Knowledge-based clinical pathway for medical quality improvement

Clinical pathways have been adopted for various diseases in clinical departments for quality improvement as a result of standardization of medical activities in treatment process. Using knowledge-based decision support on the basis of clinical pathways is a promising strategy to improve medical quality effectively. However, the clinical pathway knowledge has not been fully integrated into treatment process and thus cannot provide comprehensive support to the actual work practice. Therefore this paper proposes a knowledgebased clinical pathway management method which contributes to make use of clinical knowledge to support and optimize medical practice. We have developed a knowledgebased clinical pathway management system to demonstrate how the clinical pathway knowledge comprehensively supports the treatment process. The experiences from the use of this system show that the treatment quality can be effectively improved by the extracted and classified clinical pathway knowledge, seamless integration of patient-specific clinical pathway recommendations with medical tasks and the evaluating pathway deviations for optimization.

Introducing "ecoputation": a universal systems design process

A universal systems design process is specified, tested in a case study and evaluated. It links English narratives to numbers using a categorical language framework with mathematical mappings taking the place of conjunctions and numbers. The framework is a ring of English narrative words between 1 (option) and 360 (capital); beyond 360 the ring cycles again to 1. English narratives are shown to correspond to the field of fractional numbers. The process can enable the development, presentation and communication of complex narrative policy information among communities of any scale, on a software implementation known as the "ecoputer". The information is more accessible and comprehensive than that in conventional decision support, because: (1) it is expressed in narrative language; and (2) the narratives are expressed as compounds of words within the framework. Hence option generation is made more effective than in conventional decision support processes including Multiple Criteria Decision Analysis, Life Cycle Assessment and Cost-Benefit Analysis.The case study is of a participatory workshop in UK bioenergy project objectives and criteria, at which attributes were elicited in environmental, economic and social systems. From the attributes, the framework was used to derive consequences at a range of levels of precision; these are compared with the project objectives and criteria as set out in the Case for Support. The design process is to be supported by a social information manipulation, storage and retrieval system for numeric and verbal narratives attached to the "ecoputer". The "ecoputer" will have an integrated verbal and numeric operating system. Novel design source code language will assist the development of narrative policy. The utility of the program, including in the transition to sustainable development and in applications at both community micro-scale and policy macro-scale, is discussed from public, stakeholder, corporate, Governmental and regulatory perspectives.

An evaluation of decadal probability forecasts from state-of-the-art climate models

While state-of-the-art models of Earth's climate system have improved tremendously over the last 20 years, nontrivial structural flaws still hinder their ability to forecast the decadal dynamics of the Earth system realistically. Contrasting the skill of these models not only with each other but also with empirical models can reveal the space and time scales on which simulation models exploit their physical basis effectively and quantify their ability to add information to operational forecasts. The skill of decadal probabilistic hindcasts for annual global-mean and regional-mean temperatures from the EU Ensemble-Based Predictions of Climate Changes and Their Impacts (ENSEMBLES) project is contrasted with several empirical models. Both the ENSEMBLES models and a “dynamic climatology” empirical model show probabilistic skill above that of a static climatology for global-mean temperature. The dynamic climatology model, however, often outperforms the ENSEMBLES models. The fact that empirical models display skill similar to that of today's state-of-the-art simulation models suggests that empirical forecasts can improve decadal forecasts for climate services, just as in weather, medium-range, and seasonal forecasting. It is suggested that the direct comparison of simulation models with empirical models becomes a regular component of large model forecast evaluations. Doing so would clarify the extent to which state-of-the-art simulation models provide information beyond that available from simpler empirical models and clarify current limitations in using simulation forecasting for decision support. Ultimately, the skill of simulation models based on physical principles is expected to surpass that of empirical models in a changing climate; their direct comparison provides information on progress toward that goal, which is not available in model–model intercomparisons.

Improving productivity and water use efficiency: a case study of farms in England

The idea of Sustainable Intensification comes as a response to the challenge of avoiding resources such as land, water and energy being overexploited while increasing food production for an increasing demand from a growing global population. Sustainable Intensification means that farmers need to simultaneously increase yields and sustainably use limited natural resources, such as water. Within the agricultural sector water has a number of uses including irrigation, spraying, drinking for livestock and washing (vegetables, livestock buildings). In order to achieve Sustainable Intensification measures are needed that enable policy makers and managers to inform them about the relative performance of farms as well as of possible ways to improve such performance. We provide a benchmarking tool to assess water use (relative) efficiency at a farm level, suggest pathways to improve farm level productivity by identifying best practices for reducing excessive use of water for irrigation. Data Envelopment Analysis techniques including analysis of returns to scale were used to evaluate any excess in agricultural water use of 66 Horticulture Farms based on different River Basin Catchments across England. We found that farms in the sample can reduce on average water requirements by 35% to achieve the same output (Gross Margin) when compared to their peers on the frontier. In addition, 47% of the farms operate under increasing returns to scale, indicating that farms will need to develop economies of scale to achieve input cost savings. Regarding the adoption of specific water use efficiency management practices, we found that the use of a decision support tool, recycling water and the installation of trickle/drip/spray lines irrigation system has a positive impact on water use efficiency at a farm level whereas the use of other irrigation systems such as the overhead irrigation system was found to have a negative effect on water use efficiency.

Exploring smart grid possibilities: a complex systems modelling approach

Smart grid research has tended to be compartmentalised, with notable contributions from economics, electrical engineering and science and technology studies. However, there is an acknowledged and growing need for an integrated systems approach to the evaluation of smart grid initiatives. The capacity to simulate and explore smart grid possibilities on various scales is key to such an integrated approach but existing models – even if multidisciplinary – tend to have a limited focus. This paper describes an innovative and flexible framework that has been developed to facilitate the simulation of various smart grid scenarios and the interconnected social, technical and economic networks from a complex systems perspective. The architecture is described and related to realised examples of its use, both to model the electricity system as it is today and to model futures that have been envisioned in the literature. Potential future applications of the framework are explored, along with its utility as an analytic and decision support tool for smart grid stakeholders.

A web application for follow-up of results from a mobile device test battery for parkinson’s disease patients

Background: A test battery consisting of self-assessments and motor tests (tapping and spiral drawing) was developed for a hand computer with touch screen in a telemedicine setting. Objectives: To develop and evaluate a web-based system that delivers decision support information to the treating clinical staff for assessing PD symptoms in their patients based on the test battery data. Methods: The test battery is currently being used in a clinical trial (DAPHNE, EudraCT No. 2005-002654-21) by sixty five patients with advanced Parkinson’s disease (PD) on 9991 test occasions (four tests per day during in all 362 week-long test periods) at nine clinics around Sweden. Test results are sent continuously from the hand unit over a mobile net to a central computer and processed with statistical methods. They are summarized into scores for different dimensions of the symptom state and an ‘overall test score’ reflecting the overall condition of the patient during a test period. The information in the web application is organized and presented graphically in a way that the general overview of the patient performance per test period is emphasized. Focus is on the overall test score, symptom dimensions and daily summaries. In a recent preliminary user evaluation, the web application was demonstrated to the fifteen study nurses who had used the test battery in the clinical trial. At least one patient per clinic was shown. Results: In general, the responses from nurses were positive. They claimed that the test results shown in the system were consistent with their own clinical observations. They could follow complications, changes and trends within their patients. Discussion: In conclusion, the system is able to summarise the various time series of motor test results and self-assessments during test periods and present them in a useful manner. Its main contribution is a novel and reliable way to capture and easily access symptom information from patients’ home environment. The convenient access to current symptom profile as well as symptom history provides a basis for individualized evaluation and adjustment of treatments.

Visualization of spirography-based objective measures in Parkinson's disease

Objective: To investigate whether advanced visualizations of spirography-based objective measures are useful in differentiating drug-related motor dysfunctions between Off and dyskinesia in Parkinson’s disease (PD). Background: During the course of a 3 year longitudinal clinical study, in total 65 patients (43 males and 22 females with mean age of 65) with advanced PD and 10 healthy elderly (HE) subjects (5 males and 5 females with mean age of 61) were assessed. Both patients and HE subjects performed repeated and time-stamped assessments of their objective health indicators using a test battery implemented on a telemetry touch screen handheld computer, in their home environment settings. Among other tasks, the subjects were asked to trace a pre-drawn Archimedes spiral using the dominant hand and repeat the test three times per test occasion. Methods: A web-based framework was developed to enable a visual exploration of relevant spirography-based kinematic features by clinicians so they can in turn evaluate the motor states of the patients i.e. Off and dyskinesia. The system uses different visualization techniques such as time series plots, animation, and interaction and organizes them into different views to aid clinicians in measuring spatial and time-dependent irregularities that could be associated with the motor states. Along with the animation view, the system displays two time series plots for representing drawing speed (blue line) and displacement from ideal trajectory (orange line). The views are coordinated and linked i.e. user interactions in one of the views will be reflected in other views. For instance, when the user points in one of the pixels in the spiral view, the circle size of the underlying pixel increases and a vertical line appears in the time series views to depict the corresponding position. In addition, in order to enable clinicians to observe erratic movements more clearly and thus improve the detection of irregularities, the system displays a color-map which gives an idea of the longevity of the spirography task. Figure 2 shows single randomly selected spirals drawn by a: A) patient who experienced dyskinesias, B) HE subject, and C) patient in Off state. Results: According to a domain expert (DN), the spirals drawn in the Off and dyskinesia motor states are characterized by different spatial and time features. For instance, the spiral shown in Fig. 2A was drawn by a patient who showed symptoms of dyskinesia; the drawing speed was relatively high (cf. blue-colored time series plot and the short timestamp scale in the x axis) and the spatial displacement was high (cf. orange-colored time series plot) associated with smooth deviations as a result of uncontrollable movements. The patient also exhibited low amount of hesitation which could be reflected both in the animation of the spiral as well as time series plots. In contrast, the patient who was in the Off state exhibited different kinematic features, as shown in Fig. 2C. In the case of spirals drawn by a HE subject, there was a great precision during the drawing process as well as unchanging levels of time-dependent features over the test trial, as seen in Fig. 2B. Conclusions: Visualizing spirography-based objective measures enables identification of trends and patterns of drug-related motor dysfunctions at the patient’s individual level. Dynamic access of visualized motor tests may be useful during the evaluation of drug-related complications such as under- and over-medications, providing decision support to clinicians during evaluation of treatment effects as well as improve the quality of life of patients and their caregivers. In future, we plan to evaluate the proposed approach by assessing within- and between-clinician variability in ratings in order to determine its actual usefulness and then use these ratings as target outcomes in supervised machine learning, similarly as it was previously done in the study performed by Memedi et al. (2013).

First-principle data-driven models for assessment of motor disorders in Parkinson’s disease

Parkinson’s disease (PD) is an increasing neurological disorder in an aging society. The motor and non-motor symptoms of PD advance with the disease progression and occur in varying frequency and duration. In order to affirm the full extent of a patient’s condition, repeated assessments are necessary to adjust medical prescription. In clinical studies, symptoms are assessed using the unified Parkinson’s disease rating scale (UPDRS). On one hand, the subjective rating using UPDRS relies on clinical expertise. On the other hand, it requires the physical presence of patients in clinics which implies high logistical costs. Another limitation of clinical assessment is that the observation in hospital may not accurately represent a patient’s situation at home. For such reasons, the practical frequency of tracking PD symptoms may under-represent the true time scale of PD fluctuations and may result in an overall inaccurate assessment. Current technologies for at-home PD treatment are based on data-driven approaches for which the interpretation and reproduction of results are problematic.  The overall objective of this thesis is to develop and evaluate unobtrusive computer methods for enabling remote monitoring of patients with PD. It investigates first-principle data-driven model based novel signal and image processing techniques for extraction of clinically useful information from audio recordings of speech (in texts read aloud) and video recordings of gait and finger-tapping motor examinations. The aim is to map between PD symptoms severities estimated using novel computer methods and the clinical ratings based on UPDRS part-III (motor examination). A web-based test battery system consisting of self-assessment of symptoms and motor function tests was previously constructed for a touch screen mobile device. A comprehensive speech framework has been developed for this device to analyze text-dependent running speech by: (1) extracting novel signal features that are able to represent PD deficits in each individual component of the speech system, (2) mapping between clinical ratings and feature estimates of speech symptom severity, and (3) classifying between UPDRS part-III severity levels using speech features and statistical machine learning tools. A novel speech processing method called cepstral separation difference showed stronger ability to classify between speech symptom severities as compared to existing features of PD speech. In the case of finger tapping, the recorded videos of rapid finger tapping examination were processed using a novel computer-vision (CV) algorithm that extracts symptom information from video-based tapping signals using motion analysis of the index-finger which incorporates a face detection module for signal calibration. This algorithm was able to discriminate between UPDRS part III severity levels of finger tapping with high classification rates. Further analysis was performed on novel CV based gait features constructed using a standard human model to discriminate between a healthy gait and a Parkinsonian gait. The findings of this study suggest that the symptom severity levels in PD can be discriminated with high accuracies by involving a combination of first-principle (features) and data-driven (classification) approaches. The processing of audio and video recordings on one hand allows remote monitoring of speech, gait and finger-tapping examinations by the clinical staff. On the other hand, the first-principles approach eases the understanding of symptom estimates for clinicians. We have demonstrated that the selected features of speech, gait and finger tapping were able to discriminate between symptom severity levels, as well as, between healthy controls and PD patients with high classification rates. The findings support suitability of these methods to be used as decision support tools in the context of PD assessment.

Effective Data Management Enables Intelligent Utility Management

Instrumentation and automation plays a vital role to managing the water industry. These systems generate vast amounts of data that must be effectively managed in order to enable intelligent decision making. Time series data management software, commonly known as data historians are used for collecting and managing real-time (time series) information. More advanced software solutions provide a data infrastructure or utility wide Operations Data Management System (ODMS) that stores, manages, calculates, displays, shares, and integrates data from multiple disparate automation and business systems that are used daily in water utilities. These ODMS solutions are proven and have the ability to manage data from smart water meters to the collaboration of data across third party corporations. This paper focuses on practical, utility successes in the water industry where utility managers are leveraging instantaneous access to data from proven, commercial off-the-shelf ODMS solutions to enable better real-time decision making. Successes include saving $650,000 / year in water loss control, safeguarding water quality, saving millions of dollars in energy management and asset management. Immediate opportunities exist to integrate the research being done in academia with these ODMS solutions in the field and to leverage these successes to utilities around the world.

Evaluation Of Reservoir Model Integration With Deterministic And Probabilistic Streamflow Forecasts

Due to the increase in water demand and hydropower energy, it is getting more important to operate hydraulic structures in an efficient manner while sustaining multiple demands. Especially, companies, governmental agencies, consultant offices require effective, practical integrated tools and decision support frameworks to operate reservoirs, cascades of run-of-river plants and related elements such as canals by merging hydrological and reservoir simulation/optimization models with various numerical weather predictions, radar and satellite data. The model performance is highly related with the streamflow forecast, related uncertainty and its consideration in the decision making. While deterministic weather predictions and its corresponding streamflow forecasts directly restrict the manager to single deterministic trajectories, probabilistic forecasts can be a key solution by including uncertainty in flow forecast scenarios for dam operation. The objective of this study is to compare deterministic and probabilistic streamflow forecasts on an earlier developed basin/reservoir model for short term reservoir management. The study is applied to the Yuvacık Reservoir and its upstream basin which is the main water supply of Kocaeli City located in the northwestern part of Turkey. The reservoir represents a typical example by its limited capacity, downstream channel restrictions and high snowmelt potential. Mesoscale Model 5 and Ensemble Prediction System data are used as a main input and the flow forecasts are done for 2012 year using HEC-HMS. Hydrometeorological rule-based reservoir simulation model is accomplished with HEC-ResSim and integrated with forecasts. Since EPS based hydrological model produce a large number of equal probable scenarios, it will indicate how uncertainty spreads in the future. Thus, it will provide risk ranges in terms of spillway discharges and reservoir level for operator when it is compared with deterministic approach. The framework is fully data driven, applicable, useful to the profession and the knowledge can be transferred to other similar reservoir systems.

Optimized Water Demand Management Through Intelligent Sensing And Analytics: The WISDOM Approach

New business and technology platforms are required to sustainably manage urban water resources [1,2]. However, any proposed solutions must be cognisant of security, privacy and other factors that may inhibit adoption and hence impact. The FP7 WISDOM project (funded by the European Commission - GA 619795) aims to achieve a step change in water and energy savings via the integration of innovative Information and Communication Technologies (ICT) frameworks to optimize water distribution networks and to enable change in consumer behavior through innovative demand management and adaptive pricing schemes [1,2,3]. The WISDOM concept centres on the integration of water distribution, sensor monitoring and communication systems coupled with semantic modelling (using ontologies, potentially connected to BIM, to serve as intelligent linkages throughout the entire framework) and control capabilities to provide for near real-time management of urban water resources. Fundamental to this framework are the needs and operational requirements of users and stakeholders at domestic, corporate and city levels and this requires the interoperability of a number of demand and operational models, fed with data from diverse sources such as sensor networks and crowsourced information. This has implications regarding the provenance and trustworthiness of such data and how it can be used in not only the understanding of system and user behaviours, but more importantly in the real-time control of such systems. Adaptive and intelligent analytics will be used to produce decision support systems that will drive the ability to increase the variability of both supply and consumption [3]. This in turn paves the way for adaptive pricing incentives and a greater understanding of the water-energy nexus. This integration is complex and uncertain yet being typical of a cyber-physical system, and its relevance transcends the water resource management domain. The WISDOM framework will be modeled and simulated with initial testing at an experimental facility in France (AQUASIM – a full-scale test-bed facility to study sustainable water management), then deployed and evaluated in in two pilots in Cardiff (UK) and La Spezia (Italy). These demonstrators will evaluate the integrated concept providing insight for wider adoption.

Sistema fuzzy para estimativa do bem-estar de matrizes pesadas

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Social support and infant malnutrition: a case-control study in an urban area of Southeastern Brazil

The relationship between malnutrition and social support was first suggested in the mid-1990s. Despite its plausibility, no empirical studies aimed at obtaining evidence of this association could be located. The goal of the present study was to investigate such evidence. A case-control study was carried out including 101 malnourished children (weight-for-age National Center for Health Statistics/WHO 5th percentile) aged 12-23 months, who were compared with 200 well-nourished children with regard to exposure to a series of factors related to their social support system. Univariate and multiple logistic regressions were carried out, odds ratios being adjusted for per capita family income, mother's schooling, and number of children. The presence of an interaction between income and social support variables was also tested. Absence of a partner living with the mother increased risk of malnutrition (odds ratio 2.4 (95 % CI 1.19, 4.89)), even after adjustment for per capita family income, mother's schooling, and number of children. The lack of economic support during adverse situations accounted for a very high risk of malnutrition (odds ratio 10.1 (95 % CI 3.48, 29.13)) among low-income children, but had no effect on children of higher-income families. Results indicate that receiving economic support is an efficient risk modulator for malnutrition among low-income children. In addition, it was shown that the absence of a partner living with the mother is an important risk factor for malnutrition, with an effect independent from per capita family income, mother's schooling, and number of children.

The impact of soybean expansion on mammal and bird, in the Balsas region, north Brasilian Cerrado

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Conflitos por múltiplos usos da água no reservatório da UHE de Tucuruí

Os conflitos por múltiplos usos da água, no reservatório da UHE Tucuruí, surgem com o anúncio da construção da mega hidrelétrica na região, e os conflitos socioambientais subseqüentes. Aliada a elevação do nível de percepção social em relação aos problemas ambientais cresce também a busca por eficientes processos de gestão e gerenciamento de recursos hídricos. Este estudo objetiva analisar e tipificar os conflitos por múltiplos usos da água no reservatório da UHE Tucuruí, utilizando-se como ferramenta de apoio à decisão o software de modelagem qualitativa NVivo 8, e dessa forma verificar as melhores alternativas a serem adotadas para a conciliação dos usos múltiplos no reservatório. As tipificações realizadas basearam-se na análise dos conflitos, seus componentes, elementos e aspectos, tipo, natureza e origem. Sendo assim, identificaram-se três principais tipos de conflitos no reservatório da UHE Tucuruí: conflitos entre distintos grupos de usuários da água, conflitos por obras hidráulicas e conflitos decorrentes de poluição ambiental. Para este estudo adotou - se uma abordagem qualitativa, através do método de mapeamento cognitivo. Este tipo de mapeamento possibilitou a construção de um modelo cognitivo para a gestão dos conflitos no reservatório de Tucuruí. Sendo assim, o software NVivo 8 possibilitou, além da análise dos dados obtidos nas entrevistas e no levantamento bibliográfico, a construção do modelo gráfico de apoio à gestão de conflitos por múltiplos usos da água. Verificou-se que uma das formas de solução dos conflitos é através da análise destes, em vistas de se investigar os mecanismos adequados para sua resolução, e posterior proposição de medidas estruturais e/ou nãoestruturais para a gestão de recursos hídricos. As principais ações para a solução dos conflitos estão enquadradas nos métodos de resolução institucional de longo prazo. O modelo pode funcionar como suporte ao planejamento e tomada de decisão, tendo em vista os problemas ambientais, a participação dos usuários da água no sistema hídrico, as políticas públicas, e também a gestão integrada dos recursos hídricos. Concluiu- se, então, que a exploração dos recursos hídricos deve proporcionar os múltiplos usos da água em atendimento aos princípios da sustentabilidade ambiental, inseridos num processo de gestão dos conflitos por múltiplos usos da água e gerenciamento integrado dos recursos hídricos.