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BACKGROUND Understanding geographic patterns of injury is essential to operating an effective trauma system and targeting injury prevention. Choropleth maps are helpful in showing spatial relationships, but are unable to provide estimates of spread or degrees of confidence. Funnel plots overcome this issue and are a recommended graphical aid for comparisons that allow quantification of precision. The purpose of this project was to demonstrate the complementary roles of choropleth maps and funnel plots in providing a thorough representation of geographic trauma data. METHODS This is a retrospective analysis of EMS transport data of adult patients in Alabama from July 2015 through June 2020. Choropleth maps of case volume and observed-to-expected ratios of incidence were created utilizing U.S. Census Bureau data. Funnel plots were created to relate incidence rate to county population. Subgroup analyses included patients with critical physiology, penetrating, blunt, and burn injuries. RESULTS We identified 65,247 trauma incidents during the study period. The overall statewide incidence rate was 133 per 10,000 persons. The highest number of incidents occurred in the most populous counties (Jefferson - 10,768, Mobile - 5,642). Choropleth maps for overall incidence and subgroups highlighted that spatial distribution of overall case volume and observed-to-expected ratios are not always congruent. Funnel plots identified possible and probable outliers, and revealed skewed or otherwise unique patterns among injury subgroups. CONCLUSIONS This study demonstrates the complementarity of choropleth maps and funnel plots in describing trauma patterns. Comprehensive geospatial analyses may help guide a data-driven approach to trauma system optimization and injury prevention. Combining maps of case counts, incidence, and funnel plots helps to not only identify geographic trends in data, but also quantifies outliers and displays how far results fall outside the expected range. The combination of these tools provides a more comprehensive geospatial analysis than either tool could provide on its own. LEVEL OF EVIDENCE IV Epidemiological.

Introduction: The Emergency Medical Stroke Assessment (EMSA) is a six point stroke severity scale with one point each for gaze preference, facial droop, arm drift, leg drift, abnormal naming, and abnormal repetition that was developed to help emergency medical services (EMS) providers identify acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). We hypothesized that the EMSA would detect left hemisphere LVO with a higher sensitivity than right hemisphere LVO. Methods: We trained 24 trauma system-based emergency communication center (ECC) paramedics in the EMSA. ECC-guided EMS in performance of the EMSA on patients with suspected stroke. We compared the sensitivity, specificity, area under the curve (AUC), and 95% confidence interval (CI) of ECC-guided prehospital EMSA for right versus left hemisphere ICA or M1 occlusion. Results: We enrolled 569 patients from September 2016 through February 2018, out of which 236 had a discharge diagnosis of stroke and 173 had a diagnosis of AIS. We excluded patients with bilateral (n=21) and brainstem (n=21) AIS. There were 64 patients with left hemisphere AIS including 19 with LVO. There were 67 patients with right hemisphere AIS including 22 with LVO. A score of ≥ 4 points yielded a sensitivity of 84.2 (95% CI = 60.4-96.6) and specificity of 66.7 (51.1-80.0) for left hemisphere LVO compared to a sensitivity of 68.2 (45.1-86.1) and specificity of 73.9 (58.9-85.7) for right hemisphere LVO. For predicting a left hemisphere LVO, the AUC was 0.77 (0.65-0.90) compared to 0.66 (0.50-0.82) for right-sided LVO. Assigning 2 points for abnormal gaze yielded an AUC of 0.78 (0.66-0.91) versus 0.67 (0.52-0.83) for left and right hemisphere LVO, respectively. Conclusions: The EMSA, like the National Institutes of Health Stroke Scale (NIHSS) upon which it is based, is more sensitive to left compared to right hemisphere LVO. More heavily weighting abnormal gaze did not improve the sensitivity of the EMSA for right hemisphere LVO. There is no comparable data on the right versus left hemisphere performance of other prehospital scales. There is a need to develop sensitive tests of right hemisphere dysfunction that are suitable for use in the field.

Objective: Improve prehospital identification of acute ischemic stroke patients with large vessel occlusion (LVO) by using a trauma system-based emergency communication center (ECC) to guide the emergency medical service (EMS). Methods: We trained 24 ECC paramedics in the Emergency Medical Stroke Assessment (EMSA). ECC-guided EMS in performance of the EMSA on patients with suspected stroke. During the second half of the study, we provided focused feedback to ECC after reviewing recorded ECC-EMS interactions. We compared the sensitivity, specificity, and area under the receiver operator characteristics curve (AUC) and 95% confidence interval of ECC-guided EMSA to the NIH Stroke Scale (NIHSS) for predicting a discharge diagnosis of LVO. Results: We enrolled 569 patients from September 2016 through February 2018. Of 463 patients analyzed, 236 (51%) had a discharge diagnosis of stroke and 227 (49%) had a nonstroke diagnosis. There were 45 (19%) stroke patients with LVO. For predicting LVO, there was no significant difference between the EMSA AUC = .68 (.59-.77) and the NIHSS AUC = .73 (.65-.81). An EMSA score greater than or equal to 4 had sensitivity = 75.6 (60.5-87.1) and specificity = 62.4 (57.6-67.1) for LVO. During the first 9 months of the study, the EMSA AUC = .61 (.44-.77) compared to an AUC = .74 (.64-.84) during the second 9 months. Conclusions: ECC-guided prehospital EMSA is feasible, has similar ability to predict LVO compared to the NIHSS, and has sustained performance over time.

Introduction: We are prospectively validating a model of communication center guided prehospital identification of stroke patients with large vessel occlusion (LVO). Goal: Assess the inter-rater agreement between a Vascular Neurologist and Alabama Trauma Communication Center (ATCC) personnel in diagnostic classification of stroke patients. Methods: The ATCC is staffed by paramedic-trained dispatchers who field calls from Emergency Medical Service (EMS) responders and maintain up-to-the-minute status of hospitals and resources 24/7. We trained ATCC personnel in stroke pathology, pathophysiology, appropriate patient selection for thrombolytic and endovascular therapies; and the previously derived 6 point Emergency Medical Stroke Assessment (EMSA). ATCC personnel guided EMS responders in the Birmingham Regional Emergency Medical Services System (BREMSS), and paged-out a hospital stroke prenotification that included specific EMSA scale items (gaze, facial droop, arm drift, leg drift, naming, and repetition). All interactions between the ATCC and EMS responders were recorded, allowing review of audio files and ongoing quality improvement. ATCC personnel and a vascular neurologist separately reviewed recordings and assigned scores to each patient according to the deficit stated by the EMS. To determine inter-rater reliability we utilized the Kappa statistic with a significance level of 0.05, and 95% confidence intervals (CI). Results: We sampled a total of 146 patients. We observed statistically significant agreement between the raters for all EMSA components, with 71% (CI=45-97%, p Conclusion: We conclude that there is moderate to substantial agreement in most stroke assessment items by a paramedic staffed communication center and a vascular neurologist. There was only fair inter-rater agreement for repetition. Paramedic-trained dispatchers can reliably guide EMS responders and score the Emergency Medical Stroke Assessment.

Introduction: There is need for sustainable models of effective prehospital stroke triage. Goal: Prospectively validate communication center guided prehospital identification of stroke patients with large vessel occlusion (LVO). Methods: We trained Alabama Trauma Communication Center (ATCC) paramedics in the previously derived 6 point Emergency Medical Stroke Assessment (EMSA). ATCC staff guided Emergency Medical Service (EMS) responders in the Birmingham Regional Emergency Medical Services System (BREMSS), and paged-out a hospital prenotification that included specific EMSA items (gaze, facial droop, arm drift, leg drift, naming, and repetition). Ongoing quality improvement was designed to enable the ATCC staff to effectively guide EMS responders. We derived the sensitivity, specificity, negative likelihood ratio (LR-), positive likelihood ratio (LR+), and receiver operator characteristics area under the curve (AUC) and 95% confidence intervals (CI) of ATCC guided EMSA for predicting a discharge diagnosis of LVO for patients transported to the University of Alabama at Birmingham. Results: We enrolled 521 patients from September 2016 through February 2018. Patients who only responded to pain (n=29, 5.6%) or who were unresponsive (n=21, 4%) were excluded. Of 471 patients analyzed, 247(52%) had a discharge diagnosis of stroke, including 182 (74%) acute ischemic stroke, 36 (14%) intracerebral hemorrhage, and 29 (11%) transient ischemic attack. There were 45 (18%) stroke patients with proximal LVO, including 31 middle cerebral artery stem, 12 internal carotid artery, and 2 basilar artery. Overall, an EMSA score ≥ 4 had sensitivity = 75.6%, specificity = 62.2%, LR- = 0.39, and LR+ = 2.00 for proximal LVO. During the first 9 months of the study, the EMSA AUC = 0.61 (CI = 0.45 – 0.77) compared to an AUC = 0.74 (CI = 0.64 – 0.84) during the second 9 month period of the study. Conclusions: EMS stroke medical control based on communication center guided prehospital stroke assessment and ongoing quality improvement is feasible and results in sustained ability to identify patients with LVO. Further studies are needed to evaluate the impact of guided prehospital triage of patients with suspected LVO on health outcomes.

Objective The objective was to pilot a socioculturally tailored church-based stroke prevention program delivered by trained community health workers (CHWs) and to test its effects on participant knowledge scores. Design and Sample A single-group, pre-post test pilot study was conducted with a convenience sample of 201 adult African-Americans recruited from nine churches in three Alabama counties. Measurements included participant weight, blood pressure (BP), physical activity level; knowledge related to hypertension, heart disease, and stroke; cigarette smoking; and access to care, as well as the Stages of Change constructs within the Transtheoretical Model. The intervention was a six-session group-based health education program delivered by trained CHWs. Measures Measurements included participant weight, blood pressure (BP), physical activity level; knowledge related to hypertension, heart disease, and stroke; cigarette smoking; and access to care, as well as the Stages of Change constructs within the Transtheoretical Model. The intervention was a six-session group-based health education program delivered by trained CHWs. Results From baseline to 12 weeks, knowledge increased significantly (p < .001). Systolic BP measures improved (p = .0008). More than half of participants lost weight; however, weight change did not reach significance (p = .1380). Most (87%) participants indicated having a medical home at baseline; at the end of the study the percentage increased to 92% (p = .0138). Conclusion A church-based intervention delivered by trained CHWs is feasible and may be a promising public health strategy to increase knowledge regarding hypertension and stroke prevention among African-Americans.

We evaluate the effectiveness of global virtual student collaboration projects in international management education. Over 6,000 students from nearly 80 universities in 43 countries worked in globa...

Purpose – This paper aims to discuss the first effort to examine the relationships between satisfaction, the four loyalty phases, fortitude, and a sense of virtual community. Design/methodology/approach – Oliver proposed an innovative framework to explain the relationships between satisfaction, loyalty, fortitude, and a sense of community. Findings – Analysis of questionnaire responses of 493 customers of banks and credit unions indicated that satisfaction, cognitive, affective, conative, and action loyalty are positively related to fortitude. Research limitations/implications – The Beyond Loyalty Model (BLM) does not address important strategic issues often associated with loyalty, such as firm profitability, complaint resolution, and firm profitability. Practical implications – This research is the first to find that customers of financial institutions acquire satisfaction and strong loyalty ties with their bank or credit union after dealing with their financial services provider for a relatively short period of time. Thus financial institutions should consistently seek relationship-building opportunities from the outset of their relationships with their customers. Originality/value – The resulting Beyond Loyalty Model (BLM) improves upon the American Bankers Association ' s ABA Financial Client Satisfaction Index, and is a means by which financial institutions can monitor and enhance the satisfaction, loyalty, and fortitude of the customers of financial institutions. Further, the increasing acceptance of virtual banking calls for additional study of this area.

Purpose – The goal of this paper is to develop a customer typology for 3D virtual world by grouping similar Second Life (SL) virtual world users into homogeneous groups.Design/methodology/approach – The research method entails the empirical analysis of 176 survey respondents. The evaluation of the data was done using cluster analysis technique. The use of cluster analysis is appropriate for developing marketplace typology.Findings – The outcome of the study reveals the presence of three distinct customer clusters in SL virtual world: virtualskeptics, evirtualist, and virtualcentrist. Overall, the three distinct customer clusters differ on individual flow state and individual attitude toward SL.Research limitations/implications – Marketers can implement specific marketing strategies/tactics that take into consideration the similarities and differences among the members of the three groups identified in the analysis.Originality/value – The study reveals the existence of unique customer use behavior in the 3...

PurposeThe purpose of this research is to develop and test a sense of consumption community measurement scale. The concept is examined in an exploratory study in the context of the perceptions of customers of financial services firms.Design/methodology/approachThis research consults the marketing, banking, psychology, and public policy literature. A sense of consumption community scale is tested for validity via exploratory and confirmatory factor analysis. Scale reliability analysis is also conducted.FindingsThe result is a second‐order construct composed of the first‐order constructs, camaraderie and communality, and social capital. The construct is found to be a means of measuring the strength of consumers' perceptions of consumption community. Additional evidence of its practical value is demonstrated in four findings. First, partial support is found that men perceive a greater sense of community than women. Second, there is a positive relationship between age and perceived sense of community. Third, no significant relationship was found between the various types of financial institutions and customers' sense of consumption community. Fourth, an identical finding was obtained for the relationship between sense of community and longevity. And fifth, this research also documents limitations of the Sense of Consumption Community Construct due to the exploratory nature of this research effort.Originality/valueThe scale formulated in this research is the first to measure a sense of community among the customers of financial institutions.

Advergames are gaining recognition around the world as a new, captivating, and persuasive environment among advertisers. Despite its growing popularity, very little is known about the formation of attitudes toward advergames in emerging economies. The objectives of our study were the refinement and empirical testing of a model of the reactions generated by exposure to advergames among Mexicans, Peruvians, and Americans. A series of experiments revealed that Hispanics exhibited positive attitudes toward advergames. Intrusiveness was found as the factor accounting for most of the negative attitude toward advergames. Lack of congruence was found to be a precursor of intrusiveness. Interestingly, although ads in games were perceived as more intrusive, they were perceived as less irritating. Implications for advertisers are discussed.

This paper investigates the international marketing research published between 1982 and 1991. Specifically, the study extends previous work in two ways: 1) it considers the identity of the countries which are included in the publications, and 2) it considers whether the volume of international manuscripts in published journals has increased.

This study explores the effect of celebrities on consumers’ online behavior. The increased presence of online consumers has led to a need to self-present, and to develop oneself as a personal brand because online social media require members to create a personal profile. Online users developed their image(s), created and shared stories, and gradually built a presence in the online world.

This study examines the pattern of entry mode strategies of large U.S. and Japanese firms in the years 1987 to 1993. By following a total of 972 transactions, we found the country of origin of the investment had the most significant effect on the entry mode strategy. Further analysis indicated that U.S. firms favor acquisitions, followed by joint ventures and startups, whereas Japanese organizations prefer joint ventures to acquisitions and startups. In general, multinational firms from both countries avoid startups. Our findings suggest that governments should encourage U.S. investment if they are seeking capital inflows, but encourage Japanese involvement if they want locals to have greater operational control.

“Privatization” as a process is easily understood but the location of the privatization affects how complicated this process may be (see e.g. Hartley and Minor, 1995; Culpan & Kumar, 1995; Frydman & Rapaczynski, 1994; Jackson & Bilsen, 1994; Rondinelli, 1994; Welfens & Jasinski, 1994). For example, in the United States contracting with private firms to provide public services is already widespread. Many cities have recently transferred the collection and disposal of the waste generated by the businesses and people of the city to private firms. In most cases, public employees were competent, but savings were possible by having a private firm perform the work. Janitorial work in public schools is another area where private enterprises have been active. Considerable interest has also been shown in privatizing penal systems, and in privatizing Amtrak, the Tennessee Valley Authority, and the U.S. Postal Service, among others.

Restructuring activities in the former Soviet Union and Eastern Europe present enticing opportunities for firms to consider foreign investment in these emerging areas. Geographically, the population of the entire region is relatively conveniently concentrated, rendering delivery and servicing of goods and services relatively simple. Further, the population is greatly underserved, particularly in terms of consumer goods and services. The problems, as chronicled in the popular press, are, however, daunting. Based on a number of consultancies with firms over the last two years, identifies typical problems to be anticipated and suggests concrete steps to take in order to solve these problems.

This paper reports data collected on expropriation activity by developing countries from 1980–1992, extending previous work by Kobrin [1984]. Kobrin's assumption that expropriation activity would continue to decrease over time, and his reasons for this assumption, are supported. The paper introduces recent phenomena which further indicate that expropriation is unlikely to resurface in the near future as a source of multinational corporation-developing country contention. Many developing countries now protect foreign direct investors from expropriation. The broad-scale movement in developing countries to privatize state-owned enterprises also indicates that governments will not be eager to replace private-sector activity with state ownership.

Restructuring activities in Eastern Europe have been widely discussed. Examines firm‐level impediments to the conversion of state‐owned enterprises to market‐oriented firms operated for a profit. Based on the experience gained in several consultancies in Hungarian plants, the greatest problems faced by these firms may be at the operational level — accounting, personnel decisions, manufacturing processes. Suggestions for improvements in each of these areas, and others, are offered.

The impact of increasing clinical costs and the need for more data to support higher efficacy demands and overcome regulatory hurdles for market entry means that every Company is faced with the challenge of how to do more with a smaller budget. As budgets get squeezed the pharmaceutical Industry has been looking at how to contain or reduce cost and support an increased number of projects. With the growing sophistication of outsourcing, this is an increasingly important area of focus. Some Pharmaceutical Companies have moved from tactical, case by case, outsourcing to new, more strategic relationships, which involve outsourcing functions that were historically held as core pharmaceutical functions. An increasing number of Sponsors are looking at strategic relationships which are based on more creative outsourcing approaches. As the need and sophistication of these outsourcing models and the sponsors / CROs involved in them, these approaches are becoming more transformational and need to be based on a strong partnership. Lessons learned from working with sponsors in a partnership model have been examined and two key challenges addressed in detail: the need for bilateral central control though a strong governance model and the importance of early planning and commitment.

While international market entry strategy has been examined extensively, relatively little has been said about the contingencies affecting entry mode decisions, or interactions between these contingencies and their effect on the entry mode decision. A series of propositions is drawn to develop a contingency framework for entry strategy decisions, based on environmental factors, industry and product/market contingencies, organizational strengths, and strategic objectives of the firm, and preliminary propositions are provided which illustrate the interrelationships between these contingencies. A research agenda to integrate the study of interrelationships between contingencies affecting entry strategy is recommended.

(1990). The “Little Dragons” as Role Models. International Studies of Management & Organization: Vol. 20, Organization and Management in China: 1979–1990, pp. 85-95.

It has been noticed that merger and acquisitions (M&A) are one of the most interesting issues in research. In the history of M&A, global merger and acquisitions activities have increased dramatically during the 90s. In 1998, global merger and acquisitions transactions reached the record $1 trillion level - reaching a staggering $133 trillion. However, little was known about how the increase in global acquisitions during the 90s would spread out through all major regions of the world. Also, whether the Asian economic crisis would either encourage or discourage M&A activities was unclear. There were two possible streams that could be examined. The first stream was to observe acquisition activities of multinational firms in major regions before the Asian crisis (before 1997), and the second stream was to observe their acquisition activities after the crisis (after 1997). The first stream is the scope of this study. The study found that U.S. multinational firms exercised most of their M&A activities in their own region. The evidence shows the same result for British, German and French firms. This study shows that European multinational firms executed their M&A investments mostly in Europe. However, Japanese multinational firms made their M&A investments in the United States. This paper suggests that geography, location advantage, government policy, firm nationality, and type of industry might affect the investment behaviours of U.S., European and Japanese firms. Discussion and future research are presented in the paper.

This paper compares approaches to environmental risk management in Japan and the United States. The paper includes an historical examination of two case studies of environmental risk management: synthetic detergents and lead in gasoline. In addition, the paper discusses several important differences between Japan and the United States, including (a) different attitudes toward separating environmental risk management from environmental risk assessment, and (b) different approaches toward environmental risk management. Specifically, the Japanese approach is based largely on a cooperative model of risk management, with a strong emphasis on negotiation and consensus-building, while the U.S. approach is based largely on a confrontational model of risk management, with a strong emphasis on rigorous scientific analysis and open adverserial processes.

Risk management practices are the result of scientific risk analysis, subjective risk evaluation, governmental policy, economic concerns, interest group pressure, and cultural influences. One way of analyzing the relative influence of scientific, cultural and political factors is to examine how decisions for similar risks are made in different countries. Cross-national comparisons may suggest new or alternative approaches to improving the interaction between risk assessment and risk management.

Over the past two decades, concerns for the societal impacts- whether realized or potential- created by the adoption and application of technologies has both widened and deepened in most industrialized societies. This trend mirrors sharpening public concerns over the risks to human health and safety posed by technological hazards.

The theories of international political economy certainly lend themselves to classroom teaching. And courses on Asian politics and society have long been offered. Typically, however, international political economy and Asian studies are not formally mixed in a single course offering.My task was to devise a restricted-enrollment, upper-level seminar which encompassed political economy theory applied specifically to Asia. The department offered no courses in political economy, and the only offerings on Asia were two courses in Chinese politics I had taught the prior semester.Despite the lack of supporting coursework, the topic proved to provide an interesting conceptual focus, and students became quite engaged with the subject matter. Further, it appears that an explicit geographical focus may help, rather than hinder, the teaching of political economy concepts. The body of theory in international political economy is rather abstract in the absence of application to concrete situations. The Asian areas examined (Japan, China, Taiwan, and South Korea) provided stimulating grist for such concepts as interdependence, the connections between “high politics” (security policy) and “low politics” (economic relations), and the dependency-vs.-developmental models of economic growth.