A formal evaluation of data flow path selection criteria

A number of path selection criteria have been proposed throughout the years. Unfortunately, little work has been done on comparing these criteria. To determine what would be an effective path selection criterion for revealing errors in programs, we have undertaken an evaluation of these criteria. This paper reports on the results of our evaluation of path selection criteria based on data flow relationships. We show how these criteria relate to each other, thereby demonstrating some of their strengths and weaknesses. In addition, we suggest minor changes to some criteria that improve their performance. We conclude with a discussion of the major limitations of these criteria and directions for future research

Performance of externally validated enhanced computer-aided versions of the National Early Warning Score in predicting mortality following an emergency admission to hospital in England: a cross-sectional study

YesOBJECTIVES: In the English National Health Service, the patient's vital signs are monitored and summarised into a National Early Warning Score (NEWS) to support clinical decision making, but it does not provide an estimate of the patient's risk of death. We examine the extent to which the accuracy of NEWS for predicting mortality could be improved by enhanced computer versions of NEWS (cNEWS). DESIGN: Logistic regression model development and external validation study. SETTING: Two acute hospitals (YH-York Hospital for model development; NH-Northern Lincolnshire and Goole Hospital for external model validation). PARTICIPANTS: Adult (≥16 years) medical admissions discharged over a 24-month period with electronic NEWS (eNEWS) recorded on admission are used to predict mortality at four time points (in-hospital, 24 hours, 48 hours and 72 hours) using the first electronically recorded NEWS (model M0) versus a cNEWS model which included age+sex (model M1) +subcomponents of NEWS (including diastolic blood pressure) (model M2). RESULTS: The risk of dying in-hospital following emergency medical admission was 5.8% (YH: 2080/35 807) and 5.4% (NH: 1900/35 161). The c-statistics for model M2 in YH for predicting mortality (in-hospital=0.82, 24 hours=0.91, 48 hours=0.88 and 72 hours=0.88) was higher than model M0 (in-hospital=0.74, 24 hours=0.89, 48 hours=0.86 and 72 hours=0.85) with higher Positive Predictive Value (PPVs) for in-hospital mortality (M2 19.3% and M0 16.6%). Similar findings were seen in NH. Model M2 performed better than M0 in almost all major disease subgroups. CONCLUSIONS: An externally validated enhanced computer-aided NEWS model (cNEWS) incrementally improves on the performance of a NEWS only model. Since cNEWS places no additional data collection burden on clinicians and is readily automated, it may now be carefully introduced and evaluated to determine if it can improve care in hospitals that have eNEWS systems.This research was supported by the Health Foundation. The Health Foundation is an independent charity working to improve the quality of healthcare in the UK. This research was also supported by the National Institute for Health Research (NIHR) Yorkshire and Humberside Patient Safety Translational Research Centre (YHPSTRC)

Food security outcomes under a changing climate: impacts of mitigation and adaptation on vulnerability to food insecurity

Climate change is a potential threat to achieving food security, particularly in the most food insecure regions. However, interpreting climate change projections to better understand the potential impacts of a changing climate on food security outcomes is challenging. This paper addresses this challenge through presenting a framework that enables rapid country-level assessment of vulnerability to food insecurity under a range of climate change and adaptation investment scenarios. The results show that vulnerability to food insecurity is projected to increase under all emissions scenarios, and the geographic distribution of vulnerability is similar to that of the present-day; parts of sub-Saharan Africa and South Asia are most severely affected. High levels of adaptation act to off-set these increases; however, only the scenario with the highest level of mitigation combined with high levels of adaptation shows improvements in vulnerability compared to the present-day. The results highlight the dual requirement for mitigation and adaptation to avoid the worst impacts of climate change and to make gains in tackling food insecurity. The approach is an update to the existing Hunger and Climate Vulnerability Index methodology to enable future projections, and the framework presented allows rapid updates to the results as and when new information becomes available, such as updated country-level yield data or climate model output. This approach provides a framework for assessing policy-relevant human food security outcomes for use in long-term climate change and food security planning; the results have been made available on an interactive website for policymakers ( www.metoffice.gov.uk/food-insecurity-index )

Génération d'impulsions ultrabrèves de haute puissance et a haut taux de répétition par amplification fibrée en régime auto-similaire ou d'auto-modulation de phase

Nous démontrons l’amplification d’impulsions pico- et femto-secondes par un dispositif fibré à un taux de répétition de 1 GHz obtenu par utilisation d’un VECSEL passivement mode-locké. Deux régimes non-linéaires d’amplification sont alors clairement mis en évidence, l’un dominé par l’auto-modulation de phase et l’autre par une évolution autosimilaire. Ce dernier régime conduit après recompression temporelle à des impulsions en limite de Fourier avec une durée temporelle inférieure à 150 fs

The inclusion of delirium in version 2 of the National Early Warning Score will substantially increase the alerts for escalating levels of care: findings from a retrospective database study of emergency medical admissions in two hospitals

YesBackground The National Early Warning Score (NEWS) is being replaced with NEWS2 which adds 3 points for new confusion or delirium. We estimated the impact of adding delirium on the number of medium/high level alerts that are triggers to escalate care. Methods Analysis of emergency medical admissions in two acute hospitals (York Hospital (YH) and Northern Lincolnshire and Goole NHS Foundation Trust hospitals (NH)) in England. Twenty per cent were randomly assigned to have delirium. Results The number of emergency admissions (YH: 35584; NH: 35795), mortality (YH: 5.7%; NH: 5.5%), index NEWS (YH: 2.5; NH: 2.1) and numbers of NEWS recorded (YH: 879193; NH: 884072) were similar in each hospital. The mean number of patients with medium level alerts per day increased from 55.3 (NEWS) to 69.5 (NEWS2), a 25.7% increase in YH and 64.1 (NEWS) to 77.4 (NEWS2), a 20.7% increase in NH. The mean number of patients with high level alerts per day increased from 27.3 (NEWS) to 34.4 (NEWS2), a 26.0% increase in YH and 29.9 (NEWS) to 37.7 (NEWS2), a 26.1% increase in NH. Conclusions The addition of delirium in NEWS2 will have a substantial increase in medium and high level alerts in hospitalised emergency medical patients. Rigorous evaluation of NEWS2 is required before widespread implementation because the extent to which staff can cope with this increase without adverse consequences remains unknown

Patients' use of a home-based virtual reality system to provide rehabilitation of the upper limb following stroke

Background: A low cost, virtual reality system that translates movements of the hand, fingers and thumb into game play was designed to provide a flexible and motivating approach to increasing adherence to home based rehabilitation. Objective: Effectiveness depends on adherence, so did patients use the intervention to the recommended level. If not, what reasons did they give? Design: Prospective cohort study plus qualitative analysis of interviews. Methods: 17 patients recovering from stroke recruited to the intervention arm of a feasibility trial had the equipment left in their homes for eight weeks and were advised to use it three times a day for periods of no more than 20 minutes. Frequency and duration of use were automatically recorded. At the end of the intervention, participants were interviewed to determine barriers to using it in the recommended way. Results: Duration of use and how many days they used the equipment are presented for the 13 participants who successfully started the intervention. These figures were highly variable and could fall far short of our recommendations. There was a weak (p=0.053) positive correlation between duration and baseline reported activities of daily living. Participants reported familiarity with technology and competing commitments as barriers to use although appreciated the flexibility of the intervention and found it motivating

A season long investigation into the effects of injury, match selection and training load on mental wellbeing in professional under 23 soccer players: A team case study

This study examined the influence of injury, match selection and training load on mental wellbeing (MW) in a squad of professional soccer players. Using a longitudinal design, twenty-five male soccer players (age, 20 ± 1 years, height, 1.80 ± 5.79 m, body mass 76.33 ± 7.52 kg) from the under 23 squad playing in the Premier League 2 division in the UK completed the Warwick–Edinburgh Mental Well-being Scale (WEMWBS) each week of the 2017/2018 season (37 weeks in total). Injury and non-selection for the match squad were the only significant predictors of MW (P  0.05). These findings highlight the importance of monitoring MW in professional soccer players and suggest that injured players and those rarely selected for the match squad should be educated on the strategies available for managing their mental health and wellbeing

The National Early Warning Score and its subcomponents recorded within ±24 hours of emergency medical admission are poor predictors of hospital-acquired acute kidney injury

YesBackground: Hospital-acquired Acute Kidney Injury (H-AKI) is a common cause of avoidable morbidity and mortality. Aim: To determine if the patients’ vital signs data as defined by a National Early Warning Score (NEWS), can predict H-AKI following emergency admission to hospital. Methods: Analyses of emergency admissions to York hospital over 24-months with NEWS data. We report the area under the curve (AUC) for logistic regression models that used the index NEWS (model A0), plus age and sex (A1), plus subcomponents of NEWS (A2) and two-way interactions (A3). Likewise for maximum NEWS (models B0,B1,B2,B3). Results: 4.05% (1361/33608) of emergency admissions had H-AKI. Models using the index NEWS had the lower AUCs (0.59 to 0.68) than models using the maximum NEWS AUCs (0.75 to 0.77). The maximum NEWS model (B3) was more sensitivity than the index NEWS model (A0) (67.60% vs 19.84%) but identified twice as many cases as being at risk of H-AKI (9581 vs 4099) at a NEWS of 5. Conclusions: The index NEWS is a poor predictor of H-AKI. The maximum NEWS is a better predictor but seems unfeasible because it is only knowable in retrospect and is associated with a substantial increase in workload albeit with improved sensitivity.The Health Foundatio

A prospective study of consecutive emergency medical admissions to compare a novel automated computer-aided mortality risk score and clinical judgement of patient mortality risk

YesObjectives: To compare the performance of a validated automatic computer-aided risk of mortality (CARM) score versus medical judgement in predicting the risk of in-hospital mortality for patients following emergency medical admission. Design: A prospective study. Setting: Consecutive emergency medical admissions in York hospital. Participants: Elderly medical admissions in one ward were assigned a risk of death at the first post-take ward round by consultant staff over a 2-week period. The consultant medical staff used the same variables to assign a risk of death to the patient as the CARM (age, sex, National Early Warning Score and blood test results) but also had access to the clinical history, examination findings and any immediately available investigations such as ECGs. The performance of the CARM versus consultant medical judgement was compared using the c-statistic and the positive predictive value (PPV). Results: The in-hospital mortality was 31.8% (130/409). For patients with complete blood test results, the c-statistic for CARM was 0.75 (95% CI: 0.69 to 0.81) versus 0.72 (95% CI: 0.66 to 0.78) for medical judgements (p=0.28). For patients with at least one missing blood test result, the c-statistics were similar (medical judgements 0.70 (95% CI: 0.60 to 0.81) vs CARM 0.70 (95% CI: 0.59 to 0.80)). At a 10% mortality risk, the PPV for CARM was higher than medical judgements in patients with complete blood test results, 62.0% (95% CI: 51.2 to 71.9) versus 49.2% (95% CI: 39.8 to 58.5) but not when blood test results were missing, 50.0% (95% CI: 24.7 to 75.3) versus 53.3% (95% CI: 34.3 to 71.7). Conclusions: CARM is comparable with medical judgements in discriminating in-hospital mortality following emergency admission to an elderly care ward. CARM may have a promising role in supporting medical judgements in determining the patient's risk of death in hospital. Further evaluation of CARM in routine practice is required.Supported by the Health Foundation, National Institute for Health Research (NIHR) Yorkshire and Humberside Patient Safety Translational Research Centre (NIHR YHPSTRC)

Computer-aided National Early Warning Score to predict the risk of sepsis following emergency medical admission to hospital: a model development and external validation study

YesBackground: In English hospitals, the patient’s vital signs are monitored and summarised into a National Early Warning Score (NEWS). NEWS is more accurate than the quick sepsis related organ failure assessment (qSOFA) score at identifying patients with sepsis. We investigate the extent to which the accuracy of the NEWS is enhanced by developing computer-aided NEWS (cNEWS) models. We compared three cNEWS models (M0=NEWS alone; M1=M0 + age + sex; M2=M1 + subcomponents of NEWS + diastolic blood pressure) to predict the risk of sepsis. Methods: All adult emergency medical admissions discharged over 24-months from two acute hospitals (YH–York Hospital for model development; NH–Northern Lincolnshire and Goole Hospital for external model validation). We used a validated Canadian method for defining sepsis from administrative hospital data. Findings: The prevalence of sepsis was lower in YH (4.5%=1596/35807) than NH (8.5%=2983/35161). The c-statistic increased across models (YH: M0: 0.705, M1:0.763, M2:0.777; NH:M0: 0.708, M1:0.777, M2:0.791). At NEWS 5+, sensitivity increased (YH: 47.24% vs 50.56% vs 52.69%; NH: 37.91% vs 43.35% vs 48.07%)., the positive likelihood ratio increased (YH: 2.77 vs 2.99 vs 3.06; NH: 3.18 vs 3.32 vs 3.45) and the positive predictive value increased (YH: 11.44% vs 12.24% vs 12.49%; NH: 22.75% vs 23.55% vs 24.21%). Interpretation: From the three cNEWS models, Model M2 is the most accurate. Since it places no additional data collection burden on clinicians and can be automated, it may now be carefully introduced and evaluated in hospitals with sufficient informatics infrastructure.The Health Foundation, National Institute for Health Research (NIHR) Yorkshire and Humberside Patient Safety Translational Research CentreResearch Development Fund Publication Prize Award winner, April 2019