Specifying Exposure Classification Parameters for Sensitivity Analysis: Family Breast Cancer History

One of the challenges to implementing sensitivity analysis for exposure misclassification is the process of specifying the classification proportions (eg, sensitivity and specificity). The specification of these assignments is guided by three sources of information: estimates from validation studies, expert judgment, and numerical constraints given the data. The purpose of this teaching paper is to describe the process of using validation data and expert judgment to adjust a breast cancer odds ratio for misclassification of family breast cancer history. The parameterization of various point estimates and prior distributions for sensitivity and specificity were guided by external validation data and expert judgment. We used both nonprobabilistic and probabilistic sensitivity analyses to investigate the dependence of the odds ratio estimate on the classification error. With our assumptions, a wider range of odds ratios adjusted for family breast cancer history misclassification resulted than portrayed in the conventional frequentist confidence interval.Children's Cancer Research Fund, Minneapolis, MN, US

The nature of the emission-line nebulae in powerful far-infrared galaxies

The authors discuss their program of narrow-band (H alpha + (NII)) imaging of a sample of 30 powerful far-infrared galaxies (FIRG's) chosen to have far-infrared spectral energy distributions similar to the prototype FIRG's Arp 220, NGC 3690, NGC 6240, and M82. The emission-line nebulae of these IR color-selected sample (ICSS) galaxies as a class are both impressively large (mean half light radius, r approx. 1.3 Kpc, and mean diameter, D approx. 16 Kpc) and luminous (L sub TOT approx. 10(exp 8) solar lumninosity; uncorrected for internal extinction). The mean total H alpha + (NII) luminosity of the FIRG's is comparable to that found for pairs of optically selected interacting galaxies (Bushouse, Lamb, and Werner 1988), but is a factor of approx. 5 greater than that of isolated spirals (Kennicutt and Kent 1983). Only approx. 25 percent of the nearby (z approx. less than 0.10) FIRG's have morphologies suggesting that large HII-regions contribute significantly to their emission-line appearance. The broad-band morphologies of our IR color-selected galaxies fall into three major categories. Nearly 75 percent are single galaxy systems, with the remaining FIRG's being either multiple nuclei systems, or members of interacting pairs. Since the authors saw few (10 percent) currently interacting FIRG's, yet many (80 percent) with highly distorted continuum morphologies, their IR color criteria may be preferentially selecting galaxies that have undergone highly inelastic, rapidly merging interactions

Starburst-driven superwinds from infrared galaxies

New data is presented that indicate that strong far infrared galaxies commonly have largescale emission line nebulae whose properties are suggestive of mass outflows (superwinds), presumably driven by the high supernova rate associated with the central starburst. These data include longslit spectra of M82 which show that the radial variation of the gas pressure in the emission line nebula is in excellent agreement with a previous wind model. The M82 nebula also has a LINER spectrum, consistent with shock heating. Morphologically and spectroscopically similar emission line nebulae were found in NGC253, and Arp 220 and NGC6240. A longslit spectroscopic investigation was conducted of 20 additional very powerful far-infrared galaxies and found that they generally have spatially extended emission line nebulae whose spectra closely resemble that of the M82 nebula. If the superwind interpretation is correct, it could have many important consequences in extragalactic astronomy

Detectable HIV Viral Load in Kenya: Data from a Population-Based Survey.

IntroductionAt the individual level, there is clear evidence that Human Immunodeficiency Virus (HIV) transmission can be substantially reduced by lowering viral load. However there are few data describing population-level HIV viremia especially in high-burden settings with substantial under-diagnosis of HIV infection. The 2nd Kenya AIDS Indicator Survey (KAIS 2012) provided a unique opportunity to evaluate the impact of antiretroviral therapy (ART) coverage on viremia and to examine the risks for failure to suppress viral replication. We report population-level HIV viral load suppression using data from KAIS 2012.MethodsBetween October 2012 to February 2013, KAIS 2012 surveyed household members, administered questionnaires and drew serum samples to test for HIV and, for those found to be infected with HIV, plasma viral load (PVL) was measured. Our principal outcome was unsuppressed HIV viremia, defined as a PVL ≥ 550 copies/mL. The exposure variables included current treatment with ART, prior history of an HIV diagnosis, and engagement in HIV care. All point estimates were adjusted to account for the KAIS 2012 cluster sampling design and survey non-response.ResultsOverall, 61·2% (95% CI: 56·4-66·1) of HIV-infected Kenyans aged 15-64 years had not achieved virological suppression. The base10 median (interquartile range [IQR]) and mean (95% CI) VL was 4,633 copies/mL (0-51,596) and 81,750 copies/mL (59,366-104,134), respectively. Among 266 persons taking ART, 26.1% (95% CI: 20.0-32.1) had detectable viremia. Non-ART use, younger age, and lack of awareness of HIV status were independently associated with significantly higher odds of detectable viral load. In multivariate analysis for the sub-sample of patients on ART, detectable viremia was independently associated with younger age and sub-optimal adherence to ART.DiscussionThis report adds to the limited data of nationally-representative surveys to report population- level virological suppression. We established heterogeneity across the ten administrative and HIV programmatic regions on levels of detectable viral load. Timely initiation of ART and retention in care are crucial for the elimination of transmission of HIV through sex, needle and syringe use or from mother to child. Further refinement of geospatial mapping of populations with highest risk of transmission is necessary

Free-for benefit: A stragety to improve the quality of health care and control costs through reimbursement incentives

AbstractObjectives. The purpose of this study was to determine whether reimbursement in direct proportion to expected therapeutic benefit is capable of improving the utilization and cost of health care.Background. The benefit associated with a particular medical or surgical treatment varies widely from patient to patient. Nevertheless, payment to the provider of the treatment is essentially invariant under the current fee-for-service system. Under an alternative fee-for-benefit strategy, empiric data are used to construct a multivariable model to predict the exprcted benefit to an individual patient from a particular health care service on the basis of conventional clinical descriptors. The payers and the providers of the service then openly negotiate an explicit economic relation between expected benefit and monetary payment such that payment is directly proportional to benefit.Methods. Computer simulations were performed to determine the potential impact of this fee-for-benefit strategy with respect to medical versus surgical treatment of coronary artery disease.Results. Compared with conventional fee-for-service, fee-for-benefit resulted in a 12% improvement in patient benefit (quality-adjusted survival), a 22% reduction in provider payments and a 55% increase in cost/benefit (the ratio of benefit to payment).Conclusions. The incentives embodied in a fee-for-benefit strategy can be an effective mechanism for encouraging more appropriate health care utilization while simultaneously controlling health care costs

Drug Courts: A Bridge to Recovery

Drug courts are an alternative to traditional prosecution in which a collaborative team of medical clinicians, social workers, lawyers and probation officers work together to try to find a path out of addiction. Supervised probation, mandatory treatments, as well as random drug testing with progress monitored by a supervising probation officer, the court works with a team of treatment providers, which provide clinical assessment, develop and monitor treatment placements and identify ancillary counseling, case management and outreach services. Join Judge Timothy Bibaud and Drug Court Graduates Kayla and Shenandoah for their informative, and personal stories about how drug courts address the underlying causes of criminal behavior, substance use disorder and/or mental illness. Judge Bibaud presides over the Dudley District Drug Court in Dudley, Massachusetts. Kayla and Shenandoah earned their lives back thanks to this innovative treatment strategy and Judge Bibaud’s team of caring and empathetic professionals at the Dudley District Drug Court. Learning Objectives: Participants will be able to do the following: Explain the treatment model that offers a structured approach for interacting with those involved with the justice system. Discuss how this model works with programs designed to curb criminal recidivism and reduce drug use. Discuss the prevalence of drug courts in the US. Explain the effectiveness of Drug Courts with success stories from the Dudley, MA Drug Court Discuss common problems with drug courts that can affect the successfu

Evidence of Multiple r-Process Sites in the Early Galaxy: New Observations of CS 22892-052

First results are reported of a new abundance study of neutron-capture elements in the ultra-metal-poor (UMP; [Fe/H] = -3.1) halo field giant star CS 22892-052. Using new high resolution, high signal-to-noise spectra, abundances of more than 30 neutron-capture elements (Z>30) have been determined. Six elements in the 40<Z<56 domain (Nb, Ru, Rh, Pd, Ag and Cd) have been detected for the first time in a UMP star. Abundances are also derived for three of the heaviest stable elements (Os, Ir, and Pb). A second transition of thorium, Th{4086}, confirms the abundance deduced from the standard Th{4019} line, and an upper limit to the abundance of uranium is established from the absence of the U{3859} line. As found in previous studies, the abundances of the heavier (Z>=56) stable neutron-capture elements in CS 22892-052 match well the scaled solar system r-process abundance distribution. From the observed Th abundance, an average age of ~= 16 +/- 4 Gyr is derived for cs22892-052, consistent with the lower age limit of ~= 11 Gyr derived from the upper limit on the U abundance. The concordance of scaled solar r-process and CS 22892-052 abundances breaks down for the lighter neutron-capture elements, supporting previous suggestions that different r-process production sites are responsible for lighter and heavier neutron-capture elements.Comment: To be published in the Astrophysical Journal Letter