Harris Health System

One of the most influential ideas in the past 30 years is the efficient markets hypothesis, the idea that market prices incorporate all information rationally and instantaneously. The emerging discipline of behavioral economics and finance has challenged the EMH, arguing that markets are not rational, but rather driven by fear and greed. Research in the cognitive neurosciences suggests these two perspectives are opposite sides of the same coin. An adaptive markets hypothesis that reconciles market efficiency with behavioral alternatives applies the principles of evolution?competition, adaptation, and natural selection?to financial interactions. Extending Simon9s notion of ?satisficing? with evolutionary dynamics, the author argues that much of what behaviorists cite as counter-examples to economic rationality?loss aversion, overconfidence, overreaction, mental accounting, and other behavioral biases?is in fact consistent with an evolutionary model of individual adaptation to a changing environment via simple heuristics. The adaptive markets hypothesis offers a number of surprisingly concrete implications for portfolio management.

Background-Starting in 1999, the National Health and Nutrition Examination Survey (NHANES) became a continuous, ongoing annual survey of the noninstitutionalized civilian resident population of the United States. A continuous survey allowed content to change to meet emerging needs. Objective-This report describes how NHANES for 1999-2010 was designed and implemented. NHANES is a national survey designed to provide national estimates on various health-related topics. Methods-The survey used in-person face-to-face interviews and physical examinations for data collection. Approximately 5,000 people per year participated in NHANES. The 5,000 people surveyed each year are representative of the entire U.S. population.

Abstract The Advanced Baseline Imager (ABI) on board the Geostationary Operational Environmental Satellite-R (GOES-R) is America’s next-generation geostationary advanced imager. GOES-R launched on 19 November 2016. The ABI is a state-of-the-art 16-band radiometer, with spectral bands covering the visible, near-infrared, and infrared portions of the electromagnetic spectrum. Many attributes of the ABI—such as spectral, spatial, and temporal resolution; radiometrics; and image navigation/registration—are much improved from the current series of GOES imagers. This paper highlights and discusses the expected improvements of each of these attributes. From ABI data many higher-level-derived products can be generated and used in a large number of environmental applications. The ABI’s design allows rapid-scan and contiguous U.S. imaging automatically interleaved with full-disk scanning. In this paper the expected instrument attributes are covered, as they relate to signal-to-noise ratio, image navigation and registration, the various ABI scan modes, and other parameters. There will be several methods for users to acquire GOES-R imagery and products depending on their needs. These include direct reception of the imagery via the satellite downlink and an online-accessible archive. The information from the ABI on the GOES-R series will be used for many applications related to severe weather, tropical cyclones and hurricanes, aviation, natural hazards, the atmosphere, the ocean, and the cryosphere. The ABI on the GOES-R series is America’s next-generation geostationary advanced imager and will dramatically improve the monitoring of many phenomena at finer time and space scales.

Improving health outcomes relies on patients' full engagement in prevention, decision-making, and self-management activities. Health literacy, or people's ability to obtain, process, communicate, and understand basic health information and services, is essential to those actions. Yet relatively few Americans are proficient in understanding and acting on available health information. We propose a Health Literate Care Model that would weave health literacy strategies into the widely adopted Care Model (formerly known as the Chronic Care Model). Our model calls for first approaching all patients with the assumption that they are at risk of not understanding their health conditions or how to deal with them, and then subsequently confirming and ensuring patients' understanding. For health care organizations adopting our model, health literacy would then become an organizational value infused into all aspects of planning and operations, including self-management support, delivery system design, shared decision-making support, clinical information systems to track and plan patient care, and helping patients access community resources. We also propose a measurement framework to track the impact of the new Health Literate Care Model on patient outcomes and quality of care.

Brominated flame retardants have come into common use in the United States during the past 3 decades. This study reports levels of polybrominated diphenyl ether (PBDE) flame retardants in blood from the U.S. population at the present time and 30 years previously and also current human milk levels. This is also the first study to report measured congeners and dioxin toxic equivalents (TEQs) of dioxins, dibenzofurans, and dioxin-like polychlorinated biphenyls (PCBs) from archived, 1973, blood and compare them with current levels. The findings indicate there have been significant changes in levels of each class of these persistent organic pollutants (POPs) in U.S. human blood. Although dioxin, dibenzofuran, and PCB levels are markedly higher in the 1973 blood, the opposite is true for PBDEs. Furthermore, unlike dioxins, dibenzofurans, and PCBs, which increase with age, there was no significant correlation found in our study between PBDE levels and age. Current total PBDE levels in U.S. blood are the highest reported worldwide to date, with 2 pooled samples (N = 100 each) measuring 61.7 and 79.7 parts per billion (ppb) lipid, and in a series of 39 individual analyses, the range was 4.6 to 365.5 ppb with a median of 29 ppb and a mean of 52.6 ppb. The median for women in this study was 43.3 ppb, and for men it was 25.1 ppb. Although women have a higher level of PBDEs in blood than men, in our study, this is not statistically significant. Blood levels are similar to levels in U.S. human milk from 59 women, 6.2 to 418.8 ppb lipid. Levels of PBDE in pooled 2003 serum are far higher at 61.7 ppb than in 1973 archived pooled serum in which almost no PBDEs were quantified, although the estimated level using half the detection limit for nondetects was 0.77 ppb. Although no human health studies have been conducted on PBDEs, they are of concern because in vivo and in vitro animal studies show nervous system, reproductive, developmental, and endocrine effects, as well as cancer in high-dose studies.

BACKGROUND: The risk factors for mistreatment of older people include age, race, low income, functional or cognitive impairment, a history of violence, and recent stressful events. There is little information in the literature concerning the clinical profile of mistreated older people. OBJECTIVES: To describe the characteristics of abused or neglected patients and to compare the prevalence of depression and dementia in neglected patients with that of patients referred for other reasons. DESIGN: A case control study. SETTING: Baylor College of Medicine Geriatrics Clinic at the Harris County Hospital District (Houston, Texas). PATIENTS: Forty-seven older persons referred for neglect and 97 referred for other reasons. INTERVENTION: Comprehensive geriatric assessment. MEASUREMENTS: Standard geriatric assessment tools. RESULTS: There was a statistically significant higher prevalence of depression (62% vs 12%) and dementia (51% vs 30%) in victims of self-neglect compared to patients referred for other reasons. CONCLUSIONS: This is the first primary data study that highlights a high prevalence of depression as well as dementia in mistreated older people. Geriatric clinicians should rule out elder neglect or abuse in their depressed or demented patients.

First-order necessary conditions for quadratically optimal, steady-state,fixed-order dynamic compensation of a linear, time-invariant plant in the presence of disturbance and observation noise are derived in a new and highly simplified form. In contrast to the pair of matrix Riccati equations for the full-order LQG case, the optimal steady-state fixed-order dynamic compensator is characterized by four matrix equations (two modified Riccati equations and two modified Lyapunov equations) coupled by a projection whose rank is precisely equal to the order of the compensator and which determines the optimal compensator gains. The coupling represents a graphic portrayal of the demise of the classical separation principle for the reduced-order controller case.

OBJECTIVE: To determine long-term (> 6 months) outcome of dogs with paraplegia and loss of hind limb deep pain perception (DPP) resulting from intervertebral disk herniation or trauma. DESIGN: Retrospective study. ANIMALS: 87 dogs. PROCEDURE: Outcome was determined as successful or unsuccessful. The association of neuroanatomic localization, breed, age, weight, sex, and (for dogs with intervertebral disk herniation) speed of onset of signs and duration of paraplegia prior to surgery with outcome was evaluated. Owners were contacted by telephone to identify long-term health problems. RESULTS: Nine of 17 dogs with traumatic injuries were treated, and 2 regained the ability to walk; none of the 17 dogs regained DPP. Sixty-four of 70 dogs with intervertebral disk herniation underwent surgery; 9 (14%) were euthanatized within 3 weeks after surgery (7 because of ascending myelomalacia), 37 (58%) regained DPP and the ability to walk, 7 (11%) regained the ability to walk without regaining DPP, and 11 (17%) remained paraplegic without DPP. Outcome was not associated with any of the factors evaluated, but speed of recovery of ambulation was significantly associated with body weight and age. Fifteen (41%) and 12 (32%) dogs that regained DPP had intermittent fecal and urinary incontinence, respectively. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggested that the prognosis for paraplegic dogs without DPP because of trauma was guarded, while dogs with disk herniation had a better chance of recovering motor function. A third of the dogs that recovered motor function had intermittent incontinence. Persistent loss of DPP did not preclude recovery of motor function, but such dogs remained incontinent.

OBJECTIVE: This study was carried out to compare the efficacy of lithium carbonate with that of valproate in acute mania and to determine whether pretreatment clinical characteristics, such as the presence of a mixed affective state, might predict a differential response to the two drugs. METHOD: Twenty-seven patients meeting DSM-III-R criteria for acute manic episodes underwent a 3-week, randomized, double-blind, parallel-groups trial of treatment with lithium carbonate or valproate. Symptom severity was measured by using the Schedule for Affective Disorders and Schizophrenia, change version (SADS-C), the Global Assessment Scale (GAS), and the Brief Psychiatric Rating Scale (BPRS). Drug effects were compared by using repeated measures analysis of variance (ANOVA). RESULTS: At the end of the study, nine of 14 patients treated with valproate and 12 of 13 patients treated with lithium had responded favorably, as measured by changes in the SADS-C mania, BPRS, and GAS scores. Elevated pretreatment SADS-C depression scores were associated with good response to valproate. ANOVA revealed a significant interaction between drug and mixed affective state with respect to treatment response. CONCLUSIONS: Lithium and valproate were both effective in improving manic symptoms, and lithium was slightly more efficacious overall. Unlike the case with lithium, favorable response to valproate was associated with high pretreatment depression scores. Therefore, treatment with valproate alone may be particularly effective in manic patients with mixed affective states.

BACKGROUND: Substance abuse is present in most patients with bipolar disorder and associated with poor treatment outcome and increased risk of suicide. Increased impulsivity may be a link between bipolar disorder and substance abuse. METHODS: First, we compared impulsivity as a stable trait (Barratt Impulsiveness Scale, BIS) and as state-dependent behavioral laboratory performance (Immediate Memory-Delayed Memory task, derived from the Continuous Performance Task) in interepisode bipolar and non-bipolar subjects with and without substance abuse. Secondly, we compared impulsivity in interepisode and manic bipolar subjects with and without substance abuse. RESULTS: The BIS scores were increased in interepisode bipolar disorder and in subjects with histories of substance abuse, and were increased further in interepisode bipolar subjects with substance abuse. Performance impulsivity was increased in subjects with substance abuse, regardless of whether they had bipolar disorder. Among subjects with bipolar disorder, after correction for age, BIS scores were increased in those with substance abuse. Performance impulsivity was increased in manic compared with interepisode subjects, regardless of substance abuse history, and was increased in interepisode subjects with substance abuse similarly to manic subjects without substance abuse. These differences could not be accounted for by age, gender, or course of illness. CONCLUSIONS: Trait impulsivity is increased additively in bipolar disorder and substance abuse. Performance impulsivity is increased in interepisode bipolar disorder only if a history of substance abuse is present. This increased predisposition to impulsivity when not manic may contribute to the decrement in treatment outcome and compliance, and increased risk for suicide and aggression, in bipolar disorder with substance abuse.

BACKGROUND: In the United States many correctional facilities now operate at far over capacity, with the potential for living conditions that permit outbreaks of respiratory infections. We investigated an outbreak that was identified in an overcrowded Houston jail after two inmates died of pneumococcal sepsis on the same day. Outbreaks of pneumococcal disease have been rare in the era of antibiotics. METHODS: We assessed risk factors for pneumococcal disease in both a case-control and a cohort study. Ventilation was evaluated by measuring carbon dioxide levels and air flow to the living areas of the jail. The extent of asymptomatic infection was determined by culturing pharyngeal specimens from a random sample of inmates. Type-specific immunity was determined with an enzyme immunoassay. RESULTS: Over a four-week period, 46 inmates had either acute pneumonia or invasive pneumococcal disease due to Streptococcus pneumoniae serotype 12F. The jail's capacity had been set at 3500 inmates, but it housed 6700 at the time of the outbreak; the inmates had a median living area of only 34 ft2 (3.2 m2) (interquartile range, 28 to 56 ft2 [2.6 to 5.2 m2]) per person. There were significantly fewer cases of disease among inmates with 80 ft2 (7.4 m2) per person or more (P = 0.030). Carbon dioxide levels ranged from 1100 to 2500 ppm (acceptable, < 1000), and the ventilation system delivered a median of only 6.1 ft3 of outside air per minute per person (interquartile range, 4.4 to 8.5 ft3; recommended, > or = 20 ft3). The attack rate was highest among inmates in cells with the highest carbon dioxide levels and the lowest volume of outside air delivered by the ventilation system (relative risk, 1.94; 95 percent confidence interval, 1.08 to 3.48). Of underlying medical conditions, intravenous drug use was most strongly associated with disease (odds ratio, 4.50). The epidemic strain (serotype 12F) was cultured from 7 percent of the asymptomatic inmates. Of 11 case patients tested with the enzyme immunoassay, 9 (82 percent) lacked preexisting immunity to this strain. CONCLUSIONS: Severe overcrowding, inadequate ventilation, and altered host susceptibility all contributed to this outbreak of pneumococcal disease in a large urban jail.

The artificial neural network (ANN) technique for short-term load forecasting (STLF) has been proposed previously. In order to evaluate ANNs as a viable technique for STLF, one has to evaluate the performance of ANN methodology for practical considerations of STLF problems. The authors make an attempt to address these issues. The results of a study to investigate whether the ANN model is system dependent, and/or case dependent, are presented. Data from two utilities are used in modeling and forecasting. In addition, the effectiveness of a next 24 h ANN model in predicting 24 h load profile at one time was compared with the traditional next 1 h ANN model.&gt;

The key problem in testing for racial profiling in traffic stops is estimating the risk set, or “benchmark,” against which to compare the race distribution of stopped drivers. To date, the two most common approaches have been to use residential population data or to conduct traffic surveys in which observers tally the race distribution of drivers at a certain location. It is widely recognized that residential population data provide poor estimates of the population at risk of a traffic stop; at the same time, traffic surveys have limitations and are more costly to carry out than the alternative that we propose herein. In this article we propose a test for racial profiling that does not require explicit, external estimates of the risk set. Rather, our approach makes use of what we call the “veil of darkness” hypothesis, which asserts that police are less likely to know the race of a motorist before making a stop after dark than they are during daylight. If we assume that racial differences in traffic patterns, driving behavior, and exposure to law enforcement do not vary between daylight and darkness, then we can test for racial profiling by comparing the race distribution of stops made during daylight to the race distribution of stops made after dark. We propose a means of weakening this assumption by restricting the sample to stops made during the evening hours and controlling for clock time while estimating daylight/darkness contrasts in the race distribution of stopped drivers. We provide conditions under which our estimates are robust to a substantial nonreporting problem present in our data and in many other studies of racial profiling. We propose an approach to assess the sensitivity of our results to departures from our maintained assumptions. Finally, we apply our method to data from Oakland, California and find that in this example the data yield little evidence of racial profiling in traffic stops.

Eighty-seven patients with the clinical syndrome of infective endocarditis were examined by M-mode and two-dimensional echocardiography. Patients were divided into two groups based on the presence or absence of echocardiographically detected vegetative lesions. Group 1 consisted of 47 patients with one or more vegetations. Group 2 consisted of 40 patients without evidence of vegetations. Group 1 patients had a higher rate of complications: emboli, congestive heart failure and the need for surgical intervention. Analysis of morphologic characteristics of the vegetations in group 1 was of no predictive value for complications in individual patients. Two-thirds of the vegetations persisted unaltered well beyond the period of bacteriologic cure without significant complications. No characteristic alteration of the vegetations predicted the efficacy of medical therapy. Although the detection of vegetations by echocardiography in patients with the clinical syndrome of endocarditis clearly identifies a subgroup at risk for complications, decisions regarding clinical management made solely on the basis of the presence or absence of vegetative lesions are hazardous. Management of such patients must continue to be based on the clinical integration of multiple factors.

Diets rich in omega-3 fatty acids derived from fish oils lower the plasma concentrations of low density lipoproteins (LDL) and very low density lipoproteins in humans. The present study was designed to examine the mechanism(s) by which diets enriched in omega-3 fatty acids reduce plasma LDL cholesterol levels in normal subjects. Seven healthy volunteers with normal plasma lipid levels consumed two metabolically controlled diets for a period of 4 weeks each. The control diet contained predominantly saturated and monounsaturated fatty acids, whereas the fish-oil diet contained 24 gm of omega-3 fatty acids per day. The total fat and cholesterol content of the two diets were similar for each subject. Total and LDL cholesterol levels decreased from 162 +/- 26 mg/dl and 103 +/- 27 mg/dl on the control diet to 124 +/- 26 mg/dl and 82 +/- 27 mg/dl on the omega-3-rich diet. Triglyceride levels fell from 91 +/- 34 mg/dl to 52 +/- 19 mg/dl. Kinetic studies of 125I-LDL metabolism disclosed a significantly lower rate of synthesis of LDL apoprotein B on the omega-3-rich diet (9.5 +/- 1.3 mg/kg/day) as compared to the control diet (13.6 +/- 3.7 mg/kg/day; p less than 0.05). In contrast, the fractional catabolic rate was similar on both diets. We conclude that dietary omega-3 fatty acids lower plasma LDL levels in normal human subjects by reducing the rate of synthesis of apoprotein B.

The responsibility of identifying elder mistreatment (EM) often falls on the healthcare professional. Many different screening and assessment instruments have been developed to aid healthcare professionals in making determinations about EM. The purpose of this article is to review existing EM screening and assessment instruments to examine progress in this field. The value and limitations of these instruments with regard to their use in different clinical and healthcare settings are discussed. The settings in which EM screening and assessment are conducted are also considered. The authors conclude that there is much to be done in terms of achieving consensus on what constitutes an appropriate screen or assessment instrument for detecting EM. Effort must be focused on instruments that can be used for brief, rapid screenings and those that can be used for more-detailed diagnostic assessments.

OBJECTIVE: There are limited data on the effects of financial distress (FD) on overall suffering and quality of life (QOL) of patients with advanced cancer (AdCa). In this cross-sectional study, we examined the frequency of FD and its correlates in AdCa. PATIENTS AND METHODS: We interviewed 149 patients, 77 at a comprehensive cancer center (CCC) and 72 at a general public hospital (GPH). AdCa completed a self-rated FD (subjective experience of distress attributed to financial problems) numeric rating scale (0 = best, 10 = worst) and validated questionnaires assessing symptoms (Edmonton Symptom Assessment System [ESAS]), psychosocial distress (Hospital Anxiety and Depression Scale [HADS]), and QOL (Functional Assessment of Cancer Therapy-General [FACT-G]). RESULTS: The patients' median age was 60 years (95% confidence interval [CI]: 58.6-61.5 years); 74 (50%) were female; 48 of 77 at CCC (62%) versus 13 of 72 at GPH (18%) were white; 21 of 77 (27%) versus 32 of 72 (38%) at CCC and GPH, respectively, were black; and 7 of 77 (9%) versus 27 of 72 (38%) at CCC and GPH, respectively, were Hispanic (p < .0001). FD was present in 65 of 75 at CCC (86%; 95% CI: 76%-93%) versus 65 of 72 at GPH (90%; 95% CI: 81%-96%; p = .45). The median intensity of FD at CCC and GPH was 4 (interquartile range [IQR]: 1-7) versus 8 (IQR: 3-10), respectively (p = .0003). FD was reported as more severe than physical distress, distress about physical functioning, social/family distress, and emotional distress by 45 (30%), 46 (31%), 64 (43%), and 55 (37%) AdCa, respectively (all significantly worse for patients at GPH) (p < .05). AdCa reported that FD was affecting their general well-being (0 = not at all, 10 = very much) with a median score of 5 (IQR: 1-8). FD correlated (Spearman correlation) with FACT-G (r = -0.23, p = .0057); HADS-anxiety (r = .27, p = .0014), ESAS-anxiety (r = .2, p = .0151), and ESAS-depression (r = .18, p = .0336). CONCLUSION: FD was very frequent in both groups, but median intensity was double among GPH patients. More than 30% of AdCa rated FD to be more severe than physical, family, and emotional distress. More research is needed to better characterize FD and its correlates in AdCa and possible interventions. IMPLICATIONS FOR PRACTICE: Financial distress is an important and common factor contributing to the suffering of advanced cancer patients and their caregivers. It should be suspected in patients with persistent, refractory symptom expression. Early identification, measurement, and documentation will allow clinical teams to develop interventions to improve financial distress and its impact on quality of life of advanced cancer patients.

CONTEXT: Fine-needle aspiration has become an accepted and cost-effective procedure for rapid diagnosis of thyroid lesions. The routine use of fine-needle aspiration has reduced the rate of unnecessary surgery for thyroid nodules. OBJECTIVES: To determine the accuracy of fine-needle aspiration biopsy diagnosis and to discuss the possible pitfalls. Design, Setting, and Participants.-Reports of 6226 fine-needle aspiration biopsies of the thyroid performed during a period of 16 years (1982-1998) were reviewed. Computerized reports of the fine-needle aspiration biopsies were sent to the physicians who performed the procedures, and clinical follow-up information regarding the patients was requested. Twenty-four clinicians participated in the study. Histologic diagnoses were available for 354 cases. The cytopathologic diagnoses were correlated with the histologic findings or clinical outcomes. RESULTS: The cytologic diagnoses were as follows: 210 (3.4%) malignant, 450 (7.2%) suspicious, 3731 (60%) benign, and 1845 (29.5%) unsatisfactory. Most of the cases with negative or unsatisfactory aspirates were followed clinically or by repeat fine-needle aspiration. We identified 11 false-negative and 7 false-positive diagnoses. For aspirates considered sufficient for diagnosis, the sensitivity and specificity levels were 93% and 96%, respectively. CONCLUSIONS: Fine-needle aspiration of the thyroid gland is highly accurate and has a low rate of false-negative and false-positive diagnoses. The major diagnostic problems are caused by diagnosis using a marginally adequate specimen, diagnosis of malignancy based on just 1 or 2 atypical cytologic features, or overlapping cytologic features of follicular neoplasm with those of follicular variant of papillary carcinoma.

Bus Rapid Transit (BRT) is growing in popularity throughout the world. The reasons for this phenomenon include its passenger and developer attractiveness, its high performance and quality, and its ability to be built quickly, incrementally, and economically. BRT also provides sufficient transport capacity to meet demands in many corridors, even in the largest metropolitan regions. In the United States, the development of BRT projects has been spurred by the Federal Transit Administration’s (FTA) BRT initiative. These projects have been undertaken, in part, because of the imbalance between the demand for “New Starts” funds and available resources. Decisions to make BRT investments should be the result of a planning process that stresses problem solving, addressing needs, and the objective examination of a full range of potential solutions, of which BRT is only one. Good planning practice means matching potential market characteristics with available rights-of-way. BRT involves an integrated system of facilities, services, amenities, operations, and Intelligent Transportation Systems (ITS) improvements that are designed to improve performance, attractiveness to passengers, image, and identity. Because they can be steered as well as guided, BRT vehicles can operate in a wide range of environments without forcing transfers or requiring expensive running way construction over the entire range of their operation. Through this flexibility, BRT can provide one-seat, high-quality transit performance over a geographic range beyond that of dedicated guideways. To the maximum extent practical, the system should transfer the service attributes of rail transit to BRT. Even where implementation of a comprehensive, integrated BRT system is not possible, many of its components can be adapted for use in conventional bus systems with attendant benefits in speed, reliability, and transit image/attractiveness. In summary, BRT is growing in popularity because it can be cost-effective and it works. This article describes BRT concepts and components, traces BRT’s evolution, gives its current status, and outlines some of the findings to date of the Transportation Research Board’s (TRB) Transit Cooperative Research Program (TCRP) A-23 project, “Implementation Guidelines for Bus Rapid Transit.”

OBJECTIVE: The authors' goal was to determine the rate of comorbid panic disorder in individuals with bipolar disorder. METHOD: They used the Epidemiologic Catchment Area survey database to determine the prevalence of comorbid panic disorder in individuals with unipolar depression, those with bipolar disorder, and comparison subjects without bipolar or unipolar disorder. RESULTS: The lifetime prevalence of panic disorder among subjects with bipolar disorder was 20.8%; among subjects with unipolar depression it was 10.0%, and among comparison subjects it was 0.8%. CONCLUSIONS: Individuals with bipolar disorder have a particularly high risk of comorbid panic disorder. The evaluation of patients with bipolar disorder should include screening for panic disorder.