Interest in bariatric surgery among obese patients with obstructive sleep apnea

BACKGROUND: Standard obstructive sleep apnea (OSA) therapies are poorly tolerated. Bariatric surgery is a potential alternative but the level of interest in this intervention among OSA patients is unknown. OBJECTIVES: Determine the proportion of OSA patients who would be interested in bariatric surgery. SETTING: Sleep clinics, United States. METHODS: Consecutive adult patients with untreated severe OSA and a body mass index of 35-45 kg/m2 were approached. Patients at low perioperative risk and no urgent indication for OSA treatment were invited to a separate informational visit about bariatric surgery as primary treatment for OSA. RESULTS: Of 767 eligible patients, 230 (30.0%) were not at low perioperative risk, 49 (6.4%) had drowsy driving, and 16 (2.1%) had no insurance coverage for bariatric surgery. Of the remaining 482 patients, over one third (35.5%) were interested in bariatric surgery. Surgical interest was 47.2% in women versus 27.6% in men (

What Automated Planning Can Do for Business Process Management

Business Process Management (BPM) is a central element of today organizations. Despite over the years its main focus has been the support of processes in highly controlled domains, nowadays many domains of interest to the BPM community are characterized by ever-changing requirements, unpredictable environments and increasing amounts of data that influence the execution of process instances. Under such dynamic conditions, BPM systems must increase their level of automation to provide the reactivity and flexibility necessary for process management. On the other hand, the Artificial Intelligence (AI) community has concentrated its efforts on investigating dynamic domains that involve active control of computational entities and physical devices (e.g., robots, software agents, etc.). In this context, Automated Planning, which is one of the oldest areas in AI, is conceived as a model-based approach to synthesize autonomous behaviours in automated way from a model. In this paper, we discuss how automated planning techniques can be leveraged to enable new levels of automation and support for business processing, and we show some concrete examples of their successful application to the different stages of the BPM life cycle

The Shape and Figure Rotation of NGC 2915's Dark Halo

NGC 2915 is a blue compact dwarf galaxy with a very extended HI disk showing a short central bar and extended spiral arms, both reaching far beyond the optical component. We use Tremaine & Weinberg (1984) method to measure the pattern speed of the bar from HI radio synthesis data. Our measurements yield a pattern speed of 0.21+/-0.06 km/s/arcsec (8.0+/-2.4 km/s/kpc for D=5.3 Mpc), in disagreement with the general view that corotation in barred disks lies just outside the end of the bar, but consistent with recent models of barred galaxies with dense dark matter halos. Our adopted bar semi-length puts corotation at more than 1.7 bar radii. The existence of the pattern is also problematic. Because NGC 2915 is isolated, interactions cannot account for the structure observed in the HI disk. We also demonstrate that the low observed disk surface density and the location of the pseudo-rings make it unlikely that swing amplification or bar-driven spiral arms could explain the bar and spiral pattern. Based on the similarity of the dark matter and HI surface density profiles, we discuss the possibility of dark matter distributed in a disk and following closely the HI distribution. The disk then becomes unstable and can naturally form a bar and spiral pattern. However, this explanation is hard to reconcile with some properties of NGC 2915. We also consider the effect of a massive and extended triaxial dark matter halo with a rotating figure. The existence of such halos is supported by CDM simulations showing strongly triaxial dark halos with slow figure rotation. The observed structure of the HI disk can then arise through forcing by the rotating triaxial figure. We associate the measured pattern speed in NGC 2915 with the figure rotation of its dark halo.Comment: 37 pages, including 8 figures and 2 tables (AASTeX, aaspp4.sty). Fig.1 and 2 available as jpg. Accepted for publication in The Astronomical Journal. Online manuscript with PostScript figures available at: http://www.strw.leidenuniv.nl/~bureau/pub_list.htm

Bridging the gap between business processes and IoT

© 2020 ACM. This paper discusses a novel way of making business processes and Internet of Things (IoT) work together. Indeed each suffers from many limitations that the other could help address them and vice versa. On the one hand, business processes are known for capturing organizations\u27 best practices when satisfying users\u27 demands but do not have the capabilities of controlling the physical surrounding that comprises millions of devices/things. On the other hand, IoT is known for provisioning contextualized services to users thanks to millions of devices/things but does not have the capabilities of making these devices/things collaborate. The paper presents a framework to support the collaboration of business processes and IoT. This collaboration is exemplified with 2 types of processes referred as thing-Aware processes (TaP) and process-of-Things (PoT). A system illustrating the development of PoT is presented in the paper as well

Refining and testing the diagnostic accuracy of an assessment tool (PAT-POPS) to predict admission and discharge of children and young people who attend an emergency department : protocol for an observational study

Background: Increasing attendances by children (aged 0–16 years) to United Kingdom Emergency Departments (EDs) challenges patient safety within the National Health Service (NHS) with health professionals required to make complex judgements on whether children attending urgent and emergency care services can be sent home safely or require admission. Health regulation bodies have recommended that an early identification systems should be developed to recognise children developing critical illnesses. The Pennine Acute Hospitals NHS Trust Paediatric Observation Priority Score (PAT-POPS) was developed as an ED-specific tool for this purpose. This study aims to revise and improve the existing tool and determine its utility in determining safe admission and discharge decision making. Methods/design: An observational study to improve diagnostic accuracy using data from children and young people attending the ED and Urgent Care Centre (UCC) at three hospitals over a 12 month period. The data being collected is part of routine practice; therefore opt-out methods of consent will be used. The reference standard is admission or discharge. A revised PAT-POPs scoring tool will be developed using clinically guided logistic regression models to explore which components best predict hospital admission and safe discharge. Suitable cut-points for safe admission and discharge will be established using sensitivity and specificity as judged by an expert consensus meeting. The diagnostic accuracy of the revised tool will be assessed, and it will be compared to the former version of PAT-POPS using ROC analysis. Discussion: This new predictive tool will aid discharge and admission decision-making in relation to children and young people in hospital urgent and emergency care facilities. Trial registration: NIHR RfPB Grant: PB-PG-0815-20034. ClinicalTrials.gov: 213469. Retrospectively registered on 11 April 2018. Keywords: Paediatric, Emergency department, Diagnostic accuracy, Early identification systems, screening tool, Observational, Early warning score, Early warning system, hospital admission

Social meanings and understandings in patient-nurse interaction in the community practice setting: a grounded theory study

Provisional: Background: The patient-nurse relationship is a traditional concern of healthcare research. However, patient-nurse interaction is under examined from a social perspective. Current research focuses mostly on specific contexts of care delivery and experience related to medical condition or illness, or to nurses' speciality. Consequentially, this paper is about the social meanings and understandings at play within situated patient-nurse interaction in the community practice setting in a transforming healthcare service. Methods: Grounded theory methodology was used and the research process was characterised by principles of theoretical sensitivity and constant comparative analysis. The field of study was four health centres in the community. The participants were patients and nurses representative of those attending or working in the health centres and meeting there by scheduled appointment. Data collection methods were observations, informal interviews and semi-structured interviews. Results: Key properties of 'Being a good patient, being a good nurse', 'Institutional experiences' and 'Expectations about healthcare' were associated with the construction of a category entitled 'Experience'. Those key properties captured that in an evolving healthcare environment individuals continually re-constructed their reality of being a patient or nurse as they endeavoured to perform appropriately; articulation of past and present healthcare experiences was important in that process. Modus operandi in role as patient was influenced by past experiences in healthcare and by those in non-healthcare institutions in terms of engagement and involvement (or not) in interaction. Patients' expectations about interaction in healthcare included some uncertainly as they strived to make sense of the changing roles and expertise of nurses and, differentiating between the roles and expertise of nurses and doctors. Conclusions: The importance of social meanings and understandings in patient-nurse interaction is not fully apparent to nurses, but important in the patient experience. Seeking understanding from a social perspective makes a contribution to enhancing knowledge about patient-nurse interaction with subsequent impact on practice, in particular the development of the patient-nurse relationship. The implications are that the meanings and understandings patients and nurses generate from experiences beyond and within their situated interaction are pivotal to the development of their relationship in the transforming community healthcare environment

Improving the Manchester Triage System for pediatric emergency care: an international multicenter study

OBJECTIVE:To validate use of the Manchester triage system in paediatric emergency care. DESIGN: Prospective observational study. SETTING: Emergency departments of a university hospital and a teaching hospital in the Netherlands, 2006-7. PARTICIPANTS: 17,600 children (aged <16) visiting an emergency department over 13 months (university hospital) and seven months (teaching hospital). INTERVENTION: Nurses triaged 16,735/17,600 patients (95%) using a computerised Manchester triage system, which calculated urgency levels from the selection of discriminators embedded in flowcharts for presenting problems. Nurses over-ruled the urgency level in 1714 (10%) children, who were excluded from analysis. Complete data for the reference standard were unavailable in 1467 (9%) children leaving 13,554 patients for analysis. MAIN OUTCOME MEASURES: Urgency according to the Manchester triage system compared with a predefined and independently assessed reference standard for five urgency levels. This reference standard was based on a combination of vital signs at presentation, potentially life threatening conditions, diagnostic resources, therapeutic interventions, and follow-up. Sensitivity, specificity, and likelihood ratios for high urgency (immediate and very urgent) and 95% confidence intervals for subgroups based on age, use of flowcharts, and discriminators. RESULTS: The Manchester urgency level agreed with the reference standard in 4582 of 13,554 (34%) children; 7311 (54%) were over-triaged and 1661 (12%) under-triaged. The likelihood ratio was 3.0 (95% confidence interval 2.8 to 3.2) for high urgency and 0.5 (0.4 to 0.5) for low urgency; though the likelihood ratios were lower for those presenting with a medical problem (2.3 (2.2 to 2.5) v 12.0 (7.8 to 18.0) for trauma) and in younger children (2.4 (1.9 to 2.9) at 0-2 months [corrected] v 5.4 (4.5 to 6.5) at 8-16 years). CONCLUSIONS: The Manchester triage system has moderate validity in paediatric emergency care. It errs on the safe side, with much more over-triage than under-triage compared with an independent reference standard for urgency. Triage of patients with a medical problem or in younger children is particularly difficult

Validation of a HLA-A2 tetramer flow cytometric method, IFNgamma real time RT-PCR, and IFNgamma ELISPOT for detection of immunologic response to gp100 and MelanA/MART-1 in melanoma patients

<p>Abstract</p> <p>Background</p> <p>HLA-A2 tetramer flow cytometry, IFNγ real time RT-PCR and IFNγ ELISPOT assays are commonly used as surrogate immunological endpoints for cancer immunotherapy. While these are often used as research assays to assess patient's immunologic response, assay validation is necessary to ensure reliable and reproducible results and enable more accurate data interpretation. Here we describe a rigorous validation approach for each of these assays prior to their use for clinical sample analysis.</p> <p>Methods</p> <p>Standard operating procedures for each assay were established. HLA-A2 (A*0201) tetramer assay specific for gp100_209(210M)and MART-1_26–35(27L), IFNγ real time RT-PCR and ELISPOT methods were validated using tumor infiltrating lymphocyte cell lines (TIL) isolated from HLA-A2 melanoma patients. TIL cells, specific for gp100 (TIL 1520) or MART-1 (TIL 1143 and TIL1235), were used alone or spiked into cryopreserved HLA-A2 PBMC from healthy subjects. TIL/PBMC were stimulated with peptides (gp100₂₀₉, gp100_pool, MART-1_27–35, or influenza-M1 and negative control peptide HIV) to further assess assay performance characteristics for real time RT-PCR and ELISPOT methods. Validation parameters included specificity, accuracy, precision, linearity of dilution, limit of detection (LOD) and limit of quantification (LOQ). In addition, distribution was established in normal HLA-A2 PBMC samples. Reference ranges for assay controls were established.</p> <p>Results</p> <p>The validation process demonstrated that the HLA-A2 tetramer, IFNγ real time RT-PCR, and IFNγ ELISPOT were highly specific for each antigen, with minimal cross-reactivity between gp100 and MelanA/MART-1. The assays were sensitive; detection could be achieved at as few as 1/4545–1/6667 cells by tetramer analysis, 1/50,000 cells by real time RT-PCR, and 1/10,000–1/20,000 by ELISPOT. The assays met criteria for precision with %CV < 20% (except ELISPOT using high PBMC numbers with %CV < 25%) although flow cytometric assays and cell based functional assays are known to have high assay variability. Most importantly, assays were demonstrated to be effective for their intended use. A positive IFNγ response (by RT-PCR and ELISPOT) to gp100 was demonstrated in PBMC from 3 melanoma patients. Another patient showed a positive MART-1 response measured by all 3 validated methods.</p> <p>Conclusion</p> <p>Our results demonstrated the tetramer flow cytometry assay, IFNγ real-time RT-PCR, and INFγ ELISPOT met validation criteria. Validation approaches provide a guide for others in the field to validate these and other similar assays for assessment of patient T cell response. These methods can be applied not only to cancer vaccines but to other therapeutic proteins as part of immunogenicity and safety analyses.</p

Lumbale herniaoperatie: Endoscopisch of open?

_Achtergrond en het waarom van de studie_ In Nederland vinden jaarlijks veel operaties voor een lumbale discushernia plaats. Patiënten krijgen meestal een open microdiscectomie, waarbij de hernia wordt opgeheven via een klein sneetje in de rug en de zenuwwortel wordt vrijgelegd (figuur a). Een andere techniek is percutane transforaminale endoscopische discectomie (PTED) (figuur b). Hierbij wordt de hernia onder indirect zicht opgeheven door een kleinere snee van 8 mm via het wortelkanaal, dus meer vanaf de zijkant. PTED vindt plaats in dagbehandeling onder lichte sedatie, waardoor de patiënt gedurende de ingreep aanspreekbaar is. Mogelijke voordelen van deze techniek zijn minder risico op littekenvorming en een snellere revalidatie. Een mogelijk nadeel is een groter risico op recidieven omdat er minder discusmateriaal kan worden uitgeruimd. PTED behoort nog niet tot het basispakket, omdat Zorginstituut Nederland meent dat PTED niet voldoet aan de stand van de wetenschap en praktijk. Met de PTED-studie willen wij de hypothese toetsen dat PTED bij patiënten met een lumbale hernia niet minder effectief is dan open microdiscectomie. Daarnaast zullen wij ook de kosteneffectiviteit analyseren. _Vraagstelling:_ Is PTED niet minder effectief en niet minder kosteneffectief dan microdiscectomie bij patiënten met lumbosacraal radiculair syndroom door een discushernia

A Feedback-Based Adaptive Service-Oriented Paradigm for the Internet of Things

© Springer International Publishing AG, part of Springer Nature 2018. With integrating physical devices into digital world, Internet of Things (IoT) have presented tremendous potential in various different application domains such as smart cities, intelligent transportation, smart home, healthcare and industrial automation. However, current IoT solutions and usage scenarios are still very limited because of the difficulty in sensing the context in continuously changing environments and adaptation to the changes accordingly. The complex dynamic interactions between system components and physical environments are a bit challenging especially when there are other concerns such as scalability and heterogeneity. To solve this problem, a novel adaptive service-oriented paradigm is proposed to support IoT from a low-level viewpoint. The paradigm can overcome some disadvantages of REST (Representational State Transfer) architecture style in the IoT. Two classical examples are illustrated using the proposed paradigm by adding an extra constraint based on REST to improve system states verification and enhance the functionality in modelling physical processes