Queer(y)ing Agent-Based Modeling for Use in LGBTQ Studies: An Example from Workplace Inequalities.

This article explores the contribution agent-based modeling (ABM) can make to the study of LGBTQ workplace inequalities and, conversely, how ABM can adapt to theoretical traditions integral to LGBTQ studies. It introduces an example LGBTQ workplace model, developed as part of the CILIA-LGBTQI+ project, to illustrate how ABM complements existing methods, can address methodological binarism and bridge macro and micro accounts within LGBTQ studies of the workplace. The model is intended as an important starting point in developing the role of ABM in LGBTQ research and for bridging qualitative- and quantitative-derived insights. Likewise, the article discusses some approaches for negotiating theoretical and methodological tensions identified when integrating queer and intersectional insight with ABM.

Hospital Costs Related to Early Extubation After Infant Cardiac Surgery.

BACKGROUND: The Pediatric Heart Network Collaborative Learning Study (PHN CLS) increased early extubation rates after infant tetralogy of Fallot (TOF) and coarctation of the aorta (CoA) repair across participating sites by implementing a clinical practice guideline (CPG). The impact of the CPG on hospital costs has not been studied. METHODS: PHN CLS clinical data were linked to cost data from Children's Hospital Association by matching on indirect identifiers. Hospital costs were evaluated across active and control sites in the pre- and post-CPG periods using generalized linear mixed-effects models. A difference-in-difference approach was used to assess whether changes in cost observed in active sites were beyond secular trends in control sites. RESULTS: Data were successfully linked on 410 of 428 eligible patients (96%) from four active and four control sites. Mean adjusted cost per case for TOF repair was significantly reduced in the post-CPG period at active sites ($42,833 vs $56,304, p < 0.01) and unchanged at control sites ($47,007 vs $46,476, p = 0.91), with an overall cost reduction of 27% in active versus control sites (p = 0.03). Specific categories of cost reduced in the TOF cohort included clinical (-66%, p < 0.01), pharmacy (-46%, p = 0.04), lab (-44%, p < 0.01), and imaging (-32%, p < 0.01). There was no change in costs for CoA repair at active or control sites. CONCLUSIONS: The early extubation CPG was associated with a reduction in hospital costs for infants undergoing repair of TOF but not CoA. This CPG represents an opportunity to both optimize clinical outcome and reduce costs for certain infant cardiac surgeries.

Cost Variation Across Centers for the Norwood Operation.

BACKGROUND: The Norwood operation is associated with high health care utilization, and prior studies reported substantial variability in Norwood costs across centers. However, specific factors driving this cost variation are unclear. We assessed center variability in Norwood costs and underlying mechanisms in a multicenter cohort. METHODS: Clinical data from the Pediatric Heart Network Single Ventricle Reconstruction trial were linked with cost data from the Children's Hospital Association Inpatient Essentials database. Center variation was assessed by modeling Norwood costs adjusted for baseline patient characteristics, and the relationship with complications, length of stay (LOS), and specific cost categories was examined. Patients undergoing transplantation or stage 2 palliation during the Norwood admission were excluded. RESULTS: Nine centers (332 patients) were included. Adjusted mean cost/case varied 4.6-fold across centers (range: $50,559 to $230,851, p < 0.001). In addition, variation was found across centers in the adjusted mean number of complications/case (2.6-fold variation) and adjusted mean LOS/case (1.9-fold variation). Differences in complications explained 63% of the cost variation across centers. After accounting for complications, differences in LOS explained 66% of the remaining cost variation. Seven specific complications were found to occur more frequently at high-cost centers: pleural effusion, seizures, wound infection, thrombus, liver dysfunction, sepsis, necrotizing enterocolitis (all p < 0.001). With regard to types of cost, room and board/supplies and laboratory costs were the primary drivers of cost variation across centers. CONCLUSIONS: This study identified several factors associated with center variation in Norwood costs, which may be targeted in subsequent initiatives aimed at both improving quality of care and reducing costs.

Impact of postoperative complications on hospital costs following the Norwood operation.

UNLABELLED: Introduction Patients undergoing the Norwood operation consume considerable healthcare resources; however, detailed information regarding factors impacting hospitalisation costs is lacking. We evaluated the association of postoperative complications with hospital costs. METHODS: In the present study, we utilised a unique data set consisting of prospectively collected clinical data from the Pediatric Heart Network Single Ventricle Reconstruction trial linked at the patient level with cost data for 10 hospitals participating in the Children's Hospital Association Case Mix database during the trial period. The relationship between complications and cost was modelled using linear regression, accounting for the skewed distribution of cost, adjusting for within-centre clustering and baseline patient characteristics. RESULTS: A total of 334 eligible Norwood records (97.5%) were matched between data sets. Overall, 82% suffered from at least one complication (median 2; with a range from 0 to 33). Those with complications had longer postoperative length of stay (25 versus 12 days, p<0.001), more total ventilator days (7 versus 5 days, p<0.001), and higher in-hospital mortality (17.6 versus 3.4%, p<0.006). Mean adjusted hospital cost in those with a complication was $190,689 (95% CI $111,344-$326,577) versus $120,584 (95% CI $69,246-$209,983) in those without complications (p=0.002). Costs increased with the number of complications (1-2 complications=$132,800 versus 3-4 complications=$182,353 versus ⩾5 complications=$309,372 [p<0.001]). CONCLUSIONS: This merged data set of clinical trial and cost data demonstrated that postoperative complications are common following the Norwood operation and are associated with worse clinical outcomes and higher costs. Efforts to reduce complications in this population may lead to improved outcomes and cost savings.

Mediators of change in psychosocial interventions for cancer patients: a systematic review.

Careful reviews and meta-analyses have made valuable contributions to understanding the efficacy of psychosocial interventions for cancer patients. An important next step is to determine the mediators that explain the influence of efficacious interventions on outcomes. This systematic review summarizes tests of mediating variables from twenty-two projects conducted from 1989-2010. Although all authors provided some type of rationale for considering particular mediating relationships, the investigations varied widely with respect to the extent to which formal theoretical constructs were tested, the type and goals of the interventions studied, and the broad types of outcomes and potential mediators examined. Although there was some evidence supporting selected mediating relationships, with positive findings often found when mediating variables represented behaviors targeted by an intervention, the findings were mixed. Expanding the focus of research to include mechanisms in psychosocial oncology intervention research is necessary for providing a unified picture of how mediating relationships may be operating in this field.

Ultrafast switching of photonic entanglement.

To deploy and operate a quantum network which utilizes existing telecommunications infrastructure, it is necessary to be able to route entangled photons at high speeds, with minimal loss and signal-band noise, and--most importantly--without disturbing the photons' quantum state. Here we present a switch which fulfills these requirements and characterize its performance at the single photon level. Furthermore, because this type of switch couples the temporal and spatial degrees of freedom, it provides an important new tool with which to encode multiple-qubit states in a single photon. As a proof-of-principle demonstration of this capability, we demultiplex a single quantum channel from a dual-channel, time-division-multiplexed entangled photon stream, effectively performing a controlled-bit-flip on a two-qubit subspace of a five-qubit, two-photon state.

Fiber-based telecommunication-band source of degenerate entangled photons.

We have constructed and experimentally characterized what we believe to be the first fiber-based source of degenerate polarization-entangled photon pairs in the telecommunication band. Our source design utilizes bichromatic pump pulses and an optical-fiber Sagnac loop aligned to deterministically separate degenerate photon pairs at a central wavelength. The source exhibits 0.997+/-0.006 fidelity with a maximally entangled state, measured using quantum state tomography. When reconfigured to produce identical photon pairs, the source exhibits a Hong-Ou-Mandel interference visibility of 0.97+/-0.04.

Drop-in compatible entanglement for optical-fiber networks.

A growing number of quantum communication protocols require entanglement distribution among remote parties, which is best accomplished by exploiting the mature technology and extensive infrastructure of low-loss optical fiber. For this reason, a practical source of entangled photons must be drop-in compatible with optical fiber networks. Here we demonstrate such a source for the first time, in which the nonlinearity of standard single-mode fiber is utilized to yield entangled photon pairs in the 1310-nm O-band. Using an ultra-stable design, we produce polarization entanglement with 98.0% +/- 0.5% fidelity to a maximally entangled state as characterized via coincidence-basis tomography. To demonstrate the source's drop-in capability, we transmit one photon from each entangled pair through a telecommunications-grade optical amplifier set to boost classical 1550-nm (C-band) communication signals. We verify that the photon pairs experience no measurable decoherence upon passing through the active amplifier (the output state's fidelity with a maximally entangled state is 98.4% +/- 1.4%).

A multi-institutional, 5-year analysis of initial and multiple ventricular shunt revisions in children.

OBJECTIVE: To evaluate risk factors and predictors of cerebrospinal ventricular shunt revisions in children. METHODS: A retrospective, longitudinal cohort of 1307 children ages 0 to 18 years undergoing initial ventricular shunt placement in the year 2000, with follow-up through 2005, from 32 freestanding children's hospitals within the Pediatric Health Information Systems database was studied. Rates of ventricular shunt revision were compared with patient demographic, clinical, and hospital characteristics with use of bivariate and multivariate regression accounting for hospital clustering. RESULTS: Thirty-seven percent of children required at least one shunt revision within 5 years of initial shunt placement; 20% of children required two or more revisions. Institutional rates of first shunt revision ranged from 20 to 70% of initial shunts placed among the 32 hospitals in the cohort. Hospitals where one to 20 initial shunt placements per year experienced the highest initial shunt revision rate (42%). Hospitals performing over 83 initial shunt placements per year experienced the lowest revision rate (22%). We found that children undergoing shunt placement in the Midwest were more likely to experience multiple shunt revisions (odds ratio, 1.25; 95% confidence interval, 1.06-1.47) after controlling for hospital volume, shunt type, age, and diagnosis associated with initial shunt placement. CONCLUSION: Higher hospital volume of initial shunt placement was associated with lower revision rates. Substantial hospital variation in the rates of ventricular shunt revision exists among children's hospitals. Future prospective studies are needed to examine the reasons for the variability in shunt revision rates among hospitals, including differences in specific processes of care.

Physicians' intention to educate about emergency contraception.

BACKGROUND AND OBJECTIVES: Our objective was to examine the intention of academic primary care physicians to educate women about emergency contraception (EC) and whether differences in their intention varies with patient situation, knowledge and attitudes about EC, gender, or specialty. METHODS: As part of a larger cross-sectional survey about intention to prescribe EC with 96 faculty physicians from one Southern and three Midwestern universities, we analyzed factors associated with intention to educate patients about EC. Physicians were from departments of family medicine, obstetrics-gynecology, and pediatrics. RESULTS: The main outcome variable was intention to educate about EC. Attitudes and perceived peer expectations on educating about EC predicted physicians' intentions to provide EC education to their patients. Neither knowledge about EC nor physician demographics predicted intention to educate. Almost one in five respondents were reluctant to provide education to sexually active adolescents. Physicians who had high intention to educate were more likely than others to believe that educating about EC enhances a woman's reproductive options and that EC education reduces unintended pregnancy and abortion. Providers with low intention to educate were more likely to consider EC education to be inconvenient and to take too much clinic time. CONCLUSIONS: To maximize training programs, physicians' attitudes, beliefs, and professional expectations should be examined when designing and initiating educational interventions.

Impact of different levels of weight loss on blood pressure in overweight and obese women.

This study sought to determine the impact of different levels of weight loss on blood pressure in overweight/obese women. One hundred fifty-nine overweight/obese women (age 48.7 +/- 9.7, weight 101.3 +/- 18.7 kg, BMI 37.3 +/- 6.6 kg/m(2)) completed a six-month clinical weight loss program that included weekly nutrition, behavior, and exercise instruction. Participants consumed a very-low-energy diet (VLED) for 12 weeks. VLED was followed by four weeks of gradual reintroduction to solid foods. At week 16, participants received a diet to maintain weight or slightly reduce weight (<0.5 lb/week) which they followed for the duration of the study. All lab and blood pressure assessments were performed at baseline and six months. Three groups were formed according to the proportion of weight loss after six months; Group 1 had < 10% (n = 19), Group 2 had 10%-20% (n = 64), and Group 3 had >20% (n = 76) weight loss. Differences in systolic blood pressure (mm Hg) were found in dose response fashion for weight loss at six months with 125 +/- 17 (<10%), 119 +/- 13 (10%-20%), and 117 +/- 15 (>20%; p = 0.005). Differences in diastolic blood pressure (mm Hg) were also found in dose response fashion with 81 +/- 9 (<10%), 77 +/- 9 (10%-20%), and 75 +/- 9 (20%; p = 0.003). These data indicate that increasing weight loss beyond 10% of initial body weight may provide added improvements in blood pressure compared to less than 10% weight loss in overweight or obese women.

P-wave morphology correlation with left atrial volumes assessed by 2-dimensional echocardiography.

To correlate prespecified P-wave morphologies with echocardiographically derived left atrial volumes (LAVs), we studied a convenience sample of 71 patients with predominantly normal left ventricular systolic function (mean ejection fraction = 58.2% +/- 6.6%) who underwent concurrent 2-dimensional echocardiogram and 12-lead electrocardiogram. Left atrial volume was calculated from apical end-systolic images by the biplane method of disks and was indexed for body surface area (BSA). Electrocardiograms were assessed manually with calipers, measuring leading edge to leading edge. Patients included 34 men and 37 women with a mean age of 53 +/- 14 years. P-wave duration/PR-segment duration in lead II and depth and duration of terminal P wave in lead V1 (P terminal force) correlate poorly with LAV and provided only modest predictive power (area under receiver operating characteristic curve = 0.466-0.619 and r = 0.30-0.42, P = .014-.021). Total P-wave duration in lead II correlated moderately (r = 0.47, P < .001) and predicted LAV (LAV/BSA = 8.0 + 0.2 [P-wave duration in lead II]), as did P-wave area in lead II (r = 0.49, P < .001) (LAV/BSA = 18.6 + 1.7 [P-wave duration in lead II]). The 4 P-wave morphologies were found to be poorly sensitive but highly specific for left atrial enlargement.

Using the theory of reasoned action to explain physician intention to prescribe emergency contraception.

CONTEXT: Although research has examined providers' knowledge, attitudes and prescribing behaviors with regard to emergency contraception, none has used a theory-based approach to understanding the interplay of these factors. METHODS: A cross-sectional survey of 96 faculty physicians from one Southern and three Midwestern universities was conducted in 2004 to assess factors associated with intention to prescribe emergency contraception. The theory of reasoned action guided the study hypotheses and survey design. Correlation and regression analyses were used to examine the data. RESULTS: Only 42% of respondents strongly intended to prescribe emergency contraception for teenagers, but 65-77% intended to do so for all other specified groups (women who ask for the method, who have had a method problem, who have experienced rape or incest, and who have had unprotected sex). Consistent with the theory of reasoned action, high intention to prescribe emergency contraception was associated with positive attitudes toward doing so and with the perception that specific colleagues or professional groups support prescribing it; however, the perception of support by colleagues or professional groups in general did not predict intention. Also consistent with the theory, physicians' knowledge about emergency contraception and their demographic characteristics were not significant. CONCLUSIONS: Interventions to encourage physicians to provide emergency contraception should take into account their attitudes toward the method and the components of those attitudes.

A comparison of meal replacements and medication in weight maintenance after weight loss.

OBJECTIVE: To compare the use of meal replacements or medication during weight maintenance subsequent to weight loss using a very low-energy diet (VLED) in overweight or obese adults. DESIGN: Participants followed a liquid VLED of 2177 kJ for 12 weeks followed by 4 weeks of re-orientation to solid foods. Participants were randomized at week 16 to receive either meal replacements or Orlistat both combined with a structured meal plan containing an energy value calculated to maintain weight loss. SUBJECTS: Sixty-four women (age = 49.9 +/- 10 y, weight = 101.6 +/- 17.1 kg, height = 164.9 +/- 6.0 cm, BMI = 36.7 +/- 5.4 kg/m(2)) and 28 men (age = 53.7 +/- 9.6 y, weight = 121.8 +/- 16.0 kg, height = 178.7 +/- 5.6 cm, BMI = 37.8 +/- 4.9 kg/m(2)) completed a 1 year weight management program. Behavioral weight management clinics included topics on lifestyle, physical activity (PA), and nutrition. Participants met for 90 min weekly for 26 weeks, and then biweekly for the remaining 26 weeks. OUTCOMES: Minutes of PA, fruits and vegetables (FV), and pedometer steps were recorded on a daily basis and reported at each group meeting. Body weight was obtained at each group meeting. RESULTS: During VLED, the MR group decreased body weight by 22.8 +/- 6.1 kg and the Orlistat group decreased body weight by 22.3 +/- 6.1 kg. During weight maintenance, there was no significant group by time interaction for body weight, PA, FV consumption, or pedometer steps. At week 16, the meal replacement group had a body weight of 85.4 +/- 14.3 kg that increased to 88.1 +/- 16.5 kg at 52 weeks (p < 0.05). At week 16, the Orlistat group had a body weight of 85.7 +/- 17.9 kg that increased to 88.5 +/- 20.3 kg at 52 weeks (p < 0.05). CONCLUSIONS: Subsequent to weight loss from a VLED, meal replacements and Orlistat treatments were both effective in maintaining weight significantly below baseline levels over a 52 week period of time. Meal replacements may be a viable alternative strategy to medications for weight maintenance.

Cancer information needs in rural areas.

Although cancer presents obstacles for all who experience it, persons in rural communities must negotiate additional challenges. This study determined the cancer information (CI) needs and the CI-seeking behavior and preferences among rural-dwelling persons. Patients (N = 801) = 50 years of age seen in 36 rural Kansas primary care practices completed a Cancer Care Information Needs Survey (CCINS); physicians completed a cancer resource knowledge and preference survey. Of the 801 patients, 184 (23%) reported a CI need. Of these 184 patients, 45% reported either not discussing cancer or having insufficient discussion time with their physicians; 44% needed more information after consulting their physician. Patients more likely to report a CI need were young, female, Internet users, persons with a prior cancer diagnosis, and persons seeing male physicians or physicians in group/multispecialty practices. Patients and physicians were unfamiliar with services provided by national cancer organizations. Physicians are a primary CI source; however, patients who need CI report insufficient cancer discussion time with their physician and need more CI after consulting their physician. Promoting access to national CI sources could bridge the CI needs gap that exists in rural areas currently.

Barriers to colorectal cancer screening in rural primary care.

BACKGROUND: Residents of rural communities may face unique barriers to obtaining colorectal cancer (CRC) screening, including reduced access to services. This study assessed the impact of patient, physician, and practice characteristics on rural primary care patient receipt of CRC screening. METHODS: We surveyed patients (N = 801) over 50 years of age and primary care physicians (N = 36) in rural practices. Medical students administered surveys to assess patient demographics, self-reported CRC screening, practice features, local availability of endoscopy, and physician screening test preferences. We used multivariable logistic regression analyses to investigate associations between independent variables, and (1) patient CRC screening status and (2) adequacy of CRC discussions between physicians and patients. RESULTS: Fifty-seven percent of patients reported being up-to-date with colorectal cancer screening and most in this group had received FOBT and endoscopy. A minority of patients (39%) reported adequate time to discuss CRC screening, and this was positively associated with being up-to-date with CRC screening in a multivariable analysis. Endoscopy was available in 58% of the practices and 44% of the practices had local gastroenterologists available on at least a monthly basis. The availability of endoscopic procedures and gastroenterological services were not associated with CRC screening or with use of endoscopy as a screening method. CONCLUSIONS: CRC screening among rural primary care patients is related to adequacy of physician CRC screening discussions but not access to endoscopic procedures. Efforts to improve CRC screening should focus on improving physician-patient discussions of CRC.