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The purpose of this paper is to identify a workhorse mortality model for the adult age range (i.e., excluding the accident hump and younger ages). It applies the “general procedure” (GP) of Hunt & Blake [(2014), North American Actuarial Journal, 18, 116–138] to identify an age-period model that fits the data well before adding in a cohort effect that captures the residual year-of-birth effects arising in the original age-period model. The resulting model is intended to be suitable for a variety of populations, but economises on the number of period effects in comparison with a full implementation of the GP. We estimate the model using two different iterative maximum likelihood (ML) approaches – one Partial ML and the other Full ML – that avoid the need to specify identifiability constraints.
Antimicrobial use in the surgical setting is common and frequently inappropriate. Understanding the behavioral context of antimicrobial use is a critical step to developing stewardship programs.
In this study, we employed qualitative methodologies to describe the phenomenon of antimicrobial use in 2 surgical units: orthopedic surgery and cardiothoracic surgery.
This study was conducted at a public, quaternary, university-affiliated hospital.
Healthcare professionals from the 2 surgical unit teams participated in the study.
We used focused ethnographic and face-to-face semi-structured interviews to observe antimicrobial decision-making behaviors across the patient’s journey from the preadmission clinic to the operating room to the postoperative ward.
We identified 4 key themes influencing decision making in the surgical setting. Compartmentalized communication (theme 1) was observed with demarcated roles and defined pathways for communication (theme 2). Antimicrobial decisions in the operating room were driven by the most senior members of the team. These decisions, however, were delegated to more junior members of staff in the ward and clinic environment (theme 3). Throughout the patient’s journey, communication with the patient about antimicrobial use was limited (theme 4).
Approaches to decision making in surgery are highly structured. Although this structure appears to facilitate smooth flow of responsibility, more junior members of the staff may be disempowered. In addition, opportunities for shared decision making with patients were limited. Antimicrobial stewardship programs need to recognize the hierarchal structure as well as opportunities to engage the patient in shared decision making.
We introduce a new modelling framework to explain socio-economic differences in mortality in terms of an affluence index that combines information on individual wealth and income. The model is illustrated using data on older Danish males over the period 1985–2012 reported in the Statistics Denmark national register database. The model fits the historical mortality data well, captures their key features, generates smoothed death rates that allow us to work with a larger number of sub-groups than has previously been considered feasible, and has plausible projection properties.
We describe the motivation and design details of the ‘Phase II’ upgrade of the Murchison Widefield Array radio telescope. The expansion doubles to 256 the number of antenna tiles deployed in the array. The new antenna tiles enhance the capabilities of the Murchison Widefield Array in several key science areas. Seventy-two of the new tiles are deployed in a regular configuration near the existing array core. These new tiles enhance the surface brightness sensitivity of the array and will improve the ability of the Murchison Widefield Array to estimate the slope of the Epoch of Reionisation power spectrum by a factor of ∼3.5. The remaining 56 tiles are deployed on long baselines, doubling the maximum baseline of the array and improving the array u, v coverage. The improved imaging capabilities will provide an order of magnitude improvement in the noise floor of Murchison Widefield Array continuum images. The upgrade retains all of the features that have underpinned the Murchison Widefield Array’s success (large field of view, snapshot image quality, and pointing agility) and boosts the scientific potential with enhanced imaging capabilities and by enabling new calibration strategies.
Burn patients are particularly vulnerable to infection, and an estimated half of all burn deaths are due to infections. This study explored risk factors for healthcare-associated infections (HAIs) in adult burn patients.
Retrospective cohort study.
Tertiary-care burn center.
Adults (≥18 years old) admitted with burn injury for at least 2 days between 2004 and 2013.
HAIs were determined in real-time by infection preventionists using Centers for Disease Control and Prevention criteria. Multivariable Cox proportional hazards regression was used to estimate the direct effect of each risk factor on time to HAI, with inverse probability of censor weights to address potentially informative censoring. Effect measure modification by burn size was also assessed.
Overall, 4,426 patients met inclusion criteria, and 349 (7.9%) patients had at least 1 HAI within 60 days of admission. Compared to <5% total body surface area (TBSA), patients with 5%–10% TBSA were almost 3 times as likely to acquire an HAI (hazard ratio [HR], 2.92; 95% CI, 1.63–5.23); patients with 10%–20% TBSA were >6 times as likely to acquire an HAI (HR, 6.38; 95% CI, 3.64–11.17); and patients with >20% TBSA were >10 times as likely to acquire an HAI (HR, 10.33; 95% CI, 5.74–18.60). Patients with inhalational injury were 1.5 times as likely to acquire an HAI (HR, 1.61; 95% CI, 1.17–2.22). The effect of inhalational injury (P=.09) appeared to be larger among patients with ≤20% TBSA.
Larger burns and inhalational injury were associated with increased incidence of HAIs. Future research should use these risk factors to identify potential interventions.
Ventilator-associated pneumonia (VAP) is a frequent complication of severe burn injury. Comparing the current ventilator-associated event-possible VAP definition to the pre-2013 VAP definition, we identified considerably fewer VAP cases in our burn ICU. The new definition does not capture many VAP cases that would have been reported using the pre-2013 definition.
Burn injuries are a common source of morbidity and mortality in the United States, with an estimated 450,000 burn injuries requiring medical treatment, 40,000 requiring hospitalization, and 3,400 deaths from burns annually in the United States. Patients with severe burns are at high risk for local and systemic infections. Furthermore, burn patients are immunosuppressed, as thermal injury results in less phagocytic activity and lymphokine production by macrophages. In recent years, multidrug-resistant (MDR) pathogens have become major contributors to morbidity and mortality in burn patients.
Since only limited data are available on the incidence of both device- and nondevice-associated healthcare-associated infections (HAIs) in burn patients, we undertook this retrospective cohort analysis of patients admitted to our burn intensive care unit (ICU) from 2008 to 2012.
We construct yield curve models for the UK nominal, real and implied inflation spot rates considering the linkage between their term structures and some macroeconomic variables, in particular, realised inflation and real GDP growth. The paper extends the benchmark “yield-only” model proposed by Şahin et al. (2014) by exploring the bidirectional relations between the yield curve factors and the macroeconomic variables and proposes a “yield-macro” model. Although a simple autoregressive order one process fits the yield curve factors quite well the insertion of some macroeconomic variables such as realised inflation and real GDP growth improves the models significantly. We also model macroeconomic variables that take the term structures into account and compare the yield-macro model with Wilkie’s model both philosophically and empirically.
This paper develops a term structure model for the UK nominal, real and implied inflation spot zero-coupon rates simultaneously. We start with fitting a descriptive yield curve model proposed by Cairns (1998) to fill the missing values for certain given days at certain maturities in the yield curve data provided by the Bank of England. We compare four different fixed ‘exponential rate’ parameter sets and decide the set of parameters which fits the data best. With the chosen set of parameters we fit the Cairns model to the daily values of the term structures. By applying principal component analysis on the hybrid data (Bank of England data and fitted spot rates for the missing values) we find three principal components, which can be described as ‘level’, ‘slope’ and ‘curvature’, for each of these series. We explore the relation between these principal components to construct a ‘yield-only’ model for actuarial applications. Main contribution of this paper is that the models developed in the paper enable the practitioners to forecast three term structures simultaneously and it also provides the forecast for whole term structures rather than just short and long end of the yield curves.
Significant new opportunities for astrophysics and cosmology have been identified at low radio frequencies. The Murchison Widefield Array is the first telescope in the southern hemisphere designed specifically to explore the low-frequency astronomical sky between 80 and 300 MHz with arcminute angular resolution and high survey efficiency. The telescope will enable new advances along four key science themes, including searching for redshifted 21-cm emission from the EoR in the early Universe; Galactic and extragalactic all-sky southern hemisphere surveys; time-domain astrophysics; and solar, heliospheric, and ionospheric science and space weather. The Murchison Widefield Array is located in Western Australia at the site of the planned Square Kilometre Array (SKA) low-band telescope and is the only low-frequency SKA precursor facility. In this paper, we review the performance properties of the Murchison Widefield Array and describe its primary scientific objectives.
This paper introduces a new framework for modelling the joint development over time of mortality rates in a pair of related populations with the primary aim of producing consistent mortality forecasts for the two populations. The primary aim is achieved by combining a number of recent and novel developments in stochastic mortality modelling, but these, additionally, provide us with a number of side benefits and insights for stochastic mortality modelling. By way of example, we propose an Age-Period-Cohort model which incorporates a mean-reverting stochastic spread that allows for different trends in mortality improvement rates in the short-run, but parallel improvements in the long run. Second, we fit the model using a Bayesian framework that allows us to combine estimation of the unobservable state variables and the parameters of the stochastic processes driving them into a single procedure. Key benefits of this include dampening down of the impact of Poisson variation in death counts, full allowance for paramater uncertainty, and the flexibility to deal with missing data. The framework is designed for large populations coupled with a small sub-population and is applied to the England & Wales national and Continuous Mortality Investigation assured lives males populations. We compare and contrast results based on the two-population approach with single-population results.
Angus Watson has set himself to survey the entire body of chamber works composed by Beethoven between 1792, when he settled in Vienna, and 1827, the year of his death, and to place each one in the context of Beethoven's life and his relationships with contemporaries, and of the works in other genres that he was writing at the time – a formidable challenge and one that, to my mind, he rises to magnificently.
The story of the thirty-five year journey from the piano trios, op. 1, startling fruit of Beethoven's studies with Haydn, to the visionary beauties of the last string quartets is arguably without parallel in the history of music, and it is told here in absorbing detail: a constantly changing landscape, as Beethoven's ‘restlessly and profoundly ranging mind’ (Richard Capell's phrase) impels him to strike out new paths and open up unknown worlds of music. But though the author does moving justice to those last transcendent creations, he never falls into the error of patronizing the early works and treating them as mere forerunners. On the contrary, he is equally alive to the energy and extraordinary self-confidence, the sheer originality of those first sonatas, trios and quartets with which the young Beethoven disconcerted the Viennese as much as he dazzled them.
Throughout, the book benefits richly from the fact that its wisdom is grounded in the experience of a professional string player who has played and lived, note by note, the music he writes about with such deep and searching insight.
It is now widely accepted that stochastic mortality – the risk that aggregate mortality might differ from that anticipated – is an important risk factor in both life insurance and pensions. As such it affects how fair values, premium rates, and risk reserves are calculated.
This paper makes use of the similarities between the force of mortality and interest rates to examine how we might model mortality risks and price mortality-related instruments using adaptations of the arbitrage-free pricing frameworks that have been developed for interest-rate derivatives. In so doing, the paper pulls together a range of arbitrage-free (or risk-neutral) frameworks for pricing and hedging mortality risk that allow for both interest and mortality factors to be stochastic. The different frameworks that we describe – short-rate models, forward-mortality models, positive-mortality models and mortality market models – are all based on positive-interest-rate modelling frameworks since the force of mortality can be treated in a similar way to the short-term risk-free rate of interest. While much of this paper is a review of the possible frameworks, the key new development is the introduction of mortality market models equivalent to the LIBOR and swap market models in the interest-rate literature.
These frameworks can be applied to a great variety of mortality-related instruments, from vanilla longevity bonds to exotic mortality derivatives.
Previous work on the reliability of mental capacity assessments in patients with psychiatric illness has been limited.
To describe the interrater reliability of two independent assessments of capacity to consent to treatment, as well as assessments made by a panel of clinicians based on the same interview.
Fifty-five patients were interviewed by two interviewers 1–7 days apart and a binary (yes/no) capacity judgement was made, guided by the MacArthur Competence Assessment Tool for Treatment (MacCAT-T). Four senior clinicians used transcripts of the interviews to judge capacity.
There was excellent agreement between the two interviewers for capacity judgements made at separate interviews (kappa=0.82). A high level of agreement was seen between senior clinicians for capacity judgements of the same interview (mean kappa=0.84)
In combination with a clinical interview, the MacCAT–T can be used to produce highly reliable judgements of capacity.
Little is known about the proportion of psychiatric in-patients who lack capacity to make treatment decisions, or the associations of lack of capacity.
To determine the prevalence of psychiatric in-patients who lack capacity to make decisions about current treatment and to identify demographic and clinical associations with lack of mental capacity.
Patients (n=112) were interviewed soon after admission to hospital and a binary judgement of capacity was made, guided by the MacArthur Competence Tool for Treatment. Demographic and clinical information was collected from an interview and case notes.
Of the 112 participants, 49 (43.8%) lacked treatment-related decisional capacity Mania and psychosis, poor insight, delusions and Black and minority ethnic group were associated with mental incapacity. Of the 49 patients lacking capacity, 30 (61%) were detained under the Mental Health Act 1983. Of the 63 with capacity, 6 (9.5%) were detained.
Lack of treatment-related decisional capacity is a common but by no means inevitable correlate of admission to a psychiatric in-patient unit.