Ethnic and socioeconomic disparities in initiation of second-line antidiabetic treatment for people with type 2 diabetes in England: A cross-sectional study.

AIMS: To assess any disparities in the initiation of second-line antidiabetic treatments prescribed among people with type 2 diabetes mellitus (T2DM) in England according to ethnicity and social deprivation level. MATERIALS AND METHODS: This cross-sectional study used linked primary (Clinical Practice Research Datalink) and secondary care data (Hospital Episode Statistics), and the Index of Multiple Deprivation (IMD). We included people aged 18 years or older with T2DM who intensified to second-line oral antidiabetic medication between 2014 and 2020 to investigate disparities in second-line antidiabetic treatment prescribing (one of sulphonylureas [SUs], dipeptidyl peptidase-4 [DPP-4] inhibitors, or sodium-glucose cotransporter-2 [SGLT2] inhibitors, in combination with metformin) by ethnicity (White, South Asian, Black, mixed/other) and deprivation level (IMD quintiles). We report prescriptions of the alternative treatments by ethnicity and deprivation level according to predicted percentages derived from multivariable, multinomial logistic regression. RESULTS: Among 36 023 people, 85% were White, 10% South Asian, 4% Black and 1% mixed/other. After adjustment, the predicted percentages for SGLT2 inhibitor prescribing by ethnicity were 21% (95% confidence interval [CI] 19-23%), 20% (95% CI 18-22%), 19% (95% CI 16-22%) and 17% (95% CI 14-21%) among people with White, South Asian, Black, and mixed/other ethnicity, respectively. After adjustment, the predicted percentages for SGLT2 inhibitor prescribing by deprivation were 22% (95% CI 20-25%) and 19% (95% CI 17-21%) for the least deprived and the most deprived quintile, respectively. When stratifying by prevalent cardiovascular disease (CVD) status, we found lower predicted percentages of people with prevalent CVD prescribed SGLT2 inhibitors compared with people without prevalent CVD across all ethnicity groups and all levels of social deprivation. CONCLUSIONS: Among people with T2DM, there were no substantial differences by ethnicity or deprivation level in the percentage prescribed either SGLT2 inhibitors, DPP-4 inhibitors or SUs as second-line antidiabetic treatment.

Back to basics: A mediation analysis approach to addressing the fundamental questions of integrated care evaluations.

Health systems around the world are aiming to improve the integration of health and social care services to deliver better care for patients. Existing evaluations have focused exclusively on the impact of care integration on health outcomes and found little effect. That suggests the need to take a step back and ask whether integrated care programmes actually lead to greater clinical integration of care and indeed whether greater integration is associated with improved health outcomes. We propose a mediation analysis approach to address these two fundamental questions when evaluating integrated care programmes. We illustrate our approach by re-examining the impact of an English integrated care program on clinical integration and assessing whether greater integration is causally associated with fewer admissions for ambulatory care sensitive conditions. We measure clinical integration using a concentration index of outpatient referrals at the general practice level. While we find that the scheme increased integration of primary and secondary care, clinical integration did not mediate a decrease in unplanned hospital admissions. Our analysis emphasizes the need to better understand the hypothesized causal impact of integration on health outcomes and demonstrates how mediation analysis can inform future evaluations and program design.

A firebreak placement model for optimizing biodiversity protection at landscape scale.

A solution approach is proposed to optimize the selection of landscape cells for inclusion in firebreaks. It involves linking spatially explicit information on a landscape's ecological values, historical ignition patterns and fire spread behavior. A firebreak placement optimization model is formulated that captures the tradeoff between the direct loss of biodiversity due to the elimination of vegetation in areas designated for placement of firebreaks and the protection provided by the firebreaks from losses due to future forest fires. The optimal solution generated by the model reduced expected losses from wildfires on a biodiversity combined index due to wildfires by 30% relative to a landscape without any treatment. It also reduced expected losses by 16% compared to a randomly chosen solution. These results suggest that biodiversity loss resulting from the removal of vegetation in areas where firebreaks are placed can be offset by the reduction in biodiversity loss due to the firebreaks' protective function.

Active Learning Methodology for Expert-Assisted Anomaly Detection in Mobile Communications.

Due to the great complexity, heterogeneity, and variety of services, anomaly detection is becoming an increasingly important challenge in the operation of new generations of mobile communications. In many cases, the underlying relationships between the multiplicity of parameters and factors that can cause anomalous behavior are only determined by human expert knowledge. On the other hand, although automatic algorithms have a great capacity to process multiple sources of information, they are not always able to correctly signal such abnormalities. In this sense, this paper proposes the integration of both components in a framework based on Active Learning that enables enhanced performance in anomaly detection tasks. A series of tests have been conducted using an online anomaly detection algorithm comparing the proposed solution with a method based on the algorithm output alone. The obtained results demonstrate that a hybrid anomaly detection model that automates part of the process and includes the knowledge of an expert following the described methodology yields increased performance.

Optimization of Dominant Frequency and Bandwidth Analysis in Multi-Frequency 3D GPR Signals to Identify Contaminated Areas.

Ground-penetrating radar (GPR) has been widely used in investigations of contaminated areas because of its sensitivity to variations associated with the nature of pore fluids. However, most of the studies were usually based on the visual interpretation of radargrams or on a time domain amplitude analysis. In this work, we propose a methodology that consists of analyzing the spectral content of the signal recorded in multi-frequency 3D GPR profiles. A remarkable advantage of this type of antenna is its step-frequency system, which provides a much wider emission spectrum than the one corresponding to conventional single-frequency antennas. From the data in the frequency domain, the dominant frequency and bandwidth were calculated as parameters whose variation could be related to the presence of light non-aqueous phase liquid (LNAPL) in the subsurface. By analyzing the variations of these two parameters simultaneously, we were able to delimit the contaminated zones in a case study, associating them with a significant shift of the frequency spectrum with respect to the average of the study area. Finally, as a validation method of the proposed methodology, the results of the frequency analysis were compared with resistivity data obtained with an electromagnetic conductivity meter, showing a very good correlation between the results.

Kinetic Modeling, Thermodynamic Approach and Molecular Dynamics Simulation of Thermal Inactivation of Lipases from Burkholderia cepacia and Rhizomucor miehei.

The behavior against temperature and thermal stability of enzymes is a topic of importance for industrial biocatalysis. This study focuses on the kinetics and thermodynamics of the thermal inactivation of Lipase PS from B. cepacia and Palatase from R. miehei. Thermal inactivation was investigated using eight inactivation models at a temperature range of 40-70 °C. Kinetic modeling showed that the first-order model and Weibull distribution were the best equations to describe the residual activity of Lipase PS and Palatase, respectively. The results obtained from the kinetic parameters, decimal reduction time (D and tR), and temperature required (z and z') indicated a higher thermal stability of Lipase PS compared to Palatase. The activation energy values (Ea) also indicated that higher energy was required to denature bacterial (34.8 kJ mol-1) than fungal (23.3 kJ mol-1) lipase. The thermodynamic inactivation parameters, Gibbs free energy (ΔG#), entropy (ΔS#), and enthalpy (ΔH#) were also determined. The results showed a ΔG# for Palatase (86.0-92.1 kJ mol-1) lower than for Lipase PS (98.6-104.9 kJ mol-1), and a negative entropic and positive enthalpic contribution for both lipases. A comparative molecular dynamics simulation and structural analysis at 40 °C and 70 °C were also performed.

Stroke impairment categories: A new way to classify the effects of stroke based on stroke-related impairments.

OBJECTIVE: To create a classification system based on stroke-related impairments. DATA SOURCE: All adults with stroke admitted for at least 72 hours in England, Wales and Northern Ireland from July 2013 to July 2015 extracted from the Sentinel Stroke National Audit Programme. ANALYSIS: Impairments were defined using the National Institute of Health Stroke Scale scores at admission. Common combinations of impairments were identified based on geometric coding and expert knowledge. Validity of the classification was assessed using standard descriptive statistics to report and compare patients' characteristics, therapy received and outcomes in each group. RESULTS: Data from 94,905 patients were extracted. The items of the National Institute of Health Stroke Scale (on admission) were initially grouped into four body systems: Cognitive, Motor, Sensory and Consciousness. Seven common combinations of these impairments were identified (in order of stroke severity); Patients with Loss of Consciousness (n = 6034, 6.4%); those with Motor + Cognitive + Sensory impairments (n = 28,226, 29.7%); Motor + Cognitive impairments (n = 16,967, 17.9%); Motor + Sensory impairments (n = 9882, 10.4%); Motor Only impairments (n = 20,471, 21.6%); Any Non-Motor impairments (n = 7498, 7.9%); and No Impairments (n = 5827, 6.1%). There was a gradation of age, premorbid disability, mortality and disability on discharge. People with the most and least severe categories were least likely to receive therapy, and received least therapy (-20 minutes/day of stay) compared to -35 minutes/day of stay for the moderately severe categories. CONCLUSIONS: A classification system of seven Stroke Impairment Categories has been presented.

QoE Optimization in a Live Cellular Network through RLC Parameter Tuning.

The mobile communication networks sector has experienced a great evolution during the last few years. The emergence of new services as well as the growth in the number of subscribers have motivated the search for new ways to optimize mobile networks. In this way, the objective pursued by optimization techniques has been evolving, shifting from the traditional optimization of radio parameters to the improvement of the quality perceived by users, known as quality of experience (QoE). In mobile networks, the radio link control (RLC) layer provides a reliable link between both ends of the communication and has a great impact on the QoE. In this paper, the optimization of the QoE for users based on the adjustment of the RLC layer is proposed. For this purpose, two typical services demanded by the users of mobile networks have been selected: the real-time video streaming service and file transfer service. For a broader view of the behavior of the QoE in relation to RLC, optimization tests have been carried out in scenarios with different system bandwidths. In this way, the relationship between the QoE and the optimal configuration of RLC in different network load situations has been analyzed. A proof of concept has been carried out to show the capability of this optimization. To that end, both a cellular network simulator and a live cellular network devised for research purposes have been used.

Framework for Behavioral Analysis of Mobile Networks.

The arrival of the Fifth Generation (5G) entails a significant evolution in the context of mobile communication networks. This new technology will bring heterogeneous scenarios with new types of services and an increasingly high number of users and nodes. The efficient management of such complex networks has become an important challenge. To address this problem, automatic and efficient algorithms must be developed to facilitate operators' management and optimization of their networks. These algorithms must be able to cope with a very high number of heterogeneous data and different types of scenarios. In this paper, a novel framework for a cellular network behavioral analysis and monitoring is presented. This framework is based on a combination of unsupervised and supervised machine learning techniques. The proposed system can analyze the behavior of cells and monitor them, searching for behavior changes over time. The information extracted by the framework can be used to improve subsequent management and optimization functions.

Delphi-based recommendations for the management of cardiovascular comorbidities in patients with psoriatic arthritis and moderate-to-severe psoriasis.

The aim of this study was to generate practical recommendations to assist rheumatologists and dermatologists in the management of cardiovascular (CV) comorbidities in patients with moderate-to-severe psoriasis (MS-PSO) and psoriatic arthritis (PsA). A two-round Delphi study was conducted. A panel of experts rated their agreement with a set of statements (n = 52) on a nine-point Likert scale (1 = totally disagree; 9 = totally agree). Statements were classified as inappropriate (median 1-3), irrelevant (median 4-6) or appropriate (median 7-9). Consensus was established when at least two-thirds of the panel responded with a score within any one range. A total of 25 experts, 60% rheumatologists and 40% dermatologists, participated in two consultation rounds. There was overall unanimity on the appropriateness of an initial assessment for CV risk factors in all patients with MS-PSO and PsA. Most panelists (88.0%) also supported the evaluation of patients' psychological and physical status. Additionally, most panelists (72.2%) agreed on a novel sequential approach for the management of CV comorbidities. This sequence starts with the assessment of hypertension, diabetes and dyslipidemia along with the identification of depression and anxiety disorders. Once these factors are under control, smoking cessation programs might be initiated. Finally, if patients have not met weight loss goals with lifestyle modifications, they should receive specialized treatment for obesity. This study has drawn up a set of practical recommendations that will facilitate the management of CV comorbidities in patients with MS-PSO and PsA.

How do patients pass through stroke services? Identifying stroke care pathways using national audit data.

OBJECTIVE: To map and describe how patients pass through stroke services. METHODS: Data from 94,905 stroke patients (July 2013-July 2015) who were still inpatients 72 hours after hospital admission were extracted from a national stroke register and were used to identify the routes patients took through hospital and community stroke services. We sought to categorize these routes through iterative consultations with clinical experts and to describe patient characteristics, therapy provision, outcomes and costs within each category. RESULTS: We identified 874 routes defined by the type of admitting stroke team and subsequent transfer history. We consolidated these into nine distinct routes and further summarized these into three overlapping 'pathways' that accounted for 99% of the patients. These were direct discharge (44%), community rehabilitation (47%) and inpatient transfer (19%) with 12% of the patients receiving both inpatient transfer and community rehabilitation. Patients with the mildest and most severe strokes were more likely to follow the direct discharge pathway. Those perceived to need most therapy were more likely to follow the inpatient transfer pathway. Costs were lowest and mortality was highest for patients on the direct discharge pathway. Outcomes were best for patients on the community rehabilitation pathway and costs were highest where patients underwent inpatient transfers. CONCLUSION: Three overarching stroke care pathways were identified which differ according to patient characteristics, therapy needs and outcomes. This pathway mapping provides a benchmark to develop and plan clinical services, and for future research.

Factors influencing the amount of therapy received during inpatient stroke care: an analysis of data from the UK Sentinel Stroke National Audit Programme.

OBJECTIVES: To understand why most stroke patients receive little therapy. We investigated the factors associated with the amount of stroke therapy delivered. METHODS: Data regarding adults admitted to hospital with stroke for at least 72 hours (July 2013-July 2015) were extracted from the UK's Sentinel Stroke National Audit Programme. Descriptive statistics and multilevel mixed effects regression models explored the factors that influenced the amount of therapy received while adjusting for confounding. RESULTS: Of the 94,905 patients in the study cohort (mean age: 76 (SD: 13.2) years, 78% had a mild or moderate severity stroke. In all, 92% required physiotherapy, 87% required occupational therapy, 57% required speech therapy but only 5% were considered to need psychology. The average amount of therapy ranged from 2 minutes (psychology) to 14 minutes (physiotherapy) per day of inpatient stay. Unmodifiable characteristics (such as stroke severity) dominated the variation in the amount of therapy. However important, modifiable organizational factors were the day and time of admission, type of stroke team, timely therapy assessments, therapy and nursing staffing levels (qualified and support staff), and presence of weekend or early supported discharge services. CONCLUSION: The amount of stroke therapy is associated with unmodifiable patient-related characteristics and modifiable organizational factors in that more therapy was associated with higher therapy and nurse staffing levels, specialist stroke rehabilitation services, timely therapy assessments, and the presence of weekend and early discharge services.

Feature Extraction for Dimensionality Reduction in Cellular Networks Performance Analysis.

Next-generation mobile communications networks will have to cope with an extraordinary amount and variety of network performance indicators, causing an increase in the storage needs of the network databases and the degradation of the management functions due to the high-dimensionality of every network observation. In this paper, different techniques for feature extraction are described and proposed as a means for reducing this high dimensionality, to be integrated as an intermediate stage between the monitoring of the network performance indicators and their usage in mobile networks' management functions. Results using a dataset gathered from a live cellular network show the benefits of this approach, in terms both of storage savings and subsequent management function improvements.

On the Capability of QoE Improvement Based on the Adjustment of RLC Parameters.

The constant evolution in mobile communications networks have led operators to seek new techniques to optimize their mobile networks with the objective of satisfying the expectations of the users. In this way, traditional optimization techniques based on improving radio indicators, have given way to new techniques based on improving the quality of experience (QoE) perceived by users. This paper is focused on analyzing the impact of the adjustment of radio link control (RLC) layer configuration parameters on the QoE perceived by the users of two different types of services. Firstly, an evaluation of the QoE experienced by the user of a real-time video streaming service with respect to the transmission buffer size of the RLC layer in unacknowledged mode (UM) has been carried out. Secondly, the QoE perceived by the user of a file transfer service in relation to the variation of the configuration parameters of the RLC layer in acknowledged mode (AM) has been evaluated. The study, which has been carried out in a simulated cellular environment, has been performed for different system bandwidth values, thus proving the relationship between the QoE perceived by the users, the optimal RLC configuration parameters values and the available bandwidth.

Online Anomaly Detection System for Mobile Networks.

The arrival of the fifth generation (5G) standard has further accelerated the need for operators to improve the network capacity. With this purpose, mobile network topologies with smaller cells are currently being deployed to increase the frequency reuse. In this way, the number of nodes that collect performance data is being further risen, so the number of metrics to be managed and analyzed is being highly increased. Therefore, it is fundamental to have tools that automatically inform the network operator of the relevant information within the vast amount of metrics collected. The continuous monitoring of the performance indicators and the automatic detection of anomalies is especially important for network operators to prevent the network degradation and user complaints. Therefore, this paper proposes a methodology to detect and track anomalies in the mobile networks performance indicators online, i.e., in real time. The feasibility of this system was evaluated with several performance metrics and a real LTE Advanced dataset. In addition, it was also compared with the performances of other state-of-the-art anomaly detection systems.

The impact of a combinatorial digital and organisational intervention on the management of long-term conditions in UK primary care: a non-randomised evaluation.

BACKGROUND: Better management of long-term conditions remains a policy priority, with a focus on improving outcomes and reducing use of expensive hospital services. A number of interventions have been tested, but many have failed to show benefit in rigorous comparative research. In 2016, the NHS Test Beds scheme was launched to implement and test interventions combining digital technologies and pathway redesign in routine health care settings, with each intervention comprising multiple innovations to better realise benefit from their 'combinatorial' effect. We present the evaluation of one of the NHS Test Beds, which combined risk stratification algorithms, practice-based quality improvement and health monitoring and coaching to improve management of long-term conditions in a single health economy in the north-west of England. METHODS: The NHS Test Bed was implemented in one clinical commissioning group in the north-west of England (patient population 235,800 served by 36 general practices). Routine administrative data on hospital use (the primary outcome) and a selection of secondary outcomes (data from both hospital and primary care) were collected in the intervention site, and from a comparator area in the same region. We used difference-in-differences analysis to compare outcomes in the NHS Test Bed area and the comparator after initiation of the combinatorial intervention. RESULTS: Tests confirmed the existence of parallel trends in the intervention and comparator sites for hospital outcomes for the period April 2016 to March 2017, and for some of the planned primary care outcomes. Based on 10 months of post-intervention secondary care data and 13 months post-intervention primary care data, we found no significant impact on primary outcomes between the intervention and comparator site, and a significant impact on only one secondary outcome. CONCLUSION: A combinatorial digital and organisational intervention to improve the management of long-term conditions was implemented across a whole health economy, but we found no evidence of a positive impact on health care utilisation outcomes in hospital and primary care.

The Campus as a Smart City: University of Málaga Environmental, Learning, and Research Approaches.

For the past few years, the concept of the Internet of Things (IoT) has been a recurrent view of the technological environment where nearly every object is expected to be connected to the network. This infrastructure will progressively allow one to monitor and efficiently manage the environment. Until recent years, the IoT applications have been constrained by the limited computational capacity and especially by efficient communications, but the emergence of new communication technologies allows us to overcome most of these issues. This situation paves the way for the fulfillment of the Smart-City concept, where the cities become a fully efficient, monitored, and managed environment able to sustain the increasing needs of its citizens and achieve environmental goals and challenges. However, many Smart-City approaches still require testing and study for their full development and adoption. To facilitate this, the university of Málaga made the commitment to investigate and innovate the concept of Smart-Campus. The goal is to transform university campuses into "small" smart cities able to support efficient management of their area as well as innovative educational and research activities, which would be key factors to the proper development of the smart-cities of the future. This paper presents the University of Málaga long-term commitment to the development of its Smart-Campus in the fields of its infrastructure, management, research support, and learning activities. In this way, the adopted IoT and telecommunication architecture is presented, detailing the schemes and initiatives defined for its use in learning activities. This approach is then assessed, establishing the principles for its general application.

[The effect of Seguro Popular de Salud on catastrophic and impoverishing expenditures in Mexico, 2004-2012]. / Efecto del Seguro Popular de Salud sobre los gastos catastróficos y empobrecedores en México, 2004-2012.

OBJECTIVE: To determine the impact of Seguro Popular (SPS) on catastrophic and impoverishing household expenditures and on the financial protection of the Mexican health system. MATERIAL AND METHODS: The propensity score matching (PSM) method was applied to the population affiliated to SPS to determine the program's attributable effect on health expenditure. This analysis uses the National Household Income and Expenditure Survey (ENIGH) during 2004-2012, conducted by Mexico's National Institute of Statistics andGeography (INEGI). RESULTS: It was found that SPS has a significant effect on reducing the likelihood that households will incur impoverishing expenditures. A negative effect on catastrophic expenditures was also found, but it was not statistically significant. CONCLUSIONS: This paper shows the effect that SPS, in particular health insurance, has as an instrument of financial protection. Future studies using longer periods of ENIGH data should analyze the persistence of high out-of-pocket expenditure.

OBJETIVO: Determinar el impacto del Seguro Popular (SPS) en los gastos catastróficos y empobrecedores de los hogares y la protección financiera del sistema de salud en México. MATERIAL Y MÉTODOS: Se aplicó el método de pareo por puntaje de propensión sobre la afiliación al SPS y se determinó el efecto atribuible en el gasto en salud. Se hizo uso de la Encuesta Nacional de Ingresos y Gastos de los Hogares (ENIGH) de 2004 a 2012, del Instituto Nacional de Estadística y Geografía. RESULTADOS: El SPS tiene un efecto significativo reductor en la probabilidad de sufrir gastos empobrecedores. En lo que respecta a los gastos catastróficos hubo reducción sin ser significativa entre grupos. CONCLUSIONES: Este estudio demuestra el efecto que el SPS, y en particular el aseguramiento en salud, tiene como un instrumento de protección financiera. Para futuros estudios se propone analizar la persistencia del alto porcentaje del gasto de bolsillo aprovechando series de tiempo más largas de la ENIGH.

Measuring the burden of preventable diabetic hospitalisations in the Mexican Institute of Social Security (IMSS).

BACKGROUND: The prevalence of diabetes among adults in Mexico has increased markedly from 6.7 % in 1994 to 14.7 % in 2015. Although the main diabetic complications can be prevented or delayed with timely and effective primary care, a high percentage of diabetic patients have developed them imposing an important preventable burden on Mexican society and on the health system. This paper estimates the financial and health burden caused by potentially preventable hospitalisations due to diabetic complications in hospitals operated by the largest social security institution in Latin America, the Mexican Institute of Social Security (IMSS), in the period 2007-2014. METHODS: Hospitalisations in IMSS hospitals whose main cause was a diabetic complication were identified. The financial burden was estimated using IMSS diagnostic-related groups. To estimate the health burden, DALYs were computed under the assumption that patients would not have experienced complications if they had received timely and effective primary care. RESULTS: A total of 322,977 hospitalisations due to five diabetic complications were identified during the period studied, of which hospitalisations due to kidney failure and diabetic foot represent 78 %. The financial burden increased by 8.4 % in real terms between 2007 and 2014. However, when measured as cost per IMSS affiliate, it decreased by 11.3 %. The health burden had an overall decrease of 13.6 % and the associated DALYs in 2014 reached 103,688. CONCLUSIONS: Resources used for the hospital treatment of diabetic complications are then not available for other health care interventions. In order to prevent these hospitalisations more resources might need to be invested in primary care; the first step could be to consider the financial burden of these hospitalisations as a potential target for switching resources from hospital care to primary care services. However, more evidence of the effectiveness of different primary care interventions is needed to know how much of the burden could be prevented by better primary care.

The financial and health burden of diabetic ambulatory care sensitive hospitalisations in Mexico.

OBJECTIVE: To estimate the financial and health burden of diabetic ambulatory care sensitive hospitalisations (ACSH) in Mexico during 2001-2011. MATERIALS AND METHODS: We identified ACSH due to diabetic complications in general hospitals run by local health ministries and estimated their financial cost using diagnostic related groups. The health burden estimation assumes that patients would not have experienced complications if they had received appropriate primary care and computes the associated Disability-Adjusted Life Years (DALYs). RESULTS: The financial cost of diabetic ACSH increased by 125% in real terms and their health burden in 2010 accounted for 4.2% of total DALYs associated with diabetes in Mexico. CONCLUSION: Avoiding preventable hospitalisations could free resources within the health system for other health purposes. In addition, patients with ACSH suffer preventable losses of health that should be considered when assessing the performance of any primary care intervention.