Abstract The purpose of this study was to examine the effects of story mapping on the reading comprehension scores, on-task behaviors, and attitudes of third- -grade students (N = 6) with ADHD. Students' reading grade equivalencies were assessed before and after the study. The teacher-researcher compared two other achievement measures before and during story mapping to assess growth. The practical difference in scores as calculated with Cohen's d revealed that story mapping was successful in improving students' comprehension. On tests from the reading basal, students' scores improved an average of 16.00%, while tests from a computerized reading program improved 20.00%. Students exhibited on-task behavior 79.33% of the time and positive attitudes 82.33% of the time during the intervention. The implications of this study are important in determining effective instructional strategies to promote the active engagement of students and combat the core symptoms of ADHD.


Breast cancer has been reported by American Cancer Society as the second leading cause
of death among all the cancers of women. It is also reported that the early detection of
breast cancer can improve survival rate by allowing a wider range of treatment options.
Mammography is believed to be an effective tool to help radiologists to detect the malignant
breast cancer at the early stage. Image enhancement techniques can improve the
quality of mammogram images with enhancing the details of key features, like the shape of
microcalcifications. This thesis proposed a novel method to enhance mammogram images.
The proposed method uses a three level Laplacian Pyramid (LP) scheme that applies the
Squeeze Box Filter (SBF) instead of conventional low pass filtering. A previously proposed
nonlinear local enhancement technique is applied to the difference image produced
in the Laplacian Pyramid to contrast enhance the structural details of mammogram images.
The enhanced mammogram image is reconstructed by adding all the enhanced difference
images to the origianl SBF filtered image. Experimentation and quantitative results reported
in this thesis provide empirical evidence on the robustness of the proposed image
enhancement method on mammographic images.


Countries around the world face a retirement crisis brought on by aging populations, declining birthrates, and fiscal shortfalls. As a result, policy makers increasingly seek to understand retirement savings patterns, a crucial component of the safety net for the elderly. Drawing on the 2014 Global Findex database, which provides individual-level data on the use of financial products in more than 140 countries, this paper examines how adults save for old age. It finds that about 25 percent of adults worldwide save for old age, with rates exceeding 35 percent in high-income Organisation for Economic Co-operation and Development economies and the East Asia and Pacific region. On average, men are slightly more likely than women to save for this purpose, but the gender gap is deeper in developing countries. Worldwide, saving for old age is more common among older adults, more educated adults, and adults who own accounts. Adults in countries with English legal origin, and with high savings rates, are also more likely to save for old age. The paper also finds that measures to increase trust in the financial system, such as the safety net/moral hazard index based on deposit insurance, lead to higher rates of saving for old age. Finally, the paper finds little evidence of substitution between pension system provisions and contribution rates with saving for old age.


A novel, basic region leucine zipper transcription factor (TH/bZIP) is dramatically up-regulated at the climax of metamorphosis in Xenopus laevis. It can be induced in tadpoles prematurely by thyroid hormone (TH) with kinetics that are intermediate between early and late Xenopus TH response genes. A small amount of early, cycloheximide-resistant up-regulation is observed, but the majority of TH/ bZIP mRNA accumulation occurs after 12 h of treatment in parallel with late response gene induction. There are two genomic TH/bZIP genes in the pseudotetraploid X. laevis genome that are coordinately regulated. They have highly conserved regulatory regions that contain two conserved, adjoining DR+4 thyroid response elements (TRE) in opposite orientation. The early/late TH induction kinetics has been reproduced in transient transfection assays. The secondary rise of transcriptional activity requires DNA regions other than the TREs and, therefore, the interaction of transcription factors other than the TH receptors. Finally, the regulatory region of the TH/bZIP gene has been used to drive green fluorescent protein in transgenic X. laevis tadpoles. Regulation of the transgene during spontaneous and induced metamorphosis mimics that of the endogenous TH/bZIP gene. The newly developed X. laevis transgenesis method has distinct advantages for the analysis of transcriptional regulatory elements over transient transfection assays and will be useful for further in vivo studies of TH-response gene regulation during development.


RNAs not encoding proteins have gained prominence over the last couple of decades as fundamental regulators of cellular function. Not surprisingly, their dysregulation is increasingly being linked to pathology. Here, we review recent reports investigating the pathophysiological relevance of this species of RNA for the cardiovascular system, concentrating mainly on recent findings on long noncoding RNAs and microRNAs in cardiac hypertrophy and failure.


The purpose of this study was to examine the relationship between the professional experiences of agricultural education teacher candidates during their internship, their sense of teacher self-efficacy, and their perceptions of their preparation. The population included the entire cohort (n=24) of teacher candidates during the 2007 fall quarter at The Ohio State University. Teacher self-efficacy was measured using the Teacher Sense of Efficacy Scale (Tschannen-Moran & Woolfolk Hoy, 2001). Candidates reported high levels of teacher self-efficacy at the end of the experience. The candidates' perception of their level of preparation was similar to their sense of teacher self-efficacy. The largest discrepancy score was for the student engagement domain. Professional development experiences categorized as vicarious experiences revealed the strongest overall relationship with teacher self-efficacy. The experience of observing a first-year agriculture teacher had the strongest positive relationship with overall teacher selfefficacy. This variable explained 11 percent of the variance in overall teacher selfefficacy, and 14 percent of the variance in the instructional strategies domain. Verbal feedback that candidates received from their cooperating teacher was positively related to teacher self-efficacy. The number of courses teacher candidates taught was negatively related to their sense of efficacy in the classroom management domain.


Retaining trees in low-input, low-productivity grazing systems in southern Queensland can provide biodiversity benefits without adversely impacting upon production. Although previous research conducted during period of extended drought, may have failed to determine the overall biodiversity potential in relation to management practices. We describe a grazing exclusion trial designed to monitor biodiversity changes following the removal of grazing in the Traprock wool producing region of southern Queensland. Eighteen sites across 10 properties were sampled across two vegetation types (grassy box woodland and ironbark/gum woodland), three overstorey tree densities ( 20 trees/ha), and three exclosure types (full exclosure; partial exclosure and control (open). Exclosures were established in 2005 and sampled over a four year period for understorey composition and above-ground biomass. No differences were apparent in composition between exclosure treatments (ANOSIM, p > 0.05), although patterns were observed in overstorey tree density treatments within vegetation types. There were no differences (p > 0.05) in biomass between exclosures, although significantly higher plant biomass was observed in low density treatments. Exclusion of grazing has not significantly altered composition after 4 years. However, above-ground biomass has responded to the removal of grazing in open paddock areas. A longer period of exclusion may be necessary to detect changes (if any) in plant species composition.


For machine learning models trained with limited labeled training data, validation stands to become the main bottleneck to reducing overall annotation costs. We propose a statistical validation algorithm that accurately estimates the F-score of binary classifiers for rare categories, where finding relevant examples to evaluate on is particularly challenging. Our key insight is that simultaneous calibration and importance sampling enables accurate estimates even in the low-sample regime (< 300 samples). Critically, we also derive an accurate single-trial estimator of the variance of our method and demonstrate that this estimator is empirically accurate at low sample counts, enabling a practitioner to know how well they can trust a given low-sample estimate. When validating state-of-the-art semi-supervised models on ImageNet and iNatural-ist2017, our method achieves the same estimates of model performance with up to 10× fewer labels than competing approaches. In particular, we can estimate model F1 scores with a variance of 0.005 using as few as 100 labels.


It is crucial to understand the natural history of genital human papillomavirus (HPV) infection in men to prevent the increasing male HPV-related disease burden. We evaluated the associations between HPV infection and circumcision, smoking, and alcohol use after accounting for sexual behavior. The study included 2331 male personnel from Danish barracks. Penile swabs were tested for HPV DNA with a polymerase chain reaction assay, INNO-LiPA. All men completed a self-administered questionnaire providing data on potential risk factors for HPV such as lifestyle and sexual habits. Using multivariable logistic regression, associations between potential risk factors and HPV infection were estimated and expressed as odds ratios (ORs) with 95% confidence intervals (CI). Current cigarette smoking was associated with increased odds of HPV detection (OR = 1.2; 95% CI: 1.0–1.4), but we found no association with alcohol use in the analysis adjusted for sexual behavior. Circumcision reduced the odds of a prevalent HPV infection (OR = 0.7; 95% CI: 0.5–1.0) although not statistically significantly. Strong associations with lifetime and recent number of female sex partners were observed, but in contrast to uncircumcised men, increasing number of sex partners was not associated with higher HPV prevalence in circumcised men. In conclusion, smoking was associated with increased odds of penile HPV in men from the general population in Denmark, whereas circumcision seemed to reduce the risk. Moreover, our results indicated that there might be differences in the viral susceptibility between circumcised and uncircumcised men.


For realizing all-solid-state batteries (ASSBs), it is highly desirable to develop a robust solid electrolyte (SE) that has exceptional ionic conductivity and electrochemical stability at room temperature. While argyrodite-type Li6PS5Cl (LPSCl) SE has garnered attention for its relatively high ionic conductivity (∼3.19 × 10-3 S cm-1), it tends to emit hydrogen sulfide (H2S) in the presence of moisture, which can hinder the performance of ASSBs. To address this issue, researchers are exploring approaches that promote structural stability and moisture resistance through elemental doping or substitution. Herein, we suggest using zeolite imidazolate framework-8 as a moisture absorbent in LPSCl without modifying the structure of the SE or the electrode configuration. By incorporating highly ordered porous materials, we demonstrate that ASSBs configured with LPSCl SE display stable cyclability due to effective and long-lasting moisture absorption. This approach not only improves the overall quality of ASSBs but also lays the foundation for developing a moisture-resistant sulfide electrolyte.


Inhaling a new experimental vaccine may offer protection against severe acute respiratory syndrome, or SARS. The vaccine, tested in African green monkeys, is the first to be administered directly to the respiratory tract and is also the first that confers immunity with a single dose. "This could be used for local outbreak control," says Peter L. Collins of the National Institute for Allergy and Infectious Diseases in Bethesda, Md. "It would be the most rapid way to vaccinate those at risk for SARS," especially vulnerable health care workers, he says. SARS became a health crisis in 2003. To date, it has infected more than 8,000 people worldwide, killing 774. The virus that causes SARS has spiky molecules called S proteins protruding from its surface. These proteins enable the virus to infect mucosal cells in the respiratory system. To make the vaccine, scientists added the viral gene that encodes the S protein to the DNA of a different virus, BHPIV3. This bovine-human hybrid virus provokes an immune response, but no illness, in people and monkeys. BHPIV3 is also being tested as a vaccine against the human form of the virus, which causes respiratory infections and pneumonia in children. "A respiratory virus is really the ideal route for a SARS vaccine," says Collins. The researchers gave four monkeys respiratory doses of BHPIV3 containing the gene for S protein and provided four other monkeys with BHPIV3 augmented with an irrelevant gene. The BHPIV3 virus replicated in the respiratory tracts of all the animals, but only those monkeys that received the S-protein gene developed antibodies against the SARS virus, the scientists report in the June 26 Lancet. After a month, Collins exposed the animals to the SARS virus to see whether those antibodies protected the monkeys from the disease. The SARS virus wasn't detectable in the noses and throats of monkeys that received the S-protein vaccine but did show up in the others. None of the animals became ill because African green monkeys don't develop the symptoms of SARS. Collins says that BHPIV3 is a good choice as the basis for a vaccine because it's already been shown to be safe in people, a factor that would speed the FDAapproval process. The vaccine, however, may not work in adults. Most have immunity to BHPIV3 through childhood exposure to the human form of the virus. Decorating the viral surface with proteins that the human immune system doesn't recognize could remedy this problem, Collins suggests. Other vaccines against SARS are in the pipeline. One is already being tested in people in China. The developer of an injectable experimental vaccine for SARS (SN: 1/10/04, p. 28), Andrea Gambotto of the University of Pittsburgh School of Medicine, says that his vaccine, too, could possibly be administered through the intranasal route. No clinical trials are now planned for the BHPIV3 vaccine. "If SARS was rampaging through China, we'd probably rush it through testing," says Collins. But because SARS currently seems to be under control, scientists are exploring multiple avenues to develop the most effective vaccine. "I think all this research is exciting and interesting," says Donna Ambrosino of Massachusetts Biologics Laboratories in Worcester, "but which [approach] at the end of day truly benefits us remains to be seen." —C. LOCK


The article compares the IR absorption spectra of the gases of the Earth's atmosphere with frequencies, close to the frequency of the maximum of thermal radiation of human. It is shown that such a gas is ozone. Being in the transparency window of the atmosphere, it emits absorbed thermal radiation from the Earth. This radiation, in turn, gets to maximum heat absorption (radiation) of a human, and being with it in resonance, fuels him with energy. In larger cities this nourishment is weakened because of the smog due to the strong scattering of Earth radiation and ozone. Thus, the "greenhouse ozone" as a natural source of infrared radiation has beneficial effect on human.


Introduction Emergency rooms (ERs) generally assign a preliminary diagnosis to patients, who are then hospitalised and may subsequently experience a change in their lead diagnosis (cDx). In ERs, the cDx rate varies from around 15% to more than 50%. Among the most frequent reasons for diagnostic errors are cognitive slips, which mostly result from faulty data synthesis. Furthermore, physicians have been repeatedly found to be poor self-assessors and to be overconfident in the quality of their diagnosis, which limits their ability to improve. Therefore, some of the clinically most relevant research questions concern how diagnostic decisions are made, what determines their quality and what can be done to improve them. Research that addresses these questions is, however, still rare. In particular, field studies that allow for generalising findings from controlled experimental settings are lacking. The ER, with its high throughput and its many simultaneous visits, is perfectly suited for the study of factors contributing to diagnostic error. With this study, we aim to identify factors that allow prediction of an ER's diagnostic performance. Knowledge of these factors as well as of their relative importance allows for the development of organisational, medical and educational strategies to improve the diagnostic performance of ERs. Methods and analysis We will conduct a field study by collecting diagnostic decision data, physician confidence and a number of influencing factors in a real-world setting to model real-world diagnostic decisions and investigate the adequacy, validity and informativeness of physician confidence in these decisions. We will specifically collect data on patient, physician and encounter factors as predictors of the dependent variables. Statistical methods will include analysis of variance and a linear mixed-effects model. Ethics and dissemination The Bern ethics committee approved the study under KEK Number 197/15. Results will be published in peer-reviewed scientific medical journals. Authorship will be determined according to ICMJE guidelines. Trial registration number The study protocol Version 1.0 from 17 May 2015 is registered in the Inselspital Research Database Information System (IRDIS) and with the IRB ('Kantonale Ethikkomission') Bern under KEK Number 197/15.


This chapter explores some practical issues that have arisen in the WTO negotiations on environmental goods and services, especially issues pertaining to liberalising trade in environmental goods. Since environmental goods are not covered by a single chapter of the Harmonized Commodity Description and Coding System (HS) — the international basis for codifying trade and tariffs — an agreement on environmental goods must be defined by reference to an agreed list. In such a case, when the most detailed (6-digit) product level is insufficiently specific, it becomes necessary to agree to create common commodity descriptions at the 8- or 10-digit level in national tariff schedules. Another important concern is the so-called "dual use" problem: many goods with environmental uses also can be used for nonenvironmental purposes. Possible solutions to these problems are explored, drawing on past experience in negotiating and implementing sectoral liberalisation agreements. The chapter also discusses issues relating to separate tariff lines for whole plants and to goods distinguished by their superior environmental performance in use. Finally, it considers some procedural and institutional issues that will have to be addressed before an agreement is concluded, notably whether to allow for the periodic addition of new goods to the agreement, and how to deal with the problem of changes over time in the relative environmental performance of competing goods.


In January 1970 a 56-year-old married man consulted me with his 50-year-old wife. The man, a dyestuffs worker, complained of a three-day history of frequency of micturition, dysuria, offensive urine, and pain in the left testicle. His wife complained of a two-day history of frequency of micturition, dysuria, right loin pain, offensive urine, and "flu-like" symptoms. Both patients had suffered similar attacks before and both on this occasion blamed sexual intercourse, which had occurred four days previously. Haematological examination revealed a leucocyte count of 17 x 109/l (17 000/mm3) (10 o neutrophils) in the man and 9 x 109/1 (9000/mm3) (870o neutrophils) in the woman. Urine examination revealed that both patients were infected with Escherichia coli serogroup 06, which was present in concentration greater than 108/1. A rectal swab was taken from the man and rectal and vaginal swabs were taken from his wife. E coli serogroup 06 was found in all of these. Subsequent and more detailed serological examination at the Salmonella Reference Laboratory, Colindale, revealed that the responsible organism was E coli serotype 06 Hi, which was isolated from all swabs except the rectal swab in the husband, from which no organism could be grown, presumably owing to loss in transit. That husband and wife had the same urinary pathogen would appear to be beyond dispute, but the pathogenesis of the infection in the man remains speculative. One interpretation of the facts is that the husband developed an ascending infection that was sexually transmitted in that he received an inoculum from the wife's vagina rather than his own bowel flora. Subsequent urological investigations revealed mild bladder neck obstruction only, but attacks (often associated with epididymitis) continued until vasectomy in 1971. This was the second such case I had encountered within a 12month period and subsequent inquiry among local colleagues revealed that other family practitioners had experienced the same phenomenon. Lt-Col Simpson suggests that prophylactic chemotherapy might be considered in this situation when a wife has urinary tract infection. If the above hypothesis is correct the results might be disappointing, as vaginal colonisation with a urinary pathogen might occur without urinary tract infection. Prophylactic chemotherapy might well be of value in selected men after intercourse, however.


We consider homogeneous factor models on uniformly sparse graph sequences converging locally to a (unimodular) random tree T, and study the existence of the free energy density ϕ, the limit of the log-partition function divided by the number of vertices n as n tends to infinity. We provide a new interpolation scheme and use it to prove existence of, and to explicitly compute, the quantity ϕ subject to uniqueness of a relevant Gibbs measure for the factor model on T. By way of example we compute ϕ for the independent set (or hard-core) model at low fugacity, for the ferromagnetic Ising model at all parameter values, and for the ferromagnetic Potts model with both weak enough and strong enough interactions. Even beyond uniqueness regimes our interpolation provides useful explicit bounds on ϕ.

In the regimes in which we establish existence of the limit, we show that it coincides with the Bethe free energy functional evaluated at a suitable fixed point of the belief propagation (Bethe) recursions on T. In the special case that T has a Galton–Watson law, this formula coincides with the nonrigorous "Bethe prediction" obtained by statistical physicists using the "replica" or "cavity" methods. Thus our work is a rigorous generalization of these heuristic calculations to the broader class of sparse graph sequences converging locally to trees. We also provide a variational characterization for the Bethe prediction in this general setting, which is of independent interest.


Pulmonary infections in patients with cystic fibrosis (CF), are a major cause of morbidity and mortality. Prevention, diagnosis and therapy in cystic fibrosis, lead to the necessary collaboration between clinical and laboratory to identify effective strategies and appropriate solutions to address the problems inherent isolation micro-organisms, antibiotic strategies, overcoming of bacterial resistance and other problems management of these patients. The task of the microbiology laboratory and research in quickly and accurately, the agents responsible for these infectious processes, in order to isolate them from material, identify and determine their sensitivity antibiotics. A microbiological surveillance on 34 patients (13 males and 21 females) with CF and related to the "Support Services Provincial Trento for the treatment of cystic fibrosis "in the period July 2005 - August 2008, was carried out. 180 Gram positive and 278 of Gram negative bacteria as well as 235 fungi wre collected. Staphylococcus aureus was the most frequently organism found in patients with CF with an incidence of 23% on 156 strains isolated, Pseudomonas aeruginosa was collected 19% of all microorganisms isolated corresponding to 131 strains, Candida albicans is the yeast often isolated with a frequency 22% equal to 149 isolates, Aspergillus fumigatus was isolated at a rate of 8%. From the data we collected and processed has been noted that the local epidemiology of CF patients reflects as reported in the scientific literature and national international consulting, both as a type microorganisms that frequency also isolated compared to age groups. Considering the score of Bartlett as discriminating respiratory fitness of the material, it has been observed that only 32 samples over 327 total (10%) would materials insignificant. It follows therefore that the time of sample collection, followed by personnel (physiotherapists dedicated to CF patients), represents a crucial step in guarantee the quality of the preanalytical phase.


Use of an air filter material combined with antibacterial agents is one of the most effective methods to resolve the problem of air filter contaminated by pathogenic microbes. ε-Polylysine and Natamycin are two biogenic antimicrobials that have been widely applied in recent years because of their high antibacterial efficiency, harmlessness to human body and environmental friendliness. In this paper, a novel antibacterial air filter material was prepared by immobilizing ε-Polylysine and Natamycin onto fiberglass high efficiency air filter media by acrylate adhesive bonding. The mechanical properties, aerosol filtration properties, and antibacterial properties were then evaluated. An improvement in the mechanical properties of the material prepared was seen compared to the untreated filter media. The filtration efficiency of the material prepared for particle aerosols and bioaerosols both greater than 99.997%. Antibacterial efficiency of the material prepared against Staphylococcus aureus and Escherichia coli in suspensions were both greater than 99.99% compared to the untreated filter media. The anti-mildew effect against Aspergillus niger in suspension was strong compared to the untreated filter media. Antibacterial efficiency of the material prepared against bacteria in bioaerosols was greater than 99.99%. Observed with Scanning Electron Microscope, most bacteria on antibacterial filter media appeared to be dead. Thus, antibacterial air filter material prepared by immobilizing bio-antimicrobials on fiberglass had a strong inhibitory effect against gram-positive bacteria, gram-negative bacteria and fungi, with no impairment of the intrinsic properties. This kind of material appears to be promising for application in air cleaning and biological protection fields.


The continued viability of the Eurozone as a single currency area is challenged from time to time. Some doubt the ability of Italy and other Member States to remain in the zone, given their difficulties in complying with the applicable budgetary rules. Even the French Prime Minister has commented that life was sometimes easier with the franc. This article considers some of the consequences which may ensue in the event that a Member State felt compelled to seek an exit from the Eurozone, and to reintroduce its own national currency. The Treaty does not legislate for this type of situation and any such attempt would clearly cause severe strains at a political level. But it would also have a major impact on the financial markets. In particular, there may be doubts about the currency in which continuing monetary obligations should be settled. This article seeks to analyze the legal issues which would arise in this context.


Characterizing the TCRα and TCRβ chains expressed by T cells responding to a given pathogen or underlying autoimmunity helps in the development of vaccines and immunotherapies, respectively. However, our understanding of complementary TCRα and TCRβ chain utilization is very limited for pathogen- and autoantigen-induced immunity. To address this problem, we have developed a multiplex nested RT-PCR method for the simultaneous amplification of transcripts encoding the TCRα and TCRβ chains from single cells. This multiplex method circumvented the lack of antibodies specific for variable regions of mouse TCRα chains and the need for prior knowledge of variable region usage in the TCRβ chain, resulting in a comprehensive, unbiased TCR repertoire analysis with paired coexpression of TCRα and TCRβ chains with single-cell resolution. Using CD8+ CTLs specific for an influenza epitope recovered directly from the pneumonic lungs of mice, this technique determined that 25% of such effectors expressed a dominant, nonproductively rearranged Tcra transcript. T cells with these out-of-frame Tcra mRNAs also expressed an alternate, in-frame Tcra, whereas approximately 10% of T cells had 2 productive Tcra transcripts. The proportion of cells with biallelic transcription increased over the course of a response, a finding that has implications for immune memory and autoimmunity. This technique may have broad applications in mouse models of human disease.


The physical investigations on the accuracy improvement to the measurement of the Earth's gravity field recovery are carried out based on the next-generation Pendulum-A/B out-of-plane twin-satellite formation in this paper. Firstly, the Earth's gravity field complete up to degree and order 100 is, respectively, recovered by the collinear and pendulum satellite formations using the orbital parameters of the satellite and the matching accuracies of key payloads from the twin GRACE satellites. The research results show that the accuracy of the Earth's gravity field model from the Pendulum-A/B satellite formation is about two times higher than from the collinear satellite formation, and the further improvement of the determination accuracy of the Earth's gravity field model is feasible by the next-generation Pendulum-A/B out-of-plane twin-satellite formation. Secondly, the Earth's gravity field from Pendulum-A/B complete up to degree and order 100 is accurately recovered based on the orbital parameters of the satellite (e.g., an orbital altitude of 400 km, an intersatellite range of 100 km, an orbital inclination of 89° and an orbital eccentricity of 0.001), the matching accuracies of space-borne instruments (e.g. 10−6 m in the intersatellite range, 10−3 m in the orbital position, 10−6 m/s in orbital velocity, and 10−11 m/s2 in non-conservative force), an observation time of 30 days and a sampling interval of 10 s. The measurement accuracy of the Earth's gravity field from the next-generation Pendulum-A/B out-of-plane twin-satellite formation is full of promise for being improved by about 10 times compared with that from the current GRACE satellite formation. Finally, the physical requirements for the next-generation Pendulum-A/B out-of-plane twin-satellite formation are analyzed, and it is proposed that the satellite orbital altitude be preferably designed to be close to 400±50 km and the matching precision of key sensors from the Pendulum-A/B mission be about one order of magnitude higher than from the GRACE program.


Most business data are stored in relational database systems, and SQL (Structured Query Language) is used for data retrieval and manipulation. With XML (Extensible Markup Language) rapidly becoming the de facto standard for retrieving and exchanging data, new functionality is expected from traditional databases. Existing SQL applications will evolve to retrieve relational data as XML data using database or SQL extensions for XML. New XML data will be stored, searched, and manipulated in the database as a "first class" citizen along with existing relational data. Furthermore, new applications will emerge that solely operate in terms of XML. These new XML applications operate on the same database using an XML query language, XQuery. In this paper, we describe an integrated database architecture that enables SQL applications with XML extensions as well as XQuery applications to operate on the same data. The architecture allows for a seamless flow from relational data to XML and back.


The study aims to investigate and test a new algorithm applying to the sampled projection to generate high quality images by reducing the noise in the cone-beam computed tomography (CBCT). A single sampling without object is first employed in scanning to obtain the noise as the knowledge, then a random Gaussian Matrix (GM) is used to get a new noise map that is consistent with the previous one based on the knowledge. Study results demonstrated significant improvement in the signal-to-noise ratios (SNRs) of the images by overlapping the noise map on the projection for average. Since the noise is reduced, it has the potential to improve projection quality by using the original noise sampled on flat panel detector (FDP).


Two classes of mutants, con and tolG, that appeared to be very similar in a number of respects have been shown to be identical and cotransducible with pyrD. By diethylaminoethyl-cellulose chromatography of the outer membranes, we have shown that the mutants are missing only protein 3A and retain protein 3B. Using con mutants, we were thus able to identify protein 3B on the pH 7.2 gel system of Maizel where it runs separately from protein 3A if unheated samples are used. tolG mutants were shown to be identical to con mutants in being conjugation defective with most F-like plasmid donors but not with I-like plasmid donors, and in their resistance pattern to bacteriophages and colicins. During the course of this study, it was observed that the bacteriocin produced by Serratia marcescenc JF246 was identical in its activity spectrum to colicin L-398 and is now considered to be a colicin of type L.


Objective: To ascertain if antidepressants, as a group, increase the risk for major malformations, as well as assessing each individual antidepressant. Methods: At The Motherisk Program, we analyzed pregnancy outcomes of women (n = 1243) from prospectively collected cases in our database, who were exposed to antidepressants during their pregnancy. We then compared them with a matched comparison group of women (n = 1243) who were not exposed (nonteratogen group). Results: Women (n = 928) who fit the criteria for inclusion, were exposed in the first trimester of pregnancy, and gave birth to a live-born infant were matched to women (n = 928) in the comparison group. There were 30 (3.2%) major malformations in the antidepressant group and 31 (3.3%) in the comparison group (OR 0.9; 95% CI 0.5 to 1.61). The antidepressants included in the analysis were: bupropion (113), citalopram (184), escitalopram (21), fluvoxamine (52), nefazodone (49), paroxetine (148), mirtazepine (68), fluoxetine (61), trazodone (17), venlafaxine (154), and sertraline (61). Conclusions: As a group, antidepressant use in the first trimester of pregnancy is not associated with an increased risk for major malformation above the baseline. In addition, no individual antidepressant was associated with an increased risk of a specific malformation.


For many years, improvements to CMOS process technologies fueled rapid growth in processor performance and throughput. Each process generation brought exponentially more transistors and exponentially reduced the per-transistor switching power. However, concerns over leakage currents have moved us out of the classical CMOS scaling regime. Although the number of available transistors continues to rise, their switching power no longer declines. In contrast to transistor counts, power budgets remain fixed due to limitations on cooling or battery life. Thus, with each new process generation, an exponentially decreasing fraction of the available transistors can be simultaneously switched. The growing divide between available transistors and utilizable transistors leads to a utilization wall.
This dissertation characterizes the utilization wall and proposes conservation cores as a means of surmounting its most pressing challenges. Conservation cores, or C-Cores, are application-specific hardware circuits created to reduce energy consumption on computationally-intensive applications with complex control logic and irregular memory access patterns. C-Cores are drop-in replacements for existing source code, and make use of limited reconfigurability to adapt to software changes over time. The design and implementation of these specialized execution engines pose challenges with respect to code selection, automatic synthesis, choice of programming model, longevity/robustness, and system integration.
This dissertation addresses many of these challenges through the development of an automated conservation core toolchain. The toolchain automatically extracts the key kernels from a target workload and uses a custom C-to-silicon infrastructure to generate 45 nm implementations of the C-Cores. C-Cores employ a new pipeline design technique called pipeline splitting, or pipesplitting. This technique reduces clock power, increases memory parallelism, and further exploits operation-level parallelism. C-Cores also incorporate specialized energy-efficient per-instruction data caches called cachelets into the datapath, which allow for sub-cycle cache-coherent memory accesses.
An evaluation of C-Cores against an efficient in-order processor shows that C-Cores speed up the code they target by 1.5×, improve EDP by 6.9× and accelerate the whole application by 1.33× on average, while reducing application energy-delay by 57%.


Computational methods are required for prediction of non-coding RNAs (ncRNAs), which are involved in many biological processes, especially at post-transcriptional level. Among these ncRNAs, miRNAs have been largely studied and biologists need efficient and fast tools for their identification. In particular, ab initio methods are usually required when predicting novel miRNAs. Here we present a web server dedicated for miRNA precursors identification at a large scale in genomes. It is based on an algorithm called miRNAFold that allows predicting miRNA hairpin structures quickly with high sensitivity. miRNAFold is implemented as a web server with an intuitive and user-friendly interface, as well as a standalone version. The web server is freely available at: http://EvryRNA.ibisc.univ-evry.fr/miRNAFold.


The Czech Republic is in the process of transforming its social system which is not capable of managing adequate care of its old citizens. In the last years we have witnessed an increase in the number of mediating agencies that import mainly Ukranian migrants for the purpose of engaging them in care work focusing on elderly people. The paper presents results of pilot ethnograpic research and focuses on commodification of care work for elderly people and the vulnerable character of domestic care work provided by Ukrainian female migrants in the Czech Republic. I argue that this specific "product" – the Ukrainian female caregiver – is based on the intersections of gender, ethnicity and migration.


The Kalman filter technique has come into wide use for charged track reconstruction in high-energy physics experiments. It is also well suited for detector design studies, allowing for the efficient estimation of optimal track covariance matrices without the need of a hit level Monte Carlo simulation. Although much has been published about the Kalman filter equations, there is a lack of previous literature explaining how to implement the equations. In this paper, the operators necessary to implement the Kalman filter equations for two common detector configurations are worked out: a central detector in a uniform solenoidal magnetic field, and a fixed-target detector with no magnetic field in the region of the interactions. With the track covariance matrices in hand, vertex and invariant mass errors are readily calculable. These quantities are particularly interesting for evaluating experiments designed to study weakly decaying particles which give rise to displaced vertices. The optimal vertex errors are obtained via a constrained vertex fit. Solutions are presented to the constrained vertex problem with and without kinematic constraints. Invariant mass errors are obtained via propagation of errors; the use of vertex constrained track parameters is discussed. Many of the derivations are new or previously unpublished. >


As a signatory to the Alma-Ata Declaration in 1978, the Government of India is committed to taking steps to provide 'Health for All' to its citizens by 2000 AD. We have agreed to adopt the primary health care approach, for achieving the goal of HFA. In this context, it is very essential to redefine the role of hospital. It will not be possible to achieve the goal-HFA unless, hospitals start functioning as health centres. This paper discusses in details how a hospital can function as health centre.


Since the end of the World War II the World Bank and the International Monetary Fund (IMF) emerged as the pre-eminent international financial institutions (IFIs). Their roles have evolved overtime and today they are viewed inter alia as dictating access to development aid and promoting free-market policies. The BRICS (Brazil, Russia, India, China and South Africa) have created the BRICS Bank as an alternative to the traditional dominance of the IMF/World Bank. This paper pinpoints the role and functioning of the IMF/World Bank and their relations with Latin American and Caribbean (LAC) countries. It assesses the implications of the BRICS countries as an economic bloc and their emergent BRICS Bank for the LAC region. Official reports and secondary data are used to support the analyses.


In this paper a combined method of image compression and encryption is presented. Unlike earlier method of image compression and encryption presented separately. The model is achieved by using discrete wavelet transform (DWT) of any image is decompose into n levels, which corresponds to higher frequency band and then apply RLE for each decomposition blocks. The encryption part of this model is implemented by using chaotic based feedback system with logistic map and external secrete key of 256 bits.


A study on the effect of alkaline treatment on the mechanical properties of cotton fabric reinforced epoxy composites is presented in this paper. One hour treatment of cotton fabric was performed using three different concentrations of sodium hydroxide (NaOH) solution. 1% NaOH treated fabric reinforced composites exhibited maximum improvement in tensile strength. It was concluded that the said NaOH concentration improves interfacial adhesion between the cotton fabric and epoxy resin. Moreover the morphology of the fracture surface, evaluated by scanning electron microscopy (SEM), indicated that surface treatment can yield better adhesion between the fabric and matrix, demonstrating the effectiveness of the treatment. The dynamic mechanical analysis (DMA) results revealed that alkali treated (1% and 3% NaOH) fabric composites exhibit higher storage moduli and glass transition temperature (Tg) values as compared to the untreated fabric composites. However, for all the composite specimens, the storage modulus decreased with increasing temperature (25 100 °C). Tg values of 50.9, 56.7, 52.8 and 37.7 °C were recorded for the untreated and (1%, 3% and 5%) treated composites, respectively. The tan δ values decreased for all the composites with increasing temperature, indicating enhanced interactions between the polymer matrix and fabric reinforcement.


Context Biomass serves as a major fuel source for > 50% of the world's population. The global burden of disease attributed to indoor air pollution from biomass combustion accounts for approximately 3% of worldwide disability-adjusted life-years lost. This is due to pneumonia in children and chronic obstructive pulmonary disease and lung cancer in women. Case Presentation A 53-year-old man from Mexico was referred to the pulmonary clinic for evaluation of chronic productive cough and pulmonary nodules. In his youth, he worked at a charcoal plant in Mexico, where he burned wood and was exposed to massive amounts of smoke. His evaluation revealed thickened bronchovascular bundles with nodules on thoracic computed tomography, dark black plaques in large airways on bronchoscopy, and carbon-laden macrophages and fibrotic scars on lung biopsy. Discussion The patient was diagnosed with "hut lung," a term that refers to the noninfectious, nonmalignant respiratory manifestations of chronic, high-level exposures to biomass smoke. This is the first reported case of hut lung associated with charcoal production. This case highlights that histopathologic abnormalities of the lung parenchyma may be present in patients with only mild symptoms and that clinical progression is likely a function of both the duration and intensity of exposure. Relevance to Clinical Practice As residents of lesser developed countries continue to be exposed to high levels of biomass smoke at work or at home and continue to immigrate to developed countries, it is important that health care providers in developed countries be aware of biomass-smoke–related pulmonary disease.


Salt crystallization represents one of the major causes for the degradation of building and ornamental stone. As such, it has attracted the attention of researchers, who over the years have progressively unraveled most mechanisms involved in salt damage. Despite this mechanistic understanding, many questions subsist about how to quantitatively predict damage or its progression, and in particular how to relate performance on site to that in laboratory tests. In this context, a new RILEM TC 271‐ASC has been started with the objective of defining laboratory tests that deliver more reliable predictions of field behavior. One deliverable of this TC is to provide a theoretical insight into this question based on recent progress on the understanding of salt damage. This paper presents a summary of this work, highlighting key aspects relating to crystallization pressure, chemo‐mechanics and mass transport. Implications are discussed in relation to the most used accelerated salt crystallization tests in an attempt to better define which field exposure conditions that these tests best represent and may be used for, or define effective test procedures representing specific field conditions. A simple conceptual model for the development of salt damage is introduced. During an initial "induction" phase, transport of ions and accumulation of salt in the porous materials occurs without causing detectable damage until a critical point, termed "damage onset" is reached. Beyond this point, during the "propagation phase", the material degrades, typically losing strength and cohesiveness. The implications of these two phases are discussed in relation to the selection of appropriate salt weathering tests and conservation interventions.


Many school psychologists focus their interpretation on composite scores from intelligence test batteries designed to measure the broad abilities from the Cattell–Horn–Carroll theory. The purpose of this study was to investigate the general factor loadings and specificity of the broad ability composite scores from one such intelligence test battery, the Woodcock–Johnson III Tests of Cognitive Abilities Normative Update (Woodcock, McGrew, Schrank, & Mather, 2007). Results from samples beginning at age 4 and continuing through age 60 indicate that Comprehension–Knowledge, Long-Term Retrieval, and Fluid Reasoning appear to be primarily measures of the general factor at many ages. In contrast, Visual-Spatial Thinking, Auditory Processing, and Processing Speed appear to be primarily measures of specific abilities at most ages. We offer suggestions for considering both the general factor and specific abilities when interpreting Cattell–Horn–Carroll broad ability composite scores.


AIM
Long-term stability testing of drug candidates in biological matrix is a key parameter in bioanalytical method validation. The European Bioanalysis Forum formed a Topic Team to evaluate the use of isochronic design for long-term stability testing of large molecules.

METHOD
Isochronic design is based on storage of samples at a reference temperature (below -130°C) where the samples are considered stable. The stability samples are stored at the intended storage temperature and then transferred to the reference temperature, while a set of reference samples is stored the entire storage period at the reference temperature. Stability and reference samples will then be analyzed in one run at the end of the storage period. The mean concentrations of the stability samples are compared either to their nominal concentrations or to the mean concentrations of the reference samples.

CONCLUSION
The design minimizes day-to-day variation, reduces workload and adds to the flexibility in the laboratory.


Adversarial attacks on machine learning-based classifiers, along with defense mechanisms, have been widely studied in the context of single-label classification problems. In this paper, we shift the attention to multi-label classification, where the availability of domain knowledge on the relationships among the considered classes may offer a natural way to spot incoherent predictions, i.e., predictions associated to adversarial examples lying outside of the training data distribution. We explore this intuition in a framework in which first-order logic knowledge is converted into constraints and injected into a semi-supervised learning problem. Within this setting, the constrained classifier learns to fulfill the domain knowledge over the marginal distribution, and can naturally reject samples with incoherent predictions. Even though our method does not exploit any knowledge of attacks during training, our experimental analysis surprisingly unveils that domain-knowledge constraints can help detect adversarial examples effectively, especially if such constraints are not known to the attacker. While we also show that an adaptive attack exploiting knowledge of the constraints may still deceive our classifier, it remains an open issue to understand how hard for an attacker would be to infer such constraints in practical cases. For this reason, we believe that our approach may provide a significant step towards designing robust multi-label classifiers.


Surimi-based product is a white meat protein extract based products. The protein was obtained from washing process where the kind of protein fraction depends on the type and concentration of the solution washing. Therefore need to study the influence of NaCl concentration used in washing process on the physicochemical properties. This study used a randomized block design with surimi-based product NaCl concentration (PN) consists of 6 level 0.1; 0.2; 0.3; 0.4; 0.5; and 0.6%, which was repeated three times. The parameters was the physicochemical properties of surimi-based product consist of the gel quality (gel strength and folding test), thaw-drip, water holding capacity, water content. The effects were analyzed uses ANOVA followed by DMRT for the one that save significant effect. The results showed that the NaCl concentration gave significant effect to the water content and water holding capacity of meat porridge II, gel strength and folding test of surimi-based product. The higher concentration of NaCl the lower water content of the meat slurry II (82.6418% - 74.4874%), water holding capacity of meat slurry II (71.4175% - 59,4225%), gel strength (3851.082 g.s - 2381.608 g.s) and folding test (15382.186 g.s - 26955.768 g.s), but the higher the thaw-drip (2,0583% - 5,3603%) . Gel strength and folding test graph were quadratic curve. The increase concentration of NaCl in the washing stages reduce the water binding capacity of the protein because of leaching in washing solution so that the reduced strength and elasticity of chicken surimi-based products.


Policymakers in the Brazilian Amazon face the challenge of meeting environmental and developmental goals as cities and towns within these tropical forests continue to face migration pressure. Alternative government planning strategies have been implemented to address forest clearing in conjunction with meeting social agendas. This paper uses panel estimation methods to investigate the impact of settlement design on land use. Results indicate that new settlement designs developed to further social interaction have had a negative impact on land cover and land use transformation. Thus, while new settlement designs appear to positively impact stated social goals, including greater contact between families and access to water and services, these social advances have come at the expense of environmental goals.


This thesis deals with the design and fabrication of tunable Vertical-Cavity Surface-Emitting Lasers (VCSELs). The focus has been the application of tunable VCSELs in medical diagnostics, specifically OCT. VCSELs are candidates as light sources for swept-source OCT where their high sweep rate, wide sweep range and high degree of coherence enable deep probing of tissue at acquisition rates that will eliminate the effects of rapid involuntary eye movements. The main achievement of the dissertation work has been the development of an electro-statically tunable VCSEL at 1060 nm with wide tuning range and high tuning rate. The VCSEL is highly single-mode and inherently polarization stable due to the use of a High-index Contrast subwavelength Grating (HCG). HCG VCSELs are presented with 1.5% relative tuning range at a tuning rate of 850 kHz. The thesis reports on the analysis of narrow linewidth Fabry-Perot filters with dissimilar mirrors and the design of such Fabry-Perot cavities for VCSELs. Fabrication of InGaAs multiple quantum wells with GaAsP strain balancing layers is covered together with the growth and wet chemical etching of InAlP. The fabrication of the proposed Fabry-Perot filters and VCSELs is outlined and the results on their characterization reported.


Introduction Major hyperferritinemia is a rare feature in clinical laboratories associated with a wide variety of disorders, including hemophagocytic lymphohistiocytosis (HLH). The diagnosis of HLH is based on clinical and biological criteria, such as those proposed by the Histiocyte Society. However, several of these criteria are not relevant in the specific setting of hematologic malignancies. Materials and methods A 69-year-old male was treated for an acute myeloid leukaemia. On day 15 after the start of chemotherapy, he developed severe sepsis with high fever, low blood pressure and hepatosplenomegaly. Results Blood tests were marked by extreme hyperferritinemia (191,000 µg/L, reference range: 26-388 µg/L) with increased C-reactive protein (87.0 mg/L) and procalcitonin (1.94 µg/L) and aspartate aminotransferase (499 U/L 37 °C) in the setting of chemotherapy-induced aplasia. This unusual extreme ferritinemia led to suspect HLH triggered by an invasive infection. Under intensive treatment, the clinical status improved and ferritin levels significantly decreased. Conclusions The diagnosis of HLH is usually based on clinical and biological criteria, mainly fever, splenomegaly, cytopenias, hypertriglyceridemia, hypofibrinogenemia, hemophagocytosis and hyperferritinemia. In this patient, the diagnosis of HLH was challenging because several criteria, such as hypertriglyceridemia, hemophagocytosis and hypofibrinogenemia, were absent. In addition, some criteria of HLH are not relevant in the setting of hematologic malignancy, in which fever, splenomegaly, cytopenias and elevated lactate dehydrogenase are commonly observed independently of HLH. This unusual case of extremely high ferritinemia emphasizes the important weight of the ferritin level for the diagnosis of HLH in adult patients in the setting of hematologic malignancies.


OBJECTIVE
The study presents the results of reconstruction surgery of lesions on n. facialis with n. hypoglossus and n. accessorius performed in our clinic.

PATIENT GROUP AND METHODS
10 patients were treated by anastomosis of n. facialis with n. hypoglossus (HFA), 1 patient by anastomosis of n. facialis with n. accessorius (AFA). All operations were performed under the microscope; HFA and AFA anastomoses were sewed without tension at perineurium. The techique of suturation of facial nerves did not differ from the suturation of peripheral nerves in extremities. For the connection of n. VII-XII was not used plasma pasting. We did not use end to side anastomosis or reconstruction of n. VIIVII in pontocerebellar angle, in pyramid, or symetrical anastomoses of n. VII-VII, in any case. The results were objectivized by a VI grade Brudny's modification of House-Brackman classification introduced originally for scaling of the outcome of HFA anastomosis. In this study, this classification has been used for the objectivization of AFA anastomosis results.

RESULTS
Reconstruction surgery by HFA and AFA resulted in all cases in grade III of the scale. Glossal hemiatrophy or atrophy of m. sternocleidomastoideus and m. trapesius were observed in patients treated by cross anastomosis with n. hypoglossus or n. accessorius. In patients treated by HFA and even more pronounced in patient with AFA anastomosis, minute synkineses in the region of labial angle, chin, also in the region of lower eyelid, occurred in the excited emotional state or during a long-lasting speech. Major diskincses were not observed in any of reported treatments. Recovery in older patients up to 60 years was coming more slowly, in one case after 6 months.

CONCLUSION
Compared to AFA anastomosis, HFA anastomoses resulted in improved mimics and synkineses present here were finer. We prefer HFA anastomosis also because the discomfort caused by atrophy of ni. trapesius and ni. sternocleidomastoideus was apparently more perceived by patient treated by AFA than the negative effects of hemiatrophy reported by patients treated by FIFA.


Murat Alkanat Department of Pathology, Faculty of Medicine, Ege University, Bornova Izmir, Turkey ABSTRACT The passage of viable endogenous bacteria and their products across the intact intestinal mucosal barrier, disseminating to the mesenteric lymph nodes, peritoneal cavity, spleen, liver, and circulation, is deŽ ned as bacterial translocation. Intestinal obstruction induces bacterial translocation due to mucosal disruption, motility dysfunction, and increased intestinal volume, leading to bacterial overgrowth. In a rat model of intestinal obstruction, the effects of both high-dose vitamin C (350 l g/kg), an antioxidant agent known to have a cytoprotective effect in ischemia–reperfusion injury, and somatostatin (20 l g/kg), a gastrointestinal antisecretory agent, in preventing bacterial translocation were studied. Both intestinal and liver samples from the rats was observed, and it was found that the rate of bacterial translocation was 100% in the control group, and only 43% for the rats who were given intraperitoneal vitamin C and somatostatin. The difference was statistically signiŽ cant. In conclusion, we are convinced that vitamin C and somatostatin analogues may have protective effects against bacterial translocation in mechanical bowel obstruction.


Effects of photoperiod and temperature on rhizome enlargement (dormancy induction) and accompanied dormancy depth were investigated in this study. Nine-day-old seedlings were transplanted from 26 July at 1 week intervals, and they were grown under a natural photoperiod for 5 weeks in an unheated greenhouse in Fukuoka Prefecture, Japan. Although subterranean stems elongated in the plants grown until 30 August or 6 September, enlarged rhizomes were formed in those grown until 13 September or 20 September. It was revealed from these results that the lotus recognizes a natural photoperiod after 6 September as a short day. When 9 treatments of day length combinations (LD0+SD8–LD8+SD0) were applied to the seedlings, the plants grown under short day after long day treatment of 0 (LD0+SD8), 1 (LD1+SD7), 2 (LD2+SD6), 3 (LD3+SD5), 4 (LD4+SD4), 5 (LD5+SD3), 6 (LD6+SD2), or 7 (LD7+SD1) weeks formed enlarged rhizomes from the fifth, fifth, sixth, seventh, eighth, tenth, twelfth, and fourteenth internodes, respectively. Although photoperiodic treatment in the first week was different between LD0+SD8 and LD1+SD7 treatments, subterranean stems began to enlarge from the same internode (fifth internode) in both treatments. This indicates that photoperiod treatments for the first week do not affect morphology of subterranean stems. Seven treatments of day length combinations (LD2+SD0+LD6–LD2+SD6+LD0) were applied to seedlings after long day treatment for 2 weeks. Enlarged subterranean stems were observed in the plants grown under short day for 6 weeks (LD2+SD6+LD0), but not in those under long day for 6 weeks (LD2+SD0+LD6). On the other hand, subterranean stems elongated again after rhizome enlargement under a subsequent long day following 1 (LD2+SD1+LD5), 2 (LD2+SD2+LD4), 3 (LD2+SD3+LD3), or 4 (LD2+SD4+LD2) weeks of short day. This clarified that morphogenesis in subterranean stems is completely dependent on photoperiod. Further, it is expected that such growth resumption may be attributed to a weak dormant state in the enlarged rhizome. The enlarged rhizomes were exposed to natural low temperatures to examine environmental factors for deepening dormancy. Rhizomes sprouted in all treatments irrespective of exposure to low temperatures when they were transferred to ideal conditions. Rapid growth in leaves and subterranean stems was particularly observed by exposure to low temperature. It was suggested that low temperature is an environmental factor for releasing dormancy, but not for deepening dormancy. It is proposed from these results that subterranean stem growth is completely dependent on photoperiod, and that enlarged rhizomes show weak dormancy.


The direct force on a migrating proton embedded in an electron gas is calculated by implementing recently derived theoretical expressions for this quantity. A self-consistent Kohn–Sham calculation of the scattering potential leads to a doubly populated bound state and a sign change of the direct charge at lower electron densities. A self-consistent calculation under the constraint of single occupancy leads to positive values for all densities. This result is supported by employing constrained model potentials as well. A special constraint on the screening of a proton, related to the strength of the dipolar backflow pattern around it, results in a fairly constant value around unity for the direct charge in the whole metallic density range. Results based on square-well model potentials with prefixed width and depth show a lowering of the direct charge as soon as a bound state is formed. An open question remains regarding the completeness of the formalism in view of the fact that no cancellation of the direct charge is found for a system with a bound state.


Logemann and colleagues highlight an aspect of the treatment of patients with head and neck cancer that is frequently ignored; ie, the importance of rehabilitation efforts and evaluations of post-therapy quality of life. As oncologists, whether surgical, radiation, or medical, our studies and publications have traditionally focused on overall survival, disease-free survival, and, particularly in the management of head and neck cancer, local control of disease. More recently, investigators have begun to address quality of life when constructing studies for patients with all kinds of malignancies, and newer performance outcome instruments have been designed specifically for patients with head and neck cancer.[1]


The author compares the relative successes of two different teaching techniques in seminars for a first year university course in Finance. This paper tests to see if there is one overriding approach that enables all students to learn effectively in seminars or whether different students benefit from different teaching techniques. An experiment will be carried out on a subset of a first year Finance group in Semester 1, 2001 for five separate fifty- minute sessions. Four groups (i.e. sixty students) will be taught using one teaching technique. The remaining four groups will face an alternative approach. The author will consider the performance of the students in these groups in the light of a personality questionnaire designed to ascertain preferred learning styles. The ultimate goal is to deliver seminars that offer the students the best possible learning environment.


Abstract : Amid an age of increasing technology, innovation, and global business competition, there is no question that the pace organizational changes are introduced will increase, as well. With this pace of change, organizational leaders might find themselves short on the time and resources necessary to properly create readiness by utilizing implementation strategies. Frequently, a change initiative that is not introduced properly will meet resistance within the organization. When strong resistance is encountered, the initiative is often abandoned and replaced with some other effort. However, in some situations, the initiative can not be abandoned and implementation must continue. This research effort sought to identify the barriers leaders face as change initiatives stall by thematically analyzing responses from consultants in the organization development field. Then these barriers were reaffirmed by practitioners that experienced a stalled change initiative. Furthermore, strategies to overcome these barriers were identified by the consultants and then correlated to interview excerpts from the practitioners. The results indicate that the main barriers of stalled change initiatives include distrust, cynicism, and uncertain personal consequences. The suggested strategies to overcome these barriers included communication, creation of an open and inspirational environment, alignment of policies with the change, and reevaluation of the change effort.


Nephron-sparing surgery of renal cell carcinoma in the 1970's and 1980's in patients with bilateral renal tumors or reduced renal function (imperative indication) has shown a very low risk of recurrent cancer. Today, nephron-sparing surgery in renal cell carcinoma is considered in an increasing number of patients with expected sufficient renal function after nephrectomy (elective indication). Resection technique, the use of Tabotamp(R) to reduce bleeding, and pseudotumors do complicate the interpretation of the images. It has been not yet defined which diagnostic modality is best suited for follow-up after renal cell carcinoma resection. Follow-up protocols in different institutions show a wide variety. The follow-up of patients after nephron-sparing surgery is performed by annual sonography or MRI every three months. Up to now, CT and ultrasound are the standard methods. MRI with its multiplanar imaging and improved soft tissue contrast seems to have an equal diagnostic value. Additionally, MRI seems to be suited for patients with reduced renal function. The aim of this paper is to give guidelines for the radiologist to understand the different surgical procedures and to evaluate the postoperative findings. Different imaging modalities in the follow-up of patients and special radiological phenomena are discussed.


We run a randomized controlled trial coupled with lab-in-the-field social network experiments in urban Dakar. Decision spillovers and health externalities play a large role in determining uptake of sanitation technology, with decision spillovers being largest among households that don't receive significant subsidies. There is no evidence that social mechanisms such as social pressure, learning from others, or reciprocity explain the spillovers. We do find evidence of a fourth, non-social, mechanism impacting decisions: increasing returns to scale. As more neighbors adopt the sanitary technology, it becomes more worthwhile for other households to adopt as well.


The authors insist on the emergency state each ophthalmologist has to consider during the diagnosis of uveitis. The key symptoms are shown and the therapy of uveitis is updated.


BM742401 is a tumor suppressor lncRNA downregulated in gastric cancer. As the promoter region and the entire transcript are embedded in a CpG island, we postulated that BM742401 is a tumor suppressor lncRNA inactivated by DNA methylation in chronic lymphocytic leukemia (CLL). The promoter of BM742401 was unmethylated in normal controls including three each of normal bone marrow, peripheral blood buffy coats, and CD19-sorted peripheral B-cells, but methylated in four (57.1%) CLL cell lines. Methylation of BM742401 correlated inversely with expression. In the completely methylated WAC3CD5+ CLL cells, 5-Aza-2ʹ-deoxycytidine treatment led to promoter demethylation and re-expression of BM742401 transcript. Functionally, stable overexpression of BM742401 resulted in inhibition of cellular proliferation and enhanced apoptosis through caspase-9-dependent intrinsic but not caspase8-dependent extrinsic apoptosis pathway, suggesting a tumor suppressor role of BM742401 in CLL. In primary CLL samples, methylation of BM742401 was detected in 43/98 (43.9%) of patients. Moreover, among CLL patients with standard-risk cytogenetic aberrations, methylation of BM742401 correlated with advanced Rai stage (≥ stage 2)(P = 0.002). Furthermore, BM742401 methylation was associated with miR-129-2 methylation (P = 0.05). BM742401 is a tumor suppressor lncRNA frequently methylated in CLL. The mechanism of BM742401 as a tumor suppressor warrants further studies.


As the environment surrounding the delivery of health care remains unpredictable, nurse managers are challenged to create new and innovative ways to meet the demands before them. The ever-increasing challenges and decreasing resources can have great impact on the stress level of even the most seasoned nurse manager. This article offers nurse managers 10 useful strategies to enhance their stress management skills. The key for successful stress management is taking time to care for oneself and thus remain an effective leader in the organization.


The regional and local impacts of the restrictive measures taken to mitigate the covid-19 crisis are highly heterogeneous and have significant consequences for the efficiency of society's functioning, the emergency management of the state administration, and the political responses of the governing parties. The paper deals with the assessment of threats and risks resulting from the restrictive measures of the government as part of the solution to the pandemic crisis situation in the Czech Republic (CR). The aim of the authors is to identify the most serious threats and risks that can affect the democracy and internal security of the CR during a pandemic and to propose recommendations for their mitigation. To assess the defined threats and risks, a point semi-quantitative method was used, working with values for probability, impact and the opinion of evaluators, called the PCE method (Probability, Consequences, Evaluator). Out of the twenty assessed threats, a group of evaluators identified the eight most serious ones, using the PCE method.


The Situation, Background, Assessment, Recommendation (SBAR) handoff tool is designed to improve communication. The effects of integrating an electronic medical record (EMR) with a SBAR template are unclear. The research team hypothesizes that an electronic SBAR template improves documentation and communication between nurses and physicians. In all, 84 patient events were recorded from 542 admissions to the pediatric intensive care unit. Three time periods were studied: (a) paper documentation only, (b) electronic documentation, and (c) electronic documentation with an SBAR template. Documentation quality was assessed using a 4-point scoring system. The frequency of event notes increased progressively during the 3 study periods. Mean quality scores improved significantly from paper documentation to EMR free-text notes and to electronic SBAR-template notes, as did nurse and attending physician notification. The implementation of an electronic SBAR note is associated with more complete documentation and increased frequency of documentation of communication among nurses and physicians.


In recent years, the UK clothing and fashion industry has undergone some major changes. While the demise of traditional high street brands such as C&A have been widely heralded in the media, a new phenomenon has dramatically changed the children's garment landscape with the emergence of supermarkets as viable alternative providers. In a world where fashion is the prerogative of a substantial majority of the population, image, social status, personality, identity and self expression are so crucial and modelled around key top brands, the main UK supermarket chains seem - rather against the odds - to have created a new, socially-acceptable type of fashion consumption. Have supermarkets own label brands really moved from 'me too' to suitable everyday prestige alternatives? In addition, while parents control purchases for the smallest children, are they convinced to stay loyal across the age ranges - without somehow stigmatizing themselves or their children? Our exploratory research encompasses supermarket stores that are located on the outskirts of town - not accessible by walking from city centres - as a reflection of current spatial change in shopping patterns in the UK. Fifty nine interviews conducted in two ASDA and two TESCO stores in Devon and in Glasgow were analyzed. Our theoretical perspective draws on a body of research covering areas such as intra-household economy and relationships, children and childhood imagery, the consumer decision making process, and retailing. We surmise that, due to the nature of the products/services, clothing shopping is, in effect, bringing new complexities for consumers which have yet to be addressed by most retailers' marketing strategies. While ease of access (through linked grocery shopping) price and quality are perceived as the main decision factors, we reveal that style and design, commendation by word of mouth, refund policies and assortment/variety also linked to multiplicity of usage are greatly influencing parental choice. We highlight the increasing importance of browsing as a modern improvisation choice practice (planned impulse buying). We then provide a re-definition of 'taste and style' and another view of what it could be to be a good parent. Supermarket clothing ranges are perceived as a way to help in grounding, forming and assessing future clothing consumptions.


The almost-real time estimation of ground shaking and losses after a major earthquake in the Euro-Mediterranean region was performed in the framework of the Joint Research Activity 3 (JRA-3) component of the EU FP6 Project entitled "Network of Research Infra-structures for European Seismology, NERIES". This project consists of finding the most likely location of the earthquake source by estimating the fault rupture parameters on the basis of rapid inversion of data from on-line regional broadband stations. It also includes an estimation of the spatial distribution of selected site-specific ground motion parameters at engineering bedrock through region-specific ground motion prediction equations (GMPEs) or physical simulation of ground motion. By using the Earthquake Loss Estimation Routine (ELER) software, the multi-level methodology developed for real time estimation of losses is capable of incorporating regional variability and sources of uncertainty stemming from GMPEs, fault finiteness, site modifications, inventory of physical and social elements subjected to earthquake hazard and the associated vulnerability relationships.


One of the most popular algorithms for connected word (or subword phonetic unit) recognition is the one-stage dynamic programming algorithm. In its available formulation, this algorithm is not designed to provide multiple hypothesis; such a limitation is currently becoming a drawback, since the need of alternative recognitions in the systems presently under research is being acknowledged. This paper introduces a modified version of the one-stage dynamic programming algorithm tailored to afford multiple hypothesis.


Abstract The resistance of heat treated (HT) wood to brown rot fungi has been investigated, while the role of the Fenton reaction (FR) in the initial phase of degradation was in focus. Micro-veneers made of Scots pine, were HT with various intensities and their mass losses (MLHT) were determined before soaking with a solution of Fenton's reagent containing Fe ions and hydrogen peroxide. The mass loss of the veneers treated that way (MLFT), their tensile strength loss (TSLFT) and the H2O2 decomposition were observed. The MLFT, TSLFT, and H2O2 loss decreased with increasing MLHT of the veneers. Soaking of the veneers in acetate buffer containing only Fe without H2O2 revealed that the heat treatment (HT) strongly reduces the Fe uptake by the cell walls. FTIR spectroscopy indicated oxidation of the unmodified control veneers but did not reveal predominant decay of cell wall components; the HT veneers were not changed at all due to FR. It was concluded that the reason for the enhanced resistance of HT wood to FR is attributable to hindered diffusion of Fe ions into the wood cell wall.


The problem of air pollution with fine particulate matter and aerosols is more than topical and extremely serious. There is a need to develop and build reliable geographically distributed air quality monitoring networks to enable real-time data collection. The analysis of such data would help identify the origin of the particles and timely operational measures by the authorities. The research aims at the development of a mobile modular station with autonomous power supply and the experimental feasibility study and as a first step in the construction of a complete network.


Endoplasmin is a molecular chaperone of the heat-shock protein 90 class located in the endoplasmic reticulum and its activity is poorly characterized in plants. We assessed the ability of endoplasmin to alleviate stress via its transient overexpression in tobacco protoplasts treated with tunicamycin, an inhibitor of glycosylation and inducer of the unfolded protein response (UPR). Endoplasmin supported the secretion of a model secretory protein but was less effective than BiP, the endoplasmic reticulum member of the heat-shock protein 70 family. Consistently, immunoprecipitation experiments with in vivo radioactively labelled proteins using an antiserum prepared against Arabidopsis endoplasmin showed that a much smaller number of newly synthesized polypeptides associated with endoplasmin than with BiP. Synthesis of endoplasmin was enhanced by UPR inducers in tobacco seedlings but not protoplasts. As BiP synthesis was induced in both systems, we conclude that the UPR acts differently, at least in part, on the expression of the two chaperones. Endoplasmin was not detectable in extracts of leaves and stems of the Arabidopsis endoplasmin T-DNA insertion mutant shepherd. However, the chaperone is present, albeit at low levels, in shepherd mutant callus, mature roots and tunicamycin-treated seedlings, demonstrating that the mutation is leaky. Reduced endoplasmin in the shepherd mutant has no effect on BiP protein levels in callus or mature roots, leaves and stems, but is compensated by increased BiP in seedlings. This increase occurs in proliferating rather than expanding leaf cells, indicating an important role for endoplasmin in proliferating plant tissues.


Identification and decipherment of the writings on Gyeongju Anapji Pond Wooden Tablet no. 20 and Gyeongju National Museum Wooden Tablet no. 1 reveal that these tablets contain fragments of Silla poetry. Thus, there is a need to designate tablets containing poetry as a distinct category of poetry mokgan 木簡 (wooden tablet).Gyeongju Anapji Pond Wooden Tablet no. 20 contains a poem expressing the emotional agony of a general who successfully suppressed a revolt. This poetry fragment is typified by its rhythm (syllable count) consisting of the transposition of six-character lines and five-character lines, along with mixed Chinese and Korean word order, and can thus be categorized as an irregular form of hansi (classical Chinese poetry). Therefore, there is a need to designate a phase of irregular verse as a distinct stage in the developmental process of hansi in Korea that occurred prior to the advent of regular form hansi.The identification of the writings on Gyeongju National Museum Wooden Tablet no. 1 reveals the prevalence of many graphs often used in Sino-graphic orthography including hyangchal, idu, and gugyeol. Since most of the graphs on this tablet are also used in hyangchal, it is hypothesized that the text on this wooden tablet is written in hyangchal. Based on this hypothesis, line segmentation of the text on this tablet is compared to that of hyangga. Results show that both the structure and content of the poem resemble Silla hyangga. Thus, it is concluded that this tablet contains lines 8-9-10 of a ten-line Silla hyangga. In the poem, the speaker is applauding the king who is gathering and distributing wealth under a standardized system.


The COSMOS (Integrated In Silico Models for the Prediction of Human Repeated Dose Toxicity of COSMetics to Optimise Safety) Project is a unique international collaboration developing computational approaches for the prediction of repeated dose toxicity. The project comprises 15 partners from academia, industry, regulatory agencies and SMEs from across Europe and the US. Moreover, COSMOS is part of a cluster of six research projects within the SEURAT-1 (Safety Evaluation Ultimately Replacing Animal Testing) Research Initiative. Organ level toxicity involves complex mechanisms, thus it cannot be predicted by a single simplified in silico model. Therefore COSMOS is taking an innovative approach integrating different technologies, e.g. the threshold of toxicological concern approach, grouping of chemicals, (Q)SARs for toxicity prediction and modelling of biokinetics. All are being developed with a special emphasis on the mechanistic basis of the models considered. Computational workflows as well as a new comprehensive database with reliable structures and repeated dose toxicity data will be freely available to support safety assessment without the use of animals and will thus contribute to the 3Rs. The international dimension is important for the development and especially regulatory acceptance of the models proposed, the international companies having to assure the safety of their products on a global scale. Therefore industry, regulatory agencies and NGOs in Europe and the US are involved either as project partners or as external experts.


Quantitative research aimed to verify the relevance of Action Control Theory for the identification of risk for poor performance in the planning of preventive care for pressure ulcers. The action - state orientation deals with individual differences and the ability to regulate emotions, cognitions and attitudes to complete the intentional actions. The instruments used were the Student Assessment Instrument and HAKEMP 90, derived from this theory, in 46 undergraduate nursing students. The analysis showed high sensitivity (0.84) for the diagnosis of risk for poor performance and high specificity (0.90) for detecting the absence of risk in the care planning. The results suggest the HAKEMP 90 as a diagnostic tool for identifying essential elements of nursing education as active learning, regulation of cognitive processes and relevance of basic nursing care in hospital.


Administrative law is a complex field replete with regulations and delicate separation of powers issues. Indeed, "[a]dministrative law is not for sissies...."(1) The various factors at play in administrative law make the seemingly most elementary facets hard to understand. The problems in administrative law are amplified by the role of politics. Administrative law influences the way agencies make policy.(2) Agencies are thus among the most important players in the formation and approval of policy.(3) Although the most obvious ways that agencies make policy are through positive rulemaking and adjudication measures,(4) agencies also set policy through inaction.(5) Agencies often set policy by not doing anything at all.(6) When an agency does not make the requisite regulations through either rulemaking or adjudication, the agency maintains the status quo. This inaction is thus itself a form of policymaking in the sense that it prevents the legislative and executive branches from implementing enacted legislation. Congress needs the agencies to carry out its laws by passing specific rules. Otherwise, congressional mandates are thwarted. In an effort to ensure that agencies implement enacted legislation, Congress mandated judicial review of agency inaction and delay in section 706(1) of the Administrative Procedure Act (APA).(7) Section 706(1) enables the judiciary to review agency behavior and ensure that it comports with the statutory requirements set forth by Congress either in the enabling statute or in the default standards of the APA. Recent decisions out of the Tenth Circuit(8) have invigorated the debate over the role of agency inaction in agency policymaking decisions. Although some courts have encouraged judicial discretion when determining whether agency inaction is unlawful,(9) other courts have found that the language in section 706(1) is strictly binding in the area of statutorily imposed deadlines.(10) Circuit courts are now split over whether courts have discretion when an agency misses a mandatory deadline or if they are mandated by law to force the agency to act without granting discretion to agency priorities.(11) This Note explores the problems of agency inaction and delay in violation of statutory requirements. First, this Note discusses the legislative history of section 706(1) to determine congressional intent. Second, this Note examines the conflicting cases that fuel the confusion over the appropriate remedy for agency inaction. Finally, this Note concludes that section 706(1) requires strict statutory construction that requires judges to prohibit agencies from violating a mandatory statutory deadline unless the agency has an impossibility defense. As a result, although agencies are important policymaking entities, they must respect congressional intent evident in blatant statutory deadlines. When agencies do not abide by congressional mandates, courts must require immediate action in compliance with the law. BACKGROUND: THE STATUTE AND ITS LEGISLATIVE HISTORY The APA granted judicial review of agency behavior in section 706.(12) Although section 706 as a whole grants judicial review, section 706(1) specifically addresses the issue of agency inaction.(13) On its face, the statute is extremely clear. Section 706(1) states that a court shall "compel agency action unlawfully withheld or unreasonably delayed."(14) Although this language is strong and does not appear to leave anything open for debate, courts disagree over whether Congress intended to allow any room for discretion.(15) Legislative History The legislative history of the APA supports the idea that Congress intended courts to force agencies to implement legislation. One basis for this support is the Senate Judiciary Committee report of May 1945 that discussed the upcoming APA.(16) This report contained earlier versions of the APA that had the same language requiring the judiciary to force agency action when it was unlawfully withheld or unreasonably delayed. …


The stiffness of microstructure is an important parameter of the microsensor. It is usually obtained by FEM approach, which is difficult to give an analytical expression. This paper reports on a 2-D microaccelerometer with the complex microstructure. Its main axial stiffness is carried out by using force method as well as principle of work and strain energy. During the deduction, deformation of all beams is taken into account, so the theoretical results are in accordance with that of FEM approach very well and the error is less than one in thousand. Furthermore, we neither introduce the other assumptions nor design the special dimension. So this methodology is strict in theory, and can be extended to analysis for the displacement and stiffness of the symmetric and statically indeterminate microstructure.


OBJECTIVE: The goal was to evaluate 3-dimensional airway CT for upper airway assessment in obstructive sleep apnea syndrome (OSAS). DESIGN: Airway CT was obtained and 3-dimensional airway models were constructed prospectively for 40 patients with OSAS and 10 controls. Airway dimensions were correlated with polysomnography, and comparison was made between patients with and without OSAS. RESULTS: OSAS patients had a mean respiratory distress index of 51.9 events per hour. The mean minimum cross-sectional area (XSA) in the neutral position was 67.1 mm 2 . Minimum XSA decreased in both the inspiratory and expiratory phases to 16.3 mm 2 and 15.0 mm 2 , respectively (P < 0.001). Complete airway obstruction occurred in 1 or more phases of respiration in 28 patients. Neither airway XSA nor length of obstruction correlated with sleep apnea parameters. No statistically significant differences in airway dimensions were found between OSAS and control patients. CONCLUSIONS: Airway CT demonstrates dynamic airway obstruction in OSAS but does not correlate well with clinically important disease parameters. (Otolaryngol Head Neck Surg 2000;123:444-9.)


Many health care services provided in the United States are of low value, meaning that the cost of providing those services is high relative to the health care benefit they confer. In some cases, the care provided may have no value or even, on average, be harmful. Examples of low or negative value services include unnecessary surgery or diagnostic imaging that will not change management. Given estimates that 30% of the $2.5 trillion the U.S. spends on health care services each year may provide little benefit,1 there is a widespread eagerness to enhance the ratio of benefits to costs.

Because value matters in health care, when new health care programs are proposed it has become common to ask, "What is the Return on Investment (ROI) from implementing this new program?" Implicit in this question is that programs should be supported if they save money, but not otherwise. Positive ROI, meaning that more money is saved than is spent, has become the standard by which new initiatives are evaluated. This standard has been used to evaluate new programs such as the primary care medical home, disease management, and the projects submitted for the new Center for Medicare and Medicaid Services Innovation Challenge.

Although asking about ROI might seem to make sense given concerns about health care cost and value, asking about ROI is the wrong question when assessing whether a health care program is successful. What would happen if the rule were applied to every health care decision that is made? Beyond childhood vaccination and flu shots for the elderly, few health care services save money.2 The positive ROI criterion is not applied to most health care services because almost nothing satisfies it. Medicare is prohibited by law from considering cost in coverage decisions, and other insurers tend to follow suit, even if the benefits are small and the costs very large. Would anyone ever ask: "What is the return on investment in treatment of this patient's cancer?" It is not a meaningless question, but almost certainly one that most people would think inappropriate to ask.

Cost is important and should be considered in many more settings, for both existing and new services. Clinicians and policymakers should not apply one standard when tacitly continuing the status quo and a different standard when evaluating innovative programs that might be implemented. It certainly does not make sense to use one criterion (are there clinical benefits?) for coverage decisions for treatments and a different criterion (are health care savings greater than program costs?) for preventive services or delivery system innovations designed to improve health. Programs designed to improve health and prevent disease should be evaluated based on whether they improve health at a reasonable price, in essence comparing whether improvements in health are achieved for less resources than through alternatives, e.g. expenditures t on health care services. Health care reimbursement tends to be 'disease fixated' and should be evaluated the same way based on the value of expenditures in achieving improvements in health.3 If an employer spends $100,000 treating late-stage emphysema or lung cancer for its employees—an expenditure with a negative ROI, but one that adds value to employees' lives --should that employer be willing to spend money on smoking cessation programs? The answer is almost undoubtedly yes. However, if health promotion programs or health system delivery innovations are required to save money, they will likely be labeled 'failures' even if they improve health at a lower price than many of the services that we now willingly pay for under Medicare and private insurance. Ironically, if we continue with the approach of insisting on a positive ROI to fund such programs, low value spending will persist at higher rates than would otherwise be the case.

For example, consider a program that would improve medication adherence after acute myocardial infarction (AMI). Adherence rates to beta blockers, statins, ace-inhibitors or angiotensin receptor blockers post AMI is poor; a recent large-scale study showed that even when copayments are lowered to $0 among insured patients, average adherence for these medications is only about 45%.4 If a new program could increase adherence to 70% it is plausible that the program could significantly reduce the rate of hospital admissions for MI, stroke, and revascularization procedures. If the average cost of health events requiring hospitalization in the 12 months following a hospital admission for a new MI is about $20,000 and the new program reduced the rate of events requiring hospitalization by 10%, the new program could cost up to $2,000 per year and still save money. Does that mean the program should not be adopted if it costs $3,000? At that point, the calculated ROI for the program is negative because it costs more than it saves. But wouldn't this program still be a much better use of money than letting those MIs occur (mortality rates from AMI are typically more than 10% among hospitalized patients in the 30 days post-admission and many patients die before making it to a hospital)? If this is not a good use of money, then why are so many other services covered that yield lower value?5 Many insurers, including Medicare, are continuing to cover Bevacizumab for metastatic breast cancer, despite unanimous recommendation by an FDA panel that the drug not be covered because it was not helping patients to live longer, did not control their tumors, and exposed them to serious adverse effects6 despite an average cost per year of $99,000.7

There are political, ethical, and emotional challenges to making explicit resource allocation issues in treating diseases and applying the same metrics used to evaluate the effectiveness of programs that prevent diseases in largely unidentified patients. It is always more difficult to shut down existing programs than to say no to new ones, a phenomenon known as status quo bias.8 It is also harder to justify investments in prevention across broad populations than investments in the treatment of identifiable patients, a phenomenon known as the rule of rescue.9 Changing the criteria used to evaluate health system delivery innovations might help overcome these tendencies. Evaluating success using the same criteria – whether a preventive service, delivery system innovation, or treatment - may be the best way to ensure the maximal value (improvements in health) for the resources expended on health care services.

A recent conversation with a benefits manager from a medium-sized employer brought home this point. She told us that she was asked by the Chief Financial Officer "What is the ROI in putting in place this $125,000 wellness program?" She responded by asking "What is the ROI on the $28 million we are spending on treating disease through our health benefits?" If cost is not considered when thinking about the value of covered treatments, it doesn't make sense to use positive ROI (cost savings) as a criterion for determining whether promising new delivery system innovations get covered. A better approach would be to adopt similar metrics for treatment and prevention and for current and proposed care, where the goal in all cases is getting the biggest possible improvements in health for the available resources.


This guide is a starting point for faculty and students at Penn State University. Members of the Penn State Law or Dickinson Law School communities may have additional resources available.