too low, could be addressed by changing and/or increasing exogenously administered P4. However, the question must be raised whether the sole measurement of systemic P4 levels is reflective for the endometrial status and the endometrial receptivity in HRT FET cycles, since systemic P4 levels do not reflect the dynamic of the endometrial changes, deemed necessary to prepare the endometrium for implantation. Moreover, different types of P4 administration routes will exhibit distinct different patterns of P4 release, affecting the process of secretory transformation and last but not least, embryonic factors are almost fully neglected in this concept. This opinion article aims to raise critical points towards the 'sole' focus on systemic P4 levels in HRT FET cycles and raises the question whether 'serum P4 measurements are truly representative for the identification of an adequate luteal phase in HRT FETs'?.

Cultivating health policy capacity through network governance in New Zealand: learning from divergent stories of policy implementation

Abstract Wu, Howlett, and Ramesh’s understanding of policy capacity has been used to identify generalizable strengths and weaknesses of specific jurisdictions and policy sectors such as health. In an extension of this work, Howlett and Ramesh have argued that the mode of governance of a policy sector accentuates the importance of specific elements of policy capacity. In this paper we focus on the implementation of the System Level Measures Framework (SLMF) in New Zealand that has been specifically focused on health systems improvement and which aimed to do so by fostering network governance at the local level. However, this policy is introduced in a context in which there has been significant contestation regarding which mode of governance—network or hierarchy—is dominant in New Zealand health policy. By exploring three divergent local cases of implementation of the SLMF we develop three arguments that contribute to the literature on policy capacity and health. Firstly, local histories of interorganizational play a crucial role in shaping health policy capacity. Secondly, it is crucially important to understand the dynamics and feedback loops between operational, political, and analytical policy capacity. Network and hierarchical governance are characterized by distinct and contrasting understandings of the content of policy capacity elements and of the way in which they are dynamically related. Thirdly, the key challenge in developing policy capacity compatible with network governance is how to facilitate this capacity when connections between operational, political, and analytical policy capacity fail to fire.

Low-Value Care at the Actionable Level of Individual Health Systems

Low-value health care remains prevalent in the US despite decades of work to measure and reduce such care. Efforts have been only modestly effective in part because the measurement of low-value care has largely been restricted to the national or regional level, limiting actionability. To measure and report low-value care use across and within individual health systems and identify system characteristics associated with higher use using Medicare administrative data. This retrospective cohort study of health system-attributed Medicare beneficiaries was conducted among 556 health systems in the Agency for Healthcare Research and Quality Compendium of US Health Systems and included system-attributed beneficiaries who were older than 65 years, continuously enrolled in Medicare Parts A and B for at least 12 months in 2016 or 2017, and eligible for specific low-value services. Statistical analysis was conducted from January 26 to July 15, 2021. Use of 41 individual low-value services and a composite measure of the 28 most common services among system-attributed beneficiaries, standardized to distance from the mean value. Measures were based on the Milliman MedInsight Health Waste Calculator and published claims-based definitions. Across 556 health systems serving a total of 11 637 763 beneficiaries, the mean (SD) use of each of the 41 low-value services ranged from 0% (0.01%) to 28% (4%) of eligible beneficiaries. The most common low-value services were preoperative laboratory testing (mean [SD] rate, 28% [4%] of eligible beneficiaries), prostate-specific antigen testing in men older than 70 years (mean [SD] rate, 27% [8%]), and use of antipsychotic medications in patients with dementia (mean [SD] rate, 24% [8%]). In multivariable analysis, the health system characteristics associated with higher use of low-value care were smaller proportion of primary care physicians (adjusted composite score, 0.15 [95% CI, 0.04-0.26] for systems with less than the median percentage of primary care physicians vs -0.16 [95% CI, -0.27 to -0.05] for those with more than the median percentage of primary care physicians; P < .001), no major teaching hospital (adjusted composite, 0.10 [95% CI, -0.01 to 0.20] without a teaching hospital vs -0.18 [95% CI, -0.34 to -0.02] with a teaching hospital; P = .01), larger proportion of non-White patients (adjusted composite, 0.15 [95% CI, -0.02 to 0.32] for systems with >20% of non-White beneficiaries vs -0.06 [95% CI, -0.16 to 0.03] for systems with ≤20% of non-White beneficiaries; P = .04), headquartered in the South or West (adjusted composite, 0.28 [95% CI, 0.14-0.43] for the South and 0.22 [95% CI, 0.02-0.42] for the West compared with -0.09 [95% CI, -0.26 to 0.08] for the Northeast and -0.44 [95% CI, -0.60 to -0.28] for the Midwest; P < .001), and serving areas with more health care spending (adjusted composite, 0.23 [95% CI, 0.11-0.35] for areas above the median level of spending vs -0.24 [95% CI, -0.36 to -0.12] for areas below the median level of spending; P < .001). The findings of this large cohort study suggest that system-level measurement and reporting of specific low-value services is feasible, enables cross-system comparisons, and reveals a broad range of low-value care use.

Overwriting New Public Management with New Public Governance in New Zealand's approach to health system improvement

PurposeIn 2016, New Zealand's Ministry of Health introduced the System Level Measures Framework which marked a departure from health targets and pay-for-performance incentives towards an approach based on local, collaborative approaches to health system improvement. This exemplifies an attempt to “overwrite” New Public Management (NPM) institutional practices with New Public Governance (NPG). We aim to trace this process of overwriting so as to understand how attempts to change institutional practices were facilitated, blocked, translated and edited.Design/methodology/approachWe develop a conceptual framework for understanding and tracing institutional change towards NPG which emphasises the importance of discursive strategies in policy attempts to overwrite NPM with NPG. To analyse the New Zealand case, we drew on policy documents and interviews conducted in 2017–18 with twelve national key informants and fifty interviewees closely involved in local development and/or implementation of the SLMF.FindingsPolicy sponsors of collaborative approaches to health system improvement first attempted formal institutional change, arguing that adopting collaborative, quality improvement (NPG) approaches would supplement existing performance management (NPM) practices, to create a superior synthesis. When this formal approach was blocked, they adopted an approach based on informal persuasion of local organisational actors that quality improvement should supplant performance improvement. This approach was edited and translated by local actors, and the success of local implementation varied considerably.Research limitations/implicationsThis article offers a novel conceptualisation of public management institutional change, which can help explain why it is difficult to completely erase NPM practices in health.Originality/valueThis paper explores the rhetorical practices that are used in the introduction of a New Public Governance policy framework.

Navigability assessment of large-scale redesigns in nine public transport networks: Open timetable data approach

Redesigns of public transport networks are complex undertakings requiring a careful balancing of several conflicting perspectives (e.g., user requirements vs system performance) and aims (e.g., increasing spatial coverage, increasing frequency). Current assessment tools omit an explicit focus on navigability, often identified as a key aspect of the user perspective. For understanding the multidimensional perspective of navigability, this research introduces an assessment framework with both system and journey-level measures. The system-level measures provide an overview of redesigns based on static network representations. The journey-level measures are based on journey trajectories generated with a customized routing algorithm, assessing the distributive effects of the redesign. The framework is applied to public transport networks from nine cities with recently implemented redesigns, namely Amsterdam, Auckland, Austin, Baltimore, Columbus, Helsinki, Houston, Indianapolis, and Wellington. Results indicate that the redesigns have improved navigability both from a system-level and user perspective in general. However, in some cases, improvements in navigability come at the cost of increased travel time and number of transfers. Furthermore, the results suggest that the redesigns have differing emphasis within the regions, for different times of day, and for different aspects of network structure. The results are discussed both from the perspective of the case findings and for drawing more general planning and policy recommendations. Finally, this research provides a basis for further transdisciplinary approaches, encouraging connections between transport modeling and complex networks approaches.

An Experience of Public Dental Care during the COVID-19 Pandemic: Reflection and Analysis.

Since its emergence in China, the COVID-19 pandemic has become the number 1 health challenge in the world with all affected countries trying to learn from each other’s experiences. When it comes to health services, dental care does not seem to be a priority area, despite the fact that it is among the highest risk medical specialisations in terms of spreading the infection. Using the Department of Community Dentistry of Semmelweis University as a case study, the objective of this paper is to introduce and analyze the system and organizational level measures, which have been implemented in dental care in Hungary during the first months of the COVID-19 outbreak. The system level measures to promote social distancing, to reduce the use of health services and to protect high risk health professionals, together with the deployment of protective equipment and the reorganization of patient pathways at the organizational level proved to be effective in keeping the outbreak in control. There are two, less frequently mentioned ingredients of successful coping with the COVID-19 challenge. First, mental health support is at least as important as physical protection. Second, most of the interventions do not require big financial investments, but behavioural change, which in turn requires leadership and change management skills.

Exposure to domoic acid is an ecological driver of cardiac disease in southern sea otters✰

Harmful algal blooms produce toxins that bioaccumulate in the food web and adversely affect humans, animals, and entire marine ecosystems. Blooms of the diatom Pseudo-nitzschia can produce domoic acid (DA), a toxin that most commonly causes neurological disease in endothermic animals, with cardiovascular effects that were first recognized in southern sea otters. Over the last 20 years, DA toxicosis has caused significant morbidity and mortality in marine mammals and seabirds along the west coast of the USA. Identifying DA exposure has been limited to toxin detection in biological fluids using biochemical assays, yet measurement of systemic toxin levels is an unreliable indicator of exposure dose or timing. Furthermore, there is little information regarding repeated DA exposure in marine wildlife. Here, the association between long-term environmental DA exposure and fatal cardiac disease was investigated in a longitudinal study of 186 free-ranging sea otters in California from 2001 – 2017, highlighting the chronic health effects of a marine toxin. A novel Bayesian spatiotemporal approach was used to characterize environmental DA exposure by combining several DA surveillance datasets and integrating this with life history data from radio-tagged otters in a time-dependent survival model. In this study, a sea otter with high DA exposure had a 1.7-fold increased hazard of fatal cardiomyopathy compared to an otter with low exposure. Otters that consumed a high proportion of crab and clam had a 2.5- and 1.2-times greater hazard of death due to cardiomyopathy than otters that consumed low proportions. Increasing age is a well-established predictor of cardiac disease, but this study is the first to identify that DA exposure affects the risk of cardiomyopathy more substantially in prime-age adults than aged adults. A 4-year-old otter with high DA exposure had 2.3 times greater risk of fatal cardiomyopathy than an otter with low exposure, while a 10-year old otter with high DA exposure had just 1.2 times greater risk. High Toxoplasma gondii titers also increased the hazard of death due to heart disease 2.4-fold. Domoic acid exposure was most detrimental for prime-age adults, whose survival and reproduction are vital for population growth, suggesting that persistent DA exposure will likely impact long-term viability of this threatened species. These results offer insight into the pervasiveness of DA in the food web and raise awareness of under-recognized chronic health effects of DA for wildlife at a time when toxic blooms are on the rise.

Full-Duplexing With SDR Devices: Algorithms, FPGA Implementation, and Real-Time Results

In this paper, we present a novel nonlinear digital self-interference canceller algorithm, its implementation details on a software-defined radio (SDR) platform, and performance results of real-time full-duplex experiments on both device and link level. The canceller algorithm is based on an augmented Hammerstein model, with a nonlinear part modeling the transmitter non-idealities followed by a linear filter to model the self-interference (SI) channel. The nonlinear part includes a spline-based model for the nonlinear power amplifier, a polynomial model for baseband nonlinearities, as well as models for I/Q mismatch and LO leakage. The canceller is implemented on an FPGA as a part of an OFDM transceiver testbed for real-time measurements. Extensive real-time measurements show excellent performance: (1) the digital canceller, together with an RF isolator, can suppress the SI to within 1-2 dB's of the receiver noise floor, with total SI suppression of up to 103 dB; (2) digital cancellation of up to 46 dB is evidenced, which is among the highest real-time cancellations in literature; (3) system-level measurements with OFDM signals demonstrate the benefit of utilizing the proposed canceller in a two-way communication scenario, showing up to 90 % increase in sum-rate compared to half-duplex communication.

Race/ethnicity and running away from foster care

• The paper explores the issue of running away from foster care. • The study also examines Black/White and Hispanic/White disparities in running away. • Black and Hispanic youth are more likely to runaway than White youth are, but county context matters. • The supply of congregate care influences the level of disparity. Running away from foster care is fairly common, but there is no body of research that explores explicitly the question of whether Black and Hispanic youth run away from foster care at rates that are different from those for White youth. Using data from 17 states, I measured the probability of running away from foster care for Black, Hispanic, and White youth. This approach yields an unambiguous measure of disparity based on the odds ratio, a standard measure for summarizing group differences. In addition to individual differences in rates of running away (e.g., age, gender, race/ethnicity), I was also interested in knowing whether context matters. Context was measured at the county-level using urbanicity, social disadvantage, and a system-level measure of congregate care utilization. I also included whether the state where the county was located had policies that require an assessment of running-away risk. Older youth, girls, and youth with a history of placement in congregate care all have higher rates of running away. Further, Black and Hispanic youth are more likely to run away than White youth, but the magnitude of those differences depends on context. In particular, as measured, disparity in counties where I detected a tendency to use congregate care as a county-level attribute, disparity was greater. Among the implications, better reporting of running away by the federal government is highlighted. Regarding contextual effects and the dynamics of congregate utilization, the results point toward system effects as an important avenue for future research.

Development of a Patient-centered Quality Measurement Framework for Measuring, Monitoring, and Optimizing Rheumatoid Arthritis Care in Canada.

The aim of this study was to develop a patient-centered quality measurement framework to address a predefined vision statement and 7 strategic objectives for rheumatoid arthritis (RA) care that was developed in prior qualitative work with arthritis stakeholders. One hundred forty-seven RA-related performance measures (PMs) were identified from a systematic review. A candidate list of 26 PMs meeting predefined criteria and addressing the strategic objectives previously defined was then assessed during a 3-round (R) modified Delphi. Seventeen panelists with expertise in RA, quality measurement, and/or lived experience with RA rated each PM on a 1-9 scale based on the items of importance, feasibility, and priority for inclusion in the framework during R1 and R3, with a moderated discussion in R2. PMs with median scores ≥ 7 on all 3 items without disagreement were included in the final set, which then underwent public comment. Twenty-one measures were included in the final framework (15 PMs from the Delphi and 6 published system-level measures on access to care and treatment). The measures included 4 addressing early access to care and timely diagnosis, 12 evidence-based care for RA and related comorbidities, 1 addressing patient participation as an informed partner in care, and 4 on patient outcomes. The proposed framework builds upon existing measures capturing early access to care and treatment in RA and adds important PMs to promote high-quality RA care and outcome measurement. In the next phase, the authors will test the framework in clinical practice in addition to addressing certain areas where no suitable PMs were identified.