Совершенствование механизмов формирования доходов бюджета АРК

Целью нашей работы является исследование механизмов формирования доходов бюджета Автономной Республики Крым и разработка мероприятий по их совершенствованию

Aide à la décision médicale grâce à la classification automatique

The main objective of this thesis is to develop innovative machine learning techniquesto aid in medical decision making. In the thesis, several case studies were examined, concerning readmission to the emergency room, readmission to the hospital and decision support for the treatment of breast cancer.Firstly, a combination of DAMIP with tabu search is developed. It is shown that this method gives better results than classical machine learning methods on data concerning hospital readmission.After, we developed a method that combines an autoencoder for dimensionality reduction with DAMIP for classification. This method was tested on CLB breast cancer treatment data. The results are similar to those of the Tabu/DAMIP framework, but they are obtained much faster by using an autoencoder. Finally, we developed a simulation model to show the impact of our methods when used in a real application regarding hospital readmission. In this model, we apply the Tabu/DAMIP framework for prediction on whether a patient will returnor not. If we predict that a patient is likely to be readmitted, we make a new prediction with an extended length of stay. Based on our predictions a decision on an extended stay is made. The goal of this approach is to reduce the number ofreadmissions. The results show that we can indeed manage to decrease the number of readmissions, even though in this case the cost may increase.L'objectif principal de cette thèse consiste à développer des techniques innovantes d'apprentissage automatique pour aider à la décision. Dans la thèse, plusieurs études de cas ont été examinées, concernant la réadmission aux urgences, la réadmission à l'hôpital et l'aide à la décision pour le traitement du cancer du sein.Tout d'abord, une combinaison de DAMIP avec la recherche tabou a été développée. Il a été démontré que cette méthode donne de meilleurs résultats que les méthodes classiques d'apprentissage automatique sur les données de réadmission à l'hôpital.Ensuite, nous avons développé une méthode qui combine un autoencodeur pour la réduction de dimensionnalité avec DAMIP pour la classification. Cette méthode a été testée sur les données de traitement du cancer du sein du CLB. Les résultats sont similaires à la méthode précédente, mais sont obtenus beaucoup plus rapidement.Enfin, nous avons développé un modèle de simulation pour montrer l'impact de nos méthodes lorsqu'elles sont utilisées dans une application réelle de réadmission à l'hôpital. Dans ce modèle, nous appliquons le méthode Tabu / DAMIP pour prédire si un patient reviendra ou non. Si nous prédisons qu'un patient est susceptible d'être réadmis, nous faisons une nouvelle prédiction avec une durée de séjour prolongée. Sur la base de nos prévisions, une décision sur un séjour prolongé est prise. Le but de cette approche est de réduire le nombre de réadmissions. Les résultats montrent que l'on parvient effectivement à diminuer le nombre de réadmissions, même si dans ce cas le coût peut augmenter

Adjuvant therapeutic strategy decision support for an elderly population with localized breast cancer: A monocentric cohort retrospective study

International audienceGuidelines for the management of elderly patients with early breast cancer are scarce. Additional adjuvant systemic treatment to surgery for early breast cancer in elderly populations is challenged by increasing comorbidities with age. In non-metastatic settings, treatment decisions are often made under considerable uncertainty; this commonly leads to undertreatment and, consequently, poorer outcomes. This study aimed to develop a decision support tool that can help to identify candidate adjuvant post-surgery treatment schemes for elderly breast cancer patients based on tumor and patient characteristics. Our approach was to generate predictions of patient outcomes for different courses of action; these predictions can, in turn, be used to inform clinical decisions for new patients. We used a cohort of elderly patients (� 70 years) who underwent surgery with curative intent for early breast cancer to train the models. We tested seven classification algorithms using 5-fold cross-validation, with 80% of the data being randomly selected for training and the remaining 20% for testing. We assessed model performance using accuracy, precision, recall, F1-score, and AUC score. We used an autoencoder to perform dimensionality reduction prior to classification. We observed consistently better performance using logistic regression and linear discriminant analysis models when compared to the other models we tested. Classification performance generally improved when an autoencoder was used, except for when we predicted the need for adjuvant treatment. We obtained overall best results using a logistic regression model without autoencoding to predict the need for adjuvant treatment (F1-score = 0.869)

Preventive antibiotics in stroke study: rationale and protocol for a randomised trial

Rationale Stroke is a leading cause of death worldwide. Fever after stroke is a strong predictor of a poor outcome. Infections occur in up to 40% of patients with stroke and have also been associated with poor outcomes. Preventive antibiotic therapy lowers the infection rates in patients after stroke, as shown in a recent meta-analysis of randomised studies. Phase III trials evaluating the effect of antibiotic prophylaxis on clinical outcomes in sufficient numbers of patients with stroke have, however, not been performed to date. Ceftriaxone, an off-patent medicine, is an antibiotic with a broad defence against the bacteria that cause the most common infections after stroke. Preventive antibiotic therapy with ceftriaxone may potentially reduce poor outcome after acute stroke and, therefore, a randomised clinical trial is warranted. Aim The aim of the present study is to investigate whether the preventive use of the antibiotic ceftriaxone improves functional outcome in patients with stroke. Design We will conduct a multicentre prospective, randomised, open-label, blinded end point trial of standard care with preventive ceftriaxone treatment and compare it with standard care without preventive ceftriaxone. Study Adult patients with stroke (both ischaemic and haemorrhagic) and a score >= 1 on the National Institutes of Health Stroke Scale will be included. The 3200 patients will be randomly assigned to two groups of 1600 patients. One group will receive standard care and ceftriaxone at a dose of 2 g, given every 24 h intravenously for four-days, and the other group will receive stroke-unit care without preventive antibiotic treatment. Outcomes The primary end point will be functional outcome at a three-month follow-up on the modified Rankin Scale, dichotomised as a favourable outcome (0-2) or an unfavourable outcome (3-6). Secondary outcome measures will be death rate at discharge and three-months, infection rate during hospital admission, length of hospital admission, volume of poststroke care, use of antibiotics during the three-month follow-up, functional outcome using the full ordinal scoring range of the modified Rankin Scale, quality-adjusted life years and costs

Objective and Subjective Improvement of Cognition After Discontinuing Efavirenz in Asymptomatic Patients : A Randomized Controlled Trial

BACKGROUND: Efavirenz is well known for its clinical cognitive side-effects. Even asymptomatic patients who switch for other reasons than neurocognitive complaints have reported a subjective improvement in cognitive functioning after discontinuing Efavirenz. The aim of this study was to assess the effect on cognition of switching Atripla (TDF/FTC/EFV) to Eviplera (TDF/FTC/RPV), hypothesizing an improvement when discontinuing Efavirenz. SETTING: a randomized controlled design with a highly comparable comparator drug was used to minimize bias and to differentiate drug- versus learning effects. An extensive sensitive neuropsychological assessment (NPA) was used to detect subtle changes. METHODS: virologically suppressed, cognitively asymptomatic male HIV-infected patients on Atripla were included and randomized (2:1) to switch to Eviplera (switch group) or continue on Atripla (control group) for 12 weeks. At baseline and week 12, patients underwent an extensive NPA. RESULTS: 14 control and 34 switch subjects completed the study. There were no differences at baseline. Group-analysis demonstrated a significantly better improvement for the switch group on the domains attention (p=0.041) and speed of information processing (p=0.014). Normative comparison analyses showed that 5 out of the 34 patients who switched (15%) improved on NPA-score as compared to the control group. Interestingly, subjective improvement after discontinuing Efavirenz made 74% of the switch group chose for a regime without Efavirenz after study completion. CONCLUSION: switching from Atripla to Eviplera resulted in objective cognitive improvement on group level in cognitively asymptomatic patients. Discrepancies in objective and subjective cognitive complaints make it challenging to identify patients that would benefit from discontinuing Efavirenz

Objective and Subjective Improvement of Cognition After Discontinuing Efavirenz in Asymptomatic Patients : A Randomized Controlled Trial

Background:Efavirenz is well known for its clinical cognitive side effects. Even asymptomatic patients who switch for other reasons than neurocognitive complaints have reported a subjective improvement in cognitive functioning after discontinuing efavirenz. The aim of this study was to assess the effect on cognition of switching Atripla (TDF/FTC/EFV) to Eviplera (TDF/FTC/RPV), hypothesizing an improvement when discontinuing efavirenz.Setting:A randomized controlled design with a highly comparable comparator drug was used to minimize bias and to differentiate drug versus learning effects. An extensive sensitive neuropsychological assessment (NPA) was used to detect subtle changes.Methods:Virologically suppressed, cognitively asymptomatic male HIV-infected patients on Atripla were included and randomized (2:1) to switch to Eviplera (switch group) or continue on Atripla (control group) for 12 weeks. At baseline and week 12, patients underwent an extensive NPA.Results:Fourteen control and 34 switch subjects completed the study. There were no differences at baseline. Group analysis demonstrated a significantly better improvement for the switch group on the domains attention (P = 0.041) and speed of information processing (P = 0.014). Normative comparison analyses showed that 5 of the 34 patients who switched (15%) improved on NPA score as compared to the control group. Interestingly, subjective improvement after discontinuing efavirenz made 74% of the switch group chose for a regime without efavirenz after study completion.Conclusions:Switching from Atripla to Eviplera resulted in objective cognitive improvement on the group level in cognitively asymptomatic patients. Discrepancies in objective and subjective cognitive complaints make it challenging to identify patients who would benefit from discontinuing efavirenz

Objective and Subjective Improvement of Cognition After Discontinuing Efavirenz in Asymptomatic Patients : A Randomized Controlled Trial

BACKGROUND: Efavirenz is well known for its clinical cognitive side-effects. Even asymptomatic patients who switch for other reasons than neurocognitive complaints have reported a subjective improvement in cognitive functioning after discontinuing Efavirenz. The aim of this study was to assess the effect on cognition of switching Atripla (TDF/FTC/EFV) to Eviplera (TDF/FTC/RPV), hypothesizing an improvement when discontinuing Efavirenz. SETTING: a randomized controlled design with a highly comparable comparator drug was used to minimize bias and to differentiate drug- versus learning effects. An extensive sensitive neuropsychological assessment (NPA) was used to detect subtle changes. METHODS: virologically suppressed, cognitively asymptomatic male HIV-infected patients on Atripla were included and randomized (2:1) to switch to Eviplera (switch group) or continue on Atripla (control group) for 12 weeks. At baseline and week 12, patients underwent an extensive NPA. RESULTS: 14 control and 34 switch subjects completed the study. There were no differences at baseline. Group-analysis demonstrated a significantly better improvement for the switch group on the domains attention (p=0.041) and speed of information processing (p=0.014). Normative comparison analyses showed that 5 out of the 34 patients who switched (15%) improved on NPA-score as compared to the control group. Interestingly, subjective improvement after discontinuing Efavirenz made 74% of the switch group chose for a regime without Efavirenz after study completion. CONCLUSION: switching from Atripla to Eviplera resulted in objective cognitive improvement on group level in cognitively asymptomatic patients. Discrepancies in objective and subjective cognitive complaints make it challenging to identify patients that would benefit from discontinuing Efavirenz

Preventive Antibiotics in Stroke Study: Rationale and Protocol for a Randomised Trial

Rationale Stroke is a leading cause of death worldwide. Fever after stroke is a strong predictor of a poor outcome. Infections occur in up to 40% of patients with stroke and have also been associated with poor outcomes. Preventive antibiotic therapy lowers the infection rates in patients after stroke, as shown in a recent meta-analysis of randomised studies. Phase III trials evaluating the effect of antibiotic prophylaxis on clinical outcomes in sufficient numbers of patients with stroke have, however, not been performed to date. Ceftriaxone, an off-patent medicine, is an antibiotic with a broad defence against the bacteria that cause the most common infections after stroke. Preventive antibiotic therapy with ceftriaxone may potentially reduce poor outcome after acute stroke and, therefore, a randomised clinical trial is warranted. Aim The aim of the present study is to investigate whether the preventive use of the antibiotic ceftriaxone improves functional outcome in patients with stroke. Design We will conduct a multicentre prospective, randomised, open-label, blinded end point trial of standard care with preventive ceftriaxone treatment and compare it with standard care without preventive ceftriaxone. Study Adult patients with stroke (both ischaemic and haemorrhagic) and a score >= 1 on the National Institutes of Health Stroke Scale will be included. The 3200 patients will be randomly assigned to two groups of 1600 patients. One group will receive standard care and ceftriaxone at a dose of 2 g, given every 24 h intravenously for four-days, and the other group will receive stroke-unit care without preventive antibiotic treatment. Outcomes The primary end point will be functional outcome at a three-month follow-up on the modified Rankin Scale, dichotomised as a favourable outcome (0-2) or an unfavourable outcome (3-6). Secondary outcome measures will be death rate at discharge and three-months, infection rate during hospital admission, length of hospital admission, volume of poststroke care, use of antibiotics during the three-month follow-up, functional outcome using the full ordinal scoring range of the modified Rankin Scale, quality-adjusted life years and cost

The Preventive Antibiotics in Stroke Study (PASS): a pragmatic randomised open-label masked endpoint clinical trial

Item does not contain fulltextBACKGROUND: In adults with acute stroke, infections occur commonly and are associated with an unfavourable functional outcome. In the Preventive Antibiotics in Stroke Study (PASS) we aimed to establish whether or not preventive antimicrobial therapy with a third-generation cephalosporin, ceftriaxone, improves functional outcome in patients with acute stroke. METHODS: In this multicentre, randomised, open-label trial with masked endpoint assessment, patients with acute stroke were randomly assigned to intravenous ceftriaxone at a dose of 2 g, given every 24 h intravenously for 4 days, in addition to stroke unit care, or standard stroke unit care without preventive antimicrobial therapy; assignments were made within 24 h after symptom onset. The primary endpoint was functional outcome at 3 months, defined according to the modified Rankin Scale and analysed by intention to treat. The primary analysis was by ordinal regression of the primary outcome. Secondary outcomes included death, infection rates, antimicrobial use, and length of hospital stay. Participants and caregivers were aware of treatment allocation but assessors of outcome were masked to group assignment. This trial is registered with controlled-trials.com, number ISRCTN66140176. FINDINGS: Between July 6, 2010, and March 23, 2014, a total of 2550 patients from 30 sites in the Netherlands, including academic and non-academic medical centres, were randomly assigned to the two treatment groups: 1275 patients to ceftriaxone and 1275 patients to standard treatment (control group). 12 patients (seven in the ceftriaxone group and five in the control group) withdrew consent immediately after randomisation, leaving 2538 patients available for the intention-to-treat-analysis (1268 in the ceftriaxone group and 1270 in the control group). 2514 (99%) of 2538 patients (1257 in each group) completed 3-month follow-up. Preventive ceftriaxone did not affect the distribution of functional outcome scores on the modified Rankin Scale at 3 months (adjusted common odds ratio 0.95 [95% CI 0.82-1.09], p=0.46). Preventive ceftriaxone did not result in an increased occurrence of adverse events. Overgrowth infection with Clostridium difficile occurred in two patients (<1%) in the ceftriaxone group and none in the control group. INTERPRETATION: Preventive ceftriaxone does not improve functional outcome at 3 months in adults with acute stroke. The results of our trial do not support the use of preventive antibiotics in adults with acute stroke. FUNDING: Netherlands Organization for Health Research and Development, Netherlands Heart Foundation, and the European Research Council

Hyperglycemia predicts poststroke infections in acute ischemic stroke

Paroxysmal Cerebral Disorder