Diabetes Disease Management in a Community-Based Setting

through 1 year. Differences in behavior are compared at program intake and at a 6-month reassessment. Differences in medical-service utilization are compared in the baseline year and the year subsequent to program enrollment. Poisson multivariateregression models are estimated for counts of inpatient, emergency department, physician evaluation and management, and facility visits, while also controlling for potential confounders. Principal findings. Behaviors improved between program intake and the 6-month reassessment. From patient reports, the number of participants having a hemoglobin A 1c test increased by 44.9 percent (p<.001), and there was a 53.2-percent decrease in symptoms of hyperglycemia (p=.002). From medical claims after program enrollment, a drop occurred during the program year in every dimension of medical-service utilization. Regression results show that inpatient admissions decreased by 391 (p<.001) per 1,000 for each group, while controlling for age, length of membership, and the number of comorbid claims for congestive heart failure. In the analysis of costs that were pre-and post-enrollment, which included disease-management program costs, a 4.34:1 return on investment was calculated. Conclusion. The diabetes program provides patients with comprehensive information and counseling relative to practicing self-management of diabetes through a number of integrated program components. This study strongly suggests that the implementation of such a program is associated with positive behavioral change and, thus, with substantial reduction in medical-service utiliza

Landscape science: a Russian geographical tradition

The Russian geographical tradition of landscape science (landshaftovedenie) is analyzed with particular reference to its initiator, Lev Semenovich Berg (1876-1950). The differences between prevailing Russian and Western concepts of landscape in geography are discussed, and their common origins in German geographical thought in the late nineteenth and early twentieth centuries are delineated. It is argued that the principal differences are accounted for by a number of factors, of which Russia's own distinctive tradition in environmental science deriving from the work of V. V. Dokuchaev (1846-1903), the activities of certain key individuals (such as Berg and C. O. Sauer), and the very different social and political circumstances in different parts of the world appear to be the most significant. At the same time it is noted that neither in Russia nor in the West have geographers succeeded in specifying an agreed and unproblematic understanding of landscape, or more broadly in promoting a common geographical conception of human-environment relationships. In light of such uncertainties, the latter part of the article argues for closer international links between the variant landscape traditions in geography as an important contribution to the quest for sustainability

D-brane potentials in the warped resolved conifold and natural inflation

In this paper we obtain a model of Natural Inflation from string theory with a Planckian decay constant. We investigate D-brane dynamics in the background of the warped resolved conifold (WRC) throat approximation of Type IIB string compactifications on Calabi-Yau manifolds. When we glue the throat to a compact bulk Calabi-Yau, we generate a D-brane potential which is a solution to the Laplace equation on the resolved conifold. We can exactly solve this equation, including dependence on the angular coordinates. The solutions are valid down to the tip of the resolved conifold, which is not the case for the more commonly used deformed conifold. This allows us to exploit the effect of the warping, which is strongest at the tip. We inflate near the tip using an angular coordinate of a D5-brane in the WRC which has a discrete shift symmetry, and feels a cosine potential, giving us a model of Natural Inflation, from which it is possible to get a Planckian decay constant whilst maintaining control over the backreaction. This is because the decay constant for a wrapped brane contains powers of the warp factor, and so can be made large, while the wrapping parameter can be kept small enough so that backreaction is under control.Comment: 41 pages, 3 appendices, 1 figure, PDFLaTex; various clarifications added along with a new appendix on b-axions and wrapped D5 branes;version matches the one published in JHE

The welfare of water buffaloes during the slaughter process: a review

This paper reviews the scientific literature on water buffalo welfare in all stages of the live animal supply chain from the farm gate to slaughter (loading/unloading, markets, transportation, handling, lairage, stunning and slaughter) with the objective of identifying risk factors and potential mitigation strategies. Although in some countries legislation exists to protect the welfare of farm animals during transport and killing, the handling practices used to load and unload buffaloes and move them in livestock markets and abattoirs are often harsh. This is frequently due to inadequate equipment designed principally for cattle, and the fact that water buffaloes are considered more temperamental than cattle. Additionally, more reactive animals have increased stress responses to handling, which can lead to more negative human interventions with increased numbers of skin lesions and bruises to the carcasses. During transport, buffaloes may suffer periods of thermal stress due to overstocking, inadequate ventilation and because in many tropical climates trips are made during the hottest time of the day. The anatomical and physiological characteristics of water buffalo make them particularly susceptible to thermal stress in the absence of water for wallowing. Although water buffaloes belong to the same Bovidae family as domestic cattle, certain anatomical features of the head make effective stunning very problematic. Buffaloes have extensive sinuses and frontal bones, meaning that the penetrating captive bolt devices recommended for cattle may prove ineffective in reliably inducing unconsciousness. There is a need for further development of procedures, stunning positions and appropriate devices to improve the efficiency of buffalo stunning. Finally, in many parts of the world where buffalo are routinely slaughtered in basic conditions without prior stunning. Slaughter without stunning can result in pain and stress associated with delays in the time to loss of consciousness, pain from the cutting of the neck and potential distress associated with aspiration of blood into the respiratory tract. Specific legislation, guidelines and handler/stockman/operator training programmes should be developed to improve the welfare of buffaloes during all ante mortem stages of loading, unloading, handling, stunning and slaughter

What Can a Pilot Congestive Heart Failure Disease Management Program Tell Us about Likely Return on Investment?: A Case Study from a Program Offered to Federal Employees

In 1999, the Blue Cross and Blue Shield Federal Employee Program (FEP) implemented a pilot disease management program to manage congestive heart failure (CHF) among members. The purpose of this project was to estimate the financial return on investment in the pilot CHF program, prior to a full program rollout. A cohort of 457 participants from the state of Maryland was matched to a cohort of 803 nonparticipants from a neighboring state where the CHF program was not offered. Each cohort was followed for 12 months before the program began and 12 months afterward. The outcome measures of primary interest were the differences over time in medical care expenditures paid by FEP and by all payers. Independent variables included indicators of program participation, type of heart disease, comorbidity measures, and demographics. From the perspective of the funding organization (FEP), the estimated return on investment for the pilot CHF disease management program was a savings of $1.08 in medical expenditure for every dollar spent on the program. Adding savings to other payers as well, the return on investment was a savings of$1.15 in medical expenditures per dollar spent on the program. The amount of savings depended upon CHF risk levels. The value of a pilot initiative and evaluation is that lessons for larger-scale efforts can be learned prior to full-scale rollout. (Disease Management 2005;8:346-360)Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63402/1/dis.2005.8.346.pd

The Impact of Parameterized Convection on the Simulation of Crop Processes

Global climate and weather models are a key tool for the prediction of future crop productivity, but they all rely on parameterizations of atmospheric convection, which often produce significant biases in rainfall characteristics over the tropics. The authors evaluate the impact of these biases by driving the General Large Area Model for annual crops (GLAM) with regional-scale atmospheric simulations of one cropping season over West Africa at different resolutions, with and without a parameterization of convection, and compare these with a GLAM run driven by observations. The parameterization of convection produces too light and frequent rainfall throughout the domain, as compared with the short, localized, high-intensity events in the observations and in the convection-permitting runs. Persistent light rain increases surface evaporation, and much heavier rainfall is required to trigger planting. Planting is therefore delayed in the runs with parameterized convection and occurs at a seasonally cooler time, altering the environmental conditions experienced by the crops. Even at high resolutions, runs driven by parameterized convection underpredict the small-scale variability in yields produced by realistic rainfall patterns. Correcting the distribution of rainfall frequencies and intensities before use in crop models will improve the process-based representation of the crop life cycle, increasing confidence in the predictions of crop yield. The rainfall biases described here are a common feature of parameterizations of convection, and therefore the crop-model errors described are likely to occur when using any global weather or climate model, thus remaining hidden when using climate-model intercomparisons to evaluate uncertainty

Lateralization of mesial temporal lobe epilepsy with chronic ambulatory electrocorticography

OBJECTIVE: Patients with suspected mesial temporal lobe (MTL) epilepsy typically undergo inpatient video-electroencephalography (EEG) monitoring with scalp and/or intracranial electrodes for 1 to 2 weeks to localize and lateralize the seizure focus or foci. Chronic ambulatory electrocorticography (ECoG) in patients with MTL epilepsy may provide additional information about seizure lateralization. This analysis describes data obtained from chronic ambulatory ECoG in patients with suspected bilateral MTL epilepsy in order to assess the time required to determine the seizure lateralization and whether this information could influence treatment decisions. METHODS: Ambulatory ECoG was reviewed in patients with suspected bilateral MTL epilepsy who were among a larger cohort with intractable epilepsy participating in a randomized controlled trial of responsive neurostimulation. Subjects were implanted with bilateral MTL leads and a cranially implanted neurostimulator programmed to detect abnormal interictal and ictal ECoG activity. ECoG data stored by the neurostimulator were reviewed to determine the lateralization of electrographic seizures and the interval of time until independent bilateral MTL electrographic seizures were recorded. RESULTS: Eighty-two subjects were implanted with bilateral MTL leads and followed for 4.7 years on average (median 4.9 years). Independent bilateral MTL electrographic seizures were recorded in 84%. The average time to record bilateral electrographic seizures in the ambulatory setting was 41.6 days (median 13 days, range 0-376 days). Sixteen percent had only unilateral electrographic seizures after an average of 4.6 years of recording. SIGNIFICANCE: About one third of the subjects implanted with bilateral MTL electrodes required >1 month of chronic ambulatory ECoG before the first contralateral MTL electrographic seizure was recorded. Some patients with suspected bilateral MTL seizures had only unilateral electrographic seizures. Chronic ambulatory ECoG in patients with suspected bilateral MTL seizures provides data in a naturalistic setting, may complement data from inpatient video-EEG monitoring, and can contribute to treatment decisions

Spin-2 spectrum of defect theories

We study spin-2 excitations in the background of the recently-discovered type-IIB solutions of D'Hoker et al. These are holographically-dual to defect conformal field theories, and they are also of interest in the context of the Karch-Randall proposal for a string-theory embedding of localized gravity. We first generalize an argument by Csaki et al to show that for any solution with four-dimensional anti-de Sitter, Poincare or de Sitter invariance the spin-2 excitations obey the massless scalar wave equation in ten dimensions. For the interface solutions at hand this reduces to a Laplace-Beltrami equation on a Riemann surface with disk topology, and in the simplest case of the supersymmetric Janus solution it further reduces to an ordinary differential equation known as Heun's equation. We solve this equation numerically, and exhibit the spectrum as a function of the dilaton-jump parameter $\Delta\phi$. In the limit of large $\Delta\phi$ a nearly-flat linear-dilaton dimension grows large, and the Janus geometry becomes effectively five-dimensional. We also discuss the difficulties of localizing four-dimensional gravity in the more general backgrounds with NS5-brane or D5-brane charge, which will be analyzed in detail in a companion paper.Comment: 41 pages, 6 figure

Intermediate mass excess of dilepton production in heavy ion collisions at BEVALAC energies

Dielectron mass spectra are examined for various nuclear reactions recently measured by the DLS collaboration. A detailed description is given of all dilepton channels included in the transport model UrQMD 1.0, i.e. Dalitz decays of $\pi^0,\eta,\omega,\eta'$ mesons and of the $\Delta(1232)$ resonance, direct decays of vector mesons and $pn$ bremsstrahlung. The microscopic calculations reproduce data for light systems fairly well, but tend to underestimate the data in $pp$ at high energies and in $pd$ at low energies. These conventional sources, however, cannot explain the recently reported enhancement for nucleus-nucleus collisions in the mass region 0.15 GeV<$M_{ee}$<0.6 GeV. Chiral scaling and $\omega$ meson broadening in the medium are investigated as a source of this mass excess. They also cannot explain the recent DLS data.Comment: 26 pages, 9 figures, references update

Transplanckian axions !?

We discuss quantum gravitational effects in Einstein theory coupled to periodic axion scalars to analyze the viability of several proposals to achieve superplanckian axion periods (aka decay constants) and their possible application to large field inflation models. The effects we study correspond to the nucleation of euclidean gravitational instantons charged under the axion, and our results are essentially compatible with (but independent of) the Weak Gravity Conjecture, as follows: Single axion theories with superplanckian periods contain gravitational instantons inducing sizable higher harmonics in the axion potential, which spoil superplanckian inflaton field range. A similar result holds for multi-axion models with lattice alignment (like the Kim-Nilles-Peloso model). Finally, theories with $N$ axions can still achieve a moderately superplanckian periodicity (by a $\sqrt{N}$ factor) with no higher harmonics in the axion potential. The Weak Gravity Conjecture fails to hold in this case due to the absence of some instantons, which are forbidden by a discrete $\mathbf{Z}_N$ gauge symmetry. Finally we discuss the realization of these instantons as euclidean D-branes in string compactifications.Comment: 46 pages, 6 figures. Added references, clarifications, and missing factor of 1/2 to instanton action. Conclusions unchange