Prioritizing Patients: Stochastic Dynamic Programming for Surgery Scheduling and Mass Casualty Incident Triage

The research presented in this dissertation contributes to the growing literature on applications of operations research models to problems in healthcare through the development and analysis of mathematical models for two fundamental problems facing nearly all hospitals: the single-day surgery scheduling problem and planning for triage in the event of a mass casualty incident. Both of these problems can be understood as sequential decision-making processes aimed at prioritizing between different classes of patients under significant uncertainty and are modeled using stochastic dynamic programming. Our study of the single-day surgery scheduling problem represents the first model to capture the sequential nature of the operating room (OR) manager's decisions during the transition between the generality of cyclical block schedules (which allocate OR time to surgical specialties) and the specificity of schedules for a particular day (which assign individual patients to specific ORs). A case study of the scheduling system at the University of Maryland Medical Center highlights the importance of the decision to release unused blocks of OR time and use them to schedule cases from the surgical request queue (RQ). Our results indicate that high quality block release and RQ decisions can be made using threshold-based policies that preserve a specific amount of OR time for late-arriving demand from the specialties on the block schedule. The development of mass casualty incident (MCI) response plans has become a priority for hospitals, and especially emergency departments and trauma centers, in recent years. Central to all MCI response plans is the triage process, which sorts casualties into different categories in order to facilitate the identification and prioritization of those who should receive immediate treatment. Our research relates MCI triage to the problem of scheduling impatient jobs in a clearing system and extends earlier research by incorporating the important trauma principle that patients' long-term (post-treatment) survival probabilities deteriorate the longer they wait for treatment. Our results indicate that the consideration of deteriorating survival probabilities during MCI triage decisions, in addition to previously studied patient characteristics and overall patient volume, increases the total number of expected survivors

Medical Response Planning and Triage for Mass Casualty Terrorist Bombings

The medical response to mass casualty terrorist bombings (MCTB) has received extensive treatment in the trauma and emergency medicine literature over the past 25 years. An effective medical response must consider four fundamental aspects: (1) the objective of the response, (2) the typical injury pattern, (3) triage, and (4) the delivery of care. This report discusses the key components of each of these aspects, identifying points of consensus and contention and articulating unresolved research questions. Particular attention is given to the triage process because of its importance to the overall response and the array of differing opinions on how, where, and by whom it should be completed. Mathematical models of the trauma system during an MCTB are limited, but this approach offers the potential to answer many of the proposed research questions.This research was supported by an OR of the Future grant (W81XWH-06-2-0057) from the US Army Medical Research Acquisition Activity

Correlative analysis of structure and chemistry of LixFePO4 platelets using 4D-STEM and X-ray ptychography

Lithium iron phosphate (LixFePO4), a cathode material used in rechargeable Li-ion batteries, phase separates upon de/lithiation under equilibrium. The interfacial structure and chemistry within these cathode materials affects Li-ion transport, and therefore battery performance. Correlative imaging of LixFePO4 was performed using four-dimensional scanning transmission electron microscopy (4D-STEM), scanning transmission X-ray microscopy (STXM), and X-ray ptychography in order to analyze the local structure and chemistry of the same particle set. Over 50,000 diffraction patterns from 10 particles provided measurements of both structure and chemistry at a nanoscale spatial resolution (16.6-49.5 nm) over wide (several micron) fields-of-view with statistical robustness.LixFePO4 particles at varying stages of delithiation were measured to examine the evolution of structure and chemistry as a function of delithiation. In lithiated and delithiated particles, local variations were observed in the degree of lithiation even while local lattice structures remained comparatively constant, and calculation of linear coefficients of chemical expansion suggest pinning of the lattice structures in these populations. Partially delithiated particles displayed broadly core-shell-like structures, however, with highly variable behavior both locally and per individual particle that exhibited distinctive intermediate regions at the interface between phases, and pockets within the lithiated core that correspond to FePO4 in structure and chemistry.The results provide insight into the LixFePO4 system, subtleties in the scope and applicability of Vegards law (linear lattice parameter-composition behavior) under local versus global measurements, and demonstrate a powerful new combination of experimental and analytical modalities for bridging the crucial gap between local and statistical characterization.Comment: 17 pages, 4 figure

Genome-scale resources for Thermoanaerobacterium saccharolyticum

Background Thermoanaerobacterium saccharolyticum is a hemicellulose-degrading thermophilic anaerobe that was previously engineered to produce ethanol at high yield. A major project was undertaken to develop this organism into an industrial biocatalyst, but the lack of genome information and resources were recognized early on as a key limitation. Results Here we present a set of genome-scale resources to enable the systems level investigation and development of this potentially important industrial organism. Resources include a complete genome sequence for strain JW/SL-YS485, a genome-scale reconstruction of metabolism, tiled microarray data showing transcription units, mRNA expression data from 71 different growth conditions or timepoints and GC/MS-based metabolite analysis data from 42 different conditions or timepoints. Growth conditions include hemicellulose hydrolysate, the inhibitors HMF, furfural, diamide, and ethanol, as well as high levels of cellulose, xylose, cellobiose or maltodextrin. The genome consists of a 2.7 Mbp chromosome and a 110 Kbp megaplasmid. An active prophage was also detected, and the expression levels of CRISPR genes were observed to increase in association with those of the phage. Hemicellulose hydrolysate elicited a response of carbohydrate transport and catabolism genes, as well as poorly characterized genes suggesting a redox challenge. In some conditions, a time series of combined transcription and metabolite measurements were made to allow careful study of microbial physiology under process conditions. As a demonstration of the potential utility of the metabolic reconstruction, the OptKnock algorithm was used to predict a set of gene knockouts that maximize growth-coupled ethanol production. The predictions validated intuitive strain designs and matched previous experimental results. Conclusion These data will be a useful asset for efforts to develop T. saccharolyticum for efficient industrial production of biofuels. The resources presented herein may also be useful on a comparative basis for development of other lignocellulose degrading microbes, such as Clostridium thermocellum. Electronic supplementary material The online version of this article (doi:10.1186/s12918-015-0159-x) contains supplementary material, which is available to authorized users

Single-Nucleotide Polymorphisms in Nucleotide Excision Repair Genes, Cigarette Smoking, and the Risk of Head and Neck Cancer

Cigarette smoking is associated with increased head and neck cancer (HNC) risk. Tobacco-related carcinogens are known to cause bulky DNA adducts. Nucleotide excision repair (NER) genes encode enzymes that remove adducts and may be independently associated with HNC, as well as modifiers of the association between smoking and HNC

Single nucleotide polymorphisms in nucleotide excision repair genes, cancer treatment, and head and neck cancer survival

Head and neck cancers (HNC) are commonly treated with radiation and platinum-based chemotherapy, which produce bulky DNA adducts to eradicate cancerous cells. Because nucleotide excision repair (NER) enzymes remove adducts, variants in NER genes may be associated with survival among HNC cases both independently and jointly with treatment

Consensus statement on concussion in sport—the 5 th international conference on concussion in sport held in Berlin, October 2016

The 2017 Concussion in Sport Group (CISG) consensus statement is designed to build on the principles outlined in the previous statements1–4 and to develop further conceptual understanding of sport-related concussion (SRC) using an expert consensus-based approach. This document is developed for physicians and healthcare providers who are involved in athlete care, whether at a recreational, elite or professional level. While agreement exists on the principal messages conveyed by this document, the authors acknowledge that the science of SRC is evolving and therefore individual management and return-to-play decisions remain in the realm of clinical judgement. This consensus document reflects the current state of knowledge and will need to be modified as new knowledge develops. It provides an overview of issues that may be of importance to healthcare providers involved in the management of SRC. This paper should be read in conjunction with the systematic reviews and methodology paper that accompany it. First and foremost, this document is intended to guide clinical practice; however, the authors feel that it can also help form the agenda for future research relevant to SRC by identifying knowledge gaps

The genetic architecture of the human cerebral cortex

The cerebral cortex underlies our complex cognitive capabilities, yet little is known about the specific genetic loci that influence human cortical structure. To identify genetic variants that affect cortical structure, we conducted a genome-wide association meta-analysis of brain magnetic resonance imaging data from 51,665 individuals. We analyzed the surface area and average thickness of the whole cortex and 34 regions with known functional specializations. We identified 199 significant loci and found significant enrichment for loci influencing total surface area within regulatory elements that are active during prenatal cortical development, supporting the radial unit hypothesis. Loci that affect regional surface area cluster near genes in Wnt signaling pathways, which influence progenitor expansion and areal identity. Variation in cortical structure is genetically correlated with cognitive function, Parkinson's disease, insomnia, depression, neuroticism, and attention deficit hyperactivity disorder

Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016

The 2017 Concussion in Sport Group (CISG) consensus statement is designed to build on the principles outlined in the previous statements1–4 and to develop further conceptual understanding of sport-related concussion (SRC) using an expert consensus-based approach. This document is developed for physicians and healthcare providers who are involved in athlete care, whether at a recreational, elite or professional level. While agreement exists on the principal messages conveyed by this document, the authors acknowledge that the science of SRC is evolving and therefore individual management and return-to-play decisions remain in the realm of clinical judgement. This consensus document reflects the current state of knowledge and will need to be modified as new knowledge develops. It provides an overview of issues that may be of importance to healthcare providers involved in the management of SRC. This paper should be read in conjunction with the systematic reviews and methodology paper that accompany it. First and foremost, this document is intended to guide clinical practice; however, the authors feel that it can also help form the agenda for future research relevant to SRC by identifying knowledge gaps.http://bjsm.bmj.comhj2017Sports Medicin