The Pneumonia Severity Index: A Decade after the Initial Derivation and Validation

The prognosis of community-acquired pneumonia ranges from rapid resolution of symptoms and full recovery of functional status to the development of severe medical complications and death. The pneumonia severity index is a rigorously studied prediction rule for prognosis that objectively stratifies patients into quintiles of risk for short-term mortality on the basis of 20 demographic and clinical variables routinely available at presentation. The pneumonia severity index was derived and validated with data on >50,000 patients with community-acquired pneumonia by use of well-accepted methodological standards and is the only pneumonia decision aid that has been empirically shown to safely increase the proportion of patients given treatment in the outpatient setting. Because of its prognostic accuracy, methodological rigor, and effectiveness and safety as a decision aid, the pneumonia severity index has become the reference standard for risk stratification of community-acquired pneumoni

Large-N Universality of the Two-Dimensional Yang-Mills String

We exhibit the gauge-group independence (``universality'') of all normalized non-intersecting Wilson loop expectation values in the large N limit of two-dimensional Yang-Mills theory. This universality is most easily understood via the string theory reformulation of these gauge theories. By constructing an isomorphism between the string maps contributing to normalized Wilson loop expectation values in the different theories, we prove the large N universality of these observables on any surface. The string calculation of the Wilson loop expectation value on the sphere also leads to an indication of the large N phase transition separating strong- and weak-coupling phases.Comment: 18 pages, phyzzx macro, no figure

A monument to the player: Preserving a landscape of socio-cultural capital in the transitional MMORPG

This is the pre-print version of the Article. The official published version can be accessed from the links below - Copyright @ 2012 Taylor & Francis LtdMassively multiplayer online role-playing games (MMORPGs) produce dynamic socio-ludic worlds that nurture both culture and gameplay to shape experiences. Despite the persistent nature of these games, however, the virtual spaces that anchor these worlds may not always be able to exist in perpetuity. Encouraging a community to migrate from one space to another is a challenge now facing some game developers. This paper examines the case of Guild Wars® and its “Hall of Monuments”, a feature that bridges the accomplishments of players from the current game to the forthcoming sequel. Two factor analyses describe the perspectives of 105 and 187 self-selected participants. The results reveal four factors affecting attitudes towards the feature, but they do not strongly correlate with existing motivational frameworks, and significant differences were found between different cultures within the game. This informs a discussion about the implications and facilitation of such transitions, investigating themes of capital, value perception and assumptive worlds. It is concluded that the way subcultures produce meaning needs to be considered when attempting to preserve the socio-cultural landscape

Reasons Why Emergency Department Providers Do Not Rely on the Pneumonia Severity Index to Determine the Initial Site of Treatment for Patients with Pneumonia

Background. Many emergency department (ED) providers do not follow guideline recommendations for the use of the pneumonia severity index (PSI) to determine the initial site of treatment for patients with community-acquired pneumonia (CAP). We identified the reasons why ED providers hospitalize low-risk patients or manage higher-risk patients as outpatients. Methods. As a part of a trial to implement a PSI-based guideline for the initial site of treatment of patients with CAP, we analyzed data for patients managed at 12 EDs allocated to a high-intensity guideline implementation strategy study arm. The guideline recommended outpatient care for low-risk patients (nonhypoxemic patients with a PSI risk classification of I, II, or III) and hospitalization for higher-risk patients (hypoxemic patients or patients with a PSI risk classification of IV or V). We asked providers who made guideline-discordant decisions on site of treatment to detail the reasons for nonadherence to guideline recommendations. Results. There were 1,306 patients with CAP (689 low-risk patients and 617 higher-risk patients). Among these patients, physicians admitted 258 (37.4%) of 689 low-risk patients and treated 20 (3.2%) of 617 higher-risk patients as outpatients. The most commonly reported reasons for admitting low-risk patients were the presence of a comorbid illness (178 [71.5%] of 249 patients); a laboratory value, vital sign, or symptom that precluded ED discharge (73 patients [29.3%]); or a recommendation from a primary care or a consulting physician (48 patients [19.3%]). Higher-risk patients were most often treated as outpatients because of a recommendation by a primary care or consulting physician (6 [40.0%] of 15 patients). Conclusion. ED providers hospitalize many low-risk patients with CAP, most frequently for a comorbid illness. Although higher-risk patients are infrequently treated as outpatients, this decision is often based on the request of an involved physicia

Sources of inaccuracy in photoplethysmography for continuous cardiovascular monitoring

Photoplethysmography (PPG) is a low-cost, noninvasive optical technique that uses change in light transmission with changes in blood volume within tissue to provide information for cardiovascular health and fitness. As remote health and wearable medical devices become more prevalent, PPG devices are being developed as part of wearable systems to monitor parameters such as heart rate (HR) that do not require complex analysis of the PPG waveform. However, complex analyses of the PPG waveform yield valuable clinical information, such as: blood pressure, respiratory information, sympathetic nervous system activity, and heart rate variability. Systems aiming to derive such complex parameters do not always account for realistic sources of noise, as testing is performed within controlled parameter spaces. A wearable monitoring tool to be used beyond fitness and heart rate must account for noise sources originating from individual patient variations (e.g., skin tone, obesity, age, and gender), physiology (e.g., respiration, venous pulsation, body site of measurement, and body temperature), and external perturbations of the device itself (e.g., motion artifact, ambient light, and applied pressure to the skin). Here, we present a comprehensive review of the literature that aims to summarize these noise sources for future PPG device development for use in health monitoring

Dust Streamers in the Virgo Galaxy M86 from Ram Pressure Stripping of its Companion VCC 882

The giant elliptical galaxy M86 in Virgo has a ~28 kpc long dust trail inside its optical halo that points toward the nucleated dwarf elliptical galaxy, VCC 882. The trail seems to be stripped material from the dwarf. Extinction measurements suggest that the ratio of the total gas mass in the trail to the blue luminosity of the dwarf is about unity, which is comparable to such ratios in dwarf irregular galaxies. The ram pressure experienced by the dwarf galaxy in the hot gaseous halo of M86 was comparable to the internal gravitational binding energy density of the presumed former gas disk in VCC 882. Published numerical models of this case are consistent with the overall trail-like morphology observed here. Three concentrations in the trail may be evidence for the predicted periodicity of the mass loss. The evaporation time of the trail is comparable to the trail age obtained from the relative speed of the galaxies and the trail length. Thus the trail could be continuously formed from stripped replenished gas if the VCC 882 orbit is bound. However, the high gas mass and the low expected replenishment rate suggest that this is only the first stripping event. Implications for the origin of nucleated dwarf ellipticals are briefly discussed.Comment: 22 pages, 7 figures, Astronomical Journal, August 2000, in pres

Validation of a model to predict adverse outcomes in patients with pulmonary embolism

Aims To validate a model for quantifying the prognosis of patients with pulmonary embolism (PE). The model was previously derived from 10 534 US patients. Methods and results We validated the model in 367 patients prospectively diagnosed with PE at 117 European emergency departments. We used baseline data for the model's 11 prognostic variables to stratify patients into five risk classes (I-V). We compared 90-day mortality within each risk class and the area under the receiver operating characteristic curve between the validation and the original derivation samples. We also assessed the rate of recurrent venous thrombo-embolism and major bleeding within each risk class. Mortality was 0% in Risk Class I, 1.0% in Class II, 3.1% in Class III, 10.4% in Class IV, and 24.4% in Class V and did not differ between the validation and the original derivation samples. The area under the curve was larger in the validation sample (0.87 vs. 0.78, P=0.01). No patients in Classes I and II developed recurrent thrombo-embolism or major bleeding. Conclusion The model accurately stratifies patients with PE into categories of increasing risk of mortality and other relevant complications. Patients in Risk Classes I and II are at low risk of adverse outcomes and are potential candidates for outpatient treatmen

Hyperentangled States

We investigate a new class of entangled states, which we call 'hyperentangled',that have EPR correlations identical to those in the vacuum state of a relativistic quantum field. We show that whenever hyperentangled states exist in any quantum theory, they are dense in its state space. We also give prescriptions for constructing hyperentangled states that involve an arbitrarily large collection of systems.Comment: 23 pages, LaTeX, Submitted to Physical Review

What Affects Influenza Vaccination Rates among Older Patients? An Analysis from Inner-city, Suburban, Rural, and Veterans Affairs Practices

BACKGROUND: Despite strong evidence of the effectiveness of influenza vaccination, immunization rates have reached a plateau that is below the 2010 national goals. Our objective was to identify facilitators of, and barriers to, vaccination in diverse groups of older patients. METHODS: A survey was conducted in 2000 by computer-assisted telephone interviewing of patients from inner-city health centers, Veterans Affairs (VA) outpatient clinics, rural practices, and suburban practices. The inclusion criteria were age ≥66 years and an office visit after September 30, 1998. RESULTS: Overall, 1007 (73%) interviews were completed among 1383 patients. Influenza vaccination rates were 91% at VA clinics, 79% at rural practices, 79% at suburban practices, and 67% at inner-city health centers. There was substantial variability in vaccination rates among practices, except at the VA. Nearly all persons who were vaccinated reported that their physicians recommended influenza vaccinations, compared with 63% of unvaccinated patients (P \u3c 0.001). Thirty-eight percent of unvaccinated patients were concerned that they would get influenza from the vaccine, compared with only 6% of vaccinated persons (P \u3c 0.001). Sixty-three percent of those vaccinated, in contrast with 22% of unvaccinated persons, thought that an unvaccinated person would probably contract influenza (P \u3c 0.001). CONCLUSION: Older patients need intentional messages from physicians that recommend vaccination. Furthermore, more patient education is needed to counter myths about adverse reactions