Background: Healthcare-associated pneumonia (HCAP) guidelines were first proposed in 2005 but have not yet been validated. The objective of this study was to compare 30-day mortality and length of stay (LOS) in HCAP patients treated with either guideline-concordant HCAP (GC-HCAP) therapy or guideline-concordant community-acquired pneumonia (GC-CAP) therapy. Methods: We performed a retrospective cohort study of >150 hospitals in the Veterans Health Administration. Patients were included if they had ≥1 HCAP risk factor and received antibiotic therapy within 48 hours of admission. Patients were excluded if they received ICU care, had cardiovascular or respiratory organ failure, or received invasive mechanical ventilation and/or vasopressors. We determined independent risk factors for 30-day mortality with a multivariable logistic regression model including baseline characteristics, individual HCAP risk factors, comorbidities, and organ failure as dichotomous covariates. Propensity scores were calculated for the probability to receive GC-HCAP therapy and incorporated into a second logistic regression model. Results: A total of 15,071 patients met study criteria and received GC-HCAP therapy (8.0%), GC-CAP therapy (75.7%), or non-guideline-concordant therapy (16.3%). GC-HCAP patients were more likely to have neoplastic disease; whereas, GC-CAP patients had a higher prevalence of other comorbidities, tobacco use, and recent medication use. In multivariable regression, recent hospital admission (OR 2.47, 95% CI 2.10-2.91) and GC-HCAP therapy (2.13, 1.82-2.48) were the strongest predictors of 30-day mortality. Hematologic organ failure, non-invasive mechanical ventilation, neoplastic disease, renal organ failure, and cerebrovascular disease were also independent risk factors. Use of cardiovascular medications, inhaled corticosteroids, and tobacco were protective. GC-HCAP therapy continued to be an independent risk factor for 30-day mortality (OR 2.12, 95% CI 1.82-2.48) in the propensity score analysis. Conclusions: GC-HCAP therapy is not associated with improved survival in HCAP patients. / text

In this study two nonlinear analysis methods are proposed for investigation of nonlinear effects of high temperature superconductive(HTSC) thin film planar microwave circuits. The MoM-HB combination method is based on the combination formulation of the moment method(MoM) and the harmonic balance(HB) technique. It consists of linear and nonlinear solvers. The power series method treats the voltages at higher order frequencies as the excitations at the corresponding frequencies, and the higher order current distributions are then obtained by using the moment method again. The power series method is simple and fast for finding the output power at higher order frequencies. The MoM-HB combination method is suitable for strong nonlinearity, and it can be also used to find the fundamental current redistribution, conductor loss, and the scattering parameters variation at the fundamental frequency. These two proposed methods are efficient, accurate, and suitable for distributed-type HTSC nonlinearity. They can be easily incorporated into commercial EM CAD softwares to expand their capabilities. These two nonlinear analysis method are validated by analyzing a HTSC stripline filter and HTSC antenna dipole circuits. HTSC microstrip lines are then investigated for the nonlinear effects of HTSC material on the current density distribution over the cross section and the conductor loss as a function of the applied power. The HTSC microstrip patch filters are then studied to show that the HTSCinterconnecting line could dominate the behaviors of the circuits at high power. The variation of the transmission and reflection coefficients with the applied power and the third output power are calculated. The HTSC microstrip line structure with gilded edges is proposed for improving the power handling capability of HTSC thin film circuit based on a specified limit of harmonic generation and conductor loss. A general analysis approach suitable for any thickness of gilding layer is developed by integrating the multi-port network theory into aforementioned proposed nonlinear analysis methods. The conductor loss and harmonic generation of the gilded HTSC microstrip line are investigated.

We present results on smooth and nonsmooth variational properties of {it symmetric} functions of the eigenvalues of a real symmetric matrix argument, as well as {it absolutely symmetric} functions of the singular values of a real rectangular matrix. Such results underpin the theory of optimization problems involving such functions. We answer the question of when a symmetric function of the eigenvalues allows a quadratic expansion around a matrix, and then the stronger question of when it is twice differentiable. We develop simple formulae for the most important nonsmooth subdifferentials of functions depending on the singular values of a real rectangular matrix argument and give several examples. The analysis of the above two classes of functions may be generalized in various larger abstract frameworks. In particular, we investigate how functions depending on the eigenvalues or the singular values of a matrix argument may be viewed as the composition of symmetric functions with the roots of {it hyperbolic polynomials}. We extend the relationship between hyperbolic polynomials and {it self-concordant barriers} (an extremely important class of functions in contemporary interior point methods for convex optimization) by exhibiting a new class of self-concordant barriers obtainable from hyperbolic polynomials.

In this study two nonlinear analysis methods are proposed for investigation of nonlinear effects of high temperature superconductive(HTSC) thin film planar microwave circuits. The MoM-HB combination method is based on the combination formulation of the moment method(MoM) and the harmonic balance(HB) technique. It consists of linear and nonlinear solvers. The power series method treats the voltages at higher order frequencies as the excitations at the corresponding frequencies, and the higher order current distributions are then obtained by using the moment method again. The power series method is simple and fast for finding the output power at higher order frequencies. The MoM-HB combination method is suitable for strong nonlinearity, and it can be also used to find the fundamental current redistribution, conductor loss, and the scattering parameters variation at the fundamental frequency. These two proposed methods are efficient, accurate, and suitable for distributed-type HTSC nonlinearity. They can be easily incorporated into commercial EM CAD softwares to expand their capabilities. These two nonlinear analysis method are validated by analyzing a HTSC stripline filter and HTSC antenna dipole circuits. HTSC microstrip lines are then investigated for the nonlinear effects of HTSC material on the current density distribution over the cross section and the conductor loss as a function of the applied power. The HTSC microstrip patch filters are then studied to show that the HTSCinterconnecting line could dominate the behaviors of the circuits at high power. The variation of the transmission and reflection coefficients with the applied power and the third output power are calculated. The HTSC microstrip line structure with gilded edges is proposed for improving the power handling capability of HTSC thin film circuit based on a specified limit of harmonic generation and conductor loss. A general analysis approach suitable for any thickness of gilding layer is developed by integrating the multi-port network theory into aforementioned proposed nonlinear analysis methods. The conductor loss and harmonic generation of the gilded HTSC microstrip line are investigated.

We present results on smooth and nonsmooth variational properties of {it symmetric} functions of the eigenvalues of a real symmetric matrix argument, as well as {it absolutely symmetric} functions of the singular values of a real rectangular matrix. Such results underpin the theory of optimization problems involving such functions. We answer the question of when a symmetric function of the eigenvalues allows a quadratic expansion around a matrix, and then the stronger question of when it is twice differentiable. We develop simple formulae for the most important nonsmooth subdifferentials of functions depending on the singular values of a real rectangular matrix argument and give several examples. The analysis of the above two classes of functions may be generalized in various larger abstract frameworks. In particular, we investigate how functions depending on the eigenvalues or the singular values of a matrix argument may be viewed as the composition of symmetric functions with the roots of {it hyperbolic polynomials}. We extend the relationship between hyperbolic polynomials and {it self-concordant barriers} (an extremely important class of functions in contemporary interior point methods for convex optimization) by exhibiting a new class of self-concordant barriers obtainable from hyperbolic polynomials.

Advance care planning is a conversation about personal values, future treatment choices, and designation of a surrogate decision-maker, that someone has in advance of a health crisis. Most existing studies on advance care planning have taken place outside of home health among populations with HIV/AIDS, cancer, dementia, and end stage renal disease. The U.S. home health population is living longer with chronic conditions such as pulmonary and cardiovascular illnesses, and hospitalization is a poor outcome. In 2016, Medicare implemented the Home Health Value-Based Purchasing Model, in which reimbursement rates for agencies in 9 regionally representative states were dependent on quantitative measures of quality performance. Part of the program was a process-level mandate requiring agencies to report on advance care planning. The aim of this study was to examine the relationship of home health advance care planning protocols with hospitalization rates. Descriptive and regression analyses were conducted on survey data of protocols and agency data of demographics and outcomes. Statistical significance was found in the positive correlation between advance care planning protocols and hospitalization. Recommendations are made for broadening the scope of evaluation of quality in home health to include goal-concordant care and transitions to appropriate services.

京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第20288号 / 社医博第77号 / 社新制||医||9(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 川上 浩司, 教授 一山 智, 教授 伊達 洋至 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DGAM

Chronic cardiovascular and pulmonary diseases are prevalent in the US home health population. Heart failure and chronic obstructive pulmonary disease are both chronic and terminal, but they are not always perceived as serious illnesses with imminent death. Therefore, they provide a context for advance care planning that is distinct from the diagnostic contexts of cancer, end-stage renal disease, or dementia. Advance care planning is defined as a process that supports adults at any age or stage of health in understanding and sharing their goals, values, and preferences about future medical care, including the designation of a surrogate decision-maker. This study tests the hypothesis that US home health agencies with higher percentages of patients with chronic cardiovascular and pulmonary conditions have less robust advance care planning protocols. The Spearman correlation coefficient was r = 0.22 (S = 74684, P =.025, 1-tailed), which was statistically significant and an unexpected finding. The greater percentage of patients with chronic cardiac and pulmonary diagnoses in an agency, the more robust the advance care planning protocol was. This supports our previous findings and existing literature indicating that agencies may be using exacerbation events marked by acute care use as opportunities to initiate or repeat advance care planning.

Advance care planning is a conversation about personal values, future treatment choices, and designation of a surrogate decision-maker, that someone has in advance of a health crisis. Most existing studies on advance care planning have taken place outside of home health among populations with HIV/AIDS, cancer, dementia, and end stage renal disease. The U.S. home health population is living longer with chronic conditions such as pulmonary and cardiovascular illnesses, and hospitalization is a poor outcome. In 2016, Medicare implemented the Home Health Value-Based Purchasing Model, in which reimbursement rates for agencies in 9 regionally representative states were dependent on quantitative measures of quality performance. Part of the program was a process-level mandate requiring agencies to report on advance care planning. The aim of this study was to examine the relationship of home health advance care planning protocols with hospitalization rates. Descriptive and regression analyses were conducted on survey data of protocols and agency data of demographics and outcomes. Statistical significance was found in the positive correlation between advance care planning protocols and hospitalization. Recommendations are made for broadening the scope of evaluation of quality in home health to include goal-concordant care and transitions to appropriate services.

Screen-based educational media, as an extension of the schooling process whose history has mirrored brick and mortar institutions, have traditionally espoused narratives of Eurocentricity, shifting relatively recently to multicultural yet simultaneously raceless narratives. While many viewers have learned from and been inspired by these media, the enthusiastic response to the film Black Panther (2018), as demonstrated by financial earnings and sustained social media energy, revealed an intense yearning in the Black community for media positively centering the strengths and successes of Black lives. Launched from the sociocultural fervor for Black concordance in media, and extending concordance into the educational media landscape, this qualitative study sought to assess responses from African-American children, ages 3-8, to educational media concordant to them, and contextualize these responses in recognition of race socialization patterns within the home. Children’s responses to the media ranged from acknowledgment of skin color as well as hair texture and style, to full identification with and enthusiasm for animated protagonists. Caregivers responded positively to the samples while self- reporting varying degrees of race socialization. These responses demonstrated promising potential for identification with concordant educational media based on phenotypic resemblance, particularly for children approximately 8 years of age.