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The Brief Symptom Inventory (BSI)-18 is a widely-used tool to assess changes in general distress in patients despite an ongoing debate about its factorial structure and lack of evidence for longitudinal measurement invariance (LMI). We investigated BSI-18 scores from 1,081 patients from an outpatient clinic collected after the 2nd, 6th, 10th, 18th, and 26th therapy session. Confirmatory factor analysis (CFA) was used to compare models comprising one, three, and four latent dimensions that were proposed in the literature. LMI was investigated using a series of model comparisons, based on chi-square tests, effect sizes, and changes in comparative fit index (CFI). Psychological distress diminished over the course of therapy. A four-factor structure (depression, somatic symptoms, generalized anxiety, and panic) showed the best fit to the data at all measurement occasions. The series of model comparisons showed that constraining parameters to be equal across time resulted in very small decreases in model fit that did not exceed the cutoff for the assumption of measurement in variance. Our results show that the BSI-18 is best conceptualized as a four-dimensional tool that exhibits strict longitudinal measurement invariance. Clinicians and applied researchers do not have to be concerned about the interpretation of mean differences over time.
Background
Diabetes mellitus is a major global health issue with a growing prevalence. In this context, the number of diabetic complications is also on the rise, such as diabetic foot ulcers (DFU), which are closely linked to the risk of lower extremity amputation (LEA). Statistical prediction tools may support clinicians to initiate early tertiary LEA prevention for DFU patients. Thus, we designed Bayesian prediction models, as they produce transparent decision rules, quantify uncertainty intuitively and acknowledge prior available scientific knowledge.
Method
A logistic regression using observational collected according to the standardised PEDIS classification was utilised to compute the six-month amputation risk of DFU patients for two types of LEA: 1.) any-amputation and 2.) major-amputation. Being able to incorporate information which is available before the analysis, the Bayesian models were fitted following a twofold strategy. First, the designed prediction models waive the available information and, second, we incorporated the a priori available scientific knowledge into our models. Then, we evaluated each model with respect to the effect of the predictors and validity of the models. Next, we compared the performance of both models with respect to the incorporation of prior knowledge.
Results
This study included 237 patients. The mean age was 65.9 (SD 12.3), and 83.5% were male. Concerning the outcome, 31.6% underwent any- and 12.2% underwent a major-amputation procedure. The risk factors of perfusion, ulcer extent and depth revealed an impact on the outcomes, whereas the infection status and sensation did not. The major-amputation model using prior information outperformed the uninformed counterpart (AUC 0.765 vs AUC 0.790, Cohen’s d 2.21). In contrast, the models predicting any-amputation performed similarly (0.793 vs 0.790, Cohen’s d 0.22).
Conclusions
Both of the Bayesian amputation risk models showed acceptable prognostic values, and the major-amputation model benefitted from incorporating a priori information from a previous study. Thus, PEDIS serves as a valid foundation for a clinical decision support tool for the prediction of the amputation risk in DFU patients. Furthermore, we demonstrated the use of the available prior scientific information within a Bayesian framework to establish chains of knowledge.
Various overoxidized poly(1H-pyrrole) (PPy), poly(N-methylpyrrole) (PMePy) or poly(3,4-ethylenedioxythiophene) (PEDOT) membranes incorporated into an acrylate-based solid polymer electrolyte matrix (SPE) were directly electrosynthesized by a two-step in situ procedure. The aim was to extend and improve fundamental properties of pure SPE materials. The polymer matrix is based on the cross-linking of glycerol propoxylate (1PO/OH) triacrylate (GPTA) with poly(ethylene glycol) diacrylate (PEGDA) and lithium bis(trifluoromethanesulfonyl)imide (LiTFSI) as a conducting salt. A self-standing and flexible polymer electrolyte film is formed during the UV-induced photopolymerization of the acrylate precursors, followed by an electrochemical polymerization of the conducting polymers to form a 3D-IPN. The electrical conductivity of the conducting polymer is destroyed by electrochemical overoxidation in order to convert the conducting polymer into an ion-exchange membrane by introduction of electron-rich groups onto polymer units. The resulting polymer films were characterized by scanning electron microscopy, cyclic voltammetry, electrochemical impedance spectroscopy, differential scanning calorimetry, thermal analysis and infrared spectroscopy. The results of this study show that the combination of a polyacrylate-matrix with ion selective properties of overoxidized CPs leads to new 3D materials with higher ionic conductivity than SPEs and separator or selective ion-exchange membrane properties with good stability by facile fabrication.
The simulation of the residual stress field achieved by shot peening cannot be carried out on component-large models. Hence, an efficient unit cell model for the simulation of the shot peening process is developed. The model allows both, the simple inclusion of a pre-stress and the evaluation of the up-arching of the Almen strip. For this purpose, generalized coupling constraints for the periodic boundaries of the unit cell are developed. These allow for displacement and rotation of the coupled boundaries relative to each other. In the coupling constraints, this is accomplished by respective variables, which can either be prescribed to the analysis or read out as a result from the analysis. Hence, the unit cell can expand, shear, bend and twist under driving forces like, e. g., residual stresses or thermal effects. At the same time, deformations of the cell’s periodic boundary pairs are kept congruent by the generalized coupling. The ability to cover expansion is novel regarding known periodic boundary conditions. Also, the application of a generalized unit cell to shot peening is new.
Results obtained with the generalized unit cell are displayed, demonstrating its capabilities: A fundamental analysis of the residual stress field from shot peening shows inhomogeneities at a fatigue relevant level to be inevitable. A validation of the model was done by comparison with experimental Almen strip shot peening tests reported in literature. Shot peening under pre-stress is demonstrated and its results in terms of residual stress are evaluated. The application of the generalized unit cell is not limited to shot peening.
The central aim of the investigation at hand is to deal with the problem areas of Human Resource Management, which arise by demographic changes and migration. The paper focuses on mutual relationships. Managers and human resource managers are considered as multipliers. Older employees, migrants and women are important potential. Therefore, following research questions have been investigated: Which competences are necessary to promote to recognise the potential of migrants correctly and to promote them? Do the multipliers have to be more sensitized for the issue diversity? Do they have to develop specific competences to make the system more permeable and to make the entry and promotion of migrants possible? Which competences should be promoted to increase the sensitivity for diversity? The questions were examined by a qualitative investigation to develop hypotheses for a quantitative study. Overall, 30 interviews with managers, human resource managers and diversity representatives of the large DAX companies were conducted. Furthermore, 17 employees with immigration background and 15 employees without an immigration background were interviewed. The data was transcribed and analysed by the qualitative content analysis according to Mayring (2010). Comparative analyses were made with single items with Likert Scales. The investigation of managers and employees is a highly diversified issue. Therefore, the main focus of the project lays on the problem areas, conflicts and competences of human resources managers in demographic-sensitive personnel management. In comparison, employees with and without an immigration background were asked. The results show an interesting field of tension between self-perception and perception of others and the assessment of the relevance of diversity attitudes and measures, competences and their implementation. Furthermore, a contrary perception regarding strains and stresses of person with and without immigration background is determined, which is developed in the consequences of migrations stress and experiences of discrimination. The results indicate the need of promotion of competences, especially regarding intercultural competence. A critical analysis of the results will be presented.
Aims: This study examines the relationship between the time, students spent abroad, personality traits and circumstances during this time with the student’s intercultural competence and integration performance in the target culture. Design and sample: The study had a correlative cross-sectional design. 202 academic subjects were surveyed. The average age was 22 years. There was one measuring time, to which 58 % of the participants stated that they have had a stay abroad. Measurements: Metacognitive, cognitive, motivational and behavioural intercultural competence were measured with the Cultural Intelligence Scale. The personality traits involvement, discipline, social competence, cooperation, dominance and stability were captured with the "Bochum inventory for job-related personality description-6F". Work-related attitudes as patterns of behaviour and experience were measured using the "Work-related Behaviour and Experiencing Pattern 44" (Geman: Arbeitsbezogene Verhaltens- und Erlebensmuster; AVEM). In addition, the demographic factors and characteristics of stays abroad as well as the integration into the target culture based on the Sociocultural Adaption Scale were examined. The data was tested for relationships and differences by tests for mean differences, variance and regression analyses. Results: There was a positive correlation between duration and cognitive, motivational and behavioural intercultural competence. The motivational competence is higher in subjects who have no risk pattern in the AVEM. The different types of competence influence each other at diverse times. Moreover, the suggested structural equation model could be confirmed. This showed the effect of the AVEM pattern on intercultural competence, moderated by the stay abroad and the social competence.
Career Decisions of Indian Female Talent: Implications for Gender-sensitive Talent Management
(2020)
Purpose: Talent scarcity in emerging economies such as India poses challenges for companies,and limited labour market participation among well-educated women has been observed. The reasons that professionals decide not to pursue a further corporate career remain unclear. By investigating career decision making, this article aims to highlight (1) the contextual factors that impact those decisions, (2) individuals’ agency to handle them, and (3) the implications for talent management (TM).
Design/methodology/approach: Following a qualitative research design, computer-aided analysis was conducted on interviews with 24 internationally experienced Indian business professionals. A novel application of neo-institutionalism in the Indian context was combined with the family-relatedness of work decisions (FRWD) model.
Findings: Career decisions indicate that rebellion against Indian societal and family expectations is essential to following a career path, especially for women. TM as part of the current institutional framework serves as a legitimising façade veiling traditional practices that hinder females’ careers.
Research limitations: Interviewees adopted a retrospective perspective when describing their career decisions; therefore, different views might have existed at the moment of decision making.
Practical implications: Design and implementation of gender-sensitive TM adjusted to fit the specific Indian context can contribute to retaining female talent in companies and the labour market.
Originality/value: The importance of gender-sensitive TM can be concluded from an empirical study of the context-based career decision making of experienced business professionals from India. The synthesis of neo-institutionalism, the FRWD model and the research results provides assistance in mapping talent experiences and implications for overcoming the challenges of talent scarcity in India.
Background
Against the background of a steadily increasing degree of digitalization in health care, a professional information management (IM) is required to successfully plan, implement, and evaluate information technology (IT). At its core, IM has to ensure a high quality of health data and health information systems to support patient care.
Objectives
The goal of the present study was to define what constitutes professional IM as a construct as well as to propose a reliable and valid measurement instrument.
Methods
To develop and validate the construct of professionalism of information management (PIM) and itsmeasurement, a stepwise approach followed an established procedure from information systems and behavioral research. The procedure included an analysis of the pertaining literature and expert rounds on the construct and the
instrument, two consecutive and comprehensive surveys at the national and international level, exploratory and confirmatory factor analyses as well as reliability and validity testing.
Results
Professionalism of information management was developed as a construct consisting of the three dimensions of strategic, tactical, and operational IMas well as of the regularity and cyclical phases of IM procedures as the two elements of professionalism.
The PIM instrument operationalized the construct providing items that incorporated IM procedures along the three dimensions and cyclical phases. These procedures had to be evaluated against their degree of regularity in the instrument. The instrument proved to be reliable and valid in two consecutive measurement phases
and across three countries.
Conclusion
It can be concluded that professionalism of information management is a meaningful construct that can be operationalized in a scientifically rigorous manner. Both science and practice can benefit from these developments in terms of improved self-assessment, benchmarking capabilities, and eventually, obtaining a better understanding of health IT maturity.
Vanadium carbide (VC) reinforced FeCrVC hardfacings have become important to improving the lifetime of tools suffering abrasive and impressive loads. This is because the microstructural properties of such hardfacings enable the primary VCs to act as obstacles against the penetrating abrasive. Because dilution is supposed to be the key issue influencing the precipitation behaviour of primary carbides during surfacing, the development of deposit welding processes exhibiting a reduced thermal impact, and hence lower dilution to the base material, is the primary focus of the current research. By inserting an additional hot wire in the melt, an approach was developed to separate the material and energy input during gas metal arc welding (GMAW) and hence realised low dilution claddings. The carbide content could be increased, and a grain refinement was observed compared with conventional GMAW. These effects could be attributed to both the reduced dilution and heterogeneous nucleation.
With the increasing size and complexity of embedded systems, the impact of software on energy consumption is becoming more important. Previous research focused mainly on energy optimization at the hardware level. However, little research has been carried out regarding energy optimization at the software design level. This paper focuses on the software design level and addresses the gap between software and hardware design for embedded systems. This is achieved by proposing a framework for software design patterns, which takes aspects of power consumption and time behavior of the hardware level into account. We evaluate the expressiveness of the framework by applying it to well-known and novel design patterns. Furthermore, we introduce a dimensionless numerical efficiency factor to make possible energy savings quantifiable.
The location of manufacturing is operationally and strategically important for multinational companies. The spatial dispersion of manufacturing is determined by firm-specific as well as external factors, both of which are subject to constant change. After decades of offshoring production, the paper uses interview data from UK high value manufacturing companies to explore the recent phenomenon of reshoring and the strategic and operational effects of manufacturing location. The analyses show that concentrating manufacturing in home countries enables firms to increase organizational agility and stimulate innovation. However, under certain conditions, firms also continue benefiting from the known advantages of offshoring. This underlines that there is no universal recommendation for improving competitiveness by a certain spatial configuration of manufacturing. Instead, firms need to consider their specific markets, competitive context, and capabilities when strategizing manufacturing location."
Background: Pancreatic cancer is one of the malignant diseases with the highest cancer-specific mortality. At the time of diagnosis, life expectancy is often already very limited, as it is usually discovered late and in an advanced stage. Coping with cancer is a complex process. Coping strategies of patients with pancreatic cancer probably differ from those of other malignancies. Yet to date, there exists no pancreatic cancer-specific coping model.
Objective: The objective of this scoping review is to explore and characterize the academic literature related to coping processes in patients with pancreatic cancer.
Methods/Design: The JBI's three-step search strategy, combined with the Arksey and O'Malley framework, will be used to identify articles via PubMed/MEDLINE, CINAHL, Cochrane Library, Google Scholar, CAMbase, CareLit, CC Med, Scopus, and PsycARTICLES (Arksey & O'Malley, 2005; Peters et al., 2017). It follows the PRISMA guidelines for scoping reviews (Tricco et al., 2018). Primary and secondary studies and reviews which report on coping with pancreatic cancer (adenocarcinoma) in adults in English or German language will be included in this scoping review, regardless of publication date or study design.
Discussion: This scoping review will add new insights on coping with pancreatic cancer by summarizing current knowledge, and identifying research
Injection of slurry or digestate below maize seeds is a relatively new technique developed to improve nitrogen use efficiency. However, this practice has the major drawback of increasing nitrous oxide (N2O) emissions. The application of a nitrification inhibitor (NI) is an effective method to reduce these emissions. To evaluate the effect of the NI 3,4‐dimethypyrazole phosphate (DMPP) on N2O emissions and the stabilization of ammonium, a two‐factorial soil‐column experiment was conducted. PVC pipes (20 cm diameter and 30 cm length) were used as incubation vessels for the soil‐columns. The trial consisted of four treatments in a randomized block design with four replications: slurry injection, slurry injection + DMPP, digestate injection, and digestate injection + DMPP. During the 47‐day incubation period, N2O fluxes were measured twice a week and cumulated by linear interpolation of the gas‐fluxes of consecutive measurement dates. After completion of the gas flux measurement, concentration of ammonium and nitrate within the soil‐columns was determined. DMPP delayed the conversion of ammonium within the manure injection zone significantly. This effect was considerably more pronounced in treatment digestate + NI than in treatment slurry + NI. Regarding the cumulated N2O emissions, no difference between slurry and digestate treatments was determined. DMPP reduced the release of N2O significantly. Transferring the results into practice, the use of DMPP is a promising way to reduce greenhouse gas emissions and nitrate leaching, following the injection of slurry or digestate.
In this paper, we evaluate the application of Bayesian Optimization (BO) to discrete event simulation (DES) models. In a first step, we create a simple model, for which we know the optimal set of parameter values in advance. We implement the model in SimPy, a framework for DES written in Python. We then interpret the simulation model as a black box function subject to optimization. We show that it is possible to find the optimal set of parameter values using the open source library GPyOpt. To enhance our evaluation, we create a second and more complex model. To better handle the complexity of the model, and to add a visual component, we build the second model in Simio, a commercial off-the-shelf simulation modeling tool. To apply BO to a model in Simio, we use the Simio API to write an extension for optimization plug-ins. This extension encapsulates the logic of the BO algorithm, which we deployed as a web service in the cloud.
The fact that simulation models are black box functions with regard to their behavior and the influence of their input parameters makes them an apparent candidate for Bayesian Optimization (BO). Simulation models are multivariable and stochastic, and their behavior is to a large extent unpredictable. In particular, we do not know for sure which input parameters to adjust to maximize (or minimize) the model’s outcome. In addition, the complex models can take a substantial amount of time to run.
Bayesian Optimization is a sequential and self-learning algorithm to optimize black box functions similar to as we find them in simulation models: they contain a set of parameters for which we want to identify the optimal set, they are expensive to evaluate, and they exhibit stochastic noise. BO has proven to efficiently optimize black box functions from varius disciplines. Among those, and most notably, it is successfully applied in machine learning algorithms to optimize hyperparameters.
This paper presents an optimized algorithm for estimating static and dynamic gait parameters. We use a marker- and contact-less motion capture system that identifies 20 joints of a person walking along a corridor.
Based on the proposed gait cycle detection basic metrics as walking frequency, step/stride length, and support phases are estimated automatically. Applying a rigid body model, we are capable to calculate static and dynamic gait stability metrics. We conclude with initial results of a clinical study evaluating orthopaedic technical support.
The objective of this review is a global assessment of the economics of second‐generation biorefineries, with a focus on the use of food waste and agricultural residues for chemical production by applying biotechnological processes. Analyses are conducted on feedstock and product distribution, applied economic models, and profitability figures for the period 2013–2018. In a study of 163 articles on different biorefinery systems, the production of chemicals is identified as the second major product class, after bioenergy. Bagasse and straw are frequently analyzed second‐generation feedstocks. Based on the evaluation of 22 articles, second‐generation biorefineries producing chemicals by applying biotechnological processes proves to be economically feasible. On average, both the internal rate of return (IRR) and the return on investment (ROI) are 20% and the payback period (PP) is 6 years. The cost share of feedstock in biorefineries is between 0–50%. The price of the end product and the fermentation yields have the most impact on profitability. The processing of food waste that has industrial and municipal origins appears more economical than the processing of agricultural residues. Scientists, policy makers and entrepreneurs with an appropriate risk tolerance are advised to pay particular attention to municipal food waste and the potential economic production of carboxylic acids. For various economic issues related to biorefineries, dynamic‐deterministic models are recommended, which can be extended by a stochastic model. This review provides an initial overview of the economic feasibility of second‐generation biorefineries. Further techno‐economic analyses are required to produce statistically significant statements on key profitability figures. © 2020 The Authors. Biofuels, Bioproducts, and Biorefining published by Society of Chemical Industry and John Wiley & Sons, Ltd.
Background: In aged nursing care receivers, the prevalence of adverse skin conditions such as xerosis cutis, intertrigo, pressure ulcers or skin tears is high. Adequate skin care strategies are an effective method for maintaining and enhancing skin health and integrity in this population.
Objectives: The objective was to summarize the empirical evidence about the effects and effectiveness of non-drug topical skin care interventions to promote and to maintain skin integrity and skin barrier function in the aged, to identify outcome domains and outcome measurement instruments in this field.
Design: An update of a previous systematic review published in 2013 was conducted.
Data sources: Databases MEDLINE and EMBASE via OvidSP and CINAHL (original search January 1990 to August 2012, update September 2012 to May 2018) and reference lists were searched. Forward searches in Web of Science were conducted.
Methods: A review protocol was registered in Prospero (CRD42018100792). Main inclusion criteria were primary intervention studies reporting treatment effects of basic skin care strategies in aged people with a lower limit of age range of 50 years and published between 1990 and 2018. Primary empirical studies were included with experimental study designs including randomized controlled trials and quasi-experimental designs. Methodological quality of included randomized controlled trials was evaluated using the Cochrane Collaboration's Tool for assessing risk of bias. Levels of evidence were assigned to all included studies.
Results: Sixty-three articles were included in the final analysis reporting effects of interventions to treat and/or to prevent skin dryness, pruritus, general skin barrier improvement, incontinence-associated dermatitis, skin tears and pressure ulcers. Skin cleansers containing syndets or amphotheric surfactants compared with standard soap and water improved skin dryness. Lipophilic leave-on products containing humectants decreased skin dryness and reduced pruritus. Products with pH 4 improved the skin barrier. Application of skin protectants and structured skin care protocols decreased the severity of incontinence-associated dermatitis. Formulations containing glycerin and petrolatum reduced the incidence of skin tears. Thirty-five outcome domains were identified with nearly 100 different outcome measurement instruments.
Conclusion: Included studies showed substantial heterogeneity regarding design, interventions and outcomes. Basic skin care strategies including low-irritating cleansers and lipophilic humectant-containing leave-on products are helpful for treating dry skin and improving skin barrier in the aged. Lower pH of leave-on products improves the skin barrier. The number of different outcome domains was unexpectedly high. We recommend to identify critical outcome domains in the field of skin care to make trial results more comparable in the future and to measure possible performance differences between different skin care strategies and products.
This article is based on an international comparative social policy module held annually at Malmö University (Sweden) with partner universities from several countries. Our study examines the results of intra- and interpersonal dynamics among participants and lecturers, which we call "productive tension", in relation to overarching questions about knowledge acquisition and the importance of reflexivity and reflectivity in the learning process. Students and faculty create a "community of practice" (CoP) (Lave & Wenger 1991) that benefits from a continuous interactive environment and direct engagement. Our study uses a mixed method approach. The analysis considers qualitative data from interviews with the participating students and quantitative data from questionnaires. In this article, we focus on the productive tension inherent in the reflective and reflexive processes. Reflective and reflexive processes are identified that influence the students' experience of cross-border cooperation and their professional identity. Our study also demonstrates how the knowledge about "Social Work" as a profession can be broadened through international comparative teaching and learning. The main conclusion of this work is that reflective and reflexive learning processes in social work education enable participants to see and understand themselves from a broader perspective and strengthen their own professional identity.
Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potential mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.
Entrapment neuropathies are a heterogenous condition reflecting distinct underlying pathomechanisms. A contemporary assessment aimed at identifying potential mechanisms may help target management for these patients.
Background/Aim
This study aimed to establish the somatosensory profile of patients with lumbar radiculopathy at pre-and post-microdiscectomy and to explore any association between pre-surgical quantitative sensory test (QST) parameters and post-surgical clinical outcomes.
Methods
A standardized QST protocol was performed in 53 patients (mean age 38 ± 11 years, 26 females) with unilateral L5/S1 radiculopathy in the main pain area (MPA), affected dermatome and contralateral mirror sites and in age- and gender-,and body site-matched healthy controls. Repeat measures at 3 months included QST, the Oswestry Disability Index (ODI) and numerous other clinical measures; at 12 months, only clinical measures were repeated. A change <30% on the ODI was defined as ‘no clinically meaningful improvement’.
Results
Patients showed a significant loss of function in their symptomatic leg both in the dermatome (thermal, mechanical, vibration detection p < .002), and MPA (thermal, mechanical, vibration detection, mechanical pain threshold, mechanical pain sensitivity p < .041) and increased cold sensitivity in the MPA (p < .001). Pre-surgical altered QST parameters improved significantly post-surgery in the dermatome (p < .018) in the symptomatic leg and in the MPA (p < .010), except for thermal detection thresholds and cold sensitivity. Clinical outcomes improved at 3 and 12 months (p < .001). Seven patients demonstrated <30% change on the ODI at 12 months. Baseline loss of function in mechanical detection in the MPA was associated with <30% change on the ODI at 12 months (OR 2.63, 95% CI 1.09–6.37, p = .032).
Conclusion
Microdiscectomy resulted in improvements in affected somatosensory parameters and clinical outcomes. Pre-surgical mechanical detection thresholds may be predictive of clinical outcome.
Significance
This study documented quantitative sensory testing (QST) profiles in patients with lumbar radiculopathy in their main pain area (MPA) and dermatome pre- and post-microdiscectomy and explored associations between QST parameters and clinical outcome. Lumbar radiculopathy was associated with loss of function in modalities mediated by large and small sensory fibres. Microdiscectomy resulted in significant improvements in loss of function and clinical outcomes in 85% of our cohort. Pre-surgical mechanical detection thresholds in the MPA may be predictive of clinical outcome.