Individual surgeon mortality rates: can outliers be detected? A national utility analysis

Objectives: There is controversy on the proposed benefits of publishing mortality rates for individual surgeons. In some procedures, analysis at the level of an individual surgeon may lack statistical power. The aim was to determine the likelihood that variation in surgeon performance will be detected using published outcome data. Design: A national analysis surgeon-level mortality rates to calculate the level of power for the reported mortality rate across multiple surgical procedures. Setting: The UK from 2010 to 2014. Participants: Surgeons who performed colon cancer resection, oesophagectomy or gastrectomy, elective aortic aneurysm repair, hip replacement, bariatric surgery or thyroidectomy. Outcomes: The likelihood of detecting an individual with a 30-day, 90-day or in-patient mortality rate of up to 5 times the national mean or median (as available). This was represented using a novel heat-map approach. Results: Overall mortality rates for the procedures ranged from 0.07% to 4.5% and mean/median surgeon volume was between 23 and 75 cases. The national median case volume for colorectal (n=55) and upper gastrointestinal (n=23) cancer resections provides around 20% power to detect a mortality rate of 3 times the national median, while, for hip replacement, this is a rate 5 times the national average. At the mortality rates reported for thyroid (0.08%) and bariatric (0.07%) procedures, it is unlikely a surgeon would perform a sufficient number of procedures in his/her entire career to stand a good chance of detecting a mortality rate 5 times the national average. Conclusions: At present, surgeons with increased mortality rates are unlikely to be detected. Performance within an expected mortality rate range cannot be considered reliable evidence of acceptable performance. Alternative approaches should focus on commonly occurring meaningful outcome measures, with infrequent events analysed predominately at the hospital level

Neural Networks, Heart Attack and Bayesian Decisions: An Application of the Boltzmann Perceptron Network

A decision aid is proposed for the diagnosis of the most commonly occurring cause of emergency admission to hospital in the developed world-acute myocardial infarction, or heart attack. The motivation for the proposal lies in the Bayesian ( minimum risk)decision theory which is briefly reviewed. The fact that many feedforward artificial neural networks are known to estimate the conditional class probabilities required for Bayesian decision theory is explored and one candidate-the Boltzmann Perceptron Network-is selected as possessing the most desirable properties. A brief account of the theory (based upon the so-called Boltzmann machine) underlying this little known network is presented. The Boltzmann Perceptron Network is trained to diagnose the presence or absence of myocardial infarction on data gathered from a large UK teaching hospital and is found to perform as well as senior registras with specific cardiological training (diagnostic accuracy in excess of 80%). In addition, the Boltzmann Perceptron Network is found to provide greater user confidence than the multi-layer Perceptron

Mineral resource information in support of national, regional and local planning : Suffolk

This report is one of a series prepared by the British Geological Survey for various administrative areas in England for the Office of the Deputy Prime Minister's research project Mineral Resource Information in Support of National, Regional and Local Planning. The accompanying map relates to the county of Suffolk and delineates the mineral resources of current, or potential, economic interest in the area and the sites where minerals are or have been worked. It also relates these to national planning designations, which may represent constraints on the extraction of minerals. Three major elements of information are presented: • the geological distribution and importance of mineral resources; • the extent of mineral planning permissions and the location of current mineral workings, and • the extent of selected, nationally-designated planning constraints. This wide range of information, much of which is scattered and not always available in a consistent and convenient form, is presented on a digitally-generated summary map on the scale of 1:100 000. This scale is convenient for the overall display of the data and allows for a legible topographic base on which to depict the information. However, all the data are held digitally at larger scales using a Geographical Information System (GIS), which allows easy revision, updating and customisation of the information together with its possible integration with other datasets. The information will form part of a Summary of the Mineral Resources of the East of England Region. The purpose of the work is to assist all interested parties involved in the preparation and review of development plans, both in relation to the extraction of minerals and the protection of mineral resources from sterilisation. It provides a knowledge base, in a consistent format, on the nature and extent of mineral resources and the environmental constraints, which may affect their extraction. An important objective is to provide baseline data for the long term. The results may also provide a starting point for discussions on specific planning proposals for mineral extraction or on proposals, which may sterilise resources. It is anticipated that the maps and report will also provide valuable background data for a much wider audience, including the different sectors of the minerals industry, other agencies and authorities (e.g. The Planning Inspectorate Agency, the Environment Agency, the Countryside Agency and English Nature), environmental interests and the general public. Basic mineral resource information is essential to support mineral exploration and development activities, for resource management and land-use planning, and to establish baseline data for environmental impact studies and environmental guidelines. It also enables a more sustainable pattern and standard of development to be achieved by valuing mineral resources as national assets. The mineral resources covered are sand and gravel, brick clay, hydrocarbons, building stone, chalk and peat

Hormonal circadian rhythms in patients with congenital adrenal hyperplasia: identifying optimal monitoring times and novel disease biomarkers

Objectives: The treatment goal in congenital adrenal hyperplasia (CAH) is to replace glucocorticoids while avoiding androgen excess and iatrogenic Cushing's syndrome. However, there is no consensus on how to monitor disease control. Our main objectives were to evaluate hormonal circadian rhythms and use these profiles to identify optimal monitoring times and novel disease biomarkers in CAH adults on intermediate- and long-acting glucocorticoids. Design: This was an observational, cross-sectional study at the National Institutes of Health Clinical Center in 16 patients with classic CAH. Methods: Twenty-four-hour serum sampling for ACTH, 17-hydroxyprogesterone (17OHP), androstenedione (A4), androsterone, DHEA, testosterone, progesterone and 24-h urinary pdiol and 5β-pdiol was carried out. Bayesian spectral analysis and cosinor analysis were performed to detect circadian rhythmicity. The number of hours to minimal (TminAC) and maximal (TmaxAC) adrenocortical hormone levels after dose administration was calculated. Results: A significant rhythm was confirmed for ACTH (r2, 0.95; P<0.001), 17OHP (r2, 0.70; P=0.003), androstenedione (r2, 0.47; P=0.043), androsterone (r2, 0.80; P<0.001), testosterone (r2, 0.47; P=0.042) and progesterone (r2, 0.64; P=0.006). The mean (S.D.) TminAC and TmaxAC for 17OHP and A4 were: morning prednisone (4.3 (2.3) and 9.7 (3.5) h), evening prednisone (4.5 (2.0) and 10.3 (2.4) h), and daily dexamethasone (9.2 (3.5) and 16.4 (7.2) h). AUC0–24 h progesterone, androsterone and 24-h urine pdiol were significantly related to 17OHP. Conclusion: In CAH patients, adrenal androgens exhibit circadian rhythms influenced by glucocorticoid replacement. Measurement of adrenocortical hormones and interpretation of results should take into account the type of glucocorticoid and time of dose administration. Progesterone and backdoor metabolites may provide alternative disease biomarkers

Evidence that a salt bridge in the light chain contributes to the physical stability difference between heavy and light human ferritins.

Human ferritin, a multimeric iron storage protein, is composed by various proportions of two subunit types: the H- and L-chains. The biological functions of these two genic products have not been clarified, although differences in reactivity with iron have been shown. Starting from the hypothesis that the high stability typical of ferritin is an important property which may be relevant for its iron storage function, we studied ferritin homopolymers of H- and L-chains in different denaturing conditions. In addition we analyzed 13 H-chain variants with alterations in regions conserved within mammalian H-chains. In all the denaturation experiments H-chain ferritin showed lower stability than L-chain ferritin. The difference was greater in guanidine HCl denaturation experiments, where the end products are fully unfolded peptides, than in acidic denaturation experiments, where the end products are peptides with properties analogous to "molten globule." The study on H-chain variants showed: (i) ferritin stability was not affected by alterations of regions exposed to the inner or outer surface of the shell and not involved in intra- or inter-chain interactions; (ii) stability was reduced by alterations of sequences involved in inter-subunit interactions such as the deletion of the N-terminal extension or substitutions along the hydrophobic and hydrophilic channels; (iii) stability was increased by the substitution of 2 amino acids inside the four-helix bundle with those of the homologous L-chain. One of the residues is involved in a salt bridge in the L-chain, and we concluded that the stability difference between H- and L-ferritins is to a large extent due to the stabilizing effect of this salt bridge on the L-subunit fold

Accuracy and Limitations of Fitting and Stereoscopic Methods to Determine the Direction of Coronal Mass Ejections from Heliospheric Imagers Observations

Using data from the Heliospheric Imagers (HIs) onboard STEREO, it is possible to derive the direction of propagation of coronal mass ejections (CMEs) in addition to their speed with a variety of methods. For CMEs observed by both STEREO spacecraft, it is possible to derive their direction using simultaneous observations from the twin spacecraft and also, using observations from only one spacecraft with fitting methods. This makes it possible to test and compare different analyses techniques. In this article, we propose a new fitting method based on observations from one spacecraft, which we compare to the commonly used fitting method of Sheeley et al. (1999). We also compare the results from these two fitting methods with those from two stereoscopic methods, focusing on 12 CMEs observed simultaneously by the two STEREO spacecraft in 2008 and 2009. We find evidence that the fitting method of Sheeley et al. (1999) can result in significant errors in the determination of the CME direction when the CME propagates outside of 60deg \pm 20 deg from the Sun-spacecraft line. We expect our new fitting method to be better adapted to the analysis of halo or limb CMEs with respect to the observing spacecraft. We also find some evidence that direct triangulation in the HI fields-of-view should only be applied to CMEs propagating approximatively towards Earth (\pm 20deg from the Sun-Earth line). Last, we address one of the possible sources of errors of fitting methods: the assumption of radial propagation. Using stereoscopic methods, we find that at least seven of the 12 studied CMEs had an heliospheric deflection of less than 20deg as they propagated in the HI fields-of-view, which, we believe, validates this approximation.Comment: 17 pages, 6 figures, 2 tables, accepted to Solar Physic

Brief communication : subglacial lake drainage beneath Isunguata Sermia, west Greenland : geomorphic and ice dynamic effects

We report three active subglacial lakes within 2 km of the lateral margin of Isunguata Sermia, West Greenland, identified by differencing time-stamped ArcticDEM strips. Each lake underwent one drainage–refill event between 2009 and 2017, with two lakes draining in < 1 month in August 2014 and August 2015. The 2015 drainage caused a ∼ 1-month down-glacier slowdown in ice flow and flooded the foreland, aggrading the proglacial channel by 8 m. The proglacial flooding confirms the ice-surface elevation anomalies as subglacial water bodies and demonstrates how their drainage can significantly modify proglacial environments. These subglacial lakes offer accessible targets for geophysical investigations and exploration

The Tiber Valley Project: The Tiber and Rome through Two Millennia

In 1997 a new collaborative research project was initiated by the British School at Rome. This project draws on a variety of sources of archaeological information to explore the regional impact of the City of Rome throughout the period from 1000 BC to AD 1300. The project provides a common collaborative research framework which brings together a range of archaeologists and historians working in various institutions. In this paper those involved in different aspects of this new project outline their work and its overall objectives

The Effect of Hybrid Photovoltaic Thermal Device Operating Conditions on Intrinsic Layer Thickness Optimization of Hydrogenated Amorphous Silicon Solar Cells

Historically, the design of hybrid solar photovoltaic thermal (PVT) systems has focused on cooling crystalline silicon (c-Si)-based photovoltaic (PV) devices to avoid temperature-related losses. This approach neglects the associated performance losses in the thermal system and leads to a decrease in the overall exergy of the system. Consequently, this paper explores the use of hydrogenated amorphous silicon (a-Si:H) as an absorber material for PVT in an effort to maintain higher and more favourable operating temperatures for the thermal system. Amorphous silicon not only has a smaller temperature coefficient than c-Si, but also can display improved PV performance over extended periods of higher temperatures by annealing out defect states from the Staebler-Wronski effect. In order to determine the potential improvements in a-Si:H PV performance associated with increased thicknesses of the i-layers made possible by higher operating temperatures, a-Si:H PV cells were tested under 1 sun illumination (AM1.5) at temperatures of 25oC (STC), 50oC (representative PV operating conditions), and 90 oC (representative PVT operating conditions). PV cells with an i-layer thicknesses of 420, 630 and 840 nm were evaluated at each temperature. Results show that operating a-Si:H-based PV at 90 oC, with thicker i-layers than the cells currently used in commercial production, provided a greater power output compared to the thinner cells operating at either PV or PVT operating temperatures. These results indicate that incorporating a-Si:H as the absorber material in a PVT system can improve the thermal performance, while simultaneously improving the electrical performance of a-Si:H-based PV