Defining emergency department episodes by severity and intensity: A 15-year study of Medicare beneficiaries

Background. Episodes of Emergency Department (ED) service use among older adults previously have not been constructed, or evaluated as multi-dimensional phenomena. In this study, we constructed episodes of ED service use among a cohort of older adults over a 15-year observation period, measured the episodes by severity and intensity, and compared these measures in predicting subsequent hospitalization. Methods. We conducted a secondary analysis of the prospective cohort study entitled the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). Baseline (1993) data on 5,511 self-respondents 70 years old were linked to their Medicare claims for 1991-2005. Claims then were organized into episodes of ED care according to Medicare guidelines. The severity of ED episodes was measured with a modified-NYU algorithm using ICD9-CM diagnoses, and the intensity of the episodes was measured using CPT codes. Measures were evaluated against subsequent hospitalization to estimate comparative predictive validity. Results. Over 15 years, three-fourths (4,171) of the 5,511 AHEAD participants had at least 1 ED episode, with a mean of 4.5 episodes. Cross-classification indicated the modified-NYU severity measure and the CPT-based intensity measure captured different aspects of ED episodes (kappa = 0.18). While both measures were significant independent predictors of hospital admission from ED episodes, the CPT measure had substantially higher predictive validity than the modified-NYU measure (AORs 5.70 vs. 3.31; p < .001). Conclusions. We demonstrated an innovative approach for how claims data can be used to construct episodes of ED care among a sample of older adults. We also determined that the modified-NYU measure of severity and the CPT measure of intensity tap different aspects of ED episodes, and that both measures were predictive of subsequent hospitalization. © 2010 Kaskie et al; licensee BioMed Central Ltd

Personalized versus standardized dosing strategies for the treatment of childhood amblyopia: study protocol for a randomized controlled trial

Background: Amblyopia is the commonest visual disorder of childhood in Western societies, affecting, predominantly, spatial visual function. Treatment typically requires a period of refractive correction (‘optical treatment’) followed by occlusion: covering the nonamblyopic eye with a fabric patch for varying daily durations. Recent studies have provided insight into the optimal amount of patching (‘dose’), leading to the adoption of standardized dosing strategies, which, though an advance on previous ad-hoc regimens, take little account of individual patient characteristics. This trial compares the effectiveness of a standardized dosing strategy (that is, a fixed daily occlusion dose based on disease severity) with a personalized dosing strategy (derived from known treatment dose-response functions), in which an initially prescribed occlusion dose is modulated, in a systematic manner, dependent on treatment compliance. Methods/design: A total of 120 children aged between 3 and 8 years of age diagnosed with amblyopia in association with either anisometropia or strabismus, or both, will be randomized to receive either a standardized or a personalized occlusion dose regimen. To avoid confounding by the known benefits of refractive correction, participants will not be randomized until they have completed an optical treatment phase. The primary study objective is to determine whether, at trial endpoint, participants receiving a personalized dosing strategy require fewer hours of occlusion than those in receipt of a standardized dosing strategy. Secondary objectives are to quantify the relationship between observed changes in visual acuity (logMAR, logarithm of the Minimum Angle of Resolution) with age, amblyopia type, and severity of amblyopic visual acuity deficit. Discussion: This is the first randomized controlled trial of occlusion therapy for amblyopia to compare a treatment arm representative of current best practice with an arm representative of an entirely novel treatment regimen based on statistical modelling of previous trial outcome data. Should the personalized dosing strategy demonstrate superiority over the standardized dosing strategy, then its adoption into routine practice could bring practical benefits in reducing the duration of treatment needed to achieve an optimal outcome

Identifying the Machine Learning Family from Black-Box Models

[EN] We address the novel question of determining which kind of machine learning model is behind the predictions when we interact with a black-box model. This may allow us to identify families of techniques whose models exhibit similar vulnerabilities and strengths. In our method, we first consider how an adversary can systematically query a given black-box model (oracle) to label an artificially-generated dataset. This labelled dataset is then used for training different surrogate models (each one trying to imitate the oracle¿s behaviour). The method has two different approaches. First, we assume that the family of the surrogate model that achieves the maximum Kappa metric against the oracle labels corresponds to the family of the oracle model. The other approach, based on machine learning, consists in learning a meta-model that is able to predict the model family of a new black-box model. We compare these two approaches experimentally, giving us insight about how explanatory and predictable our concept of family is.This material is based upon work supported by the Air Force Office of Scientific Research under award number FA9550-17-1-0287, the EU (FEDER), and the Spanish MINECO under grant TIN 2015-69175-C4-1-R, the Generalitat Valenciana PROMETEOII/2015/013. F. Martinez-Plumed was also supported by INCIBE under grant INCIBEI-2015-27345 (Ayudas para la excelencia de los equipos de investigacion avanzada en ciberseguridad). J. H-Orallo also received a Salvador de Madariaga grant (PRX17/00467) from the Spanish MECD for a research stay at the CFI, Cambridge, and a BEST grant (BEST/2017/045) from the GVA for another research stay at the CFI.Fabra-Boluda, R.; Ferri Ramírez, C.; Hernández-Orallo, J.; Martínez-Plumed, F.; Ramírez Quintana, MJ. (2018). Identifying the Machine Learning Family from Black-Box Models. Lecture Notes in Computer Science. 11160:55-65. https://doi.org/10.1007/978-3-030-00374-6_6S556511160Angluin, D.: Queries and concept learning. Mach. Learn. 2(4), 319–342 (1988)Benedek, G.M., Itai, A.: Learnability with respect to fixed distributions. Theor. Comput. Sci. 86(2), 377–389 (1991)Biggio, B., et al.: Security Evaluation of support vector machines in adversarial environments. In: Ma, Y., Guo, G. (eds.) Support Vector Machines Applications, pp. 105–153. Springer, Cham (2014). https://doi.org/10.1007/978-3-319-02300-7_4Blanco-Vega, R., Hernández-Orallo, J., Ramírez-Quintana, M.J.: Analysing the trade-off between comprehensibility and accuracy in mimetic models. In: Suzuki, E., Arikawa, S. (eds.) DS 2004. LNCS (LNAI), vol. 3245, pp. 338–346. Springer, Heidelberg (2004). https://doi.org/10.1007/978-3-540-30214-8_29Dalvi, N., Domingos, P., Sanghai, S., Verma, D., et al.: Adversarial classification. In: Proceedings of the 10th ACM SIGKDD International Conference on Knowledge Discovery and Data Mining, pp. 99–108. ACM (2004)Dheeru, D., Karra Taniskidou, E.: UCI machine learning repository (2017). http://archive.ics.uci.edu/mlDomingos, P.: Knowledge discovery via multiple models. Intell. Data Anal. 2(3), 187–202 (1998)Duin, R.P.W., Loog, M., Pȩkalska, E., Tax, D.M.J.: Feature-based dissimilarity space classification. In: Ünay, D., Çataltepe, Z., Aksoy, S. (eds.) ICPR 2010. LNCS, vol. 6388, pp. 46–55. Springer, Heidelberg (2010). https://doi.org/10.1007/978-3-642-17711-8_5Fernández-Delgado, M., Cernadas, E., Barro, S., Amorim, D.: Do we need hundreds of classifiers to solve real world classification problems. J. Mach. Learn. Res. 15(1), 3133–3181 (2014)Ferri, C., Hernández-Orallo, J., Modroiu, R.: An experimental comparison of performance measures for classification. Pattern Recognit. Lett. 30(1), 27–38 (2009)Giacinto, G., Perdisci, R., Del Rio, M., Roli, F.: Intrusion detection in computer networks by a modular ensemble of one-class classifiers. Inf. Fusion 9(1), 69–82 (2008)Huang, L., Joseph, A.D., Nelson, B., Rubinstein, B.I., Tygar, J.: Adversarial machine learning. In: Proceedings of the 4th ACM Workshop on Security and Artificial Intelligence, pp. 43–58 (2011)Kuncheva, L.I., Whitaker, C.J.: Measures of diversity in classifier ensembles and their relationship with the ensemble accuracy. Mach. Learn. 51(2), 181–207 (2003)Landis, J.R., Koch, G.G.: An application of hierarchical kappa-type statistics in the assessment of majority agreement among multiple observers. Biometrics 33, 363–374 (1977)Lowd, D., Meek, C.: Adversarial learning. In: Proceedings of the 11th ACM SIGKDD International Conference on Knowledge Discovery in Data mining, pp. 641–647. ACM (2005)Martınez-Plumed, F., Prudêncio, R.B., Martınez-Usó, A., Hernández-Orallo, J.: Making sense of item response theory in machine learning. In: Proceedings of 22nd European Conference on Artificial Intelligence (ECAI). Frontiers in Artificial Intelligence and Applications, vol. 285, pp. 1140–1148 (2016)Papernot, N., McDaniel, P., Goodfellow, I.: Transferability in machine learning: from phenomena to black-box attacks using adversarial samples. arXiv preprint arXiv:1605.07277 (2016)Papernot, N., McDaniel, P., Jha, S., Fredrikson, M., Celik, Z.B., Swami, A.: The limitations of deep learning in adversarial settings. In: 2016 IEEE European Symposium on Security and Privacy (EuroS&P), pp. 372–387. IEEE (2016)Papernot, N., McDaniel, P., Wu, X., Jha, S., Swami, A.: Distillation as a defense to adversarial perturbations against deep neural networks. In: 2016 IEEE Symposium on Security and Privacy (SP), pp. 582–597. IEEE (2016)Sesmero, M.P., Ledezma, A.I., Sanchis, A.: Generating ensembles of heterogeneous classifiers using stacked generalization. Wiley Interdiscip. Rev.: Data Min. Knowl. Discov. 5(1), 21–34 (2015)Smith, M.R., Martinez, T., Giraud-Carrier, C.: An instance level analysis of data complexity. Mach. Learn. 95(2), 225–256 (2014)Tramèr, F., Zhang, F., Juels, A., Reiter, M.K., Ristenpart, T.: Stealing machine learning models via prediction APIs. In: USENIX Security Symposium, pp. 601–618 (2016)Valiant, L.G.: A theory of the learnable. Commun. ACM 27(11), 1134–1142 (1984)Wallace, C.S., Boulton, D.M.: An information measure for classification. Comput. J. 11(2), 185–194 (1968)Wolpert, D.H.: Stacked generalization. Neural Netw. 5(2), 241–259 (1992

The association of health literacy with adherence in older 2 adults, and its role in interventions: a systematic meta-review

Background: Low health literacy is a common problem among older adults. It is often suggested to be associated with poor adherence. This suggested association implies a need for effective adherence interventions in low health literate people. However, previous reviews show mixed results on the association between low health literacy and poor adherence. A systematic meta-review of systematic reviews was conducted to study the association between health literacy and adherence in adults above the age of 50. Evidence for the effectiveness of adherence interventions among adults in this older age group with low health literacy was also explored. Methods: Eight electronic databases (MEDLINE, ERIC, EMBASE, PsycINFO, CINAHL, DARE, the Cochrane Library, and Web of Knowledge) were searched using a variety of keywords regarding health literacy and adherence. Additionally, references of identified articles were checked. Systematic reviews were included if they assessed the association between health literacy and adherence or evaluated the effectiveness of interventions to improve adherence in adults with low health literacy. The AMSTAR tool was used to assess the quality of the included reviews. The selection procedure, data-extraction, and quality assessment were performed by two independent reviewers. Seventeen reviews were selected for inclusion. Results: Reviews varied widely in quality. Both reviews of high and low quality found only weak or mixed associations between health literacy and adherence among older adults. Reviews report on seven studies that assess the effectiveness of adherence interventions among low health literate older adults. The results suggest that some adherence interventions are effective for this group. The interventions described in the reviews focused mainly on education and on lowering the health literacy demands of adherence instructions. No conclusions could be drawn about which type of intervention could be most beneficial for this population. Conclusions: Evidence on the association between health literacy and adherence in older adults is relatively weak. Adherence interventions are potentially effective for the vulnerable population of older adults with low levels of health literacy, but the evidence on this topic is limited. Further research is needed on the association between health literacy and general health behavior, and on the effectiveness of interventions

Accelerated in vivo proliferation of memory phenotype CD4+ T-cells in human HIV-1 infection irrespective of viral chemokine co-receptor tropism.

CD4(+) T-cell loss is the hallmark of HIV-1 infection. CD4 counts fall more rapidly in advanced disease when CCR5-tropic viral strains tend to be replaced by X4-tropic viruses. We hypothesized: (i) that the early dominance of CCR5-tropic viruses results from faster turnover rates of CCR5(+) cells, and (ii) that X4-tropic strains exert greater pathogenicity by preferentially increasing turnover rates within the CXCR4(+) compartment. To test these hypotheses we measured in vivo turnover rates of CD4(+) T-cell subpopulations sorted by chemokine receptor expression, using in vivo deuterium-glucose labeling. Deuterium enrichment was modeled to derive in vivo proliferation (p) and disappearance (d*) rates which were related to viral tropism data. 13 healthy controls and 13 treatment-naive HIV-1-infected subjects (CD4 143-569 cells/ul) participated. CCR5-expression defined a CD4(+) subpopulation of predominantly CD45R0(+) memory cells with accelerated in vivo proliferation (p = 2.50 vs 1.60%/d, CCR5(+) vs CCR5(-); healthy controls; P<0.01). Conversely, CXCR4 expression defined CD4(+) T-cells (predominantly CD45RA(+) naive cells) with low turnover rates. The dominant effect of HIV infection was accelerated turnover of CCR5(+)CD45R0(+)CD4(+) memory T-cells (p = 5.16 vs 2.50%/d, HIV vs controls; P<0.05), naïve cells being relatively unaffected. Similar patterns were observed whether the dominant circulating HIV-1 strain was R5-tropic (n = 9) or X4-tropic (n = 4). Although numbers were small, X4-tropic viruses did not appear to specifically drive turnover of CXCR4-expressing cells (p = 0.54 vs 0.72 vs 0.44%/d in control, R5-tropic, and X4-tropic groups respectively). Our data are most consistent with models in which CD4(+) T-cell loss is primarily driven by non-specific immune activation

Malaria rapid diagnostic kits: quality of packaging, design and labelling of boxes and components and readability and accuracy of information inserts

<p>Abstract</p> <p>Background</p> <p>The present study assessed malaria RDT kits for adequate and correct packaging, design and labelling of boxes and components. Information inserts were studied for readability and accuracy of information.</p> <p>Methods</p> <p>Criteria for packaging, design, labelling and information were compiled from Directive 98/79 of the European Community (EC), relevant World Health Organization (WHO) documents and studies on end-users' performance of RDTs. Typography and readability level (Flesch-Kincaid grade level) were assessed.</p> <p>Results</p> <p>Forty-two RDT kits from 22 manufacturers were assessed, 35 of which had evidence of good manufacturing practice according to available information (<it>i.e</it>. CE-label affixed or inclusion in the WHO list of ISO13485:2003 certified manufacturers). Shortcomings in devices were (i) insufficient place for writing sample identification (n = 40) and (ii) ambiguous labelling of the reading window (n = 6). Buffer vial labels were lacking essential information (n = 24) or were of poor quality (n = 16). Information inserts had elevated readability levels (median Flesch Kincaid grade 8.9, range 7.1 - 12.9) and user-unfriendly typography (median font size 8, range 5 - 10). Inadequacies included (i) no referral to biosafety (n = 18), (ii) critical differences between depicted and real devices (n = 8), (iii) figures with unrealistic colours (n = 4), (iv) incomplete information about RDT line interpretations (n = 31) and no data on test characteristics (n = 8). Other problems included (i) kit names that referred to <it>Plasmodium vivax </it>although targeting a pan-species <it>Plasmodium </it>antigen (n = 4), (ii) not stating the identity of the pan-species antigen (n = 2) and (iii) slight but numerous differences in names displayed on boxes, device packages and information inserts. Three CE labelled RDT kits produced outside the EC had no authorized representative affixed and the shape and relative dimensions of the CE symbol affixed did not comply with the Directive 98/79/EC. Overall, RDTs with evidence of GMP scored better compared to those without but inadequacies were observed in both groups.</p> <p>Conclusion</p> <p>Overall, malaria RDTs showed shortcomings in quality of construction, design and labelling of boxes, device packages, devices and buffers. Information inserts were difficult to read and lacked relevant information.</p

Why is it difficult to implement e-health initiatives? A qualitative study

&lt;b&gt;Background&lt;/b&gt; The use of information and communication technologies in healthcare is seen as essential for high quality and cost-effective healthcare. However, implementation of e-health initiatives has often been problematic, with many failing to demonstrate predicted benefits. This study aimed to explore and understand the experiences of implementers - the senior managers and other staff charged with implementing e-health initiatives and their assessment of factors which promote or inhibit the successful implementation, embedding, and integration of e-health initiatives.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Methods&lt;/b&gt; We used a case study methodology, using semi-structured interviews with implementers for data collection. Case studies were selected to provide a range of healthcare contexts (primary, secondary, community care), e-health initiatives, and degrees of normalization. The initiatives studied were Picture Archiving and Communication System (PACS) in secondary care, a Community Nurse Information System (CNIS) in community care, and Choose and Book (C&#38;B) across the primary-secondary care interface. Implementers were selected to provide a range of seniority, including chief executive officers, middle managers, and staff with 'on the ground' experience. Interview data were analyzed using a framework derived from Normalization Process Theory (NPT).&lt;p&gt;&lt;/p&gt; &lt;b&gt;Results&lt;/b&gt; Twenty-three interviews were completed across the three case studies. There were wide differences in experiences of implementation and embedding across these case studies; these differences were well explained by collective action components of NPT. New technology was most likely to 'normalize' where implementers perceived that it had a positive impact on interactions between professionals and patients and between different professional groups, and fit well with the organisational goals and skill sets of existing staff. However, where implementers perceived problems in one or more of these areas, they also perceived a lower level of normalization.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Conclusions&lt;/b&gt; Implementers had rich understandings of barriers and facilitators to successful implementation of e-health initiatives, and their views should continue to be sought in future research. NPT can be used to explain observed variations in implementation processes, and may be useful in drawing planners' attention to potential problems with a view to addressing them during implementation planning

Enteric Neurospheres Are Not Specific to Neural Crest Cultures: Implications for Neural Stem Cell Therapies

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited

Synthesis of freestanding HfO2 nanostructures

Two new methods for synthesizing nanostructured HfO2 have been developed. The first method entails exposing HfTe2 powders to air. This simple process resulted in the formation of nanometer scale crystallites of HfO2. The second method involved a two-step heating process by which macroscopic, freestanding nanosheets of HfO2 were formed as a byproduct during the synthesis of HfTe2. These highly two-dimensional sheets had side lengths measuring up to several millimeters and were stable enough to be manipulated with tweezers and other instruments. The thickness of the sheets ranged from a few to a few hundred nanometers. The thinnest sheets appeared transparent when viewed in a scanning electron microscope. It was found that the presence of Mn enhanced the formation of HfO2 by exposure to ambient conditions and was necessary for the formation of the large scale nanosheets. These results present new routes to create freestanding nanostructured hafnium dioxide

Theoretical study on the electronic, structural, properties and reactivity of a series of mono-, di-, tri- and tetrachlorothiophenes as well as corresponding radical cation forms as monomers for conducting polymers

In this paper, electrical and structural properties of mono-, di-, tri- and tetrachlorothiophenes and their radical cations have been studied using the density functional theory and B3LYP method with 6-311++G** basis set. The effects of the number and position of the substituent of chlorine atoms on the properties of the thiophene ring for all chlorothiophenes and their radical cations have been studied. Vibrational frequencies, nuclear chemical shielding constants, spin-density distribution, size and direction of dipole moment vector, ionization potential, electric polarizabilities and NICS values of these compounds have been calculated as well. The analysis of these data showed that double bonds in 3-chlorothiophene are more delocalized and it is the best possible candidate monomer among all chlorothiophenes for the synthesis of corresponding conducting polymers with modified characteristics