Practice analysis of certified public accountants: technical report

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BMQ

BMQ: Boston Medical Quarterly was published from 1950-1966 by the Boston University School of Medicine and the Massachusetts Memorial Hospitals

Impact of metabolic syndrome and its components on cardiovascular disease event rates in 4900 patients with type 2 diabetes assigned to placebo in the field randomised trial

<p>Abstract</p> <p>Background</p> <p>Patients with the metabolic syndrome are more likely to develop type 2 diabetes and may have an increased risk of cardiovascular disease (CVD) events.We aimed to establish whether CVD event rates were influenced by the metabolic syndrome as defined by the World Health Organisation (WHO), the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) and the International Diabetes Federation (IDF) and to determine which component(s) of the metabolic syndrome (MS) conferred the highest cardiovascular risk in in 4900 patients with type 2 diabetes allocated to placebo in the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) trial.</p> <p>Research design and methods</p> <p>We determined the influence of MS variables, as defined by NCEP ATPIII, IDF and WHO, on CVD risk over 5 years, after adjustment for CVD, sex, HbA_1c, creatinine, and age, and interactions between the MS variables in a Cox proportional-hazards model.</p> <p>Results</p> <p>About 80% had hypertension, and about half had other features of the metabolic syndrome (IDF, ATPIII). There was no difference in the prevalence of metabolic syndrome variables between those with and without CVD at study entry. The WHO definition identified those at higher CVD risk across both sexes, all ages, and in those without prior CVD, while the ATPIII definition predicted risk only in those aged over 65 years and in men but not in women. Patients meeting the IDF definition did not have higher risk than those without IDF MS.</p> <p>CVD risk was strongly influenced by prior CVD, sex, age (particularly in women), baseline HbA1_c, renal dysfunction, hypertension, and dyslipidemia (low HDL-c, triglycerides > 1.7 mmol/L). The combination of low HDL-c and marked hypertriglyceridemia (> 2.3 mmol/L) increased CVD risk by 41%. Baseline systolic blood pressure increased risk by 16% per 10 mmHg in those with no prior CVD, but had no effect in those with CVD. In those without prior CVD, increasing numbers of metabolic syndrome variables (excluding waist) escalated risk.</p> <p>Conclusion</p> <p>Absence of the metabolic syndrome (by the WHO definition) identifies diabetes patients without prior CVD, who have a lower risk of future CVD events. Hypertension and dyslipidemia increase risk.</p

The IMPROVEDD VTE risk score: Incorporation of D-dimer into the IMPROVE score to improve venous thromboembolism risk stratification

Background The IMPROVE score is a validated venous thromboembolism (VTE) assessment tool to risk stratify hospitalized, medically ill patients based on clinical variables. It was hypothesized that addition of D-dimer measurement to derive a new IMPROVEDD score would improve identification of at risk of VTE. Methods The association of the IMPROVE score and D-dimer ≥ 2 × the upper limit of normal (ULN) with the risk of symptomatic deep vein thrombosis, nonfatal pulmonary embolism, or VTE-related death was evaluated in 7,441 hospitalized, medically ill patients randomized in the APEX trial. Based on the Cox regression analysis, the IMPROVEDD score was derived by adding two points to the IMPROVE score if the D-dimer was ≥ 2 × ULN. Results Baseline D-dimer was independently associated with symptomatic VTE through 77 days (adjusted HR: 2.22 [95% CI: 1.38–1.58], p = 0.001). Incorporation of D-dimer into the IMPROVE score improved VTE risk discrimination (ΔAUC: 0.06 [95% CI: 0.02–0.09], p = 0.0006) and reclassification (continuous NRI: 0.34 [95% CI: 0.17–0.51], p = 0.001; categorical NRI: 0.13 [95% CI: 0.03–0.23], p = 0.0159). Patients with an IMPROVEDD score of ≥2 had a greater VTE risk compared with those with an IMPROVEDD score of 0 to 1 (HR: 2.73 [95% CI: 1.52–4.90], p = 0.0007). Conclusion Incorporation of D-dimer into the IMPROVE VTE risk assessment model further improves risk stratification in hospitalized, medically ill patients who received thromboprophylaxis. An IMPROVEDD score of ≥2 identifies hospitalized, medically ill patients with a heightened risk for VTE through 77 days.</jats:p

Antarctic penguin response to habitat change as Earth's troposphere reaches 2°C above preindustrial levels

Author Posting. © Ecological Society of America, 2010. This article is posted here by permission of Ecological Society of America for personal use, not for redistribution. The definitive version was published in Ecological Monographs 80 (2010): 49–66, doi:10.1890/08-2289.1.We assess the response of pack ice penguins, Emperor (Aptenodytes forsteri) and Adélie (Pygoscelis adeliae), to habitat variability and, then, by modeling habitat alterations, the qualitative changes to their populations, size and distribution, as Earth's average tropospheric temperature reaches 2°C above preindustrial levels (ca. 1860), the benchmark set by the European Union in efforts to reduce greenhouse gases. First, we assessed models used in the Intergovernmental Panel on Climate Change Fourth Assessment Report (AR4) on penguin performance duplicating existing conditions in the Southern Ocean. We chose four models appropriate for gauging changes to penguin habitat: GFDL-CM2.1, GFDL-CM2.0, MIROC3.2(hi-res), and MRI-CGCM2.3.2a. Second, we analyzed the composited model ENSEMBLE to estimate the point of 2°C warming (2025–2052) and the projected changes to sea ice coverage (extent, persistence, and concentration), sea ice thickness, wind speeds, precipitation, and air temperatures. Third, we considered studies of ancient colonies and sediment cores and some recent modeling, which indicate the (space/time) large/centennial-scale penguin response to habitat limits of all ice or no ice. Then we considered results of statistical modeling at the temporal interannual-decadal scale in regard to penguin response over a continuum of rather complex, meso- to large-scale habitat conditions, some of which have opposing and others interacting effects. The ENSEMBLE meso/decadal-scale output projects a marked narrowing of penguins' zoogeographic range at the 2°C point. Colonies north of 70° S are projected to decrease or disappear: 50% of Emperor colonies (40% of breeding population) and 75% of Adélie colonies (70% of breeding population), but limited growth might occur south of 73° S. Net change would result largely from positive responses to increase in polynya persistence at high latitudes, overcome by decreases in pack ice cover at lower latitudes and, particularly for Emperors, ice thickness. Adélie Penguins might colonize new breeding habitat where concentrated pack ice diverges and/or disintegrating ice shelves expose coastline. Limiting increase will be decreased persistence of pack ice north of the Antarctic Circle, as this species requires daylight in its wintering areas. Adélies would be affected negatively by increasing snowfall, predicted to increase in certain areas owing to intrusions of warm, moist marine air due to changes in the Polar Jet Stream.This project was funded by the World Wildlife Fund and the National Science Foundation, NSF grant OPP-0440643 (D. G. Ainley), and a Marie-Curie Fellowship to S. Jenouvrier

Regional to global scale atmospheric effects of the emerging mainland Chinese transportation system

This is the final report of a one-year Laboratory Directed Research and Development (LDRD) project at Los Alamos National Laboratory (LANL). The People`s Republic of China will be moving toward considerably increased use of motorized vehicles over the next human generation. Estimates are for a fleet of 100 million vehicles or more. Large increases in ozone and other types of pollution associated with automobiles will result and this will have significant impact across Asia and into the Pacific. In this project the authors have taken a continental scale approach in a two-dimensional photochemical model to estimate the ozone concentrations to be expected. Potential levels of nitrate/soot in aerosols and increase in carbon dioxide are also discussed. Major pollution problems are forecast for the Pacific Rim if Chinese projections for their automotive sector are realized