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Background: Speech discrimination assessments are used to validate amplification fittings of older children who are hard of hearing (CHH). Unfortunately, speech discrimination is not assessed clinically ≤24 months and in turn no studies have investigated the relationship between speech discrimination during infancy and later language development among CHH. Objective: To examine the relationship between an individual infant’s speech discrimination measured at 9 months and their expressive/receptive spoken language at 30 months for children with normal hearing (CNH) and CHH. Methods: Behavioral speech discrimination was assessed at 9 months and language assessments were conducted at 16, 24, and 30 months using a parent questionnaire, and at 30 months using the Mullen Scales of Early Learning among 90 infants (49 CNH; 41 CHH). Results: Conditioned Head Turn (CHT) performance for /a-i/ significantly predicted expressive and receptive language at 30 months across both groups. Parental questionnaires were also predictive of later language ability. No significant differences in speech discrimination or language outcomes between CNH and CHH were found. Conclusions: This is the first study to document a positive relationship between infant speech discrimination and later language abilities in both early-identified CHH and CNH.

Early periods of perceptual skill development are driven by the dynamic interplay between language experiences and maturation of auditory sensory pathways. Among infants with normal hearing (INH), the first year of life is a seminal period for refining speech perception abilities shaped by exposure to language. Research suggests that refinement of speech discrimination abilities depends on an infant’s exposure to speech sounds, thus infants who are hard-of-hearing (IHH) are susceptible to atypical development during this period. Currently, the impact of inconsistent auditory cue access on development of speech perception is unknown among IHH. To investigate this, our lab has employed both electroencephalography (EEG) and a conditioned head turn (CHT) paradigm to examine auditory cue access and speech perception abilities, respectively, over the first year of life. We will provide a broad overview of our recent and continuing work among IHH and INH using EEG and CHT findings which suggest: (1) early EEG measures of cue access predict later behavioral speech perception abilities, (2) hearing age (duration of time between hearing aid fitting and testing) is related to speech perception abilities measured by CHT, and (3) a significant relationship between infant speech perception and both spoken expressive and receptive language abilities.

Patient activation, the propensity for patients to engage in adaptive health behaviors, is a modifiable factor associated with health outcomes and treatment compliance. The authors evaluated the effect of a question-building intervention (QBI) on patient activation among patients with musculoskeletal symptoms and a low baseline level of activation. Patients seeking treatment for musculoskeletal pain were recruited at the beginning of their outpatient clinic appointment, and they completed the Patient Activation Measure 10-item version (PAM-10) and a demographic questionnaire. Those identified as low activating, based on the initial PAM-10 scores, completed a QBI protocol before their consultation with their provider. A follow-up PAM-10 survey was administered at the end of the visit. A paired sample Student's t test was used to evaluate preintervention and postintervention PAM-10 scores. Fisher's exact test and an unpaired t test were used to assess the association between demographic variables and achievement of minimal clinically important difference (MCID) for PAM-10. Of 194 patients who consented to participate, 60 were identified as low activating and completed the QBI. A paired Student's t test showed a statistically significant increase in mean PAM-10 scores from preintervention (47.3±7.4) to postintervention (54.8±16.8; P Orthopedics . 2021;44(5):e661–e667.]

Newborn hearing screening has led to improved detection and treatment of hearing loss (HL) in infants and young children, supporting improved communication outcomes in early childhood and beyond. However, current screening protocols are not equally sensitive to all forms of HL, limiting diagnostic accuracy and, ultimately, identification of appropriate treatment options. Correspondingly, treatment outcomes in children with HL remain quite variable. One fundamental and persistent challenge is the assessment of bone conduction hearing, which is essential to differentiate conductive versus sensorineural pathology. Whereas hearing via air conduction can be effectively assessed using the auditory brainstem response (ABR), a noninvasive electrophysiologic measure, bone conduction ABR measurements suffer from comparatively poor signal quality (including significant stimulus artifact), transducer acoustic output limitations, and generally lower test-retest reliability. Here we evaluated the prospective benefits of measuring infant bone conduction ABRs using a modified bone conduction transducer designed to reduce stimulus artifact and thereby improve measurement quality. Measurements obtained using a standard bone conduction transducer were compared on several dimensions to measurements obtained using the modified transducer. Improved bone conduction measurement tools are expected to support improved detection and classification of conductive and mixed HL, leading to improved treatment outcomes for this important patient population.

IntroductionOsteoarthritis (OA) is a major clinical and public health concern. The primary surgical treatment of knee OA is total knee replacement (TKR), a procedure that aims to alleviate pain and restore physical function. TKR is expensive, however, and based on professional guidelines, inappropriately performed in up to a third of patients. Patient-reported outcome measures (PROMs) help evaluate treatment options by quantifying health outcomes that matter to patients and can thus inform shared decision-making (SDM) between patients and health professionals.Methods and analysisThis is a US-based 2-year, two-site hybrid type 1 study to assess clinical effectiveness and implementation of a machine learning-based patient decision aid (PDA) integrating patient-reported outcomes and clinical variables to support SDM for patients with knee OA considering TKR. Substudy 1: At one study site, a randomised controlled trial is evaluating the clinical effectiveness of the PDA and SDM process on decision quality as measured after the baseline consultation and treatment choice measured 3 and 6 months after the baseline visit among 200 patients with knee OA. Substudy 2: At a second study site, a qualitative assessment using principles of behaviour design and intervention mapping is evaluating the feasibility and acceptability of the PROMs, PDA and SDM process by interviewing seven health professionals and 25 patients before and 25 patients after PDA implementation.Ethics and disseminationEthics approval has been obtained from The University of Texas at Austin Institutional Review Board (protocol number: 2018-11-0042). Informed consent will be obtained from all participants. Study results will be disseminated through conference presentations, publications and professional societies.Trial registration numberNCT04805554.

Background Treatment for femoral neck fracture among patients aged 65 years or older varies, with many surgeons preferring hemiarthroplasty (HA) over total hip arthroplasty (THA). There is evidence that THA may lead to better functional outcomes, although it also carries greater risk of mortality and dislocation rates. Methods We created a Markov decision model to examine the expected health utility for older patients with femoral neck fracture treated with early HA (performed within 48 hours) vs delayed THA (performed after 48 hours). Model inputs were derived from the literature. Health utilities were derived from previously fit patients aged more than 60 years. Sensitivity analyses on mortality and dislocation rates were conducted to examine the effect of uncertainty in the model parameters. Results In the base case, the average cumulative utility over 2 years was 0.895 for HA and 0.994 for THA. In sensitivity analyses, THA was preferred over HA until THA 30-day and 1-year mortality rates were increased to 1.3× the base case rates. THA was preferred over HA until the health utility for HA reached 98% that of THA. THA remained the preferred strategy when increasing the cumulative incidence of dislocation among THA patients from a base case of 4.4% up to 26.1%. Conclusion We found that delayed THA provides greater health utility than early HA for older patients with femoral neck fracture, despite the increased 30-day and 1-year mortality associated with delayed surgery. Future studies should examine the cost-effectiveness of THA for femoral neck fracture.

Acute pain intensity has conventionally been assessed with a patient self-reported, unidimensional pain scale. This approach can inadvertently underestimate analgesia and result in large cumulative opioid doses and greater dose-dependent side effects and complications. We have thus created the Therapeutic Activity Goal (TAG) as an alternate, more comprehensive way to assess acute postoperative pain, and even more so, to define and determine adequate postoperative analgesia. The TAG comprises the level of acceptable pain intensity, the level and types of desired activities, and accomplishing other patient-centered functional goals. The TAG evolves throughout the patient's hospitalization to promote timely discharge.

Importance Decision aids can help inform appropriate selection of total knee replacement (TKR) for advanced knee osteoarthritis (OA). However, few decision aids combine patient education, preference assessment, and artificial intelligence (AI) using patient-reported outcome measurement data to generate personalized estimations of outcomes to augment shared decision-making (SDM). Objective To assess the effect of an AI-enabled patient decision aid that includes education, preference assessment, and personalized outcome estimations (using patient-reported outcome measurements) on decision quality, patient experience, functional outcomes, and process-level outcomes among individuals with advanced knee OA considering TKR in comparison with education only. Design, Setting, and Participants This randomized clinical trial at a single US academic orthopedic practice included 129 new adult patients presenting for OA-related knee pain from March 2019 to January 2020. Data were analyzed from April to May 2020. Intervention Patients were randomized into a group that received a decision aid including patient education, preference assessment, and personalized outcome estimations (intervention group) or a group receiving educational material only (control group) alongside usual care. Main Outcomes and Measures The primary outcome was decision quality, measured using the Knee OA Decision Quality Instrument (K-DQI). Secondary outcomes were collaborative decision-making (assessed using the CollaboRATE survey), patient satisfaction with consultation (using a numerical rating scale), Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS JR) score, consultation time, TKR rate, and treatment concordance. Results A total of 69 patients in the intervention group (46 [67%] women) and 60 patients in the control group (37 [62%] women) were included in the analysis. The intervention group showed better decisional quality (K-DQI mean difference, 20.0%; SE, 3.02; 95% CI, 14.2%-26.1%;P Conclusions and Relevance In this randomized clinical trial, an AI-enabled decision aid significantly improved decision quality, level of SDM, satisfaction, and physical limitations without significantly impacting consultation times, TKR rates, or treatment concordance in patients with knee OA considering TKR. Decision aids using a personalized, data-driven approach can enhance SDM in the management of knee OA. Trial Registration ClinicalTrials.gov Identifier:NCT03956004

Background: Audiologists often lack confidence in results produced by current protocols for diagnosticelectrophysiologic testing of infants. This leads to repeat testing appointments and slow protocols whichextend the time needed to complete the testing and consequently delay fitting of amplification. A recentpublication (Sininger et al, 2018) has shown how new technologies can be applied to electrophysiologictesting systems to improve confidence in results and allow faster test protocols. Average test times forcomplete audiogram predictions when using new technologies and protocols were found to be just over32 minutes using auditory brainstem response (ABR) and just under 20 minutes using auditory steadystateresponse (ASSR) technology.Purpose: The purpose of this manuscript is to provide details of expedited test protocols for infant andtoddler diagnostic electrophysiologic testing.Summary: Several new technologies and their role in test speed and confidence are described includingCE-Chirp stimuli, automated detection of ABRs using a technique called FMP, Bayesian weighting which isan alternative to standard artifact rejection and Next-Generation ASSR with improved response detectionand chirp stimuli. The test protocol has the following features: (1) preliminary testing includes impedancemeasures and otoacoustic emissions, (2) starting test levels are based on Broad-Band CE-Chirp thresholdsin each ear, (3) ABRs or ASSRs are considered present based on automated detection rather thanon replication of responses, (4) number of test levels is minimized, (5) ASSR generally evaluates fourfrequencies in each ear simultaneously with flexibility to change all test levels independently.Conclusions: Combining new technologies with common-sense strategies has been shown to substantiallyreduce test times for predicting audiometric thresholds in infants and toddlers (Sininger et al, 2018).Details and rationales for changing test strategies and protocols are given and case examples are used toillustrate.

Objective Large-scale otoscopic and audiometric assessment of populations is difficult due to logistic impracticalities, particularly in low- and middle-income countries (LMIC). We report a novel assessment methodology based on training local field workers, advances in audiometric testing equipment and cloud-based technology. Methods Prospective observational study in Bohol, Philippines. A U.S. otolaryngologist/audiologist team trained 5 local nurses on all procedures in a didactic and hands-on process. An operating otoscope (Welch-AllynR) was used to clear cerumen and view the tympanic membrane, images of which were recorded using a video otoscope (JedMedR). Subjects underwent tympanometry and distortion product otoacoustic emission (DPOAE) (Path SentieroR), and underwent screening audiometry using noise cancelling headphones and a handheld Android device (HearScreenR). Sound-booth audiometry was reserved for failed subjects. Data were uploaded to a REDCap database. Teenage children previously enrolled in a 2000–2004 Phase 3 pneumococcal conjugate vaccine trial, were the subjects of the trainees. Results During 4 days of training, 47 Filipino children (M/F = 28/19; mean/median age = 14.6/14.6 years) were the subjects of the trainee nurses. After the training, all nurses could perform all procedures independently. Otoscopic findings by ears included: normal (N = 77), otitis media with effusion (N = 2), myringosclerosis (N = 5), healed perforation (N = 6), perforation (N = 2) and retraction pocket/cholesteatoma (N = 2). Abnormal audiometric findings included: tympanogram (N = 4), DPOAE (N = 4) and screening audiometry (N = 0). Conclusion Training of local nurses has been shown to be robust and this methodology overcomes challenges of distant large-scale population otologic/audiometric assessment.

Background: Patients with limited health literacy may have less knowledge and fewer resources for efficient access and navigation of the health care system. We tested the null hypothesis that there is no correlation between health literacy and total time spent seeking hand surgery care. Methods: New patients visiting a hand surgery clinic at a suburban academic medical center were asked to complete a questionnaire to determine demographics, total time spent seeking hand surgery care, and outcomes. A total of 112 patients were included in this study. Results: We found health literacy levels did not correlate with total time seeking hand surgery care or from booking an appointment to being evaluated in clinic. Conclusions: In this suburban academic medical center, patients with low health literacy do not spend more time seeking hand surgery care and do have longer delays between seeking and receiving care. The finding that—at least in this setting—health literacy does not impact patient time seeking hand care suggests that resources to improve health disparities can be focused elsewhere in the care continuum.

The primary aim of this article is to describe the structure and challenges of Medicare and Medicaid reimbursement for a total hip or knee arthroplasty within the context of the Comprehensive Care for Joint Replacement model. The secondary aims are to identify potential challenges for reimbursement and solutions to overcome challenges for the orthopedic surgeon, and to describe and compare the current and projected reimbursement structures for total arthroplasty procedures. Final decisions on reimbursement for total arthroplasty as outlined by the Centers for Medicare & Medicaid Services are reviewed. The impact of these decisions and the effect of the Centers for Medicare & Medicaid Services' payment structure on reimbursement for surgeons and organizations and the effect on patient care are highlighted. [ Orthopedics . 2017; 40(2):77–80.]

Background Although shared decision making (SDM) is the preferred model of making complex treatment decisions with patients, patients' and doctors' attitudes towards SDM for advance care planning are unknown. Objective We sought to: (i) gain general insights into the current practice of SDM and attitudes about patient involvement, and (ii) gain specific insights into experience with, and attitudes about, SDM for advance care planning. Design Qualitative analysis of face-to-face semi-structured interviews. Setting and participants Patients with chronic lung disease and their doctors at a New York City public hospital. Results Although patients described participation in decision making, many deferred the final decision to their doctors. Doctors indicated a preference for SDM but expressed barriers including perceived lack of patient understanding and lack of patient empowerment. With regard to end-of-life discussions, patients were generally open to having these discussions with their doctors, although their openness sometimes depended on the circumstance (i.e. end-of-life discussions may be more acceptable to patients for whom the chance of dying is high). Doctors reported engaging in end-of-life treatment decisions with their patients, although expressed the need for conversations to take place earlier, in advance of acute illness, and identified a lack of prognostic estimates as one barrier to engaging in this discussion. Conclusions Doctors should explore their patients' attitudes regarding end-of-life discussions and preferences for decision-making styles. There is a need for tools such as decision aids which can empower patients to participate in decision making and can support doctors with prognostic estimates pertinent to individual patients.

Background HIV remains a major cause of preventable morbidity and mortality in Kenya. The effects of behaviors that accompany unhealthy alcohol consumption are a pervasive risk factor for HIV transmission and progression. Our objective was to estimate the portion of HIV infections attributable to unhealthy alcohol use and to evaluate the impact of hypothetical interventions directed at unhealthy alcohol use on HIV infections and deaths. Methods We estimated outcomes over a time horizon of 20 years using a computer simulation of the Kenyan population. This computer simulation integrates a compartmental model of HIV transmission with a mechanistic model of HIV progression that was previously validated in sub-Saharan Africa. Integration of the transmission and progression models allows simultaneous consideration of alcohol's effects on HIV transmission and progression (e.g., lowering antiretroviral adherence may increase transmission risk by elevating viral load, and may simultaneously increase progression by increasing the likelihood of AIDS). The simulation considers important aspects of heterogeneous sexual mixing patterns, including assortativeness of partners by age and activity level, age-discordant relationships, and high activity subgroups. Outcomes included number of new HIV infections, number of AIDS deaths, and infectivity (number of new infections per infected person per year). Results Our model estimated that the effects of behaviors accompanying unhealthy alcohol consumption are responsible for 13.0% of new HIV infections in Kenya. An alcohol intervention with effectiveness similar to that observed in a published randomized controlled trial of a cognitive-behavioral therapy-based intervention in Kenya (45% reduction in unhealthy alcohol consumption) could prevent nearly half of these infections, reducing their number by 69,858 and reducing AIDS deaths by 17,824 over 20 years. Estimates were sensitive to assumptions with respect to the magnitude of alcohol's underlying effects on condom use, antiretroviral therapy adherence, and sexually transmitted infection prevalence. Conclusions A substantial number of new HIV infections in Kenya are attributable to unhealthy alcohol use. An alcohol intervention with the effectiveness observed in a published randomized controlled trial has the potential to reduce infections over 20 years by nearly 5% and avert nearly 18,000 deaths related to HIV.

Der Peritonsillarabszess (PTA) ist ein haufiges Erkrankungsbild der Hals-Nasen-Ohrenheilkunde. Die genaue Pathogenese, fordernde Faktoren und optimale Therapie sind Gegenstand zahlreicher Untersuchungen. Im Rahmen einer retrospektiven Analyse sollte geklart werden, welchen Stellenwert das Rauchverhalten, die praoperative Gerinnungsdiagnostik und die angewandte Therapie beim PTA haben. Von 460 Patienten mit einem PTA wurden die Daten aus dem Behandlungszeitraum vom 01.01.2000 bis zum 31.12.2009 retrospektiv analysiert. Die hochste Inzidenz beim PTA zeigte sich bei jungen Mannern, die Pravalenz des Nikotinkonsums war im Vergleich zur Gesamtbevolkerung deutlich erhoht. Die Therapie erfolgte hauptsachlich mittels Abszesstonsillektomie. Auch bei praoperativ pathologischen Gerinnungsparametern zeigte sich kein erhohtes Nachblutungsrisiko. Der Anteil von Rauchern unter Patienten mit PTA ist im Vergleich zur altersentsprechenden Normalbevolkerung erhoht. Eine routinemasige praoperative Analyse der Blutgerinnung vor operativer Therapie bei PTA hat nur einen geringen prognostischen Nutzen bezuglich der Vorhersagekraft des Nachblutungsrisikos. Die operative Therapie mittels Abszesstonsillektomie ist ein sicheres Verfahren und hat sich im klinischen Alltag bewahrt.

Since 2010, the state of Rhineland-Palatinate in Germany has developed a cultural landscape information system as a process to secure and further enrich aggregate data about its cultural assets. In an open dialogue between governing authorities and citizens, the intention of the project is an active cooperation of public and private actors. A cultural landscape information system called KuLIS was designed as a web platform, combining semantic wiki software with a geographic information system. Based on data sets from public administrations, the information about cultural assets can be extended and enhanced by interested participants. The developed infrastructure facilitates local information accumulation through a crowdsourcing approach. This capability offers new possibilities for e-governance and open data developments. The collaborative approach allows governing authorities to manage and supervise official data, while public participation enables affordable information acquisition. Gathered cultural heritage information can provide incentives for touristic valorisation of communities or concepts for strengthening regional identification. It can also influence political decisions in defining significant cultural regions worth of protecting from industrial influences. The presented cultural landscape information allows citizens to influence the statewide development of cultural landscapes in a democratic way.

Background: Whether shared decision making (SDM) has been evaluated for end-of-life (EOL) decisions as compared to other forms of decision making has not been studied. Purpose: To summarize the evidence on SDM being associated with better outcomes for EOL decision making, as compared to other forms of decision making. Data Sources: PubMed, Web of Science, Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO, and CINAHL databases were searched through April 2014. Study Selection: Studies were selected that evaluated SDM, compared to any other decision making style, for an EOL decision. Data Extraction: Components of SDM tested, comparators to SDM, EOL decision being assessed, and outcomes measured. Data Synthesis: Seven studies met the inclusion criteria (three experimental and four observational studies). Results were analyzed using narrative synthesis. All three experimental studies compared SDM interventions to usual care. The four observational studies compared SDM to doctor-controlled decision making, or reported the correlation between level of SDM and outcomes. Components of SDM specified in each study differed widely, but the component most frequently included was presenting information on the risks/benefits of treatment choices (five of seven studies). The outcome most frequently measured was communication, although with different measurement tools. Other outcomes included decisional conflict, trust, satisfaction, and “quality of dying.” Limitations: We could not analyze the strength of evidence for a given outcome due to heterogeneity in the outcomes reported and measurement tools. Conclusions: There is insufficient evidence supporting SDM being associated with improved outcomes for EOL decisions as opposed to other forms of decision making. Future studies should describe which components of SDM are being tested, outline the comparator decision making style, and use validated tools to measure outcomes.

Quality, experience, and cost are important indicators of value to patients. However, stakeholders have yet to reach agreement on how to define quality and which measures should be used to assess quality. Measures that have been used to assess quality in health care include structural, process, patient experience, efficiency, and outcomes measures. Payers and other quality rating organizations use a combination of measures to rate or rank hospitals on the quality of care they provide. These ratings can be strictly informational or can be used to steer patients, for contracting between payers and providers, and more recently, for adjustments to reimbursements. Physicians and hospitals have a crucial role to play in the development of quality measures that are used to measure and improve value. Consensus on quality measures will facilitate meaningful comparisons across providers and insights that will enable improvements in the value of care we deliver to our patients.

Automotive gasoline is a common petroleum product found at contaminated terrestrial sites. The need to recognize and distinguish different types of gasoline(s) that may be present at a contaminated site and the need to determine the relative proportion of inputs from different sources, are often critical components of environmental 'forensic' investigations. Historically, identification and differentiation of automotive gasolines (particularly when weathered) has been hampered by analytical limitations of existing methods, notably US EPA Method 8260. In this article, we describe a modified EPA Method 8260 that is suitable for environmental investigations involving gasoline (and other light petroleum products). In the modified EPA 8260 method, 109 analytes that can occur in automotive gasoline are quantified in nonaqueous liquid samples (NAPL), water, and soil matrices. The accuracy and precision of the method is demonstrated through comparative analysis using several NIST SRM gasoline standards and replic...

HIV remains a major cause of preventable morbidity and mortality with 100000 new infections and an estimated 62000 deaths in 2011. At the same time unhealthy alcohol consumption is an important risk factor for HIV acquisition and progression. Kenya has one of the highest rates of unhealthy alcohol use worldwide and as many as 13% of new HIV infections in Kenya may be attributable to unhealthy alcohol use. Randomized controlled trials (RCTs) of cognitive behavioral therapy (CBT)-based interventions addressing unhealthy alcohol consumption in Kenya show promising results increasing abstinence by 45% and decreasing risky sex. However alcohol remains conspicuously absent from programming in HIV and substance abuse. In low-resource settings the benefits of scaling up an effective intervention must be balanced against the opportunity costs of using those resources to scale up alternative interventions with potential benefit (for example increasingly eligibility for first-line antiretroviral therapy). Accordingly the researchers used a published validated computer simulation of the HIV epidemic in Kenya incorporating HIV transmission and disease progression to evaluate the cost-effectiveness of the alcohol intervention reported by Papas et al. Given the uncertainty surrounding costs of scale-up they varied costing assumption over a wide range to identify the threshold at which its incremental cost-effectiveness ratio (ICER) descended below those of alternative resource uses (e.g. when an alcohol intervention brought more “health” than alternative resource uses). [excerpt]

Polycyclic aromatic hydrocarbons (PAH) are ubiquitous constituents in urban sedimentary environments. The accurate characterization of their source(s) in sediments influences decisions regarding the liability for clean-up and remedial options. In this study, an extensive PAH dataset that included 50 non-alkylated (parent) and alkylated PAH groups and isomers was acquired using a modified EPA Method 8270 for the study of 5 cm intervals from 10 sediment cores (28-78 cm) obtained from the Eagle Harbor Superfund Site on Bainbridge Island, Washington. Conventional hydrocarbon "fingerprinting" and the PAH profiles in the Pb 210 age-dated cores revealed three primary PAH sources to the sediments over the past 220 years, namely (1) naturally occurring background; (2) urban runoff, and (3) creosote, the latter resulting from prior operations at the former Wyckoff wood-processing facility located on the Harbor. Naturally occurring background PAH in the pre-industrial (

The need for identification, delineation, and differentiation of petroleum-derived contaminants in support of NRDA investigations of chronic or catastrophic release of petroleum is paramount for the equitable settlement of damages related to the incidents. Significant advances have been made over the last decade with regard to these issues for crude oil and heavy residual fuels, but less emphasis has been place on the forensic chemistry of light- and middle-distillates. Historically, identification and differentiation among similar light-distillates by standard EPA methods have been hampered by analytical limitations. In this paper the authors suggest analysis of light-distillate products begin with a chromatographic profile obtained using a modified EPA 8015 GC/FID. Subsequently, the detailed chemical composition of the distillate products is accomplished via a modified version of EPA Method 8260, examining a targeted list of diagnostic petroleum compounds in the C5 to C12 range that represent five important categories of hydrocarbons: Paraffins, Isoparaffins, Aromatics, Naphthenes, and Olefins. Detailed analysis of over 50 2–6 ring PAH and related heteroatomics from a modified EPA 8270 GC/MS analysis can be used to compliment the data set. The analysis of the full suite of hydrocarbons across a broad molecular weight range provides much of the information necessary to identify and distinguish among light- and middle-distillate products.

BACKGROUND: Increased eligibility guidelines of antiretroviral therapy (ART) may lead to greater routine viral load monitoring. However in resource-constrained settings the additional resources required by greater routine viral load monitoring may impair ability to comply with expanded eligibility guidelines for ART. OBJECTIVE: We use a published validated computer simulation of the HIV epidemic in East African countries (expanded to include transmission as well as disease progression) to evaluate the cost-effectiveness of routine viral load monitoring. METHODS: We explored alternative scenarios regarding cost frequency and switching threshold of routine viral load monitoring (including every 6 or every 12 months; and switching thresholds of 1000 or 10 000 copies/ml) as well as alternative scenarios regarding ART initiation (200 350 500 cells/mul and no CD4 cell threshold). For each ART initiation strategy we sought to identify the viral load monitoring strategy at which the incremental cost-effectiveness ratio (ICER) of more frequent routine viral load testing became more favorable than the ICER of more expansive ART eligibility. Cost inputs were based on data provided by the Academic Model Providing Access to Healthcare (AMPATH) and disease progression inputs were based on prior published work. We used a discount rate of 3% a time horizon of 20 years and a payer perspective. RESULTS: Across a wide range of scenarios and even when considering the beneficial effect of virological monitoring at reducing HIV transmission earlier ART initiation conferred far greater health benefits for resources spent than routine virological testing with ICERs of approximately $1000 to $2000 for earlier ART initiation versus ICERs of approximately $5000 to $25 000 for routine virological monitoring. ICERs of viral load testing were insensitive to the cost of the viral load test because most of the costs originated from the downstream higher costs of later regimens. ICERs of viral load testing were very sensitive to the relative cost of second-line compared with first-line regimens assuming favorable value when the costs of these regimens were equal. CONCLUSION: If all HIV patients are not yet treated with ART starting at 500 cells/mul and costs of second regimens remain substantially more expensive than first-line regimens resources would buy more population health if they are spent on earlier ART rather than being spent on routine virological testing.

Background Initiation of antiretroviral therapy (ART) in all HIV-infected adults, regardless of CD4+ T-cell count, is a proposed strategy for reducing HIV transmission. We investigated the conditions under which starting ART early could entail more risks than benefits for patients with high CD4+ T-cell counts. Methods We used a simulation model to compare ART initiation upon entry to care (‘immediate ART') to initiation at CD4+ T-cell count ≤350 cells/μl (‘WHO 2010 ART') in African adults with CD4+ T-cell counts >500 cells/μl. We varied inputs to determine the combination of parameters (population characteristics, conditions of care, treatment outcomes) that would result in higher 15-year mortality with immediate ART. Results The 15-year mortality was 56.7% for WHO 2010 ART and 51.8% for immediate ART. In one-way sensitivity analysis, lower 15-year mortality was consistently achieved with immediate ART unless the rate of fatal ART toxicity was >1.0/100 person-years, the rate of withdrawal from care was >1.2-fold higher or the rate of ART failure due to poor adherence was >4.3-fold higher on immediate than on WHO 2010 ART. In multi-way sensitivity analysis, immediate ART led to higher mortality when moderate rates of fatal ART toxicity (0.25/100 person-years) were combined with rates of withdrawal from care >1.1-fold higher and rates of treatment failure >2.1-fold higher on immediate than on WHO 2010 ART. Conclusions In sub-Saharan Africa, ART initiation at entry into care would improve long-term survival of patients with high CD4+ T-cell counts, unless it is associated with increased withdrawal from care and decreased adherence. In early ART trials, a focus on retention and adherence will be crucial.

Background Regimens for isoniazid-based preventive therapy (IPT) for tuberculosis (TB) in HIV-infected individuals have not been widely adopted given concerns regarding efficacy, adherence and drug resistance. Further, the cost-effectiveness of IPT has not been studied in India. Methods We used an HIV/TB model to project TB incidence, life expectancy, cost and incremental cost-effectiveness of six months of isoniazid plus ethambutol (6EH), thirty-six months of isoniazid (36H) and no IPT for HIV-infected patients in India. Model input parameters included a median CD4 count of 324 cells/mm3, and a rate ratio of developing TB of 0.35 for 6EH and 0.22 for 36H at three years as compared to no IPT. Results of 6EH and 36H were also compared to six months of isoniazid (6H), three months of isoniazid plus rifampin (3RH) and three months of isoniazid plus rifapentine (3RPTH). Results Projected TB incidence decreased in the 6EH and 36H regimens by 51% and 62% respectively at three-year follow-up compared to no IPT. Without IPT, projected life expectancy was 136.1 months at a lifetime per person cost of $5,630. 6EH increased life expectancy by 0.8 months at an additional per person cost of $100 (incremental cost-effectiveness ratio (ICER) of $1,490/year of life saved (YLS)). 36H further increased life expectancy by 0.2 months with an additional per person cost of $55 (ICER of $3,120/YLS). The projected clinical impact of 6EH was comparable to 6H and 3RH; however when compared to these other options, 6EH was no longer cost-effective given the high cost of ethambutol. Results were sensitive to baseline CD4 count and adherence. Conclusions Three, six and thirty-six-month regimens of isoniazid-based therapy are effective in preventing TB. Three months of isoniazid plus rifampin and six-months of isoniazid are similarly cost-effective in India, and should be considered part of HIV care.

Normozoospermic semen samples (n = 82) were examined to investigate whether the degree of sperm tail swelling in hypo-osmotic medium (fructose and sodium citrate; 150 mOsm/l), and motility characteristics after a 15-min exposure to hypotonic saline (sodium chloride; 150 mOsm/l) could predict the cryosurvival rate (% post-thaw motility/% pre-freeze motility x 100%) of spermatozoa after cryopreservation by the liquid nitrogen vapour freezing method using the TEST-glycerol-egg yolk buffer. The CellSoft automated semen analyser was used to analyse sperm motility in pre-freeze and post-thaw semen samples, and after exposure to hypotonic saline. Sperm tail hypo-osmotic swelling and sperm motility in pre-freeze semen showed no significant correlations (P0.05) with the cryosurvival rate. There were significant correlations (P0.05) between the cryosurvival rate and the following sperm motility parameters in hypotonic saline: % motility (r = 0.2846), motility index (% motility x curvilinear velocity; r = 0.2809) and % decrease in motility index from the baseline value in semen (r = 0.3378). The % decrease in motility index after hypotonic saline treatment was significantly less (P0.05) in the normal (or = 50% cryosurvival rate; mean +/- SEM 5.9 +/- 3.2%; n = 33) compared with the subnormal (50% cryosurvival rate; 27.3 +/- 4.8%; n = 49) cryosurvival groups. This parameter was also determined, by multivariate discriminant analysis, to be capable of classifying each pre-freeze semen sample into either cryosurvival group with 69.5% accuracy.(ABSTRACT TRUNCATED AT 250 WORDS)

The new millennium ushers in changes for refiners of automobile gasoline in the United States, as well as for the state and federal regulators who establish guidelines for gasoline formulation and environmental regulation governing the fate of gasoline-related chemicals in the nation's air, soil and groundwater. One current issue in the gasoline formulation debate centers on the comparison of the proven benefits of the addition of chemical oxygenates--especially methyl tert -butyl ether (MTBE)--to gasoline (to improve tailpipe emission quality) against the presumed environmental problems caused by the presence of oxygenates in ground- and surface waters due to fugitive releases of gasoline. Credible debate on this subject presumes that current and past environmental monitoring data for MTBE in environmental samples is accurate and precise. Experience suggests that this assumption is not correct, in part because certain analytical methodologies--particularly older methods supported by the U.S. Environmenta...

Background: Indian guidelines recommend routine referral for HIV testing of all tuberculosis (TB) patients in the nine states with the highest HIV prevalence, and selective referral for testing elsewhere. We assessed the clinical impact and costeffectiveness of alternative HIV testing referral strategies among TB patients in India. Methods and Findings: We utilized a computer model of HIV and TB disease to project outcomes for patients with active TB in India. We compared life expectancy, cost, and cost-effectiveness for three HIV testing referral strategies: 1) selective referral for HIV testing of those with increased HIV risk, 2) routine referral of patients in the nine highest HIV prevalence states with selective referral elsewhere (current standard), and 3) routine referral of all patients for HIV testing. TB-related data were from the World Health Organization. HIV prevalence among TB patients was 9.0% in the highest prevalence states, 2.9% in the other states, and 4.9% overall. The selective referral strategy, beginning from age 33.50 years, had a projected discounted life expectancy of 16.88 years and a mean lifetime HIV/TB treatment cost of US$100. The current standard increased mean life expectancy to 16.90 years with additional per-person cost of US$10; the incremental costeffectiveness ratio was US$650/year of life saved (YLS) compared to selective referral. Routine referral of all patients for HIV testing increased life expectancy to 16.91 years, with an incremental cost-effectiveness ratio of US$730/YLS compared to the current standard. For HIV-infected patients cured of TB, receiving antiretroviral therapy increased survival from 4.71 to 13.87 years. Results were most sensitive to the HIV prevalence and the cost of second-line antiretroviral therapy. Conclusions: Referral of all patients with active TB in India for HIV testing will be both effective and cost-effective. While effective implementation of this strategy would require investment, routine, voluntary HIV testing of TB patients in India should be recommended.

To evaluate rates of antiretroviral therapy (ART) initiation within 12 months of a new HIV diagnosis in Durban, South Africa.Prospective observational cohort.Adults (or=18 years) were enrolled before HIV testing at two outpatient clinics into the South African Test, Identify and Link cohort. Both sites offer comprehensive HIV care. HIV test results, CD4 cell counts, dates of ART initiation and dates of death were collected from medical records and 12-month patient/family interviews were conducted. ART eligibility was defined as a CD4 cell count less than 200 cells/microl within 90 days of HIV diagnosis. The primary endpoint was ART initiation within 12 months for ART-eligible subjects.From November 2006 to October 2008, 1474 newly diagnosed HIV-infected outpatients were enrolled, 1012 (69%) of whom underwent CD4 cell count testing within 90 days. The median CD4 cell count was 159 cells/microl (interquartile range 65-299). Of those who underwent CD4 cell count testing, 538 (53%) were ART-eligible. Only 210 (39%) eligible enrollees were known to have initiated ART within 12 months. Among ART-eligible subjects, there were 108 known deaths; 82% occurred before ART initiation or with unknown ART initiation status. Men [rate ratio (RR) 1.3, 95% confidence interval (CI) 1.1-1.5] and subjects without an HIV-infected family member/friend (RR 1.3, 95% CI 1.1-1.7) were more likely not to start ART.Less than half of ART-eligible subjects started ART within 12 months. Substantial attrition and mortality follow HIV diagnosis before ART initiation in Durban, South Africa. Major efforts directed towards earlier HIV diagnosis, effective linkage to care and timely ART initiation are urgently needed.

Based on data from West Africa, Elena Losina and colleagues predict that interventions to reduce dropout rates from HIV treatment programs (such as eliminating copayments) will be cost-effective., Background Data from HIV treatment programs in resource-limited settings show extensive rates of loss to follow-up (LTFU) ranging from 5% to 40% within 6 mo of antiretroviral therapy (ART) initiation. Our objective was to project the clinical impact and cost-effectiveness of interventions to prevent LTFU from HIV care in West Africa. Methods and Findings We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) International model to project the clinical benefits and cost-effectiveness of LTFU-prevention programs from a payer perspective. These programs include components such as eliminating ART co-payments, eliminating charges to patients for opportunistic infection-related drugs, improving personnel training, and providing meals and reimbursing for transportation for participants. The efficacies and costs of these interventions were extensively varied in sensitivity analyses. We used World Health Organization criteria of, Editors' Summary Background Acquired immunodeficiency syndrome (AIDS) has killed more than 25 million people since the first reported case in 1981. Currently, about 33 million people are infected with the human immunodeficiency virus (HIV), which causes AIDS. Two-thirds of people infected with HIV live in sub-Saharan Africa. HIV infects and destroys immune system cells, thereby weakening the immune system and rendering infected individuals susceptible to infection. There is no cure for HIV/AIDS. Combination antiretroviral therapy (ART), a mixture of antiretroviral drugs that suppress the replication of the virus in the body, is used to treat and prevent HIV infection. ART is expensive but major international efforts by governments, international organizations, and funding bodies have increased ART availability. According to World Health Organization (WHO) estimates, at least 9.7 million people in low- and middle-income countries need ART and as of 2007, 3 million of those people had reliable access to the drugs. Why Was This Study Done? Although ART is an effective treatment for HIV, a large number of individuals who initiate ART do not receive long-term follow-up care. These patients are generally sicker and have a worse long-term outcome than those who receive follow-up care. Loss to follow up (LTFU) is a significant problem that can undermine the benefits of expanding ART availability. Strategies to improve follow up concentrate on bringing lost patients back into the health care system, but such patients often die before they can be contacted. Prevention of LTFU might be a better strategy to improve HIV care after ART initiation, but there is little information available on which specific interventions might best accomplish this goal. What Did the Researchers Do and Find? Given the lack of reported data on the actual costs and effectiveness of LTFU prevention, the researchers used a model to estimate the clinical impact and cost-effectiveness of several possible strategies to prevent LTFU in HIV-infected persons receiving ART in Côte d'Ivoire, West Africa. The researchers used the previously developed Cost-Effectiveness of Preventing AIDS Complications (CEPAC) computer simulation model and combined it with data from a program of ART delivery in Abidjan, Côte d'Ivoire. They then projected the clinical benefits and the cost required to attain a given level of benefit (cost-effectiveness ratio) of different LTFU-prevention strategies from the perspective of the payer (the organization that pays all the medical costs to provide care). Several interventions were considered, including reducing costs to patients (eliminating patient co-payments and paying for transportation) and increasing services to patients at their visits (improving staff training in HIV care, and providing meals at clinic times). LTFU was predicted to cause a 54.3%–58.3% reduction in the estimated life expectancy beyond age 37; patients continuing HIV care were predicted to live a further 144.7 months whie those lost to follow up by 1 year after ART initiation were predicted to live only for a further 73.9–80.7 months. LTFU-prevention strategies in the Côte d'Ivoire were deemed to be cost-effective if they cost less than $2,823 (which is 3× gross domestic product per capita) per year of life saved. The efficacy and cost of the different LTFU-prevention strategies varied in the analyses; stopping ART co-payment alone would be cost-effective at a cost of $22/person/year if it reduced LTFU rates by 12%, while including all the LTFU-prevention strategies described would be cost-effective at $77/person/year if they reduced LTFU-rates by 41%. What Do These Findings Mean? The findings suggest that moderately effective strategies for preventing LTFU in resource-limited settings would improve survival, provide good value for money, and should be used to improve HIV treatment programs. Although modeling is valuable to explore the costs and effectiveness of LTFU-prevention strategies it cannot replace the need for more reported data to shed light on problems leading to LTFU and the prevention strategies required to combat it. Also, Côte d'Ivoire might not be representative of all West African countries or resource-limited settings. A similar analysis using data from other ART programs in different countries would be useful to provide better understanding of the impact of LTFU in HIV treatment programs. Finally, the research highlights the cost of second-line ART (a new antiretroviral drug combination for patients in whom first-line treatment fails) as a crucial issue. It is estimated that 5% of all people receiving ART in low- and middle-income countries receive second-line ART and these numbers are expected to increase. Second-line ART had major effects on cost-effectiveness, and a reduction in the cost of this treatment is critical in order to guarantee continued access to HIV treatment. Additional Information Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000173. This study is further discussed in a PLoS Medicine Perspective by Gregory Bisson and Jeffrey Stringer WHO provides information on disease prevention, treatment, and HIV/AIDS programs and projects The UN Millennium Development Goals project site contains information on worldwide efforts to halt the spread of HIV/AIDS aidsmap, a nonprofit, nongovernmental organization, provides information on HIV and supporting those living with HIV

BackgroundAdvance care planning may help patients receive treatments that better align with their goals for care. We developed a Web-based decision aid called InformedTogether to facilitate shared advance care planning between chronic obstructive pulmonary disease (COPD) patients and their doctors. ObjectiveOur objective was to assess the usability of the InformedTogether decision aid, including whether users could interact with the decision aid to engage in tasks required for shared decision making, whether users found the decision aid acceptable, and implications for redesign. MethodsWe conducted an observational study with 15 patients and 8 doctors at two ethnically and socioeconomically diverse outpatient clinics. Data included quantitative and qualitative observations of patients and doctors using the decision aid on tablet or laptop computers and data from semistructured interviews. Patients were shown the decision aid by a researcher acting as the doctor. Pulmonary doctors were observed using the decision aid independently and asked to think aloud (ie, verbalize their thoughts). A thematic analysis was implemented to explore key issues related to decision aid usability. ResultsAlthough patients and doctors found InformedTogether acceptable and would recommend that doctors use the decision aid with COPD patients, many patients had difficulty understanding the icon arrays that were used to communicate estimated prognoses and could not articulate the definitions of the two treatment choices—Full Code and Do Not Resuscitate (DNR). Minor usability problems regarding content, links, layout, and consistency were also identified and corresponding recommendations were outlined. In particular, participants suggested including more information about potential changes in quality of life resulting from the alternative advance directives. Some doctor participants thought the decision aid was too long and some thought it may cause nervousness among patients due to the topic area. ConclusionsA decision aid for shared advance care planning for severe COPD was found acceptable to most COPD patients and their doctors. However, many patient participants did not demonstrate understanding of the treatment options or prognostic estimates. Many participants endorsed the use of the decision aid between doctors and their patients with COPD, although they desired more information about quality of life. The design must optimize comprehensibility, including revising the presentation of statistical information in the icon array, and feasibility of integration into clinical workflow, including shortening the decision aid.

A macropipelined CISC microprocessor implemented in a 0.75- mu m CMOS 3.3-V three-metal-layer technology is described. The 1.3 M-transistor custom chip measures 1.62*1.46 cm/sup 2/, dissipates 18 W (peak), and is packaged in a 339-pin PGA. The chip implements a macroinstruction pipeline to execute the instruction set of a popular CISC minicomputer. A block diagram of the major functional units is shown along with die micrograph. >

Summary form only given. The author describes NVAX, a high-performance, single-chip implementation of the VAX architecture, which is fully compatible with previous VAX implementations. The chip is used in the VAX 6000 model 600 and VAX 4000 model 500 systems. In its highest performance version NVAX runs at 83.3 MHz, and delivers 40.4 SPECmarks and 83.6 transactions per second on the TPC-A benchmark. NVAX is implemented in Digital's 0.75- mu m CMOS 3.3-V technology, contains 1.3 M transistors, and is packaged in a 339-pin PGA. The NVAX design uses RISC (reduced instruction set computer) principles to improve performance. Included on the chip are a 96-entry, fully associative translation buffer, a 2-KB direct-mapped virtual instruction cache, an 8-KB, 2-set associative instruction and data cache and a writeback backup cache controller that interfaces to tag and data RAMs on the module. >

Rectal swabs were collected from 304 Bob calves (calves under 10 d old) brought to slaughter in the States of Washington (77 swabs), California (127 swabs), and Wisconsin (100 swabs). The swab samples were tested for the presence of Escherichia coli O157:H7 by the use of a direct smear method, enrichment method, and the use of the Petrifilm™ Test Kit-HEC-for hemorrhagic E. coli O157:H7 (3M Company, St. Paul, MN). The organism was not isolated from any of the samples by any method, though the 3M test kit did give 21 positive signals. Of these positive signals, three were shown to be caused by sorbitol-positive, O157-positive, H7-negative E. coli . The cause of the other 18 signals was not determined.

The defensible identification of spilled crude oils and petroleum products and their correlation to suspected sources is a critical part of many oil spill assessments. Quantitative ‘fingerprinting’ analysis, when evaluated using straightforward statistical and numerical analyses, can provide simple yet defensible means to differentiate among qualitatively similar oils and provide the best assessment of a source(s) for spilled oils. Biomarker concentration data are a particularly useful quantitative measure that can benefit most oil spill investigations. Biomarkers’ specificity, diversity, complexity, and relative resistance to weathering make them extremely useful ‘markers’ in the characterization and differentiation of spilled oils, any candidate source oils, and background contamination. In this paper the methodology and precision of data developed by quantitative gas chromatography-mass spectrometry operated in the selected ion monitoring mode (GCMS-SIM) is demonstrated. These data are evaluated using a statistical and numerical process that results in the defensible identification the source(s) of a spilled oil (heavy fuel oil) from among over 50 candidate sources.

Tuboovarian abscess is a serious consequence of pelvic inflammatory disease, especially in the adolescent population. Early diagnosis and treatment are essential to prevent further sequelae including infertility, ectopic pregnancy, and chronic pelvic pain. Not all patients, however, present with pelvic pain, pelvic mass, fever, and leukocytosis. We present the case of a sexually active 15-year-old black girl who presented with mild abdominal pain and excessive vaginal bleeding without pelvic mass, fever, or leukocytosis. Erythrocyte sedimentation rate was 66 mm/h. Pelvic ultrasound revealed bilateral complex ovarian masses. At laparoscopy, the patient had bilateral tuboovarian abscesses with extensive adhesions to the pelvic side walls. This case illustrates the need for a high index of suspicion of tuboovarian abscess in sexually active adolescents.