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Kusumabangsa, Gilang. "EVALUATION OF VAT COLLECTION ON TRADING THROUGH ELECTRONIC SYSTEM." Jurnal Akuntansi dan Keuangan Indonesia 18, no. 2 (December 31, 2021): 183–203. http://dx.doi.org/10.21002/jaki.2021.10.
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This research aims to evaluate the Value-added Tax (VAT) collection on trading through the electronic system (TTES) from the TTES VAT Collector’s perception, based on "The Four Maxims" tax collection principle. This research uses a qualitative research method with a case study approach. Data was collected using interview techniques with eight respondents from TTES VAT Collectors. The results showed that TTES VAT collection in Indonesia has fulfilled the equality, convenience and efficiency principles based on "The Four Maxims". However, the collection of TTES VAT in Indonesia has failed to meet the criterion of certainty, owing to uncertainties in the definition, the legal status of the collector, the method for calculating the tax basis, tax procedures, and the enforcement of fines.
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BABA, Alina. "STRATEGIES AND IMPACTS OF FINANCING TECHNOLOGY TRANSFER ENTITIES: A MULTIFACETED APPROACH." Journal of Public Administration, Finance and Law 31 (2024): 34–45. http://dx.doi.org/10.47743/jopafl-2024-31-3.
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The article investigates the impact of various funding sources on Technology Transfer Entities (TTEs), including government support, private sector investments, grants, and European funds. It emphasizes the crucial role these financial mechanisms play in enabling TTEs to bridge the gap between academic research and commercial application. By analyzing the influence of government funding, the significance of licensing and patent revenues, and the benefits of private and European investments, the article demonstrates how these resources assist TTEs in achieving financial stability, fostering innovation commercialization, and navigating the market. It also highlights the importance of aligning TTEs' goals with broader societal and economic objectives. Through case studies, the research illustrates the essential need for a diverse funding strategy and effective management for TTEs to optimize their contribution to the technological innovation ecosystem, economic growth, and societal well-being
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Abe, Ryosuke, and Kay W. Axhausen. "Impact of Major Road Supply on Individual Travel Time Expenditure: An Exploration with a 30-Year Variation of Infrastructure and Travel." Transportation Research Record: Journal of the Transportation Research Board 2672, no. 3 (August 25, 2018): 56–68. http://dx.doi.org/10.1177/0361198118791866.
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This study estimates the impact of major road supply on individual travel time expenditures (TTEs) using data that cover 30-year variations in transportation infrastructure and travel behavior. The impacts of the supply of road and rail infrastructure are estimated with a data set that combines records of large-scale household travel surveys in the Tokyo metropolitan area conducted in 1978, 1988, 1998, and 2008. Linear and Tobit models of individual TTEs are estimated by following the behavior of birth cohorts over the 30-year period. The models incorporate the changes in transportation infrastructure, measured as lane kilometers of two levels of major road stock and vehicle kilometers of urban rail service. The results show significant negative effects of lane kilometers for higher-level and lower-level major roads on the TTEs for all travel purposes and for commuting, after controlling for socioeconomic backgrounds and generations of individuals. This study discusses that, in Tokyo, the estimated effect is more likely to reflect the effect of a major road network per se on individual TTEs than the (indirect) effect of major road supply on individual TTEs working through land development activities (i.e., induced car travel demand). For example, the caveat is that actual road investment decisions still need to consider the induced component of road traffic in addition to the (direct) effect that is estimated in this study.
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BABA, Alina. "ASSESS THE FINANCIAL PERFORMANCE OF TECHNOLOGY TRANSFER ENTITIES USING EXISTING ECONOMIC AND FINANCIAL MODELS." Journal of Public Administration, Finance and Law 32 (2024): 105–13. http://dx.doi.org/10.47743/jopafl-2024-32-8.
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This paper evaluates the financial performance of technology transfer entities (TTEs) by analyzing both economic and financial models. Traditional financial models, such as Discounted Cash Flow (DCF) and Capital Asset Pricing Model (CAPM), provide insights into investment viability and risk management in TTEs. Economic models, like IS-LM and growth models, help understand the macroeconomic environment's influence on technological innovation. Specific models, such as the linear innovation model and the Triple Helix framework, emphasize the collaboration between academia, industry, and government in fostering innovation. The integration of real options analysis and venture capital methods further supports investment decisions in high-uncertainty technological projects. This approach helps TTEs optimize resource allocation and strategic investments, contributing to sustainable economic growth.
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Cave, Andrew T., Sarah A. Lowenstein, Christena McBride, Joylyn Michaud, Erin J. Madriago, and Christina Ronai. "Pulse Oximetry Screening and Critical Congenital Heart Disease in the State of Oregon." Clinical Pediatrics 60, no. 6-7 (April 15, 2021): 290–97. http://dx.doi.org/10.1177/00099228211008704.
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Late diagnosis of critical congenital heart disease (CCHD) is associated with higher levels of morbidity and mortality in neonates. Nearly all states have passed laws mandating universal pulse oximetry screening (POxS) of newborns to improve early detection rates of CCHD. We performed a retrospective chart review of all transthoracic echocardiograms (TTEs) interpreted by our institution on patients between 0 and 30 days of life in the years 2010 (prior to POxS) and 2015 (after POxS). Between 2010 and 2015, the number of neonatal TTEs interpreted by our institution decreased by 18.2%. In 2015, there were 46 neonates diagnosed with CCHD with a 78% prenatal detection rate. There was only one case of a true-positive POxS. Our study demonstrated that the initiation of POxS coincided with a significant decrease in neonatal TTEs, suggesting universal POxS may impart reassurance to primary providers leading to a decrease in TTE utilization.
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Akbar, Julhiju Hadiatil, Muhlis Muhlis, Gito Hadiprayitno, and I. Putu Artayasa. "Perbedaan Prestasi Belajar IPA Menggunakan Model Pembelajaran Sains Teknologi Masyarakat (STM) dengan Model Problem Based Learning (PBL) di SMPN 7 Mataram." Jurnal Ilmiah Profesi Pendidikan 9, no. 2 (May 6, 2024): 1016–22. http://dx.doi.org/10.29303/jipp.v9i2.2220.
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Rendahnya mutu belajar siswa, kurang aktifnya siswa dalam pembelajaran, kebiasaan siswa menunggu instruksi guru, dan kesibukan guru dengan kegiatan-kegiatannya menyebabkan pembelajaran yang diselenggarakan belum maksimal. Hal ini memberikan dampak buruk terhadap prestasi belajar siswa. Penelitian ini bertujuan untuk mengetahui perbedaan prestasi belajar IPA di SMPN 7 Mataram menggunakan model pembelajaran Sains Teknologi Masyarakat (STM) dengan model Problem Based Learning (PBL) di SMPN 7 Mataram. Jenis penelitian yang digunakan adalah penelitian quasi eksperimen dengan desain pre test post-test nonequivalent Control Group Design. Populasi penelitian adalah seluruh siswa kelas VIII di SMPN 7 Mataram. Sampel penelitian ini adalah kelas VII G dan VII H dengan masing-masing kelas berjumlah 40 siswa. Instrumen yang digunakan untuk memperoleh data hasil belajar adalah tes yang terdiri dari 15 soal pilihan ganda. Analisis data dilakukan dengan teknik uji independen sample Ttest setelah dilakukan uji prasyarat seperti uji normalitas dan uji homogenitas. Hasil perhitungan uji hipotesis diperoleh Ttes pada hasil pretest adalah signifikansi 0.512>0.05 artinya kemampuan awal siswa pada kelas STM dan kelas PBL sama. Sedangkan Ttes pada hasil Postest adalah signifikansi 0.024 < 0.05 artinya bahwa HO ditolak dan Ha diterima artinya terdapat perbedaan penggunaan model pembelajaran STM dengan model PBL terhadap prestasi belajar IPA di SMPN 7 Mataram. Berdasarkan data hasil nilai posttest kelas STM diperoleh 75 dan posttest PBL sebesar 69.35 sehingga dapat disimpulkan bahwa penggunaan model STM terbukti lebih baik dibandingkan model PBL.
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Taccola, Silvia, Aliria Poliziani, Daniele Santonocito, Alessio Mondini, Christian Denk, Alessandro Noriaki Ide, Markus Oberparleiter, Francesco Greco, and Virgilio Mattoli. "Toward the Use of Temporary Tattoo Electrodes for Impedancemetric Respiration Monitoring and Other Electrophysiological Recordings on Skin." Sensors 21, no. 4 (February 8, 2021): 1197. http://dx.doi.org/10.3390/s21041197.
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The development of dry, ultra-conformable and unperceivable temporary tattoo electrodes (TTEs), based on the ink-jet printing of poly(3,4-ethylenedioxythiophene) polystyrene sulfonate (PEDOT:PSS) on top of commercially available temporary tattoo paper, has gained increasing attention as a new and promising technology for electrophysiological recordings on skin. In this work, we present a TTEs epidermal sensor for real time monitoring of respiration through transthoracic impedance measurements, exploiting a new design, based on the application of soft screen printed Ag ink and magnetic interlink, that guarantees a repositionable, long-term stable and robust interconnection of TTEs with external “docking” devices. The efficiency of the TTE and the proposed interconnection strategy under stretching (up to 10%) and over time (up to 96 h) has been verified on a dedicated experimental setup and on humans, fulfilling the proposed specific application of transthoracic impedance measurements. The proposed approach makes this technology suitable for large-scale production and suitable not only for the specific use case presented, but also for real time monitoring of different bio-electric signals, as demonstrated through specific proof of concept demonstrators.
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Elkadi, Tarek Talaat Harb. "T-tube enterostomy in neonates with perforated necrotizing enterocolitis as an alternative option." International Surgery Journal 7, no. 2 (January 27, 2020): 338. http://dx.doi.org/10.18203/2349-2902.isj20200280.
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Background: The use of T tube enterostomy (TTES) as an alternative option for stoma in neonatal emergency is known long time ago.Methods: We introduced T-tube ileostomy as technical innovation in our institution as a way of treatment for intestinal perforation in low birth weight premature neonates.Results: In this study 14 neonates underwent TTES procedures at university-based pediatric surgery and neonatology department. 11 (78.6%) patients treated with TTES, discharged home. Three babies (22.4%) died in postoperative course. One of them developed recurrent severe fulminant NEC ileostomy was created and kept on TPN but died after 2 weeks due to septicaemia. The two others were dysmorphic with metabolic diseases.Conclusions: T tube is effective in selected cases of necrotizing enterocolitis (NEC) because of its simplicity in application and removal. But it could not replace the formal stoma in general, its advantages are saving one more time exposure to surgery in those risky patients, Author recommend the use it in cases of post NEC intestinal perforation and extreme low birth weight neonates.
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Shim, K., K. R. Potvin, K. Mills, F. Whiston, L. Stitt, and E. Winquist. "Risk factors for thromboembolic events in testicular cancer patients receiving chemotherapy." Journal of Clinical Oncology 27, no. 15_suppl (May 20, 2009): e16109-e16109. http://dx.doi.org/10.1200/jco.2009.27.15_suppl.e16109.
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e16109 Background: Cancer patients are at increased risk for thromboembolic events (TTEs), and those receiving chemotherapy are at even greater risk. Clinical experience and the literature have suggested that men receiving cisplatin-based chemotherapy for metastatic germ cell tumors are at particularly high risk. As TTEs can be fatal and treatment is curative, the stakes are high. Despite this, prophylactic anticoagulation (PA) is not routinely used. Methods: All men treated with cisplatin-based chemotherapy for metastatic germ cell cancer at the London Regional Cancer Program from January 1978 to December 2007 were identified from electronic databases. Data including type and timing of TTEs were extracted by retrospective chart review. Multivariable analyses were used to identify predictors of TTEs. Results: 196 eligible patients were identified with median age 31 years (range, 15–75). No patients received PA. Thirty-two TTEs were identified in 29 patients for an overall incidence of 14.8% (95% CI, 9.8–19.8%). The majority of events were deep venous thromboses, and five patients died due to TTE or its complications. Sixteen of the patients with TTE (55.2%) were diagnosed while on treatment (defined as TTE within 6 months of chemotherapy initiation); 8 (27.6%) had their TTE prior to, and 5 (17.2%) after this time period. Age greater than 30 years (OR = 3.02; 95% CI, 1.10–8.33; p = 0.033) and elevated LDH (OR = 1.93; 95% CI, 1.07–3.48; p = 0.029) were independently associated with an increased risk of TTE. If both adverse risk factors were present, the risk of TTE on treatment was 21.7% (95% CI, 9.8–33.7%). If neither were present, the negative predictive value was 97% (95% CI, 92–100%). Conclusions: The overall TTE incidence rate of 14.8% is consistent with prior reports (8.4–19%). The risk of TTE appears greatest during chemotherapy and shortly thereafter, and nearly one in 10 patients in this group had a TTE. These data support the concept of PA for selected patients starting chemotherapy for metastatic germ cell cancer. However, the efficacy of PA and risk of hemorrhage in this group is unknown. In this cohort, patients under 30 with normal LDH were at very low risk for TTE. Confirmation of these findings to help guide the study and optimal use of PA should be pursued. No significant financial relationships to disclose.
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Lanferdini, Fábio Juner, Bruno Manfredini Baroni, Caetano Decian Lazzari, Raphael Luiz Sakugawa, Rodolfo André Dellagrana, Fernando Diefenthaeler, Fabrizio Caputo, and Marco Aurélio Vaz. "Effects of Photobiomodulation Therapy on Performance in Successive Time-to-Exhaustion Cycling Tests: A Randomized Double-Blinded Placebo-Controlled Trial." Journal of Functional Morphology and Kinesiology 8, no. 4 (October 11, 2023): 144. http://dx.doi.org/10.3390/jfmk8040144.
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The goal of this study was to investigate the effects of photobiomodulation therapy (PBMT) on performance, oxygen uptake (VO2) kinetics, and lower limb muscle oxygenation during three successive time-to-exhaustions (TTEs) in cyclists. This was a double-blind, randomized, crossover, placebo-controlled trial study. Sixteen cyclists (~23 years) with a cycling training volume of ~460 km/week volunteered for this study. In the first session, cyclists performed a maximal incremental test to determine maximal oxygen uptake and maximal power output (POMAX). In the following sessions, cyclists performed three consecutive TTEs at POMAX. Before each test, PBMT (135 J/thigh) or a placebo (PLA) was applied to both thighs. VO2 amplitude, O2 deficit, time delay, oxyhemoglobin (O2Hb), deoxyhemoglobin (HHb), and total hemoglobin (tHb) were measured during tests on the right vastus lateralis. The PBMT applied before three successive TTE increased performance of the first and second TTE (~10–12%) tests, speed of VO2 and HHb kinetics during the first test, and increased peripheral muscle oxygenation (increase in HHb and tHb) in the first and second exhaustion tests. However, the PBMT effects were attenuated in the third TTE, as performance and all the other outcomes were similar to the ones from the PLA intervention. In summary, PBMT application increased the first and second successive TTEs, speed of VO2, and muscle oxygenation.
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Prasojo, Dwi Aji, and Alfian Yahya. "PENGARUH UMPAN TETAP DAN UMPAN BERUBAH TERHADAP AKURASI SMASH DALAM PERMAINAN BULUTANGKIS SMK PENERBANGAN SINGOSARI 2016/2017." JP.JOK (Jurnal Pendidikan Jasmani, Olahraga dan Kesehatan) 1, no. 1 (November 20, 2017): 23–29. http://dx.doi.org/10.33503/jpjok.v1i1.248.
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Penelitian ini merupakan penelitian eksperimen. Rancangan atau desain yang digunakan eksperimen 1 dan eksperimen 2 dengan pola one group pretest and posttesdesign. Dalam penelitian ini, jumlah sampel penelitian diambil dari seluruh populasi, yaitu 15 kelompok eksperimen 1 dan 15 kelompok eksperimen 2 dengan jumlah 30 siswa. Berdasarkan perhitungan hasil analisis data, dapat dikemukakan kesimpulan, bahwa: (1) Ada pengaruh latihan umpan tetap terhadap akurasi forehand smash. Hal ini terbukti berdasarkan hasil kelompok eksperimen nilai ttes = 9,556 > ttabel = 2,145, (2) Ada pengaruh latihan umpan berubah terhadap akurasi forehand smash. Hal ini terbukti berdasarkan nilai kelompok eksperimen nilai tes = 15,877 > ttabel = 2,145, (3) Ada perbedaan antara pengaruh latihan umpan tetap dan latihan umpan berubah terhadap peningkatan akurasi forehand smash hal tersebut terbukti nilai uji-t beda mean t-test = 25,65, sedangkan nilai t-tabel adalah adalah ts0,95 = 1,70 dan ts0,99 =2,47 dengan d.b. 28. Dari hasil analisis data di atas, diketahui bahwa nilai ttest = 25,65 >nilai ts0,95 = 1,70 dan ts0,99 = 2,47.
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Hooks, Brandon, Vinay Sharma, Gavin Taylor, Sumeet Wadhwani, and Muhammad Ehtesham. "Outcome Measures for Acute Submassive Pulmonary Embolisms at a Community-Based Hospital Using Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis." Vascular and Endovascular Surgery 54, no. 2 (November 26, 2019): 135–40. http://dx.doi.org/10.1177/1538574419885275.
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Purpose: Ultrasound-facilitated, catheter-directed, low-dose fibrinolysis (USAT) appears to provide promising results for the management of acute submassive pulmonary embolisms (ASMPEs) at tertiary care centers. This study assessed outcome measures at a community-based hospital systems and compared results to known studies. Materials and Methods: This is a single-center, retrospective study assessing clinical outcomes of the EkoSonic Endovascular System intervention for ASMPEs performed by three surgical 3 subspecialties (interventional radiology, interventional cardiology, and vascular surgery) part of a pulmonary embolism response team (PERT). We reviewed 146 PERT activations from June 2013 to December 2017. Eighty-three patients with ASMPEs underwent USAT. Results: Our study showed greater differences ( P = .01) between baseline and follow-up pulmonary artery systolic pressures (20.9 ± 9.8 mm Hg [n = 14]) compared to the ULTIMA study (12.3 ± 10 mm Hg [n = 30]). Our length-of-stay measures were shorter (6.1 ± 5.1 [n = 83]; P = .0001) compared to the SEATTLE II study (8.8 ± 5.0 [n = 150]). Preprocedure transthoracic echocardiograms (TTEs) were performed for 54 (65%) of 83 patients. Postprocedure TTEs at 48 hours was performed for 52 (62%) of 83 patients. Use of TTEs before and after intervention did not change outcomes. Intracranial hemorrhage was not observed in our patient population. There was no difference in outcomes between the three subspecialties in our study. Conclusions: Use of USAT in a community-based hospital PERT has similar outcomes to tertiary care centers. Furthermore, similar outcomes were observed between the three subspecialties suggesting development of a comprehensive care team for management of ASMPEs.
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Momen, Awad Abdalla, Mohamed Hesham Mahmoud, Dafaalla Mohammed Hag Ali, Saad Hmoud Alotaibi, Mohammed Awad Khalid, and Malik Abdalla Elsheikh. "Validation of Microwave and ICP Parameters for Assessment of Selected Toxic Trace Elements in Fresh Fruits from Turabah Valley of Saudi Arabia." Asian Journal of Chemistry 31, no. 12 (November 16, 2019): 2793–800. http://dx.doi.org/10.14233/ajchem.2019.22135.
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The analytical parameters of the microwave assisted oven and of the inductively coupled plasma (ICP) method were extensively studied and well validated in terms of spectral lines (nm), linearity (R2), accuracy (recovery %), precision (RSDs), detection and quantification limits (LODs and LOQs). The validated analytical method was used to determine the contents of selected toxic trace elements (TTEs) in fresh fruit samples from Turabah Valley of Saudi Arabia. Samples were digested by a microwave-assisted oven at the ratio of 1:2.5 (v/v) (H2O2:HNO3). The R2 > 0.9990 or better, the recovery (%) were within the acceptable range (100 ± 8), the RSDs were below 4 %, the LODs and the LOQs were ranged between 0.0005-0.0556 mg kg-1 and 0.003-0.174 mg L-1, respectively. It was found that Al, Mn, Pb, As and Cd were detected in most analyzed samples, while Co, Ni and Cr were below the detection limits of the method. A considerable variation were observed with regard to TTEs concentrations in different studied fruit samples. TTEs content of fruits were compared with those of soil and well water samples in the same area. Elevated levels of Al were obtained in some fruit samples, while other elements were within the critical safety levels specified by the FAO/WHO/SASO. Some physico-chemical properties such as moisture, ash and total solid contents (%) of fruits were also estimated and compared with the reference values. The results indicate that the developed ICP method was well suited for determination of toxic and/or nutrient trace elements in fruits and possibly similar matrices.
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Martin, Paul-Vincent, Anaïs Chataigneau, François-Xavier Arnaud, Faye Rozwadowski, Jean-Marie Cournac, and Anne-Céline Martin. "Transthoracic Doppler echocardiography during a military mission in a French role II in Mali: is it useful to learn this practice?" Military Medicine 185, no. 9-10 (June 27, 2020): e1562-e1568. http://dx.doi.org/10.1093/milmed/usaa126.
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Abstract Introduction Ultrasound is now recognized as a key tool in the practice of medicine in isolated situations. This study aims to evaluate the impact of transthoracic echocardiography (TTE) in a military mission when performed by a trained military practitioner (MP). Materials and Methods We conducted a 2-month retrospective observational study on the use of TTE in a French medical complex in Mali with a mission that included providing a medical aid to the population. All patients were included. Every ultrasound performed by the MP was listed, and the epidemiologic data, indication for the exam and results were collected for each TTE. Results A total of 349 patients were included, 16 were war-wounded patients and 333 came for a general medical consultation. In all, 153 ultrasounds were performed, including 48 TTEs. Sixteen TTEs were performed to evaluate injuries in war-wounded patients. During the 333 medical consultations, 32 TTEs were realized. The indications were dyspnoea (10), heart murmur (7), acute chest pain (5) and assessment of heart disease (10). TTE permitted a direct positive diagnosis for 18 patients: 7 with acute heart failure and 11 with morphologic problems. The normality of the exam was a supplementary argument to exclude a cardiac implication for eight patients. Conclusions TTE can provide important information with a direct impact on the management of patients. Faced with cardiac emergencies, an adapted training can be proposed for the MP. Thereby, the transfer of conventional cardiac views could facilitate the advice of a cardiologist.
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Kim, Sam-Taek. "The Development of Tactical Training Evaluation System using WMN." Journal of the Institute of Webcasting, Internet and Telecommunication 12, no. 5 (October 31, 2012): 191–96. http://dx.doi.org/10.7236/jiwit.2012.12.5.191.
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Mamirova, Aigerim, Almagul Baubekova, Valentina Pidlisnyuk, Elvira Shadenova, Leyla Djansugurova, and Stefan Jurjanz. "Phytoremediation of Soil Contaminated by Organochlorine Pesticides and Toxic Trace Elements: Prospects and Limitations of Paulownia tomentosa." Toxics 10, no. 8 (August 11, 2022): 465. http://dx.doi.org/10.3390/toxics10080465.
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Paulownia tomentosa (Thunb.) Steud is a drought-resistant, low-maintenance and fast-growing energy crop that can withstand a wide range of climatic conditions, provides a high biomass yield (approximately 50 t DM ha−1 yr−1), and develops successfully in contaminated sites. In Kazakhstan, there are many historically contaminated sites polluted by a mixture of xenobiotics of organic and inorganic origin that need to be revitalised. Pilot-scale research evaluated the potential of P. tomentosa for the phytoremediation of soils historically contaminated with organochlorine pesticides (OCPs) and toxic trace elements (TTEs) to minimise their impact on the environment. Targeted soils from the obsolete pesticide stockpiles located in three villages of Talgar district, Almaty region, Kazakhstan, i.e., Amangeldy (soil A), Beskainar (soil B), and Kyzylkairat (soil K), were subjected to research. Twenty OCPs and eight TTEs (As, Cr, Co, Ni, Cu, Zn, Cd, and Pb) were detected in the soils. The phytoremediation potential of P. tomentosa was investigated for OCPs whose concentrations in the soils were significantly different (aldrin, endosulfans, endrin aldehyde, HCB, heptachlor, hexabromobenzene, keltan, methoxychlor, and γ-HCH) and for TTEs (Cu, Zn, and Cd) whose concentrations exceeded maximum permissible concentrations. Bioconcentration (BCF) and translocation (TLF) factors were used as indicators of the phytoremediation process. It was ensured that the uptake and translocation of contaminants by P. tomentosa was highly variable and depended on their properties and concentrations in soil. Besides the ability to bioconcentrate Cr, Ni, and Cu, P. tomentosa demonstrated very encouraging results in the accumulation of endosulfans, keltan, and methoxychlor and the phytoextraction of γ-HCH (TLFs of 1.9–9.9) and HCB (BCFs of 197–571). The results of the pilot trials support the need to further investigate the potential of P. tomentosa for phytoremediation on a field scale.
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Ramadani, Sari, Alfian, and Nanda Gusriani. "Model Pembelajaran Reading Questioning and Answering Berpengaruh Terhadap Hasil Belajar Biologi Siswa di Madrasah Aliyah." EDU-BIO: Jurnal Pendidikan Biologi 6, no. 2 (November 22, 2022): 36–43. http://dx.doi.org/10.30631/edubio.v6i2.20.
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Tujuan penelitian ini adalah untuk mengetahui Pengaruh Model Pembelajaran Reading Questioning and Answering (RQA) Terhadap Hasil Belajar Biologi Siswa di Madrasah Aliyah As’ad Olak Kemang, Kota Jambi. Penelitian ini merupakan penelitian kuantitatif dengan menggunakan desain Posttest-Only Control Design sedangkan pengumpulan data dengan teknik tes akhir (pos test). Analisis dengan ttes. Teknik pengambilan sampel menggunakan Simple Random Sampling dengan sampel berjumlah 30 siswa di kelas eksperimen dan 30 siswa di kelas kontrol. Data hasil penelitian diperoleh skor tertinggi di kelas eksperimen adalah 95,7 dan skor terendah 48 dengan rata-rata 76 sedangkan pada kelas kontrol diperoleh skor tertinggi 95,7 dan skor terendah 43,5 dengan rata-rata 70,20. Dari uji ttes pada taraf signifikan 5% = 1,672 dan 1% = 2,394 diperoleh 1,672 < 2,447 >2,394 jadi thitung > ttabel atau HO ditolak dan Ha diterima dengan besar pengaruh 0,6 pada kriteria sedang persentase 38,2%. Berarti terdapat perbedaan yang signifikan antara hasil belajar siswa yang menggunakan model pembelajaran Reading Questioning and Answering (RQA) dengan yang tidak menggunakan model pembelajaran Reading Questioning and Answering (RQA) di Madrasah Aliyah As’ad Olak Kemang, Kota Jambi.
Kata kunci: Reading Questioning and Answering (RQA), hasil belajar.
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Yu, Anthony Francis, Chau T. Dang, Justine Jorgensen, Chaya S. Moskowitz, Joseph Wallins, Patricia Anne DeFusco, Eric Oligino, Kevin C. Oeffinger, Jennifer Liu, and Richard Steingart. "Cardiac safety of reduced surveillance for cancer therapy related cardiac dysfunction in patients with breast cancer treated with HER2-targeted therapy." Journal of Clinical Oncology 41, no. 16_suppl (June 1, 2023): 12083. http://dx.doi.org/10.1200/jco.2023.41.16_suppl.12083.
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12083 Background: Non-anthracycline-based therapy is a treatment option for patients (pts) with HER2-positive breast cancer (BC) and is associated with lower risk of cancer therapy related cardiac dysfunction (CTRCD) compared to anthracycline-based treatment. Given the reduced CTRCD risk with non-anthracycline HER2-targeted therapies, updates to practice guidelines that recommend surveillance echocardiograms (TTE) every 3 months are needed. We evaluated the cardiac safety of reduced CTRCD surveillance in pts receiving non-anthracycline HER2-targeted therapies. Methods: Pts with BC treated with non-anthracycline HER2-targeted therapy were enrolled in this single-arm prospective study. Pts with previous anthracycline exposure, uncontrolled hypertension (systolic blood pressure ≥ 160 mmHg), or significant cardiovascular disease were excluded. TTEs were performed at baseline, 6 months, and 12 months during HER2-targeted treatment. The primary endpoint was a cardiac event, defined by clinical heart failure (New York Heart Association Class III/IV) or cardiovascular death, with a prespecified non-inferiority margin of 2.9% relative to a cardiac event rate of 1.1% based upon prior studies. Secondary endpoints were CTRCD, defined by decline of left ventricular ejection fraction (LVEF) ≥10% to < 53%, and interruption of HER2-targeted treatment secondary to CTRCD. Results: Between May 2019 and January 2022, 190 pts (age 52 ± 11 y) with HER2-positive BC were enrolled: 143 (75%) had stage I disease, 8 (4%) had diabetes, 38 (20%) had hypertension, and baseline LVEF was 64 ± 5% (Table). Additional TTEs outside the prespecified 6- and 12-month timepoints were performed for 35 (18%) pts, of which 20 were to assess for possible cardiac symptoms. After 1-year follow-up, there were 0 (0%; 97.5% CI 0- 1.9%) cardiac events. Two (1.1%) pts developed CTRCD and 1 (0.5%) pt had a temporary CTRCD-related treatment interruption. Conclusions: Reduced CTRCD surveillance every 6 months is feasible and safe for selected pts with HER2-positive BC receiving non-anthracycline HER2-targeted therapy. Our findings support the need to update cardio-oncology practice guidelines and allow for less frequent surveillance TTEs among pts at low-risk for CTRCD. Clinical trial information: NCT03983382 . [Table: see text]
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Pugh, Kevin J., Cassendra M. Bergstrom, Benjamin C. Heddy, and Karen E. Krob. "Supporting Deep Engagement: The Teaching for Transformative Experiences in Science (TTES) Model." Journal of Experimental Education 85, no. 4 (February 6, 2017): 629–57. http://dx.doi.org/10.1080/00220973.2016.1277333.
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Tallon, Erin M., Mary Pat Gallagher, Vincent S. Staggs, Diana Ferro, Deepa Badrinath Murthy, Osagie Ebekozien, Mikhail N. Kosiborod, et al. "Diabetes status and other factors as correlates of risk for thrombotic and thromboembolic events during SARS-CoV-2 infection: A nationwide retrospective case–control study usingCerner Real-World Data™." BMJ Open 13, no. 7 (July 2023): e071475. http://dx.doi.org/10.1136/bmjopen-2022-071475.
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ObjectivesWe sought to examine in individuals with SARS-CoV-2 infection whether risk for thrombotic and thromboembolic events (TTE) is modified by presence of a diabetes diagnosis. Furthermore, we analysed whether differential risk for TTEs exists in type 1 diabetes mellitus (T1DM) versus type 2 diabetes mellitus (T2DM).DesignRetrospective case–control study.SettingThe December 2020 version of theCerner Real-World DataCOVID-19 database is a deidentified, nationwide database containing electronic medical record (EMR) data from 87 US-based health systems.ParticipantsWe analysed EMR data for 322 482 patients >17 years old with suspected or confirmed SARS-CoV-2 infection who received care between December 2019 and mid-September 2020. Of these, 2750 had T1DM; 57 811 had T2DM; and 261 921 did not have diabetes.OutcomeTTE, defined as presence of a diagnosis code for myocardial infarction, thrombotic stroke, pulmonary embolism, deep vein thrombosis or other TTE.ResultsOdds of TTE were substantially higher in patients with T1DM (adjusted OR (AOR) 2.23 (1.93–2.59)) and T2DM (AOR 1.52 (1.46–1.58)) versus no diabetes. Among patients with diabetes, odds of TTE were lower in T2DM versus T1DM (AOR 0.84 (0.72–0.98)).ConclusionsRisk of TTE during COVID-19 illness is substantially higher in patients with diabetes. Further, risk for TTEs is higher in those with T1DM versus T2DM. Confirmation of increased diabetes-associated clotting risk in future studies may warrant incorporation of diabetes status into SARS-CoV-2 infection treatment algorithms.
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Bastika, Ayu, and Mujiburrahman Mujiburrahman. "PENGARUH MODEL PEMBELAJARAN INDUKTIF KATA BERGAMBAR TERHADAP HASIL BELAJAR SISWA." Jurnal Teknologi Pendidikan : Jurnal Penelitian dan Pengembangan Pembelajaran 3, no. 1 (February 8, 2019): 48. http://dx.doi.org/10.33394/jtp.v3i1.1226.
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Pada pengamatan awal, guru Bahasa Inggris pada SD Integral Luqman Al-Hakim Mataram seringkali menggunakan metode konvensional yaitu metode ceramah. Karena Bahasa Inggris adalah mata pelajaran yang membutuhkan partisipasi aktif siswa untuk mempelajarinya, maka metode ceramah yang lebih bersifat berpusat pada guru tidak tepat untuk digunakan. Sering kali siswa tidak dapat menangkap penjelasan guru. Kebanyakan siswa hanya mendengarkan dan mencatat apa yang dijelaskan oleh guru sedangkan mereka tidak memahami materi pembelajaran itu sendiri. Rumusan masalah dalam penelitian ini adalah: Apakah Ada Pengaruh Model Pembelajaran Induktif Kata Bergambar terhadap Hasil Belajar Siswa Pada Mata Pelajaran Bahasa Inggris Kelas V di SD Integral Luqman Al-Hakim Tahun Ajaran 2017/2018. Tujuan penelitian ini adalah: Untuk mengetahui Apakah Ada Pengaruh Model Pembelajaran Induktif Kata Bergambar terhadap Hasil Belajar Siswa Pada Mata Pelajaran Bahasa Inggris Kelas V Di SD Integral Luqman Al-Hakim Mataram Tahun Ajaran 2017/2018. Populasi dalam penelitian ini adalah siswa kelas V di SD Integral Luqman Al-Hakim Mataram yang berjumlah 65 orang siswa. Karena populasi kurang dari 100 maka penelitian ini menggunakan studi populasi. Rancanagan penelitian menggunakan one-Group pretes-posttes design. Data dikumpulkan dengan menggunakan metode tes sebagai metode pokok sedangkan dokumentasi sebagai metode pelengkap. Tehnik analisis data menggunakan analisis statistik dengan rumus ttes. Hasil analisis diperoleh nilai ttest sebesar 5,170 dan nilai ttabel pada taraf signifikan 5% dengan db = N-1 = 25 lebih besar daripada nilai ttest pada tabel (5,170>2,060), berarti bahwa ditolak dan Ha diterima yang berbunyi: Ada Pengaruh Model Pembelajaran Induktif Kata Bergamabar terhadap Hasil Belajar Siswa Pada Mata Pelajaran Bahasa Inggris Kelas V Di SD Integral Luqman Al- Hakim Mataram Tahun Ajaran 2017/2018, sehingga dapat disimpulkan bahwa hasil penelitian ini “signifikan”. Kata Kunci: Model Pembelajaran Induktif Kata Bergambar, Hasil Belajar.
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Nath, Ermin, Michael B. Sawyer, and Jonathan Choy. "First Case of Regression of Carcinoid Heart Disease on Serial Transthoracic Echocardiograms following Octreotide Monotherapy in a Patient with Metastatic Pancreatic Neuroendocrine Tumor." Case Reports in Oncology 13, no. 3 (December 10, 2020): 1454–62. http://dx.doi.org/10.1159/000511414.
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Well-differentiated neuroendocrine tumors (NETs) arising in the gastrointestinal (GI) tract and pancreas are relatively rare; however, the annual incidence has been increasing. Carcinoid syndrome (CS) is a constellation of symptoms that occur when a GI NET metastasizes to the liver and releases high levels of vasoactive substances into the systemic circulation. CS occurs in 19% of NETs patients at diagnosis and is associated with shorter survival. Carcinoid heart disease (CHD) occurs in over 50% of patients with CS and is associated with poor long-term prognosis. NET-induced valvular fibrosis is a significant cause of mortality and morbidity in these patients. Somatostatin analogs relieve CS symptoms, but they have never been shown to reverse CHD progression or improve overall survival. Surgical therapy for right-sided valve disease is associated with improved symptoms and quality of life and possibly improved survival, despite relatively high morbidity and mortality associated with cardiac intervention. A 65-year-old woman with a metastatic pancreatic NET had typical signs and symptoms of CS. She presented in congestive heart failure and was found to have severe tricuspid regurgitation with characteristic features of CHD on transthoracic echocardiogram (TTE). Following octreotide monotherapy, serial TTEs demonstrated regression of tricuspid valve involvement. The patient improved clinically and remained asymptomatic on subsequent visits. This is the first case of CHD regression with medical therapy supported by serial TTEs. Developing a deeper understanding of cases like this will help us unlock new intervention targets and strategies for treatments in the future.
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Peng, J., and M. Lee. "The study on the optimum fermentation conditions of the TTES-12 GABA tea production." New Biotechnology 25 (September 2009): S232. http://dx.doi.org/10.1016/j.nbt.2009.06.211.
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Goras, Michal, and Frantisek Vranay. "Use of renewable sources with thermal accumulation of solar energy for the energy consumption of buildings." E3S Web of Conferences 550 (2024): 01031. http://dx.doi.org/10.1051/e3sconf/202455001031.
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Today, there is an increasing demand for renewable energy sources in Europe to minimise the carbon footprint and achieve a sustainable energy supply. One of the cleanest and most affordable energy sources is solar energy, which can be used efficiently for heating and hot water in buildings. However, efficient storage and use of solar energy is key. This paper focuses on a comparison of two main solar thermal energy storage systems: Pit Thermal Energy Storage (PTES) and Tank Thermal Energy Storage (TTES). The case studies include an analysis of the effectiveness of these systems in real scenarios, along with their advantages, disadvantages and potential future applications.
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Siregar, Dwi Aninditya. "PERBANDINGAN HASIL BELAJAR FISIKA PADA MATERI POKOK ENERGI DENGAN MENGGUNAKAN METODE DISKUSI DAN METODE INKUIRI PADA SISWA KELAS VIII SMP NEGERI 1 BATANG ANGKOLA." JURNAL PhysEdu (PHYSICS EDUCATION) 6, no. 1 (February 18, 2024): 47–52. http://dx.doi.org/10.37081/physedu.v6i1.5091.
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This study aims to see a comparison of the results of studying physics in the subject matter of energy by using the method of discussion and inquiry method in class VIII SMP Negeri 1 Batang Angkola. The method used in this study is the experimental method, and conduct experiments on two classes. The population in this study were all eighth grade students of SMP Negeri 1 Batang Angkola consisting of 6 classes totaling 192 students. Samples were numbered 32 class X1 and X2 are 32 people were determined by cluster random sampling. This research instrument manifold observation sheet given to the observer to evaluate and test in the form of multiple-choice questions to test amounted to 20 and 20 aspects are assessed for observation sheet. The data collected were analyzed in two ways, namely descriptive analysis (to see a general overview of both variables) and statistical analysis (to test the proposed hypothesis whether accepted or rejected). Student learning outcomes using the discussion reaches an average value of 70.8 which is included in the category of "good", while the learning outcomes of students using inquiry method reaches an average value of 64.06 which is included in the category of "enough". Based on the results of hypothesis testing is done, obtained ttes = 2.21 while ttable at the level of 95% with an error rate of 5% df = N - 2 = 64-2 = 62 is 2:00. Thus it can be seen that ttes greater than ttable (2:21 > 2:00). This shows that the proposed hypothesis is accepted or approved truth, meaning that there is a significant comparison between the use of the method of discussion and inquiry method to student learning outcomes in energy pokok material in class VIII SMP Negeri 1 Batang Angkola.
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BABA, Alina. "FINANCING INNOVATION: THE ROLE OF FUNDING IN THE EFFICACY OF UNIVERSITY TECHNOLOGY TRANSFER ENTITIES." Annals of the University of Oradea. Economic Sciences 33, no. 1 (July 31, 2024): 223–30. http://dx.doi.org/10.47535/1991auoes33(1)025.
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This study explores the evolving role of universities in the modern economy, focusing on their transformation from traditional centers of education and research to dynamic hubs of entrepreneurship and technology transfer. Drawing from Schumpeter's theory of entrepreneurship, which emphasizes the critical role of innovation and the entrepreneur in catalysing economic change, this paper argues that contemporary universities have adopted a third mission of economic development, complementing their foundational roles in teaching and research. The paper introduces the concept of the entrepreneurial university, a term that captures the institution's enhanced involvement in technological innovation and its contribution to economic growth through the commercialization of research. The research discusses various models of innovation that have shaped our understanding of the knowledge transfer process, including the linear model of innovation, the triple helix model, and the open innovation model. These models provide a theoretical framework for analysing the mechanisms through which universities contribute to the economy, highlighting the importance of collaboration between academia, industry, and government. The paper pays particular attention to the role of Technology Transfer Entities (TTEs) within universities, which are instrumental in managing intellectual property, licensing inventions, and fostering partnerships with external stakeholders. Through a comprehensive analysis, the paper reveals that while the financial benefits of knowledge transfer from universities are increasingly recognized, there remains a significant research gap in understanding how university knowledge can be effectively transformed into economic benefits. This gap is particularly pronounced in the context of transition economies, where data on knowledge transfer mechanisms and their impact on innovation and economic growth is scarce. The study emphasizes the need for a multidimensional approach to assess the effectiveness of university TTEs, considering individual, organizational, and ecosystem-level characteristics.
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Sparks, Rachel, and Rebekka Darner. "Fostering Nonscientist Thinking on Evolution Concepts Through the Teaching for Transformative Experiences in Science (TTES) Model." Journal of College Science Teaching 50, no. 2 (November 2020): 40–48. http://dx.doi.org/10.1080/0047231x.2020.12290683.
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Sandhu, Alexander T., and Paul A. Heidenreich. "Abstract 131: Association Between Limited Left Ventricle Ejection Fraction (LVEF) Transthoracic Echocardiograms (TTEs) and Overall TTE Utilization." Circulation: Cardiovascular Quality and Outcomes 10, suppl_3 (March 2017). http://dx.doi.org/10.1161/circoutcomes.10.suppl_3.131.
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Objectives: To evaluate the change in utilization of TTEs associated with introduction of limited LVEF TTEs. Methods: We measured the number of total, full and limited TTEs before (2005) and after (2006-2015) implementation of limited LVEF TTEs at the Palo Alto VA Hospital (PAVA) and compared to other VA hospitals. We estimated the association between introduction of the LVEF TTEs at PAVA and TTEs volume using a linear regression model with other facilities as controls adjusted for facility, number of outpatients and average patient age. Results: There were 119 VA facilities that performed over 100 TTEs in 2005. Between PAVA and 118 control VA facilities, there was no significant difference in the number of outpatients (52,654 vs. 44,552 +/- 25,342[SD], p=0.37), average age (61.4 vs. 61.8 years +/- 2.5, p=0.44) total TTEs in 2005 (2,395 vs. 1,594.8 +/- 1,069.6, p=0.23) or limited TTEs (19 vs. 25.8 +/-101.5, p=0.48) in 2005. In 2005, limited TTEs were 0.8% of all TTEs at PAVA and 1.2% at controls. Between 2006-2010, limited TTEs were 8.3% of total at PAVA and 1.7% at controls. Between 2011-2015, limited TTEs were 19.5% of total at PAVA and 2.2% at controls. In 2005, total TTEs per outpatient were 4.5 per 100 at PAVA and 3.5 per 100 at other VA hospitals. Between 2006-2010, total TTEs were 4.5 per 100 patient-years at PAVA and 3.9 per 100 patient-years at controls. Between 2011-2015, total TTEs per capita were 4.6 per 100 patient-years at PAVA and 4.3 per 100 patient-years at controls. In an adjusted model, limited LVEF TTE introduction was associated with an average of -383 (CI: -554 to -211) annual full TTEs with no significant difference in total TTEs (-26.8; CI: -156 to 102). The decrease in full TTEs increased each year with an estimated -67.0 (CI: -97 to -37) full TTEs per year after 2006. This was equivalent to 683 fewer full TTEs (30.0% of total) in 2015. Conclusion: The introduction of limited LVEF TTEs at PAVA was associated with an increase in limited TTEs, a decrease in full TTEs, and no significant change in total TTEs when compared with control facilities. This suggests the introduction of LVEF studies was associated with substitution of limited TTEs for full studies. This could lead to substantial reductions in resource utilization and costs. We did not evaluate potential changes in outcomes associated with this change in TTE utilization.
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Abdullah, Kazeen N., Jeff Hastings, Shuaib Abdullah, and Susan Matulevicius. "Abstract 239: Appropriateness and Impact of Transthoracic Echocardiography in a Veterans Affairs Health Care System." Circulation: Cardiovascular Quality and Outcomes 7, suppl_1 (July 2014). http://dx.doi.org/10.1161/circoutcomes.7.suppl_1.239.
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Background: Appropriate Use Criteria (AUC) for transthoracic echocardiograms (TTEs) was developed in 2007 and later revised in 2011 to meet the need for guidance on appropriate use of diagnostic imaging. Few studies have evaluated the correlation between AUC and downstream clinical impact. We describe the association of AUC and clinical impact for TTEs from a VA center. Methods: All TTEs from April 2011 at a VA center were retrospectively reviewed. TTEs were excluded for LVAD/ transplant patients or for inadequate clinical data to assign AUC or clinical impact. Based on 2011 AUC , TTEs were classified as: appropriate, inappropriate, or uncertain. After blinding to AUC, TTEs were assessed for clinical impact as: change in care, continuation of current care, or no change in care. Results: Among 441 TTEs (43% inpatient), 82.7% were appropriate, 9% inappropriate and 8% uncertain. Overall, change of care was seen in 39% of TTEs, continuation of current care in 32% and no change in care in 30%. Appropriate TTEs more frequently resulted in a change in care than inappropriate TTEs (41% vs. 23%, p<0.03, Figure 1). Conclusions: Although only 8 in 10 TTEs were appropriate by 2011 AUC, almost 4 in 10 TTEs lead to an active change in care. Appropriate TTEs were more likely to change patient care than inappropriate TTEs. Additional research is needed to evaluate the association of clinical impact and differences in TTE practice at VA vs. non VA medical centers.
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Castaneda, Jason, corey rearick, Joseph Weber, Eve Edstrom, Kimisha Cassidy, Vineet Arora, and R. Ward. "Abstract 15537: An Electronic Health Record Intervention to Optimize Utilization of Transthoracic Echocardiography: Opportunity for Cost Savings in the Era of Value Based-care." Circulation 142, Suppl_3 (November 17, 2020). http://dx.doi.org/10.1161/circ.142.suppl_3.15537.
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Introduction: In the current value-based era, targeting diagnostic resources and minimizing unnecessary testing is of paramount importance. Transthoracic echocardiography (TTE) is a common and costly test, and available Appropriate Use Criteria (AUC) guide optimal utilization. Limited TTE (L-TTE) shortens sonographer time, lowers cost and may be ideal for repeat TTEs (R-TTE) with a focused indication. However, many clinicians are unfamiliar with the AUC and opportunities for L-TTE. We prospectively tested an Electronic Health Record (EHR)-based intervention aimed at optimizing TTE utilization in a large academic medical center. Methods: TTE utilization at the University of Chicago Medicine was assessed over a 6-month period and complete TTE (C-TTE), L-TTE and R-TTE (TTE repeated within 6 months) were recorded. An EHR-based intervention was then implemented and TTE utilization was assessed over the ensuing 8 weeks. The intervention included presenting new descriptive L-TTE options (i.e. “Limited TTE: EF or Effusion Only”) when any “echo” was searched in the EHR order panel, an alert to prior TTEs (i.e. date & LVEF) and a link to AUC-based guidance for TTE ordering. Educational materials were also distributed to frequent TTE ordering providers. Results: Among 9121 TTEs (53% inpatient) pre-intervention , 11% (n=1002) were L-TTEs and 25% (n=2320) were R-TTEs. There were more L-TTEs and R-TTEs in pre-intervention inpatients compared to outpatients (L-TTE 14% vs 7%, p<0.0001, R-TTE 33% vs 17%, p<0.0001). Post-intervention (2879 TTEs, 53% inpatient), R-TTEs significantly decreased (22.6% vs 25.4%, p=0.0019) and L-TTEs significantly increased (14% vs 11%, p<0.0001) compared to pre-intervention, with inpatient TTEs most impacted (R-TTE 28% vs 33%, p=0.0016, L-TTE 19% vs 14%, p<0.001). The intervention’s greatest impact was to markedly increase L-TTEs among inpatient R-TTEs (44% vs 35%, p=0.0002). Conclusions: Despite AUC discouraging frequent repeat TTEs, R-TTEs are common in an academic medical center and utilization of L-TTE is rare. An EHR-based intervention with prior TTE alerts and descriptive L-TTE options increases L-TTEs and reduces R-TTEs. Further study is warranted to describe the full clinical and financial impact of this intervention.
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Wan, Sheng, Yanglin Hu, Li Cheng, Da He, Zengsi Wang, and Yanmin Zhang. "Prognostic value of transthoracic echocardiography score for the prognosis of continuous ambulatory peritoneal dialysis patients." BMC Nephrology 25, no. 1 (February 23, 2024). http://dx.doi.org/10.1186/s12882-024-03493-2.
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Abstract Background We devoted ourselves to proving that the initial transthoracic echocardiography score (TTES) had predictive significance for patients with continuous ambulatory peritoneal dialysis (CAPD). Methods In this retrospective analysis, 274 CAPD patients who had PD therapy were recruited sequentially. TTE exams were performed three months following the start of PD therapy. All patients were divided into two groups based on the strength of their TTES levels. TTES’s predictive value for CAPD patients was then determined using LASSO regression and Cox regression. Results During a median of 52 months, 46 patients (16.8%) died from all causes, and 32 patients (11.7%) died from cardiovascular disease (CV). The TTES was computed as follows: 0.109 × aortic root diameter (ARD, mm) − 0.976 × LVEF (> 55%, yes or no) + 0.010 × left ventricular max index, (LVMI, g/m2) + 0.035 × E/e’ ratio. The higher TTES value (≥ 3.7) had a higher risk of all-cause death (hazard ratio, HR, 3.70, 95% confidence index, 95%CI, 1.45–9.46, P = 0.006) as well as CV mortality (HR, 2.74, 95%CI 1.15–19.17, P = 0.042). Moreover, the TTES had an attractive predictive efficiency for all-cause mortality (AUC = 0.762, 95%CI 0.645–0.849) and CV mortality (AUC = 0.746, 95%CI 0.640–0.852). The introduced nomogram, which was based on TTES and clinical variables, exhibited a high predictive value for all-cause and CV mortality in CAPD patients. Conclusion TTES is a pretty good predictor of clinical outcomes, and the introduced TTES-based nomogram yields an accurate prediction value for CAPD patients.
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Vellanki, Anu, Stephen P. Baker, Gerard P. Aurigemma, and Dennis A. Tighe. "Abstract 19632: Appropriate Use of Inpatient Repeat Echocardiography in a Tertiary Care Center." Circulation 126, suppl_21 (November 20, 2012). http://dx.doi.org/10.1161/circ.126.suppl_21.a19632.
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Background: Echocardiography is used with increasing frequency to address clinical cardiac questions. With its increasing use, criteria have been promulgated for the appropriate use (AUC) of Echo by the ACC/ASE. Little information currently exists on the inpatient use of transthoracic echocardiography (TTE) when a prior study (repeat) has been performed recently. Our aim was to study the application of 2011 AUC criteria on clinical management for inpatient repeat TTE in a tertiary care center. Methods: Over a 1-month period in 2012, written requests for 500 consecutive inpatient TTEs were evaluated. The echo database was queried to determine if a TTE had been performed within 1 yr. Indications for repeat TTE were categorized as appropriate (A), uncertain (U) and inappropriate (I) based on AUC criteria. A retrospective chart review was performed to assess impact of the AUC categorized results on clinical management. Results: Of the 500 TTEs, 131(26%) were repeat studies. Per AUC, 49% were considered A, 17% U and 34% I. Among these repeat TTEs, 53% played a role in clinical management, while 47% had no discernible role. A significant difference was found in clinical management among A, U, I groups (84.4% vs. 50% vs. 8.9%, p<0.0001). Of 131 repeat TTEs, 39(30%) were ordered by cardiology while non- cardiology providers ordered 92(70%). The top 3 indications of (A) TTEs were heart failure (22%), pericardial effusion (15%) and hemodynamic instability (15%), while (I) TTEs were heart failure (26%), syncope (12%) and pericardial effusion (11%). No significant difference was found among cardiology and non-cardiology providers in ordering A, U and I TTEs (41% vs. 53.5%, p=0.4, 20.5% vs. 16.3%, p=0.4 and 38.5% vs. 30.2%, p=0.4). Conclusions: Approximately one-third of repeat TTEs in a tertiary care medical center can be classified as (I). Noncardiology services were comparable to cardiology providers in applying AUC criteria. In an effort to reduce (I) repeat TTEs, knowledge of prior TTE data and incorporation of AUC criteria into order entry mechanisms should occur to aid inpatient provider decisions on ordering TTEs.
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Smith, Jeremy A., and Ravi Mistry. "Management change following transthoracic echocardiogram in the intensive care unit." Australasian Journal of Ultrasound in Medicine, June 25, 2024. http://dx.doi.org/10.1002/ajum.12397.
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AbstractIntroduction/PurposeThe optimal utilisation of echocardiography in intensive care units (ICU) is not yet known; however, its use is becoming more frequent. Management change from transthoracic echocardiography (TTE) in ICU is quoted to be from 3% to 50%.MethodsA retrospective review of clinical practice was performed over a 2‐month period in a tertiary adult ICU, to explore the utilisation of formal TTEs and the findings of these. The rate of management change and critical findings were investigated, along with the indication for TTE and the patient cohort.ResultsSixty‐three TTEs were performed in 54 patients. A change in management occurred in 25.4% (16/63) of TTEs, with critical findings being found in 47.6% (30/63) of all TTEs. The most common indications for formal TTEs were incompletely differentiated or further evaluation of shock, and post arrest cardiac function.DiscussionAlmost half of the TTEs performed had critical findings, with common critical findings being severe LV dysfunction, severe RV dysfunction and regional wall motion abnormalities. Despite critical findings being seen frequently, there was only management change in 25%, suggesting that several of the critical findings were already suspected, clinically confirmed or had anticipatory management prior to TTE.ConclusionCritical findings are common in critically ill patients. However, not all critical findings will lead to a change in management. Formal TTEs in the ICU should be focussed to the clinical question being asked and a screening intensivist performed bedside TTE may be appropriate in certain situations to decrease workload of cardiology department.
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Faridi, Kamil F., Zhaohan Zhu, Nimish N. Shah, Ian Crandall, Robert L. McNamara, Peter Flueckiger, Karen Bachand, et al. "Factors associated with reporting left ventricular ejection fraction with 3D echocardiography in real‐world practice." Echocardiography 41, no. 2 (February 2024). http://dx.doi.org/10.1111/echo.15774.
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AbstractBackgroundGuidelines recommend 3D echocardiography (3DE) to assess left ventricular ejection fraction (LVEF) on transthoracic echocardiogram (TTE) when possible, but it is unclear which factors are most strongly associated with reporting 3DE LVEF in real‐world practice.MethodsWe evaluated 3DE LVEF reporting by age, sex, BMI, TTE location and variation in reporting by sonographer and reader. All TTEs were performed without contrast enhancement agent at a large medical center from 9/2015 to 12/2020 using ultrasound machines capable of 3DE. We used multivariable logistic regression to assess which factors were most associated with reporting 3DE LVEF.ResultsAmong 35 641 TTEs included in this study, 57.4% were performed on women. 3DE LVEF was reported on 18 391 TTEs (51.6% of cohort; 50.5% for women and 52.4% for men). Portable inpatient TTEs (n = 5569) had the lowest rates of 3DE LVEF reporting (30.9%), while general outpatient TTEs (n = 15 933) had greater reporting (56.9%). Outpatient TTEs with an indication for chemotherapy (n = 3244) had the highest rates of 3DE LVEF (87.2%). The median (IQR) percentage of TTEs reporting 3D LVEF was 52.7% (43.1%–68.1%) among sonographers and 51.6% (46.5%–59.6%) among readers. Among 20082 (56.3%) TTEs with 3DE LVEF measured by sonographers, 91.6% were included by readers in the final report. After adjustment, performing sonographer in the highest reporting quartile was most strongly associated with reporting 3DE LVEF (OR 7.04, 95% CI 6.55–7.56), while an inpatient portable study had the strongest negative association for reporting (OR .38, 95% CI .35–.40).ConclusionsUse of 3DE LVEF in real‐world practice varies substantially based on performing sonographer and is low for hospitalized patients, but can be frequently used for chemotherapy. Initiatives are needed to increase sonographer 3DE acquisition in most clinical settings.
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Varghese, Merilyn S., Jordan B. Strom, Sarah Fostello, and Warren J. Manning. "Abstract 16125: Impact of COVID-19 on Echocardiography Volume at a Large Academic Medical Center." Circulation 142, Suppl_3 (November 17, 2020). http://dx.doi.org/10.1161/circ.142.suppl_3.16125.
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Introduction: COVID-19 has significantly impacted hospital systems worldwide. The impact of statewide stay-at-home mandates on echocardiography volumes is unclear. Methods: We queried our institutional echocardiography database from 6/1/2018 to 6/13/2020 to examine rates of transthoracic (TTE), stress (SE), and transesophageal echocardiograms (TEE) prior to and following the COVID-19 Massachusetts stay-at-home order on March 15, 2020. Results: Among 36,377 total studies performed during the study period, mean weekly study volume dropped from 332 + 3 TTEs/week, 30 + 1 SEs/week, and 21 + 1 TEEs/week prior to the stay-at-home order (6/1/2018-3/15/2020) to 158 + 13 TTEs/week, 8 + 2 SEs/week, and 8 + 1 TEEs/week after (% change, -52%, -73%, and -62% respectively, all p < 0.001 when comparing volume prior to March 15 versus after). Weekly TTEs correlated strongly with hospital admissions throughout the study period (r = 0.93, 95% CI 0.89-0.95, p < 0.001) ( Figure ). Outpatient TTEs declined more than inpatient TTEs (% change, -74% vs. -39%, p <0.001). As of 3 weeks following the cessation of the stay-at-home order, TTE, SE, and TEE weekly volumes have increased to 73%, 66%, and 81% of pre-pandemic levels, respectively. Conclusions: Echocardiography volumes fell precipitously following the Massachusetts stay-at-home order, strongly paralleling declines in overall hospitalizations. Outpatient TTEs declined more than inpatient TTEs. Despite lifting of the order, echocardiography volumes remain substantially below pre-pandemic levels. The impact of the decreased use of echocardiographic services on patient outcomes remains to be determined.
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Welch, Megan, Molly Paras, Amber Moore, Jonathan Wing, Alyssa Letourneau, Tyler Tucker, Kristen Solemina, Judy Hung, and Rory Weiner. "Abstract 4140366: Diagnostic Stewardship to Improve Appropriate Use of Inpatient Echocardiography." Circulation 150, Suppl_1 (November 12, 2024). http://dx.doi.org/10.1161/circ.150.suppl_1.4140366.
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Background: Overuse of cardiovascular imaging, including echocardiography, is a form of low-value care contributing to waste in the US healthcare system. Historically, appropriate use criteria (AUC)-based educational programs and feedback reports have improved transthoracic echocardiography (TTE) ordering practices, but prior efforts have shown only modest and short-lived impact and have focused on the outpatient setting. Contemporary capacity and financial constraints highlight the importance of leveraging AUC to promote more efficient utilization of echocardiography resources. Methods: We conducted a prospective controlled cohort study testing an education-based diagnostic stewardship intervention to reduce rarely appropriate TTEs on inpatient medical services. AUC categorize TTE indications into three groups: appropriate (A), may be appropriate (mA), and rarely appropriate (rA). Modeled after successful antimicrobial stewardship programs, the intervention involved screening TTE orders from control and intervention units for appropriateness in real-time. For medical units in the intervention group, the diagnostic steward contacted ordering clinicians of those with mA and rA orders. The steward clarified order indications and made recommendations regarding the utility of the TTE. The ordering clinician chose to continue or discontinue the order. The primary outcome was the odds of rA TTEs in the intervention vs control groups. Results: Over 3 months, 150 TTEs were screened in the control group and 160 were screened in the intervention group. After initial screening, 8.8% (13) and 10.6% (17) were rA in the control and intervention groups, respectively. The stewardship intervention was employed for 17 rA TTEs and 13 mA TTEs. After the stewardship intervention, 17 of the rA TTEs remained classified as rA and 1 of the mA TTEs was reclassified as rA. Of the 18 rA orders, 16 were discontinued and 2 were completed (88% reduction). The stewardship intervention was associated with a significant reduction in completed rA TTEs when compared to the control group (OR = 0.15; 95% CI 0.03, 0.67; p = 0.005; Table). Conclusion: A stewardship intervention resulted in a significant decrease in completed rA inpatient TTEs among screened orders. In the era of capacity constraints, such a reduction represents a solution to improve clinical operations through targeted resource allocation. Future work to partially automate this initiative is important for scalability.
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Yuan, Neal, Nathan R. Stein, Grant Duffy, Roopinder K. Sandhu, Sumeet S. Chugh, Peng-Sheng Chen, Carine Rosenberg, et al. "Deep learning evaluation of echocardiograms to identify occult atrial fibrillation." npj Digital Medicine 7, no. 1 (April 13, 2024). http://dx.doi.org/10.1038/s41746-024-01090-z.
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AbstractAtrial fibrillation (AF) often escapes detection, given its frequent paroxysmal and asymptomatic presentation. Deep learning of transthoracic echocardiograms (TTEs), which have structural information, could help identify occult AF. We created a two-stage deep learning algorithm using a video-based convolutional neural network model that (1) distinguished whether TTEs were in sinus rhythm or AF and then (2) predicted which of the TTEs in sinus rhythm were in patients who had experienced AF within 90 days. Our model, trained on 111,319 TTE videos, distinguished TTEs in AF from those in sinus rhythm with high accuracy in a held-out test cohort (AUC 0.96 (0.95–0.96), AUPRC 0.91 (0.90–0.92)). Among TTEs in sinus rhythm, the model predicted the presence of concurrent paroxysmal AF (AUC 0.74 (0.71–0.77), AUPRC 0.19 (0.16–0.23)). Model discrimination remained similar in an external cohort of 10,203 TTEs (AUC of 0.69 (0.67–0.70), AUPRC 0.34 (0.31–0.36)). Performance held across patients who were women (AUC 0.76 (0.72–0.81)), older than 65 years (0.73 (0.69–0.76)), or had a CHA2DS2VASc ≥2 (0.73 (0.79–0.77)). The model performed better than using clinical risk factors (AUC 0.64 (0.62–0.67)), TTE measurements (0.64 (0.62–0.67)), left atrial size (0.63 (0.62–0.64)), or CHA2DS2VASc (0.61 (0.60–0.62)). An ensemble model in a cohort subset combining the TTE model with an electrocardiogram (ECGs) deep learning model performed better than using the ECG model alone (AUC 0.81 vs. 0.79, p = 0.01). Deep learning using TTEs can predict patients with active or occult AF and could be used for opportunistic AF screening that could lead to earlier treatment.
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Xiao, Ran, Christopher R. Broda, Darren Harrison, Shivani R. Aggarwal, Peter R. Ermis, Angeline Opina, Wayne Franklin, Dhaval R. Parekh, and Wilson W. Lam. "Abstract 16879: Utility of Transthoracic Echocardiography in Adult Patients With D-Transposition of the Great Arteries and Atrial Switch Operation." Circulation 142, Suppl_3 (November 17, 2020). http://dx.doi.org/10.1161/circ.142.suppl_3.16879.
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Introduction: Per 2018 ACC AHA adult congenital heart disease guidelines, routine transthoracic echocardiography (TTE) is recommended for follow-up in patients with d-transposition of the great arteries (dTGA) after atrial switch operation at least annually. Little data are available to suggest utility in clinical management with frequent surveillance, either with or without symptoms. Hypothesis: We hypothesized that frequent TTEs would not lead to significant clinical changes in management and that TTEs performed for symptoms would lead to more detection of pathology and clinically relevant management decisions. Methods: We conducted a retrospective review of all echocardiograms performed for dTGA patients corrected with the atrial switch procedure at Texas Children’s Hospital from 2000-2009 to obtain baseline TTEs and 2010-2019 to analyze for changes in clinical management, associated with TTE performance. Results: We identified 50 patients with dTGA and atrial switch operation with 54% Mustard operation. A total of 333 echocardiograms were performed (6.7/person), 30% (100) with symptoms. The average age at time of all TTEs was 35 +/- 11 years. Most frequent symptoms were palpitations (n=39), dyspnea (n=30), and fatigue (n=27). Changes in management occurred after 9% of studies (10/100 of symptomatic, 21/233 asymptomatic patients, p = NS). Most of these were medication changes (n=18, 11 asymptomatic) and advanced imaging (n=12, 9 asymptomatic). Invasive management after TTE was rare (1 baffle stenting in asymptomatic patient) but after advanced imaging included 4 baffle stent implantations (3 asymptomatic). The interval between TTEs was 1.2 +/- 0.9 years, regardless of symptoms. Conclusions: In dTGA patients after atrial switch operation, routine screening TTEs and symptomatic TTEs had similar yield in detecting pathology leading to a clinical change in management. TTE and subsequent advanced imaging preceded invasive intervention (baffle stenting) in 10% of patients, mostly asymptomatic. Less frequent surveillance TTEs in asymptomatic and advanced imaging in symptomatic dTGA patients with atrial switch operation is cost-effective and should be considered .
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Kalwani, Neil M., Samantha M. R. Kling, Stacie Vilendrer, Donn W. Garvert, Darlene Veruttipong, Juliana Baratta, Erika A. Saliba-Gustafsson, et al. "Electronic Health Record Alert to Promote Adoption of Limited Transthoracic Echocardiograms in Primary Care and Cardiology Clinics: A Mixed Methods Evaluation." Circulation: Cardiovascular Quality and Outcomes 17, no. 11 (November 2024). http://dx.doi.org/10.1161/circoutcomes.123.010621.
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BACKGROUND: A limited transthoracic echocardiogram (TTE) can be an appropriate, lower-cost substitute for a full TTE. We assessed the impact of an electronic health record alternative alert promoting the adoption of limited TTEs on the ordering practices of cardiology clinicians and primary care providers and captured their perspectives on the initiative. METHODS: The alert was deployed in a cardiology clinic and 4 primary care clinics at an academic medical center. The alert provided clinical guidance on the appropriate use of limited TTEs when a clinician selected a full TTE order. We used logistic regression to estimate the change in the proportion of limited versus full TTEs ordered between the baseline and intervention periods in clinics with and without the alert. We also conducted interviews with 24 clinicians (5 cardiologists and 19 primary care providers) to identify implementation barriers and facilitators. RESULTS: Cardiology clinicians ordered 10 654 and 3761 TTEs during the baseline and intervention periods, respectively, for 9100 patients. Primary care providers ordered 723 and 617 TTEs during the baseline and intervention periods for 1273 patients. The model estimated that the percentage of limited TTEs ordered increased by 16.1±2.3 percentage points ( P <0.0001) in the cardiology clinic with the alert and by 13.2±1.5 percentage points ( P <0.0001) in the primary care clinics with the alert from baseline to post-intervention. Ordering practices did not change in the cardiology (0.7±0.6 percentage points; P =0.24) or primary care (0.7±1.0 percentage points; P =0.52) clinics without the alert. Clinicians viewed the alert as acceptable. Cardiologists appreciated that the alert was concise, whereas primary care providers wanted more information from the alert. CONCLUSIONS: An alternative alert providing clinical guidance on the use of limited TTEs at the point of care increased the selection of this lower-cost test in cardiology and primary care clinics. Perspectives on the alert differed between specialists and nonspecialists, highlighting the importance of tailoring intervention design to clinical expertise.
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Hyland, Patrick M., Jiaman Xu, Changyu Shen, Lawrence Markson, Warren J. Manning, and Jordan B. Strom. "Abstract 15407: Comorbidities and the Associated Long-term Utilization of Transthoracic Echocardiography Among Medicare Beneficiaries at a Large Academic Center." Circulation 142, Suppl_3 (November 17, 2020). http://dx.doi.org/10.1161/circ.142.suppl_3.15407.
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Introduction: The association between baseline patient characteristics and the long-term utilization of transthoracic echocardiography (TTE) is unknown and may help focus value-based care initiatives. Methods: TTE reports from patients with ≥ 2 TTEs at our institution were linked to 100% Medicare Fee-for-service inpatient claims, 1/1/2000 – 12/31/2017. To avoid inclusion of individuals with short-interval follow-up, TTEs with < 1 year between studies were excluded. Validated claims algorithms were used to create 12 baseline cardiovascular comorbidities. Multivariable Poisson regression was used to estimate adjusted rates of TTE intensity according to baseline comorbidities. Results: Over a median (IQR) follow-up of 5.8 (3.1 – 9.5) years, 18,579 individuals (69.3 ± 12.8 years; 50.5% female) underwent a total of 59,759 TTEs (range 2 – 59). The median TTE intensity was 0.64 TTEs/patient/year (IQR 0.35 – 1.24; range 0.11 – 22.02). The top five contributors to TTE intensity were heart failure, chronic kidney disease, history of myocardial infarction, smoking, and hyperlipidemia ( Figure ). Female sex was associated with decreased TTE utilization (adjusted RR 0.95, 95% CI 0.94-0.96, p < 0.0001). Atrial fibrillation, hypertension, and history of ischemic stroke or transient ischemic attack were not significantly related to TTE intensity after multivariable adjustment (all p > 0.05). Conclusions: Among Medicare beneficiaries with ≥ 2 TTEs at our institution, the median TTE intensity was 0.64 TTEs/patient/year but varied widely. Heart failure, chronic kidney disease, and history of myocardial infarction were the strongest predictors of increased utilization. Female sex was associated with decreased utilization, reflecting broader disparities in utilization of cardiovascular procedures. Further research is needed to clarify reasons for this sex disparity and associations with cardiovascular outcomes.
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Li, Jie, Lei Yue, Zhihua Li, Wenting Zhang, Bing Zhang, Fangqing Zhao, and Xiuzhu Dong. "aCPSF1 cooperates with terminator U-tract to dictate archaeal transcription termination efficacy." eLife 10 (December 29, 2021). http://dx.doi.org/10.7554/elife.70464.
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Recently, aCPSF1 was reported to function as the long-sought global transcription termination factor of archaea; however, the working mechanism remains elusive. This work, through analyzing transcript-3′end-sequencing data of Methanococcus maripaludis, found genome-wide positive correlations of both the terminator uridine(U)-tract and aCPSF1 with hierarchical transcription termination efficacies (TTEs). In vitro assays determined that aCPSF1 specifically binds to the terminator U-tract with U-tract number-related binding affinity, and in vivo assays demonstrated the two elements are indispensable in dictating high TTEs, revealing that aCPSF1 and the terminator U-tract cooperatively determine high TTEs. The N-terminal KH domains equip aCPSF1 with specific-binding capacity to terminator U-tract and the aCPSF1-terminator U-tract cooperation; while the nuclease activity of aCPSF1 was also required for TTEs. aCPSF1 also guarantees the terminations of transcripts with weak intrinsic terminator signals. aCPSF1 orthologs from Lokiarchaeota and Thaumarchaeota exhibited similar U-tract cooperation in dictating TTEs. Therefore, aCPSF1 and the intrinsic U-rich terminator could work in a noteworthy two-in-one termination mode in archaea, which may be widely employed by archaeal phyla; using one trans-action factor to recognize U-rich terminator signal and cleave transcript 3′-end, the archaeal aCPSF1-dependent transcription termination may represent a simplified archetypal mode of the eukaryotic RNA polymerase II termination machinery.
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Gupta, Kush, Neil M. Kalwani, Cindie Gaspar, Zarrina Bobokalonova, Ria Paul, Sandra Tsai, and Eleanor Levin. "Abstract 81: Appropriateness And Clinical Utility Of Echocardiograms For (Pre)Syncope And Palpitations In An Academic Primary Care Practice." Circulation: Cardiovascular Quality and Outcomes 15, Suppl_1 (May 2022). http://dx.doi.org/10.1161/circoutcomes.15.suppl_1.81.
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Introduction: Patients with (pre)syncope and palpitations are often assessed in primary care clinic. Guidelines recommend evaluation with history, physical exam, and an EKG followed by a transthoracic echocardiogram (TTE) only when structural heart disease is suspected. Hypothesis: We hypothesized that many TTEs ordered for (pre)syncope and palpitations from primary care clinic do not meet appropriateness criteria. Methods: We reviewed charts for TTE orders for (pre)syncope and palpitations from the primary care clinics of a large academic health system from 9/1/20 - 4/30/21. We extracted visit type, evaluation completed prior to the TTE order, and TTE findings. Appropriateness was assessed based on published clinical guidelines and practice recommendations. Results: During the study period, 6.0% of all TTEs ordered (31/520) were for (pre)syncope and 5.4% were for palpitations. Of these, 39% for (pre)syncope and 46% for palpitations met appropriateness criteria. At the time of the TTE order, 51% (30/59) of patients had a recent physical exam and 63% (37/59) had an EKG or cardiac monitor completed in the past 6 months. Of the visits completed, 42% (25/59) were virtual / telemedicine, and the rate of TTE appropriateness did not differ between virtual and in-person visits (40%, 10/25 vs 44%, 15/34, p=0.752). Of the TTEs completed, 7% (2/29) for (pre)syncope and 17% (4/23) for palpitations revealed clinically significant findings. The proportion of TTEs with clinically significant findings was low for both studies deemed appropriate and inappropriate (14.3%, 3/21 vs 9.7%, 3/31, p=0.610). Conclusions: At this primary care practice, a large proportion of TTEs ordered for (pre)syncope and palpitations did not meet appropriateness criteria. Few TTEs deemed inappropriate revealed clinically significant findings. Improved education and decision support for these clinical scenarios may increase appropriate use of cardiac imaging and decrease costs.
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Goel, Swecha, Kevin Bliden, Sahib Singh, Aravind Dilli Babu, Nivedita Kharkongor Chengappa, Chiranjeevi Sainatham, Lekshminarayan Raghavakurup, Damian Sidorski, and Paul Gurbel. "Abstract 18420: Appropriateness and Cost Analysis of Adult Inpatient Transthoracic Echocardiograms in a Community Hospital." Circulation 148, Suppl_1 (November 7, 2023). http://dx.doi.org/10.1161/circ.148.suppl_1.18420.
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Introduction: Although inpatient transthoracic echocardiograms (TTEs) are important for guiding patient management, their overuse could be a concern leading to delayed discharges, unnecessary burden on hospital staff, and increased hospital costs. We analyzed the appropriateness, benefits, cost expenditure and unnecessary burden of TTE testing. Methods: A retrospective cohort analysis of a subset of patients undergoing TTEs in 2022 from a community hospital was performed. Appropriateness of use criteria (AUC) in accordance with American Society of Echocardiography and alteration in medical management was evaluated by 3 independent reviewers. Hospital cost analysis was performed based on median TTE cost ($682), yearly total adult TTEs performed (n=4,636), AUC criteria, and alteration in management under Maryland all-payer insurance model. Results: In 234 TTEs matched by age, gender, and race, AUC was not met in 32.5% of patients. Most TTEs were indicated for LV function assessment and ACS (Figure). Change in management was significantly higher in patients who met vs. not meeting AUC (54 vs. 11%, p<0.001). In patients meeting AUC, men had a higher change in management compared to women (61 vs. 46%, p = 0.05). No significant differences were found in the percentage of patients who benefitted from inpatient TTE by subgroups based on indications, except for cardiac trauma. Inappropriate TTE testing led to a yearly loss of approximately $313,000 in hospital revenue and an additional loss of $150,000/year for every 5% of patients who meet AUC with no alteration in medical management. Conclusion: In this community hospital analysis, nearly one-third of adult inpatient TTEs were obtained outside the recommendations of established guidelines. Strategies to improve adherence to ASE guidelines and patient selection for TTE testing are warranted to reduce unnecessary resource utilization and healthcare costs.
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Hanania, Richard, and Max Abrahms. "What Do Think Tanks Think? Proximity to Power and Foreign Policy Preferences." Foreign Policy Analysis 19, no. 1 (December 12, 2022). http://dx.doi.org/10.1093/fpa/orac031.
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Abstract Through the use of survey methods, the study presents the first systematic comparison of America-based international relations professors to think tank employees (TTEs) in terms of their preferred conduct of the United States in international affairs. The difference between the two groups in their support for military intervention is stark. TTEs are 0.47 standard deviations more hawkish than professors based on a standard measure of militant internationalism (MI). Controlling for self-described ideology mitigates this effect although it remains statistically significant. Beyond quantifying their relative foreign policy preferences, this study helps to resolve why TTEs tend to assume more hawkish policies. The authors find evidence that hawkishness is associated with proximity to power. Professors who have worked for the federal government score higher on MI, as do TTEs based at institutions located closer to Capitol Hill. In general, the results point to a self-selection mechanism whereby those who favor interventionist policies are more likely to pursue positions to increase their policy influence, perhaps because they know that powerful institutions are more likely to hire hawks. Alternative explanations for differences, such as levels or kinds of foreign policy expertise, have weaker empirical support.
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Fernandes, Benedicto A., Tracey M. Thompson, Ty E. Hasselman, and David Jantzen. "Abstract 16645: Comparison of Primary Care Providers and Pediatric Cardiologists in the Appropriateness Use Criteria and Associated Cost Differences for Outpatient Pediatric Echocardiograms." Circulation 138, Suppl_1 (November 6, 2018). http://dx.doi.org/10.1161/circ.138.suppl_1.16645.
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Introduction: Appropriate use criteria (AUC) have been established for the transthoracic echocardiogram (TTE) in pediatric cardiology, but, in many labs, echocardiograms can be ordered by the primary care provider (PCP). There is limited data comparing appropriateness between pediatric cardiologists and PCPs and the associated costs of rarely appropriate echocardiograms. Hypothesis: Pediatric cardiologists order less rarely appropriate TTEs and have a lower proportion of cost attributed to rarely appropriate studies. Methods: Patients with initial outpatient pediatric or congenital TTE ordered by a pediatric cardiologist or PCP and interpreted at our institution from November 2016 to October 2017 were included. Appropriateness of TTE indications were classified as appropriate, maybe appropriate, rarely appropriate, and unclassifiable. TTE findings were classified as normal, incidental or abnormal. TTE cost was estimated using the Healthcare Bluebook. The sum cost of rarely appropriate TTEs was divided by total number of patients in each group (pediatric cardiologists vs. PCPs). Data was compared using chi-squared testing. Results: 311 pediatric cardiology and 193 PCP patients were included for analysis. Two percent of pediatric cardiology and 18% of PCP TTE indications were unclassifiable. Of those classified, pediatric cardiologists had a higher rate of appropriate TTEs compared to PCPs (69% vs. 35%; p<0.001) and lower rate of rarely appropriate TTEs (17% vs. 62%; p<0.001). Abnormalities were present in 13% of TTEs ordered by pediatric cardiologists compared to 3% ordered by PCPs (p<0.001). Based on cost of $526 per TTE, $326 per patient was attributed to rarely appropriate indications when ordered by PCPs compared to $90 per patient for pediatric cardiologists. This cost difference decreases substantially when taking referral and ECG costs into account ($326 vs $273). Conclusions: PCPs order more rarely appropriate TTEs, and subsequently have a higher cost incurred per TTE for rarely appropriate indications. However, this cost difference decreases substantially when taking into account referral and ECG costs. Therefore, PCP education of the AUC would have a significant impact in reducing cost for rarely appropriate indications.
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Anderson, David Roy, Sarah Blissett, Patricia O’Sullivan, and Atif Qasim. "Differences in echocardiography interpretation techniques among trainees and expert readers." Journal of Echocardiography, May 29, 2021. http://dx.doi.org/10.1007/s12574-021-00531-y.
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Abstract Background Trainees learn transthoracic echocardiogram (TTE) interpretation through independently completing and reviewing selected portions of the study with experts. The diagnostic accuracy of novice TTE interpretation is known to be low and schema for reading TTEs systematically are lacking. The purpose of our study is to identify techniques experts use while reading TTEs which could be used to more effectively teach novice readers. Methods We performed a prospective qualitative case study to observe how experts and trainees interpret TTEs in an academic institution using a concurrent think aloud (CTA) method. Three TTEs of intermediate complexity were given to 3 advanced imaging fellows, 3 first year fellows and 3 expert TTE readers Participants filled out a report while reading and described aloud their thought processes. Sessions were video and audiotaped for analysis. Results Experts and advanced fellows used specific techniques that novices did not including: previewing studies, reviewing multiple images simultaneously, having flexibility in image review order and disease coding, and saving hardest elements to code for the end. Direct observation of TTE reading informed trainee inefficiencies and was a well-received educational tool. Conclusions In this single centered study we identified several unique approaches experts use to interpret TTEs which may be teachable to novices. Although limited in generalizability the findings of this study suggests that a more systematic approach to TTE interpretation, using techniques found in experts, might be of significant value for trainees. Further study is needed to evaluate teaching practices at other institutions and to assess whether implementation of these techniques by novices improves can improve their diagnostic accuracy and efficiency of reading at an earlier stage in their training.
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Fijany, Arman J., Sara C. Chaker, Ya-Ching Hung, Ilana Zago, Nicole Friedlich, Sofia E. Olsson, Lisandro Montorfano, et al. "Complication Profiles of Smooth vs Textured Tissue Expanders in Breast Reconstruction: A Systematic Review and Meta-Analysis." Aesthetic Surgery Journal, September 27, 2023. http://dx.doi.org/10.1093/asj/sjad319.
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Abstract Background Breast-Implant Associated-Anaplastic Large Cell Lymphoma (BIA-ALCL) is a type of non-Hodgkin lymphoma first linked with breast implants in 2011. The correlation between BIA-ALCL and textured devices has led to increased use of smooth devices. However, much of the data surrounding smooth and textured devices investigates breast implants specifically and not tissue expanders (TEs). Objectives We performed a systematic review and a meta-analysis to compare surgical outcomes for smooth tissue expanders (STEs) and textured tissue expanders (TTEs). Methods A search was performed on PubMed, including articles from 2016 to 2023 (n = 419). Studies comparing TTEs and STEs and reported complications were included. A random-effects model was utilized for meta-analysis. Results A total of 5 articles met inclusion criteria, representing 1,709 patients in the STE cohort and 1,716 patients in the TTE cohort. The mean duration of tissue expansion with STEs was 221.25 days, while TTEs had a mean time of tissue expansion of 220.43 days. Our meta-analysis found no differences in all surgical outcomes besides explantation risk. STE use was associated with increasing odds of explantation by over 50% compared to TTE use [OR = 1.53; 95% CI = 1.15 to 2.02; P = 0.003]. Conclusions Overall, STE and TTE had similar complication profiles. However, STE had 1.5 times higher odds of explantation. The incidence of BIA-ALCL is low, and only a single BIA-ALCL has been reported with TTEs. This indicates that TTEs are safe and may lower the risk of early complications requiring explantation. Further studies are warranted to further define the relationship between tissue expanders and BIA-ALCL.
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Hyland, Patrick M., Jiaman Xu, Changyu Shen, Lawrence J. Markson, Warren J. Manning, and Jordan B. Strom. "Race, sex and age disparities in echocardiography among Medicare beneficiaries in an integrated healthcare system." Heart, October 6, 2021, heartjnl—2021–319951. http://dx.doi.org/10.1136/heartjnl-2021-319951.
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ObjectiveTo identify potential race, sex and age disparities in performance of transthoracic echocardiography (TTE) over several decades.MethodsTTE reports from five academic and community sites within a single integrated healthcare system were linked to 100% Medicare fee-for-service claims from 1 January 2005 to 31 December 2017. Multivariable Poisson regression was used to estimate adjusted rates of TTE utilisation after the index TTE according to baseline age, sex, race and comorbidities among individuals with ≥2 TTEs. Non-white race was defined as black, Asian, North American Native, Hispanic or other categories using Medicare-assigned race categories.ResultsA total of 15 870 individuals (50.1% female, mean 72.2±12.7 years) underwent a total of 63 535 TTEs (range 2–55/person) over a median (IQR) follow-up time of 4.9 (2.4–8.5) years. After the index TTE, the median TTE use was 0.72 TTEs/person/year (IQR 0.43–1.33; range 0.12–26.76). TTE use was lower in older individuals (relative risk (RR) for 10-year increase in age, 0.91, 95% CI 0.89 to 0.92, p<0.001), women (RR 0.97, 95% CI 0.95 to 0.99, p<0.001) and non-white individuals (RR 0.95, 95% CI 0.93 to 0.97, p<0.001). Black women in particular had the lowest relative use of TTE (RR 0.92, 95% CI 0.88 to 0.95, p<0.001). The only clinical conditions associated with increased TTE use after multivariable adjustment were heart failure (RR 1.04, 95% CI 1.00 to 1.08, p=0.04) and chronic obstructive pulmonary disease (RR 1.05, 95% CI 1.00 to 1.10, p=0.04).ConclusionsAmong Medicare beneficiaries with multiple TTEs in a single large healthcare system, the median TTE use after the index TTE was 0.72 TTEs/person/year, although this varied widely. Adjusted for comorbidities, female sex, non-white race and advancing age were associated with decreased TTE utilisation.
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Sachdeva, Ritu, Michael S. Kelleman, Courtney McCracken, Joseph Allen, Oscar Benavidez, Robert M. Campbell, Pamela S. Douglas, et al. "Abstract 14711: Effect of Release of the First Pediatric Appropriate Use Criteria on Outpatient Transthoracic Echocardiogram Ordering Practice." Circulation 132, suppl_3 (November 10, 2015). http://dx.doi.org/10.1161/circ.132.suppl_3.14711.
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Background: The first pediatric appropriate use criteria (PAUC) were recently published for initial outpatient transthoracic echocardiography (TTE). We sought to determine the effect of release of the PAUC on the appropriateness of TTE ordering patterns of pediatric cardiologists. Methods: Data were prospectively collected from patients having initial outpatient TTE ordered prior to (Phase I, 6 mo) and 3 months after release (Phase II, 4 mo) of PAUC. Site-investigators determined the indication of the study and assigned appropriateness rating based on the PAUC document [Appropriate (A), May Be Appropriate (M), or Rarely Appropriate (R)] or "Unclassifiable" (U). Results: A total of 4562 TTEs (2655 Phase I, 1907 Phase II) were ordered by 103 physicians at 6 sites. Overall comparison of appropriateness rating for Phase I and II showed no change in the rate for A or M, but a decline in the rate of R and increase in U. Similar results were noted when comparisons were made for physicians that ordered at least 20 TTEs during each phase (N = 30/103, 29%), Table 1. There was no change in any appropriateness rating at 3 sites, a decline in R at 2, an increase in A at 1, and an increase in U at 2 sites. Overall and site-specific comparisons of rate of R TTEs are shown in Fig 1. Conclusions: The release of PAUC document had only a small impact on physician ordering behavior for initial TTEs, including a small decrease in R. Overall, these data suggest that more focused interventions are required to fully implement guideline recommendations and improve the appropriate use of pediatric TTE. This information should be helpful in designing educational interventions to reduce the rate of TTEs ordered for R indications.
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Riley, Alan F., Rachael Rose, Susan Denfield, James A. Thomas, Adam M. Vogel, Ryan Coleman, and Fong Wilson Lam. "Assessment of echocardiographic interpretation of dual‐lumen cannula during venovenous extracorporeal membrane oxygenation use for pediatric respiratory failure." Echocardiography 41, no. 7 (July 2024). http://dx.doi.org/10.1111/echo.15878.
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AbstractPurposeEchocardiography is considered essential during cannulation placement and manipulations. Literature evaluating transthoracic echocardiography (TTE) usage during pediatric VV‐ECMO is scant. The purpose of this study is to describe the use of echocardiography during VV‐ECMO at a large, quaternary children's hospital.MethodsA retrospective, single‐year cohort study was performed of pediatric patients on VV‐ECMO via dual‐lumen cannula at our institution from January 2019 through December 2019. For each echocardiogram, final cannula component (re‐infusion port (ReP), distal tip, proximal port and distal port) positions were evaluated by one echocardiographer. For TTEs with ReP in the right atrium, two echocardiographers independently evaluated ReP direction using 2‐point (Yes/No) and 4‐point scales, which were semi‐quantitative protocols using color Doppler images to estimate ReP jet direction to the tricuspid valve. Cohen's kappa or weighted kappa was used to measure interrater agreement.ResultsDuring study period, 11 patients (64% male) received VV‐ECMO with 49 TTEs and one transesophageal echocardiogram performed. The median patient age was 4.3 years [IQR: 1.1–11.5] and median VV‐ECMO run time of 192 h [90–349]. The median time between TTEs on VV‐ECMO was 34 h [8.3–65]. Most common position for the ReP was the right atrium (n = 33, 67%), and ReP location was not identified in five TTEs (10%). For ReP flow direction, echocardiographers agreed on 82% of TTEs using 2‐point evaluation. There was only moderate agreement between echocardiographers on the 2‐point and 4‐point assessments (k = .54, kw = .46 respectively).ConclusionsTTE is the predominant cardiac ultrasound modality used during VV‐ECMO for pediatric respiratory failure. Subjective evaluation of VV‐ECMO ReP jet direction in the right atrium is challenging, regardless of assessment method.