Shifts in the architecture of the Nationwide Health Information Network

In the midst of a US $30 billion USD investment in the Nationwide Health Information Network (NwHIN) and electronic health records systems, a significant change in the architecture of the NwHIN is taking place. Prior to 2010, the focus of information exchange in the NwHIN was the Regional Health Information Organization (RHIO). Since 2010, the Office of the National Coordinator (ONC) has been sponsoring policies that promote an internet-like architecture that encourages point to-point information exchange and private health information exchange networks. The net effect of these activities is to undercut the limited business model for RHIOs, decreasing the likelihood of their success, while making the NwHIN dependent on nascent technologies for community level functions such as record locator services. These changes may impact the health of patients and communities. Independent, scientifically focused debate is needed on the wisdom of ONC's proposed changes in its strategy for the NwHIN

A pilot Internet "Value of Health" Panel: recruitment, participation and compliance

Objectives To pilot using a panel of members of the public to provide preference data via the Internet Methods A stratified random sample of members of the general public was recruited and familiarised with the standard gamble procedure using an Internet based tool. Health states were perdiodically presented in "sets" corresponding to different conditions, during the study. The following were described: Recruitment (proportion of people approached who were trained); Participation (a) the proportion of people trained who provided any preferences and (b) the proportion of panel members who contributed to each "set" of values; and Compliance (the proportion, per participant, of preference tasks which were completed). The influence of covariates on these outcomes was investigated using univariate and multivariate analyses. Results A panel of 112 people was recruited. 23% of those approached (n = 5,320) responded to the invitation, and 24% of respondents (n = 1,215) were willing to participate (net = 5.5%). However, eventual recruitment rates, following training, were low (2.1% of those approached). Recruitment from areas of high socioeconomic deprivation and among ethnic minority communities was low. Eighteen sets of health state descriptions were considered over 14 months. 74% of panel members carried out at least one valuation task. People from areas of higher socioeconomic deprivation and unmarried people were less likely to participate. An average of 41% of panel members expressed preferences on each set of descriptions. Compliance ranged from 3% to 100%. Conclusion It is feasible to establish a panel of members of the general public to express preferences on a wide range of health state descriptions using the Internet, although differential recruitment and attrition are important challenges. Particular attention to recruitment and retention in areas of high socioeconomic deprivation and among ethnic minority communities is necessary. Nevertheless, the panel approach to preference measurement using the Internet offers the potential to provide specific utility data in a responsive manner for use in economic evaluations and to address some of the outstanding methodological uncertainties in this field

A computer program for statistically-based decision analysis

The majority of patients with coronary artery disease do not fall into the well defined populations from randomized clinical trials. Observational databases contain a rich source of information that could be used by practicing physicians to evaluate treatment alternatives for their patients. We describe a computer system, the CABG Kibitzer, which uses an integrated approach to evaluate the treatment alternatives for CAD patients. We combine a statistical multivariate model for calculating survival advantages with DA techniques for assessing patient preferences and sensitivity analysis, to create one tool that physicians find easy to use in daily clinical practice. The development of tools of this kind is a necessary step in making the data of outcome studies accessible to practicing physicians

Difficulties in the Production of Ausferritic Nodular Cast Iron without Heat Treatment

The paper presents results of tests carried out on ausferrite carbide matrix alloyed ductile cast iron. The ausferrite was obtained via addition of Cu and Mo alloying elements. This eliminated heat treatment from the alloy production cycle. The article presents results of tests of the quality of the obtained material. Emphasis was put on metallographic analysis using light and scanning microscopy. Works also included chemical composition tests and EDS analysis. Strength tests were executed in an accredited laboratory. It is possible to create a raw ausferrite carbide matrix without subjecting an alloy to heat treatment. However, it turned out that quality parameters of cast iron were insufficient. The obtained material hardness was 515 HB, while Rm strength and A5 ductility were very low. The low tensile strength of the analyzed alloy resulted from the presence of degenerate graphite secretion (of flake or vermicular shape) in the cast iron. The tests also demonstrated that the alloy was prone to shrinkage-related porosity, which further weakened the material. Alloys made of alloyed ductile iron of ausferrite matrix micro-structure are very attractive due to elimination of the heat treatment process. However, their production process and chemical composition must be optimized

Radiative thermal runaway due to negative differential thermal emission across a solid-solid phase transition

Thermal runaway occurs when a rise in system temperature results in heat generation rates exceeding dissipation rates. Here we demonstrate that thermal runaway occurs in thermal radiative systems, given a sufficient level of negative differential thermal emission. By exploiting the insulator-to-metal phase transition of vanadium dioxide, we show that a small increase in heat generation (e.g., 10 nW/mm2) can result in a large change in surface temperature (e.g., ~35 K), as the thermal emitter switches from high emissivity to low emissivity. While thermal runaway is typically associated with catastrophic failure mechanisms, detailed understanding and control of this phenomenon may give rise to new opportunities in infrared sensing, camouflage, and rectification

An exploration of methods for obtaining 0 = dead anchors for latent scale EQ-5D-Y values

Objectives Discrete choice experiments (DCEs) can be used to obtain latent scale values for the EQ-5D-Y, but these require anchoring at 0 = dead to meet the conventions of quality-adjusted life year (QALY) estimation. The primary aim of this study is to compare four preference elicitation methods for obtaining anchors for latent scale EQ-5D-Y values. Methods Four methods were tested: visual analogue scale (VAS), DCE (with a duration attribute), lag-time time trade-off (TTO) and the location-of-dead (LOD) approach. In computer-assisted personal interviews, UK general public respondents valued EQ-5D-3L health states from an adult perspective and EQ-5D-Y health states from a 10-year-old child perspective. Respondents completed valuation tasks using all four methods, under both perspectives. Results 349 interviews were conducted. Overall, respondents gave lower values under the adult perspective compared to the child perspective, with some variation across methods. The mean TTO value for the worst health state (33333) was about equal to dead in the child perspective and worse than dead in the adult perspective. The mean VAS rescaled value for 33333 was also higher in the child perspective. The DCE produced positive child perspective values and negative adult perspective values, though the models were not consistent. The LOD median rescaled value for 33333 was negative under both perspectives and higher in the child perspective. Discussion There was broad agreement across methods. Potential criteria for selecting a preferred anchoring method are presented. We conclude by discussing the decision-making circumstances under which utilities and QALY estimates for children and adults need to be commensurate to achieve allocative efficiency

Identifying patient preferences for communicating risk estimates: A descriptive pilot study

BACKGROUND: Patients increasingly seek more active involvement in health care decisions, but little is known about how to communicate complex risk information to patients. The objective of this study was to elicit patient preferences for the presentation and framing of complex risk information. METHOD: To accomplish this, eight focus group discussions and 15 one-on-one interviews were conducted, where women were presented with risk data in a variety of different graphical formats, metrics, and time horizons. Risk data were based on a hypothetical woman's risk for coronary heart disease, hip fracture, and breast cancer, with and without hormone replacement therapy. Participants' preferences were assessed using likert scales, ranking, and abstractions of focus group discussions. RESULTS: Forty peri- and postmenopausal women were recruited through hospital fliers (n = 25) and a community health fair (n = 15). Mean age was 51 years, 50% were non-Caucasian, and all had completed high school. Bar graphs were preferred by 83% of participants over line graphs, thermometer graphs, 100 representative faces, and survival curves. Lifetime risk estimates were preferred over 10 or 20-year horizons, and absolute risks were preferred over relative risks and number needed to treat. CONCLUSION: Although there are many different formats for presenting and framing risk information, simple bar charts depicting absolute lifetime risk were rated and ranked highest overall for patient preferences for format

TLR1/2, TLR7, and TLR9 Signals Directly Activate Human Peripheral Blood Naive and Memory B Cell Subsets to Produce Cytokines, Chemokines, and Hematopoietic Growth Factors

Recently, it has been reported that using multiple signals, murine and human B cells secrete several cytokines with pro-inflammatory and immunoregulatory properties. We present the first comprehensive analysis of 24 cytokines, chemokines, and hematopoietic growth factors production by purified human peripheral blood B cells (CD19+), and naive (CD19+CD27-) and memory (CD19+CD27+) B cells in response to direct and exclusive signaling provided by toll-like receptor (TLR) ligands Pam3CSK (TLR1/TLR2), Imiquimod (TLR7), and GpG-ODN2006 (TLR9). All three TLR ligands stimulated B cells (CD19+) to produce cytokines IL-1α, IL-1β, IL-6, TNF-α, IL-13, and IL-10, and chemokines MIP-1α, MIP-1β, MCP-1, IP-10, and IL-8. However, GM-CSF and G-CSF production was predominantly induced by TLR2 agonist. Most cytokines/chemokines/hematopoietic growth factors were predominantly or exclusively produced by memory B cells, and in general, TLR2 signal was more powerful than signal provided viaTLR7 and TLR9. No significant secretion of eotaxin, IFN-α, IFN-γ, IL-2, IL-3, IL-4, IL-5, IL-7, IL-15, IL-17, IL-12p40, IL-12p70, and TNF-β (lymphotoxin) was observed. These data demonstrate that human B cells can be directly activated viaTLR1/TLR2, TLR7, and TLR9 to induce secretion of cytokines, chemokines, and hematopoietic growth factors and suggest a role of B cells in immune response against microbial pathogenesis and immune homeostasis

Enhancing quantum efficiency of thin-film silicon solar cells by Pareto optimality

We present a composite design methodology for the simulation and optimization of the solar cell performance. Our method is based on the synergy of different computational techniques and it is especially designed for the thin-film cell technology. In particular, we aim to efficiently simulate light trapping and plasmonic effects to enhance the light harvesting of the cell. The methodology is based on the sequential application of a hierarchy of approaches: (a) full Maxwell simulations are applied to derive the photon’s scattering probability in systems presenting textured interfaces; (b) calibrated Photonic Monte Carlo is used in junction with the scattering matrices method to evaluate coherent and scattered photon absorption in the full cell architectures; (c) the results of these advanced optical simulations are used as the pair generation terms in model implemented in an effective Technology Computer Aided Design tool for the derivation of the cell performance; (d) the models are investigated by qualitative and quantitative sensitivity analysis algorithms, to evaluate the importance of the design parameters considered on the models output and to get a first order descriptions of the objective space; (e) sensitivity analysis results are used to guide and simplify the optimization of the model achieved through both Single Objective Optimization (in order to fully maximize devices efficiency) and Multi Objective Optimization (in order to balance efficiency and cost); (f) Local, Global and “Glocal” robustness of optimal solutions found by the optimization algorithms are statistically evaluated; (g) data-based Identifiability Analysis is used to study the relationship between parameters. The results obtained show a noteworthy improvement with respect to the quantum efficiency of the reference cell demonstrating that the methodology presented is suitable for effective optimization of solar cell devices

The host response to the probiotic Escherichia coli strain Nissle 1917: Specific up-regulation of the proinflammatory chemokine MCP-1

BACKGROUND: The use of live microorganisms to influence positively the course of intestinal disorders such as infectious diarrhea or chronic inflammatory conditions has recently gained increasing interest as a therapeutic alternative. In vitro and in vivo investigations have demonstrated that probiotic-host eukaryotic cell interactions evoke a large number of responses potentially responsible for the effects of probiotics. The aim of this study was to improve our understanding of the E. coli Nissle 1917-host interaction by analyzing the gene expression pattern initiated by this probiotic in human intestinal epithelial cells. METHODS: Gene expression profiles of Caco-2 cells treated with E. coli Nissle 1917 were analyzed with microarrays. A second human intestinal cell line and also pieces of small intestine from BALB/c mice were used to confirm regulatory data of selected genes by real-time RT-PCR and cytometric bead array (CBA) to detect secretion of corresponding proteins. RESULTS: Whole genome expression analysis revealed 126 genes specifically regulated after treatment of confluent Caco-2 cells with E. coli Nissle 1917. Among others, expression of genes encoding the proinflammatory molecules monocyte chemoattractant protein-1 ligand 2 (MCP-1), macrophage inflammatory protein-2 alpha (MIP-2α) and macrophage inflammatory protein-2 beta (MIP-2β) was increased up to 10 fold. Caco-2 cells cocultured with E. coli Nissle 1917 also secreted high amounts of MCP-1 protein. Elevated levels of MCP-1 and MIP-2α mRNA could be confirmed with Lovo cells. MCP-1 gene expression was also up-regulated in mouse intestinal tissue. CONCLUSION: Thus, probiotic E. coli Nissle 1917 specifically upregulates expression of proinflammatory genes and proteins in human and mouse intestinal epithelial cells