Optimal Dividend Payments for the Piecewise-Deterministic Poisson Risk Model

This paper considers the optimal dividend payment problem in piecewise-deterministic compound Poisson risk models. The objective is to maximize the expected discounted dividend payout up to the time of ruin. We provide a comparative study in this general framework of both restricted and unrestricted payment schemes, which were only previously treated separately in certain special cases of risk models in the literature. In the case of restricted payment scheme, the value function is shown to be a classical solution of the corresponding HJB equation, which in turn leads to an optimal restricted payment policy known as the threshold strategy. In the case of unrestricted payment scheme, by solving the associated integro-differential quasi-variational inequality, we obtain the value function as well as an optimal unrestricted dividend payment scheme known as the barrier strategy. When claim sizes are exponentially distributed, we provide easily verifiable conditions under which the threshold and barrier strategies are optimal restricted and unrestricted dividend payment policies, respectively. The main results are illustrated with several examples, including a new example concerning regressive growth rates.Comment: Key Words: Piecewise-deterministic compound Poisson model, optimal stochastic control, HJB equation, quasi-variational inequality, threshold strategy, barrier strateg

Double arterial perfusion strategy for extensive thoracic aortic surgery to avoid lower body hypothermic circulatory arrest

OBJECTIVE To analyse our results of using a double arterial perfusion strategy to avoid lower body hypothermic circulatory arrest after extensive thoracic aortic surgery. METHODS We analysed the intra- and perioperative courses of 10 patients (median age 58 years, median logistic EuroSCORE 14.6) who underwent extensive thoracic aortic surgery with a double arterial perfusion strategy. The main goal of double arterial perfusion is to separate myocardial and supra-aortic from systemic perfusion. Aortic repair starts at the most distal level of the descending aorta, followed by reinsertion of the supra-aortic vessels, and ends with completion of the proximal anastomosis or by any kind of root repair as needed. RESULTS Seven of 10 patients had prior surgery of the thoracic aorta. Indications for surgery were post-dissection aneurysm in 4 patients, true aneurysm in 3, anastomotic aneurysms in 2 and Type B aortic dissection with pseudo-coarctation in 1. Surgical access was performed through median sternotomy with left hemi-clamshell extension in all cases. There was no in-hospital mortality, but perioperative neurological symptoms occurred in 2 patients. These 2 patients developed delayed stroke (after awaking) after an initial uneventful clinical course, and in 1 of them, neurological symptoms resolved completely during follow-up. The median follow-up was 7 (±13) months. There was no death and no need for additional redo surgery during this observational period. CONCLUSIONS Extensive surgery of the thoracic aorta using a double arterial perfusion technique in order to avoid lower body hypothermic circulatory arrest is an attractive option. Further refinements of this technique may enable the safe and effective simultaneous multisegmental treatment of thoracic aortic pathology in patients who would otherwise have to undergo a two-step surgical approac

Technical advances improved outcome in patients undergoing surgery of the ascending aorta and/or aortic arch: ten years experience

Background: Several technical advances in thoracic aortic surgery, such as the use of antegrade cerebral perfusion, avoidance of cross-clamping and the application of glue, have beneficially influenced postoperative outcome. The aim of the present study was to analyse the impact of these developments on outcome of patients undergoing surgery of the thoracic aorta. Methods and results: Between January 1996 and December 2005, 835 patients (37.6%) out of 2215 aortic patients underwent surgery on the thoracic ascending aorta or the aortic arch at our institution. All in-hospital data were assessed. Two hundred and forty-one patients (28.8%) suffered from acute type A dissection (AADA). Overall aortic caseload increased from 41 patients in 1996 to 141 in 2005 (+339%). The increase was more pronounced for thoracic aortic aneurysms (TAA) (+367.9%), than for acute type A aortic dissections (+276.9%). Especially in TAA, combined procedures increased and the amount of patients with impaired left ventricular function (EF <50%) raised up from 14% in 1996 to 24% in 2005. Average age remained stable. Logistic regression curve revealed a significant decrease in mortality (AADA) and in the overall incidence of neurological deficits. Conclusions: Technical advances in the field of thoracic aortic surgery lead to a decrease of mortality and morbidity, especially in the incidence of adverse neurological events, in a large collective of patients. Long-term outcome and quality of life are better, since antegrade cerebral perfusion has been introduce

Thoracic endovascular aortic repair: impact of urgency on outcome and quality of life

Objectives: Endovascular repair of the descending thoracic aorta is a very promising technique in elective and, particularly, emergency situations. This study assessed the impact of urgency of the procedure on outcome and mid-term quality of life in surviving patients. Methods: Post hoc analysis of prospectively collected data of 58 consecutive patients (January 2001-December 2005) with surgical pathologies of the descending thoracic aorta treated by endovascular means. Six patients were excluded due to recent operations on the ascending aorta before thoracic endovascular repair. The remaining patients (n=52) were 69±10 years old, and 43 were men (83%). Twenty-seven had been treated electively, and 25 for emergency indications. Reasons for emergency were acute type B aortic dissections with or without malperfusion syndrome in 14, and aortic ruptures in 11 cases. Follow-up was 29±16 months. Endpoints were perioperative and late morbidity and mortality rates and long-term quality of life as assessed by the short form health survey (SF-36) and Hospital Anxiety and Depression Scale questionnaires. Results: Cohorts were comparable regarding age, sex, cardiovascular risk factors, and comorbidities. Perioperative mortality was somewhat higher in emergency cases (12% vs 4%, p=0.34). Paraplegia occurred in one patient in each cohort (4%). Overall quality of life after two and a half years was similar in both treatment cohorts: 72 (58-124) after emergency, and 85 (61-105) after elective endovascular aortic repair (p=0.98). Normal scores range from 85 to 115. Anxiety and depression scores were in the normal range and comparable. Conclusions: Thoracic endovascular aortic repair is an excellent and safe treatment option for the diseased descending aorta, particularly in emergency situations. Early morbidity and mortality rates can be kept very low. Mid-term quality of life was not affected by the urgency of the procedure. Similarly, mid-term anxiety and depression scores were not increased after emergency situation

Interactions between the night time valley-wind system and a developing cold-air pool

This is a pre-copyedited, author-produced PDF of an article accepted for publication in Boundary-Layer Meteorology following peer review. The version of record [Arduini, G., Staquet, C & Chemel, C., ‘Interactions between the night time valley-wind system and a developing cold-air pool’, Boundary-Layer Meteorol (2016) 161:1 (49-72), first published online June 2, 2016, is available at Springer online at doi: 10.1007/s10546-016-0155-8The Weather Research and Forecast (WRF) numerical model is used to characterize the influence of a thermally-driven down-valley flow on a developing cold-air pool in an idealized alpine valley decoupled from the atmosphere above. Results for a three-dimensional (3D) valley, which allows for the formation of a down-valley flow, and for a two-dimensional (2D) valley, where the formation of a down-valley flow is inhibited, are analyzed and compared. A key result is that advection leads to a net cooling in the 2D valley and to a warming in the 3D valley, once the down-valley flow is fully developed. This difference stems from the suppression of the slope-flow induced upward motions over the valley centre in the 3D valley. As a result, the downslope flows develop a cross-valley circulation within the cold-air pool, the growth of the cold-air pool is reduced and the valley atmosphere is generally warmer than in the 2D valley. A quasi-steady state is reached for which the divergence of the down-valley flow along the valley is balanced by the convergence of the downslope flows at the top of the cold-air pool, with no net contribution of subsiding motions far from the slope layer. More precisely, the inflow of air at the top of the cold-air pool is found to be driven by an interplay between the return flow from the plain region and subsidence over the plateaux. Finally, the mechanisms that control the structure of the cold-air pool and its evolution are found to be independent of the valley length as soon as the quasi-steady state is reached and the down-valley flow is fully developed.Peer reviewedFinal Accepted Versio

Is surgery in acute aortic dissection type A still contraindicated in the presence of preoperative neurological symptoms?†

OBJECTIVES Severe neurological deficit (ND) due to acute aortic dissection type A (AADA) was considered a contraindication for surgery because of poor prognosis. Recently, more aggressive indication for surgery despite neurological symptoms has shown acceptable postoperative clinical results. The aim of this study was to evaluate early and mid-term outcomes of patients with AADA presenting with acute ND. METHODS Data from 53 patients with new-onset ND who received surgical repair for AADA between 2005 and 2012 at our institution were retrospectively reviewed. ND was defined as focal motor or sensory deficit, hemiplegia, paraplegia, convulsions or coma. Neurological symptoms were evaluated preoperatively using the Glasgow Coma Scale (GCS) and modified Rankin Scale (mRS), and at discharge as well as 3-6 months postoperatively using the mRS and National Institutes of Health Stroke Scale. Involvement of carotid arteries was assessed in the pre- and postoperative computed tomography. Logistic regression analysis was performed to detect predictive factors for recovery of ND. RESULTS Of the 53 patients, 29 (54.7%) showed complete recovery from focal ND at follow-up. Neurological symptoms persisted in 24 (45.3%) patients, of which 8 (33%) died without neurological assessment at follow-up. Between the two groups (patients with recovery and those with persisting ND), there was no significant difference regarding the duration of hypothermic circulatory arrest (28 ± 14 vs 36 ± 20 min) or severely reduced consciousness (GCS <8). Multivariate analysis showed significant differences for the preoperative mRS between the two groups (P < 0.007). A high preoperative mRS was associated with persistence of neurological symptoms (P < 0.02). Cardiovascular risk factors, age or involvement of supra-aortic branches were not predictive for persistence of ND. CONCLUSION More than half of our patients recovered completely from ND due to AADA after surgery. Severity of clinical symptoms had a predictive value. Patients suffering from AADA and presenting with ND before surgery should not be excluded from emergency surger

Weekly low-dose treatment with intravenous iron sucrose maintains iron status and decreases epoetin requirement in iron-replete haemodialysis patients

Background. Haemodialysis patients need sustained treatment with intravenous iron because iron deficiency limits the efficacy of recombinant human epoetin therapy in these patients. However, the optimal intravenous iron maintenance dose has not been established yet. Methods. We performed a prospective multicentre clinical trial in iron-replete haemodialysis patients to evaluate the efficacy of weekly low-dose (50 mg) intravenous iron sucrose administration for 6 months to maintain the iron status, and to examine the effect on epoetin dosage needed to maintain stable haemoglobin values in these patients. Fifty patients were enrolled in this prospective, open-label, single arm, phase IV study. Results. Forty-two patients (84%) completed the study. After 6 months of intravenous iron sucrose treatment, the mean ferritin value showed a tendency to increase slightly from 405 ± 159 at baseline to 490 ± 275 µg/l at the end of the study, but iron, transferrin levels and transferrin saturation did not change. The haemoglobin level remained stable (12 ± 1.1 at baseline and 12.1 ± 1.5 g/dl at the end of the study). The mean dose of darbepoetin alfa could be reduced from 0.75 to 0.46 µg/kg/week; epoetin alfa was decreased from 101 to 74 IU/kg/week; and the mean dose of epoetin beta could be reduced from 148 to 131 IU/kg/week at the end of treatment. Conclusions. A regular 50 mg weekly dosing schedule of iron sucrose maintains stable iron stores and haemoglobin levels in haemodialysed patients and allows considerable dose reductions for epoetins. Low-dose intravenous iron therapy may represent an optimal approach to treat the continuous loss of iron in dialysis patient

Inactivity of nitric oxide synthase gene in the atherosclerotic human carotid artery

Objective : Nitric oxide (NO) inhibits thrombus formation, vascular contraction, and smooth muscle cell proliferation. We investigated whether NO release is enhanced after endothelial NO synthase (eNOS) gene transfer in atherosclerotic human carotid artery ex vivo. Methods and Results : Western blotting and immunohistochemistry revealed that transduction enhanced eNOS expression; however, neither nitrite production nor NO release measured by porphyrinic microsensor was altered. In contrast, transduction enhanced NO production in non-atherosclerotic rat aorta and human internal mammary artery. In transduced carotid artery, calcium-dependent eNOS activity was minimal and did not differ from control conditions. Vascular tetrahydrobiopterin concentrations did not differ between the experimental groups.Treatment of transduced carotid artery with FAD, FMN, NADPH, L-arginine, and either sepiapterin or tetrahydrobiopterin did not alter NO release. Superoxide formation was similar in transduced carotid artery and control. Treatment of transduced carotid artery with superoxide dismutase (SOD), PEG-SOD, PEG-catalase did not affect NO release. Conclusions : eNOS transduction in atherosclerotic human carotid artery results in high expression without any measurable activity of the recombinant protein. The defect in the atherosclerotic vessels is neither caused by cofactor deficiency nor enhanced NO breakdown. Since angioplasty is performed in atherosclerotic arteries,eNOS gene therapy is unlikely to provide clinical benefi

Optimal Risk Transfers in Insurance Groups

Optimal risk transfers are derived within an insurance group consisting of two separate legal entities, operating under potentially different regulatory capital requirements and capital costs. Consistent with regulatory practice, capital requirements for each entity are computed by either a value-at-risk or an expected shortfall risk measure. The optimality criterion consists of minimising the risk-adjusted value of the total group liabilities, with valuation carried out using a cost-of-capital approach. The optimisation problems are analytically solved and it is seen that optimal risk transfers often involve the transfer of tail risk (unlimited reinsurance layers) to the more weakly regulated entity. We show that, in the absence of a capital requirement for the credit risk that specifically arises from the risk transfer, optimal risk transfers achieve capital efficiency at the cost of increasing policyholder deficit. However, when credit risk is properly reflected in the capital requirement, incentives for tail-risk transfers vanish and policyholder welfare is restored