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A primer on how to analyze contracts and avoid the traps.

Contracts from preferred provider organizations, health maintenance organizations, independent practice associations, and managed health plans present numerous problems for primary care physicians. The ability to understand the terms and conditions is an essential part of the practice of medicine today. Additionally, physicians need to involve experts in the preparation of counterproposals that will render contracts fair and equitable for physicians. The blind acceptance of a contract may dramatically increase a physician's liability exposure. Although contracts have become a permanent fixture in the current health care delivery environment, physicians can formulate informed and intelligent responses. They and their office personnel can learn basic analysis techniques of such documents that will aid in surviving the onslaught of contracts.

Contract Services↗

Decision making in rehabilitative audiology.

With the emphasis on quality assurance and patient satisfaction in health care, decision making in rehabilitative audiology is a critical issue. Traditionally, rehabilitative decisions have been based on questionable assessment procedures and unproven treatment methods. In this paper, current strategies for decision making with hearing-impaired adults will be presented. Discussion will focus on nonacoustic factors influencing hearing aid fitting, the decision processes necessary for management of the hearing-impaired adult, and expanded uses of self-assessment inventories of hearing handicap.

Aged↗

Turning gap acceptance decision-making: the impact of driver distraction.

PROBLEM: A number of studies have found that use of in-car phones by drivers can interfere with the cognitive processing necessary for making appropriate and timely vehicle control decisions. However, the specific linkage between communication-based distraction and unsafe decision-making has not been sufficiently explored. METHOD: In a closed-course driving experiment, 39 subjects were exposed to approximately 100 gaps each in a circulating traffic stream of eight vehicles on an instrumented test track that was wet about half the time. The subjects were at the controls of an instrumented car, which was oriented in a typical left-turn configuration (traffic-crossing situation in North America) and with parking brake on and the transmission in neutral. The subjects were instructed to press on the accelerator pedal when they felt that a gap was safe to accept. Their performances were monitored and incentives were provided for balancing safe decision-making with expeditious completion of the task. For half of the gap exposures (randomly assigned), each subject was required to listen and respond to a complex verbal message. RESULTS: When not distracted, the subjects' gap acceptance judgment was found to be significantly influenced by their age, the gap size, the speed of the trailing vehicle, the level of "indecision," and the condition of the track surface. However, when distracted, the subjects did not factor pavement surface condition into the decision process. On wet pavement, the subjects were judged to have initiated twice the level of potential collisions when distracted by the messages that they did when not distracted. DISCUSSION: Listening/responding to verbal messages may reduce the capacity of drivers to process adequately all the important information necessary for safe decision-making. The effects of the messages in our study seemed to cause the subjects to misjudge gap size and speed information when operating under the additional disadvantage of adverse pavement condition. SUMMARY: Attention to complex messages while making decisions about turning through gaps in an on-coming vehicle stream was associated with significantly increased unsafe decision making by subjects in our experiment when the additional complexity of wet surface condition was introduced. IMPACT ON INDUSTRY: While the results reflected a somewhat artificial situation where the measure was signaled intention to act rather than the act itself, nevertheless, they do strongly suggest a scenario in which mental distraction could contribute to crash risk. With the rapid proliferation of telematics in the vehicle market, even with the laudable objectives represented by the Intelligent Transportation Systems initiative, there is a danger of the primary task of the driver being subordinated to a perceived need to enhance information flow to/from the external "world." Industry and governments need to work together to ensure that apparently desirable in-vehicle communication improvements do not compromise safety.

Accidents, Traffic↗

Automated extraction, labelling and analysis of the coronary vasculature from arteriograms.

For clinical decision-making and documentation purposes we have developed techniques to extract, label and analyze the coronary vasculature from arteriograms in an automated, quantitative manner. Advanced image processing techniques were applied to extract and analyze the vasculatures from non-subtracted arteriograms while artificial intelligence techniques were employed to assign anatomical labels. Lumen diameters of 11 phantom vessels were assessed with an accuracy of 0.27 +/- 0.19 mm (dtrue = 0.45 + 0.92dmeasured; r > 0.99) and 0.21 +/- 0.15 mm (dtrue = 0.42 + 0.91dmeasured; r > 0.99), from cine and digital images, respectively. We collected a total of 15 routinely acquired cine-arteriograms showing 74 vessel segments with 18 stenoses (severity larger than 30% assessed quantitatively), and 53 digital arteriograms showing 236 vessel segments with 69 stenoses. From the cine arteriograms we extracted 64 (86%) of the vessel segments without manual correction and 196 (83%) from the digital arteriograms. Repeated analysis (3 times) of the arteriograms by the same operator resulted in a standard deviation of the mean segment diameters (precision) of 0.064 mm for the cine-images and 0.020 mm for the digital images, while the standard deviations in the measurement of the minimal luminal diameter of the observed stenoses were 0.020 mm and 0.019 mm, respectively. The LAD artery, the septal and diagonal branches were correctly identified automatically in 86% of the segments. From these evaluations we conclude that our automated approach provides reliable tools for the assessment of multi-vessel disease, both in an off- and on-line environment.

Cineangiography↗

Timing of operation for ruptured cerebral aneurysm and long-term recovery of cognitive functions.

Advantage and disadvantages of early and late operation for ruptured cerebral aneurysm are controversially evaluated with regard to peri-operative operation outcome and long-term cognitive recovery. In this retrospective analysis 22 patients with early surgery (ES) within three days after subarachnoid haemorrhage (SAH) and 22 patients with late surgery (LS) at least 14 days after SAH were studied. Patients were pair-wise matched by degree of SAH localisation of aneurysm and age at SAH. On average three years after SAH both groups were examined individually with a comprehensive neuropsychological test battery including tests of premorbid intelligence, concept formation, memory, visuomotor speed, aphasia screening, and mood. ES and LS patients were well comparable in terms of years of education and level of premorbid intelligence. There was a clear influence of patients age on fluid intelligence tests, indicating a general change-sensitivity of tests. No influence of degree of SAH and localisation of aneurysm could be detected. There were also no differences between ES and LS patients in neuropsychological tests sensitive to brain damage, suggesting that the decision for early or late surgery for ruptured cerebral aneurysm can be based upon surgical reasons at the time of the SAH.

Adult↗

The neurological complications of achondroplasia.

The genetics of achondroplasia are discussed, and then the clinical features. The respiratory complications are only considered when related to the neurological ones which are the concern of this paper; and their effects on morbidity and mortality. Cervicomedullary compression can cause pain, ataxia, incontinence, apnea, and respiratory arrest. One of the signs can be progressive quadriparesis which can be a presenting symptom; and may be caused by a vascular lesion as well as by cord compression. Also nerve root compression in the neural foramina can cause symptoms and signs in the limbs. Enlargement of the head is a feature of achondroplasia. This may be due to subdural haematoma related to the wide subarachnoid spaces, and to trauma. Hydrocephalus is common, and may be non-communicating and due to aqueduct stenosis, but is much more often communicating and the result of raised intracranial venous pressure. Shunting may be necessary, but surgery directed towards relieving the venous pressure may be more logical. Otitis media often affects these children, and can cause deafness and subsequently delayed language development. Sleep disturbances can be the result of both neurological and respiratory complications. Apart from the treatment for hydrocephalus the most important decision is often the question of operating on the cervical medullary compression. Risk factors such as brisk reflexes, small foramen magnum, and central hypopnea, can be an indication for surgery; but timing can be difficult as the cord compression can resolve spontaneously. The intelligence levels of these children are usually normal, and studies have shown a surprisingly high level of satisfaction with the services provided.

Achondroplasia↗

Variables related to the decision of young adults with learning disabilities to participate in postsecondary education.

This article examines the relationship between specific factors and the decision to participate in postsecondary education by young adults with learning disabilities. Data concerning 539 subjects with learning disabilities were included in this study. T test and chi square indicated that involvement in extracurricular activities while in high school, use of community resources, intelligence quotient, and reading and mathematics grade equivalent scores were important factors that differentiated between subjects choosing to participate or not to participate in postsecondary education during the year after high school. Implications and recommendations for secondary school curriculum are discussed.

Adaptation, Psychological↗

Evolutionary origins of leadership and followership.

Drawing upon evolutionary logic, leadership is reconceptualized in terms of the outcome of strategic interactions among individuals who are following different, yet complementary, decision rules to solve recurrent coordination problems. This article uses the vast psychological literature on leadership as a database to test several evolutionary hypotheses about the origins of leadership and followership in humans. As expected, leadership correlates with initiative taking, trait measures of intelligence, specific task competencies, and several indicators of generosity. The review finds no link between leadership and dominance. The evolutionary analysis accounts for reliable age, health, and sex differences in leadership emergence. In general, evolutionary theory provides a useful, integrative framework for studying leader-follower relationships and generates various novel research hypotheses.

Biological Evolution↗

Hierarchical morphological design of immunoassay technology.

The paper describes a hierarchical design approach to an immunoassay. A morphology for an immunoassay technology is considered as a basis to generate system versions. A 5-stage technology is analyzed. The problem is: Find the best composite version for each stage while taking into account requirements (criteria) at each stage and compatibility between selected design alternatives at different stages. Hierarchical solving procedure consists of two parts: (a) multicriteria ranking of alternative versions at each stage (e.g., selection of Pareto-effective local decisions), (b) composition of the selected versions into a parallel-series composite system (technology). A realistic numerical example illustrates the approach.

Artificial Intelligence↗

Machine learning in prognosis of the femoral neck fracture recovery.

We compare the performance of several machine learning algorithms in the problem of prognostics of the femoral neck fracture recovery: the K-nearest neighbours algorithm, the semi-naive Bayesian classifier, backpropagation with weight elimination learning of the multilayered neural networks, the LFC (lookahead feature construction) algorithm, and the Assistant-I and Assistant-R algorithms for top down induction of decision trees using information gain and RELIEFF as search heuristics, respectively. We compare the prognostic accuracy and the explanation ability of different classifiers. Among the different algorithms the semi-naive Bayesian classifier and Assistant-R seem to be the most appropriate. We analyze the combination of decisions of several classifiers for solving prediction problems and show that the combined classifier improves both performance and the explanation ability.

Algorithms↗

String matching artificial neural networks.

Three artificial neural networks (ANNs) are proposed for solving a variety of on- and off-line string matching problems. The ANN structure employed as the building block of these ANNs is derived from the harmony theory (HT) ANN, whereby the resulting string matching ANNs are characterized by fast match-mismatch decisions, low computational complexity, and activation values of the ANN output nodes that can be used as indicators of substitution, insertion (addition) and deletion spelling errors.

Artificial Intelligence↗

A data-mining approach to spacer oligonucleotide typing of Mycobacterium tuberculosis.

MOTIVATION: The Direct Repeat (DR) locus of Mycobacterium tuberculosis is a suitable model to study (i) molecular epidemiology and (ii) the evolutionary genetics of tuberculosis. This is achieved by a DNA analysis technique (genotyping), called sp acer oligo nucleotide typing (spoligotyping ). In this paper, we investigated data analysis methods to discover intelligible knowledge rules from spoligotyping, that has not yet been applied on such representation. This processing was achieved by applying the C4.5 induction algorithm and knowledge rules were produced. Finally, a Prototype Selection (PS) procedure was applied to eliminate noisy data. This both simplified decision rules, as well as the number of spacers to be tested to solve classification tasks. In the second part of this paper, the contribution of 25 new additional spacers and the knowledge rules inferred were studied from a machine learning point of view. From a statistical point of view, the correlations between spacers were analyzed and suggested that both negative and positive ones may be related to potential structural constraints within the DR locus that may shape its evolution directly or indirectly. RESULTS: By generating knowledge rules induced from decision trees, it was shown that not only the expert knowledge may be modeled but also improved and simplified to solve automatic classification tasks on unknown patterns. A practical consequence of this study may be a simplification of the spoligotyping technique, resulting in a reduction of the experimental constraints and an increase in the number of samples processed.

Algorithms↗

Cognitive screening for silent cerebral infarction in children with sickle cell disease.

Silent cerebral infarctions have been shown to cause major morbidity in children with sickle cell disease, suggesting that silent infarctions are not as "silent" as once thought. The current definition of silent infarction includes signal changes on magnetic resonance imaging, the absence of overt abnormalities on neurologic examination, and no history of focal neurologic event. Using a decision tree algorithm, we identified a cognitive profile distinguishing children with (n=16) and without (n=49) silent infarctions. The best model combined learning slope from the California Verbal Learning Test-Children's Version and Block Design from the Wechsler Abbreviated Scale of Intelligence. Accuracy was 75%, with 75% sensitivity and 76% specificity. Administration of a brief cognitive battery may be the most feasible approach to screen for silent infarctions in children with sickle cell disease.

Adolescent↗

5-fluorouracil alone versus 5-fluorouracil plus folinic acid in the treatment of colorectal carcinoma: meta-analysis.

OBJECTIVE: Innovative techniques in the field of artificial intelligence could help to resolve several methodological problems. A model taking into account all the parameters involved in a therapy can foresee the results of each type of treatment or therapeutic protocol on patients at different stages of a disease. We used a Computer Decision Support System in order to verify the reliability and efficacy of this method on chemotherapy of colorectal carcinoma. MATERIAL AND METHODS: We analyzed 8 randomized clinical trials employing 5-fluorouracil alone (5-FU) or 5-fluorouracil (5-FU) plus leucovorin (FA) in the management of advanced colorectal carcinoma. Computer Decision Support System (CDSS) was used to perform four basic tasks: data acquisition and organization; data recruitment; combination of the various principles and specific data; user-friendly display of the analysis results and responses to treatment. RESULTS: In the majority of the studies examined, the death rates were lower in patients treated with 5-FU + FA than in those on 5-FU alone, even though the difference was not statistically significant. However, there were wide fluctuations in the efficacy/tolerability ratio between the two protocols investigated, depending on the patients' clinical status. Our data showed that a strong attack using 5-FU + FA is feasible whenever the patients' clinical conditions are not particularly severe, whereas a moderate attack using 5-FU alone is recommended as the patients' clinical condition worsens. CONCLUSION: The use of CDSS in the management of colorectal carcinoma indicates which therapy is the best in terms of efficacy, overall survival and incidence of side effects.

Antimetabolites, Antineoplastic↗

Clinical course of cognitive dysfunction in systemic lupus erythematosus.

OBJECTIVE: To prospectively evaluate changes in cognitive function in a cohort of unselected patients with systemic lupus erythematosus (SLE) and controls over a 12 month period. METHODS: Seventy female patients with SLE, 25 patients with rheumatoid arthritis (RA) and 23 healthy subjects (age and sex matched) were evaluated using the Wechsler Adult Intelligence Scale-Revised (WAIS-R), the Wechsler Memory Scale-Revised (WMS-R), the California Verbal Learning Test (CVLT) and the National Adult Reading Test-Revised to identify impairment in 8 areas of cognitive function. Cumulative disease manifestations and current medications were documented, and disease activity was expressed using the SLE disease activity index (SLEDAI). Decision rules were determined for overall cognitive impairment. RESULTS: At baseline, 21% (15/70) of patients with SLE were impaired compared to 4% (1/25) of patients with RA and 4% (1/23) of healthy subjects (p = 0.042). After a mean interval of 12.8 months (range: 11-17) 84% (59/70) of patients with SLE, 44% (11/25) of patients with RA and 80% (17/23) of healthy subjects were reassessed. This included all subjects who were impaired at the initial assessment. Using the same decision rules as at baseline, 12% (7/59) of patients with SLE were impaired at followup compared to none of the patients with RA and healthy subjects. Over the period of study cognitive impairment persisted in 3 patients with SLE, resolved in 12 and evolved in 4 others. There was no apparent association between changes in cognitive function and concurrent changes in generalized disease activity, overt neuropsychiatric disease or corticosteroid medication. CONCLUSION: Our results suggest that cognitive dysfunction in patients with SLE is evanescent, does not necessarily lead to irreversible neurologic compromise and changes independently of other clinical variables.

Adult↗

Pattern analysis of serum proteome distinguishes renal cell carcinoma from other urologic diseases and healthy persons.

Despite having a relatively low incidence, renal cell carcinoma (RCC) is one of the most lethal urologic cancers. For successful treatment including surgery, early detection is essential. Currently there is no screening method such as biomarker assays for early diagnosis of RCC. Surface-enhanced laser desorption/ionization-time of flight mass spectrometry (SELDI-TOF) is a recent technical advance that can be used to identify biomarkers for cancers. In this study, we investigated whether SELDI protein profiling and artificial intelligence analysis of serum could distinguish RCC from healthy persons and other urologic diseases (nonRCC). The SELDI-TOF data was acquired from a total of 36 serum samples with weak cation exchange-2 protein chip arrays and filtered using ProteinChip software. We used a decision tree algorithm c4.5 to classify the three groups of sera. Five proteins were identified with masses of 3900, 4107, 4153, 5352, and 5987 Da. These biomarkers can correctly separate RCC from healthy and nonRCC samples.

Biomarkers, Tumor↗

Impact of missing data in evaluating artificial neural networks trained on complete data.

This study investigated the impact of missing data in the evaluation of artificial neural network (ANN) models trained on complete data for the task of predicting whether breast lesions are benign or malignant from their mammographic Breast Imaging and Reporting Data System (BI-RADS) descriptors. A feed-forward, back-propagation ANN was tested with three methods for estimating the missing values. Similar results were achieved with a constraint satisfaction ANN, which can accommodate missing values without a separate estimation step. This empirical study highlights the need for additional research on developing robust clinical decision support systems for realistic environments in which key information may be unknown or inaccessible.

Area Under Curve↗