Risk adjustment in maternity care: the use of indirect standardization

James M NicholsonDepartment of Family Practice and Community Medicine, University of Pennsylvania Health System, University of Pennsylvania, Philadelphia, PA, USAPurpose: Annual US national rates of family physicians providing maternity care are ­decreasing and rates of cesarean delivery are increasing. Family physicians tend to have lower cesarean delivery rates than obstetrician specialists, but this association is usually explained by an assumed lower pre-delivery risk for cesarean delivery. This study was developed to compare the estimated risk of cesarean delivery in patients of the two specialties.Methods: A retrospective cohort study within an urban teaching hospital compared 100 ­family-physician treated subjects to 300 subjects treated by obstetrician-specialists. Risk factors for cesarean delivery were identified, and an indirect standardization procedure was used to compare the pre-38 week of gestation risk of cesarean delivery in the two groups.Results: The patients treated by family physicians had a projected pre-38 week of gestation risk of cesarean delivery (17.4%) that was similar to the actual rate of cesarean delivery in the obstetrician-specialist group (16.7%). The Standardized Cesarean Delivery Ratio was 1.04.Conclusion: Lower cesarean delivery rates provided by family physicians may not be simply due to case-mix issues. Additional studies comparing the pre-delivery estimation of cesarean delivery risk would be helpful in measuring the relative levels of obstetric risk of patients treated by different maternity-care provider types.Keywords: family medicine obstetrics, cesarean deliver

SVM-based texture classification in optical coherence tomography

This paper describes a new method for automated texture classification for glaucoma detection using high resolution retinal Optical Coherence Tomography (OCT). OCT is a non-invasive technique that produces cross-sectional imagery of ocular tissue. Here, we exploit information from OCT im-ages, specifically the inner retinal layer thickness and speckle patterns, to detect glaucoma. The proposed method relies on support vector machines (SVM), while principal component analysis (PCA) is also employed to improve classification performance. Results show that texture features can improve classification accuracy over what is achieved using only layer thickness as existing methods currently do. Index Terms — classification, support vector machine, optical coherence tomography, texture 1

Tariff-Rate Quotas : Difficult to model or plain simple?

The difficulty of reliably and accurately incorporating tariffrate quotas (TRQs) into trade models has received a lot of attention in recent years. As a result of the Uruguay Round of GATT negotiations, TRQs replaced an assortment of tariff and nontariff instruments in an effort to standardise trade barriers, and facilitate their future liberalisation. Understanding the nuances of TRQs is now particularly crucial for New Zealand because of the preferential access arrangements that New Zealand has for a number of products in highly protected markets such as the European Union, Japan, and the United States. It has been argued that TRQs are complex instruments and are difficult to model because for any trade flow between two countries, one of three regimes may be applicable : 1. The import quota may not be binding and the within-quota tariff applies; 2. The quota may be binding, the within-quota tariff applies, and a quota rent is created; or 3. Trade occurs over and above the quota, in which case an over-quota tariff applies (although, even in this regime, someone is still able to collect the quota rent on within-quota trade). But even this characterisation, which many claim is too complex to model, is a major simplification of reality. Bilateral preferences are ubiquitous, and such preferences are usually included in the determination of multilateral market access quotas. It is usual, therefore, that the TRQ instrument has several tiers to the quota schedule, plus a number of within and over-quota tariff rates applicable on either a bilateral or a multilateral basis. Further trade liberalisation creates something of a dilemma for New Zealand. Any decrease in over-quota tariffs and/or increase in quota levels potentially reduces the value of quota rents, many of which accrue to New Zealand due to the bilateral preferences. It is important, therefore, that New Zealand trade negotiators understand how much additional trade is required to offset the loss of New Zealands quota rents. Modelling trade in the presence of TRQs is the only way to ascertain this knowledge. The purpose of this paper is to show that complex TRQs can be modelled very easily and precisely. The only catch is that the model must be formulated as a complementarity problem rather than the more conventional linear or nonlinear optimisation problem. The concept will be demonstrated using a simple 3-region, single commodity spatial price equilibrium model of trade.Tariff-rate quota, trade modelling, mathematical programming, complementarity

The Active Management of Impending Cephalopelvic Disproportion in Nulliparous Women at Term: A Case Series

Background. The Active Management of Risk in Pregnancy at Term (AMOR-IPAT) protocol has been associated in several studies with significant reductions of group cesarean delivery rate. Present within each of these studies were nulliparous women with risk factors for cephalopelvic disproportion. Risk factors for cephalopelvic disproportion in nulliparous women are especially important because they represent the precursors for the most common indication for primary cesarean delivery. Cases. Three examples of exposure of urban nulliparous women to the AMOR-IPAT protocol are presented. Each woman's risk factor profile for Cephalopelvic Disproportion (CPD) was used to estimate her Upper Limit of Optimal Time of Vaginal Delivery for CPD (UL-OTDcpd). Labor management and clinical outcomes for each case are presented. A simple table summarizing induction rates and birth outcome rates of exposed versus nonexposed nulliparous women is also presented. Conclusion. Because the mode of delivery of the first birth substantially impacts birth options in later pregnancies, the impact of AMOR-IPAT on nulliparous patients is particularly important. Determining the UL-OTDcpd in nulliparous patients, and carefully inducing each patient who has not entered labor by her UL-OTDcpd, may be an effective way of lowering rates of cesarean delivery in nulliparous women

High Angular Resolution Stellar Imaging with Occultations from the Cassini Spacecraft II: Kronocyclic Tomography

We present an advance in the use of Cassini observations of stellar occultations by the rings of Saturn for stellar studies. Stewart et al. (2013) demonstrated the potential use of such observations for measuring stellar angular diameters. Here, we use these same observations, and tomographic imaging reconstruction techniques, to produce two dimensional images of complex stellar systems. We detail the determination of the basic observational reference frame. A technique for recovering model-independent brightness profiles for data from each occulting edge is discussed, along with the tomographic combination of these profiles to build an image of the source star. Finally we demonstrate the technique with recovered images of the {\alpha} Centauri binary system and the circumstellar environment of the evolved late-type giant star, Mira.Comment: 8 pages, 8 figures, Accepted by MNRA

Testing for Features in the Primordial Power Spectrum

Well-known causality arguments show that events occurring during or at the end of inflation, associated with reheating or preheating, could contribute a blue component to the spectrum of primordial curvature perturbations, with the dependence k^3. We explore the possibility that they could be observably large in CMB, LSS, and Lyman-alpha data. We find that a k^3 component with a cutoff at some maximum k can modestly improve the fits (Delta chi^2=2.0, 5.4) of the low multipoles (l ~ 10 - 50) or the second peak (l ~ 540) of the CMB angular spectrum when the three-year WMAP data are used. Moreover, the results from WMAP are consistent with the CBI, ACBAR, 2dFGRS, and SDSS data when they are included in the analysis. Including the SDSS galaxy clustering power spectrum, we find weak positive evidence for the k^3 component at the level of Delta chi' = 2.4, with the caveat that the nonlinear evolution of the power spectrum may not be properly treated in the presence of the k^3 distortion. To investigate the high-k regime, we use the Lyman-alpha forest data (LUQAS, Croft et al., and SDSS Lyman-alpha); here we find evidence at the level Delta chi^2' = 3.8. Considering that there are two additional free parameters in the model, the above results do not give a strong evidence for features; however, they show that surprisingly large bumps are not ruled out. We give constraints on the ratio between the k^3 component and the nearly scale-invariant component, r_3 < 1.5, over the range of wave numbers 0.0023/Mpc < k < 8.2/Mpc. We also discuss theoretical models which could lead to the k^3 effect, including ordinary hybrid inflation and double D-term inflation models. We show that the well-motivated k^3 component is also a good representative of the generic spikelike feature in the primordial perturbation power spectrum.Comment: 23 pages, 6 figures; added new section on theoretical motivation for k^3 term, and discussion of double D-term hybrid inflation models; title changed, added a new section discussing the generic spikelike features, published in IJMP

Gut microbiota modulation of chemotherapy efficacy and toxicity

Evidence is growing that the gut microbiota modulates the host response to chemotherapeutic drugs, with three main clinical outcomes: facilitation of drug efficacy; abrogation and compromise of anticancer effects; and mediation of toxicity. The implication is that gut microbiota are critical to the development of personalized cancer treatment strategies and, therefore, a greater insight into prokaryotic co-metabolism of chemotherapeutic drugs is now required. This thinking is based on evidence from human, animal and in vitro studies that gut bacteria are intimately linked to the pharmacological effects of chemotherapies (5-fluorouracil, cyclophosphamide, irinotecan, oxaliplatin, gemcitabine, methotrexate) and novel targeted immunotherapies such as anti-PD-L1 and anti-CLTA-4 therapies. The gut microbiota modulate these agents through key mechanisms, structured as the 'TIMER' mechanistic framework: Translocation, Immunomodulation, Metabolism, Enzymatic degradation, and Reduced diversity and ecological variation. The gut microbiota can now, therefore, be targeted to improve efficacy and reduce the toxicity of current chemotherapy agents. In this Review, we outline the implications of pharmacomicrobiomics in cancer therapeutics and define how the microbiota might be modified in clinical practice to improve efficacy and reduce the toxic burden of these compounds

Complex Genetic Interactions in a Quantitative Trait Locus

Whether in natural populations or between two unrelated members of a species, most phenotypic variation is quantitative. To analyze such quantitative traits, one must first map the underlying quantitative trait loci. Next, and far more difficult, one must identify the quantitative trait genes (QTGs), characterize QTG interactions, and identify the phenotypically relevant polymorphisms to determine how QTGs contribute to phenotype. In this work, we analyzed three Saccharomyces cerevisiae high-temperature growth (Htg) QTGs (MKT1, END3, and RHO2). We observed a high level of genetic interactions among QTGs and strain background. Interestingly, while the MKT1 and END3 coding polymorphisms contribute to phenotype, it is the RHO2 3′UTR polymorphisms that are phenotypically relevant. Reciprocal hemizygosity analysis of the Htg QTGs in hybrids between S288c and ten unrelated S. cerevisiae strains reveals that the contributions of the Htg QTGs are not conserved in nine other hybrids, which has implications for QTG identification by marker-trait association. Our findings demonstrate the variety and complexity of QTG contributions to phenotype, the impact of genetic background, and the value of quantitative genetic studies in S. cerevisiae