Simultaneous reflectometry and interferometry for measuring thin-film thickness and curvature.

A coupled reflectometer-interferometer apparatus is described for thin-film thickness and curvature characterization in the three-phase contact line region of evaporating fluids. Validation reflectometry studies are provided for Au, Ge, and Si substrates and thin-film coatings of SiO2 and hydrogel/Ti/SiO2. For interferometry, liquid/air and solid/air interferences are studied, where the solid/air samples consisted of glass/air/glass wedges, cylindrical lenses, and molded polydimethylsiloxane lenses. The liquid/air studies are based on steady-state evaporation experiments of water and isooctane on Si and SiO2/Ti/SiO2 wafers. The liquid thin-films facilitate characterization of both (i) the nano-scale thickness of the absorbed fluid layer and (ii) the macro-scale liquid meniscus thickness, curvature, and curvature gradient profiles. For our validation studies with commercial lenses, the apparatus is shown to measure thickness profiles within 4.1%-10.8% error.

Nuclear corrections in neutrino-nucleus deep inelastic scattering and their compatibility with global nuclear parton-distribution-function analyses.

We perform a global χ² analysis of nuclear parton distribution functions using data from charged current neutrino-nucleus (νA) deep-inelastic scattering (DIS), charged-lepton-nucleus (ℓ(±)A) DIS, and the Drell-Yan (DY) process. We show that the nuclear corrections in νA DIS are not compatible with the predictions derived from ℓ(±)A DIS and DY data. We quantify this result using a hypothesis-testing criterion based on the χ² distribution which we apply to the total χ² as well as to the χ² of the individual data sets. We find that it is not possible to accommodate the data from νA and ℓ(±)A DIS by an acceptable combined fit. Our result has strong implications for the extraction of both nuclear and proton parton distribution functions using combined neutrino and charged-lepton data sets.

Tomography of high-energy nuclear collisions with photon-hadron correlations.

Within the next-to-leading order (NLO) perturbative QCD (PQCD) parton model, suppression of away-side hadron spectra associated with a high pT photon due to parton energy loss is studied in high-energy heavy-ion collisions. Because of the sharp falloff of the gamma-jet spectrum in momentum imbalance pTjet-pTgamma>0 in NLO PQCD, hadron spectra at large zT=pTh/pTgamma greater than approximately 1 are more susceptible to parton energy loss and therefore are dominated by surface emission of gamma-associated jets with almost no energy loss, whereas small zT hadrons mainly come from the volume emission of jets with reduced energy. These lead to different centrality dependence of the gamma-hadron suppression for different values of zT. Therefore, a complete measurement of the suppression of gamma-triggered hadron spectra allows a true tomographic study of the quark-gluon plasma in high-energy heavy-ion collisions.

Chronic stress influences cardiovascular and neuroendocrine responses during acute stress and recovery, especially in men.

This study tests the influence of chronic stress on cardiovascular and neuroendocrine responses to and recovery from acute stressors and whether the effects are gender specific. Sixty-two healthy, middle-aged persons (50% women) performed mental-arithmetic and public-speaking tasks and relaxed thereafter for 1 hr while their cardiovascular and neuroendocrine function was measured. Participants with higher levels of chronic stress showed lower systolic blood pressure (SBP) and epinephrine (E; men only) and marginally lower levels of norepinephrine (NE) responses to the tasks and showed lower levels of cortisol and marginally lower NE responses during recovery. Relative to women, men had high diastolic blood pressure (DBP) responses to the tasks and high SBP, DBP, and E responses during recovery. Gender differences in cardiovascular disease in midlife may be due to gender differences in the inability to recover quickly, in addition to enhanced acute-stress response.

Influence of estrogen replacement therapy on cardiovascular responses to stress of healthy postmenopausal women.

Two experiments were conducted to understand the influence of estrogen exposure on cardiovascular responses to acute stress measured by impedance cardiography. Study I compared stress responses of 29 postmenopausal women who used postmenopausal hormone replacement therapy (HRT) and 29 who did not use HRT. Women who did not use HRT had higher systolic blood pressure and pulse pressure responses to the tasks relative to HRT users. Study 2 compared stress responses of 38 healthy postmenopausal women not initially on HRT who were randomly assigned to transdermal estradiol or placebo treatment for 6-8 weeks. HRT assignment did not influence substantially women's cardiovascular responses to stress. Characteristics correlated with HRT use, not HRT itself, or differences in type, duration, and dosage may account for the discrepancy in results.

Do the daily experiences of healthy men and women vary according to occupational prestige and work strain?

OBJECTIVE: This study evaluated the influence of occupational prestige and work strain on mood, the occurrence of interpersonal conflict, and ambulatory blood pressure and heart rate. METHODS: Participants were 50 men and 50 women matched for occupational prestige who were healthy and middle-aged and who completed measures of mood and conflict simultaneously with measures of ambulatory blood pressure and heart rate recorded every 30 minutes during waking hours of two workdays and one nonworkday; at the end of each day, overall ratings were made. Work strain was assessed by the Work Section of the Self-Evaluation and Social Support Interview Schedule. Multiple level random regression coefficients analyses were conducted. RESULTS: Men and women with low-prestige occupations experienced more interpersonal conflict, b = -0.03, p = .04, and higher ambulatory heart rate, b = -4.83, p = .004, throughout the three days of the study. Relative to those with low work strain, those reporting high work strain experienced negative emotion, b = -0.41, p < .0001, and boredom, b = -0.17, p < .0004. End of the day ratings of negative mood were more influenced by work strain among men than among women. No effects of occupational prestige or work strain were obtained for ambulatory blood pressure readings after adjustment for physical activity, posture, and location. CONCLUSIONS: Individuals in low-prestige occupations experience greater exposure to interpersonal conflict and arousal as indexed by heart rate, which might increase risk for stress-related illnesses often associated with social class. Individuals who report work strain experience negative mood and boredom, both at work and at home. The absence of work effects on ambulatory blood pressure may be due to the participants being healthy.

Optimism and rehospitalization after coronary artery bypass graft surgery.

OBJECTIVE: To determine whether optimism predicts lower rates of rehospitalization after coronary artery bypass graft surgery for the 6 months after surgery. METHODS: A prospective, inception cohort design was used. The sample consisted of all consenting patients (N=309) from a consecutive series of patients scheduled for elective coronary artery bypass graft surgery at a large, metropolitan hospital in Pittsburgh, Pa. To be eligible, patients could not be scheduled for any other coincidental surgery (eg, valve replacement) and could not be in the cardiac intensive care unit or experiencing angina at the time of the referral. Participants were predominantly men (69.9%) and married (80.3%), and averaged 62.8 years of age. Recruitment occurred between January 1992 and January 1994. RESULTS: Compared with pessimistic persons, optimistic persons were significantly less likely to be rehospitalized for a broad range of aggregated problems (including postsurgical sternal wound infection, angina, myocardial infarction, and the need for another bypass surgery or percutaneous transluminal coronary angioplasty) generally indicative of a poor response to the initial surgery (odds ratio=0.50, 95% confidence interval=0.33- 0.76; P=.001). The effect of optimism was independent of traditional sociodemographic and medical control variables, as well as independent of the effects of self-esteem, depression, and neuroticism. All-cause rehospitalization also tended to be less frequent for optimistic than for pessimistic persons (odds ratio=0.77, 95% confidence interval=0.57-1.05; P=.07). CONCLUSIONS: Optimism predicts a lower rate of rehospitalization after coronary artery bypass graft surgery. Fostering positive expectations may promote better recovery.

Effects of optimism, pessimism, and trait anxiety on ambulatory blood pressure and mood during everyday life.

This study tested whether dispositional measures of optimism, pessimism, and anxiety affected ambulatory blood pressure (BP) and mood and whether any cardiovascular effects of dispositions were moderated by mood. Pessimistic and anxious adults had higher BP levels and felt more negative and less positive than did optimists or low anxious adults throughout the monitoring. The few times that optimists did feel negative were associated with levels of BP as high as those observed among pessimists or anxious individuals, regardless of their mood. To the extent that trait anxiety measures neuroticism, these findings suggest that neuroticism is directly related to health indicators rather than simply to illness behavior. Furthermore, the results suggest that pessimism has broad physiological and psychological consequences.

Effects of hostility on ambulatory blood pressure and mood during daily living in healthy adults.

This study (a) tested the effects of hostile attributes on ambulatory blood pressure (BP), heart rate, and mood monitored repeatedly over 3 days in 100 healthy men and women and (b) determined whether the cardiovascular effects of trait hostility were moderated by mood. Multilevel random-coefficients regression analyses showed that hostile individuals exhibited higher systolic and diastolic BP and rated their current moods as more negative and less positive throughout the monitoring. Individuals low in hostility exhibited high BP only during the few occasions when they experienced negative mood. However, these patterns were true only when participants were classified by Potential for Hostility ratings from the Structured Interview (R. H. Rosenman, 1978), not by the Cynical Hostile Attitudes score derived from the Cook-Medley scale. Results provide convergent and ecological validity of interview rating of hostility and illuminate one possible dynamic mechanism by which overt hostile behaviors might contribute to the rates of increased cardiovascular morbidity and mortality.

Sleep disturbance in healthy middle-aged women.

OBJECTIVES: The objectives of the study were to (a) describe the sleep patterns of a sample of healthy middle-aged women, (b) to characterize the psychological, behavioral and biological profiles of middle-aged women who report sleep disturbance, and (c) to determine the influence of change in menopausal status on the quality and quantity of self-reported sleep. METHODS: A total of 521 women of varying menopausal status were evaluated in a clinic setting. Measurements included blood pressure, height, weight, waist/hip ratio, and self-reported sleep disturbances, demographic and family characteristics, psychosocial questionnaires, physical activity and nutritional intake. The women who were premenopausal at this initial visit were later evaluated, in an identical protocol, when they became postmenopausal. RESULTS: A total of 42% of the women reported some type of sleep disturbance. Trouble sleeping was associated with higher levels of anxiety, depression, stress, tension and public self-consciousness. Women with trouble falling asleep had higher systolic and diastolic blood pressures and greater waist/hip ratios. Women who woke earlier than desired had higher systolic and diastolic blood pressures. Sleep disturbance was independent of menopausal status in cross-sectional analyses. In longitudinal analyses, the transition from pre- to postmenopausal status was associated with a significant increase in sleep disturbance in women who chose to not take hormone replacement therapy. CONCLUSIONS: There is a high level of sleep disturbance in middle-aged women. Sleep disturbance is associated with worse mood, higher blood pressure and higher waist/hip ratios. Transition into postmenopausal status is associated with deleterious changes in sleep patterns among women who do not take hormone replacement therapy.

Are hostility and anxiety associated with carotid atherosclerosis in healthy postmenopausal women?

OBJECTIVE: In this article, we evaluated the prospective association between measures of trait anger, hostility, and anxiety and indices of carotid atherosclerosis in 200 healthy middle-aged postmenopausal women. METHODS: Starting in 1983, 541 premenopausal women were evaluated for their levels of standard cardiovascular risk factors and psychosocial attributes, including their scores on Spielberger Trait Anger, Anxiety, and Anger-in, and Public Self-Consciousness. Starting in 1991, the Cook-Medley Hostile Attitudes Scale was also administered. Starting in 1993, 200 women who had been menopausal for at least 5 years were scanned for carotid atherosclerosis using B-mode ultrasound. The scans were scored for average intima-media thickness (IMT) and plaque index. RESULTS: Women who had high Trait Anger, Anger-In, and Public Self-Consciousness scores had high IMT scores on average 10 years later. Women who had high Cook-Medley scores also had high IMT scores on average 1.5 years later. Multivariate analyses adjusting for the standard cardiovascular risk factors that most highly predicted IMT scores indicated that holding anger in, being self aware, and having hostile attitudes were significant predictors of IMT. Women with higher plaque scores also tended to report holding in their anger. CONCLUSIONS: Anger suppression and hostile attitudes do predict women's carotid IMT in midlife. Ultrasound measures of carotid atherosclerosis can be used to advance our understanding of the early development of atherosclerosis in women.

Stress-induced pulse pressure change predicts women's carotid atherosclerosis.

BACKGROUND AND PURPOSE: Individuals who exhibit large increases in blood pressure and heart rate during mental stress may be at risk for accelerated atherosclerosis. This report evaluates the association between stress-induced hemodynamic responses and carotid atherosclerosis in 254 healthy postmenopausal women. METHODS: The magnitude of change in blood pressure and heart rate from rest to public speaking and mirror image tracing, two stressful tasks, was measured. Average intima-media thickness (IMT) and focal plaque in the common carotid artery, bulb, and internal carotid artery were measured with the use of duplex ultrasonography on average 2.3 years later. RESULTS: The average IMT was 0.77 mm, with a range of 0.60 to 1.37; 52.5% had at least one plaque. Correlational analysis showed that greater IMT was associated with greater pulse pressure change during mental stress (r = 0.17, P < 0.01). Statistical adjustments for possible confounders (age, hormone replacement therapy use, resting pulse pressure, smoking status, and triglyceride levels) did not alter the results. The plaque index was associated with greater pulse pressure change during the mirror image tracing task (odds ratio = 1.47, P = 0.01) for women with a plaque score of > or = 2 versus 1 or 0, adjusted for possible confounders. CONCLUSIONS: Mental stress-induced pulse pressure changes may influence the development of early atherosclerosis in the carotid artery of women. Widening of pulse pressure during stress, as well as at rest, may be a marker of compromised compliance in the vessel wall.

Effects of short-term suppression of ovarian hormones on cardiovascular and neuroendocrine reactivity to stress in women.

The present study reduced the levels of ovarian hormones to early postmenopausal levels by a GnRH agonist and evaluated the effects of a temporary suppression of ovarian hormones on premenopausal women's cardiovascular and neuroendocrine responses to laboratory challenges. The stress responses of 24 healthy young women were evaluated during three tasks during the early follicular phase and then after three monthly injections of Lupron, which suppressed their levels of estradiol, FSH, and LH. Thereafter, half the group resumed menstrual cycles (labeled Cycle), and half continued having Lupron injections in combination with transdermal estradiol (labeled Patch) and all were reevaluated a third time. A third group (labeled Control) of 12 women had four monthly injections of Lupron first and then were evaluated the first time. After their cycles resumed, they were reevaluated twice 3 months apart. Results showed that the magnitude of the blood pressure and catecholamine changes declined over the three evaluations, suggesting that the women's stress responses habituated. Although the suppression of ovarian hormone levels led to alterations in ovarian hormones for several months, which were accompanied by typical menopausal symptoms, cardiovascular and neuroendocrine responses to stress did not vary. This study did not test the effects of current estrogen exposure or of long term suppression of ovarian hormones upon cardiovascular and neuroendocrine responses.

A natural experiment on the effects of ovarian hormones on cardiovascular risk factors and stress reactivity: bilateral salpingo oophorectomy versus hysterectomy only.

To test the effects of declining ovarian hormone levels on cardiovascular risk factors, blood pressure, lipids, weight, and physiological responses to stress were evaluated in 29 middle-aged premenopausal women prior to and following elective hysterectomy and/or bilateral salpingo oophorectomy (BSO). Prior to surgery, there were no group differences in standard or putative risk factors, with the exceptions of body composition measures and total cholesterol level. After surgery, women who had undergone BSO (n = 10) had higher levels of atherogenic lipids and stress-induced lipids and tended to have higher circulating levels of epinephrine and stress-induced systolic and diastolic blood pressure than women who had undergone hysterectomy only (n = 19). This study is consistent with the hypothesis that presence of ovarian hormones plays a key role in determining women's risk factor status.

Sympathetic reactivity to acute stress and immune response in women.

We evaluated if the effects of acute stress on immune parameters were apparent in only the women who showed concomitant and substantial sympathetic nervous system activation and after statistical adjustment for changes in plasma volume. Nineteen women in the follicular stage of their menstrual cycles were assessed for immunological responsiveness to a series of three 3-minute psychological tasks, which reliably elicit cardiovascular and neuroendocrine stress responses. Women were classified as high or low sympathetic reactors based on their cardiovascular and neuroendocrine responses to one of the three tasks, a public speaking task. The stress-induced decreases in CD4+ percentage and increases in natural killer cell number and cytolytic activity were only apparent among the high reactors. Further analysis adjusting for alterations in plasma volume changes showed that the increase in NK cell number remained. Stress-induced proliferative responses to pokeweed mitogen and phytohemagglutinin were not more apparent among high reactors. These results are consistent with the hypothesis that the sympathetic nervous system plays a direct role in modulating the short term response to stress of some indices of the immune system in women.

Stress-induced hemoconcentration of blood cells and lipids in healthy women during acute psychological stress.

This study examined the effects of psychological stress on hemoconcentration in women. Hematologic and hemodynamic variables were assessed in 17 women before and after a 3-min speech task. Significant changes in hematocrit, hemoglobin levels, red and white blood cell (WBC) count, and calculated plasma volume occurred during psychological stress (all ps < .05). Significant increases were also observed for total cholesterol, triglycerides, high density lipoprotein cholesterol, low density lipoprotein cholesterol, and free fatty acid (FFA; all ps < .05) during stress. After statistically correcting for the hemoconcentration effects of decreased plasma volume during stress, only WBC count and FFA concentration remained significantly elevated during the stress task (p < .006 and p < .05, respectively). In sum, acute stress alters hemoconcentration in women, which in turn can account for most stress-induced changes in lipids.

Psychological stress and immunological responsiveness in normally cycling, follicular-stage women.

Nineteen women in the follicular stage of their menstrual cycles were assessed for immunological responsiveness to a 50-min series of three psychological tasks which reliably elicit cardiovascular and neuroendocrine stress responses. Ten follicular-stage women not subjected to stress served as controls. Stress decreased lymphocyte responsiveness to PHA and PWM, percent of CD4+ cells and the ratio of CD4+/CD8+ cells. Conversely, stress increased natural killer cell number and cytolytic activity, white blood cell, lymphocyte, T and B cell count. Except for natural killer cell number, none of these changes was exhibited by controls. Most of these stress responses are similar to those reported for men and form the basis for a continuing study of the effects of reproductive hormones and stress on cardiovascular and immunological function in women.

Special Medicare reimbursement and fraud and abuse considerations for management services organizations, medical foundations, and integrated delivery systems.

This chapter discusses certain Medicare reimbursement and fraud and abuse considerations for management services organizations (MSOs), medical foundations, and integrated delivery systems. It stresses the necessity of a business plan, the sources of capitalization that might be used in creating an integrated delivery system, and their effect on Medicare reimbursement. It also discusses related party principles and considerations and the Medicare "incident to" regulations. Furthermore, it discusses the application of certain Medicare safe harbor regulations on MSOs' structures and services, and those of medical foundations and integrated delivery systems.

Miscellaneous legal issues affecting integrated delivery systems, foundations, and management services organizations.

This chapter addresses some of those legal issues that uniquely affect the formation or operations of an integrated delivery system (IDS), a foundation, or a management services organization (MSO), but which are not discussed in any other chapters. This chapter gives special insight and guidance on issues such as licensing, credentialing and peer review, employee benefit plans, prohibitions against physician self-referrals, and the rules on disclosure of ownership and control.