Triad National Security (United States)

OBJECTIVES: The aim of this study is to provide updated guidance on when The Grading of Recommendations Assessment, Development and Evaluation (GRADE) users should consider rating down more than one level for imprecision using a minimally contextualized approach. STUDY DESIGN AND SETTING: Based on the first GRADE guidance addressing imprecision rating in 2011, a project group within the GRADE Working Group conducted iterative discussions and presentations at GRADE Working Group meetings to produce this guidance. RESULTS: GRADE suggests aligning imprecision criterion for systematic reviews and guidelines using the approach that relies on thresholds and confidence intervals (CI) of absolute effects as a primary criterion for imprecision rating (i.e., CI approach). Based on the CI approach, when a CI appreciably crosses the threshold(s) of interest, one should consider rating down two or three levels. When the CI does not cross the threshold(s) and the relative effect is large, one should implement the optimal information size (OIS) approach. If the sample size of the meta-analysis is far less than the OIS, one should consider rating down more than one level for imprecision. CONCLUSION: GRADE provides updated guidance for imprecision rating in a minimally contextualized approach, with a focus on the circumstances in which one should seriously consider rating down two or three levels for imprecision.

We tested an intervention designed to increase human immunodeficiency virus (HIV) testing among men who have sex with men and transgender persons within existing and commonly used social media. At follow-up, intervention communities had significantly higher past 12-month HIV testing than the comparison communities. Findings suggest that promoting HIV testing via social media can increase testing.

As a way to value growth opportunities, real options have had a difficult time catching on with managers. Many CFOs believe the method ensures the overvaluation of risky projects. This concern is legitimate, but abandoning real options as a valuation model isn't the solution. Companies that rely solely on discounted cash flow (DCF) analysis underestimate the value of their projects and may fail to invest enough in uncertain but highly promising opportunities. CFOs need not--and should not--choose one approach over the other. Far from being a replacement for DCF analysis, real options are an essential complement, and a project's total value should encompass both. DCF captures a base estimate of value; real options take into account the potential for big gains. This is not to say that there aren't problems with real options. As currently applied, they focus almost exclusively on the risks associated with revenues, ignoring the risks associated with a project's costs. It's also true that option valuations almost always ignore assets that an initial investment in a subsequently abandoned project will often leave the company. In this article, the authors present a simple formula for combining DCF and option valuations that addresses these two problems. Using an integrated approach, managers will, in the long run, select better projects than their more timid competitors while keeping risk under control. Thus, they will outperform their rivals in both the product and the capital markets.

BACKGROUND: Patients discharged home after stroke face significant challenges managing residual neurological deficits, secondary prevention, and pre-existing chronic conditions. Post-discharge care is often fragmented leading to increased healthcare costs, readmissions, and sub-optimal utilization of rehabilitation and community services. The COMprehensive Post-Acute Stroke Services (COMPASS) Study is an ongoing cluster-randomized pragmatic trial to assess the effectiveness of a comprehensive, evidence-based, post-acute care model on patient-centered outcomes. METHODS: Forty-one hospitals in North Carolina were randomized (as 40 units) to either implement the COMPASS care model or continue their usual care. The recruitment goal is 6000 patients (3000 per arm). Hospital staff ascertain and enroll patients discharged home with a clinical diagnosis of stroke or transient ischemic attack. Patients discharged from intervention hospitals receive 2-day telephone follow-up; a comprehensive clinic visit within 2 weeks that includes a neurological evaluation, assessments of social and functional determinants of health, and an individualized COMPASS Care Plan™ integrated with a community-specific resource database; and additional follow-up calls at 30 and 60 days post-stroke discharge. This model is consistent with the Centers for Medicare and Medicaid Services transitional care management services provided by physicians or advanced practice providers with support from a nurse to conduct patient assessments and coordinate follow-up services. Patients discharged from usual care hospitals represent the control group and receive the standard of care in place at that hospital. Patient-centered outcomes are collected from telephone surveys administered at 90 days. The primary endpoint is patient-reported functional status as measured by the Stroke Impact Scale 16. Secondary outcomes are: caregiver strain, all-cause readmissions, mortality, healthcare utilization, and medication adherence. The study engages patients, caregivers, and other stakeholders (including policymakers, advocacy groups, payers, and local community coalitions) to advise and support the design, implementation, and sustainability of the COMPASS care model. DISCUSSION: Given the high societal and economic burden of stroke, identifying a care model to improve recovery, independence, and quality of life is critical for stroke survivors and their caregivers. The pragmatic trial design provides a real-world assessment of the COMPASS care model effectiveness and will facilitate rapid implementation into clinical practice if successful. TRIAL REGISTRATION: Clinicaltrials.gov: NCT02588664 ; October 23, 2015.

Men who have sex with men (MSM) continue to be disproportionately affected by HIV and sexually transmitted diseases. This study was designed to explore sexual risk among MSM using community-based participatory research (CBPR). An academic-community partnership conducted nine focus groups with 88 MSM. Participants self-identified as African American/Black (n=28), Hispanic/Latino (n=33), White (n=21), and biracial/ethnic (n=6). The mean age was 27 years (range=18-60 years). Grounded theory was used. Twelve themes related to HIV risk emerged, including low knowledge of HIV and sexually transmitted diseases, particularly among Latino MSM and MSM who use the Internet for sexual networking; stereotyping of African American MSM as sexually "dominant" and Latino MSM as less likely to be HIV infected; and the eroticization of "barebacking." Twelve intervention approaches also were identified, including developing culturally congruent programming using community-identified assets, harnessing social media used by informal networks of MSM, and promoting protection within the context of intimate relationships. A community forum was held to develop recommendations and move these themes to action.

The Internet has emerged as an important tool for the delivery of health promotion and disease prevention interventions. Our community-based participatory research (CBPR) partnership developed and piloted CyBER/testing, a culturally congruent intervention designed to promote HIV testing among men who have sex with men (MSM) within existing Internet chat rooms. Using a quasi-experimental, single-group study design, cross-sectional data were collected from chat room participants, known as "chatters," at pretest (n = 346) and posttest (n = 315). Extant profile data also were collected to describe the demographics of the online population. The intervention significantly increased self-reported HIV testing among chatters overall, increasing rates from 44.5% at pretest to nearly 60% at posttest (p < .001). Furthermore, chatters who reported having both male and female sexual partners had nearly 6 times the odds of reporting HIV testing at posttest. Findings suggest that chat room-based HIV testing intervention may increase testing among MSM who may be difficult to reach in traditional physical spaces.

The sigma1 receptor is an intracellular molecule that shares no homology with any mammalian proteins. sigma1 receptors normally localize at the endoplasmic reticulum and regulate a variety of signal transductions including intracellular Ca2+ dynamics and neurotrophic factor signaling. In the brain, sigma1 receptors are known to regulate the activity of diverse ion channels via protein-protein interactions. Accumulated evidences strongly indicate that the activation/upregulation of sigma1 receptors promotes the neuronal differentiation as well as a robust antiapoptotic action. In animals, sigma1 receptor agonists exhibit an antidepressant-like action. Furthermore, the agonists enhanced neuronal survival eventhough they were administered several hours after a brain ischemia. Thus, primary clinical targets of sigma1 receptor ligands are proposed to include stroke, neurodegenerative disorders and depression. Ligands for the sigma1 receptor may constitute a new class of therapeutic drugs targeting an endoplasmic reticular protein.

The loading dynamics of an alkali-metal-atom magneto-optical trap can be used as a reliable measure of vacuum pressure, with loading time $\ensuremath{\tau}$ indicating a pressure less than or equal to ($2\ifmmode\times\else\texttimes\fi{}{10}^{\ensuremath{-}8}$ Torr s)/$\ensuremath{\tau}$. This relation is accurate to approximately a factor of 2 over wide variations in trap parameters, background gas composition, or trapped alkali-metal species. The low-pressure limit of the method does depend on the trap parameters, but typically extends to below $1\ifmmode\times\else\texttimes\fi{}{10}^{\ensuremath{-}9}$ Torr.

We review age-related changes in the ovary and their effect on female fertility, with particular emphasis on follicle formation, follicle dynamics, and oocyte quality. The evidence indicates that the developmental processes leading to follicle formation set the rules determining follicle quiescence and growth. This regulatory system is maintained until menopause and is directly affected in at least some models of premature ovarian failure (POF), most strikingly in the Foxl2 mouse knockout, a model of human POF with monogenic etiology (blepharophimosis/ptosis/epicanthus inversus syndrome). Several lines of evidence indicate that if the ovarian germ cell lineage maintains regenerative potential, as recently suggested in the mouse, a role in follicle dynamics for germ stem cells, if any, is likely indirect or secondary. In addition, age-related variations in oocyte quality in animal models suggest that reproductive competence is acquired progressively and might depend on parallel growth and differentiation of follicle cells and stroma. Genomewide analyses of the mouse oocyte transcriptome have begun to be used to systematically investigate the mechanisms of reproductive competence that are altered with aging. Investigative and therapeutic strategies can benefit from considering the role of continuous interactions between follicle cells and oocytes from the beginning of histogenesis to full maturation.

OBJECTIVES: Chat room-based prevention interventions for human immunodeficiency virus (HIV) are being implemented to reduce the risk of HIV exposure, infection, and re-infection among men who have sex with men (MSM). METHODS: Our community-based participatory research partnership implemented a chat room-based intervention known as Cyber-Based Education and Referral/Men for Men (CyBER/M4M). We collected both quantitative and qualitative data to describe the characteristics of chat-room participants ("chatters") and their HIV risks and prevention needs, and to document intervention delivery. RESULTS: Of the 1,851 chatters who participated in the 18-month intervention, 210 completed the online assessment. The mean age was 30 years. Although the majority self-identified as gay, 25.8% self-identified as bisexual. More than half self-identified as white and one-third as black or African American. A total of 8.6% reported being HIV-positive and 14.8% reported never having been tested for HIV. Grounded theory analysis of transcripts from chat-room instant-message discussions identified 13 thematic categories related to chatter characteristics, prevention needs, and intervention delivery. Chatters were looking for sexual partners, were not open about their orientation, lacked basic information about HIV, had questions about how to be tested, and perceived a lack of general community resources to meet their needs. Furthermore, CyBER educators had to understand and respect the online culture, build trust, and deliver well-crafted and focused messages. CONCLUSIONS: Chat room-based interventions hold promise to systematically reach Internet communities of MSM, a group that is particularly at risk for infection with HIV and other sexually transmitted diseases.

The evidence for physiotherapy is growing, showing a positive impact on functional activities involving gait, transfers and balance. Specific recommendations for physiotherapists, physicians and people with Parkinson's disease were published in the European Physiotherapy Guideline for Parkinson's disease. Here, we summarize the referral criteria, highlight the importance of accurate referral to specialized physiotherapists, and emphasize the potential benefits of expert care. As such, this paper offers very practical guidance for clinicians working with Parkinson's disease patients and who consider physiotherapy treatments for their patients.

Background: Research has shown that transgender and nonbinary people experience health disparities. However, few studies have explored, in-depth, the health-related experiences, perceptions, needs, and priorities of transgender women of color living in the U.S. South, a region that poses unique challenges to achieving health for transgender people.Aims: This study explored the social determinants of health, healthcare experiences, and health-related priorities of transgender women of color living in the U.S. South.Methods: Using a community-based participatory research approach, we conducted iterative in-depth interviews with 15 African American/Black and Latinx transgender women in North Carolina in May-July 2019 for a total of 30 interviews. We analyzed interview data using constant comparison, an approach to grounded theory.Results: Participants’ mean age was 34 (range 19–56) years. Twenty themes emerged that were categorized into three domains: (1) social determinants of health (family rejection; bullying, discrimination, and violence; isolation; policy barriers; mistrust in systems; employment obstacles; sex work; high cost of care; transportation barriers; church antagonism; and substance misuse), (2) healthcare experiences (emotional burden of healthcare interactions; name and gender misidentification; staff discomfort and insensitivity; sexual risk assumptions; and use of nonmedical or predatory providers), and (3) health-related priorities (understanding healthcare; respect at all levels of healthcare; inclusive gender-affirming care; and comprehensive resources).Discussion: Transgender women of color living in the U.S. South face profound health barriers compounded throughout the life course and have unmet healthcare needs. Participants faced multilayered minority stressors: racial discrimination from society at large and within the LGTBQ community; gender identity discrimination within their regional context and racial/ethnic communities; and exclusion from existing health equity movements for transgender women of color, which often are found in and focus on larger urban communities. Health interventions mindful of this intersection are needed, including antidiscrimination policies and increasing gender-affirming healthcare access.

The relation between number of ovulations and body weight, age or maternal identity was examined in 69 ovarian cycles from 29 captive-born common marmoset monkeys (Callithrix jacchus). Specifically, we addressed the following questions: was there high repeatability of ovulation number? Most of the variation in ovulation number was within, rather than between subjects. Repeatability in number of ovulations was 0.081 (n = 20 females with 2-6 ovulatory cycles per female); was age related to number of ovulations? There was no relation between age and number of ovulations, either within or between subjects; and was weight related to number of ovulations? Weight was related to number of ovulations. When the relation between number of ovulations (1-2 versus 3-4) and weight was examined through a logistic regression, there was a significant relation. Also, of the 11 subjects which had a variable number of ovulations across cycles, 90.9% were heavier when ovulating 3-4 than when ovulating 2. These results are discussed as the basis for the proposal that callitrichid primates may have been selected for potential variation in reproductive output and that this variation may be related to energy availability.

Use of crystal nanocellulose to stabilize nano-ZVI has tremendous potential to improve the capability and applicability of nano-ZVI based subsurface remediation systems in an environmentally sustainable way.

ABSTRACT. Using a sample of 63 SMSAs for the years 1974, 1978, and 1982 I find weak support for the argument that environmental regulations retard economic activity. Regression analysis of the relationship between per unit total and air pollution abatement expenditures in the manufacturing sector of these SMSAs and manufacturing employment and earnings levels reveals that these associations are negative but that the magnitudes are relatively small. For example, 10 percent higher per unit total pollution abatement costs are associated with, on average, 1064 fewer manufacturing workers (0.17 percent of total regional employment) in Sun Belt SMSAs during 1982.

Abstract As in many other regions, the periodization of the Neolithic in the northeastern Iberian Peninsula was based upon relative dating obtained through ceramic typologies. Moreover, this prehistoric period was structured using nomenclature borrowed from the Neolithization of southern France. A total of 37 new radiocarbon dates for NE Iberia have been recently obtained with appropriate sampling criteria. These results have been used in conjunction with other reliable 14 C dates in order to assess the validity of traditional classifications established through the study of ceramic typologies. The gradual improvement in the quality of sample choice and the available archaeological records allowed the selection of 187 dates obtained mostly from short-lived taxa. This has enabled the chronological boundaries to be adjusted as precisely as possible.

Many individuals who have had a stroke leave the hospital without postacute care services in place. Despite high risks of complications and readmission, there is no standard in the United States for postacute stroke care after discharge home. We describe the rationale and methods for the development of the COMprehensive Post-Acute Stroke Services (COMPASS) care model and the structure and quality metrics used for implementation. COMPASS, an innovative, comprehensive extension of the TRAnsition Coaching for Stroke (TRACS) program, is a clinician-led quality improvement model providing early supported discharge and transitional care for individuals who have had a stroke and have been discharged home. The effectiveness of the COMPASS model is being assessed in a cluster-randomized pragmatic trial in 41 sites across North Carolina, with a recruitment goal of 6,000 participants. The COMPASS model is evidence based, person centered, and stakeholder driven. It involves identification and education of eligible individuals in the hospital; telephone follow-up 2, 30, and 60 days after discharge; and a clinic visit within 14 days conducted by a nurse and advanced practice provider. Patient and caregiver self-reported assessments of functional and social determinants of health are captured during the clinic visit using a web-based application. Embedded algorithms immediately construct an individualized care plan. The COMPASS model's pragmatic design and quality metrics may support measurable best practices for postacute stroke care.

CONTEXT: The injury incidence rate among runners is approximately 50%. Some individuals have advocated using an anterior-foot-strike pattern to reduce ground reaction forces and injury rates that they attribute to a rear-foot-strike pattern. The proportion of minimalist shoe wearers who adopt an anterior-foot-strike pattern remains unclear. OBJECTIVE: To evaluate the accuracy of self-reported foot-strike patterns, compare negative ankle- and knee-joint angular work among runners using different foot-strike patterns and wearing traditional or minimalist shoes, and describe average vertical-loading rates. DESIGN: Descriptive laboratory study. SETTING: Research laboratory. PATIENTS OR OTHER PARTICIPANTS: A total of 60 healthy volunteers (37 men, 23 women; age = 34.9 ± 8.9 years, height = 1.74 ± 0.08 m, mass = 70.9 ± 13.4 kg) with more than 6 months of experience wearing traditional or minimalist shoes were instructed to classify their foot-strike patterns. INTERVENTION(S): Participants ran in their preferred shoes on an instrumented treadmill with 3-dimensional motion capture. MAIN OUTCOME MEASURE(S): Self-reported foot-strike patterns were compared with 2-dimensional video assessments. Runners were classified into 3 groups based on video assessment: traditional-shoe rear-foot strikers (TSR; n = 22), minimalist-shoe anterior-foot strikers (MSA; n = 21), and minimalist-shoe rear-foot strikers (MSR; n = 17). Ankle and knee negative angular work and average vertical-loading rates during stance phase were compared among groups. RESULTS: Only 41 (68.3%) runners reported foot-strike patterns that agreed with the video assessment (κ = 0.42, P < .001). The TSR runners demonstrated greater ankle-dorsiflexion and knee-extension negative work than MSA and MSR runners (P < .05). The MSA (P < .001) and MSR (P = .01) runners demonstrated greater ankle plantar-flexion negative work than TSR runners. The MSR runners demonstrated a greater average vertical-loading rate than MSA and TSR runners (P < .001). CONCLUSIONS: Runners often cannot report their foot-strike patterns accurately and may not automatically adopt an anterior-foot-strike pattern after transitioning to minimalist running shoes.

Effective air flow distribution through perforated tiles is required to efficiently cool servers in a raised floor data center. We present detailed computational fluid dynamics (CFD) modeling of air flow through a perforated tile and its entrance to the adjacent server rack. The realistic geometrical details of the perforated tile, as well as of the rack are included in the model. Generally, models for air flow through perforated tiles specify a step pressure loss across the tile surface, or porous jump model based on the tile porosity. An improvement to this includes a momentum source specification above the tile to simulate the acceleration of the air flow through the pores, or body force model. In both of these models, geometrical details of tile such as pore locations and shapes are not included. More details increase the grid size as well as the computational time. However, the grid refinement can be controlled to achieve balance between the accuracy and computational time. We compared the results from CFD using geometrical resolution with the porous jump and body force model solution as well as with the measured flow field using particle image velocimetry (PIV) experiments. We observe that including tile geometrical details gives better results as compared to elimination of tile geometrical details and specifying physical models across and above the tile surface. A modification to the body force model is also suggested and improved results were achieved.

BACKGROUND: Childhood obesity is a growing health concern known to adversely affect quality of life in children and adolescents. The Patient Reported Outcomes Measurement Information System (PROMIS) pediatric measures were developed to capture child self-reports across a variety of health conditions experienced by children and adolescents. The purpose of this study is to begin the process of validation of the PROMIS pediatric measures in children and adolescents affected by obesity. METHODS: The pediatric PROMIS instruments were administered to 138 children and adolescents in a cross-sectional study of patient reported outcomes in children aged 8-17 years with age-adjusted body mass index (BMI) greater than the 85th percentile in a design to establish known-group validity. The children completed the depressive symptoms, anxiety, anger, peer relationships, pain interference, fatigue, upper extremity, and mobility PROMIS domains utilizing a computer interface. PROMIS domains and individual items were administered in random order and included a total of 95 items. Patient responses were compared between patients with BMI 85 to<99th percentile versus ≥99th percentile. RESULTS: 136 participants were recruited and had all necessary clinical data for analysis. Of the 136 participants, 5% ended the survey early resulting in missing domain scores at the end of survey administration. In multivariate analysis, patients with BMI ≥ 99th percentile had worse scores for depressive symptoms, anger, fatigue, and mobility (p<0.05). Parent-reported exercise was associated with better scores for depressive symptoms, anxiety, and fatigue (p<0.05). CONCLUSIONS: Children and adolescents ranging from overweight to severely obese can complete multiple PROMIS pediatric measures using a computer interface in the outpatient setting. In the 5% with missing domain scores, the missing scores were consistently found in the domains administered last, suggesting the length of the assessment is important. The differences in domain scores found in this study are consistent with previous reports investigating the quality of life in children and adolescents with obesity. We show that the PROMIS instrument represents a feasible and potentially valuable instrument for the future study of the effect of pediatric obesity on quality of life.