Final report on the evaluation of the RAC input data elements.

The Resource Allocation Criteria (RAC) began to develop in 1972, responding to management requirements of the Indian Health Service (IHS). The RAC is now the principal management tool of the IHS Manpower Management Program, which justifies all manpower-related budgetary requests to the Department of Health and Human Services (DHHS). RAC fulfills its obligations by identifying necessary tasks to provide quality resources for each segment of the health care system. The purpose of this study was to determine the reliability of the data inputs to RAC, the degree to which the quality of the input affects the reliability of the output. and Identification of means to improve the quality of input data. The study first identified input data elements through the use of archival (RAC) records and interviews with IHS personnel. From this data, flow charts and profile sheets were compiled. IHS Program/Area Offices site visits were then initiated. Here, patient records were sampled, meetings with site personnel to review methods in use were held, and local finance and contract personnel were interviewed to determine volume of and tracking method for services. Using these data, flow charts were developed and data estimates were constructed using all previously gathered material. From these data estimates, the accuracy of RAC input data was compared with the actual data collected and the constructed data estimates. The findings of the study included: 1) as a result of perceived undercounting, population data from IHS suffers from a lack of confidence at the Area Offices; 2) both inpatient and outpatient data are suspect because of the practice of issuing one patient more than one patient number and, conversely issuing the same patient number to more than one patient; 3) illegible record entries hinder accurate patient data gathering; 4) a high turnover in record keeping personnel; 5) a significantly lower error rate in inpatient data than in outpatient data; 6) a number of inpatient and outpatient records never enter the IHS data system; 7) alcoholism is not always reported as the cause of medical attention in projecting demand for contract health services; 8) RAC does not adequately project the additional need for P.L. 638 contracting; 9) data is often lacking from HSA-43 and HSA-64 reporting forms; 10) contract health service providers are not always audited; 11) many contract service bills are submitted after the close of the fiscal year; 12) RAC staffing tables are relatively insensitive from a statistical perspective; and 13) Service Units and Area Offices are more accurate predictors of direct service needs than are contract providers. Numerous recommendations are made concerning: 1) the national decennial census; 2) population migration and projections; 3) a unique patient identification numbering system; 4) inpatient and outpatient data verification procedures; 5) feasibility of developing the HSA-44-1 and the HSA-406 as clinical management tools; 6) an inventory of the patient record system; 7) Area Offices review systems checks; 8) the accuracy of patient data; 9) use of HSA-406 forms during itinerant visits; 10) a training program for Community Health Aides (CHAs); 11) reporting alcoholism as a primary diagnosis; 12) projected utilization of contract services to actual contract services needs; 13) a method of identifying and projecting P.L. 638 costs; 14) efforts to obtain all contractor invoices before the end of the fiscal year; 15) algorithms that support staffing tables and then perform another sensitivity analysis; and 21) standardization of collection, reporting, and recording parameters of projected and actual data and ensure a consistent application in developing RAC input data

Chronic lymphocytic leukemia and the central nervous system: a clinical and pathological study.

Chronic lymphocytic leukemia is the most common human leukemia but infrequently causes neurologic symptoms. We have reviewed all previously reported cases of chronic lymphocytic leukemia in the CNS along with three new cases; one patient was diagnosed antemortem and treated with immediate improvement and 4-year survival. In addition, we reviewed all autopsy cases since 1972 and available lumbar puncture data on patients with chronic lymphocytic leukemia admitted to the Massachusetts General Hospital. Invasion of the CNS by chronic lymphocytic leukemia often leads to confusional state, meningitis with cranial nerve abnormalities, optic neuropathy, or cerebellar dysfunction. Lumbar puncture shows a lymphocytosis consisting of monoclonal B cells, but CSF cytology studies are of limited value in establishing the diagnosis. Long-term survival may be related to the stage of chronic lymphocytic leukemia at the time of CNS disease and may be associated with intrathecal chemotherapy. A mild, asymptomatic infiltration of the brain, frequently noted in late-stage chronic lymphocytic leukemia in autopsy series, may explain the CSF lymphocytosis in some patients with late-stage chronic lymphocytic leukemia

Characteristics of C-4 photosynthesis in stems and petioles of C-3 flowering plants

Most plants are known as C-3 plants because the first product of photosynthetic CO2 fixation is a three-carbon compound. C-4 plants, which use an alternative pathway in which the first product is a four-carbon compound, have evolved independently many times and are found in at least 18 families. In addition to differences in their biochemistry, photosynthetic organs of C-4 plants show alterations in their anatomy and ultrastructure. Little is known about whether the biochemical or anatomical characteristics of C-4 photosynthesis evolved first. Here we report that tobacco, a typical C-3 plant, shows characteristics of C-4 photosynthesis in cells of stems and petioles that surround the xylem and phloem, and that these cells are supplied with carbon for photosynthesis from the vascular system and not from stomata. These photosynthetic cells possess high activities of enzymes characteristic of C-4 photosynthesis, which allow the decarboxylation of four-carbon organic acids from the xylem and phloem, thus releasing CO2 for photosynthesis. These biochemical characteristics of C-4 photosynthesis in cells around the vascular bundles of stems of C-3 plants might explain why C-4 photosynthesis has evolved independently many times

Cerebral Infarction Producing Sudden Isolated Foot Drop

Foot drop usually results from lesions affecting the peripheral neural pathway related to dorsiflexor muscles, especially the peroneal nerve. Although a central nervous system lesion is suspected when there is a lack of clinical evidence for a lower motor neuron lesion, such cases are extremely rare. We describe a patient with sudden isolated foot drop caused by a small acute cortical infarction in the high convexity of the precentral gyrus. This report indicates that a cortical infarction may have to be considered as a potential cause of foot drop

End-to-end verifiable elections in the standard model

We present the cryptographic implementation of “DEMOS”, a new e-voting system that is end-to-end verifiable in the standard model, i.e., without any additional “setup” assumption or access to a random oracle (RO). Previously known end-to-end verifiable e-voting systems required such additional assumptions (specifically, either the existence of a “randomness beacon” or were only shown secure in the RO model). In order to analyze our scheme, we also provide a modeling of end-to-end verifiability as well as privacy and receipt-freeness that encompasses previous definitions in the form of two concise attack games. Our scheme satisfies end-to-end verifiability information theoretically in the standard model and privacy/receipt-freeness under a computational assumption (subexponential Decisional Diffie Helman). In our construction, we utilize a number of techniques used for the first time in the context of e-voting schemes that include utilizing randomness from bit-fixing sources, zero-knowledge proofs with imperfect verifier randomness and complexity leveraging

Characteristics associated with quality of life among people with drug-resistant epilepsy

Quality of Life (QoL) is the preferred outcome in non-pharmacological trials, but there is little UK population evidence of QoL in epilepsy. In advance of evaluating an epilepsy self-management course we aimed to describe, among UK participants, what clinical and psycho-social characteristics are associated with QoL. We recruited 404 adults attending specialist clinics, with at least two seizures in the prior year and measured their self-reported seizure frequency, co-morbidity, psychological distress, social characteristics, including self-mastery and stigma, and epilepsy-specific QoL (QOLIE-31-P). Mean age was 42 years, 54% were female, and 75% white. Median time since diagnosis was 18 years, and 69% experienced ≥10 seizures in the prior year. Nearly half (46%) reported additional medical or psychiatric conditions, 54% reported current anxiety and 28% reported current depression symptoms at borderline or case level, with 63% reporting felt stigma. While a maximum QOLIE-31-P score is 100, participants’ mean score was 66, with a wide range (25–99). In order of large to small magnitude: depression, low self-mastery, anxiety, felt stigma, a history of medical and psychiatric comorbidity, low self-reported medication adherence, and greater seizure frequency were associated with low QOLIE-31-P scores. Despite specialist care, UK people with epilepsy and persistent seizures experience low QoL. If QoL is the main outcome in epilepsy trials, developing and evaluating ways to reduce psychological and social disadvantage are likely to be of primary importance. Educational courses may not change QoL, but be one component supporting self-management for people with long-term conditions, like epilepsy

Round-Optimal Secure Two-Party Computation from Trapdoor Permutations

In this work we continue the study on the round complexity of secure two-party computation with black-box simulation. Katz and Ostrovsky in CRYPTO 2004 showed a 5 (optimal) round construction assuming trapdoor permutations for the general case where both players receive the output. They also proved that their result is round optimal. This lower bound has been recently revisited by Garg et al. in Eurocrypt 2016 where a 4 (optimal) round protocol is showed assuming a simultaneous message exchange channel. Unfortunately there is no instantiation of the protocol of Garg et al. under standard polynomial-time hardness assumptions. In this work we close the above gap by showing a 4 (optimal) round construction for secure two-party computation in the simultaneous message channel model with black-box simulation, assuming trapdoor permutations against polynomial-time adversaries. Our construction for secure two-party computation relies on a special 4-round protocol for oblivious transfer that nicely composes with other protocols in parallel. We define and construct such special oblivious transfer protocol from trapdoor permutations. This building block is clearly interesting on its own. Our construction also makes use of a recent advance on non-malleability: a delayed-input 4-round non-malleable zero knowledge argument

Systematic assessment of training-induced changes in corticospinal output to hand using frameless stereotaxic transcranial magnetic stimulation.

Measuring changes in the characteristics of corticospinal output has become a critical part of assessing the impact of motor experience on cortical organization in both the intact and injured human brain. In this protocol we describe a method for systematically assessing training-induced changes in corticospinal output that integrates volumetric anatomical MRI with transcranial magnetic stimulation (TMS). A TMS coil is sited to a target grid superimposed onto a 3D MRI of cortex using a stereotaxic neuronavigation system. Subjects are then required to exercise the first dorsal interosseus (FDI) muscle on two different tasks for a total of 30 min. The protocol allows for reliably and repeatedly detecting changes in corticospinal output to FDI muscle in response to brief periods of motor training

Understanding and optimising patient and public involvement in trial oversight: an ethnographic study of eight clinical trials

BACKGROUND: Trial oversight is important for trial governance and conduct. Patients and/or lay members of the public are increasingly included in trial oversight committees, influenced by international patient and public involvement (PPI) initiatives to improve the quality and relevance of research. However, there is a lack of guidance on how to undertake PPI in trial oversight and tokenistic PPI remains an issue. This paper explores how PPI functions in existing trial oversight committees and provides recommendations to optimise PPI in future trials. This was part of a larger study investigating the role and function of oversight committees in trials facing challenges. METHODS: Using an ethnographic study design, we observed oversight meetings of eight UK trials and conducted semi-structured interviews with members of their trial steering committees (TSCs) and trial management groups (TMGs) including public contributors, trial sponsors and funders. Thematic analysis of data was undertaken, with findings integrated to provide a multi-perspective account of how PPI functions in trial oversight. RESULTS: Eight TSC and six TMG meetings from eight trials were observed, and 66 semi-structured interviews conducted with 52 purposively sampled oversight group members, including three public contributors. PPI was reported as beneficial in trial oversight, with public members contributing a patient voice and fulfilling a patient advocacy role. However, public contributors were not always active at oversight meetings and were sometimes felt to have a tokenistic role, with trialists reporting a lack of understanding of how to undertake PPI in trial oversight. To optimise PPI in trial oversight, the following areas were highlighted: the importance of planning effective strategies to recruit public contributors; considering the level of oversight and stage(s) of trial to include PPI; support for public contributors by the trial team between and during oversight meetings. CONCLUSIONS: We present evidence-based recommendations to inform future PPI in trial oversight. Consideration should be given at trial design stage on how to recruit and involve public contributors within trial oversight, as well as support and mentorship for both public contributors and trialists (in how to undertake PPI effectively). Findings from this study further strengthen the evidence base on facilitating meaningful PPI within clinical trials