Spatial Cluster Detection for Weighted Outcomes Using Cumulative Geographic Residuals

Spatial cluster detection is an important methodology for identifying regions with excessive numbers of adverse health events without making strong model assumptions on the underlying spatial dependence structure. Previous work has focused on point or individual-level outcome data and few advances have been made when the outcome data are reported at an aggregated level, e.g. at the county- or census tract-level. This paper proposes a new class of spatial cluster detecion methods for point or aggregate data, comprising of continuous, binary, and count data. Compared with the existing spatial cluster detection methods it has the following advantages. First, it readily incorporates region-specific weights, for example, based on a region’s population or a region’s outcome variance, which is key for aggregate data. Second, the established general framework allows for area-level and individual-level covariate adjustment. A simulation study is conducted to evaluate the performance of the method. The proposed method is then applied to assess spatial clustering of high Body Mass Index in a HMO population in the Seattle, Washington USA area

Influence of body mass index on the choice of therapy for depression and follow-up care

Overweight and obese patients commonly suffer from depression and choice of depression therapy may alter weight. We conducted a cohort study to investigate whether obesity is associated with treatment choices for depression; and whether obesity is associated with appropriate duration of depression treatment and receipt of follow-up visits. Adults with a diagnosis of depression between January 1, 2006 and March 31, 2010 who had 1+ new episodes of an antidepressant medication and/or psychotherapy were eligible. Medication use, encounters, diagnoses, height, and weight were collected from health plan databases. We modeled receipt of the different therapies (medication and psychotherapy) by BMI and BMI trajectory during the 9-months prior to initiation of therapy using logistic regression models that accommodated correlation within provider and adjusted for covariates. We modeled BMI via a restricted cubic spline. Fluoxetine was the reference treatment option in the medication models. Lower BMI was associated with greater use of mirtazapine, and a declining BMI prior to treatment was associated with greater odds of initiating mirtazapine and paroxetine. Higher BMI was associated with greater odds of initiating bupropion even after adjustment for smoking status. Obese patients were less likely to receive psychotherapy and less likely to receive appropriate duration (180-days) of depression treatment compared to normal weight subjects. Our study provides evidence that BMI is considered when choosing therapy but associations were weak. Our results should prompt discussion about recommending and choosing depression treatment plans that optimize depression care and weight management concurrently. Differences in care and follow-up by BMI warrant additional research

A New Approach to Hazard Analysis for Rotorcraft

STPA is a new hazard analysis technique that can identify more hazard causes than traditional techniques. It is based on the assumption that accidents result from unsafe control rather than component failures. To demonstrate and evaluate STPA for its application to rotorcraft, it was used to analyze the UH-60MU Warning, Caution, and Advisory (WCA) system associated with the electrical and fly-by-wire flight control system (FCS). STPA results were compared with an independently conducted hazard analysis of the UH-60MU using traditional safety processes described in SAE ARP 4761 and MIL-STD-882E. STPA found the same hazard causes as the traditional techniques and also identified things not found using traditional methods, including design flaws, human behavior, and component integration and interactions. The analysis includes organizational and physical components of systems and can be used to design safety into the system from the beginning of development while being compliant with MIL-STD-882. Copyright 2016 by American Helicopter Society International All right reserved

The 2016 Academic Emergency Medicine Consensus Conference, Shared Decision Making in the Emergency Department: Development of a Policy-relevant Patient-centered Research Agenda Diagnostic Testing Breakout Session Report.

Diagnostic testing is an integral component of patient evaluation in the emergency department (ED). Emergency clinicians frequently use diagnostic testing to more confidently exclude worst-case diagnoses rather than to determine the most likely etiology for a presenting complaint. Increased utilization of diagnostic testing has not been associated with reductions in disease-related mortality but has led to increased overall healthcare costs and other unintended consequences (e.g., incidental findings requiring further workup, unnecessary exposure to ionizing radiation or potentially nephrotoxic contrast). Shared decision making (SDM) presents an opportunity for clinicians to discuss the benefits and harms associated with diagnostic testing with patients to more closely tailor testing to patient risk. This article introduces the challenges and opportunities associated with incorporating SDM into emergency care by summarizing the conclusions of the diagnostic testing group at the 2016 Academic Emergency Medicine Consensus Conference on SDM. Three primary domains emerged: 1) characteristics of a condition or test appropriate for SDM, 2) critical elements of and potential barriers to SDM discussions on diagnostic testing, and 3) financial aspects of SDM applied to diagnostic testing. The most critical research questions to improve engagement of patients in their acute care diagnostic decisions were determined by consensus

A Randomized, Double-Blind Study of Larazotide Acetate to Prevent the Activation of Celiac Disease During Gluten Challenge

OBJECTIVES: In patients with celiac disease, enteropathy is caused by the entry of gluten peptides into the lamina propria of the intestine, in which their immunogenicity is potentiated by tissue transglutaminase (tTG) and T-helper type 1–mediated immune responses are triggered. Tight junction disassembly and paracellular permeability are believed to have an important role in the transport of gluten peptides to the lamina propria. Larazotide acetate is a tight-junction regulator peptide that, in vitro, prevents the opening of intestinal epithelial tight junctions. The aim of this study was to evaluate the efficacy and tolerability of larazotide acetate in protecting against gluten-induced intestinal permeability and gastrointestinal symptom severity in patients with celiac disease. METHODS: In this dose-ranging, placebo-controlled study, 86 patients with celiac disease controlled through diet were randomly assigned to larazotide acetate (0.25, 1, 4, or 8 mg) or placebo three times per day with or without gluten challenge (2.4 g/day) for 14 days. The primary efficacy outcome was the urinary lactulose/mannitol (LAMA) fractional excretion ratio. Secondary endpoints included gastrointestinal symptom severity, quality-of-life measures, and antibodies to tTG. RESULTS: LAMA measurements were highly variable in the outpatient setting. The increase in LAMA ratio associated with the gluten challenge was not statistically significantly greater than the increase in the gluten-free control. Among patients receiving the gluten challenge, the difference in the LAMA ratios for the larazotide acetate and placebo groups was not statistically significant. However, larazotide acetate appeared to limit gluten-induced worsening of gastrointestinal symptom severity as measured by the Gastrointestinal Symptom Rating Scale at some lower doses but not at the higher dose. Symptoms worsened significantly in the gluten challenge–placebo arm compared with the placebo–placebo arm, suggesting that 2.4 g of gluten per day is sufficient to induce reproducible gluten toxicity. Larazotide acetate was generally well tolerated. No serious adverse events were observed. The most common adverse events were headache and urinary tract infection. CONCLUSIONS: LAMA variability in the outpatient setting precluded accurate assessment of the effect of larazotide acetate on intestinal permeability. However, some lower doses of larazotide acetate appeared to prevent the increase in gastrointestinal symptom severity induced by gluten challenge

Labor Dispute and Unemployment Compensation: A Reply

Notes and Comments: Labor La

THE EARLY LIABILITY OF A BAILEE

All discussion of the origin of the absolute liability of a common carrier of goods naturally harks back to the earliest conception of a bailment and its related remedies. We have had two diametrically opposed views urged as to the first liability of the ordinary bailee. Justice Holmes and numerous other authorities take the view that the liability in the\u27 first instance was absolute in the case of all bailees. Professor Beale is the exponent of the opposing view, that such liability was qualified to such an extent that it amounted in fact, only to negligence liability. An interpretation of these early cases may be made, I think, which will bring into closer harmony the two apparently opposite views of the rules of law which might have existed before the famous cases of Coggs v. Bernard and Foward v. Pittard

Resilience and Heterogeneity Following Fire in the Nebraska Sandhills

The Nebraska Sandhills grassland is an expansive, semi-arid ecosystem characterized by vegetation-stabilized rolling sand dunes. The Sandhills grassland is managed for livestock production by seeking to minimizing disturbances, such as fire, that increase bare ground. The increase in bare ground following fire has contributed to the fear of fire leading to the emergence of a mobile sand dune state. We tracked vegetation response following a growing season wildfire that occurred during extreme drought conditions. In wildfire and drought conditions are when one would expect resilience to be overcome leading to a lack of vegetation recovery and a transition to a mobile sand dune state. However, aboveground herbaceous biomass recovered to unburned levels after two years and resisted a transition to an undesirable plant community. Next, we assessed the potential for focal fire and grazing to create heterogeneity of grassland structure and composition in order to increase biodiversity. Using patch burning, discrete patches were burned annually and grazers were allowed to select between recently burned and unburned areas. We found the Sandhills grassland is spatially homogeneous in vegetation structure and composition with greater structural heterogeneity emerging temporally in the transition from growing to dormant season. However, temporal heterogeneity manifests as an artifact of how vegetation was classified. Although live herbaceous vegetation decreases in the transition to dormant season, grassland vegetation structure is only slightly affected because herbaceous standing dead vegetation increases as a result of herbaceous vegetation senescence. Advisors: Dirac Twidwell and Walter H. Schach