Syria is a country in turmoil, making headlines almost daily with news about its violent civil war and refugee crisis.- Includes a timeline of significant events, providing students with an ...at-a-glance overview of Syria's history- Provides readers with an appendix of Notable People in the History of Syria that has brief biographies of those who have made important contributions to the country's history- Presents photos and maps to provide additional context and support the text- Offers an annotated bibliography with detailed information on resources for further research
The Nile Shoup, John A., III; Shoup, John A
2017, 2017-05-31, 2017-05-12
eBook
This book provides an avenue for students to explore the Nile-the world's longest river-and better understand its larger role in society in the past, present, and future.- Presents primary documents ...that allow students to delve deeper into the past and more recent political history of the Nile and serve librarians and teachers in their support of curricula standards- Combines historical, cultural, and geographical perspectives on the Nile River-in the long-ago past through to modern day-into one comprehensive reference work- Contains additional features, such an appendix of place names and a glossary of terms, that provide ready-reference material
We present the result of a search of the Milagro sky map for spatial correlations with sources from a subset of the recent Fermi Bright Source List (BSL). The BSL consists of the 205 most significant ...sources detected above 100 MeV by the Fermi Large Area Telescope. We select sources based on their categorization in the BSL, taking all confirmed or possible Galactic sources in the field of view of Milagro. Of the 34 Fermi sources selected, 14 are observed by Milagro at a significance of 3 standard deviations or more. We conduct this search with a new analysis which employs newly optimized gamma-hadron separation and utilizes the full eight-year Milagro data set. Milagro is sensitive to gamma rays with energy from 1 to 100 TeV with a peak sensitivity from 10 to 50 TeV depending on the source spectrum and declination. These results extend the observation of these sources far above the Fermi energy band. With the new analysis and additional data, multi-TeV emission is definitively observed associated with the Fermi pulsar, J2229.0+6114, in the Boomerang pulsar wind nebula (PWN). Furthermore, an extended region of multi-TeV emission is associated with the Fermi pulsar, J0634.0+1745, the Geminga pulsar.
Results are presented of a harmonic analysis of the large-scale cosmic-ray (CR) anisotropy as observed by the Milagro observatory. We show a two-dimensional display of the sidereal anisotropy ...projections in right ascension (R.A.) generated by the fitting of three harmonics to 18 separate declination bands. The Milagro observatory is a water Cherenkov detector located in the Jemez mountains near Los Alamos, New Mexico. With a high duty cycle and large field of view, Milagro is an excellent instrument for measuring this anisotropy with high sensitivity at TeV energies. The analysis is conducted using a seven-year data sample consisting of more than 95 billion events, the largest such data set in existence. We observe an anisotropy with a magnitude around 0.1% for CRs with a median energy of 6 TeV. The dominant feature is a deficit region of depth (2.49 - 0.02 stat. - 0.09 sys.) X10-3 in the direction of the Galactic north pole centered at 189 deg R.A. We observe a steady increase in the magnitude of the signal over seven years.
(ProQuest: ... denotes formulae and/or non-USASCII text omitted) The Cygnus region is a very bright and complex portion of the TeV sky, host to unidentified sources and a diffuse excess with respect ...to conventional cosmic-ray propagation models. Two of the brightest TeV sources, MGRO J2019+37 and MGRO J2031+41, are analyzed using Milagro data with a new technique, and their emission is tested under two different spectral assumptions: a power law and a power law with an exponential cutoff. The new analysis technique is based on an energy estimator that uses the fraction of photomultiplier tubes in the observatory that detect the extensive air shower. The photon spectrum is measured in the range 1-100 TeV using the last three years of Milagro data (2005-2008), with the detector in its final configuration. An F-test indicates that MGRO J2019+37 is better fit by a power law with an exponential cutoff than by a simple power law. The best-fitting parameters for the power law with exponential cutoff model are a normalization at 10 TeV of ... x 10 super(-10) s super(-1) m super(-2) TeV super(-1), a spectral index of ... and a cutoff energy of ... TeV. MGRO J2031+41 shows no evidence of a cutoff. The best-fitting parameters for a power law are a normalization of ... x 10 super(-10) s super(-1) m super(-2) TeV super(-1) and a spectral index of ... The overall flux is subject to a ~30% systematic uncertainty. The systematic uncertainty on the power-law indices is ~0.1. Both uncertainties have been verified with cosmic-ray data. A comparison with previous results from TeV J2032+4130, MGRO J2031+41, and MGRO J2019+37 is also presented.
Use of digital communication technology has shown potential to improve asthma adherence and outcomes. Few studies have looked at patient preference around mode of medication reminders used to improve ...and maintain asthma medication adherence.
To determine if, in a population already receiving automated medication reminders, offering a choice for preferred mode of reminder (text, email, phone) would improve their adherence and asthma outcomes over a 1-year period.
This was a pragmatic, randomized controlled trial conducted at Kaiser Permanente Colorado involving 7522 adult patients with persistent asthma. Study patients were randomized to receive usual care or their choice of medication reminder. Differences between the 2 groups in both medication adherence and asthma outcomes were then assessed over the following year.
Only 30% of those offered a choice of medication reminder modality responded by making a choice, with 52% preferring text messaging. There was less of a decrease in adherence rate over the 1-year period in those who made a choice regarding the mode of medication refill reminder. There was no difference in asthma outcomes between those who did make a choice compared with those who did not make a choice regarding the mode of medication refill reminder.
In a patient population already receiving medication reminders, offering a choice about what type of technology-enabled asthma medication reminder patients wanted did not improve outcomes but did enable a subgroup to better maintain their medication adherence.
BACKGROUND:Challenges to health care efficiency are increasingly addressed with the help of digital communication technology tools (DCTs).
OBJECTIVE:The objective of this study was to test whether ...DCT, compared with Usual Care, can reduce health care clinician burden without increasing asthma-related exacerbations among patients with asthma in a large integrated health care system.
RESEARCH DESIGN:The (Breathewell) program was a pragmatic, randomized trial at (Kaiser Permanente Colorado), where asthma nurses screen patients for poor symptom control when beta2-agonist refill requests came within 60 days of previous fill or in the absence of a controller medication fill within 4 months (beta2-agonist overfill). A total of 14,978 adults with asthma were randomized to Usual Care or 1 of 2 DCT intervention groups (Text/Phone call or Email).
SUBJECTS:Participants included adults 18 and older with an asthma diagnosis at the time of randomization and no history of chronic obstructive pulmonary disease.
MEASURES:Primary outcome measures included asthma-related health care resource utilization (eg, asthma nurse contacts), medication use, and exacerbations.
RESULTS:A total of 1933 patients had 4337 events which met beta2-agonist overfill criteria. Of the 2874 events in the intervention arm, 1188 (41%) were resolved by DCT contact and did not require additional clinician contact. Asthma medication use and exacerbations over 12 months did not differ among the 3 groups.
CONCLUSIONS:DCT tools can successfully contact adult asthma patients to screen for symptoms and facilitate intervention. The absence of differences in medication fills and health care utilization indicates that the strategic replacement of nursing interventions by digital outreach did not reduce treatment adherence or compromise health care outcomes.
ABSTRACT PURPOSE Lower continuity of care has been associated with higher rates of adverse outcomes for persons with multiple chronic medical conditions. It is unclear, however, whether this ...relationship also exists within integrated systems that offer high levels of informational continuity through shared electronic health records. METHODS We conducted a retrospective cohort study of 12,200 seniors with 3 or more chronic conditions within an integrated delivery system. Continuity of care was calculated using the Continuity of Care Index, which reflects visit concentration with individual clinicians. Using Cox proportional hazards regression permitting continuity to vary monthly until the outcome or censoring event, we separately assessed inpatient admissions and emergency department visits as a function of primary care continuity and specialty care continuity. RESULTS After adjusting for covariates (demographics; baseline, primary, and specialty care visits; baseline outcomes; and morbidity burden), greater primary care continuity and greater specialty care continuity were each associated with a lower risk of inpatient admission (respective hazard ratios (95% CIs) = 0.97 (0.96, 0.99) and 0.95 (0.93, 0.98)) and a lower risk of emergency department visits (respective hazard ratios = 0.97 (0.96, 0.98) and 0.98 (0.96, 1.00)). For the subgroup with 3 or more primary care and 3 or more specialty care visits, specialty care continuity (but not primary care continuity) was independently associated with a decreased risk of inpatient admissions (hazard ratio = 0.94 (0.92, 0.97)), and primary care continuity (but not specialty care continuity) was associated with a decreased risk of emergency department visits (hazard ratio = 0.98 (0.96, 1.00)). CONCLUSIONS In an integrated delivery system with high informational continuity, greater continuity of care is independently associated with lower hospital utilization for seniors with multiple chronic medical conditions. Different subgroups of patients will benefit from continuity with primary and specialty care clinicians depending on their care needs.
Abstract Purpose Evaluating patient-centered care for complex patients requires morbidity measurement appropriate for use with a variety of clinical outcomes. We compared the contributions of ...self-reported morbidity and morbidity measured using administrative diagnosis data for both patient-reported outcomes and utilization outcomes. Methods Using a cohort of 961 persons aged 65 years or older with 3 or more medical conditions, we explored 9 health outcomes as a function of 4 independent variables representing different types of morbidity measures: International Classification of Diseases, Ninth Revision (ICD-9) , a self-reported weighted count of conditions, and self-reported symptoms of depression and of anxiety. Outcomes varied from self-reported health status to utilization. Depending on the outcome measure, we used multivariate linear, negative binomial, or logistic regression, adjusting for demographic characteristics and length of enrollment to assess associations between dependent and all 4 independent variables. Results Higher morbidity measured by ICD-9 diagnoses was independently associated with less favorable levels of 7 of the 9 clinical outcomes. Higher self-reported disease burden was significantly associated with less favorable levels of 8 of the outcomes, controlling for the 3 other morbidity measures. Morbidity measured by diagnosis code was more strongly associated with higher utilization, whereas self-reported disease burden and emotional symptoms were more strongly associated with patient-reported outcomes. Conclusions A comprehensive assessment of morbidity requires both subjective and objective measurement of disease burden as well as an assessment of emotional symptoms. Such multidimensional morbidity measurement is particularly relevant for research or quality assessments involving the delivery of patient-centered care to complex patient populations.
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