Conventional Thresholds Research Articles

Coronary artery calcium scoring at lower tube voltages – Dose determination and scoring mechanism

PurposePopulation dose has been a concern with coronary artery calcium scoring CT since it is performed in adults with borderline risk. Lower tube voltage acquisitions are appealing but there are no agreed schemes for reduced dose determination. Moreover, conventional scoring cannot be used without changing the multiple Agatston thresholds. MethodsBy applying consistent calcium contrast-to-noise ratio to two anthropomorphic heart phantoms (medium and large) with 3-cm hydroxyapatite (HA) inserts, scanned using a dual-source CT, the relationship was derived between the volume CT dose index (CTDIvol) at lower tube voltages and the baseline CTDIvol at 120 kVp. The baseline CTDIvol was obtained using the noise thresholds from the images acquired at 120 kVp. To preserve the conventional Agatston thresholds, down-scaling with the found factors was applied to images acquired at lower voltages with a dynamic heart module and 1.2−5 mm inserts (50–400 mg/cc) on the coronary tracks. Scores were evaluated on the scaled images by six readers. ResultsThe CTDIvol at lower voltages was related to the baseline CTDIvol following a power form of the voltage (index 1.246), regardless of the phantom size. The baseline CTDIvol was 1.5 and 4.5 mGy, for the medium and large phantoms, respectively. Correspondingly, the reduced CTDIvol at 100−70 kVp were 1.28−0.76 mGy, and 3.57−2.32 mGy. The downscaling factors were 0.88−0.63. The calcium scores at lower voltages were found within 12 % of the ground-truths. ConclusionA vendor-independent approach was established to obtain the reduced dose and correct coronary calcium scores at lower tube voltages.

Accuracy of Bipolar Amplitude Voltage Thresholds to Identify Late Potential Channels in Ventricular Tachycardia Ablation

Background: Ventricular tachycardia(VT) is caused by the presence of a slow conduction channel(CC) of border zone(BZ) tissue inside the scar-core tissue. Electroanatomic mapping can depict this tissue by voltage mapping. Areas of slow conduction can be detected as late potentials (LPs) and their abolition is the most accepted ablation endpoint. In current guidelines, bipolar voltage thresholds for BZ and core scar are 1.5 and 0.5mV respectively. The performance of these values is controversial. Purpose: To analyze the diagnostic yield of current amplitude thresholds in voltage map to define VT substrate in terms of CCs of LPs. Predictors of usefulness of current thresholds will be analyzed.Methods: All patients with structural heart disease who underwent VT ablation in Hospital Clinic in 2016-2017 were included. Maps with delineation of CCs based on LPs were created with contact-force sensor catheter. Thresholds were adjusted for every patient based on CCs. Diagnostic yield and predictors of performance of conventional thresholds were analyzed.ResultsDuring study period 57 consecutive patients were included (age:60,4+/-8,5; 50,2% ischemic cardiomyopathy, LVEF 39,8{plus minus}13.5%). Cut-off voltages that better identified the scar and BZ according LPs channels were 0,32(0,02-2 mV) and 1,84(0,3-6 mV) respectively. Current voltage thresholds identified correctly core and BZ in 87,7% and 42,1% of the patients respectively. Accuracy was worse in non-ischemic cardiomyopathy (NICM) especially for BZ (28,6% vs 55,2%,p=0,042)Conclusions: Accuracy of standard voltage thresholds for scar and BZ is poor in terms of LPs detection. Diagnostic yield is worse in NICM patients specially for border zone.

Automatic opportunistic osteoporosis screening in routine CT: improved prediction of patients with prevalent vertebral fractures compared to DXA

ObjectivesTo compare spinal bone measures derived from automatic and manual assessment in routine CT with dual energy X-ray absorptiometry (DXA) in their association with prevalent osteoporotic vertebral fractures using our fully automated framework (https://anduin.bonescreen.de) to assess various bone measures in clinical CT.MethodsWe included 192 patients (141 women, 51 men; age 70.2 ± 9.7 years) who had lumbar DXA and CT available (within 1 year). Automatic assessment of spinal bone measures in CT included segmentation of vertebrae using a convolutional neural network (CNN), reduction to the vertebral body, and extraction of bone mineral content (BMC), trabecular and integral volumetric bone mineral density (vBMD), and CT-based areal BMD (aBMD) using asynchronous calibration. Moreover, trabecular bone was manually sampled (manual vBMD).ResultsA total of 148 patients (77%) had vertebral fractures and significantly lower values in all bone measures compared to patients without fractures (p ≤ 0.001). Except for BMC, all CT-based measures performed significantly better as predictors for vertebral fractures compared to DXA (e.g., AUC = 0.885 for trabecular vBMD and AUC = 0.86 for integral vBMD vs. AUC = 0.668 for DXA aBMD, respectively; both p < 0.001). Age- and sex-adjusted associations with fracture status were strongest for manual vBMD (OR = 7.3, [95%] CI 3.8–14.3) followed by automatically assessed trabecular vBMD (OR = 6.9, CI 3.5–13.4) and integral vBMD (OR = 4.3, CI 2.5–7.6). Diagnostic cutoffs of integral vBMD for osteoporosis (< 160 mg/cm3) or low bone mass (160 ≤ BMD < 190 mg/cm3) had sensitivity (84%/41%) and specificity (78%/95%) similar to trabecular vBMD.ConclusionsFully automatic osteoporosis screening in routine CT of the spine is feasible. CT-based measures can better identify individuals with reduced bone mass who suffered from vertebral fractures than DXA.Key Points• Opportunistic osteoporosis screening of spinal bone measures derived from clinical routine CT is feasible in a fully automatic fashion using a deep learning-driven framework (https://anduin.bonescreen.de).• Manually sampled volumetric BMD (vBMD) and automatically assessed trabecular and integral vBMD were the best predictors for prevalent vertebral fractures.• Except for bone mineral content, all CT-based bone measures performed significantly better than DXA-based measures.• We introduce diagnostic thresholds of integral vBMD for osteoporosis (< 160 mg/cm3) and low bone mass (160 ≤ BMD < 190 mg/cm3) with almost equal sensitivity and specificity compared to conventional thresholds of quantitative CT as proposed by the American College of Radiology (osteoporosis < 80 mg/cm3).

Usage of antecedent soil moisture for improving the performance of rainfall thresholds for landslide early warning

Landslides triggered by heavy rains are increasing in number and creating severe losses in hilly regions across the world. Rainfall thresholds on regional and local-scales are being used for forecasting such events, for efficient early warning. Empirical and probabilistic approaches for defining rainfall thresholds are traditional tools which are being used as part of the forecasting system for rainfall induced landslides. Such methods are easy-to-use and are based on statistical analyses. They can be derived without looking into the complex hydro-geological processes involved in slope failures, but are often associated with the disadvantage of higher false alarms, limiting their applications in a regional landslide early warning system (LEWS). This study is an attempt to improve the performance of conventional meteorological thresholds by considering the effect of soil moisture, using a probabilistic approach. Idukki district in southern part of India is highly susceptible to landslides and has witnessed major socio-economical setbacks in the recent disasters happened in 2018 and 2019. This tourist hub is now in need of a landslide forecasting system, which can help in landslide risk reduction. This study attempts to understand the effect of averaged soil moisture estimates derived from passive microwave remote sensing data, for improving the performance of conventional empirical and probabilistic thresholds. For defining empirical thresholds, an algorithm-based approach such as Calculation of Thresholds for Rainfall-induced Landslides Tool (CTRL-T) has been used. Probabilistic thresholds were defined using a Bayesian approach, finding the posterior probability of occurrence using the marginal and conditional probabilities of the control parameters along with the prior probability of occurrence of landslide. The derived rainfall thresholds were quantitatively compared with the Bayesian probabilistic threshold derived using rainfall severity and soil wetness using an area under the curve (AUC) based on receiver operating characteristics (ROC) curve method. The results show that when the antecedent moisture content in soil is less, only severe rainfall events can trigger landslides in the study area; while less severe rainfall events can also trigger landslides when the soil is wet. The role of soil wetness in the initiation is used to improve the performance of the conventional methods, and a ROC approach was used for the statistical comparison of different models. Further, the results indicated that the probabilistic threshold using rainfall severity and soil wetness outperformed the conventional approaches with AUC of 0.96, being the most sensitive and specific among the models considered. This result opens new promising perspectives for the development of an operational LEWS in the Idukki district based on a combination of rainfall and soil moisture data. Moreover, this work contributes to strengthen the advancing trend of hydro-meteorological thresholds based on soil moisture, which is gaining a growing attention in landslide studies and that, to date, was lacking evidences in monsoon regions.

Legal Complexities in the Service of Hybrid Warfare

Hybrid warfare is about using military and non-military measures in a non-linear and complimentary fashion. Different means and methods are not necessarily effective separately, but it is their synergy that leads to the desired outcome. Law has also become a method of warfare. States exploit deliberately legal complexities to strengthen their own positions and to undermine the positions of their opponents. They may wish to keep the intensity of the employed measures below the threshold of the use or threat of force in order to argue that international law has not been breached and that the opponents may not exercise self-defense. States may equally try to avoid the application of the rules of warfare by claiming that the situation has not crossed the threshold of an armed conflict. Because the rules governing the resort to armed force and the conduct of hostilities were drafted for conventional warfare, the ambiguities, loopholes and thresholds in these rules provide opportunities, for better or for worse, in the era of modern warfare.

Effects of primary arterial hypertension on cochlear function

Background Hypertension (HT) is one of the most common chronic diseases. The existing literature on HT and hearing contains conflicting results, and no consensus has been reached yet. Objectives This study aimed to investigate cochlear function in hypertensive and normotensive groups. Methods This study was conducted on 34 patients with primary HT and 17 healthy adults. The Cochlear function was assessed with conventional audiometry (0.125–8 kHz), ultra-high frequency audiometry (10–16 kHz), the transient evoked otoacoustic emission (TEOAE) test, and the distortion product otoacoustic emission (DPOAE) test. Results Hearing thresholds at 8, 10, 12.5, 14, and 16 kHz were significantly poorer in the HT group than in the control group (p < .05). There was no significant difference in the mean conventional thresholds between the groups. Compared to the control group, the patient group exhibited statistically significant lower amplitudes of TEOAE and DPOAE. Conclusion This study demonstrated significantly poorer high-frequency hearing and lower otoacoustic emission amplitudes for adults with HT. Impairment in hearing thresholds associated with HT begins at ultra-high frequencies in the cochlea. HT may be a potential risk factor for the development of hearing loss; therefore, individuals with HT should be screened for auditory function.

Using Field-Based Monitoring to Enhance the Performance of Rainfall Thresholds for Landslide Warning

Landslides are natural disasters which can create major setbacks to the socioeconomic of a region. Destructive landslides may happen in a quick time, resulting in severe loss of lives and properties. Landslide Early Warning Systems (LEWS) can reduce the risk associated with landslides by providing enough time for the authorities and the public to take necessary decisions and actions. LEWS are usually based on statistical rainfall thresholds, but this approach is often associated to high false alarms rates. This manuscript discusses the development of an integrated approach, considering both rainfall thresholds and field monitoring data. The method was implemented in Kalimpong, a town in the Darjeeling Himalayas, India. In this work, a decisional algorithm is proposed using rainfall and real-time field monitoring data as inputs. The tilting angles measured using MicroElectroMechanical Systems (MEMS) tilt sensors were used to reduce the false alarms issued by the empirical rainfall thresholds. When critical conditions are exceeded for both components of the systems (rainfall thresholds and tiltmeters), authorities can issue an alert to the public regarding a possible slope failure. This approach was found effective in improving the performance of the conventional rainfall thresholds. We improved the efficiency of the model from 84% (model based solely on rainfall thresholds) to 92% (model with the integration of field monitoring data). This conceptual improvement in the rainfall thresholds enhances the performance of the system significantly and makes it a potential tool that can be used in LEWS for the study area.

Diagnostic Accuracy of D-Dimer Testing and the Revised Geneva Score in the Prediction of Pulmonary Embolism.

BackgroundPulmonary embolism (PE) diagnosis can sometimes be challenging due to the disease having nonspecific signs and symptoms at the time of presentation. The present study aimed to evaluate the validity of the D-dimer in combination with the revised Geneva score (RGS) in the prediction of pulmonary embolism.Patients and MethodsThis is a retrospective study of 2010 patients with suspected PE who had undergone both D-dimer testing followed by chest CT angiography (CTPA), irrespective of the D-dimer test results, at King Abdulaziz Medical City, Riyadh, Saudi Arabia, over 3 years, from Jan. 2016 to Jan. 2019. The predictive accuracy of D-dimer, adjusted D-dimer, and RGS was calculated. The receiver operating characteristic “ROC” curve was applied to allocate the optimum RGS cutoff for PE prediction.ResultsThe overall prevalence of PE was 16%. It was 0%, 25.8%, and 88.9% in low, intermediate, and high clinical probability categories of RGS, respectively. Both conventional and age-adjusted D-dimer thresholds showed significant level of agreement (kappa=0.81, p<0.001), high sensitivity (94% and 92.8%), high negative predictive value “NPV” (91.2% and 91.4%), low specificity (12.3% and 15.3%), and low positive predictive value “PPV” (17.5% and 17.8%), respectively. Combination of the age-adjusted D-dimer threshold and RGS at a cut-off of 5 points would provide 100% sensitivity and 61.7% specificity 34.1% PPV, 100% NPV, and 0.87 area under the curve “AUC”. At an RGS cutoff <5 points, PE could have been ruled out in more than one-half (1036, 51.5%) of all suspected cases, and would have saved the cost of CTPA.ConclusionConventional and age-adjusted D-dimer tests showed high levels of agreement in the prediction of PE, high sensitivity, and low specificity. RGS has a good performance in PE prediction. Using the revised Geneva score alone rules out PE for more than one-half of all suspected without further imaging.

Monitoring Ototoxicity through Otoacoustic Emissions. Present, COVID-19, and Future Related Insights

The administration of certain drugs is directly related to inner ear damage. Due to the potential of these elements and their usage, more extensive monitoring of adverse effects should be implemented. That is why, baseline evaluation for ototoxicity must be adequately extensive and should embrace conventional PTA thresholds, HFA, immittance measurements, speech audiometry in quiet and in noise, and assessment of OAEs. Health care specialists have reasonably quested other test modalities for ototoxic monitoring, in their effort to eliminate behavioral – subjective testing and even more establishing further improvements in test efficacy. To iterate, drug induced ototoxicities typically are initially presented as OHC dysfunction, and the exact correlation between present OAEs and functional OHCs is fairly well demonstrated. This study provides recent evidence regarding OAEs’ strategic advantages as a part of an ototoxicity monitoring program, as they can detect earlier ototoxic induced thresholds shifts, do not need patient’s own cooperation and are substantially easy to perform and quick. This fact is particularly crucial during present COVID-19 pandemic where ototoxic agents such as chloroquine and hydroxychloroquine are routinely administered in many patients who may be too sick and haggard to perform adequately enough in conventional PTA or similar, behavioral based exams.

Quantification of NG2-positivity for the precise prediction of KMT2A gene rearrangements in childhood acute leukemia.

It has long been known that there is a link between neuron glial antigen 2 (NG2) surface expression and KMT2A gene rearrangements in acute leukemia (AL). However, the exact levels of NG2 positivity that predict the presence of KMT2A rearrangement are not known. The current study focuses on a cohort of 505 pediatric AL patients who showed any level of positive NG2 expression (greater than 1% of cells) for whom comprehensive genetic data were available. NG2 expression was measured as either the percentage of positive cells or the number of molecules on the cell surface. KMT2A gene rearrangements were identified by FISH. The fusion partner was detected with RT-PCR, LDI-PCR or anchored multiplex PCR followed by high-throughput sequencing. KMT2A-positive samples comprised a substantial proportion of the NG2-positive cohort (180 of 505, 36%), with a total of 19 different types of translocation. Despite its occurrence in other AL genetic subgroups, NG2 expression was significantly increased in AL patients with KMT2A rearrangements in terms of both the cell percentage and number of molecules per cell. The threshold levels (TL) for NG2-positivity were established by ROC analysis of the whole cohort and separately for children less than 1 years old and older with lymphoblastic (ALL) and myeloid (AML) leukemia. The lowest TL was defined in infants with ALL (7%), while in older children, the threshold was higher (12%). In AML patients, the situation was reversed, with 28% NG2-positivity in infants and 14% in patients >1 year old. The defined TLs resulted in improved diagnostic performance compared to the conventional thresholds of 10% and 20% for all patient groups.

Pediatric Vaccines and Cost-Effectiveness Thresholds: How Much is Too Much to Pay for Prevention?

Cost-effectiveness evaluations play an important role in recommendations for use of pediatric vaccines that are set forth by the US Advisory Committee on Immunization Practices (ACIP). The fact that these evaluations are undertaken and accorded weight suggests that a critical value for designating pediatric vaccines as cost-effective (or not) must exist. For recommended pediatric vaccines, however, reported incremental cost-effectiveness ratios (ICERs) have varied greatly, and there does not appear to be an explicit threshold used by the ACIP to define how much is too much to pay for the prevention of communicable diseases in children. Further complicating this issue is the fact that conventional ICER thresholds—expressed in terms of cost per quality-adjusted life-year (QALY) gained—accord value only to length and quality of life and may not reflect our preferences as individuals or a society. For example, risk, an important attribute of many healthcare decisions, is ignored by the QALY model, as is the distribution of health benefits across different members of society. Are we indeed indifferent about risk and do we really believe that the value of disease prevention in children should be measured by the same “yardstick” as that for older adults? Accordingly, do we really believe that “a QALY is a QALY”? These issues, which are reviewed and discussed in this article, are more than just of theoretical interest; the answers impact how public health policy is determined, which impacts the lives and well-being of entire populations as well as the budgets of payers.

Materiality Thresholds: Empirical Evidence from Change in Accounting Estimate Disclosures

SYNOPSIS This paper provides empirical evidence on the materiality thresholds adopted in “change in accounting estimate” (CAE) disclosures. We also investigate the characteristics of the disclosing firms and their auditors, as well as the characteristics of the CAEs. We analyze 4,335 CAE disclosures from 2006 to 2016 and provide the first descriptive evidence of the actual materiality thresholds used for CAE disclosures in practice. Our main finding is that quantitative materiality thresholds for CAE disclosures are significantly lower than conventional materiality thresholds, such as 5 percent of pretax income, and that firms may not only apply quantitative materiality thresholds more conservatively, but that other qualitative considerations play an important role in determining CAE materiality. Our results also show that there exists considerable variation in CAE disclosure across firm size, industry membership, auditor, financial statement account effected, and the direction of the effect on income. Data Availability: The data used in this study are publicly available from the sources listed in the paper.

Large sample size bias in empirical finance

The vast majority of empirical studies in finance employ large enough sample sizes and use the conventional thresholds for statistical significance. This routine practice can potentially lead to spurious statistically significant results. The primary aim of this paper is to present a rule of thumb that can be used to determine the appropriate thresholds for statistical significance for a given sample size. The paper argues that the list of statistically significant findings in the broader finance literature is likely to be much shorter after accounting for large sample size bias.

Post-exposure effect of music through personal listening device (PLD) on speech perception in noise test in young adults

Introduction: Tinnitus is often perceived temporarily after noise exposure, usually disappearing within a few hours. However, a significant number of young people perceive permanent tinnitus which is the most frequent symptom following exposure to noise via PLDs.Objective: To evaluate the effect of music exposure through (PLD) with and without tinnitus on results of EHFA, TEOAEs, ABR and SPIN tests in normal hearing young adults.Patients and Methods: Sixty normal hearing young adults were included in this study, fifteen as a control group and forty-five PLDs users as study group, the study group were subdivided according to the presence of tinnitus into two subgroups. All subjects were submitted to basic audiological evaluation (pure tone audiometry, speech audiometry and immittancemetry), Extended high frequency audiometry (EHFA), transient evoked otoacoustic emissions (TEOAEs), auditory brainstem response (ABR) and speech perception in noise (SPIN) test.Results: There were statistically significant differences in extended high frequency audiometry (HFA) at different frequencies among study and control groups. There were statistically significant differences in transient evoked otoacoustic emission test (TEOAEs) response among control and study groups. There were no statistically significant differences in absolute and inter-peak latencies of low and high repetition rate ABR among control and studied groups. There were statistically significant differences in speech perception in noise test (SPIN) among the control and study groups.Conclusion: : exposure to recreational noise due to excessive PLDs usage cause elevated EHFA thresholds, decreased TEOAEs amplitudes and decreased SPIN scores despite normal conventional PTA thresholds.

Skeletal muscle index is an independent predictor of early recurrence in non-obese colon cancer patients

PurposeProgressive loss (sarcopenia) and fatty infiltration of muscle mass (myosteatosis) are well-established risk factors for an adverse clinical outcome in obese patients. Data concerning non-obese sarcopenic patients in oncologic surgery are scarce and heterogeneous. The aim of this study was to determine the impact of sarcopenia and myosteatosis in non-obese patients with cancer of the right colon on clinical outcome.MethodsThis study comprised 85 patients with a BMI < 30 kg/m2, who underwent surgery for right colon cancer in a single center. Skeletal muscle area (SMA), visceral fat area (VFA), and myosteatosis were retrospectively assessed using preoperative abdominal CT images. Univariate und multivariate analysis was performed to evaluate the association between body composition, complications, and oncologic follow-up.ResultsTraditional risk factors such as visceral fat (p = 0.8653), BMI (p = 0.8033), myosteatosis (p = 0.7705), and sarcopenia (p = 0.3359) failed to show any impact on postoperative complications or early recurrence. In our cohort, the skeletal muscle index (SMI) was the only significant predictor for early cancer recurrence (p = 0.0467).ConclusionSMI is a significant prognostic factor for early cancer recurrence in non-obese colon cancer patients. Our study shows that conventional thresholds for sarcopenia and BMI do not seem to be reliable across various cohorts. Target prehabilitation programs could be useful to improve outcome after colorectal surgery.Trial RegistrationDRKS00014655, www.apps.who.int/trialsearch

The Unrecognized Prevalence of Primary Aldosteronism: A Cross-sectional Study.

Primary aldosteronism is a nonsuppressible renin-independent aldosterone production that causes hypertension and cardiovascular disease. To characterize the prevalence of nonsuppressible renin-independent aldosterone production, as well as biochemically overt primary aldosteronism, in relation to blood pressure. Cross-sectional study. 4 U.S. academic medical centers. Participants with normotension (n= 289), stage 1 hypertension (n= 115), stage 2 hypertension (n= 203), and resistant hypertension (n= 408). Participants completed an oral sodium suppression test, regardless of aldosterone or renin levels, as a confirmatory diagnostic for primary aldosteronism and to quantify the magnitude of renin-independent aldosterone production. Urinary aldosterone was measured in participants in high sodium balance with suppressed renin activity. Biochemically overt primary aldosteronism was diagnosed when urinary aldosterone levels were higher than 12 μg/24 h. Every blood pressure category had a continuum of renin-independent aldosterone production, where greater severity of production was associated with higher blood pressure, kaliuresis, and lower serum potassium levels. Mean adjusted levels of urinary aldosterone were 6.5 μg/24 h (95% CI, 5.2 to 7.7 μg/24 h) in normotension, 7.3 μg/24 h (CI, 5.6 to 8.9 μg/24 h) in stage 1 hypertension, 9.5 μg/24 h (CI, 8.2 to 10.8 μg/24 h) in stage 2 hypertension, and 14.6 μg/24 h (CI, 12.9 to 16.2 μg/24 h) in resistant hypertension; corresponding adjusted prevalence estimates for biochemically overt primary aldosteronism were 11.3% (CI, 5.9% to 16.8%), 15.7% (CI, 8.6% to 22.9%), 21.6% (CI, 16.1% to 27.0%), and 22.0% (CI, 17.2% to 26.8%). The aldosterone-renin ratio had poor sensitivity and negative predictive value for detecting biochemically overt primary aldosteronism. Prevalence estimates rely on arbitrary and conventional thresholds, and the study population may not represent nationwide demographics. The prevalence of primary aldosteronism is high and largely unrecognized. Beyond this categorical definition of primary aldosteronism, there is a prevalent continuum of renin-independent aldosterone production that parallels the severity of hypertension. These findings redefine the primary aldosteronism syndrome and implicate it in the pathogenesis of "essential" hypertension. National Institutes of Health.

An extended stroke rehabilitation service for people who have had a stroke: the EXTRAS RCT.

There is limited evidence about the effectiveness of rehabilitation in meeting the longer-term needs of stroke patients and their carers. To determine the clinical effectiveness and cost-effectiveness of an extended stroke rehabilitation service (EXTRAS). A pragmatic, observer-blind, parallel-group, multicentre randomised controlled trial with embedded health economic and process evaluations. Participants were randomised (1 : 1) to receive EXTRAS or usual care. Nineteen NHS study centres. Patients with a new stroke who received early supported discharge and their informal carers. Five EXTRAS reviews provided by an early supported discharge team member between 1 and 18 months post early supported discharge, usually over the telephone. Reviewers assessed rehabilitation needs, with goal-setting and action-planning. Control treatment was usual care post early supported discharge. The primary outcome was performance in extended activities of daily living (Nottingham Extended Activities of Daily Living Scale) at 24 months post randomisation. Secondary outcomes at 12 and 24 months included patient mood (Hospital Anxiety and Depression Scale), health status (Oxford Handicap Scale), experience of services and adverse events. For carers, secondary outcomes included carers' strain (Caregiver Strain Index) and experience of services. Cost-effectiveness was estimated using resource utilisation costs (adaptation of the Client Service Receipt Inventory) and quality-adjusted life-years. A total of 573 patients (EXTRAS, n = 285; usual care, n = 288) with 194 carers (EXTRAS, n = 103; usual care, n = 91) were randomised. Mean 24-month Nottingham Extended Activities of Daily Living Scale scores were 40.0 (standard deviation 18.1) for EXTRAS (n = 219) and 37.2 (standard deviation 18.5) for usual care (n = 231), giving an adjusted mean difference of 1.8 (95% confidence interval -0.7 to 4.2). The mean intervention group Hospital Anxiety and Depression Scale scores were not significantly different at 12 and 24 months. The intervention did not improve patient health status or carer strain. EXTRAS patients and carers reported greater satisfaction with some aspects of care. The mean cost of resource utilisation was lower in the intervention group: -£311 (95% confidence interval -£3292 to £2787), with a 68% chance of EXTRAS being cost-saving. EXTRAS was associated with 0.07 (95% confidence interval 0.01 to 0.12) additional quality-adjusted life-years. At current conventional thresholds of willingness to pay for a quality-adjusted life-year, there is a 90% chance that EXTRAS is cost-effective. EXTRAS did not improve stroke survivors' performance in extended activities of daily living but did improve their overall satisfaction with services. Given the impact on costs and quality-adjusted life-years, there is a high chance that EXTRAS could be considered cost-effective. Further research is required to identify whether or not community-based interventions can improve performance of extended activities of daily living, and to understand the improvements in health-related quality of life and costs seen by provision of intermittent longer-term specialist review. Current Controlled Trials ISRCTN45203373. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 24. See the NIHR Journals Library website for further project information.

Tailored logistic regression models for sex estimation of unknown individuals using the published population data of the humeral epiphyses.

This paper introduces a far-flung approach to formulate population independent models based on the humeral epiphyses as a supplementary tool for biological sex estimation of unknown partial remains. Resources for this study include the published summary statistics of 7 modern populations inhabited the continents of Africa, Asia, Europe, and South America. The regenerated humeral metric data (n=1490) via truncation approach were modeled using logistic regression. Three fitted models were evaluated for applicability across populations on an independent test sample (n=430). The experiment was assessed graphically and quantitatively using histogram of posterior probabilities and the classification table. The predictive power of the models was evaluated at the conventional (0.5) and high (0.95) posterior probability thresholds. It was found that the vertical humeral head model is insufficient for sex estimation especially in the European females due to different levels of interpopulation size variability. Interestingly, the distal biepicondylar breadth model showed overall better performance achieving the highest total and sex specific accuracies. Findings indicated that together, the epiphyseal measurements are capable of discriminating sex with overall accuracy of 90.2% which is raised up to 98.8% with 95% confidence of accurate estimates in more than 50% of the test sample. While evidences have been presented pointing to the biological and statistical meaningfulness of the humeral epiphyses model, the analysis allowed pinpointing the utility of the distal biepicondylar breadth model in sex diagnosis in transpopulation application settings. Additionally, few variables are needed to reach satisfactory sex prediction in a diverse sample.

The efficacy and economic evaluation of roxadustat treatment for anemia in patients with kidney disease not receiving dialysis

ABSTRACT Background This study aimed to assess the efficacy, tolerance, and cost-effectiveness of roxadustat treatment for anemia in patients with chronic kidney disease not receiving dialysis (CKD ND). Methods A meta-analysis was conducted to evaluate the clinical efficacy and tolerance of roxadustat for the correction of anemia associated with CKD ND, and a Markov model was developed to evaluate the cost-effectiveness of roxadustat compared with a placebo. Results The meta-analysis results showed that compared with a placebo, roxadustat treatment was associated with a remarkably higher rate of clinical response and the differences in the rate of adverse events between these two regimens were not significant. Moreover, roxadustat treatment (70 mg, three times per week) provided an additional 0.49 QALYs at a cost of $12,526 in the time horizon of 5 years, resulting in an ICER of $25,563 per QALY, with approximately 60% probability to be cost-effective at a $29,295 per QALY willingness-to-pay (WTP) threshold from the perspective of Chinese medical system. Conclusion For the treatment of anemia in Chinese patients with CKD ND, roxadustat is much more effective than a placebo; moreover, it is cost-effective at conventional WTP thresholds.

Background noise suppression using trainable nonlinear reaction diffusion assisted by robust principal component analysis

Due to the severe interference of background noise, the signal-to-noise ratio of desert seismic data is extremely low. In addition, due to low-frequency characteristics of sand in the Tarim desert region, the background noise in desert seismic data is mainly distributed in low-frequency band, so that the frequency spectrum aliasing of effective signals and background noise is more serious than the general land seismic data. Thus, conventional filtering methods cannot effectively suppress background noise in desert seismic data and recover effective signals. In order to overcome the problem that low-frequency background noise in desert seismic data is hard to suppress, a new method called R-TNRD based on robust principal component analysis (RPCA) algorithm and trainable nonlinear reaction diffusion (TNRD) network is proposed in this paper. By using the good sparsity of RPCA, the input noisy desert seismic data are decomposed into a low-rank matrix and a sparse matrix, and these two matrices contain background noise and effective signals. Due to the serious spectrum aliasing of desert seismic data, conventional thresholds have been unable to extract effective signals from the two matrices obtained by RPCA effectively. Therefore, we introduce TNRD network into desert seismic data denoising. By network training with a low-frequency noise set, the optimisation of TNRD network can be achieved, so as to accurately extract the effective signals from the low-rank matrix and the sparse matrix. In the experimental part, we test the performance of R-TNRD on both synthetic and real seismic data. The results demonstrate that the proposed method can suppress background noise more effectively than conventional methods.