text:
Automated buildings
More general concepts than this:
- Sort by:
- Newest first
- Titles A to Z
Filter by subject:
- Computer and control engineering [48]
- Control technology [48]
- Control applications [48]
- Automated buildings [48]
- Computer software [48]
- Software techniques and systems [48]
- Computer applications [48]
- Engineering computing [39]
- Control engineering computing [39]
- Other computer applications [35]
- [34]
- http://iet.metastore.ingenta.com/content/subject/c6180,http://iet.metastore.ingenta.com/content/subject/c6150,http://iet.metastore.ingenta.com/content/subject/c6150n,http://iet.metastore.ingenta.com/content/subject/c6170,http://iet.metastore.ingenta.com/content/subject/c5000,http://iet.metastore.ingenta.com/content/subject/b,http://iet.metastore.ingenta.com/content/subject/b6000,http://iet.metastore.ingenta.com/content/subject/c6170k,http://iet.metastore.ingenta.com/content/subject/b6200,http://iet.metastore.ingenta.com/content/subject/c6130,http://iet.metastore.ingenta.com/content/subject/c5200,http://iet.metastore.ingenta.com/content/subject/b6210,http://iet.metastore.ingenta.com/content/subject/b6210l,http://iet.metastore.ingenta.com/content/subject/c5260,http://iet.metastore.ingenta.com/content/subject/c5600,http://iet.metastore.ingenta.com/content/subject/c5620,http://iet.metastore.ingenta.com/content/subject/c6110,http://iet.metastore.ingenta.com/content/subject/c1000,http://iet.metastore.ingenta.com/content/subject/b6100,http://iet.metastore.ingenta.com/content/subject/b6250,http://iet.metastore.ingenta.com/content/subject/b7000,http://iet.metastore.ingenta.com/content/subject/c0000,http://iet.metastore.ingenta.com/content/subject/c0200,http://iet.metastore.ingenta.com/content/subject/c0240,http://iet.metastore.ingenta.com/content/subject/c3200,http://iet.metastore.ingenta.com/content/subject/c3240,http://iet.metastore.ingenta.com/content/subject/c5500,http://iet.metastore.ingenta.com/content/subject/c6130s,http://iet.metastore.ingenta.com/content/subject/b0000,http://iet.metastore.ingenta.com/content/subject/b6135,http://iet.metastore.ingenta.com/content/subject/b7200,http://iet.metastore.ingenta.com/content/subject/c1100,http://iet.metastore.ingenta.com/content/subject/c1140,http://iet.metastore.ingenta.com/content/subject/c5260b,http://iet.metastore.ingenta.com/content/subject/c5540,http://iet.metastore.ingenta.com/content/subject/b0200,http://iet.metastore.ingenta.com/content/subject/b0240,http://iet.metastore.ingenta.com/content/subject/b7230,http://iet.metastore.ingenta.com/content/subject/c1140z,http://iet.metastore.ingenta.com/content/subject/c1300,http://iet.metastore.ingenta.com/content/subject/c1340,http://iet.metastore.ingenta.com/content/subject/c1340f,http://iet.metastore.ingenta.com/content/subject/c3240n,http://iet.metastore.ingenta.com/content/subject/c5540b,http://iet.metastore.ingenta.com/content/subject/c5620l,http://iet.metastore.ingenta.com/content/subject/c6110j,http://iet.metastore.ingenta.com/content/subject/c6110l,http://iet.metastore.ingenta.com/content/subject/c7100,http://iet.metastore.ingenta.com/content/subject/c7410,http://iet.metastore.ingenta.com/content/subject/e,http://iet.metastore.ingenta.com/content/subject/b0100,http://iet.metastore.ingenta.com/content/subject/b0170,http://iet.metastore.ingenta.com/content/subject/b0170l,http://iet.metastore.ingenta.com/content/subject/b0240j,http://iet.metastore.ingenta.com/content/subject/b0240z,http://iet.metastore.ingenta.com/content/subject/b1000,http://iet.metastore.ingenta.com/content/subject/b1200,http://iet.metastore.ingenta.com/content/subject/b1265,http://iet.metastore.ingenta.com/content/subject/b1265f,http://iet.metastore.ingenta.com/content/subject/b6130,http://iet.metastore.ingenta.com/content/subject/b6130e,http://iet.metastore.ingenta.com/content/subject/b6135e,http://iet.metastore.ingenta.com/content/subject/b6230,http://iet.metastore.ingenta.com/content/subject/b6250f,http://iet.metastore.ingenta.com/content/subject/b6250z,http://iet.metastore.ingenta.com/content/subject/b6400,http://iet.metastore.ingenta.com/content/subject/b6430,http://iet.metastore.ingenta.com/content/subject/b6430f,http://iet.metastore.ingenta.com/content/subject/b6430g,http://iet.metastore.ingenta.com/content/subject/b7210,http://iet.metastore.ingenta.com/content/subject/b7230g,http://iet.metastore.ingenta.com/content/subject/b7500,http://iet.metastore.ingenta.com/content/subject/b7510,http://iet.metastore.ingenta.com/content/subject/b7510d,http://iet.metastore.ingenta.com/content/subject/b8000,http://iet.metastore.ingenta.com/content/subject/b8500,http://iet.metastore.ingenta.com/content/subject/b8550,http://iet.metastore.ingenta.com/content/subject/c1140j,http://iet.metastore.ingenta.com/content/subject/c1200,http://iet.metastore.ingenta.com/content/subject/c1230,http://iet.metastore.ingenta.com/content/subject/c1230l,http://iet.metastore.ingenta.com/content/subject/c3240k,http://iet.metastore.ingenta.com/content/subject/c3240m,http://iet.metastore.ingenta.com/content/subject/c3340,http://iet.metastore.ingenta.com/content/subject/c3340b,http://iet.metastore.ingenta.com/content/subject/c3370,http://iet.metastore.ingenta.com/content/subject/c3370l,http://iet.metastore.ingenta.com/content/subject/c3390,http://iet.metastore.ingenta.com/content/subject/c3390c
- c6180,c6150,c6150n,c6170,c5000,b,b6000,c6170k,b6200,c6130,c5200,b6210,b6210l,c5260,c5600,c5620,c6110,c1000,b6100,b6250,b7000,c0000,c0200,c0240,c3200,c3240,c5500,c6130s,b0000,b6135,b7200,c1100,c1140,c5260b,c5540,b0200,b0240,b7230,c1140z,c1300,c1340,c1340f,c3240n,c5540b,c5620l,c6110j,c6110l,c7100,c7410,e,b0100,b0170,b0170l,b0240j,b0240z,b1000,b1200,b1265,b1265f,b6130,b6130e,b6135e,b6230,b6250f,b6250z,b6400,b6430,b6430f,b6430g,b7210,b7230g,b7500,b7510,b7510d,b8000,b8500,b8550,c1140j,c1200,c1230,c1230l,c3240k,c3240m,c3340,c3340b,c3370,c3370l,c3390,c3390c
- [22],[20],[20],[17],[16],[13],[12],[10],[9],[8],[7],[6],[6],[6],[6],[6],[6],[5],[4],[4],[4],[4],[4],[4],[4],[4],[4],[4],[3],[3],[3],[3],[3],[3],[3],[2],[2],[2],[2],[2],[2],[2],[2],[2],[2],[2],[2],[2],[2],[2],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1],[1]
- /search/morefacet;jsessionid=7g048i0g7g08.x-iet-live-01
- /content/searchconcept;jsessionid=7g048i0g7g08.x-iet-live-01?operator4=AND&operator5=AND&operator6=AND&pageSize=100&sortDescending=true&value5=c7000&value6=c3000&facetNames=contentType_facet+pub_concept_facet+pub_concept_facet+pub_concept_facet+pub_concept_facet+pub_concept_facet&value3=c6000&value4=c6100&option6=pub_concept_facet&value1=c3365&option5=pub_concept_facet&value2=ConferencePaper&facetOptions=2+3+4+5+6+7&option1=pub_concept&option2=contentType_facet&option3=pub_concept_facet&option4=pub_concept_facet&sortField=prism_publicationDate&operator3=AND&operator2=AND&operator7=AND&option7=pub_concept_facet&value7=
- See more See less
Filter by content type:
- ConferencePaper [48]
Filter by publication date:
Filter by author:
- H. Hagras [3]
- V. Callaghan [3]
- C. Magerkurth [2]
- C. Rocker [2]
- G. Pratl [2]
- R. Etter [2]
- A. Almeida [1]
- A. Alvarez [1]
- A. Alvi [1]
- A. Arcos [1]
- A. Kroner [1]
- A. Lopez [1]
- A. Wolisz [1]
- A.L. Dexter [1]
- A.M. Theodoraki [1]
- A.S. Crandall [1]
- B. Daugherty [1]
- B. Dhoedt [1]
- B. Knowles [1]
- B. Mrohs [1]
- B. Qiao [1]
- B. de Ruyter [1]
- C. Bull [1]
- C. Elting [1]
- C. Monson [1]
- C. Myers [1]
- C. Newcombe [1]
- C. Ressel [1]
- C.R. Baker [1]
- D. Alvarez [1]
- D. Atkins [1]
- D. Bertini [1]
- D. Clements-Croome [1]
- D. Cook [1]
- D. Garcia [1]
- D. Gilgen [1]
- D. Greaves [1]
- D. Lopez-de-Ipina [1]
- D. Lukianow [1]
- D. Makris [1]
- D. McCarthy [1]
- D. Miller [1]
- D. Ngo [1]
- D. Rohlfing [1]
- D. Sainz [1]
- Dechuan Chen [1]
- E. Brainin [1]
- E. De Buyser [1]
- E. De Coninck [1]
- E. Naroska [1]
- E. Skorpen [1]
- F. Doctor [1]
- F. Ramparany [1]
- F. Rivera-Illingworth [1]
- G. Kortuem [1]
- H. Kautz [1]
- H. Tanaka [1]
- H.A. Boyes [1]
- I. Garcia [1]
- J. Anderson [1]
- J. Dooley [1]
- J. Fernandez [1]
- J. Kela [1]
- J. Koch [1]
- J. Maisonnasse [1]
- J. Rabaey [1]
- J. Ries [1]
- J. Sloss [1]
- J. Wawrzynek [1]
- J. Ziegler [1]
- J. van Greunen [1]
- J.I. Vazquez [1]
- J.L. Crowley [1]
- K. Berns [1]
- K. Clarke [1]
- K. Jormakka [1]
- K. Liu [1]
- K.I. Wang [1]
- Kai Fu [1]
- L. Introna [1]
- L. Vidmar [1]
- M. Anastasopoulos [1]
- M. Anderson [1]
- M. Bronder [1]
- M. Colagrosso [1]
- M. Fontenot [1]
- M. Inakage [1]
- M. Janse [1]
- M. Mikusz [1]
- M. Moccia [1]
- M. Mozer [1]
- M. Schneider [1]
- M. Weeks [1]
- M. Welch [1]
- M.R. Lewin [1]
- Meifang Wang [1]
- N. Davies [1]
- N. Hayes [1]
- N. Herrasti [1]
- N. Sabouret [1]
- See more See less
Mobile computing and the IoT offer the potential to provide new applications to support our ageing population. However, there has been little research into the implications for system design of supporting this specific user demographic. In this paper we consider these implications, focusing in particular on an architectural design that offers the potential for complex cross-device analytics while meeting the privacy and usability concerns of older adults.
The concept of an intelligent building has existed for over 30 years and is seen as a solution to a number of economic and environmental problems. Intelligent buildings are often seen as a means of improving the energy efficiency of the built environment. However they are increasingly being promoted as a means of improving the operational efficiency of buildings, providing enhanced building and personal security, and improving the availability of management information to support better and quicker decision making. The potential cyber security risks inherent in the adoption of intelligent buildings are rarely discussed.
Research on computer-based recognition of ordinary household activities of daily living (ADLs) has been spurred by the need for technology to support care of the elderly in the home environment. We address the issue of recognizing ADLs at multiple levels of detail by combining multi-view computer vision and radio-frequency identification (RFID)-based direct sensors. Multiple places in our smart home testbed are covered by distributed synchronized cameras with different imaging resolutions. Learning object appearance models without costly manual labeling is achieved by applying the RFID sensing. A hierarchical recognition scheme is proposed by building a dynamic Bayesian network (DBN) that encompasses both coarse-level and fine-level ADL recognition. Advantages of the proposed approach include robust segmentation of objects, view-independent tracking and representation of objects and persons in 3D space, efficient handling of occlusion, and the recognition of human activity at both a coarse and fine level of detail. (4 pages)
Intelligent environment research has resulted in many useful tools such as activity recognition, prediction, and automation. However, most of these techniques have been applied in the context of a single resident. A current looming issue for intelligent environment systems is performing these same techniques when multiple residents are present in the environment. In this paper we investigate the problem of attributing sensor events to individuals in a multi-resident intelligent environment. Specifically, we use a naive Bayesian classifier to identify the resident responsible for a unique sensor event. We present results of experimental validation in a real intelligent workplace testbed and discuss the unique issues that arise in addressing this challenging problem. (8 pages)
Wireless Building Management Systems (BMS) are an attractive option when it comes to building retrofitting due to the cost constraints introduced by wired systems. A crucial part of the wireless BMS is the initial planning stage, this process can be impossible for a designer to undertake, therefore highlighting the requirement for a software design tool to aid in this process. (4 pages)
A smart home is a house that is responsive to its inhabitants and their actions by being aware of their context. Potential applications for smart homes address economic and comfort aspects of living, or could provide unobtrusive support for the elderly or disabled to promote independent living. The basic building blocks of such a smart home is a computing system consisting of distributed sensors and actuators. Programming and maintaining such an infrastructure is challenging because suitable programming abstractions are currently missing. In this paper we introduce the notion of programmable space that lets the application developer perceive the smart home as an integrated runtime environment. This approach is implemented in a system called RuleCaster. Applications are developed in a high-level rule- based language. Our approach shows a notable simplification of application development and maintenance. To verify the utility of RuleCaster we use a scenario-based evaluation method.
The concept of ambient intelligence requires software architectures enabling machine intelligence in unstructured dynamic environments. Research in mobile robotics tries to address this field since many years and has successfully created several architectural concepts for behavior-based reactive systems. We describe the architectural and communication-oriented capabilities of the modular controller architecture (MCA) and how ambient intelligence systems may benefit from these. Especially the shared memory approach of MCA offers a great possibility to facilitate distributed dynamic applications. MCA has been developed for mobile robotics research, initially at the FZI in Karlsruhe (K.U. Scholl et al., 2001) and is under continuous development. MCA addresses primitive and object-related communication, re-usability, component-based development, hardware access and application distribution. We want to take a closer look on the MCA framework and how it is already in use within an assisted living environment, established during several projects at Fraunhofer IESE (J. Nehmer et al., 2006) (M. Becker et al., 2007). Several sensors and a mobile service unit were provided by the Robotics Research Lab and the MCA framework was used for service interconnection. An intelligent refrigerator, two human localisation technologies and the mobile service robot ARTOS have MCA running as described in section 3. We present our experiences with the modular controller architecture regarding the parameters identified by the ubiquitous community (M. Weiser, 1991). The outline of this paper is as follows: first the architectural approaches in other projects are mentioned. The modular controller architecture is described in detail, with focus on the requirements of ambient intelligence. We continue by describing our assisted living demonstrator and the services and applications relevant to this work. With reference to our example implementation we conclude the features of MCA that comply to the requirements. Furthermore it is described which future work shall lead to addons and concepts to overcome certain weaknesses in the current system architecture.
As digital technologies become increasingly pervasive, we might find ourselves living with almost invisible, intelligent interactive systems - an 'ambient intelligence' - that forms a part of our everyday existence and ecology. The implications of this development are far reaching for individuals, businesses and communities. Ambient intelligence could lead to great opportunities. But as with all new technologies, we know that the technology itself is neither good nor bad. It is how we might use it that makes the difference. The main challenge at this moment is to guarantee that the new ambient intelligence technologies are appropriate, sustainable and meet people's individual and social needs. The AMEC project explores how an ambient ecology of products, services and content that is adaptive and intuitive to use can support domestic life in the connected home of the future. (7 pages)
This paper discusses the potential of using computer vision systems to determine the usage of architectural spaces with the assistant of cameras. It describes a motion analysis system and explores how this functionality can be used by intelligent spaces to interact with the users in short-term, long-term or periodically, or to assess their usability. (8 pages)
In this paper, a novel physical testbed for intelligent environments and its software based multi-agent control system are presented. In the physical testbed, a fair amount of embedded sensors and actuators are interconnected in three types of physical networks, namely the LonWorks network, RS-485 network and IP network. Universal plug and play (UPnP) is introduced in the system architecture to provide unique control interface between high level multi-agent control system and low level devices on different physical networks. The multi-agent control system is developed on an existing agent platform, JAVA agent development framework (JADE). Fuzzy inference learning is implemented with multiple fuzzy inference agents, each models the human behaviour associated with a predefined group of devices in forms of fuzzy rules. Corresponding fuzzy logic controller agents can be initiated to provide user preferred control actions according to the fuzzy rule bases. A comparative analysis shows that our control system achieves a great improvement in both control accuracy and computational efficiency compared to other offline control systems. Online adaptive learning, automatic device group formation and advanced wireless device networks are within the scope of our system architecture. (10 pages)
This paper is a very brief summary of a research project which explores, through design and precedent survey, the potential of kinetic architecture to augment our kinesthetic experience of space. The term 'kinetic' here, refers to mechanical and actual motion of the structure which results to changes and modifications of the shape, form and position of the architecture. This research project regards kinetic architecture to be part of the wider context of interactive architecture and discusses issues of spatial experience through the design of an interactively kinetic room. (6 pages)
We propose in this paper a model for agent-based devices enhanced with reasoning and interactive features. More precisely, we present an interaction protocol that enables agents to answer received messages, according not only to their functionalities, but also to their role in the interaction they are involved into. This interaction protocol aims at making it possible for agents associated to physical appliances to dialogue and compose their functionalities so as to respond to a user requirement without any prior knowledge about other agents. (10 pages)
This paper introduces a novel way to enable users to create temporal smart surroundings easily at open-air events. The final goal of this research was to support social activities in public spaces, such as festivals, camps, and outdoor-ceremonies with ubiquitous computing technologies. We designed and developed universal modular units called "I/O-CRATEs", which are box-shaped units embedded with microcomputers, sensors, actuators, and batteries. We demonstrated the possibilities of our units with a one-night special event. Through this practical experience, we found "I/O-CRATEs" could easily be used to create smart and enjoyable surroundings in many places. (9 pages)
In this paper a concept is presented, that supports awareness and emotional communication between family members, distributed over multiple intelligent home environments. A technical communication infrastructure is presented, which allows connecting different types of input and output devices. This platform is extended by several examples of emotional user interfaces, which address the individual needs of different user groups. (10 pages)
This paper is centered on the use of video-communication and tele-collaborative applications in temporary architecture. Today we live in an electronic society in which computers, mobile phones, Internet have become integral part of our everyday lives. Architecture has to interject the new space characteristics: fluxes and interrelations should become the goal of research. This approach has three significant characteristics: unification of real and virtual worlds both input and output, tele-contiguity between remote participants, convergence of amplified perceptions and sensible spaces. Tele-contiguity is superintended as an improvement of body materiality through sensory amplification and not as an impoverishment of human sensory system: the system should support an environment that looks like a natural and functional extension of the space that people use in their everyday activities. (5 pages)
One of the human strengths is to utilize past experiences to solve problems. This process can be technically supported by collecting and exploiting the history of a user's interactions with an intelligent environment. However, most of today's applications cannot or do not take on the additional burden of providing the user with sophisticated memory functionality. In this paper we present the concept of an open personal memory, which allows arbitrary applications to contribute knowledge to the memory with minimal extra effort. We describe a proof-of-concept implementation and show how users can exploit such memories. (10 pages)
Project ARS (artificial recognition system) researches the future possibilities for building automation using bionic approaches. It focuses on the combination of bottom-up data processing systems with decision making inspired by modern psychoanalysis. We define a model based on a symbol processing unit and a decision unit implementing Sigmund Freud's ego-superego-id personality model, emotions and drives. This paper describes the basic principles of decision making and the complete connection down to sensors level, it shows some of the challenges in the process and first steps of implementing a prototype system. (8 pages)
This paper presents the concept of ambient awareness that pertains to using ambient intelligence technologies for the purposes of sustaining awareness between individuals or groups of people, over sustained periods of time. The first explorations of this concept are conducted within the context of supporting awareness for busy parents having young children. We sketch the requirements drawn from an interview study, involving 20 interviews with working parents and we identify unmet communication needs that this type of technology may support. (6 pages)
The following paper concentrates on examining the built fabric under extreme events. The definition of the extreme within the built environment is analyzed and models for the relief of the phenomenon are considered. The aim is to examine the fluctuations created by the event and to create models of appeasement and design typologies which intent on the imminent relief of the crisis. Theories, such as complexity, self organization, emergence, swarm intelligence, catastrophe theory, bifurcations, networks and systems theories are applied in order to find optimum ways of designing. Generative and evolutionary design, parametric design, is explored. The methodology followed is by simulating (pedestrian movement) the facts and finding optimum design solution. (6 pages)
In this paper we propose a network-based architecture module that reflects the environment; which is called "sensible node". The aim of this module is to offer the comfort and spiritual richness; not convenience that is stereotypically sought in space utilization with computing. Also, the module has considerable flexibility that enables designers to construct the space, the integrated space of real and information, with single or multiple modules linked up together. This brings you unconventional and free designs of context aware system based on multi network which differs from traditional one-on-one pair model or server client model. In this paper, lastly we introduce two application examples as the basic module of sensible node and as the module group. (10 pages)
This paper concerns the personalization of intelligent buildings, where intelligence of a building is considered in a broad sense, not confined to the computational aspects. Personalization is desired in order to give the individual greater representation in the building and for energy consumption/well-being balance in the context of measuring building intelligent quotient. The paper examines problems of programming in pervasive space, and current systems for personalization. It discusses design issues relating to human representation in the building, active and passive human participation, the nature of the personal agent, ownership and location, transparency, and norm-based agency. A design based upon active involvement of the occupant is presented. (7 pages)
Today's consumer devices are equipped with an enormous number of functions controllable by the user. Therefore, an efficient menu structure is of high interest. Nowadays each device uses its own user interface along with appropriate menu structures. As a result, different devices from different vendors are typically equipped with diverse menu structures and layouts even if they actually have similar functionalities. Thus, the user is typically confronted with inhomogeneous menu structures forcing one to learn the logic behind each structure first, before an efficient interaction with the interface is possible. This paper discusses a novel approach of interaction-structure generation, which represents the first results of our work done within the user interaction oriented task of the EU-IST funded research project Amigo. Further, this work is also based on results we gained out of our inHaus-project. In this work we present an innovative concept for a personalized graphical user interface for AmI (Aml=ambient intelligence) home environments. Functionalities of different devices and software components are bound into one operation concept to give the user the feeling of interacting with one solid system and not with a loosely coupled set of single devices. Therefore, the binding between device and functionality has been removed and device independent menu structures have been introduced. Links between devices and functionalities are only maintained for the sake of execution. The core idea of the presented approach is to automatically provide a consistent interface throughout different environments. This is reached by adapting structure and presentation to personal user preferences. These adaptations help the user to operate unknown AmI environments efficiently and as intuitively as possible. (9 pages)
The aim of the paper is to introduce a natural language processor enabling mobile multimodal interfaces to receive user driven free speech in order to enable more natural voice interaction with mobile applications and services to control devices in smart environments. Free speech of users is continuously analysed and matched against semantically defined device service commands. The concept and requirements of the language processor and the semantic description for application commands will be explained. Further the paper elaborates on how this concept was fitted into the general concept of a mobile multimodal interface and elaborates on implementation aspects of the language processor. The feasibility of the approach has been shown in a prototypical implementation. The work has been carried out as part of the research on mobile multimodal interfaces within the IST-FP6 MobiLife project. First order or main headings should commence at the left hand margin of each column, and should be in capitals and can be in bold. Except at the top of a new column the first order heading should be preceded by two lines of space and followed by two lines of space. (9 pages)
This paper discusses a novel architecture of intelligent user services that address the domain of networked home environments. The work described in this paper represents the central achievements of the first 1.5 years in the work package on intelligent user services within the EU-IST funded research project Amigo. The discussed service architecture consists of five distinct services that address both user- and system oriented issues in ambient intelligence (AmI) home environments. (10 pages)
Security monitoring systems are popular in home automation, and Zigbee is a new industrial standard wireless sensor networks. This paper introduces an experimental home security monitoring and alarming system based on Zigbee technology, it is capable of monitoring door & window magnetic contact, smoke, gas leak, water flooding, providing simple controls such as turning off the valves, and sending the alarms to the residential area security network etc. The security alarming system is based on Zigbee chip MC13192 and low power consumption micro-controller MSP430F135. A description of the system architecture, circuit principle and the firmware flowchart is presented. The system uses a control key fob for activating and de-activating the alarm easily, supports Web interface so that user can access the system remotely to control, search or review the history record, and offers a LCD panel for simple configuration. The experimental system has been designed and its wireless communication test result shows that the Zigbee wireless network can improve the home security with low power and easy to implement solution. (4 pages)
Techniques developed for the automation of production do not offer an adequate basis for the development of intelligent domestic environments. In order to respond in an intelligent manner, the automated house needs to be able to recognize complex situations, which is not possible without intentionality. Thus the challenge of ubiquitous computing in the domestic environment goes far beyond the construction of appropriate interfaces or the interaction between digital and physical environments. The central issue is the conception of buildings as cognitive agents. (6 pages)
A wide range of disconnected communication networks is emerging in the home. Each has different functions and implementation architectures. The user experience as well as the overall functionality would be vastly enhanced if these networks could collaborate in a seamless fashion. Collaboration is challenging because it requires disparate devices and components to interoperate in a user friendly, scalable and upgradeable fashion. We conjecture that such cooperation might be most efficiently assured using a supporting infrastructure. The universal contents router (UCR) is introduced as an infrastructural component. The UCR moves the burden of connectivity away from the end devices to the system core. The paper spells out ZUMA, or functions that a UCR should support, discusses UCR architecture and presents a first-order prototype. (10 pages)
Ubiquitous computing applications propose new and creative solutions to every day needs. This paper addresses the issue of recognition of every day activities inside pervasive domestic environments in order to identify patterns of behaviour that can be later used to support care systems by detecting changes to those patterns. Our system uses a temporal neural-network-driven embedded agent able to work with online, real-time data from unobtrusive low-level sensors and actuators. We present experimental results that show that our agent is able to detect temporal patterns along with spatial similarity associations found in human behaviours and activities, in everyday living environments. (7 pages)
In this keynote, the author presents selected visions of ambient intelligence and the disappearing computer and comment on the resulting challenges for designing interaction in future smart environments. Our approach is based on exploiting the affordances of real objects by augmenting their physical properties with the potential of computer-based support. Combining the best of both worlds requires an integration of real and virtual worlds resulting in hybrid worlds. In this approach, the computer "disappears" and is almost "invisible" but its functionality is ubiquitously available and provides new forms of interacting with information. The general comments are illustrated with examples taken from developing roomware components for cooperative buildings, project work in the EU-funded "Disappearing Computer" initiative, especially ambient displays and mobile devices in the "Ambient Agoras" project, and more recent developments for smart home environments. (6 pages)
Technologies currently available for home network only electronically connect devices in various forms and functions, and provide simple interaction and communication among devices. However, these technologies fail to provide mechanism for efficient and effective interoperation among devices in home network. In this paper, an architecture-globally distributed locally centralized architecture (or GDLC architecture for short) together with its middleware is represented, which can seamlessly integrate home devices and effectively interoperate devices. Moreover, it provides a good way to manage a huge amount of data. (4 pages)
The purpose of this paper is to present the potential of tactile sensing technology in creating intelligent objects. These objects constitute active components of an intelligent environment. The creation of intelligent environments requires the use of sensing technologies that can record the interaction of objects with other objects or with human beings. These sensing technologies provide the data upon which the intelligent environment acts. Tactile sensing can be used to detect the physical interaction of human beings with objects. The application concepts presented in this paper can show how diverse objects such as a keyboard, a door mat, a refrigerator, a driver's seat, a table and a chair can create intelligent environment experiences. (5 pages)
This paper presents a work in progress conducted between British Telecom (BT) and the University of Essex. The project aims to provide a suitable component AI framework supported by a network overlay (Nexus) that enables secure knowledge distribution for use by mobile agents. This is to operate while observing the background goal of maintaining an acceptable quality of service. (9 pages)
This paper addresses learning and recognition of individual roles from video data in a smart home environment. The proposed approach is part of a framework for acquiring a high-level contextual model for human behaviour in an intelligent environment. The proposed methods for role learning and recognition are based on Bayesian models. The input is the targets and their properties generated and tracked by a robust video tracking system in the environment. The output is the roles "walking", "standing", "sitting", "interacting with table", "sleeping" for each target. A Bayesian classifier produced good results for a framewise classification of these roles, while a hidden Markov model had even better performance taking into account a priori probabilities of roles and role transitions. A support vector machine produced best classification results. The classifiers had, however, problems to distinguish ambiguous roles like "walking" and "standing" in the environment. The obtained results permit to pass to the next step in future work: learning and recognizing relations and situation. (9 pages)
This paper describes an automated home environment comprising a varying population of different hardware and software modules, called pebbles, being controlled by a varying number of rules. The aim is to execute a number of concurrent applications and to be sure of their potential interactions in advance, in order to avoid any feature interaction. For this, all devices and applications must advertise their behaviour beforehand by code reflection. Our API for code reflection is our formally verifiable logic language, called Pushlogic, into which all the control software is eventually translated. We use a home control scenario to highlight different aspects of our logic-based control of these pebbles. (6 pages)
The current multimedia, processing and communication capabilities of mobile devices make them most suitable to act as our intermediaries with the surrounding environment. They are capable of sensing, processing, storing and communicating with the artefacts augmented with computing services (i.e. smart objects) deployed in a smart space. This paper describes a device-type, user-location and communication-means agnostic platform, namely EMI2lets, which fulfils a two-fold purpose: a) it transforms our mobile devices into universal remote controllers of smart objects and b) it helps us constructing smart object ecosystems, i.e. smart spaces. (10 pages)
This paper presents a novel concept for personalized privacy support on large public displays in intelligent home environments. In order to validate the conceptual approach a system called SPIROS was developed. The SPIROS system automatically adapts the information visible on public displays according to the current social situation and the individual privacy preferences of the user working at the display. (8 pages)
We present a novel software infrastructure for the seamless integration of heterogeneous output devices into intelligent environments. It dynamically coordinates the output devices to enable adaptive, multimedia presentations by taking the availability of resources and the context of the presentation into account. In this paper we focus on three topics. We present our connecting middleware which supports ad-hoc spontaneous interactions between heterogeneous devices connected by different types of networks. We focus on the multimedia output (MMO) channel which is situated atop this middleware and which is responsible for coordinating output devices according to their self-descriptions. Then we give details about the AI planner which is used by the MMO channel to compute a solution to the presentation problem given by the presentation context. Finally, we outline our implementations for an intelligent living room scenario and point out related work. (10 pages)
This paper describes the results of a series of usability trials in a test-home environment involving twenty eight participants who were provided with the means to control a number of household devices through a simple multi-modal control framework. The multi-modal control framework provided spoken and visual prompts to the user using a touch screen interface or a speech recognition system. A speaker independent speech recognition system was employed because it removed the tedious requirement for training by the user. Results from the usability trials show a higher acceptance for voice based control in the home than was expected at the start of the trials. The trials also demonstrated the potential for greater efficiencies for navigating menu based systems using voice control and show how, with good functional design, new users can quickly learn enough about the system to improve their interactions in terms of speed and efficiency.
Project ARS (advanced recognition system) researches the future possibilities for building automation. Psychological models are used to deal with massive amounts of data in order to manage complex scenarios. Such a system would enable a building automation system to detect and comprehend situations that are too complex for existing solutions. This paper describes the motivation for this system, the impressive challenges and the first steps of implementing it. (8 pages)
Ambient intelligence is nowadays an active research field. As a key matter of this concept, learning architectures for the control of the devices in an intelligent building must be developed, where the goal is to control the environmental via a set of devices using an intelligent agent which should work in a non-intrusive manner to satisfy the preferences of the user. Mainly, we have focused our attention over fuzzy logic controllers (FLC) for the internal structure of the agent. The main motivation for the work described in this paper is to check different alternatives selecting a suitable method for the off-line data driven automatic generation of FLCs for the agent. We have performed the experiments with real data gathered from the Essex Intelligent Dormitory. (7 pages)
This presentation will look at the evolution of building automation network infrastructure, the potential for integration into existing IT network infrastructure, the issues to be considered, potential benefits with reference to "Open Standards", reliability and security. (12 pages)
The promise of automated "smart homes" has been much touted in the press for the past quarter-century. However, few automation innovations have been adopted because home inhabitants seldom view the benefits as outweighing the costs. One significant cost of an automated home is that it has to be programmed to behave appropriately. We describe an alternative approach in which the goal is for the home essentially to program itself by observing the lifestyle and desires of inhabitants and then learning to anticipate their needs. This adaptive home operates almost transparently to the inhabitants, in contrast to the cumbersome user interfaces common in traditional automated homes. The author describes his experiences over the past decade with a system in his home that controls ambient temperature and lighting so as to simultaneously maintain a comfortable environment and conserve energy. Finally, this article reflect on the successes and limitations of the work. (41 pages)
In this article the author considers why it is that so much effort has been expended in designing intelligent systems for home settings and why this effort has been in large part to no avail. The author suggests that one reason has been that what intelligence might be and what an intelligent technology might do in the home has often been modelled on assumptions that are more appropriate for other places and environments. The author shows with evidence from his own research on smart homes, that people turn technology on when they get home so as to switch themselves off, that they use technology, in other words, to make themselves more dumb. The author argues that there should be no surprise in this or shock for the researcher of smart environments: rather recognition of their own everyday and all too often forgotten experience. Yet we argue that in recognising this ordinary fact about everyday lives, new opportunities can be identified for designing systems that, when turned on, do indeed help the user to unwind, to distract themselves, and to play. Having commented on the home of the future, the author then remark that developing a sensibility for home settings can also direct us toward developing a sensibility for other environments where systems can play a more embedded, more `intelligent' role. (13 pages)
This paper describes the role of wireless communications in intelligent building environments. The following areas are examined: consumer electronics; personal computing; mobile automation and control; and security. (30 pages)
This paper discussed the overview of building control systems and the customers expectations on using controls to improve building performance. The paper also presented the technology behind it such as: convergence and integration; communications standards; and Web technologies. Both embedded servers and applications servers plays important roles and allow distributed functionality and data management in geographical networks. Application service providers offer new ways to operate optimise and manage a building. (18 pages)
Emirates Towers is a state-of the art office hotel tower complex accommodating business and holiday travellers alike. The towers are home to numerous businesses and offer the latest fibre optic technology and integrated systems. The five star hotel tower has 500 rooms, including 40 suites and three main themed restaurants. A five level podium building connects the towers and includes more than 40 retail, restaurant and parking facilities. The article describes the solution provided by Johnson Controls to implement a state-of-the-art technological infrastructure scalable for future developments. They produced a total integrated IT and building management system infrastructure offering the client a single-seat operation solution. This approach, included redundant IT-network solution based on the ATM switches, video-on-demand, e-commerce, Internet, BMS, CCTV, and hotel management system data through the entire complex. (7 pages)
The paper presents the results of work being undertaken as part of the UK contribution to an International Energy Agency research project (Annex 34) concerned with computer-aided fault detection and diagnosis in real buildings. The aim of the project is to develop and test software tools, which are based on existing methods of fault detection and diagnosis, for analysing the performance of heating, ventilating and air-conditioning systems. The development of a tool, which can automate the commissioning of air-handling units in large-scale air-conditioning systems, is considered in this paper. The presence of faults is detected by a fuzzy model-based fault diagnosis scheme which uses generic reference models to describe the behaviour of the plant when it is operating correctly and when one of a predefined set of faults has occurred. The paper discusses practical issues such as the integration of the commissioning tool and the building energy management system, the automatic reconfiguration of the control strategy to implement open-loop commission tests, the automatic generation of the test sequences, and the presentation of the diagnostic results to the user. Experimental results are presented that demonstrate the use of the tool to remotely commission the cooling coil of an air-handling unit in a commercial office building.
The number of smart home appliances that can be connected to the Internet grows every day. In this paper, we explore the potential of combining two emerging head-mounted interaction devices for intuitive control of these devices. Smart glasses are used to detect the object the user wants to control, and an EEG/EMG headset is used for triggering commands to the object of interest. We discuss the research and implementation challenges of identifying devices having the users visual attention and of mapping EEG/EMG headset output to device instructions. By exploiting the user context, we improve the responsiveness and precision of the user intent detection. Despite the enthusiastic reactions of the participants in a small user study, we have learned that the consumer-grade headsets available today present many shortcomings.


text:
- ITV Report
- ITV Report
AP McCoy: I won't quit after Cheltenham
Live updates
- ITV Report
AP McCoy joins ITV Racing coverage from 2017
Sir Anthony McCoy will be part of ITV's racing team when the channel broadcasts exclusive free to air coverage of the sport from 2017Read the full story ›
- ITV Report
Sir Tony McCoy thought knighthood was practical joke
Sir Tony McCoy thought he was the victim of a practical joke when he first received news of his knighthood in the New Year Honours listRead the full story ›
- ITV Report
AP McCoy: I won't quit after Cheltenham
Tony McCoy has revealed it is extremely doubtful he will hang up his saddle at the Cheltenham FestivalRead the full story ›
Jockey AP McCoy to retire at the end of the season
Jockey Tony McCoy today announced he is to retire from racing at the end of the season.
Just minutes after Mr Mole gave McCoy his 200th winner of the season as Sire De Grugy unseated three out in an incident-packed Betfair Price Rush Chase at Newbury, the champion jockey told Channel 4 Racing of his intention to stop riding.
Not seen since following up his Champion Chase success at Sandown last April, the Gary Moore-trained Sire De Grugy was sent off at odds-on but made a bad mistake four from home before parting company with Jamie Moore at the next.
That left a simple task for Mr Mole, who will test his credentials at the top level in the two-mile championship next month.
All that was overshadowed, however, when McCoy revealed his retirement plan.
"It's going to be the last time I ride 200 winners," he said.
"Having spoken to Dave (Roberts, agent) and JP McManus, I am going to be retiring at the end of the season."
McCoy said: "I want to go out at the top, I want to go out as champion jockey and it will be my 20th year if I can win the jockeys' championship."
Trainer: McCoy could win on a monkey
AP McCoy's trainer said the record-breaking jockey is so good he could win a race riding a monkey.
Jonjo O'Neill said after McCoy's 4,000th win:
It's just amazing. You can't put words to it, but the man is fantastic. He's a fantastic man and a fantastic jockey.
Old horses, young horses, monkeys. You name it, he can win on it, that's the fantastic thing about him - it doesn't matter what it is he just wants to ride winners.
I can't finds words to describe the fella. I'm just so pleased to have him.
AP McCoy: I feel proud for the first time
Jockey AP McCoy said he felt "relieved" and "proud" after riding his 4,000th winner:
The horse was fantastic. You can't win any horse race without their help and I've ridden some fantastic horses.
There is a sense of relief, no doubt, but for the first time in my life I feel a sense of pride of what I've achieved.
This is the quickest sport in the world to bring you back down, but I do feel and happy and proud of what I've done.
Historic 4,000th win for racing legend AP McCoy
Clare Balding pays tribute to 'incredible' McCoy
Racing broadcaster Clare Balding was among those to congratulate AP McCoy on riding his 4,000th winner, calling the jockey's feat "incredible":
What a ride from @ap_mccoy! That never looked likely until two strides before the line. Incredible. Congratulations to the Champ #mccoy4000
Everyone there to witness it who should be - Jonjo, JP McManus, all his family and Uncle Toby, who was his first GB boss #mccoy4000
Sports stars hail record-breaking jockey McCoy
AP McCoy's fellow sportsmen took to Twitter to congratulate the jockey on his landmark 4,000th career win.
Former Liverpool striker Robbie Fowler, Irish golfer Shane Lowry and ex-England rugby union captain Matt Dawson were among those to pay tribute to the record-breaking rider also known as Tony McCoy:
Only one word to describe the man @ap_mccoy ..... Phenomenal
Congrats to @ap_mccoy. The man is a legend of Irish sport.
That's all well and good @ap_mccoy but 5 live rugby is now cancelled tonight to celebrate ur 4000 winner #anyotherday
Jockey AP McCoy wins 4,000th race
Jockey AP McCoy has won his 4,000th race, riding Mountain Tunes to victory in the 1510 at Towcester.

subset: commoncrawl


text:
Choose from our a la carte or enjoy our set menu
The perfect destination for any special occasion
Enjoy waterside, whilst overlooking our divine view
That will delight and excite
Creating a lasting impression on you and your guests
Located on the banks of the Georges River, Lugarno Seafood Restaurant offers the freshest of seafood, grain-fed steaks and selection of non-seafood dishes. An ideal location for a romantic dinner for two, a business lunch, a special celebration or just a gathering of family and friends.
Open 7 days. Lunch from 12pm all the way through to Dinner finishing at 11pm. (Bookings essential)


text:
You know those people who can eat whatever they want and still look like they stepped off the pages of a fitness magazine? While you may have coveted their metabolism, what you should be chasing after is their gut bacteria.
Yep, that's right. You want their gut bacteria!
Our guts are full of different types of bacteria. While you've probably always assumed bacteria is a bad thing, there are actually several kinds of bacteria that are good for us. These types of good bacteria help our bodies draw out fewer calories from the foods we eat and draw in more of the nutrients our bodies need. In addition, a gut filled with the right types of bacteria can up our satiety after a meal, and can improve our insulin response to various foods, helping fight those pesky sugar cravings.
Adding the right types of prebiotics and probiotics into your diet can help bring you back into balance and aid in your weight loss quest. In addition, balancing out your gut will help you to feel better, fight off sickness and live your life full of energy.
The Best Probiotics
I've been a firm believer in probiotics for several years. I have tried to plug them into my diet with various yogurts and over the counter pills. Over time, I've found that while the yogurt has been a great addition to my smoothies and a satiating snack, the pills have often fallen short. Which is why I have switched to Silver Fern Brand's Wai Drink Mixes.
Probiotics found in pill form, are digested into one part of your gut, and then disperse to other parts. Typically the active bacteria don't live long enough to make it through that process. If they do stay alive, they usually don't survive long enough to help you convert your food into useful nutrients.
The probiotics found in Silver Fern's Wai drink mixes are delivered to your body in liquid form, and coat the inside of your intestines (think Pepto Bismol commercial), which means they make it where they need to be, and are fully active when they get there. Wai drink mixes contain 5 million CFU's of Bacillus Subtilis HU58 and Bacillus Coagulans. These two bacterias survive the digestion process unlike the probiotics found in most stores. Once there, they reduce gas build up, support metabolic restoration (aka..help your body take in fewer calories and draw out the nutrients it needs), produce antibiotics that help fight against bad bacteria, help your body burn fat, and decrease bloating. These drink mixes give your body a little extra armor in its fight against fat, and help you stay healthy and feeling full.
I have shared a bit about Wai Drink Mixes before, but just in case you missed it, here are a few things you need to know:
- One box contains 6 packets. There are 6 different flavors to choose from!
- They are super simple to use. Just throw a packet into a bottle of water, shake and drink up.
- They taste great.
The best time to use these mixes is with a meal. I typically start a bottle with my meals and then drink some throughout the day. This helps me stay hydrated, and the fiber in the mixes keeps me feeling full.
Silver Fern has several other products that will help you keep your gut in check, including my favorite, their Paka Protein Pancake Mix (click there for 15% off!).
Whether you are new to eating clean and exercising or have been around that block a few times, adding in an effective probiotic can only accelerate your journey towards healthy living. Probiotics like the ones found in Silver Fern Brand's Wai drink mixes, will enhance your weight loss results and keep you feeling great. I have been drinking them for about a month now and really have come to rely on them. I highly recommend you give em' a try!
Are you a busy woman juggling faith, work, home and family?
I am too.
Sometimes women like us can get so focused on helping others that we forget to take some time for ourselves. We don't set aside time to spend with God, and workouts fall to the wayside. I get it. Sometimes I feel like I don't have another minute in my day to spare. But, if we don't take our spiritual and physical health seriously, we won't be able to work, serve and love well. We will end up a hot mess of frustration and anxiety.
I hear ya' sister…that struggle is real, and I feel it every day!
That's why I am committed to helping women like you refocus their faith and get back in shape. Because when we are planted in God's Word, and feeling healthy and confident, you can go out and do all of those things God calls us to do.
Sign up below and get my 3 Day Faith and Fitness Quick Start Guide for Busy Women. In it you will find 3 days of Bible study (looking at a different Psalm each day), and 3 quick, effective and simple workouts for you to do at home! This guide is totally FREE and will take you less than 30 minutes to go through each day!
Sign up here, to snag yours!
This post contains affiliate links. See my full disclosure here


text:
The Attorney General's office has asked the supreme court to determine that the parliament can only dismiss cabinet ministers for committing an impeachable offence.
According to article 101 of the constitution, a no-confidence motion can be filed by at least ten lawmakers, "specifying the reasons," and a minister shall cease to hold office if it is passed by a majority of the total membership of the People's Majlis.
But state attorneys argued in the apex court Sunday that the parliament should not be able to sack ministers with a no-confidence motion submitted for political reasons.
"The power of the parliament to take a vote of no-confidence is not an absolute power," a state attorney told the court, insisting that valid grounds or proof of an impeachable offence should be a prerequisite for the no-confidence vote.
The full bench of the supreme court is hearing the constitutional case.
Speaking at the ruling coalition's nightly rallies in Malé hours after the first hearing, Majority Leader Ahmed Nihan declared that the opposition is planning to submit no-confidence motions against ministers "with the signatures of 10 or 12 MPs, to pester the government."
He also accused the opposition of plotting to bring the state to a standstill.
A new alliance formed between opposition parties and former President Maumoon Abdul Gayoom is trying to seize the parliament's majority with defections from the divided ruling party.
After the alliance sought unsuccessfully to remove Speaker Abdulla Maseeh Mohamed in late March, the rules were changed to require a minimum of 42 signatures from the 85-member house to submit a no-confidence motion against the speaker or the deputy speaker.
Opposition lawmakers have said the government's appeal to the supreme court amounts to an admission of President Abdulla Yameen losing the previously unassailable pro-government majority.
But Nihan, the parliamentary group leader of the Progressive Party of Maldives, said the ruling coalition remains strong with 51 members.
Full details are available from the link below:
Source URL: Maldives Independent


text:
1416PD - Integrating genotype in risk classification for GIST recurrence. A Spanish Group for Sarcoma Research (GEIS) study
|27 September 2014
Pathology/Molecular Biology
Translational Research
Basic Scientific Principles
Basic Principles in the Management and Treatment (of cancer)
|Javier Martin Broto
|Annals of Oncology (2014) 25 (suppl_4): iv494-iv510. 10.1093/annonc/mdu354
J. Martin Broto1, S. Calabuig2, J. Rubio3, A. Gutierrez4, J. Duran5, F. Garcia5, J. Martinez-Trufero6, J. Maurel7, X. Garcia Del Muro8, J. Cruz9, R. Cubedo10, A.M. Poveda11, C. Valverde Morales12, L.M. De Sande González13, A. De Juan14, J.A. Lopez-Guerrero15
Relevant prognostic factors for relapse free survival (RFS) in GIST relies on clinical and pathologic variables as size, mitoses, location or tumor rupture. However, being GIST a solid tumor model for molecular research and targeted therapies, it seems legitimate to explore the integration of relevant molecular prognostic factors into the risk classification. Several authors have pointed out the detrimental prognostic role of deletion type mutations involving 557/558 (DEL-5758) codons of exon 11 in KIT gene. On the other hand, mutations of PDGFR (MUT-PDGFR) gene have been associated with lower risk of recurrence. We will analyze the influence of these genotype factors for each Miettinen risk category (MRC).
Clinical data, therapeutic and follow-up procedures stemmed from the GIST Registry of GEIS. Main inclusion criteria were: localized GIST, adequate surgery, size>2 cm, complete genotype for KIT and PDGFR genes, no adjuvant imatinib and minimum follow-up of 3 years. RFS was measured by Kaplan-Meier method. For each MRC, RFS was estimated for those harboring DEL-5758 or MUT-PDGFR. Univariate and multivariate analysis were performed using log-rank test and Cox regression.
429 patients were identified according to the inclusion criteria, 35 of them had insufficient data, thus 394 patients entered into the analysis. Median size was 7 cm and with a median follow-up of 84 months there were 137 recurrences (37%). DEL-5758 and MUT-PDGFR were present in 65 and 25 cases respectively. The 7-year RFS for low MRC were 93% in MUT-PDGFR, 76% in DEL-5758 and 90% in the remainder (p=0.35), for Intermediate MRC were 80%, 26% and 64% (p=0-009) respectively and for high MRC were 40%, 21% and 28% (p=0.79) respectively. On univariate analysis: mitoses, size, location (gastric vs non gastric) and genotype were found to be significantly correlated with RFS. Multivariate analyses revealed that size (HR 1.75; CI 1.04-2.90), location (HR 1.79; CI 1.24-2.60), mitoses (RR 3.4; CI 2.31-5.05) and DEL-5758 (RR 1.5; CI 1.02-2.32) were independent prognostic factors for RFS.
Genotype significantly affects prognosis in localized GIST and therefore should be integrated into the risk classification especially in intermediate MCR.
All authors have declared no conflicts of interest.


text:
OSAKA, JAPAN--(Marketwire - Oct 29, 2012) - SIBOS - At the SIBOS international banking conference today, Respect Network, the world's first open network for the trusted exchange of personal data, announced that Mydex has joined as an Ecosystem Partner and Disconnect as a Development Partner. These partners were announced in conjunction with the company's appointment of Gary Rowe to CEO of Respect Network.
Mr. Rowe, former president of technology analyst firm Burton Group, described the opportunity this way: "Respect Network Corporation, in concert with our Founding Partners, has a unique opportunity to build a more user-centric, trusted Internet. The Internet started out that way but as it grew, spam, phishing, and other trust issues have become endemic. The focus of our company is to re-establish that trust with a platform that allows users to control their data and interactions with businesses. The Respect Network will allow businesses to actually achieve better, more focused, more profitable relationships by giving customers the assurance they will always be in control of the data they share and the communications they receive on the network."
London-based Mydex is a pioneer in the development of personal data services that empower individuals to realize the value of their personal data, establish a trusted digital identity, and secure connections to their network of suppliers, personal networks and service providers. "As a Community Interest Company, Mydex is committed to ensuring commercial sustainability but it is not in business to maximize profits for shareholders," said Mydex CEO David Alexander, who was also appointed Respect Network Ecosystem Architect. "Our personal data store service and ISO 27001 compliant trust framework provide a robust personal data ecosystem for our members and partners, and joining the Respect Network will help us extend our ecosystem to other individuals and businesses around the world."
"I can personally attest to the vision and integrity of the Mydex founding team," said Respect Network Managing Director Drummond Reed. "I have worked with them for half a decade on establishing the technical, legal, and business layers required for a sustainable personal data ecosystem, and I truly look forward to realizing and implementing our mutual vision of this as a win/win solution for people and businesses on the Internet."
Disconnect is an award-winning startup based in Menlo Park, California whose software stops online tracking and is used by more than 850,000 people every week. "We build tools that make it simple for users to understand and control the data they share on the web," said co-founder Casey Oppenheim. "Our goal is to empower users and help them build relationships with sites and businesses based on transparency and trust, which is why it was natural for us to join the other Founding Partners of the Respect Network."
"With Mydex and Disconnect, Respect Network has reached 20 Founding Partners in just the six months since we launched the program at the European Identity Conference in April," said Mr. Rowe. "Coming with our announcement here at Sibos of our collaboration with SWIFT Innotribe on the Digital Asset Grid, we are now ready to move toward launching the production network in 2013."
Respect Network launched the Founding Partner Program in the spring of 2012 to enlist companies committed to the strong personal data control protections of the award-winning Respect Trust Framework. Neustar, one of the world's leading trusted neutral network service providers, is the first Platinum Founding Partner. Swisscom, Switzerland's leading telecom provider as well as one of the most trusted brands in Europe, is a Gold Founding Partner. Other Founding Partners include Kynetx, The Customer's Voice, Project Danube, Gluu, Planetwork, Bitworld, Miicard, BioID, Virtrue, TrustCloud, Allfiled, OwnYourInfo, Edentiti, Ctrl-Shift and The Searls Group.
Respect Network will soon begin inviting select global brands to participate in this new consortium, enabling them to empower and connect directly with customers in a way that has never been possible. For more information, visit www.respectnetwork.com.
About Respect Network Corporation
Respect Network is building the world's first trusted personal data network. All members subscribe to the Respect Trust Framework, the new model for personal data sharing that is listed with the Open Identity Exchange and won the Privacy Award at the 2011 European Identity Conference. Individuals can join the Respect Network today through the Connect.Me social business card and discovery service available at http://connect.me/.
About Mydex
Mydex, formed as a Community Interest Company under UK law, is a is a personal data sharing platform legally committed to its core social purpose of empowering individuals to manage their lives more effectively. In addition to personal data stores, Mydex offers the MydexID, a digital identity for use in federated logins, including a range of multi-factor authentication solutions designed to simplify interactions while improving security and reducing cost and risk to relying parties. Connections to the Mydex platform are via an open API that enables organisations and application developers to connect with and provide information services to their members. At the core of Mydex is a trust framework (currently being registered with the Open Identity Exchange and to be certified under tScheme) setting out clearly the rights and responsibilities of all participants, including a standard data sharing agreement under contract law. To learn more visit http://mydex.org/.
About Disconnect
Disconnect, Inc. is an award-winning startup that makes simple tools to help users understand and control the data they share on the web. Disconnect's products are top-rated browser extensions for Chrome, Firefox, and Safari that stop tracking by third parties and search engines, and are used by more than 850,000 every week. For more information visit http://disconnect.me/.


text:
Hey I am new to most paper crafts but I really want to make some spiral notebooks out of recycled materials. I'm having a lot of trouble finding the right supplies though. I found some professional places selling wire or plastic spiral binding but it says it is for binding machines. Can I buy that stuff and bind it by hand? I also see the wire binding with the double loops that looks good for binding by hand, but I'm having trouble finding a place to buy it online that gives me enough information to buy the right size.
The notebooks I want to make right now will be approx. 2.5" by 3.5" so I want a fairly close together and small rings. Any help with this would be greatly appreciated!


text:
Start Here
Click Here for Secure Login
Note: The closing NAVs reflect the year-end distributions of Thursday, December 12, 2019. View Historical Distributions.
Sign Up For Email Updates
Follow Us On Twitter
December 31, 2012
Fellow Shareholders,
I am pleased to report that both the Oakmark International Fund and the Oakmark International Small Cap Fund performed extremely well on an absolute and relative basis for the fourth calendar quarter of 2012. The Oakmark International Fund, in particular, not only experienced a standout quarter, earning 14%, it also enjoyed an exceptional year; returning just over 29%. Even more satisfying are the long-term returns of both Funds, with the Oakmark International Fund averaging just over 10% and the Oakmark International Small Cap Fund achieving an annualized return of just under 10% since their respective inceptions.
Winning by Staying Disciplined
If we revisit 2012, recalled is a year of macroeconomic and political turmoil. Due to conditions in Greece and Europe, results of the U.S. election and "fiscal cliff," and a slowdown in emerging markets, investors were told by some pundits to be happy with a zero rate of return in "safe" government bonds. In fact, so much money flocked to and, to some degree, remains in this area of perceived safety, that real rates of returns in many of the world's perceived "safe countries" are actually negative for government debt with less than a 10-year maturity. Moreover, there was a period of time this past summer when these countries had negative nominal rates for two-year maturities. Moreover, there was a period of time this past summer when the three mentioned European countries had negative nominal interest rates for two-year maturities.
Only one year ago, some experts predicted the disintegration of Europe with a strong possibility of sovereign defaults in Spain, Italy and Portugal. At the peak of the European Union's crisis, Greece's 10-year government bond yielded close to 30% and Italy's approached 7%. Today, the EU is still together, Greece's 10-year bond yields 11.25% and Italy's yields 4.3%! Perhaps Italy isn't going broke after all? And maybe Europe will eventually make it through its crisis?
Based on the past year's events, we believe the lesson to be learned is that, once again, "macro shocks" tend to provide opportunity for long-term investors. During the worst of the situation, I had mentioned that, despite the nasty macro headlines, the global economy was still growing at a rate greater than 3.5%. When you combine this growth rate with extremely low equity market valuations, exploitable opportunity arises. The source of the opportunity is conceptually (and mathematically) simple: Market fear drives down share prices at a rate that is not at all consistent with changes in long-term business value. And, given that true investors have a VERY different time horizon than traders or speculators, we believe "true" investors can benefit if they stay disciplined.
The Future
Looking back, it was a grave year in terms of headlines. Nonetheless, it was a year in which yields of sovereign bonds that were deemed "risky" plummeted and share prices spiked. In fact, a U.S. dollar-based investor buying the Euro Stoxx 50 Index would have earned over 20% in 2012. This hopefully serves as a reminder that, for investors, what really matters is the price paid for a long-term stream of a company's cash flow, not what the headlines say.
Here's to a contented 2013 for our investor base! We remain committed to working hard to provide you with acceptable performance and are confident that we have a philosophy and process that will lead to continued investment success.
David G. Herro, CFA
Portfolio Manager
Oakmark International Fund's Average Annual Total Returns (12/31/12)
10–year 11.23%
5–year 3.52%
1–year 29.22%
Expense Ratio as of 9/30/12 was 1.06%
Oakmark International Small Cap Fund's Average Annual Total Returns (12/31/12)
10–year 12.41%
5–year 1.80%
1–year 18.39%
Expense Ratio as of 9/30/12 was 1.41%
Past performance is no g2arantee of future results. The performance data quoted represents past performance. Current performance may be lower or higher than the performance data quoted. The investment return and principal value vary so that an investor's shares when redeemed may be worth more or less than the original cost. The performance of the Funds does not reflect the 2% redemption fee imposed on shares redeemed within 90 days of purchase. To obtain the most recent month-end performance data, view it here.
Investing in foreign securities presents risks that in some ways may be greater than U.S. investments. Those risks include: currency fluctuation; different regulation, accounting standards, trading practices and levels of available information; generally higher transaction costs; and political risks.
The stocks of smaller companies often involve more risk than the stocks of larger companies. Stocks of small companies tend to be more volatile and have a smaller public market than stocks of larger companies. Small companies may have a shorter history of operations than larger companies, may not have as great an ability to raise additional capital and may have a less diversified product line, making them more susceptible to market pressure.
The discussion of the Funds' investments and investment strategy (including current investment themes, the portfolio managers' research and investment process, and portfolio characteristics) represents the Funds' investments and the views of the portfolio managers and Harris Associates L.P., the Funds' investment adviser, at the time of this letter, and are subject to change without notice.
This site is intended for residents of the U.S. only. The information on the website does not constitute an offer for products or services or a solicitation of an offer to any person outside of the United States who is prohibited from receiving such information under the laws applicable to their place of citizenship, domicile or residence.
CUSIP identifiers have been provided by CUSIP Global Services, managed on behalf of the American Bankers Association by Standards and Poor's Financial Services, LLC, and are not for use or dissemination in a manner that would serve as a substitute for any CUSIP service. The CUSIP Database, © 2011 American Bankers Association. "CUSIP" is a registered trademark of the American Bankers Association.
Investing in value stocks presents the risk that value stocks may fall out of favor with investors and underperform growth stocks during given periods.
Before investing in any Oakmark Fund, you should carefully consider the Fund's investment objectives, risks, management fees and other expenses. This and other important information is contained in a Fund's prospectus and summary prospectus. Please read the prospectus and summary prospectus carefully before investing. For more information, please call 1-800-OAKMARK (625-6275).
OAKMARK, OAKMARK FUNDS, OAKMARK INTERNATIONAL, and OAKMARK and tree design are trademarks owned or registered by Harris Associates L.P. in the U.S. and/or other countries.
Copyright 2019, Harris Associates Securities L.P., Distributor, Member FINRA.
Date of first use: January 24, 2013.
Site Map


text:
aP value for comparison <.05.
Customize your JAMA Network experience by selecting one or more topics from the list below.
Hyder O, Dodson RM, Nathan H, et al. Influence of Patient, Physician, and Hospital Factors on 30-Day Readmission Following Pancreatoduodenectomy in the United States. JAMA Surg. 2013;148(12):1095–1102. doi:https://doi.org/10.1001/jamasurg.2013.2509
© 2019
It is not known whether hospital and surgeon volumes have an association with readmission among patients undergoing pancreatoduodenectomy.
To evaluate patient-, surgeon-, and hospital-level factors associated with readmission.
Design, Setting, and Participants
Retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)–Medicare data with cases diagnosed from January 1, 1998, to December 31, 2005, and followed up until December 2007. Population-based cancer registry data were linked to Medicare data for the corresponding patients. A total of 1488 unique individuals who underwent a pancreatoduodenectomy were identified.
Undergoing pancreatoduodenectomy at hospitals classified by volume of pancreatoduodenectomy procedures performed at the facility were either very-low, low, medium, or high volume. Undergoing pancreatoduodenectomy by surgeons classified by volume of pancreatoduodenectomy procedures performed by the surgeon were either very-low, low, medium, or high volume.
Main Outcomes and Measures
In-hospital morbidity, mortality, and 30-day readmission were examined.
The median age was 74 years, and 1436 patients (96.5%) had a least 1 medical comorbidity. Patients were treated by 575 distinct surgeons at 298 distinct hospitals. Length of stay was longest (median, 17 days) and 90-day mortality highest (17.2%) at very-low-volume hospitals (P < .001). Among all pancreatoduodenectomy patients, 292 (21.3%) were readmitted within 30 days of discharge. There was no effect of surgeon volume and a modest effect of hospital volume (odds ratio for highest- vs lowest-volume quartiles, 1.85; 95% CI, 1.22-2.80; P = .02). The presence of significant preoperative medical comorbidities was associated with an increased risk for hospital readmission after pancreatoduodenectomy. A comorbidity score greater than 13 had a pronounced effect on the chance of readmission following pancreatoduodenectomy (odds ratio, 2.06; 95% CI, 1.56-2.71; P < .001). The source of variation in readmission was primarily attributable to patient-related factors (95.4%), while hospital factors accounted for 4.3% of the variability and physician factors for only 0.3%.
Conclusions and Relevance
Nearly 1 in 5 patients are readmitted following pancreatoduodenectomy. While variation in readmission is, in part, attributable to differences among hospitals, the largest share of variation was found at the patient level.
Quiz Ref IDIn 2010, roughly 20% of 11 855 702 Medicare beneficiaries required readmission within 30 days of hospital discharge, resulting in an estimated cost of $17 billion.1 In fact, some groups have estimated that readmissions in the United States may cost more than $40 billion annually.1,2 In addition to health care costs, readmission has been linked to worse outcomes including increased patient morbidity and mortality.1 However, the Medicare Payment Advisory Commission estimates that up to 75% of readmissions are avoidable. Therefore, readmission has been proposed as a quality measure for hospitals, surgeons, and health care delivery systems.3
Readmission following surgical procedures may have particular significance. Several groups, including our own, have reported that readmission following hepato-pancreato-biliary or colorectal surgery was associated with increased 90-day mortality, as well as worse long-term survival.4-8 The incidence of readmission, especially after major procedures, is not inconsequential. A recent study9 of pancreatoduodenectomy (PD) procedures from 6 high-volume institutions noted a 30-day readmission of 15%. In a separate population-based study using the Surveillance, Epidemiology, and End Results (SEER)–Medicare database, our group noted an incidence of readmission of 18% following PD.8
In an attempt to understand and, in turn, mitigate the likelihood of readmission, investigators have sought to identify factors most associated with readmission.4,6-8 To our knowledge, to date, studies on readmission following surgery have almost exclusively focused on patient- and disease-specific factors. For example, increased risk for readmission has been associated with patient age and comorbidities, as well as disease stage and history of postoperative complications.4,8-10 However, the incidence and risk for readmission may be owing to other factors not related to the patient or tumor. Quiz Ref IDDonabedian11 proposed a model for assessing health care outcomes based on categorizing different factors into structures, processes, and outcomes. The Donabedian model is commonly used to describe how different variables relate and how each can act independently to influence outcomes.12,13 In light of the Donabedian model, variation in readmission may be influenced by factors not only at the patient level, but also at the health care provider and hospital levels. In addition to identifying individual variables that predict readmission, a potentially useful approach is to quantify the relative proportions of the variation in readmission occurring at the patient, surgeon, and hospital levels. Such an approach may allow focusing of quality improvement efforts at the appropriate level even when the relevant variables affecting care are not explicitly known.14 To our knowledge, no previous study has explicitly assessed readmission variability at all of these levels. Therefore, the objective of the current study was to evaluate and quantify patient-, surgeon-, and hospital-level factors associated with readmission using data from the SEER-Medicare database. Specifically, we sought to quantitatively assess the relative contributions of patient-, surgeon-, and hospital-level factors on readmission following PD.
A retrospective cohort study was performed using the SEER-Medicare–linked database from 1998-2005. Johns Hopkins Hospital's institutional review board approved this study; individual patient consent was not required. The characteristics and representativeness of this database have been previously reported.15 Patients aged 66 years and older with at least 1 year of continuous health maintenance organization Medicare Part A and Part B enrollment prior to diagnosis were identified; patients who underwent PD for pancreatic cancer, as noted in the Medicare records, were selected and comprised the study cohort. Readmission within 30 days of discharge from index admission, length of index admission, and postoperative complications were determined using the Medicare inpatient records. In this study, a readmitted patient was defined as a person who was discharged from an acute care hospital and was subsequently admitted to an acute care hospital within 30 days of the index discharge.10
Patient demographic and tumor variables were ascertained from SEER data. Median income was used as a surrogate for socioeconomic status, with a preference for census tract median income if available, followed by zip code median income, census tract per capita income, and zip code per capita income.16 Using Medicare data, patient records were linked to hospital data and hospital procedure volumes for PD. Similarly, physician procedure volume was determined using the physician billing records linked to the SEER database. Treating surgeons and hospitals were identified using encoded unique physician identification numbers from Medicare claims. Mean annual PD volumes were calculated for each provider and hospital. For descriptive and analytical purposes, providers and hospitals were grouped into quartiles and classified as very low, low, medium, and high.17
Patient comorbidities were ascertained using both inpatient and outpatient Medicare claims along with physician billing records18 for a window up to 1 year before the date of PD; comorbidities were defined using the comorbidity index proposed by Elixhauser et al19 and the composite Elixhauser et al comorbidity score proposed by van Walraven et al.20
The cohort consisted of 1488 patients who underwent PD and for whom physician- and hospital-specific data could be defined. Table 1 presents patient characteristics of the entire cohort stratified by surgeon- and physician-specific volume. The median age was 74 years and one-half of patients were female (n = 753; 50.6%); most patients were white (n = 1280; 86.0%). Among patients who underwent PD, 1436 (96.5%) had at least 1 medical comorbidity, while 1152 (77.4%) had 3 or more preoperative medical comorbidities. The median Elixhauser comorbidity score was 13. According to the SEER historic staging, most patients had regional disease (n = 975; 65.5%); among the 1287 patients for whom information was available, 599 (46.5%) had lymph node metastasis.
The 1488 patients in the study were treated by 575 distinct surgeons at 298 distinct hospitals. Most PD procedures were performed by general surgeons (n = 1214, 81.6%). Surgeons were classified into 4 volume quartiles: very-low volume (1-2 procedures annually, 56.0%), low volume (3-6 procedures annually, 28.7%), medium volume (7-20 procedures annually, 12.4%), and high volume (21-84 procedures annually, 3.0%). Similar to surgeon volume, hospitals were classified into the following quartiles based on the volume of procedures per year: very-low volume (1-4 procedures annually, 74.2%), low volume (5-12 procedures annually, 17.1%), medium volume (13-24 procedures annually, 5.7%), and high volume (25-53 procedures annually, 3.0%) (Table 1). With respect to National Cancer Institute (NCI) designation, 245 patients (18.5%) were operated on at a NCI-designated comprehensive cancer center, 37 (2.8%) at a NCI-designated clinical center, and 1041 (78.7%) at a non-NCI designated facility.
Numerical variables were described as medians and interquartile ranges. Categorical variables were described as totals and frequencies. Cells with fewer than 11 patients per variable were relabeled as fewer than 11 (<0.4%) in compliance with the NCI's regulations for the reporting of SEER-Medicare data. Bivariate comparisons were assessed using analysis of variance, Kruskal-Wallis test, or χ2 test, as appropriate. Surgeon and hospital volumes were modeled both as random effects in multilevel models and as fixed effects (as quartiles of volumes) to explore their association with readmission. Models were adjusted for only physician and hospital volumes, as well as physician and hospital volumes and case mix. All reported P values were 2-tailed; for all tests, P < .05 was considered statistically significant. All statistical analyses were performed using SAS version 9.3 (SAS Inc).
Following PD, the median length of stay (LOS) during index admission was 16 days. Length of stay was longest for patients who underwent PD at very-low-volume hospitals (median, 17 days) and shortest in the highest-volume hospitals (median, 13 days) (P < .001) (Figure 1). A similar pattern was noted for physician volume (Figure 2). Patients operated on by the lowest-volume surgeons had the longest median LOS (median, 18 days) vs patients who had PD performed by the highest-volume surgeons (median, 12.5 days) (P < .001). Quiz Ref IDWithin 90 days of surgery, 181 patients (13.8%) died. Ninety-day mortality following PD among low-volume hospitals (17.2%) and lowest-volume surgeons (16.7%) was considerably higher compared with high-volume hospitals (8.0%) and high-volume surgeons (7.7%) (all P < .05) (Table 2). Ninety-day mortality was also considerably higher among hospitals that were non-NCI designated centers (14.4%) compared with hospitals that were NCI-designated comprehensive cancer centers (4.9%) (P < .001).
Quiz Ref IDOverall, among the 1370 patients who were discharged from the index admission following PD, 292 (21.3%) were readmitted within 30 days of discharge. The median time to readmission for all readmitted patients was 9 days (interquartile range, 4.0-15.5 days). The most frequent indication for readmission was dehydration (n = 87; 29.8%), gastric outlet obstruction (n = 34; 11.6%), cholangitis (n = 14; 4.8%), venous thromboembolism (n = 12; 4.1%), and pneumonia (n = 12; 4.1%).
Rates of readmission stratified by patient, tumor, and provider and hospital characteristics are presented in Table 3. There was a noted difference in readmission rates when comparing patients with a comorbidity score of 13 or less (15.7%) vs patients who had a comorbidity score of greater than 13 (27.4%) (P < .001). Moreover, hospital volume was also associated with the risk for readmission. Paradoxically, very-low-volume hospitals had the lowest rate of 30-day readmission (16.7%); medium-volume hospitals had the highest rate of readmission (25.9%), while readmission at high- and very-high-volume hospitals was comparable (21.1% and 22.2%, respectively). Physician volume was not associated with the incidence of readmission on univariate analysis, although higher-volume surgeons tended to have a higher readmission rate (P = .06)
The effects of these characteristics were assessed using a multivariable multilevel logistic regression model that explicitly accounted for correlations in readmission among patients treated by the same surgeon or hospital. Demographic characteristics, such as age, sex, and race/ethnicity, did not demonstrate significant effects on readmission. There was no effect of surgeon volume and a modest effect of hospital volume (odds ratio for highest- vs lowest-volume quartile: 1.85; 95% CI, 1.22-2.80; P = .02; Table 4). Quiz Ref IDThe presence of significant preoperative medical comorbidities was also associated with an increased risk for hospital readmission after PD. Specifically, a comorbidity score greater than 13 (odds ratio, 2.06; 95% CI, 1.56-2.71; P < .001) had a pronounced effect on the chance of readmission following PD (Table 4). After accounting for all explanatory variables in the full model, the source of variation in patient readmission was primarily patient-related factors (95.4%), while hospital factors accounted for 4.3% of the variability and physician factors for 0.3%.
Reducing the incidence of readmission is an important goal as identified by the Centers for Medicare and Medicaid Services.2 In fact, not only will reimbursement be tied to standardized readmission rates, but the rate of readmission for any given provider or hospital may serve as a publically available quality metric in the future.10 Intuitively, one might expect to find factors associated with readmission on multiple levels of the health care delivery system. For example, the risk for readmission may be related not only to patient-specific factors, but also to individual surgeon practice variation, as well as hospital-level dynamics. To date, data on readmission following complex operations, such as PD, have been scarce,4-8 and all previous reports have focused almost exclusively on patient-level factors associated with readmission. To our knowledge, no previous study has quantified readmission variation at the patient, provider, and hospital levels simultaneously. The current study is important because it quantitatively assessed the relative contributions of the patient, surgeon, and hospital. When examining relative contributions, patient-level variation was the largest source of variation in readmission (95.4%). In comparison, the hospital-level contribution to the variation in readmission was about 5% and physician-level factors were responsible for only a negligible portion of the variability in readmission seen after PD (0.3%). In fact, on multivariate analyses, patient comorbidity level and hospital-level procedure volumes were the 2 factors most strongly associated with a higher risk for readmission. While we noted a minimal trend in the association of physician volume and the incidence of readmission, hospital-level variation was much larger. These results suggest that provider-related variation in readmission is largely a hospital-level phenomenon.
The Donabedian quality of care framework conceptualizes 3 qualities of care dimensions: structure, process, and outcome. Structural elements include the community, institution, provider, and patient, while process elements involve services rendered and types of treatment delivered. The Donabedian model attempts to make more explicit the complex relationship between structural elements (hospital volume or surgeon volume), process elements (surgery or clinical care pathway), and outcome (readmission). One problem in applying this multilevel model to studies on readmission is that detailed provider-specific data are typically not available in population-based data sets. In the current study, however, we were able to use unique physician identification numbers from Medicare claims to identify the treating surgeons so we could examine the impact of this provider-level variation on readmission. Population-based data also do not allow for the ascertainment of certain hospitalwide processes such as whether a specific hospital had formally adopted an institutionwide pathway to reduce readmission. Similar to our previous work, we addressed this issue by using a multilevel regression model that allowed us to characterize variation at each level (patient, hospital, or surgeon) without explicitly accounting for all the variables at that level.14
Previous studies4-9 have reported readmission rates after PD ranging from 16% to 50%. However, previous data published on readmission after PD are difficult to interpret owing to varying definitions of readmission (eg, within 30-day, 90-day, and 1-year periods).4,5,21 In the current study, we defined readmission as readmission to an acute care facility within 30 days, while excluding those patients admitted to a skilled nursing facility or other nonacute inpatient facility. Prior studies may also have underestimated readmission owing to the inability to capture data from secondary hospitals. Yermilov et al4 found that nearly half of readmissions occurred at a hospital other than the one where the surgery took place. A benefit of the SEER-linked Medicare data is that it covers a large population, making it more likely to capture all readmissions, even to secondary hospitals. In the current study, the incidence of readmission was 21.3%. We paradoxically found that low-volume surgeons and hospitals had a slightly lower risk for readmission compared with high-volume surgeons and hospitals (Tables 3 and 4). Multiple previous studies have demonstrated that increased procedure volume leads to a dramatic decrease in perioperative mortality.22-26 Specifically, Kennedy et al22 found that high-volume PD surgeons have better outcomes including complication rates and overall mortality. In the current study, we also noted that in-hospital and 90-day mortality were higher among lower-volume hospitals and surgeons. Interestingly, our data showed that while the volume-outcome relationship was associated with better perioperative morbidity and mortality, a similar relationship was not found for the risk for readmission. In fact, patients undergoing operations at the lowest-volume hospitals had lower rates of readmission. The reason for the higher readmission among higher-volume hospitals and surgeons is unclear and undoubtedly multifactorial. The lower readmission at low-volume hospitals did come at the expense of a longer LOS and a higher perioperative mortality. However, the effect of hospital volume on readmission was only modest; the major determinant of readmission was the presence of a higher comorbidity burden at the time of index admission.
Despite the effect of hospital-level factors on readmission, data from the current study demonstrated that the overwhelming source of variation with hospital readmissions occurred at the patient level. While age and race/ethnicity did not play important roles in predicting readmission, the presence of significant preoperative medical comorbidities was significantly associated with an increased risk for hospital readmission after PD, as patients with a comorbidity score greater than 13 were 2-fold more likely to be readmitted. The finding that preoperative comorbidities increased the risk for readmission emphasized the importance of preemptively managing certain modifiable comorbidities prior to surgery in an attempt to decrease readmission following PD. Future studies will need to better examine the impact of preoperative management of medical comorbidities to prevent unplanned readmission and by extension improve outcomes for patients undergoing PD.
The current study has several limitations. First, similar to all studies using Medicare data, the study cohort included only patients aged 66 years and older. Given that readmission was strongly associated with the presence of comorbidities, our conclusions may not be generalizable to a young cohort of patients with markedly fewer medical comorbidities.
Second, in assessing provider-level variables, we were limited to those available in the SEER-Medicare data, and we largely focused on provider-specific PD volume. In our analyses, we used a modeling approach that allowed quantification of variability without needing to explicitly identify all important variables at each level.14 Finally, SEER data may not represent a true representative sampling of hospitals and physicians with respect to the provider-level characteristics. As such, other sources of data will need to be used to corroborate our findings.
In conclusion, readmission following complex surgical procedures, such as PD, remains a problem, with nearly 1 in 5 patients being readmitted. While variation in readmission can, in part, be attributed to differences among hospitals, the largest share of variation was found to be at the patient level. Importantly, the finding that patient-to-patient variation was much greater than that attributable to health care providers may have important implications for policy makers. Specifically, our data call into question the use of any arbitrary readmission threshold as a de facto quality or performance metric. Rather, our data strongly suggest that if the readmission is to be used as a hospital quality measure, any guideline will need to extensively account for differences in patient case mix, as well as balance readmission data against other quality metrics such as LOS and perioperative mortality.
Corresponding Author: Timothy M. Pawlik, MD, MPH, PhD, Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Blalock 688, 600 N Wolfe St, Baltimore, MD 21287 (firstname.lastname@example.com).
Accepted for Publication: March 1, 2013.
Published Online: October 9, 2013. doi:10.1001/jamasurg.2013.2509.
Author Contributions: Dr Pawlik had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Hyder, Nathan, Schneider, Hirose, Herman, Pawlik.
Acquisition of data: Hyder, Nathan, Weiss, Choti, Pawlik.
Analysis and interpretation of data: Hyder, Dodson, Schneider, Weiss, Cameron, Choti, Makary, Wolfgang, Pawlik.
Drafting of the manuscript: Hyder, Dodson, Hirose, Pawlik.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Hyder, Schneider, Pawlik.
Administrative, technical, or material support: Dodson, Nathan, Cameron, Herman, Pawlik.
Study supervision: Schneider, Weiss, Choti, Makary, Wolfgang, Pawlik.
Conflict of Interest Disclosures: None reported.
Create a personal account or sign in to: