Methods of Information in Medicine Methods of Information in Medicine mim de-de Thu, 23 Feb 17 05:47:26 +0100 Ahead of print: Increasing the Efficiency on Producing Radiology Reports for Breast Cancer Diagnosis... Background: Radiology reports are commonly written on free-text using voice recognition devices. Structured reports (SR) have a high potential but they are usually considered more difficult to fill-in so their adoption in clinical practice leads to a lower efficiency. However, some studies have demonstrated that in some cases, producing SRs may require shorter time than plain-text ones. This work focuses on the definition and demonstration of a methodology to evaluate the productivity of software tools for producing radiology reports. A set of SRs for breast cancer diagnosis based on BI-RADS have been developed using this method. An analysis of their efficiency with respect to free-text reports has been performed. Material and Methods: The methodology proposed compares the Elapsed Time (ET) on a set of radiological reports. Free-text reports are produced with the speech recognition devices used in the clinical practice. Structured reports are generated using a web application generated with TRENCADIS framework. A team of six radiologists with three different levels of experience in the breast cancer diagnosis was recruited. These radiologists performed the evaluation, each one introducing 50 reports for mammography, 50 for ultrasound scan and 50 for MRI using both approaches. Also, the Relative Efficiency (REF) was computed for each report, dividing the ET of both methods. We applied the T-Student (T-S) test to compare the ETs and the ANOVA test to compare the REFs. Both tests were computed using the SPSS software. Results: The study produced three DICOM-SR templates for Breast Cancer Diagnosis on mammography, ultrasound and MRI, using RADLEX terms based on BIRADs 5th edition. The T-S test on radiologists with high or intermediate profile, showed that the difference between the ET was only statistically significant for mammography and ultrasound. The ANOVA test performed grouping the REF by modalities, indicated that there were no significant differences between mammograms and ultrasound scans, but both have significant statistical differences with MRI. The ANOVA test of the REF for each modality, indicated that there were only significant differences in Mammography (ANOVA p = 0.024) and Ultrasound (ANOVA p = 0.008). The ANOVA test for each radiologist profile, indicated that there were significant differences on the high profile (ANOVA p = 0.028) and medium (ANOVA p = 0.045). Conclusions: In this work, we have defined and demonstrated a methodology to evaluate the productivity of software tools for producing radiology reports in Breast Cancer. We have evaluated that adopting Structured Reporting in mammography and ultrasound studies in breast cancer diagnosis improves the performance in producing reports.... J. D. Segrelles (1), R. Medina (2), I. Blanquer (1, 3), L. Martí-Bonmatí (3, 4) 27208 2017-02-21 13:45:09 Ahead of print: Evaluation Results of an Ontology-based Design Model of Virtual Environments for... Objectives: 1) To enhance the content of an ontology for designing virtual environments (VEs) for upper limb motor rehabilitation of stroke patients according to the suggestions and comments of rehabilitation specialists and software developers, 2) to characterize the perceived importance level of the ontology, 3) to determine the perceived usefulness of the ontology, and 4) to identify the safety characteristics of the ontology for VEs design according to the rehabilitation specialists. Methods: Using two semi-structured Web questionnaires, we asked six rehabilitation specialists and six software developers to provide us with their perception regarding the level of importance and the usability of the ontology. From their responses we have identified themes related to perceived and required safety characteristics of the ontology. Results: Significant differences in the importance level were obtained for the Stroke Disability, VE Configuration, Outcome Measures, and Safety Calibration classes, which were perceived as highly important by rehabilitation specialists. Regarding usability, the ontology was perceived by both groups with high usefulness, ease of use, learnability and intention of use. Concerning the thematic analysis of recommendations, eight topics for safety characteristics of the ontology were identified: adjustment of therapy strategies; selection and delimitation of movements; selection and proper calibration of the interaction device; proper selection of measuring instruments; gradual modification of the difficulty of the exercise; adaptability and variability of therapy exercises; feedback according to the capabilities of the patient; and real-time support for exercise training. Conclusions: The rehabilitation specialists and software developers confirmed the importance of the information contained in the ontology regarding motor rehabilitation of the upper limb. Their recommendations highlight the safety features and the advantages of the ontology as a guide for the effective design of VEs.... C. Ramírez-Fernández (1, 2), A. L. Morán (1), E. García-Canseco (1), J. R. Gómez-Montalvo (3) 27207 2017-02-21 13:44:02 Ahead of print: Genetic Testing for Autism Spectrum Disorder is Lacking Evidence of... Background: Autism Spectrum Disorder (ASD) is a highly heritable neural development disorder characterized by social impairment. The earlier the diagnosis is made, the higher are the chances of obtaining relief of symptoms. A very early diagnosis uses molecular genetic tests, which are also offered commercially. Objective: Systematic review of the economic impact of genetic tests in ASD. Methods: We performed a systematic search of databases Pubmed, Medline, Cochrane, Econlit and the NHS Center for Reviews and Dissemination for articles in English and German from January 1, 2000 to December 31, 2015. Original articles published in peer-reviewed journals were screened in a two-step process. First, we focused our search on economic evaluations of genetic tests for ASD. Second, we searched for any economic evaluation (EE) of genetic tests. Results: We identified 185 EE of genetic tests for various diseases. However, not a single EE of genetic tests has been found for ASD. The outcomes used in the EE of the genetic tests were heterogeneous, and results were generally not comparable. Conclusion: There is no evidence for cost-effectiveness of any genetic diagnostic test for ASD, although such genetic tests are available commercially. Cost-effectiveness analyses for genetic diagnostic tests for ASD are urgently required. There is a clear lack in research for EE of genetic tests.... A. Ziegler (1, 2, 3), W. Rudolph-Rothfeld (1), R. Vonthein (1, 2) 27206 2017-02-21 13:41:28 Ahead of print: MaLT – Combined Motor and Language Therapy tool for Brain Injury Patients using... Background: The functional connectivity and structural proximity of elements of the language and motor systems result in frequent co-morbidity post brain injury. Although rehabilitation services are becoming increasingly multidisciplinary and “integrated”, treatment for language and motor functions often occurs in isolation. Thus, behavioural therapies which promote neural reorganisation do not reflect the high intersystem connectivity of the neurologically intact brain. As such, there is a pressing need for rehabilitation tools which better reflect and target the impaired cognitive networks. Objectives: The objective of this research is to develop a combined high dosage therapy tool for language and motor rehabilitation. The rehabilitation therapy tool developed, MaLT (Motor and Language Therapy), comprises a suite of computer games targeting both language and motor therapy that use the Kinect sensor as an interaction device. The games developed are intended for use in the home environment over prolonged periods of time. In order to track patients’ engagement with the games and their rehabilitation progress, the game records patient performance data for the therapist to interrogate. Methods: MaLT incorporates Kinect-based games, a database of objects and language parameters, and a reporting tool for therapists. Games have been developed that target four major language therapy tasks involving single word comprehension, initial phoneme identification, rhyme identification and a naming task. These tasks have 8 levels each increasing in difficulty. A database of 750 objects is used to programmatically generate appropriate questions for the game, providing both targeted therapy and unique gameplay every time. The design of the games has been informed by therapists and by discussions with a Public Patient Involvement (PPI) group. Results: Pilot MaLT trials have been conducted with three stroke survivors for the duration of 6 to 8 weeks. Patients’ performance is monitored through MaLT’s reporting facility presented as graphs plotted from patient game data. Performance indicators include reaction time, accuracy, number of incorrect responses and hand use. The resultant games have also been tested by the PPI with a positive response and further suggestions for future modifications made. Conclusion: MaLT provides a tool that innovatively combines motor and language therapy for high dosage rehabilitation in the home. It has demonstrated that motion sensor technology can be successfully combined with a language therapy task to target both upper limb and linguistic impairment in patients following brain injury. The initial studies on stroke survivors have demonstrated that the combined therapy approach is viable and the outputs of this study will inform planned larger scale future trials.... M. Wairagkar (1), R. McCrindle (1), H. Robson (2), L. Meteyard (2), M. Sperrin (3), A. Smith (4), M. Pugh (5) 27205 2017-02-21 13:40:21 Open Access: Discussion of “Representation of People’s Decisions in Health Information Systems: A... This article is part of a For-Discussion-Section of Methods of Information in Medicine about the paper “Representation of People’s Decisions in Health Information Systems: A Complementary Approach for Understanding Health Care Systems and Population Health” written by Fernan Gonzalez Bernaldo de Quiros, Adriana Ruth Dawidowski, and Silvana Figar. It is introduced by an editorial. This article contains the combined commentaries invited to independently comment on the paper of de Quiros, Dawidowski, and Figar. In subsequent issues the discussion can continue through letters to the editor. N. Al-Shorbaji (1), E. M. Borycki (2), M. Kimura (3), C. U. Lehmann (4), N. M. Lorenzi (4), L. A. Moura (5), A. Winter (6) 27118 2017-02-01 09:57:03 Open Access: Representation of People‘s Decisions in Health Information Systems Objectives: In this study, we aimed: 1) to conceptualize the theoretical challenges facing health information systems (HIS) to represent patients' decisions about health and medical treatments in everyday life; 2) to suggest approaches for modeling these processes. Methods: The conceptualization of the theoretical and methodological challenges was discussed in 2015 during a series of interdisciplinary meetings attended by health informatics staff, epidemiologists and health professionals working in quality management and primary and secondary prevention of chronic diseases of the Hospital Italiano de Buenos Aires, together with sociologists, anthropologists and e-health stakeholders. Results: HIS are facing the need and challenge to represent social human processes based on constructivist and complexity theories, which are the current frameworks of human sciences for understanding human learning and socio-cultural changes. Computer systems based on these theories can model processes of social construction of concrete and subjective entities and the interrelationships between them. These theories could be implemented, among other ways, through the mapping of health assets, analysis of social impact through community trials and modeling of complexity with system simulation tools. Conclusions: This analysis suggested the need to complement the traditional linear causal explanations of disease onset (and treatments) that are the bases for models of analysis of HIS with constructivist and complexity frameworks. Both may enlighten the complex interrelationships among patients, health services and the health system. The aim of this strategy is to clarify people's decision making processes to improve the efficiency, quality and equity of the health services and the health system.... F. Gonzalez Bernaldo de Quiros (1), A. R. Dawidowski (2), S. Figar (2) 27117 2017-02-01 09:52:15 Open Access: Health Information Systems Supporting Health and Resiliency Through Improved... D. Ring (1), W. M. Tierney (2) 27116 2017-02-01 09:45:27 Open Access: Research Strategies for Biomedical and Health Informatics Background: Medical informatics, or biomedical and health informatics (BMHI), has become an established scientific discipline. In all such disciplines there is a certain inertia to persist in focusing on well-established research areas and to hold on to well-known research methodologies rather than adopting new ones, which may be more appropriate. Objectives: To search for answers to the following questions: What are research fields in informatics, which are not being currently adequately addressed, and which methodological approaches might be insufficiently used? Do we know about reasons? What could be consequences of change for research and for education? Methods: Outstanding informatics scientists were invited to three panel sessions on this topic in leading international conferences (MIE 2015, Medinfo 2015, HEC 2016) in order to get their answers to these questions. Results: A variety of themes emerged in the set of answers provided by the panellists. Some panellists took the theoretical foundations of the field for granted, while several questioned whether the field was actually grounded in a strong theoretical foundation. Panellists proposed a range of suggestions for new or improved approaches, methodologies, and techniques to enhance the BMHI research agenda. Conclusions: The field of BMHI is on the one hand maturing as an academic community and intellectual endeavour. On the other hand vendor-supplied solutions may be too readily and uncritically accepted in health care practice. There is a high chance that BMHI will continue to flourish as an important discipline; its innovative interventions might then reach the original objectives of advancing science and improving health care outcomes.... R. Haux (1), C. A. Kulikowski (2), S. Bakken (3), S. de Lusignan (4), M. Kimura (5), S. Koch (6), J. Mantas (7), V. Maojo (8), M. Marschollek (1), F. Martin-Sanchez (9), A. Moen (10, 11), H.-A. Park (12), I. N. Sarkar (13), T. Y. Leong (14, 15), A. T. McCray (16) 27091 2017-01-25 08:52:27 Ahead of print: An Immersive Virtual Reality Platform to Enhance Walking Ability of Children with... Background: Acquired brain injury (ABI) may result in lifelong impairment of physical, cognitive, and psychosocial functions. Several rehabilitative treatments are often needed to support walking recovery, thus participants’ engagement becomes a crucial aspect, especially when patients are children. In the last few years, traditional physiotherapy (PT) has been flanked by innovative technologies for rehabilitation in the fields of robotics and Virtual Reality (VR). Preliminary results have shown interesting perspectives in the use of a VR system, the GRAIL (Gait Real-time Analysis Interactive Lab), in improving walking abilities in a small group of children with ABI, although further insights are needed about its use as rehabilitative tool in the pediatric population. Objectives: To evaluate the efficacy of a rehabilitation treatment on a GRAIL system for the improvement of walking abilities, in a group of children suffering from ABI. Methods: 12 children with ABI (study group – SG; mean age = 12.1 ± 3.8 years old) underwent a 10-session treatment with the GRAIL, an instrumented multi-sensor platform based on immersive VR for gait training and rehabilitation in engaging VR environments. Before (T0) and at the end of the treatment (T1), the participants were assessed by means of functional scales (Gross Motor Function Measure (GMFM), Functional Assessment Questionnaire (FAQ), 6-Minute Walk Test (6minWT) and the 3D-Gait Analysis, over ground (OGA) and on GRAIL (GGA). Results: All the participants completed the rehabilitative treatment. The functional evaluations showed an improvement in Gross Motor abilities (GMFM-88, p = 0.008), especially in standing (GMFM-D, p = 0.007) and walking (GMFM-E, p = 0.005), an increase of the endurance (6minWT, p = 0.002), and enhanced autonomy in daily life activities (FAQ, p = 0.025). OGA identified a significant decrease of the Gillette Gait Index for the impaired side and a general increase of symmetry. GGA showed improvements in spatiotemporal parameters and joints range of motion that moved towards normality and symmetry recovery. Conclusions: A 10-session treatment with GRAIL on children with ABI led to improvements in their walking abilities and enhanced their engagement during the training. This is desirable when long life impairments are faced and children’s motor functions have to be regained and it supports the leading role that VR might have in the rehabilitation field.... E. Biffi (1), E. Beretta (1), A. Cesareo (1, 2), C. Maghini (1), A. C. Turconi (1), G. Reni (1), S. Strazzer (1) 27072 2017-01-24 09:23:46 Ahead of print: Can 3D Gamified Simulations Be Valid Vocational Training Tools for Persons with... Objective: To investigate if 3D gamified simulations can be valid vocational training tools for persons with intellectual disability. Methods: A 3D gamified simulation composed by a set of training tasks for cleaning in hostelry was developed in collaboration with professionals of a real hostel and pedagogues of a special needs school. The learning objectives focus on the acquisition of vocabulary skills, work procedures, social abilities and risk prevention. Several accessibility features were developed to make the tasks easy to do from a technological point-of-view. A pilot experiment was conducted to test the pedagogical efficacy of this tool on intellectually disabled workers and students. Results: User scores in the gamified simulation follow a curve of increasing progression. When confronted with reality, they recognized the scenario and tried to reproduce what they had learned in the simulation. Finally, they were interested in the tool, they showed a strong feeling of immersion and engagement, and they reported having fun. Conclusions: On the basis of this experiment we believe that 3D gamified simulations can be efficient tools to train social and professional skills of persons with intellectual disabilities contributing thus to foster their social inclusion through work.... A. von Barnekow (1, 2), N. Bonet-Codina (1, 2), D. Tost (1, 2) 27071 2017-01-24 09:23:01 Ahead of print: Cognitive Training through mHealth for Individuals with Substance Use Disorder Background: Heroin addiction has a negative impact on cognitive functions, and even recovering addicts suffer from cognitive impairment. Recent approaches to cognitive intervention have been taking advantage of what new technologies have to offer. Objectives: We report a study testing the efficacy of a serious games approach using tablets to stimulate and rehabilitate cognitive functions in recovering addicts. Methods: A small-scale cognitive training program with serious games was run with a sample of 14 male heroin addicts undergoing a rehabilitation program. Results: We found consistent improvements in cognitive functioning between baseline and follow-up assessments for frontal lobe functions, verbal memory and sustained attention, as well as in some aspects of cognitive flexibility, decision-making and in depression levels. More than two thirds of patients in cognitive training had positive outcomes related to indicators of verbal memory cognitive flexibility, which contrasts to patients not in training, in which only one patient improved between baseline and follow-up. Conclusions: The results are promising but still require randomized control trials to determine the efficiency of this approach to cognitive rehabilitation programs for the cognitive recovery of heroin addicts.... P. Gamito (1, 2), J. Oliveira (1, 2), P. Lopes (1, 2, 3), R. Brito (1, 2), D. Morais (1, 2), C. Caçoete (3), A. Leandro (3), T. Almeida (3), H. Oliveira (3) 27070 2017-01-24 09:22:15 Ahead of print: Using Actigraphy and mHealth Systems for an Objective Analysis of Sleep Quality on... Introduction: Although sleep alterations can be an important factor contributing to the clinical state of Systemic Lupus Erythematosus, there are no studies to adequately assess sleep quality in this type of disease. Objectives: The aim of this work is to analyse the sleep quality of Systemic Lupus Erythematous (SLE) patients based on more objective information provided by actigraphy and mobile systems. The idea is to carry out a comprehensive study by analysing how environmental conditions and factors can affect sleep quality. Methods: In traditional methods the information for assessing sleep quality is obtained through questionnaires. In this work, a novel method is proposed by combining these questionnaires that provide valuable but subjective information with actigraphy and a mobile system to collect more objective information about the patient and their environment. The method provides mechanisms to detect how sleep hygiene could be associated directly with the sleep quality of the subjects, in order to provide a custom intervention to SLE patients. Moreover, this alternative provides ease of use, and non-intrusive ICT (Information and Communication Technology) through a wristband and a mHealth system. The mHealth system has been developed for environmental conditions sensing. This consists of a mobile device with built-in sensors providing input data about the bedroom environment during sleep, and a set of services of the Environmental Monitoring System for properly managing the configuration, registration and fusion of those input data. In previous studies, this information has never been taken into account. However, the information could be relevant in the case of SLE patients. The sample is composed of 9 women with SLE and 11 matched controls with a mean age of 35.78 and 32.18, respectively. Demographic and clinical variables between SLE patients and healthy controls are compared using the Fisher exact test and the Mann-Whitney U test. Relationships between psychological variables, actigraphy measures, and variables related to environmental conditions are analysed with Spearman’s rank correlation coefficient. Results: The SLE group showed poorer sleep quality, and more pain intensity, fatigue and depression than the healthy controls. Significant differences between SLE women and healthy controls in measures of actigraphy were not found. However, the fusion of the measures of the environmental conditions that were collected by the mobile system and actigraphy, has shown that light, and more specifically temperature have a direct relation with several measures of actigraphy which are related to sleep quality. It should be emphasize this result because usually the sleep problems are assessment through self-reported measures which had not revealed this association. Moreover, there are no previous studies that analyse these aspects in bedroom environments of SLE patients directly from objective measures. Conclusions: The results indicate the need to complement the subjective evaluation of sleep with objective measures. The use of actigraphy in combination with a new mHealth system provides a complete assessment especially relevant to chronic conditions as SLE. Both systems incorporate this objective information directly from objective measures in a non-intrusive way. Moreover, the measures of bedroom environmental variables provide useful and relevant clinical information to assess what is happening daily and not occasionally. This could lead to more customized interventions and adapt the treatment to each individual.... S. Balderas-Díaz (1), M. P. Martínez (2), G. Guerrero-Contreras (1), E. Miró (2), K. Benghazi (1), A. I. Sánchez (2), J. L. Garrido (1), G. Prados (3) 27069 2017-01-24 09:20:37 FIN-TIERA: A Tool for Assessing Technology Induced Errors Background: Due to the complexity of healthcare processes, the potential for Health Information Systems (HIS) to cause technology-induced errors is a growing concern. Health Information Technology (HIT) errors nearly always threaten good patient care and can lead to patient harm. Instruments to allow hospitals to proactively identify areas of Electronic Health Records (EHR) safety, to set priorities and to intervene before incidents occur are currently underdeveloped. Objectives: The aim was to design a Finnish questionnaire to measure EHR users’ perceptions of common EHR-related safety concerns in a specialized hospital district context through the lens of the theory of socio-technical dimensions. Moreover, the aim was to measure its reliability by assessing its internal consistency and validity, namely its content and construct validity. Methods: We constructed the instrument, based on the socio-technical theory and Sittig and Singh’s study findings, through a multi-stage process, and expert panels evaluated it to ensure its content validity. The final questionnaire consisted of eight error types to be assessed on a qualitative risk matrix scale. We used a cross-sectional design to test its psychometric properties. Application of the FIN-TIERA Questionnaire to a sample of 2864 clinicians in 2015 then served to evaluate the instrument’s reliability as well as its construct validity. Results: All eight multi-item scales showed high internal consistency (range α >  0.798-0.932 and CR 0.845-0.983). The average variance extracted (AVE) served to assess the confirmatory factor analysis (CFA). The results of the model fit with AGFI = .86, CFI = .898, RMSEA = .052, SRMR = .048 were deemed acceptable. For all factors, AVE yielded values > 0.5, which indicates adequate convergence and supports convergent validity. Discriminant validity was established for five out of a total of eight latent variables. Conclusions: FIN-TIERA is a new multi-dimensional instrument which may be a useful tool for assessing risk in EHR. Our testing shows its potential for use in-hospital settings: the involvement of EHR users demonstrated initial reliability and validity. Further research is recommended to assess the instrument’s psychometric properties.... S. Palojoki (1, 2), T. Pajunen (2), L. Lehtonen (2), K. Saranto (1) 26972 2016-12-06 13:28:14 Social-aware Event Handling within the FallRisk Project Objectives: With the uprise of the Internet of Things, wearables and smartphones are moving to the foreground. Ambient Assisted Living solutions are, for example, created to facilitate ageing in place. One example of such systems are fall detection systems. Currently, there exists a wide variety of fall detection systems using different methodologies and technologies. However, these systems often do not take into account the fall handling process, which starts after a fall is identified or this process only consists of sending a notification. The FallRisk system delivers an accurate analysis of incidents occurring in the home of the older adults using several sensors and smart devices. Moreover, the input from these devices can be used to create a social-aware event handling process, which leads to assisting the older adult as soon as possible and in the best possible way. Methods: The FallRisk system consists of several components, located in different places. When an incident is identified by the FallRisk system, the event handling process will be followed to assess the fall incident and select the most appropriate caregiver, based on the input of the smartphones of the caregivers. In this process, availability and location are automatically taken into account. Results: The event handling process was evaluated during a decision tree workshop to verify if the current day practices reflect the requirements of all the stakeholders. Other knowledge, which is uncovered during this workshop can be taken into account to further improve the process. Conclusions: The FallRisk offers a way to detect fall incidents in an accurate way and uses context information to assign the incident to the most appropriate caregiver. This way, the consequences of the fall are minimized and help is at location as fast as possible. It could be concluded that the current guidelines on fall handling reflect the needs of the stakeholders. However, current technology evolutions, such as the uptake of wearables and smartphones, enables the improvement of these guidelines, such as the automatic ordering of the caregivers based on their location and availability.... F. De Backere (1), J. Van den Bergh (2), S. Coppers (2), S. Elprama (3), J. Nelis (1), S. Verstichel (1), A. Jacobs (3), K. Coninx (2), F. Ongenae (1), F. De Turck (1) 26971 2016-12-06 13:26:53 Detecting Anxiety States when Caring for People with Dementia Background: Caregiving is a complex, stressful activity, which frequently leads to anxiety and the development of depressive disorders. Recent advances in wearable sensing allows to monitor relevant physiological data of the caregiver for detecting anxiety spans and for enacting coping strategies to reduce their anxiety when needed. Objectives: This work proposes a method to infer anxiety states of caregivers when caring for people with dementia, by using physiological data. Methods: A model using Markov chains for detecting internal anxiety states is proposed. The model is tested with a physiological dataset gathered from a naturalistic enactment experiment with 10 participants. A visual analysis for observing anxiety states is employed. The Markov chain model is evaluated by using Inter-beat Interval (IBI) data to detect 4 internal states: “Relaxed”, ”Arousing”, ”Anxiety”, and ”Relaxing”. Results: From the visual inspection of inter-beat interval data, self-report and observation labels a total of 823 state segments were identified which contained the following states: 137 “relaxed”, 91 “arousing”, 410 “anxious”, and 185 “relaxing”. By using the average IBI value of 60 seconds segments as classification feature, the model was evaluated with a “leave one-out” cross validation with an average accuracy of 73.03 %. Conclusions: We proposed a Markov chain model for internal anxiety state detection of caregivers that care for people with dementia. The model was evaluated in a naturalistic enactment experiment with 10 participants. The resulting accuracy is comparable to previous results on stress classification.... D. Miranda (1), J. Favela (1), B. Arnrich (2) 26970 2016-12-06 13:17:53 Wearable Therapy – Detecting Information from Wearables and Mobiles that are Relevant to Clinical... Background: This accompanying editorial provides a brief introduction into the focus theme “Wearable Therapy”. Objectives: The focus theme “Wearable Therapy” aims to present contributions which target wearable and mobile technologies to support clinical and self-directed therapy. Methods: A call for papers was announced to all participants of the “9th International Conference on Pervasive Computing Technologies for Healthcare” and was published in November 2015. A peer review process was conducted to select the papers for the focus theme. Results: Six papers were selected to be included in this focus theme. The paper topics cover a broad range including an approach to build a health informatics research program, a comprehensive literature review of self-quantification for health self-management, methods for affective state detection of informal care givers, social-aware handling of falls, smart shoes for supporting self-directed therapy of alcohol addicts, and reference information model for pervasive health systems. Conclusions: More empirical evidence is needed that confirms sustainable effects of employing wearable and mobile technology for clinical and self-directed therapy. Inconsistencies between different conceptual approaches need to be revealed in order to enable more systematic investigations and comparisons.... B. Arnrich (1), C. Ersoy (1), O. Mayora (2), A. Dey (3), N. Berthouze (4), K. Kunze (5) 26969 2016-12-06 13:16:07 Ahead of print: Combined Vision and Wearable Sensors-based System for Movement Analysis in... Background: Traditional rehabilitation sessions are often a slow, tedious, disempowering and non-motivational process, supported by clinical assessment tools, i.e. evaluation scales that are prone to subjective rating and imprecise interpretation of patient’s performance. Poor patient motivation and insufficient accuracy are thus critical factors that can be improved by new sensing / processing technologies. Objectives: We aim to develop a portable and affordable system, suitable for home rehabilitation, which combines vision-based and wearable sensors. We introduce a novel approach for examining and characterizing the rehabilitation movements, using quantitative descriptors. We propose new Movement Performance Indicators (MPIs) that are extracted directly from sensor data and quantify the symmetry, velocity, and acceleration of the movement of different body/hand parts, and that can potentially be used by therapists for diagnosis and progress assessment. Methods: First, a set of rehabilitation exercises is defined, with the supervision of neurologists and therapists for the specific case of Parkinson’s disease. It comprises full-body movements measured with a Kinect device and fine hand movements, acquired with a data glove. Then, the sensor data is used to compute 25 Movement Performance Indicators, to assist the diagnosis and progress monitoring (assessing the disease stage) in Parkinson’s disease. A kinematic hand model is developed for data verification and as an additional resource for extracting supplementary movement information. Results: Our results show that the proposed Movement Performance Indicators are relevant for the Parkinson’s disease assessment. This is further confirmed by correlation of the proposed indicators with clinical tapping test and UPDRS clinical scale. Classification results showed the potential of these indicators to discriminate between the patients and controls, as well as between the stages that characterize the evolution of the disease. Conclusions: The proposed sensor system, along with the developed approach for rehabilitation movement analysis have a significant potential to support and advance traditional rehabilitation therapy. The main impact of our work is two-fold: (i) the proposition of an approach for supporting the therapists during the diagnosis and monitoring evaluations by reducing subjectivity and imprecision, and (ii) offering the possibility of the system to be used at home for rehabilitation exercises in between sessions with doctors and therapists.... S. Spasojević (1, 2, 3), T. V. Ilić (4), S. Milanović (5), V. Potkonjak (1), A. Rodić (2), J. Santos-Victor (3) 26968 2016-12-06 13:15:20 Ahead of print: Eye Movement Analysis and Cognitive Assessment Background: An adequate behavioral response depends on attentional and mnesic processes. When these basic cognitive functions are impaired, the use of non-immersive Virtual Reality Applications (VRAs) can be a reliable technique for assessing the level of impairment. However, most non-immersive VRAs use indirect measures to make inferences about visual attention and mnesic processes (e.g., time to task completion, error rate). Objectives: To examine whether the eye movement analysis through eye tracking (ET) can be a reliable method to probe more effectively where and how attention is deployed and how it is linked with visual working memory during comparative visual search tasks (CVSTs) in non-immersive VRAs. Methods: The eye movements of 50 healthy participants were continuously recorded while CVSTs, selected from a set of cognitive tasks in the Systemic Lisbon Battery (SLB). Then a VRA designed to assess of cognitive impairments were randomly presented. Results: The total fixation duration, the number of visits in the areas of interest and in the interstimulus space, along with the total execution time was significantly different as a function of the Mini Mental State Examination (MMSE) scores. Conclusions: The present study demonstrates that CVSTs in SLB, when combined with ET, can be a reliable and unobtrusive method for assessing cognitive abilities in healthy individuals, opening it to potential use in clinical samples.... P. J. Rosa (1, 2, 3, 4, 5), P. Gamito (1, 2), J. Oliveira (1, 2), D. Morais (1, 2), M. Pavlovic (6), O. Smyth (6), I. Maia (1), T. Gomes (1) 26967 2016-12-06 13:14:21 Ensemble Pruning for Glaucoma Detection in an Unbalanced Data Set Background: Random forests are successful classifier ensemble methods consisting of typically 100 to 1000 classification trees. Ensemble pruning techniques reduce the computational cost, especially the memory demand, of random forests by reducing the number of trees without relevant loss of performance or even with increased performance of the sub-ensemble. The application to the problem of an early detection of glaucoma, a severe eye disease with low prevalence, based on topographical measurements of the eye background faces specific challenges. Objectives: We examine the performance of ensemble pruning strategies for glaucoma detection in an unbalanced data situation. Methods: The data set consists of 102 topographical features of the eye background of 254 healthy controls and 55 glaucoma patients. We compare the area under the receiver operating characteristic curve (AUC), and the Brier score on the total data set, in the majority class, and in the minority class of pruned random forest ensembles obtained with strategies based on the prediction accuracy of greedily grown sub-ensembles, the uncertainty weighted accuracy, and the similarity between single trees. To validate the findings and to examine the influence of the prevalence of glaucoma in the data set, we additionally perform a simulation study with lower prevalences of glaucoma. Results: In glaucoma classification all three pruning strategies lead to improved AUC and smaller Brier scores on the total data set with sub-ensembles as small as 30 to 80 trees compared to the classification results obtained with the full ensemble consisting of 1000 trees. In the simulation study, we were able to show that the prevalence of glaucoma is a critical factor and lower prevalence decreases the performance of our pruning strategies. Conclusions: The memory demand for glaucoma classification in an unbalanced data situation based on random forests could effectively be reduced by the application of pruning strategies without loss of performance in a population with increased risk of glaucoma.... W. Adler (1), O. Gefeller (1), A. Gul (2), F. K. Horn (3), Z. Khan (4), B. Lausen (5) 26877 2016-11-21 09:20:06 Methods Open – A New Journal Track Starting in 2017 From 2017 (volume 56) onwards the journal Methods of Information in Medicine will consist of two tracks. Authors can decide to submit their manuscript to either the subscription track that continues to publish its six print and electronic (non-open access) issues for journal subscribers, or the new Methods Open track that will consist of digitally published manuscripts (as gold open access). These two tracks will constitute from 2017 on the journal’s Tandem Model. Simultaneously, Methods will introduce a double-blinded review process and reviewer assessment by the submitting authors. Implications of these changes for both authors and reviewers are discussed. With these steps, Methods aims to improve the visibility of the journal and contribute to sharing research results as timely and as widely as possible and thereby to promote scientific progress. S. Koch (1), R. Haux (2), O. Gefeller (3), I. N. Sarkar (4), D. Bergemann (5) 26876 2016-11-21 09:19:10 Exploring Possibilities for Transforming Established Subscription-based Scientific Journals into... Background: Based on today‘s information and communication technologies the open access paradigm has become an important approach for adequately communicating new scientific knowledge. Objectives: Summarizing the present situation for journal transformation. Presenting criteria for adequate transformation as well as a specific approach for it. Describing our exemplary implementation of such a journal transformation. Methods: Studying the respective literature as well as discussing this topic in various discussion groups and meetings (primarily of editors and publishers, but also of authors and readers), with long term experience as editors and /or publishers of scientific publications as prerequisite. Results: There is a clear will, particularly of political and funding organizations, towards open access publishing. In spite of this, there is still a large amount of scientific knowledge, being communicated through subscription-based journals. For successfully transforming such journals into open access, sixteen criteria for a goal-oriented, stepwise, sustainable, and fair transformation are suggested. The Tandem Model as transformation approach is introduced. Our exemplary implementation is done in the Trans-O-MIM project. It is exploring strategies, models and evaluation metrics for journal transformation. As instance the journal Methods of Information in Medicine will apply the Tandem Model from 2017 onwards. Conclusions: Within Trans-O-MIM we will reach at least nine of the sixteen criteria for adequate transformation. It was positive to implement Trans-O-MIM as international research project. After first steps for transforming Methods have successfully been made, challenges will remain, among others, in identifying appropriate incentives for open access publishing in order to support its transformation.... R. Haux (1), S. Kuballa (1), M. Schulze (1), C. Böhm (2), O. Gefeller (3), J. Haaf (2), P. Henning (2), C. Mielke (1), F. Niggemann (2), A. Schürg (2), D. Bergemann (2) 26875 2016-11-21 09:17:18 Ahead of print: Technology in Rehabilitation: Evaluating the Single Leg Squat Exercise with Wearable... Background: The single leg squat (SLS) is a common lower limb rehabilitation exercise. It is also frequently used as an evaluative exercise to screen for an increased risk of lower limb injury. To date athlete / patient SLS technique has been assessed using expensive laboratory equipment or subjective clinical judgement; both of which are not without shortcomings. Inertial measurement units (IMUs) may offer a low cost solution for the objective evaluation of athlete / patient SLS technique. Objectives: The aims of this study were to determine if in combination or in isolation IMUs positioned on the lumbar spine, thigh and shank are capable of: (a) distinguishing between acceptable and aberrant SLS technique; (b) identifying specific deviations from acceptable SLS technique. Methods: Eighty-three healthy volunteers participated (60 males, 23 females, age: 24.68 + / − 4.91 years, height: 1.75 + / − 0.09 m, body mass: 76.01 + / − 13.29 kg). All participants performed 10 SLSs on their left leg. IMUs were positioned on participants’ lumbar spine, left shank and left thigh. These were utilized to record tri-axial accelerometer, gyroscope and magnetometer data during all repetitions of the SLS. SLS technique was labelled by a Chartered Physiotherapist using an evaluation framework. Features were extracted from the labelled sensor data. These features were used to train and evaluate a variety of random-forests classifiers that assessed SLS technique. Results: A three IMU system was moderately successful in detecting the overall quality of SLS performance (77 % accuracy, 77 % sensitivity and 78 % specificity). A single IMU worn on the shank can complete the same analysis with 76 % accuracy, 75 % sensitivity and 76 % specificity. Single sensors also produce competitive classification scores relative to multi-sensor systems in identifying specific deviations from acceptable SLS technique. Conclusions: A single IMU positioned on the shank can differentiate between acceptable and aberrant SLS technique with moderate levels of accuracy. It can also capably identify specific deviations from optimal SLS performance. IMUs may offer a low cost solution for the objective evaluation of SLS performance. Additionally, the classifiers described may provide useful input to an exercise biofeedback application.... D. F. Whelan (1, 2), M. A. O'Reilly (1, 2), T. E. Ward (3), E. Delahunt (2), B. Caulfield (1, 2) 26752 2016-10-26 11:53:26 Unobtrusive and Continuous Monitoring of Alcohol-impaired Gait Using Smart Shoes Background: Alcohol ingestion influences sensory-motor function and the overall well-being of individuals. Detecting alcohol-induced impairments in gait in daily life necessitates a continuous and unobtrusive gait monitoring system. Objectives: This paper introduces the development and use of a non-intrusive monitoring system to detect changes in gait induced by alcohol intoxication. Methods: The proposed system employed a pair of sensorized smart shoes that are equipped with pressure sensors on the insole. Gait features were extracted and adjusted based on individual’s gait profile. The adjusted gait features were used to train a machine learning classifier to discriminate alcohol-impaired gait from normal walking. In experiment of pilot study, twenty participants completed walking trials on a 12 meter walkway to measure their sober walking and alcohol-impaired walking using smart shoes. Results: The proposed system can detect alcohol-impaired gait with an accuracy of 86.2 % when pressure value analysis and person-dependent model for the classifier are applied, while statistical analysis revealed that no single feature was discriminative for the detection of gait impairment. Conclusions: Alcohol-induced gait disturbances can be detected with smart shoe technology for an automated monitoring in ubiquitous environment. We demonstrated that personal monitoring and machine learning-based prediction could be customized to detect individual variation rather than applying uniform boundary parameters of gait.... E. Park (1), S. I. Lee (2), H. S. Nam (3), J. H. Garst (4), A. Huang (4), A. Campion (4), M. Arnell (4), N. Ghalehsariand (4), S. Park (5), H.-j. Chang (6), D. C. Lu (4), M. Sarrafzadeh (7) 26751 2016-10-26 11:52:24 Graphical Presentation of Patient-Treatment Interaction Elucidated by Continuous Biomarkers Background: Biomarkers providing evidence for patient-treatment interaction are key in the development and practice of personalized medicine. Knowledge that a patient with a specific feature – as demonstrated through a biomarker – would have an advantage under a given treatment vs. a competing treatment can aid immensely in medical decision-making. Statistical strategies to establish evidence of continuous biomarkers are complex and their formal results are thus not easy to communicate. Good graphical representations would help to translate such findings for use in the clinical community. Although general guidelines on how to present figures in clinical reports are available, there remains little guidance for figures elucidating the role of continuous biomarkers in patient-treatment interaction (CBPTI). Objectives: To combat the current lack of comprehensive reviews or adequate guides on graphical presentation within this topic, our study proposes presentation principles for CBPTI plots. In order to understand current practice, we review the development of CBPTI methodology and how CBPTI plots are currently used in clinical research. Methods: The quality of a CBPTI plot is determined by how well the presentation provides key information for clinical decision-making. Several criteria for a good CBPTI plot are proposed, including general principles of visual display, use of units presenting absolute outcome measures, appropriate quantification of statistical uncertainty, correct display of benchmarks, and informative content for answering clinical questions especially on the quantitative advantage for an individual patient with regard to a specific treatment. We examined the development of CBPTI methodology from the years 2000 – 2014, and reviewed how CBPTI plots were currently used in clinical research in six major clinical journals from 2013 – 2014 using the principle of theoretical saturation. Each CBPTI plot found was assessed for appropriateness of its presentation and clinical utility. Results: In our review, a total of seven methodological papers and five clinical reports used CBPTI plots which we categorized into four types: those that distinguish the outcome effect for each treatment group; those that show the outcome differences between treatment groups (by either partitioning all individuals into subpopulations or modelling the functional form of the interaction); those that evaluate the proportion of population impact of the biomarker; and those that show the classification accuracy of the biomarker. The current practice of utilizing CBPTI plots in clinical reports suffers from methodological shortcomings: the lack of presentation of statistical uncertainty, the outcome measure scaled by relative unit instead of absolute unit, incorrect use of benchmarks, and being non-informative in answering clinical questions. Conclusions: There is considerable scope for improvement in the graphical representation of CBPTI in clinical reports. The current challenge is to develop instruments for high-quality graphical plots which not only convey quantitative concepts to readers with limited statistical knowledge, but also facilitate medical decision-making.... Y.-M. Shen (1), L. D. Le (1), R. Wilson (1), U. Mansmann (1) 26750 2016-10-26 11:39:26 Development of a Standardized Rating Tool for Drug Alerts to Reduce Information Overload Background: A well-known problem in current clinical decision support systems (CDSS) is the high number of alerts, which are often medically incorrect or irrelevant. This may lead to the so-called alert fatigue, an overriding of alerts, including those that are clinically relevant, and underuse of CDSS in general. Objectives: The aim of our study was to develop and to apply a standardized tool that allows its users to evaluate the quality of system-generated drug alerts. The users’ ratings can subsequently be used to derive recommendations for developing a filter function to reduce irrelevant alerts. Methods: We developed a rating tool for drug alerts and performed a web-based evaluation study that also included a user review of alerts. In this study the following categories were evaluated: “data linked correctly”, “medically correct”, “action required”, “medication change”, “critical alert”, “information gained” and “show again”. For this purpose, 20 anonymized clinical cases were randomly selected and displayed in our customized CDSS research prototype, which used the summary of product characteristics (SPC) for alert generation. All the alerts that were provided were evaluated by 13 physicians. The users’ ratings were used to derive a filtering algorithm to reduce overalerting. Results: In total, our CDSS research prototype generated 399 alerts. In 98 % of all alerts, medication data were rated as linked correctly to drug information; in 93 %, the alerts were assessed as “medically correct”; 19.5 % of all alerts were rated as “show again”. The interrater-agreement was, on average, 68.4 %. After the application of our filtering algorithm, the rate of alerts that should be shown again decreased to 14.8 %. Conclusions: The new standardized rating tool supports a standardized feedback of user-perceived clinical relevance of CDSS alerts. Overall, the results indicated that physicians may consider the majority of alerts formally correct but clinically irrelevant and override them. Filtering may help to reduce overalerting and increase the specificity of a CDSS.... B. Pfistermeister (1), B. Sedlmayr (2), A. Patapovas (2), G. Suttner (3), O. Tektas (3), A. Tarkhov (4), J. Kornhuber (3), M. F. Fromm (1), T. Bürkle (5), H.-U. Prokosch (2), R. Maas (1) 26749 2016-10-26 11:38:19