Late diagnosis of abdominal aortic aneurysms substantiates underutilization of abdominal aortic aneurysm screening for Medicare beneficiaries

ObjectiveAbdominal aortic aneurysm (AAA) screening remains largely underutilized in the U.S., and it is likely that the proportion of patients with aneurysms requiring prompt treatment is much higher compared with well-screened populations. The goals of this study were to determine the proportion of AAAs that required prompt repair after diagnostic abdominal imaging for U.S. Medicare beneficiaries and to identify patient and hospital factors contributing to early vs late diagnosis of AAA.MethodsData were extracted from Medicare claims records for patients at least 65 years old with complete coverage for 2 years who underwent intact AAA repair from 2006 to 2009. Preoperative ultrasound and computed tomography was tabulated from 2002 to repair. We defined early diagnosis of AAA as a patient with a time interval of greater than 6 months between the first imaging examination and the index procedure, and late diagnosis as patients who underwent the index procedure within 6 months of the first imaging examination.ResultsOf 17,626 patients who underwent AAA repair, 14,948 met inclusion criteria. Mean age was 77.5 ± 6.1 years. Early diagnosis was identified for 60.6% of patients receiving AAA repair, whereas 39.4% were repaired after a late diagnosis. Early diagnosis rates increased from 2006 to 2009 (59.8% to 63.4%; P < .0001) and were more common for intact repair compared with repair after rupture (62.9% vs 35.1%; P < .0001) and for women compared with men (66.3% vs 59.0%; P < .0001). On multivariate analysis, repair of intact vs ruptured AAAs (odds ratio, 3.1; 95% confidence interval, 2.7-3.6) and female sex (odds ratio, 1.4; 95% confidence interval, 1.3-1.5) remained the strongest predictors of surveillance. Although intact repairs were more likely to be diagnosed early, over one-third of patients undergoing repair for ruptured AAAs received diagnostic abdominal imaging greater than 6 months prior to surgery.ConclusionsDespite advances in screening practices, significant missed opportunities remain in the U.S. Medicare population for improving AAA care. It remains common for AAAs to be diagnosed when they are already at risk for rupture. In addition, a significant proportion of patients with early imaging rupture prior to repair. Our findings suggest that improved mechanisms for observational management are needed to ensure optimal preoperative care for patients with AAAs

Farsighted Risk Mitigation of Lateral Movement Using Dynamic Cognitive Honeypots

Lateral movement of advanced persistent threats has posed a severe security challenge. Due to the stealthy and persistent nature of the lateral movement, defenders need to consider time and spatial locations holistically to discover latent attack paths across a large time-scale and achieve long-term security for the target assets. In this work, we propose a time-expanded random network to model the stochastic service links in the user-host enterprise network and the adversarial lateral movement. We design cognitive honeypots at idle production nodes and disguise honey links as service links to detect and deter the adversarial lateral movement. The location of the honeypot changes randomly at different times and increases the honeypots' stealthiness. Since the defender does not know whether, when, and where the initial intrusion and the lateral movement occur, the honeypot policy aims to reduce the target assets' Long-Term Vulnerability (LTV) for proactive and persistent protection. We further characterize three tradeoffs, i.e., the probability of interference, the stealthiness level, and the roaming cost. To counter the curse of multiple attack paths, we propose an iterative algorithm and approximate the LTV with the union bound for computationally efficient deployment of cognitive honeypots. The results of the vulnerability analysis illustrate the bounds, trends, and a residue of LTV when the adversarial lateral movement has infinite duration. Besides honeypot policies, we obtain a critical threshold of compromisability to guide the design and modification of the current system parameters for a higher level of long-term security. We show that the target node can achieve zero vulnerability under infinite stages of lateral movement if the probability of movement deterrence is not less than the threshold

Local adaptation and the evolution of genome architecture in threespine stickleback.

Theory predicts that local adaptation should favour the evolution of a concentrated genetic architecture, where the alleles driving adaptive divergence are tightly clustered on chromosomes. Adaptation to marine vs. freshwater environments in threespine stickleback has resulted in an architecture that seems consistent with this prediction: divergence among populations is mainly driven by a few genomic regions harbouring multiple quantitative trait loci (QTL) for environmentally adapted traits, as well as candidate genes with well-established phenotypic effects. One theory for the evolution of these "genomic islands" is that rearrangements remodel the genome to bring causal loci into tight proximity, but this has not been studied explicitly. We tested this theory using synteny analysis to identify micro- and macro-rearrangements in the stickleback genome and assess their potential involvement in the evolution of genomic islands. To identify rearrangements, we conducted a de novo assembly of the closely-related tubesnout (Aulorhyncus flavidus) genome and compared this to the genomes of threespine stickleback and two other closely related species. We found that small rearrangements, within-chromosome duplications, and Lineage-Specific Genes (LSGs) were enriched around genomic islands, and that all three chromosomes harbouring large genomic islands have experienced macro-rearrangements. We also found that duplicates and micro-rearrangements are 9.9x and 2.9x more likely to involve genes differentially expressed between marine and freshwater genotypes. While not conclusive, these results are consistent with the explanation that strong divergent selection on candidate genes drove the recruitment of rearrangements to yield clusters of locally adaptive loci

An Attack Graph-Based Probabilistic Security Metric

Abstract. To protect critical resources in today’s networked environments, it is desirable to quantify the likelihood of potential multi-step attacks that combine multiple vulnerabilities. This now becomes feasible due to a model of causal re-lationships between vulnerabilities, namely, attack graph. This paper proposes an attack graph-based probabilistic metric for network security and studies its effi-cient computation. We first define the basic metric and provide an intuitive and meaningful interpretation to the metric. We then study the definition in more com-plex attack graphs with cycles and extend the definition accordingly. We show that computing the metric directly from its definition is not efficient in many cases and propose heuristics to improve the efficiency of such computation.

Utilization of remote sensing techniques for the quantification of fire behavior in two pine stands

Quantification of field-scale fire behavior is necessary to improve the current scientific understanding of wildland fires and to develop and test relevant, physics-based models. In particular, detailed descriptions of individual fires are required, for which the available literature is limited. In this work, two such field-scale experiments, carried out in pine stands under mild conditions, are presented. A particular focus was placed on non-intrusive measurement, as the capabilities of advanced remote sensing techniques, along with more traditional approaches, are explored. A description of the fires is presented, with spread occurring predominantly in the surface fuels with intensities in the range of 200–4400 kW m-1, and punctuated by isolated regions of crown fire. The occurrence of crown fire is investigated and linked to regions of greater canopy density, and it is found that the total fire intensity may increase locally to as much as 21,000 kW m-1. The light winds do not appear to play a direct role in the changes in fire behavior, while fuel structure may be important. The measurements described herein provided a reasonable overall description of the fires, however, the current resolution (both spatial and temporal) falls short of definitively explaining some transitional aspects of the fire behavior, and future improvements are suggested

Comprehending the multiple 'values' of green infrastructure - valuing nature-based solutions for urban water management, from multiple perspectives

The valuation of urban water management practices and associated nature-based solutions (NBS) is highly contested, and is becoming increasingly important to cities seeking to increase their resilience to climate change whilst at the same time facing budgetary pressures. Different conceptions of ‘values’ exist, each being accompanied by a set of potential measures ranging from calculative practices (closely linked to established market valuation techniques) – through to holistic assessments that seek to address wider concerns of sustainability. Each has the potential to offer important insights that often go well beyond questions of balancing the costs and benefits of the schemes concerned. However, the need to address – and go beyond – economic considerations presents policy-makers, practitioners and researchers with difficult methodological, ethical and practical challenges, especially when considered without the benefit of a broader theoretical framework or in the absence of well-established tools (as might apply within more traditional infrastructural planning contexts, such as the analysis of transport interventions). Drawing on empirical studies undertaken in Sheffield over a period of 10 years, and delivered in partnership with several other European cities and regions, we compare and examine different attempts to evaluate the benefits of urban greening options and future development scenarios. Comparing these different approaches to the valuation of nature-based solutions alongside other, more conventional forms of infrastructure – and indeed integrating both ‘green and grey’ interventions within a broader framework of infrastructures – throws up some surprising results and conclusions, as well as providing important sign-posts for future research in this rapidly emerging field

Strategic green infrastructure planning in Germany and the UK: a transnational evaluation of the evolution of urban greening policy and practice

The evolution of Green Infrastructure (GI) planning has varied dramatically between nations. Although a grounded set of principles are recognized globally, there is increasing variance in how these are implemented at a national and sub-national level. To investigate this the following paper presents an evaluation of how green infrastructure has been planned for in England and Germany illustrating how national policy structures facilitate variance in application. Adopting an evaluative framework linked to the identification of GI, its development and monitoring/ feedback the paper questions the impacts on delivery of intersecting factors including terminology, spatial distribution and functionality on effective GI investment. This process reviews how changing policy structures have influenced the framing of green infrastructure policy, and subsequent impact this has on the delivery of green infrastructure projects

A review of wildland fire spread modelling, 1990-present, 1: Physical and quasi-physical models

In recent years, advances in computational power and spatial data analysis (GIS, remote sensing, etc) have led to an increase in attempts to model the spread and behaviour of wildland fires across the landscape. This series of review papers endeavours to critically and comprehensively review all types of surface fire spread models developed since 1990. This paper reviews models of a physical or quasi-physical nature. These models are based on the fundamental chemistry and/or physics of combustion and fire spread. Other papers in the series review models of an empirical or quasi-empirical nature, and mathematical analogues and simulation models. Many models are extensions or refinements of models developed before 1990. Where this is the case, these models are also discussed but much less comprehensively.Comment: 31 pages + 8 pages references + 2 figures + 5 tables. Submitted to International Journal of Wildland Fir

The Society for Immunotherapy of Cancer consensus statement on immunotherapy for the treatment of squamous cell carcinoma of the head and neck (HNSCC).

Head and neck cancers, including those of the lip and oral cavity, nasal cavity, paranasal sinuses, oropharynx, larynx and nasopharynx represent nearly 700,000 new cases and 380,000 deaths worldwide per annum, and account for over 10,000 annual deaths in the United States alone. Improvement in outcomes are needed for patients with recurrent and or metastatic squamous cell carcinoma of the head and neck (HNSCC). In 2016, the US Food and Drug Administration (FDA) granted the first immunotherapeutic approvals - the anti-PD-1 immune checkpoint inhibitors nivolumab and pembrolizumab - for the treatment of patients with recurrent squamous cell carcinoma of the head and neck (HNSCC) that is refractory to platinum-based regimens. The European Commission followed in 2017 with approval of nivolumab for treatment of the same patient population, and shortly thereafter with approval of pembrolizumab monotherapy for the treatment of recurrent or metastatic HNSCC in adults whose tumors express PD-L1 with a ≥ 50% tumor proportion score and have progressed on or after platinum-containing chemotherapy. Then in 2019, the FDA granted approval for PD-1 inhibition as first-line treatment for patients with metastatic or unresectable, recurrent HNSCC, approving pembrolizumab in combination with platinum and fluorouracil for all patients with HNSCC and pembrolizumab as a single agent for patients with HNSCC whose tumors express a PD-L1 combined positive score ≥ 1. These approvals marked the first new therapies for these patients since 2006, as well as the first immunotherapeutic approvals in this disease. In light of the introduction of these novel therapies for the treatment of patients with head and neck cancer, The Society for Immunotherapy of Cancer (SITC) formed an expert committee tasked with generating consensus recommendations for emerging immunotherapies, including appropriate patient selection, therapy sequence, response monitoring, adverse event management, and biomarker testing. These consensus guidelines serve as a foundation to assist clinicians\u27 understanding of the role of immunotherapies in this disease setting, and to standardize utilization across the field for patient benefit. Due to country-specific variances in approvals, availability and regulations regarding the discussed agents, this panel focused solely on FDA-approved drugs for the treatment of patients in the U.S