Low income, community poverty and risk of end stage renal disease

BACKGROUND: The risk of end stage renal disease (ESRD) is increased among individuals with low income and in low income communities. However, few studies have examined the relation of both individual and community socioeconomic status (SES) with incident ESRD. METHODS: Among 23,314 U.S. adults in the population-based Reasons for Geographic and Racial Differences in Stroke study, we assessed participant differences across geospatially-linked categories of county poverty [outlier poverty, extremely high poverty, very high poverty, high poverty, neither (reference), high affluence and outlier affluence]. Multivariable Cox proportional hazards models were used to examine associations of annual household income and geospatially-linked county poverty measures with incident ESRD, while accounting for death as a competing event using the Fine and Gray method. RESULTS: There were 158 ESRD cases during follow-up. Incident ESRD rates were 178.8 per 100,000 person-years (105 py) in high poverty outlier counties and were 76.3 /105 py in affluent outlier counties, p trend = 0.06. In unadjusted competing risk models, persons residing in high poverty outlier counties had higher incidence of ESRD (which was not statistically significant) when compared to those persons residing in counties with neither high poverty nor affluence [hazard ratio (HR) 1.54, 95% Confidence Interval (CI) 0.75-3.20]. This association was markedly attenuated following adjustment for socio-demographic factors (age, sex, race, education, and income); HR 0.96, 95% CI 0.46-2.00. However, in the same adjusted model, income was independently associated with risk of ESRD [HR 3.75, 95% CI 1.62-8.64, comparing the < $20,000 income group to the > $75,000 group]. There were no statistically significant associations of county measures of poverty with incident ESRD, and no evidence of effect modification. CONCLUSIONS: In contrast to annual family income, geospatially-linked measures of county poverty have little relation with risk of ESRD. Efforts to mitigate socioeconomic disparities in kidney disease may be best appropriated at the individual level.

Support services for vulnerable patients by a multidisciplinary team in an emergency department

Introduction: Individuals with poor social determinants of health aremore likely to receive improper healthcare. Frequent Users (FUs) ofEmergency Departments (ED) (defined as >4 visits in the previous12 months) represent a subgroup of vulnerable patients presentingwith specific medical and social needs. They usually account for highhealthcare costs by overusing the healthcare system. In 2008-2009,FUs accounted for 4% of our ED patients but 17% of all our ED visits.Methods: We conducted a prospective cohort of patients admitted toour ED with vulnerabilities in ≥3 specific domains (somatic or mentaldiseases, risk behaviors, social determinants of health, and healthcareuse). Patients were either directly identified by a multidisciplinary team(two nurses, one social worker, one physician) or referred to that teamby the ED staff during opening hours from July 1st 2010 to April 30th2011.Results: 127 patients were included (67% males), aged 43 years (SD15); 65% were migrants. They had a median of 6 ED visits (interquartilerange (IQR) 8-1) in the previous 12 months, representing a total of 697visits. The most frequently affected domains during the index visit were:71% somatic, 61% psychiatric, 75% risk behaviors, 97% social and84% healthcare use issues. Each case required a median of 234minutes (IQR 300-90) dedicated to assess their outpatient network(99% of the patients), to set up an ambulatory medical follow-up (43%)or a meeting with social services (40%).Conclusions: Vulnerability affected ED patients in more than onedomain. Vulnerable patients have complex needs that were difficult toaddress in the time-pressured ED setting. Although ED consultationoffers immediate access to medical care, EDs are dedicated more foracute short-term somatic care. Caring for a growing number ofvulnerable patients requires a different type of management. Limitedevidence shows that multidisciplinary case-management interventionshave demonstrated positive outcomes in terms of reducing ED useand costs, and improvement of patient's medical and social outcomes.A randomized trial of case-management is underway to confirm theresults of observational studies.

Prevalence of cardiovascular risk factors in a middle-income country and estimated cost of a treatment strategy.

BACKGROUND: We assessed the prevalence of risk factors for cardiovascular disease (CVD) in a middle-income country in rapid epidemiological transition and estimated direct costs for treating all individuals at increased cardiovascular risk, i.e. following the so-called "high risk strategy". METHODS: Survey of risk factors using an age- and sex-stratified random sample of the population of Seychelles aged 25-64 in 2004. Assessment of CVD risk and treatment modalities were in line with international guidelines. Costs are expressed as USD per capita per year. RESULTS: 1255 persons took part in the survey (participation rate of 80.2%). Prevalence of main risk factors was: 39.6% for high blood pressure (> or =140/90 mmHg or treatment) of which 59% were under treatment; 24.2% for high cholesterol (> or =6.2 mmol/l); 20.8% for low HDL-cholesterol (<1.0 mmol/l); 9.3% for diabetes (fasting glucose > or =7.0 mmol/l); 17.5% for smoking; 25.1% for obesity (body mass index > or =30 kg/m2) and 22.1% for the metabolic syndrome. Overall, 43% had HBP, high cholesterol or diabetes and substantially increased CVD risk. The cost for medications needed to treat all high-risk individuals amounted to USD 45.6, i.e. 11.2 dollars for high blood pressure, 3.8 dollars for diabetes, and 30.6 dollars for dyslipidemia (using generic drugs except for hypercholesterolemia). Cost for minimal follow-up medical care and laboratory tests amounted to 22.6 dollars. CONCLUSION: High prevalence of major risk factors was found in a rapidly developing country and costs for treatment needed to reduce risk factors in all high-risk individuals exceeded resources generally available in low or middle income countries. Our findings emphasize the need for affordable cost-effective treatment strategies and the critical importance of population strategies aimed at reducing risk factors in the entire population.

Socioeconomic determinants of dietary patterns in low- and middle-income countries : a systematic review

BACKGROUND: In high-income countries, high socioeconomic status (SES) is generally associated with a healthier diet, but whether social differences in dietary intake are also present in low- and middle-income countries (LMICs) remains to be established. OBJECTIVE: We performed a systematic review of studies that assessed the relation between SES and dietary intake in LMICs. DESIGN: We carried out a systematic review of cohort and cross-sectional studies in adults in LMICs and published between 1996 and 2013. We assessed associations between markers of SES or urban and rural settings and dietary intake. RESULTS: A total of 33 studies from 17 LMICs were included (5 low-income countries and 12 middle-income countries; 31 cross-sectional and 2 longitudinal studies). A majority of studies were conducted in Brazil (8), China (6), and Iran (4). High SES or living in urban areas was associated with higher intakes of calories; protein; total fat; cholesterol; polyunsaturated, saturated, and monounsaturated fatty acids; iron; and vitamins A and C and with lower intakes of carbohydrates and fiber. High SES was also associated with higher fruit and/or vegetable consumption, diet quality, and diversity. Although very few studies were performed in low-income countries, similar patterns were generally observed in both LMICs except for fruit intake, which was lower in urban than in rural areas in low-income countries. CONCLUSIONS: In LMICs, high SES or living in urban areas is associated with overall healthier dietary patterns. However, it is also related to higher energy, cholesterol, and saturated fat intakes. Social inequalities in dietary intake should be considered in the prevention and control of noncommunicable diseases in LMICs.

TACI, unlike BAFF-R, is solely activated by oligomeric BAFF and APRIL to support survival of activated B cells and plasmablasts.

The cytokine BAFF binds to the receptors TACI, BCMA, and BAFF-R on B cells, whereas APRIL binds to TACI and BCMA only. The signaling properties of soluble trimeric BAFF (BAFF 3-mer) were compared with those of higher-order BAFF oligomers. All forms of BAFF bound BAFF-R and TACI, and elicited BAFF-R-dependent signals in primary B cells. In contrast, signaling through TACI in mature B cells or plasmablasts was only achieved by higher-order BAFF and APRIL oligomers, all of which were also po-tent activators of a multimerization-dependent reporter signaling pathway. These results indicate that, although BAFF-R and TACI can provide B cells with similar signals, only BAFF-R, but not TACI, can respond to soluble BAFF 3-mer, which is the main form of BAFF found in circulation. BAFF 60-mer, an efficient TACI agonist, was also detected in plasma of BAFF transgenic and nontransgenic mice and was more than 100-fold more active than BAFF 3-mer for the activation of multimerization-dependent signals. TACI supported survival of activated B cells and plasmablasts in vitro, providing a rational basis to explain the immunoglobulin deficiency reported in TACI-deficient persons.

Geomodelling of a fluvial system with semi-supervised support vector regression

Fluvial deposits are a challenge for modelling flow in sub-surface reservoirs. Connectivity and continuity of permeable bodies have a major impact on fluid flow in porous media. Contemporary object-based and multipoint statistics methods face a problem of robust representation of connected structures. An alternative approach to model petrophysical properties is based on machine learning algorithm ? Support Vector Regression (SVR). Semi-supervised SVR is able to establish spatial connectivity taking into account the prior knowledge on natural similarities. SVR as a learning algorithm is robust to noise and captures dependencies from all available data. Semi-supervised SVR applied to a synthetic fluvial reservoir demonstrated robust results, which are well matched to the flow performance

Example-based support vector machine for drug concentration analysis

Machine learning has been largely applied to analyze data in various domains, but it is still new to personalized medicine, especially dose individualization. In this paper, we focus on the prediction of drug concentrations using Support Vector Machines (S VM) and the analysis of the influence of each feature to the prediction results. Our study shows that SVM-based approaches achieve similar prediction results compared with pharmacokinetic model. The two proposed example-based SVM methods demonstrate that the individual features help to increase the accuracy in the predictions of drug concentration with a reduced library of training data.

Le Soutien psychiatrique Intensif dans le Milieu (SIM) à Lausanne: un projet pilote [Intensive Psychiatric Support at the Setting in Lausanne: a pilot project]

While the hospital remains an important element of the psychiatric health-care system, the fact that it is always the best place to treat acute psychotic episodes is still debated. After a brief review of the literature relative to the main existing community care models, the authors describe the development in the Department Universitaire de Psychiatrie Adulte (DUPA), of an alternative to hospitalisation for patient going through a severe acute psychiatric episode. They present three clinical situations and the aims of the research project, which will follow this pilot phase.

System-level Support for Mobile Ad hoc Communications: an Algorithmic & Practical Approach

A mobile ad hoc network (MANET) is a decentralized and infrastructure-less network. This thesis aims to provide support at the system-level for developers of applications or protocols in such networks. To do this, we propose contributions in both the algorithmic realm and in the practical realm. In the algorithmic realm, we contribute to the field by proposing different context-aware broadcast and multicast algorithms in MANETs, namely six-shot broadcast, six-shot multicast, PLAN-B and ageneric algorithmic approach to optimize the power consumption of existing algorithms. For each algorithm we propose, we compare it to existing algorithms that are either probabilistic or context-aware, and then we evaluate their performance based on simulations. We demonstrate that in some cases, context-aware information, such as location or signal-strength, can improve the effciency. In the practical realm, we propose a testbed framework, namely ManetLab, to implement and to deploy MANET-specific protocols, and to evaluate their performance. This testbed framework aims to increase the accuracy of performance evaluation compared to simulations, while keeping the ease of use offered by the simulators to reproduce a performance evaluation. By evaluating the performance of different probabilistic algorithms with ManetLab, we observe that both simulations and testbeds should be used in a complementary way. In addition to the above original contributions, we also provide two surveys about system-level support for ad hoc communications in order to establish a state of the art. The first is about existing broadcast algorithms and the second is about existing middleware solutions and the way they deal with privacy and especially with location privacy. - Un réseau mobile ad hoc (MANET) est un réseau avec une architecture décentralisée et sans infrastructure. Cette thèse vise à fournir un support adéquat, au niveau système, aux développeurs d'applications ou de protocoles dans de tels réseaux. Dans ce but, nous proposons des contributions à la fois dans le domaine de l'algorithmique et dans celui de la pratique. Nous contribuons au domaine algorithmique en proposant différents algorithmes de diffusion dans les MANETs, algorithmes qui sont sensibles au contexte, à savoir six-shot broadcast,six-shot multicast, PLAN-B ainsi qu'une approche générique permettant d'optimiser la consommation d'énergie de ces algorithmes. Pour chaque algorithme que nous proposons, nous le comparons à des algorithmes existants qui sont soit probabilistes, soit sensibles au contexte, puis nous évaluons leurs performances sur la base de simulations. Nous montrons que, dans certains cas, des informations liées au contexte, telles que la localisation ou l'intensité du signal, peuvent améliorer l'efficience de ces algorithmes. Sur le plan pratique, nous proposons une plateforme logicielle pour la création de bancs d'essai, intitulé ManetLab, permettant d'implémenter, et de déployer des protocoles spécifiques aux MANETs, de sorte à évaluer leur performance. Cet outil logiciel vise à accroître la précision desévaluations de performance comparativement à celles fournies par des simulations, tout en conservant la facilité d'utilisation offerte par les simulateurs pour reproduire uneévaluation de performance. En évaluant les performances de différents algorithmes probabilistes avec ManetLab, nous observons que simulateurs et bancs d'essai doivent être utilisés de manière complémentaire. En plus de ces contributions principales, nous fournissons également deux états de l'art au sujet du support nécessaire pour les communications ad hoc. Le premier porte sur les algorithmes de diffusion existants et le second sur les solutions de type middleware existantes et la façon dont elles traitent de la confidentialité, en particulier celle de la localisation.