Effect of increased central blood volume with water immersion on plasma catecholamines during exercise

To examine the influence of an increase in central blood volume with head-out water immersion (WI) on the sympathoadrenal response to graded dynamic exercise, nine healthy men underwent upright leg cycle exercise on land and with WI. Plasma norepinephrine and epinephrine concentrations were used as indexes of overall sympathoadrenal activity. Oxygen consumption (VO2), heart rate, systolic blood pressure, and plasma concentrations of norepinephrine, epinephrine, and lactate were determined at work loads corresponding to approximately 40, 60, 80, and 100% peak VO2. Peak VO2 did not differ on land and with WI. Plasma norepinephrine concentration was reduced (P less than 0.05) at 80 and 100% peak VO2 with WI and on land, respectively. Plasma epinephrine and lactate concentrations were similar on land and with WI at the three submaximal work stages, but both were reduced (P less than 0.05) at peak exertion with WI. Heart rate was lower (P less than 0.05) at the three highest work intensities with WI. These results suggest that the central shift in blood volume with WI reduces the sympathoadrenal response to high-intensity dynamic exercise.     

On Monitoring Outcomes of Medical Providers

An issue of substantial importance is the monitoring and improvement of health care facilities such as hospitals, nursing homes, dialysis units or surgical wards. In addressing this, there is a need for appropriate methods for monitoring health outcomes. On the one hand, statistical tools are needed to aid centers in instituting and evaluating quality improvement programs and, on the other hand, to aid overseers and payers in identifying and addressing sub-standard performance. In the latter case, the aim is to identify situations where there is evidence that the facility’s outcomes are outside of normal expectations; such facilities would be flagged and perhaps audited for potential difficulties or censured in some way. Methods in use are based on models where the center effects are taken as fixed or random. We take a systematic approach to assessing the merits of these methods when the patient outcome of interest arises from a linear model. We argue that methods based on fixed effects are more appropriate for the task of identifying extreme outcomes by providing better accuracy when the true facility effect is far from that of the average facility and avoiding confounding issues that arise in the random effects models when the patient risks are correlated with facility effects. Finally, we consider approaches to flagging that are based on the Z-statistics arising from the fixed effects model, but which account in a robust way for the intrinsic variation between facilities as contemplated in the standard random effects model. We provide an illustration in monitoring survival outcomes of dialysis facilities in the US.     

Optimal Decisions for Organ Exchanges in a Kidney Paired Donation Program

The traditional concept of barter exchange in economics has been extended in the modern era to the area of living-donor kidney transplantation, where one incompatible donor-candidate pair is matched to another pair with a complementary incompatibility, such that the donor from one pair gives an organ to a compatible candidate in the other pair and vice versa. Kidney paired donation (KPD) programs provide a unique and important platform for living incompatible donor-candidate pairs to exchange organs in order to achieve mutual benefit. In this paper, we propose novel organ allocation strategies to arrange kidney exchanges under uncertainties with advantages, including (i) allowance for a general utility-based evaluation of potential kidney transplants and an explicit consideration of stochastic features inherent in a KPD program; and (ii) exploitation of possible alternative exchanges when the originally planned allocation cannot be fully executed. This allocation strategy is implemented using an integer programming (IP) formulation, and its implication is assessed via a data-based simulation system by tracking an evolving KPD program over a series of match runs. Extensive simulation studies are provided to illustrate our proposed approach.     

The profile inter-unit reliability

To assess the quality of health care, patient outcomes associated with medical providers (eg, dialysis facilities) are routinely monitored in order to identify poor (or excellent) provider performance. Given the high stakes of such evaluations for payment as well as public reporting of quality, it is important to assess the reliability of quality measures. A commonly used metric is the inter-unit reliability (IUR), which is the proportion of variation in the measure that comes from inter-provider differences. Despite its wide use, however, the size of the IUR has little to do with the usefulness of the measure for profiling extreme outcomes. A large IUR can signal the need for further risk adjustment to account for differences between patients treated by different providers, while even measures with an IUR close to zero can be useful for identifying extreme providers. To address these limitations, we propose an alternative measure of reliability, which assesses more directly the value of a quality measure in identifying (or profiling) providers with extreme outcomes. The resulting metric reflects the extent to which the profiling status is consistent over repeated measurements. We use national dialysis data to examine this approach on various measures of dialysis facilities.     

Frequency and clinical patterns of stroke in Iran - Systematic and critical review

Background  

Cerebrovascular disease is the second commonest cause of death, and over a third of stroke deaths occur in developing countries. To fulfil the current gap on data, this systematic review is focused on the frequency of stroke, risk factors, stroke types and mortality in Iran.     

MIF-1 fails to modify agonist-induced oral activity in neonatal 6-OHDA-treated rats

-Prolyl- -leucyl-glycinamide (MIF-1) is known to attenuate apomorphine-induced stereotypies in adult rats that are lesioned as neonates with 6-hydroxydopamine (6-OHDA). To test whether MIF-1 would affect dopamine (DA) agonist-induced and serotonin (5-HT) agonist-induced oral activity, both intact and neonatal 6-OHDA-treated rats were studied. Rats at 3 days from birth were injected with desipramine (20 mg/kg, IP), 1 h before 6-OHDA HBr (100 μg, salt form, in each lateral ventricle) or its vehicle, saline-ascorbic acid (0.1%). At approximately 6 months rats were treated with MIF-1 (0.1, 1.0, or 10.0 mg/kg, IP), 10 min before SKF 39393 HCl (1.0 mg/kg, IP) or m-chlorophenylpiperazine 2HCl (m-CPP 2HCl; 0.5 mg/kg, IP), DA D₁ and 5-HT_1C,2 receptor agonists, respectively. Although both agonists increased oral activity in control and neonatal 6-OHDA-treated rats, MIF-1 did not modify the response. In rats that received either of the three doses of MIF-1 for 21 consecutive days, there was still no observed effect of MIF-1 on the oral response of control and 6-OHDA-lesioned rats to SKF 38393 and m-CPP. These findings indicate that MIF-1 does not modify the oral activity response of supersensitized D₁ and 5-HT_1C receptors in adult rats that are lesioned neonatally with 6-OHDA.     

Statistical Analysis of Illness–Death Processes and Semicompeting Risks Data

Summary In many instances, a subject can experience both a nonterminal and terminal event where the terminal event (e.g., death) censors the nonterminal event (e.g., relapse) but not vice versa. Typically, the two events are correlated. This situation has been termed semicompeting risks (e.g., Fine, Jiang, and Chappell, 2001 , Biometrika 88, 907–939; Wang, 2003 , Journal of the Royal Statistical Society, Series B 65, 257–273), and analysis has been based on a joint survival function of two event times over the positive quadrant but with observation restricted to the upper wedge. Implicitly, this approach entertains the idea of latent failure times and leads to discussion of a marginal distribution of the nonterminal event that is not grounded in reality. We argue that, similar to models for competing risks, latent failure times should generally be avoided in modeling such data. We note that semicompeting risks have more classically been described as an illness–death model and this formulation avoids any reference to latent times. We consider an illness–death model with shared frailty, which in its most restrictive form is identical to the semicompeting risks model that has been proposed and analyzed, but that allows for many generalizations and the simple incorporation of covariates. Nonparametric maximum likelihood estimation is used for inference and resulting estimates for the correlation parameter are compared with other proposed approaches. Asymptotic properties, simulations studies, and application to a randomized clinical trial in nasopharyngeal cancer evaluate and illustrate the methods. A simple and fast algorithm is developed for its numerical implementation.