Transformation scenarios towards multifunctional landscapes: A multi-criteria land-use allocation model applied to Jambi Province, Indonesia.

In tropical regions, shifting from forests and traditional agroforestry to intensive plantations generates conflicts between human welfare (farmers' demands and societal needs) and environmental protection. Achieving sustainability in this transformation will inevitably involve trade-offs between multiple ecological and socioeconomic functions. To address these trade-offs, our study used a new methodological approach allowing the identification of transformation scenarios, including theoretical landscape compositions that satisfy multiple ecological functions (i.e., structural complexity, microclimatic conditions, organic carbon in plant biomass, soil organic carbon and nutrient leaching losses), and farmers needs (i.e., labor and input requirements, total income to land, and return to land and labor) while accounting for the uncertain provision of these functions and having an actual potential for adoption by farmers. We combined a robust, multi-objective optimization approach with an iterative search algorithm allowing the identification of ecological and socioeconomic functions that best explain current land-use decisions. The model then optimized the theoretical land-use composition that satisfied multiple ecological and socioeconomic functions. Between these ends, we simulated transformation scenarios reflecting the transition from current land-use composition towards a normative multifunctional optimum. These transformation scenarios involve increasing the number of optimized socioeconomic or ecological functions, leading to higher functional richness (i.e., number of functions). We applied this method to smallholder farms in the Jambi Province, Indonesia, where traditional rubber agroforestry, rubber plantations, and oil palm plantations are the main land-use systems. Given the currently practiced land-use systems, our study revealed short-term returns to land as the principal factor in explaining current land-use decisions. Fostering an alternative composition that satisfies additional socioeconomic functions would require minor changes ("low-hanging fruits"). However, satisfying even a single ecological indicator (e.g., reduction of nutrient leaching losses) would demand substantial changes in the current land-use composition ("moonshot"). This would inevitably lead to a profit decline, underscoring the need for incentives if the societal goal is to establish multifunctional agricultural landscapes. With many oil palm plantations nearing the end of their production cycles in the Jambi province, there is a unique window of opportunity to transform agricultural landscapes.

Evaluation of a Regulatory Orientation Guide for Young Entrepreneurs in the Field of Digital Health.

BACKGROUND: The number of software products in the field of health and medicine increases excessively. Self-tracking, fitness, dose calculation, and analysis of physiological data - apps are popular and commonly used. For young entrepreneurs, it is difficult to recognize and understand the distinction between software as medical product and health software products. A product-related orientation guide was developed to help start-ups to understand the difference and to find the right strategy for placing their product on the market. OBJECTIVES: An initial evaluation of this orientation guide to improve the comprehensibility, the simplicity, and to validate the benefit. METHODS: The evaluation was performed using a questionnaire. In total, 15 employees from start-ups or those in foundation phase and in regulatory affairs positions or comparable were interviewed. RESULTS: the orientation guide was rated as very helpful and comprehensible. 80 % would highly recommend it to others. CONCLUSION: The orientation guide was positively evaluated and can be used in field. Nevertheless, further investigations must be performed, and a post-market surveillance will be necessary.

Pilot study on nocturnal monitoring of crackles in children with pneumonia.

BACKGROUND: The clinical diagnosis of pneumonia is usually based on crackles at auscultation, but it is not yet clear what kind of crackles are the characteristic features of pneumonia in children. Lung sound monitoring can be used as a "longtime stethoscope". Therefore, it was the aim of this pilot study to use a lung sound monitor system to detect crackles and to differentiate between fine and coarse crackles in children with acute pneumonia. The change of crackles during the course of the disease shall be investigated in a follow-up study. PATIENTS AND METHODS: Crackles were recorded overnight from 22:00 to 06:00 h in 30 children with radiographically confirmed pneumonia. The data for a total of 28 800 recorded 30-s epochs were audiovisually analysed for fine and coarse crackles. RESULTS: Fine crackles and coarse crackles were recognised in every patient with pneumonia, but the number of epochs with and without crackles varied widely among the different patients: fine crackles were detected in 40±22% (mean±sd), coarse crackles in 76±20%. The predominant localisation of crackles as recorded during overnight monitoring was in accordance with the radiographic infiltrates and the classical auscultation in most patients. The distribution of crackles was fairly equal throughout the night. However, there were time periods without any crackle in the single patients so that the diagnosis of pneumonia might be missed at sporadic auscultation. CONCLUSION: Nocturnal monitoring can be beneficial to reliably detect fine and coarse crackles in children with pneumonia.

Methods for Adventitious Respiratory Sound Analyzing Applications Based on Smartphones: A Survey.

Detection and classification of adventitious acoustic lung sounds plays an important role in diagnosing, monitoring, controlling and, caring the patients with lung diseases. Such systems can be presented as different platforms like medical devices, standalone software or smartphone application. Ubiquity of smartphones and widespread use of the corresponding applications make such a device an attractive platform for hosting the detection and classification systems for adventitious lung sounds. In this paper, the smartphone-based systems for automatic detection and classification of the adventitious lung sounds are surveyed. Such adventitious sounds include cough, wheeze, crackle and, snore. Relevant sounds related to abnormal respiratory activities are considered as well. The methods are shortly described and the analyzing algorithms are explained. The analysis includes detection and/or classification of the sound events. A summary of the main surveyed methods together with the classification parameters and used features for the sake of comparison is given. Existing challenges, open issues and future trends will be discussed as well.

Reprint of "The detection of knee joint sounds at defined loads by means of vibroarthrography".

BACKGROUND: Crepitus of the knee may mirror structural and functional changes in the joint during motion. Although the magnitude of these sounds increases with greater cartilage damage, it is unclear whether knee joint sounds also reflect joint loading. METHODS: Twelve healthy volunteers (mean 26 (SD 3.6) years, 7 females) participated in the randomized-balanced crossover study. Knee joint sounds were recorded (linear sampling, 5512 Hz) by means of two microphones, one placed on the medial tibial plateau and one on the patella. Two activities of daily living (standing up from/sitting down on a bench; descending stairs) and three open kinetic chain knee extension-flexion cycles (passive movement, 10% and 40% loading of the individual one repetition maximum) were performed. Each participant carried out three sets of five repetitions and three sets of 15 steps downwards (stairs), respectively. For data analysis, the mean sound amplitude and the median power frequency for each loading condition were determined. Friedman test and Bonferroni-Holm adjusted post-hoc test were performed to detect differences between conditions. FINDINGS: We obtained significant differences between joint sound amplitudes for all movements, both measured at the medial tibial plateau (Chi2 = 20.7, p < 0.001) and at the patella (Chi2 = 27.6, p < 0.001). We showed a significant difference in the median power frequency of the patella between all movements (Chi2 = 17.8, p < 0.5). INTERPRETATION: Overall, the larger the supposed knee joint loading was, the louder was the recorded knee crepitus. Consequently, vibroarthrographically assessed knee joint sounds can differ across knee joint loading conditions.

Disease control in patients with asthma and respiratory symptoms (wheezing, cough) during sleep.

INTRODUCTION: The Global Initiative for Asthma (GINA)-defined criteria for asthma control include questions about daytime symptoms, limitation of activity, nocturnal symptoms, need for reliever treatment and patients' satisfaction. Patients with nocturnal symptoms like wheezing and cough often suffer from lower sleep quality and impaired daytime performance. The lack of an appropriate method for standardized and objective monitoring of respiratory symptoms leads to difficulties in asthma management. The aim of this study is to present a new method for automated wheeze and cough detection during sleep and to assess the actual level of asthma control by the Asthma Control Test (ACT). METHODS: Respiratory symptoms like wheezing and cough were recorded with the LEOSound-Monitor for one night in 55 asthmatic patients in their individual domestic setting. Patients were asked to assess their level of asthma subjectively with the ACT. The study consisted of 37 women and 18 men, with a mean age of 41 years, and a mean BMI of 27 kg/m2. Most of the patients had been taking an ICS/LABA combination and would resort to a SABA as their rescue medication. RESULTS: 60% of the participants were classed as having controlled, and 40% were classed as having partially- or uncontrolled asthma. During sleep wheezing was found in 8 of the 55 asthma patients (14.5%) and coughing was found in 30 patients (54.5%). The median ACT score in wheezing-patients was 14, while in non-wheezing patients it was 21. Uncontrolled asthma was found in 6 of the 8 wheezing-patients. Coughing versus non-coughing patients did not show a significant difference in the ACT-score (20, 22 respectively). CONCLUSION: Wheezing is a sign of uncontrolled asthma. The ACT-score in wheezing patients is worse compared to patients without wheezing. LEOSound proofed to be a useful tool in providing an objective evaluation of respiratory symptoms, like coughing and wheezing. In clinical practice, this may allow an improvement in asthma therapy.

Comparison of Formative Evaluation Methods in the Usability Process on the Example of a Medical App.

BACKGROUND: The process of developing a medical device has become increasingly complex, not least because of the Medical Device Regulation. Some of the associated changes affect in particular the software development companies. One of the challenges to provide safe software products is the usability engineering process. Adequate methods must be identified to find severe usability issues effectively and efficiently. OBJECTIVES: The aim of this study was a comparison of normative recommended formative evaluation methods. METHODS: Two expert-based methods and two user-based methods were compared regarding effectiveness in finding issues, the level of detail and the temporal effort. RESULTS: The heuristics and the isometrics, both showed a significant advantage regarding the effectiveness and similarity in level of detail and temporal effort. CONCLUSION: Based on this paper, the heuristics and the isometrics, both can be recommended, but further studies are necessary to consolidate this statement. Also, further methods should be considered, and more test persons must be involved to give an overall comparison of formative evaluation methods in the usability process of medical apps.

Reliability of Vibroarthrography to Assess Knee Joint Sounds in Motion.

Knee acoustic emissions provide information about joint health and loading in motion. As the reproducibility of knee acoustic emissions by vibroarthrography is yet unknown, we evaluated the intrasession and interday reliability of knee joint sounds. In 19 volunteers (25.6 ± 2.0 years, 11 female), knee joint sounds were recorded by two acoustic sensors (16,000 Hz; medial tibial plateau, patella). All participants performed four sets standing up/sitting down (five repetitions each). For measuring intrasession reliability, we used a washout phase of 30 min between the first three sets, and for interday reliability we used a washout phase of one week between sets 3 and 4. The mean amplitude (dB) and median power frequency (Hz, MPF) were analyzed for each set. Intraclass correlation coefficients (ICCs (2,1)), standard errors of measurement (SEMs), and coefficients of variability (CVs) were calculated. The intrasession ICCs ranged from 0.85 to 0.95 (tibia) and from 0.73 to 0.87 (patella). The corresponding SEMs for the amplitude were ≤1.44 dB (tibia) and ≤2.38 dB (patella); for the MPF, SEMs were ≤13.78 Hz (tibia) and ≤14.47 Hz (patella). The intrasession CVs were ≤0.06 (tibia) and ≤0.07 (patella) (p < 0.05). The interday ICCs ranged from 0.24 to 0.33 (tibia) and from 0 to 0.82 (patella) for both the MPF and amplitude. The interday SEMs were ≤4.39 dB (tibia) and ≤6.85 dB (patella) for the amplitude and ≤35.39 Hz (tibia) and ≤15.64 Hz (patella) for the MPF. The CVs were ≤0.14 (tibia) and ≤0.08 (patella). Knee joint sounds were highly repeatable within a single session but yielded inconsistent results for the interday reliability.

The detection of knee joint sounds at defined loads by means of vibroarthrography.

BACKGROUND: Crepitus of the knee may mirror structural and functional changes in the joint during motion. Although the magnitude of these sounds increases with greater cartilage damage, it is unclear whether knee joint sounds also reflect joint loading. METHODS: Twelve healthy volunteers (mean 26 (SD 3.6) years, 7 females) participated in the randomized-balanced crossover study. Knee joint sounds were recorded (linear sampling, 5512 Hz) by means of two microphones, one placed on the medial tibial plateau and one on the patella. Two activities of daily living (standing up from/sitting down on a bench; descending stairs) and three open kinetic chain knee extension-flexion cycles (passive movement, 10% and 40% loading of the individual one repetition maximum) were performed. Each participant carried out three sets of five repetitions and three sets of 15 steps downwards (stairs), respectively. For data analysis, the mean sound amplitude and the median power frequency for each loading condition were determined. Friedman test and Bonferroni-Holm adjusted post-hoc test were performed to detect differences between conditions. FINDINGS: We obtained significant differences between joint sound amplitudes for all movements, both measured at the medial tibial plateau (Chi2 = 20.7, p < 0.001) and at the patella (Chi2 = 27.6, p < 0.001). We showed a significant difference in the median power frequency of the patella between all movements (Chi2 = 17.8, p < 0.5). INTERPRETATION: Overall, the larger the supposed knee joint loading was, the louder was the recorded knee crepitus. Consequently, vibroarthrographically assessed knee joint sounds can differ across knee joint loading conditions.

Time course of nocturnal cough and wheezing in children with acute bronchitis monitored by lung sound analysis.

Cough and wheezing are the predominant symptoms of acute bronchitis. Hitherto, the evaluation of respiratory symptoms was limited to subjective methods such as questionnaires. The main objective of this study was to objectively determine the time course of cough and wheezing in children with acute bronchitis. The impact of nocturnal cough on parent's quality of life was assessed as secondary outcome. In 36 children (2-8 years), the frequency of nocturnal cough and wheezing was recorded during three nights by automated lung sound monitoring. Additionally, parents completed symptom logs, i.e., the Bronchitis Severity Score (BSS), as well as the Parent-proxy Children's Acute Cough-specific Quality of Life Questionnaire (PAC-QoL). During the first night, patients had 34.4 ± 52.3 (mean ± SD) cough epochs, which were significantly reduced in night 5 (13.5 ± 26.5; p < 0.001) and night 9 (12.8 ± 28.1; p < 0.001). Twenty-two patients had concomitant wheezing, which declined within the observation period as well. All subjective parameters (BSS, Cough log and PAC-QoL) were found to be significantly correlated with the objectively assessed cough parameters.Conclusion: Long-term recording of cough and wheezing offers a useful opportunity to objectively evaluate the time course of respiratory symptoms in children with acute bronchitis. To assess putative effects of pharmacotherapy on nocturnal bronchitis symptoms, future studies in more homogeneous patient groups are needed. What is Known: • Cough and wheezing are the predominant symptoms of acute bronchitis. • There is a diagnostic gap in long-term assessment of these respiratory symptoms, which needs to be closed to optimize individual therapies. What is New: • Long-term recording of nocturnal cough and wheezing allows for objective evaluation of respiratory symptoms in children with acute bronchitis and provides a tool to validate the efficacy of symptomatic bronchitis therapies.

Description of nighttime cough epochs in patients with stable COPD GOLD II-IV.

PURPOSE: Chronic cough is one of the main symptoms of COPD. Ambulatory objective monitoring provides novel insights into the determinants and characteristics of nighttime cough in COPD. MATERIALS AND METHODS: Nighttime cough was monitored objectively by LEOSound lung sound monitor in patients with stable COPD II-IV. In 30 patients, with 10 patients in each stage group, nighttime cough was analyzed for epoch frequency, epoch severity (epoch length and coughs per epoch), and pattern (productive or nonproductive). RESULTS: Cough was found in all patients ranging from 1 to 294 events over the recording period. In 29 patients, cough epochs were monitored, ranging from 1 to 75 epochs. The highest amount of cough epochs was found in patients with COPD stage III. Active smokers had significantly more productive cough epochs (61%) than nonsmokers (24%). CONCLUSION: We found a high rate of nighttime cough epochs in patients with COPD, especially in those in stage III. Productive cough was predominantly found in patients with persistent smoking. LEOSound lung sound monitor offers a practical and valuable opportunity to evaluate cough objectively.

Long-term Recording of Night-Time Respiratory Symptoms in Patients with Stable COPD II-IV.

INTRODUCTION: Night-time respiratory symptoms have a considerable impact on sleep and life quality in patients with chronic obstructive pulmonary disease (COPD). Lack of awareness of night-time symptoms can lead to worsened COPD control. Automated long-term monitoring of respiratory symptoms with LEOSound enables assessment of nocturnal wheezing and cough. METHODS: In this observational study we investigated the prevalence and severity of cough and wheezing in patients with stable COPD [Global Initiative for Chronic Obstructive Lung Disease (GOLD) II-IV] disease for two consecutive nights with the LEOSound system. 48 patients (30 males, 63%) were eligible for inclusion, median age was 67 years, and body mass index (BMI) was 25.3 kg/m2. RESULTS: In 15 out of 48 patients (31%), we found wheezing periods for at least 10-minute duration. Wheezing periods >30 minutes were monitored in seven patients and wheezing periods >60 minutes were monitored in three patients. The maximum duration of wheezing was 470 minutes in one patient with COPD II. The median wheezing rate differed between the COPD stages and between active and non-active smokers. Cough was found in 42 patients (87.5%) with a range of 1-326 events. The cough-period-index in night one was 0.83 n/hour (P25:0.33||P75: 2.04) and night two 0.97 n/hour (P25:0.25||P75: 1.9). Most of the cough events were non-productive with a median of 0.86. CONCLUSIONS: Night-time symptoms are common in COPD patients. LEOSound offers an opportunity to evaluate objectively night-time symptoms like wheezing and cough in patients with COPD which remain otherwise unnoticed. We found a high incidence of night-time wheezing in these patients, which was related to persistant smoking.

Telemonitoring and medical care supporting of patients with chronic respiratory diseases.

Experts refer to innovative telemonitoring technologies to deal with chronic respiratory diseases, especially the chronic obstructive pulmonary disease - COPD. In chronic respiratory diseases, sudden acute exacerbations may occur that can be life-threatening in some cases. Telemonitoring solutions help to detect the beginning of an impaired medical condition and can induce an adequate countermeasure in time. As soon as individually determined parameters are passed, appropriate warning signs can be transmitted. As part of a project, a new monitoring device for the detection of COPD-typical parameters has been utilized and optimized. Furthermore, an innovative 3D-Video-System was used to enable the implementation of physical exercises in the domestic environment. The systems assists the patient during the entire training unit and creates a feedback based on the quality of his or her exercises.

Supporting prolonged COPD monitoring using an application for mobile devices.

COPD (chronic obstructive pulmonary disease) is the most frequent form of chronic respiratory disease. During the progress of this disease, phases of aggravation of pulmonary function (exacerbations) can occur, which reduce the quality of life. Clinical experience shows that single investigations are insufficient. Therefore a prolonged monitoring is required to recognize an exacerbation early. This home monitoring will involve a quick respiratory test and a related application for Android, iOS and Windows phones. This rapid test transmits the relevant pulmonary parameters, converted in an Extensible Markup Language file to the smartphone. The application will analyze the incoming data to evaluate the current health status of the patient. Additionally the data will be transferred to the virtual control point (server) and stored in a database. If critical values are detected, the server will send a notification to prior defined relatives and doctors. A connection to a Hospital Information System will be possible through an included Health Level 7 interface. This offers an improved site-independent patient care. The project is planned to be in development until 2016.

Estimation of respiratory flow by means of normal lung sound.

The respiratory flow is a good indicator of sleep-related breathing disorders. Common praxis is to use a pneumotachograph as the golden standard for flow measurement. However, it does not have to be necessarily the best possible test device for long-term condition, because the device is very uncomfortable and rarely suitable for measurement during sleep. A computer-based method to determine the respiratory flow, called ThorAKUSTIK, yielded a highly positive correlation between the calculated flow out of the tracheal breath sound and a measured flow signal. In order to avoid noise interference due to a breath-mask or a pneumotachograph, in this study we applied the ThorAKUSTIK-method to lung sound which was measured at the back of 18 subjects and investigated the correlation between the calculated flow and the measured flow by a pneumotachograph. The new method showed a highly positive correlation (r = 0.89 and 0.90). Additionally we examined the use of an accelerometer signal to distinguish between inspiration and expiration. In this case we got high correlation coefficients of r = 0.87 and 0.88 between the calculated and measured airflow as well.

Aminosalicylates.

Symptomatic diverticular disease has a high prevalence in countries with a western lifestyle. Besides antibiotics for acute diverticulitis there are no established medical interventions to prevent or to treat symptomatic diverticular disease. Due to its broad spectrum of anti-inflammatory activities, mesalazine is a candidate for the treatment of symptomatic diverticular disease. A review of the literature shows that randomized open studies using various treatment designs suggest a protective role of mesalazine in preventing recurrences of diverticulitis. Currently, 5 randomized placebo-controlled trials are active which will clarify the role of mesalazine to prevent recurrence of diverticulitis in the near future. Several randomized uncontrolled studies suggest that mesalazine improves symptoms in patients with symptomatic uncomplicated diverticular disease. The analysis of secondary end points from two randomized placebo-controlled trials suggests that mesalazine improves symptoms in diverticular disease although both studies failed to show a statistically significant advantage for mesalazine for the primary study end point. In segmental colitis associated with diverticulosis no prospective systematic studies are available. However, several case reports show a high efficacy of mesalazine in segmental colitis associated with diverticulosis.

Topical therapy.

Topical therapy with mesalazine and/or corticosteroids is the standard treatment for patients with distal ulcerative colitis. Rectal mesalazine is more effective than rectal systemically active corticosteroids or topically active corticosteroids like budesonide. In patients with mild to moderately active distal ulcerative colitis, topical mesalazine is therefore the treatment of choice. Doses of 1 g or higher are equally effective. The period of treatment is important (4 weeks are more effective than 2 weeks). In the case of nonresponse or nontolerability of rectal mesalazine, rectal budesonide is indicated. The standard dose of budesonide is 2 mg/day. This does not usually induce any corticosteroid-associated adverse events. Treatment with rectal mesalazine plus rectal topically active corticosteroids is even more effective than treatment with either substance alone. To overcome adherence problems with rectal therapy, rectal foam preparations have been developed which are usually better tolerated than enemas.

3g mesalazine granules are superior to 9mg budesonide for achieving remission in active ulcerative colitis: a double-blind, double-dummy, randomised trial.

BACKGROUND AND AIMS: Budesonide may be an effective therapy for mild-to-moderately active ulcerative colitis (UC). This study aimed to demonstrate non-inferiority for oral 9mg budesonide once daily (OD) versus 3g mesalazine granules OD. METHODS: This was an eight-week randomised, double-blind, double-dummy, multicentre study in which patients with mild-to-moderately active UC, defined as Clinical Activity Index (CAI) ≥6 and Endoscopic Index (EI) ≥4, received budesonide (Budenofalk® 3mg capsules×3) or mesalazine (Salofalk® 1000mg granules×3). The primary endpoint was clinical remission at week 8 (CAI ≤4 with stool frequency and rectal bleeding subscores of "0"). RESULTS: 343 patients were randomised (177 budesonide, 166 mesalazine). Fewer patients achieved the primary endpoint with budesonide versus mesalazine (70/177 [39.5%] versus 91/166 [54.8%]) with a difference in proportions of -15.3% (95% CI [-25.7%, -4.8%]; p=0.520 for non-inferiority). The median time to first resolution of symptoms was 14.0 days (budesonide) and 11.0 days (mesalazine) (hazard ratio 1.19; 95% CI [0.94, 1.51]). Mucosal healing was observed in 54/177 (30.5%) budesonide patients versus 65/166 (39.2%) mesalazine patients, a difference of -8.6% (95% CI [-18.7%, 1.4%]; p=0.093). The incidences of adverse events (budesonide 26.6%, mesalazine 25.3%) and serious adverse events (budesonide 1.7%, mesalazine 1.2%) were similar. CONCLUSIONS: Once-daily 3g mesalazine administered as granules is superior to 9mg budesonide OD administered as capsules for achieving remission in mild-to-moderately active UC. However, it is noteworthy that remission of UC was attained in about 40% of budesonide-treated patients with a rapid onset of resolution.