Can decision making in general surgery be based on evidence? An empirical study of Cochrane Reviews

BACKGROUND: This empirical study analyzes the current status of Cochrane Reviews (CRs) and their strength of recommendation for evidence-based decision making in the field of general surgery. METHODS: Systematic literature search of the Cochrane Database of Systematic Reviews and the Cochrane Collaboration's homepage to identify available CRs on surgical topics. Quantitative and qualitative characteristics, utilization, and formulated treatment recommendations were evaluated by 2 independent reviewers. Association of review characteristics with treatment recommendation was analyzed using univariate and multivariate logistic regression models. RESULTS: Ninety-three CRs, including 1,403 primary studies and 246,473 patients, were identified. Mean number of included primary studies per CR was 15.1 (standard deviation [SD] 14.5) including 2,650 (SD 3,340) study patients. Two and a half (SD 8.3) nonrandomized trials were included per analyzed CR. Seventy-two (77%) CRs were published or updated in 2005 or later. Explicit treatment recommendations were given in 45 (48%). Presence of a treatment recommendation was associated with the number of included primary studies and the proportion of randomized studies. Utilization of surgical CRs remained low and showed large inter-country differences. The most surgical CRs were accessed in UK, USA, and Australia, followed by several Western and Eastern European countries. CONCLUSION: Only a minority of available CRs address surgical questions and their current usage is low. Instead of unsystematically increasing the number of surgical CRs it would be far more efficient to focus the review process on relevant surgical questions. Prioritization of CRs needs valid methods which should be developed by the scientific surgical community.

Mass spectrometry-based analytical tools for the molecular protein characterization of human plasma lipoproteins

Lipoproteins are a heterogeneous population of blood plasma particles composed of apolipoproteins and lipids. Lipoproteins transport exogenous and endogenous triglycerides and cholesterol from sites of absorption and formation to sites of storage and usage. Three major classes of lipoproteins are distinguished according to their density: high-density (HDL), low-density (LDL) and very low-density lipoproteins (VLDL). While HDLs contain mainly apolipoproteins of lower molecular weight, the two other classes contain apolipoprotein B and apolipoprotein (a) together with triglycerides and cholesterol. HDL concentrations were found to be inversely related to coronary heart disease and LDL/VLDL concentrations directly related. Although many studies have been published in this area, few have concentrated on the exact protein composition of lipoprotein particles. Lipoproteins were separated by density gradient ultracentrifugation into different subclasses. Native gel electrophoresis revealed different gel migration behaviour of the particles, with less dense particles having higher apparent hydrodynamic radii than denser particles. Apolipoprotein composition profiles were measured by matrix-assisted laser desorption/ionization-mass spectrometry on a macromizer instrument, equipped with the recently introduced cryodetector technology, and revealed differences in apolipoprotein composition between HDL subclasses. By combining these profiles with protein identifications from native and denaturing polyacrylamide gels by liquid chromatography-tandem mass spectrometry, we characterized comprehensively the exact protein composition of different lipoprotein particles. We concluded that the differential display of protein weight information acquired by macromizer mass spectrometry is an excellent tool for revealing structural variations of different lipoprotein particles, and hence the foundation is laid for the screening of cardiovascular disease risk factors associated with lipoproteins.

Differences in Internet Usage - Social Inequality and Informal Education

In the public debate the internet is regarded as a central resource for knowledge and information. Associated with this is the idea that everyone is able and even expected to serve himself or herself according to his or her own needs via this medium. Since more and more services are also delivered online the internet seems to allow its users to enjoy specific advantages in dealing with their everyday life. However, using the internet is based on a range of preconditions. New results of empirical and theoretical research indicate the rise of a social divide in this context. Within the internet, different ways of use can be identified alongside social inequalities. Boundaries of the "real life" are mirrored in the virtual space e.g. in terms of forms of communification and spaces for appropriation. These are not only shaped by invidual preferences but particularly by social structures and processes. In the context of the broader debate on education it is stated that formal educational structures are to be completed by arrangements which are structured in informal respectively nonformal ways. Particularly the internet is suggested to play an important role in this respect. However, the phenomenon of digital inequality points to limitations consolidated by effects of economic, social, and cultural ressources: Economical resources affect opportunities of access, priorities of everyday life shape respective intentions of internet use, social relationships have an impact on the support structures available and ways of appropriation reproduce a specific understanding of informal education ("informelle Bildung"). This produces an early stratification of opportunities especially for the subsequent generation and may lead to extensive inequalities regarding the distribution of advantages in terms of education. Thus the capacity of the virtual space in terms of participatory opportunities and democratic potentials raises concerns of major relevance with respect to social and educational policy. From the perspective of different disciplines involved in these issues it is essential to clarify this question in an empirical as well as in a theoretical way and to make it utilizable for a future-orientied practice. This article discusses central questions regarding young people's internet use and its implications for informal education and social service delivery on the basis of empirical findings. It introduces a methodological approach for this particular perspective and illustrates that the phenomena of digital divide and digital inequality are as much created by social processes as by technical issues.

Developing a Web-Based Course in Phases

Introduction: Distance education has grown in popularity and usage. At the same time, enrollments at postsecondary institutions continue to increase. This places significant growth pressures on institutions of higher learning. Institutions providing nursing education have historically faced limited faculty resources. This has made it difficult to meet demand for distance education; and an “all-at-once” approach to course development does little to ease this problem. In this approach, resources are expended up front before a course is offered. [See PDF for complete abstract].

Simulator Network project report: a tool for improvement of teaching materials and targeted resource usage in Skills Labs

During the last decade, medical education in the German-speaking world has been striving to become more practice-oriented. This is currently being achieved in many schools through the implementation of simulation-based instruction in Skills Labs. Simulators are thus an essential part of this type of medical training, and their acquisition and operation by a Skills Lab require a large outlay of resources. Therefore, the Practical Skills Committee of the Medical Education Society (GMA) introduced a new project, which aims to improve the flow of information between the Skills Labs and enable a transparent assessment of the simulators via an online database (the Simulator Network).

Emergency department usage patterns among residents of Hardin, Jefferson, and Orange Counties in southeast Texas

Emergency departments (EDs) have been called the net below the safety net due to their long history of providing care to the uninsured and others lacking access to the healthcare system. In past years, those with Medicaid and, more recently, those with Medicare, are also utilizing the ED as a medical home for routine primary care. There are many reasons for this but the costs to the community have become increasingly burdensome. ^ To evaluate how often the ED is being utilized for primary care, we applied a standardized tool, the New York University Algorithm, to over 43,000 ED visits when no hospitalization was required made by Hardin, Jefferson, and Orange County residents over a 12 month period. We compared our results to Harris County, where studies using the same framework have been performed, and found that sizeable segments of the population in both areas are utilizing the ED for non-emergent primary care that could be treated in a more cost-effective community setting. ^ We also analyzed our dataset for visit-specific characteristics. We found evidence of two possible health care disparities: (1) Blacks had a higher rate of primary care-related ED visits in relation to their percentage of the population when compared to other racial/ethnic groups; and (2) when form of payment is considered, the uninsured were more likely to have a primary care-related ED visit than any other group. These findings suggest a lack of community-based primary care services for the medically needy in Southeast Texas. ^ We believe that studies such as this are warranted elsewhere in Texas as well. We plan to present our findings to local policy makers, who should find this information helpful in identifying gaps in the safety net and assist them in better allocating scarce community resources. ^

Abstract Interpretation-based verification/certification in the ciaoPP system

CiaoPP is the abstract interpretation-based preprocessor of the Ciao multi-paradigm (Constraint) Logic Programming system. It uses modular, incremental abstract interpretation as a fundamental tool to obtain information about programs. In CiaoPP, the semantic approximations thus produced have been applied to perform high- and low-level optimizations during program compilation, including transformations such as múltiple abstract specialization, parallelization, partial evaluation, resource usage control, and program verification. More recently, novel and promising applications of such semantic approximations are being applied in the more general context of program development such as program verification. In this work, we describe our extensión of the system to incorpórate Abstraction-Carrying Code (ACC), a novel approach to mobile code safety. ACC follows the standard strategy of associating safety certificates to programs, originally proposed in Proof Carrying- Code. A distinguishing feature of ACC is that we use an abstraction (or abstract model) of the program computed by standard static analyzers as a certifícate. The validity of the abstraction on the consumer side is checked in a single-pass by a very efficient and specialized abstractinterpreter. We have implemented and benchmarked ACC within CiaoPP. The experimental results show that the checking phase is indeed faster than the proof generation phase, and that the sizes of certificates are reasonable. Moreover, the preprocessor is based on compile-time (and run-time) tools for the certification of CLP programs with resource consumption assurances.

Abstract interpretation-based code certification for pervasive systems: Preliminary experiments

Proof carrying code is a general methodology for certifying that the execution of an untrusted mobile code is safe, according to a predefined safety policy. The basic idea is that the code supplier attaches a certifícate (or proof) to the mobile code which, then, the consumer checks in order to ensure that the code is indeed safe. The potential benefit is that the consumer's task is reduced from the level of proving to the level of checking, a much simpler task. Recently, the abstract interpretation techniques developed in logic programming have been proposed as a basis for proof carrying code [1]. To this end, the certifícate is generated from an abstract interpretation-based proof of safety. Intuitively, the verification condition is extracted from a set of assertions guaranteeing safety and the answer table generated during the analysis. Given this information, it is relatively simple and fast to verify that the code does meet this proof and so its execution is safe. This extended abstract reports on experiments which illustrate several issues involved in abstract interpretation-based code certification. First, we describe the implementation of our system in the context of CiaoPP: the preprocessor of the Ciao multi-paradigm (constraint) logic programming system. Then, by means of some experiments, we show how code certification is aided in the implementation of the framework. Finally, we discuss the application of our method within the área of pervasive systems which may lack the necessary computing resources to verify safety on their own. We herein illustrate the relevance of the information inferred by existing cost analysis to control resource usage in this context. Moreover, since the (rather complex) analysis phase is replaced by a simpler, efficient checking process at the code consumer side, we believe that our abstract interpretation-based approach to proof-carrying code becomes practically applicable to this kind of systems.

Power management techniques in an FPGA-Based WSN node for high performance application

In this work, the power management techniques implemented in a high-performance node for Wireless Sensor Networks (WSN) based on a RAM-based FPGA are presented. This new node custom architecture is intended for high-end WSN applications that include complex sensor management like video cameras, high compute demanding tasks such as image encoding or robust encryption, and/or higher data bandwidth needs. In the case of these complex processing tasks, yet maintaining low power design requirements, it can be shown that the combination of different techniques such as extensive HW algorithm mapping, smart management of power islands to selectively switch on and off components, smart and low-energy partial reconfiguration, an adequate set of save energy modes and wake up options, all combined, may yield energy results that may compete and improve energy usage of typical low power microcontrollers used in many WSN node architectures. Actually, results show that higher complexity tasks are in favor of HW based platforms, while the flexibility achieved by dynamic and partial reconfiguration techniques could be comparable to SW based solutions.

Mesh traversal and sorting for efficient memory usage in scientific codes

Applications that operate on meshes are very popular in High Performance Computing (HPC) environments. In the past, many techniques have been developed in order to optimize the memory accesses for these datasets. Different loop transformations and domain decompositions are com- monly used for structured meshes. However, unstructured grids are more challenging. The memory accesses, based on the mesh connectivity, do not map well to the usual lin- ear memory model. This work presents a method to improve the memory performance which is suitable for HPC codes that operate on meshes. We develop a method to adjust the sequence in which the data are used inside the algorithm, by means of traversing and sorting the mesh. This sorted mesh can be transferred sequentially to the lower memory levels and allows for minimum data transfer requirements. The method also reduces the lower memory requirements dra- matically: up to 63% of the L1 cache misses are removed in a traditional cache system. We have obtained speedups of up to 2.58 on memory operations as measured in a general- purpose CPU. An improvement is also observed with se- quential access memories, where we have observed reduc- tions of up to 99% in the required low-level memory size.

VISIONS Vehicular communication Improvement : solution based on IMS Operational Nodes and Services

Digital services and communications in vehicular scenarios provide the essential assets to improve road transport in several ways like reducing accidents, improving traffic efficiency and optimizing the transport of goods and people. Vehicular communications typically rely on VANET (Vehicular Ad hoc Networks). In these networks vehicles communicate with each other without the need of infrastructure. VANET are mainly oriented to disseminate information to the vehicles in certain geographic area for time critical services like safety warnings but present very challenging requirements that have not been successfully fulfilled nowadays. Some of these challenges are; channel saturation due to simultaneous radio access of many vehicles, routing protocols in topologies that vary rapidly, minimum quality of service assurance and security mechanisms to efficiently detect and neutralize malicious attacks. Vehicular services can be classified in four important groups: Safety, Efficiency, Sustainability and Infotainment. The benefits of these services for the transport sector are clear but many technological and business challenges need to be faced before a real mass market deployment. Service delivery platforms are not prepared for fulfilling the needs of this complex environment with restrictive requirements due to the criticism of some services To overcome this situation, we propose a solution called VISIONS “Vehicular communication Improvement: Solution based on IMS Operational Nodes and Services”. VISIONS leverages on IMS subsystem and NGN enablers, and follows the CALM reference Architecture standardized by ISO. It also avoids the use of Road Side Units (RSUs), reducing complexity and high costs in terms of deployment and maintenance. We demonstrate the benefits in the following areas: 1. VANET networks efficiency. VISIONS provide a mechanism for the vehicles to access valuable information from IMS and its capabilities through a cellular channel. This efficiency improvement will occur in two relevant areas: a. Routing mechanisms. These protocols are responsible of carrying information from a vehicle to another (or a group of vehicles) using multihop mechanisms. We do not propose a new algorithm but the use of VANET topology information provided through our solution to enrich the performance of these protocols. b. Security. Many aspects of security (privacy, key, authentication, access control, revocation mechanisms, etc) are not resolved in vehicular communications. Our solution efficiently disseminates revocation information to neutralize malicious nodes in the VANET. 2. Service delivery platform. It is based on extended enablers, reference architectures, standard protocols and open APIs. By following this approach, we reduce costs and resources for service development, deployment and maintenance. To quantify these benefits in VANET networks, we provide an analytical model of the system and simulate our solution in realistic scenarios. The simulations results demonstrate how VISIONS improves the performance of relevant routing protocols and is more efficient neutralizing security attacks than the widely proposed solutions based on RSUs. Finally, we design an innovative Social Network service based in our platform, explaining how VISIONS facilitate the deployment and usage of complex capabilities. RESUMEN Los servicios digitales y comunicaciones en entornos vehiculares proporcionan herramientas esenciales para mejorar el transporte por carretera; reduciendo el número de accidentes, mejorando la eficiencia del tráfico y optimizando el transporte de mercancías y personas. Las comunicaciones vehiculares generalmente están basadas en redes VANET (Vehicular Ad hoc Networks). En dichas redes, los vehículos se comunican entre sí sin necesidad de infraestructura. Las redes VANET están principalmente orientadas a difundir información (por ejemplo advertencias de seguridad) a los vehículos en determinadas zonas geográficas, pero presentan unos requisitos muy exigentes que no se han resuelto con éxito hasta la fecha. Algunos de estos retos son; saturación del canal de acceso de radio debido al acceso simultáneo de múltiples vehículos, la eficiencia de protocolos de encaminamiento en topologías que varían rápidamente, la calidad de servicio (QoS) y los mecanismos de seguridad para detectar y neutralizar los ataques maliciosos de manera eficiente. Los servicios vehiculares pueden clasificarse en cuatro grupos: Seguridad, Eficiencia del tráfico, Sostenibilidad, e Infotainment (información y entretenimiento). Los beneficios de estos servicios para el sector son claros, pero es necesario resolver muchos desafíos tecnológicos y de negocio antes de una implementación real. Las actuales plataformas de despliegue de servicios no están preparadas para satisfacer las necesidades de este complejo entorno con requisitos muy restrictivos debido a la criticidad de algunas aplicaciones. Con el objetivo de mejorar esta situación, proponemos una solución llamada VISIONS “Vehicular communication Improvement: Solution based on IMS Operational Nodes and Services”. VISIONS se basa en el subsistema IMS, las capacidades NGN y es compatible con la arquitectura de referencia CALM estandarizado por ISO para sistemas de transporte. También evita el uso de elementos en las carreteras, conocidos como Road Side Units (RSU), reduciendo la complejidad y los altos costes de despliegue y mantenimiento. A lo largo de la tesis, demostramos los beneficios en las siguientes áreas: 1. Eficiencia en redes VANET. VISIONS proporciona un mecanismo para que los vehículos accedan a información valiosa proporcionada por IMS y sus capacidades a través de un canal de celular. Dicho mecanismo contribuye a la mejora de dos áreas importantes: a. Mecanismos de encaminamiento. Estos protocolos son responsables de llevar información de un vehículo a otro (o a un grupo de vehículos) utilizando múltiples saltos. No proponemos un nuevo algoritmo de encaminamiento, sino el uso de información topológica de la red VANET a través de nuestra solución para enriquecer el funcionamiento de los protocolos más relevantes. b. Seguridad. Muchos aspectos de la seguridad (privacidad, gestión de claves, autenticación, control de acceso, mecanismos de revocación, etc) no están resueltos en las comunicaciones vehiculares. Nuestra solución difunde de manera eficiente la información de revocación para neutralizar los nodos maliciosos en la red. 2. Plataforma de despliegue de servicios. Está basada en capacidades NGN, arquitecturas de referencia, protocolos estándar y APIs abiertos. Siguiendo este enfoque, reducimos costes y optimizamos procesos para el desarrollo, despliegue y mantenimiento de servicios vehiculares. Para cuantificar estos beneficios en las redes VANET, ofrecemos un modelo de analítico del sistema y simulamos nuestra solución en escenarios realistas. Los resultados de las simulaciones muestran cómo VISIONS mejora el rendimiento de los protocolos de encaminamiento relevantes y neutraliza los ataques a la seguridad de forma más eficientes que las soluciones basadas en RSU. Por último, diseñamos un innovador servicio de red social basado en nuestra plataforma, explicando cómo VISIONS facilita el despliegue y el uso de las capacidades NGN.

Adaptive cross-device videoconferencing solution for wireless networks based on QoS monitoring

The increase in CPU power and screen quality of todays smartphones as well as the availability of high bandwidth wireless networks has enabled high quality mobile videoconfer- encing never seen before. However, adapting to the variety of devices and network conditions that come as a result is still not a trivial issue. In this paper, we present a multiple participant videoconferencing service that adapts to different kind of devices and access networks while providing an stable communication. By combining network quality detection and the use of a multipoint control unit for video mixing and transcoding, desktop, tablet and mobile clients can participate seamlessly. We also describe the cost in terms of bandwidth and CPU usage of this approach in a variety of scenarios.

GMM-based classifiers for the automatic detection of obstructive sleep apnea

The aim of automatic pathological voice detection systems is to serve as tools, to medical specialists, for a more objective, less invasive and improved diagnosis of diseases. In this respect, the gold standard for those system include the usage of a optimized representation of the spectral envelope, either based on cepstral coefficients from the mel-scaled Fourier spectral envelope (Mel-Frequency Cepstral Coefficients) or from an all-pole estimation (Linear Prediction Coding Cepstral Coefficients) forcharacterization, and Gaussian Mixture Models for posterior classification. However, the study of recently proposed GMM-based classifiers as well as Nuisance mitigation techniques, such as those employed in speaker recognition, has not been widely considered inpathology detection labours. The present work aims at testing whether or not the employment of such speaker recognition tools might contribute to improve system performance in pathology detection systems, specifically in the automatic detection of Obstructive Sleep Apnea. The testing procedure employs an Obstructive Sleep Apnea database, in conjunction with GMM-based classifiers looking for a better performance. The results show that an improved performance might be obtained by using such approach.

Reachability-based acyclicity analysis by Abstract Interpretation

In programming languages with dynamic use of memory, such as Java, knowing that a reference variable x points to an acyclic data structure is valuable for the analysis of termination and resource usage (e.g., execution time or memory consumption). For instance, this information guarantees that the depth of the data structure to which x points is greater than the depth of the data structure pointed to by x.f for any field f of x. This, in turn, allows bounding the number of iterations of a loop which traverses the structure by its depth, which is essential in order to prove the termination or infer the resource usage of the loop. The present paper provides an Abstract-Interpretation-based formalization of a static analysis for inferring acyclicity, which works on the reduced product of two abstract domains: reachability, which models the property that the location pointed to by a variable w can be reached by dereferencing another variable v (in this case, v is said to reach w); and cyclicity, modeling the property that v can point to a cyclic data structure. The analysis is proven to be sound and optimal with respect to the chosen abstraction.

Impedance-based stability and transient-performance assessment applying maximum peak criteria

The impedance-based stability-assessment method has turned out to be a very effective tool and its usage is rapidly growing in different applications ranging from the conventional interconnected dc/dc systems to the grid-connected renewable energy systems. The results are sometime given as a certain forbidden region in the complex plane out of which the impedance ratio--known as minor-loop gain--shall stay for ensuring robust stability. This letter discusses the circle-like forbidden region occupying minimum area in the complex plane, defined by applying maximum peak criteria, which is well-known theory in control engineering. The investigation shows that the circle-like forbidden region will ensure robust stability only if the impedance-based minor-loop gain is determined at the very input or output of each subsystem within the interconnected system. Experimental evidence is provided based on a small-scale dc/dc distributed system.