vol2Brain: A New Online Pipeline for Whole Brain MRI Analysis

Automatic and reliable quantitative tools for MR brain image analysis are a very valuable resource for both clinical and research environments. In the past few years, this field has experienced many advances with successful techniques based on label fusion and more recently deep learning. However, few of them have been specifically designed to provide a dense anatomical labeling at the multiscale level and to deal with brain anatomical alterations such as white matter lesions (WML). In this work, we present a fully automatic pipeline (vol2Brain) for whole brain segmentation and analysis, which densely labels (N > 100) the brain while being robust to the presence of WML. This new pipeline is an evolution of our previous volBrain pipeline that extends significantly the number of regions that can be analyzed. Our proposed method is based on a fast and multiscale multi-atlas label fusion technology with systematic error correction able to provide accurate volumetric information in a few minutes. We have deployed our new pipeline within our platform volBrain (www.volbrain.upv.es), which has been already demonstrated to be an efficient and effective way to share our technology with the users worldwide.

Cost-effectiveness of the CNIC-polypill strategy for the secondary prevention of CV disease in male and female patients with established coronary heart disease based on improved risk factor control

Background

The burden of CV disease is a health and economic challenge to societies that is expected to grow in future years due to an increased prevalence in CV risk factors. Adequate management and appropriate therapy positively modify risk factors and, consequently, improve outcomes and cost-effectiveness of care. The CNIC-polypill has demonstrated in real-life, clinical effectiveness studies, its superiority over monocomponents in improving the lipidic parameters and in reduction of blood pressure in secondary CV prevention patients.

Purpose

To assess the cost-effectiveness of the CNIC-polypill (acetylsalicylic acid 100mg, atorvastatin 20/40mg, ramipril 2.5/5/10mg) compared to usual care with individual monocomponents for the secondary prevention of CV events in patients with a history of coronary heart disease (CHD) based on control of CV risk factors.

Methods

A Markov cost-effectiveness model (1-year cycles; 4 health states: stable disease, subsequent CHD, subsequent stroke, death; payer perspective; direct medical costs; lifetime horizon; 4% discount rate) based on changes in TC (10,1% reduction), HDL-c (7.4% increment) and SBP (2.6% reduction) obtained from the NEPTUNO* – a real-life, clinical effectiveness study conducted in Spain – was set for Portugal (base case). The probability of transition between health states was based on the SMART risk equation (S0, t=10= 0.8107). Cost-effectiveness was calculated for a hypothetical population (n=1,000) that replicated the characteristics of the population in the proACS registry, comprised of Portuguese patients with previous CHD. Systematic reviews identified epidemiological, costs, utility and mortality data. Outcomes were costs (€, 2020), life years (LY) and quality adjusted LY (QALY) gained.

Results

In patients with a history of CHD, the incremental cost of the CNIC-polypill strategy reaches €365,527, while preventing 35 recurrent CHD events and 17 subsequent strokes. In women and men with previous CHD, the incremental cost reaches €392,529 and €354,444 respectively while preventing recurrent 47 and 30 CHD events and 19 and 16 subsequent strokes respectively. The ICER is €5,130/LY gained for the overall population, €5,768/LY gained for women and €4,884/LY gained for men. The ICUR is €5,332/QALY gained in total, €5,817/QALY gained for women and €5,137/QALY gained for men. Assuming a willingness-to-pay (WTP) threshold of €30,000/QALY gained, there is 76.1% chances in total, 75.8% in women and 76.9% in men for the CNIC-polypill to be cost-effective and 27.8% chances overall, 27.7% in women and 25.5% in men of it being cost saving compared to usual care.

Conclusion

The CNIC-polypill seems to be a cost-effective strategy in men and women compared to usual care with monocomponents for the secondary prevention of CV disease based on improved control of risk factors. A larger reduction in the number of recurrent events is seen in women compared to men at a slightly higher cost.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Ferrer International S.A. Base case resultsProbabilistic sensitivity analysis

Apathetic symptoms and white matter integrity after traumatic brain injury

PRIMARY OBJECTIVE

The aim of the study was twofold. First, to study the relationship among apathy in the long term, initial clinical measures, and standard outcome scores after traumatic brain injury (TBI). Second, to describe white matter integrity correlates of apathy symptoms.

RESEARCH DESIGN

Correlational study. Methods and Procedures: Correlation and Bayesian networks analyses were performed in a sample of 40 patients with moderate to severe TBI in order to identify the relationship among clinical variables, functionality, and apathy. A diffusion tensor imaging study was developed in 25 participants to describe correlations between fractional anisotropy (FA) measures and apathetic symptoms.

MAIN OUTCOMES AND RESULTS

Correlation analysis revealed associations between pairs of variables as apathy in the long term and functional score at discharge from hospital. Bayesian network illustrated the relevant role of axonal injury mediating the relationship between apathy and initial clinical variables. FA in the superior longitudinal fasciculus, the inferior longitudinal fasciculus, and the internal capsule were negatively correlated with apathy measures. Widespread brain areas showed positive correlations between FA and apathy.

CONCLUSIONS

These results highlight the relevance of white matter integrity measures in initial assessment after TBI and its relationship with apathetic manifestations in the chronic phase.

Cost-effectiveness of a cardiovascular polypill strategy (aspirin, atorvastatin, ramipril) for the secondary prevention of cardiovascular disease based on real life improvement in risk factor control

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Ferrer Internacional

Background

The cardiovascular (CV) polypill has consistently demonstrated cost-effectives in decreasing the risk of CV disease in patients in secondary prevention. Previous pharmacoeconomic studies addressed improvements in adherence as a driver of health gains. This economic assessment focuses on the implications of improved control of risk factors with the polypill as observed in clinical practice.

Purpose

To assess the cost-effectiveness of a fixed-dose combination polypill (ASA 100mg, atorvastatin 20/40mg, ramipril 2.5/5/10mg) strategy for the secondary prevention of CV and cerebrovascular events in adults with a history of coronary heart disease (CHD) or stroke compared to usual care with monocomponents.

Methods

A Markov cost-effectiveness model (1-year cycles; 4 health states: stable disease, subsequent CHD, subsequent stroke, death; payer perspective; direct medical costs; lifetime horizon; 4% discount rate) based on changes in CV risk factors (total cholesterol, 18.3% reduction; high density lipoprotein cholesterol, 2.1% increment; systolic blood pressure, 11.46% reduction) obtained from a real-life effectiveness study was set for Portugal. The probability of transition between health states was based on the SMART risk equation. Cost-effectiveness was calculated for two cohorts (n = 1,000) of secondary prevention patients with previous CHD or stroke. Systematic reviews, Portuguese registries, mortality tables and official reports were searched to identify effectiveness, epidemiological, costs and utility data. Outcomes were costs (€, 2020) per life year (LY) and Quality Adjusted LY (QALY) gained. One-way (OWA) and probabilistic (PSA) sensitivity analyses tested consistency. Assumptions were validated by experts.

Results

In the CHD cohort, the incremental cost-effectiveness ratio for the polypill strategy (ICER) is 2,402 €/LY and the incremental cost-utility ratio (ICUR) is 2,328 €/QALY. Incremental cost reaches 278,927 € (polypill, 13,198,506 €; monocomponents: 12,919,579 €) with less subsequent CV events (552.31 vs 641.88) and CV deaths (102.4 vs 118.68). Assuming a willingness-to-pay (WTP) threshold of 30.000 €/QALY gained, the PSA shows a 81.4% probability for the polypill to be cost-effective and 39.1% chances to be costs saving compared to usual care. In the stroke cohort, the ICER is 386 €/LY and the ICUR is 553 €/QALY. Incremental costs are 34,178 € (polypill, 10,138,807 €; monocomponents: 10,104,629 €) with less subsequent CV events (481.99 vs 564.50) and CV deaths (101.00 vs. 117.23) with the polypill. There is a 75.9% probability for the polypill to be cost-effective and 49.5% chances to be costs saving.

Conclusion

The CV polypill is a cost-effective secondary prevention strategy compared to usual care with monocomponents. Its ICER is well below acceptable thresholds in both CV and cerebrovascular disease patients. It reduces the number of recurrent events at a moderately higher cost compared to monocomponents.

How consistent are cost-effectiveness estimates of a cardiovascular polypill strategy for the secondary prevention of cardiovascular disease across different cardiovascular risk equations?

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Ferre Internacional

Background

Risk equations (RE) are crucial to individualise estimates and properly adjust preventive treatments in patients with previous cardiovascular (CV) disease. RE are also routinely incorporated into health economic assessments but it is unknown if the cost-effectiveness results vary according to the RE applied.

Purpose

To determine the cost-effectiveness of a CV polypill (ASA 100mg, atorvastatin 20/40mg and ramipril 2.5/5/10mg) strategy compared to usual practice of combining monocomponents in the prevention of recurrent events in patients with previous coronary heart disease (CHD) or stroke applying two different CV RE: SMART and FRAMINGHAM, respectively.

Methods

A Markov cost-effectiveness model (1-year cycles; 4 health states: stable disease, subsequent CHD, subsequent stroke; death; payer perspective; direct medical costs; lifetime horizon; 4% discount rate) was developed for Portugal. Transition probability between health states was based on the SMART RE and an adaptation for secondary CV prevention of the FRAMINGHAM RE, respectively. Cost-effectiveness was calculated for a mixed cohort of secondary prevention patients (weighed post-CHD: 57.9%; post-stroke: 42.1%). Systematic literature reviews, Portuguese registries, mortality tables and official reports ware used to identify effectiveness, epidemiological, costs and utility data. Outcomes were costs (€, 2020) per life year (LY) and Quality Adjusted Life Year (QALY) gained. One-way (OWA) and probabilistic (PSA) sensitivity analyses tested the consistency of results. Assumptions were validated by experts.

Results

Applying the SMART RE, the incremental cost-effectiveness ratio (ICER) is 1,555€/LY gained and the incremental cost-utility ratio (ICUR) is 1,785€/QALY gained for the polypill strategy. The incremental costs of adopting the polypill strategy are 171,378€. Recurrent CV events (550.68 vs 642.13) and CV deaths (106.05 vs 122.81) are also less frequent with the polypill strategy compared with monocomponents. Assuming a willingness-to-pay (WTP) threshold of 30.000 €/QALY gained, there is a 77.80% probability for the polypill strategy to be cost-effective and 43.00% chances to be costs saving when used in a mixed cardiovascular and cerebrovascular disease population. Applying the FRAMINGHAM RE, the ICER is 998€/LY gained and the ICUR is 1,242€/QALY. The incremental costs amount 175,122€. Recurrent CV events (452.66 vs 563.48) and CV deaths (104.77 vs 127.32) are less frequent with the polypill strategy. The PSA shows a 99.5% probability for the polypill strategy to be cost-effective and 46.8% chances to be costs saving.

Conclusion

Both risk equations result in comparable results on the cost-effectiveness of interventions for the secondary prevention of CV disease. The polypill strategy remains cost-effective compared to the common practice of using individual monocomponents concomitantly, reducing recurrent CV events at a moderately higher cost.

Psychophysiological Correlates of Emotional- and Alcohol-Related Cues Processing in Offspring of Alcohol-Dependent Patients

AIMS

To determinate if offspring of alcohol-dependent patients (OA) process affective stimuli and alcohol-related cues in a different manner than control subjects do.

METHODS

Event-related potentials (early posterior negativity [EPN]/ late positive potential [LPP]) and event-related oscillations (Theta) were obtained by electroencephalographic (EEG) recording during the viewing of International Affective Picture System (IAPS) images with positive, negative and neutral valence, as well as alcohol-related cues. The total sample was comprised of 60 participants, divided into two groups: one group consisted of OA (30) and the control group of participants with negative family history of alcohol use disorders (30).

RESULTS

Theta power analysis implies a significant interaction between condition, region and group factors. Post-hoc analysis indicates an increased theta power for the OA at different regions, during pleasant (frontal, central, parietal, occipital, right temporal); unpleasant (frontal, central, occipital); alcohol (frontal, central, parietal, occipital, right and left temporal) and neutral (occipital) cues. There are no group differences regarding any of the event-related potential measurements (EPN/LPP).

CONCLUSIONS

There is evidence of alterations in the processing of affective stimuli and alcohol-related information, evidenced by changes in theta brain oscillations. These alterations are characterized by an increased emotional reactivity, evidenced by increased theta at posterior sites. There is also an increased recruitment of emotion control, which could be a compensation mechanism, evidenced by increased theta power at anterior sites during affective stimuli and alcohol cues.

Reasons for relapses in patients with schizophrenia admitted to acute units

Introduction

Relapses are common and a higher number of relapses involve a greater cognitive impairment of the patient. Prevention of relapses is therefore the primary objective of treatment.

Objectives

To establish why a sample of patients with schizophrenia experience relapses and are admitted to acute units as a result.

Methods

A multicenter, naturalistic, retrospective study assessing medical intervention in 1346 patients with schizophrenia admitted to acute units in Spain, assessing the following causes of relapses: non-compliance, lack of efficacy, drug abuse, stress and high incidence of side effects.

Results

90.8% of patients were admitted for relapse. Reasons for admission were non-compliance in 67.1% (77.2% due to lack of insight and 30.59% due to drug abuse), lack of therapeutic efficacy in 27.2%, and drug abuse in 24.3%. In addition, stress and a high incidence of side effects in 5.8% of patients were other reasons for relapse.

Conclusions

Non compliance is the main reason for relapses followed by lack of efficacy. The results appear to confirm that drug abuse might influence in a direct (drug abuse itself) or indirect (non compliance because of drug abuse) way in a higher number of relapses.

The Taq IA polymorphism linked to the DRD2 gene is related to lower attention and less inhibitory control in alcoholic patients

The TaqIA polymorphism linked to the DRD2 gene has been associated with alcoholism. The aim of this work is to study attention and inhibitory control as per the continuous performance test and the stop task in a sample of 50 Spanish male alcoholic patients split into two groups according to the presence of the TaqIA1 allele in their genotype. Our results show that alcoholics carrying the TaqIA1 allele present lower sustained attention and less inhibitory control than those patients without such allele.

Pregabalin for the discontinuation of long-term benzodiazepines use: An assessment of its effectiveness in daily clinical practice

Purpose

To evaluate the effectiveness and tolerability of pregabalin in the management of the discontinuation of benzodiazepines in long-term users.

Subjects and methods

We performed a 12-week, prospective, uncontrolled, non-interventional, and observational study in patients aged 18 years old or above, who met DSM-IV-TR criteria for benzodiazepine dependence without other major psychiatry disorder. Evaluations included the Benzodiazepine Withdrawal Symptom Questionnaire, the Hamilton Anxiety Rating Scale, the Clinical Global Impression Scale, and the Sheehan Disability Scale. A urine drug screen for benzodiazepines was performed at baseline and every 4 weeks thereafter. The primary effectiveness variable was success rate, defined as achievement of benzodiazepine-free status at week 12 according to the urine drug screen.

Results and discussion

The mean dose at week 12 was 315 (±166) mg/day. The success rate of the benzodiazepine taper in the primary efficacy population (n = 282) was 52% (95% confidence interval [CI], 46–58). Success rates for women and men were 58% (95% CI, 49–67) and 46% (95% CI, 38–55), respectively. The success rates did not differ according to either the benzodiazepine of abuse or the presence of other substance use disorders. Significant and clinically relevant improvements were observed in withdrawal and anxiety symptoms, as well as in patients’ functioning. At week 12, tolerability was rated as good or excellent by 90% and 83% of the clinicians and patients, respectively.

Conclusion

Our results suggest that pregabalin is an efficacious and well-tolerated adjunctive treatment for benzodiazepine withdrawal.

P3 Component as a Potential Endophenotype for Control Inhibition in Offspring of Alcoholics

Aims

To assess inhibitory processes and the ongoing event-related potential (ERP) activity of offspring of alcoholics (OA) during a Go/No-Go task, with the purpose of characterizing possible psychophysiological endophenotypes for alcohol-dependent vulnerability.

Short summary

EEG recordings and ERP measurements of young adults with positive and negative family history of alcoholism where obtained while they performed a Go/No-Go task to assess inhibitory processes. Offspring of alcoholics showed a different ERP pattern compared to the control group and exerted greater effort than the control group.

Methods

ERP measurements were obtained by electroencephalogram (EEG) recordings of 65 participants divided into two groups: one group of 30 subjects with positive family history of alcoholism and a control group of 35 subjects with negative family history of alcoholism. They performed a Go/No-Go task, where each individual was required to classify visual stimuli by colour (Go) and inhibit their response to a No-Go signal.

Results

OA have higher P3 amplitudes during the Go condition in all of the regions analysed and higher No-Go P3 amplitudes than control subjects in the frontal region. Unlike controls, OA have no differences between the P3 amplitudes across conditions.

Conclusions

The absence of differences between the P3 Go and No-Go observed in the OA group can be interpreted as a possible alteration related with inhibition, in a way that they may need to recruit similar resources for inhibitory and classificational processes for both conditions. Therefore, the P3 component may be considered as a useful endophenotype and a vulnerability marker to develop addictive behaviour.

Semantic Registration and Discovery System of Subsystems and Services within an Interoperable Coordination Platform in Smart Cities

Smart subsystems like traffic, Smart Homes, the Smart Grid, outdoor lighting, etc. are built in many urban areas, each with a set of services that are offered to citizens. These subsystems are managed by self-contained embedded systems. However, coordination and cooperation between them are scarce. An integration of these systems which truly represents a "system of systems" could introduce more benefits, such as allowing the development of new applications and collective optimization. The integration should allow maximum reusability of available services provided by entities (e.g., sensors or Wireless Sensor Networks). Thus, it is of major importance to facilitate the discovery and registration of available services and subsystems in an integrated way. Therefore, an ontology-based and automatic system for subsystem and service registration and discovery is presented. Using this proposed system, heterogeneous subsystems and services could be registered and discovered in a dynamic manner with additional semantic annotations. In this way, users are able to build customized applications across different subsystems by using available services. The proposed system has been fully implemented and a case study is presented to show the usefulness of the proposed method.

Association between maltreatment and polydrug use among adolescents

Different studies have related sexual and physical abuse during childhood and adolescence to the development of substance abuse disorders. Nevertheless, we are not aware of the role that other more common maltreatment types, such as neglect, will play among the most risky pattern of consumption: the polydrug use. A clinical sample of 655 adolescents, divided into two groups: polydrug users and non-polydrug users, were assessed on their pattern of drug consumption, history of childhood maltreatment, current psychopathology and their family history of alcoholism. Polydrug users had a greater prevalence of all types of maltreatment, although the most associated to this group were sexual abuse and emotional neglect. Other relevant variables to adolescent consumption were: the diagnosis of depressive disorder, the presence of anxiety traits and the family history of alcohol dependence. Polydrug users have higher risks of having had problems during infancy and adolescence, such as maltreatment and other psychopathological conditions, with the addition of family history of alcoholism. Accordingly, practitioners should take into account that those variables may influence polydrug abuse because it is the most risky pattern for subsequent dependence of substances, and they should always be considered during treatment.

Context Aware Middleware Architectures: Survey and Challenges

Context aware applications, which can adapt their behaviors to changing environments, are attracting more and more attention. To simplify the complexity of developing applications, context aware middleware, which introduces context awareness into the traditional middleware, is highlighted to provide a homogeneous interface involving generic context management solutions. This paper provides a survey of state-of-the-art context aware middleware architectures proposed during the period from 2009 through 2015. First, a preliminary background, such as the principles of context, context awareness, context modelling, and context reasoning, is provided for a comprehensive understanding of context aware middleware. On this basis, an overview of eleven carefully selected middleware architectures is presented and their main features explained. Then, thorough comparisons and analysis of the presented middleware architectures are performed based on technical parameters including architectural style, context abstraction, context reasoning, scalability, fault tolerance, interoperability, service discovery, storage, security & privacy, context awareness level, and cloud-based big data analytics. The analysis shows that there is actually no context aware middleware architecture that complies with all requirements. Finally, challenges are pointed out as open issues for future work.