Clifford C. Dacso

Assessing the Acceptability and Usability of an Interactive Serious Game in Aiding Treatment Decisions for Patients with Localized Prostate Cancer

Background Men diagnosed with localized prostate cancer face a potentially life-altering treatment decision that can be overwhelming. Enhancing patient knowledge through education can significantly reduce feelings of uncertainty while simultaneously increasing confidence in decision making. Serious games have been shown in other populations to increase health knowledge and assist with the health decision-making process. We developed an interactive serious game, Time After Time, which translates evidence-based treatment outcome data into an accessible and understandable format that men can utilize in their prostate cancer treatment decision-making process. The game specifically aims to raise men’s awareness and understanding of the impact of health-related quality of life issues associated with the major treatment options and to enrich their conversations with their health care providers. Objective This study determined the acceptability and usability of the alpha version of Time After Time, an interactive decision aid for men diagnosed with localized prostate cancer, in order to inform future iterations of the serious game. Methods The study employed a mixed methods approach to assess the acceptability and usability of the Time After Time serious game using qualitative focus groups and a quantitative Likert scale survey. Results A total of 13 men who had already completed treatment for localized prostate cancer completed the survey and participated in focus group meetings. The majority of the study participants rated Time After Time as an appropriate decision tool for localized prostate cancer and verified that it meets its goals of increasing focus on side effects and generating questions for the patient’s health care team. However, participants also expressed concerns about game usability and the diversity of information covered regarding treatment options and potential treatment outcomes. Conclusions Serious games are a promising approach to health education and decision support for older men. Participants were receptive to the idea of a serious game as a decision aid in localized prostate cancer. However, usability issues are a major concern for this demographic, as is clarity and transparency of data sources.

Heterogeneous uncertainties in cholesterol management

Physicians use clinical guidelines to inform judgment about therapy. Clinical guidelines do not address three important uncertainties: (1) uncertain relevance of tested populations to the individual patient, (2) the patients uncertain preferences among possible outcomes, and (3) uncertain subjective and financial costs of intervention. Unreliable probabilistic information is available for some of these uncertainties; no probabilities are available for others. The uncertainties are in the values of parameters and in the shapes of functions. We explore the usefulness of info-gap decision theory in patient-physician decision making in managing cholesterol level using clinical guidelines. Info-gap models of uncertainty provide versatile tools for quantifying diverse uncertainties. Info-gap theory provides two decision functions for evaluating alternative therapies. The robustness function assesses the confidence-in light of uncertainties-in attaining acceptable outcomes. The opportuneness function assesses the potential for better-than-anticipated outcomes. Both functions assist in forming preferences among alternatives. Hypothetical case studies demonstrate that decisions using the guidelines and based on best estimates of the expected utility are sometimes, but not always, consistent with robustness and opportuneness analyses. The info-gap analysis provides guidance when judgment suggests that a deviation from the guidelines would be productive. Finally, analysis of uncertainty can help resolve ambiguous situations.

SRC-2 orchestrates polygenic inputs for fine-tuning glucose homeostasis

Significance Maintenance of glucose concentrations within a homeostatic range is essential for preserving the function of glucose-sensitive tissues. Perturbations in the mechanisms that control this homeostasis give rise to a continuum of glucopathologies associated with aberrant carbohydrate metabolism. Here we show Steroid Receptor Coactivator 2 (SRC-2) to be an integral coregulator that couples gene output with energetic demand by stabilizing and amplifying transcriptional complexes. This study highlights the collective importance of transcriptional coregulators for coordination of gene expression events and may provide insight for understanding components of polygenic diseases such as type 2 diabetes mellitus. Despite extensive efforts to understand the monogenic contributions to perturbed glucose homeostasis, the complexity of genetic events that fractionally contribute to the spectrum of this pathology remain poorly understood. Proper maintenance of glucose homeostasis is the central feature of a constellation of comorbidities that define the metabolic syndrome. The ability of the liver to balance carbohydrate uptake and release during the feeding-to-fasting transition is essential to the regulation of peripheral glucose availability. The liver coordinates the expression of gene programs that control glucose absorption, storage, and secretion. Herein, we demonstrate that Steroid Receptor Coactivator 2 (SRC-2) orchestrates a hierarchy of nutritionally responsive transcriptional complexes to precisely modulate plasma glucose availability. Using DNA pull-down technology coupled with mass spectrometry, we have identified SRC-2 as an indispensable integrator of transcriptional complexes that control the rate-limiting steps of hepatic glucose release and accretion. Collectively, these findings position SRC-2 as a major regulator of polygenic inputs to metabolic gene regulation and perhaps identify a previously unappreciated model that helps to explain the clinical spectrum of glucose dysregulation.

InSpire to Promote Lung Assessment in Youth: Evolving the Self-Management Paradigms of Young People With Asthma

Background Asthma is the most common chronic disease in childhood, disproportionately affecting urban, minority, and disadvantaged children. Individualized care plans supported by daily lung-function monitoring can reduce morbidity and mortality. However, despite 20 years of interventions to increase adherence, only 50% of US youth accurately follow their care plans, which leads to millions of preventable hospitalizations, emergency room visits, and sick days every year. We present a feasibility study of a novel, user-centered approach to increasing young people’s lung-function monitoring and asthma self-care. Promoting Lung Assessment in Youth (PLAY) helps young people become active managers of their asthma through the Web 2.0 principles of participation, cocreation, and information sharing. Specifically, PLAY combines an inexpensive, portable spirometer with the motivational power and convenience of mobile phones and virtual-community gaming. Objective The objective of this study was to develop and pilot test InSpire, a fully functional interface between a handheld spirometer and an interactive game and individualized asthma-care instant-messaging system housed on a mobile phone. Methods InSpire is an application for mobile smartphones that creates a compelling world in which youth collaborate with their physicians on managing their asthma. Drawing from design-theory on global timer mechanics and role playing, we incentivized completing spirometry maneuvers by making them an engaging part of a game young people would want to play. The data can be sent wirelessly to health specialists and return care recommendations to patients in real-time. By making it portable and similar to applications normally desired by the target demographic, InSpire is able to seamlessly incorporate asthma management into their lifestyle. Results We describe the development process of building and testing the InSpire prototype. To our knowledge, the prototype is a first-of-its kind mobile one-stop shop for asthma management. Feasibility testing in children aged 7 to 14 with asthma assessed likability of the graphical user interface as well as young people’s interest in our incentivizing system. Nearly 100% of children surveyed said they would play games like those in PLAY if they involved breathing into a spirometer. Two-thirds said they would prefer PLAY over the spirometer alone, whereas 1/3 would prefer having both. No children said they would prefer the spirometer over PLAY. Conclusions Previous efforts at home-monitoring of asthma in children have experienced rapid decline in adherence. An inexpensive monitoring technology combined with the computation, interactive communication, and display ability of a mobile phone is a promising approach to sustainable adherence to lung-function monitoring and care plans. An exciting game that redefines the way youth conduct health management by inviting them to collaborate in their health better can be an incentive and a catalyst for more far-reaching goals.

Do we know how to set decision thresholds for diabetes

The diagnosis of diabetes, based on measured fasting plasma glucose level, depends on choosing a threshold level for which the probability of failing to detect disease (missed diagnosis), as well as the probability of falsely diagnosing disease (false alarm), are both small. The Bayesian risk provides a tool for aggregating and evaluating the risks of missed diagnosis and false alarm. However, the underlying probability distributions are uncertain, which makes the choice of the decision threshold difficult. We discuss an hypothesis for choosing the threshold that can robustly achieve acceptable risk. Our analysis is based on info-gap decision theory, which is a non-probabilistic methodology for modelling and managing uncertainty. Our hypothesis is that the non-probabilistic method of info-gap robust decision making is able to select decision thresholds according to their probability of success. This hypothesis is motivated by the relationship between info-gap robustness and the probability of success, which has been observed in other disciplines (biology and economics). If true, it provides a valuable clinical tool, enabling the clinician to make reliable diagnostic decisions in the absence of extensive probabilistic information. Specifically, the hypothesis asserts that the physician is able to choose a diagnostic threshold that maximizes the probability of acceptably small Bayesian risk, without requiring accurate knowledge of the underlying probability distributions. The actual value of the Bayesian risk remains uncertain.

Rosaramicin treatment of gonococcal urethritis in men

The efficacies of two dosage regimens (2.0 g and 1.5 g each day for four days) of rosaramicin were compared in 40 men with acute uncomplicated gonococcal urethritis. After treatment 39 (97%) of 40 patients were asymptomatic and had negative cultures. Gastrointestinal side effects were reported for 12 (28%) of 43 patients; however, only two patients (5%) discontinued therapy because of side effects.

Introducing the IEEE Journal of Translational Engineering in Health and Medicine

The leadership at EMBS created the IEEE Journal of Translational Engineering in Health and Medicine (JTEHM) to address the critical need to disseminate innovative translational research in health and medicine. The journals unique aim is to support the movement of biotechnological innovations from idea to clinical trials and commercialization. We intend for JTEHM to provide a vehicle for the consilience of engineering, medicine and health, and translation. Translation is the critical step to take technological advances from the lab into the clinical environment to improve clinical practice and healthcare. We chose the open-access route not because it is easier (it is not) but because it lays waste to the barrier of cost of reading. We are proud to introduce JTEHM with an open-source, continuous-publication platform that allows multimedia presentation of clinically significant translational technologies, along with editorial blogs and comments from experts, entrepreneurs and clinicians. The papers published in JTEHM are accessible through IEEE Xplore and will be in PubMed soon, as well as in downloadable PDF versions with additional material. We welcome submission of your research findings and clinical translation studies.

Opportunities for optimizing resource utilization in ambulatory academic practices.

Growing emphasis on ambulatory service delivery in academic medical centers has heightened interest in improving operational efficiencies, while providing an optimal educational experience for medical students and residents. One significant challenge in the academic environment is maximizing resource utilization (both physical plant and personnel), through scheduling and operational effectiveness. This article examines how academic ambulatory practices can apply operational and scheduling process redesign methodologies to improve throughput and productivity, while enhancing the educational experience for students/residents.

Factors influencing ambulatory care education in the U.S. Department of Veterans Affairs.

The Department of Veterans Affairs (VA) is undergoing change in the way it delivers health care. Forces underlying this change include demographics of its population, new fiscal constraints, and the requirements of its academic affiliates. The benefit to the medical school affiliates will be the availability of patients in a structure useful for outpatient teaching of medical students and houseofficers. Barriers to effective delivery of ambulatory health care and education in VA facilities are (1) the historic focus on episodic, inpatient care, (2) continuous changes in eligibility requirements, (3) increases in patient care responsibilities for affiliated faculty, and (4) concomitant withdrawal of resources from the VA at a time when costs of health care and education are increasing. The VA medical centers will be increasingly forced to investigate innovative models for patient care delivery and education in the ambulatory setting.

Info-gap decision theory and its potential applications in the clinic

Personalized medicine seeks to match innate characteristics of patients with potential interventions in order to secure the most favorable outcome while mitigating risk. Personalized medicine does not supplant the decisions made by health care professionals in conjunction with patients. In fact, ideally, the application of personalized medicine greatly augments the quality of that interaction by adding an objective measure of disease and response to the physicians professional judgment. In that context, the practitioner faces a disparity between what is known and what needs to be known in order to realize the desired goal of a favorable outcome of treatment or an effective avoidance of disease or complication. Info-gap theory can help manage this challenge. Physician and patient both wish to choose a course of action with confidence that the consequence will be satisfactory to the patient. However, these two attributes of a treatment - success and reliability - are different from each other and conflict with each other. Ambitious goals may be risky. The crux of the challenge is uncertainty: fragmentary data and imperfect understanding. Choices that exhaustively exploit uncertain knowledge may tend to fall short of the quality of outcome which is predicted by that knowledge, precisely because some of that knowledge is imprecise. On the other hand, better-than-anticipated outcomes are also possible when our knowledge is imperfect. Treatments must be selected not only according to their predicted outcomes, but also according to the immunity of those outcomes to errors in the knowledge underlying the predictions, and according to the opportunities inherent in the uncertainty. Info-gap decision theory [1] provides a tool for evaluating both the robustness against pernicious uncertainty as well as the opportuneness from propitious uncertainty. Info-gap theory is a methodology for decision under severe uncertainty which has been applied in many disciplines [101].