Combining general and personal models for epilepsy detection with hyperdimensional computing

Epilepsy is a highly prevalent chronic neurological disorder with great negative impact on patients' daily lives. Despite this there is still no adequate technological support to enable epilepsy detection and continuous outpatient monitoring in everyday life. Hyperdimensional (HD) computing is a promising method for epilepsy detection via wearable devices, characterized by a simpler learning process and lower memory requirements compared to other methods. In this work, we demonstrate additional avenues in which HD computing and the manner in which its models are built and stored can be used to better understand, compare and create more advanced machine learning models for epilepsy detection. These possibilities are not feasible with other state-of-the-art models, such as random forests or neural networks. We compare inter-subject model similarity of different classes (seizure and non-seizure), study the process of creating general models from personal ones, and finally posit a method of combining personal and general models to create hybrid models. This results in an improved epilepsy detection performance. We also tested knowledge transfer between models trained on two different datasets. The attained insights are highly interesting not only from an engineering perspective, to create better models for wearables, but also from a neurological perspective, to better understand individual epilepsy patterns.

Personalized seizure signature: An interpretable approach to false alarm reduction for long-term epileptic seizure detection

OBJECTIVE

Long-term automatic detection of focal seizures remains one of the major challenges in epilepsy due to the unacceptably high number of false alarms from state-of-the-art methods. Our aim was to investigate to what extent a new patient-specific approach based on similarly occurring morphological electroencephalographic (EEG) signal patterns could be used to distinguish seizures from nonseizure events, as well as to estimate its maximum performance.

METHODS

We evaluated our approach on >5500 h of long-term EEG recordings using two public datasets: the PhysioNet.org Children's Hospital Boston-Massachusetts Institute of Technology (CHB-MIT) Scalp EEG database and the EPILEPSIAE European epilepsy database. We visually identified a set of similarly occurring morphological patterns (seizure signature) seen simultaneously over two different EEG channels, and within two randomly selected seizures from each individual. The same seizure signature was then searched for in the entire recording from the same patient using dynamic time warping (DTW) as a similarity metric, with a threshold set to reflect the maximum sensitivity our algorithm could achieve without false alarm.

RESULTS

At a DTW threshold providing no false alarm during the entire recordings, the mean seizure detection sensitivity across patients was 84%, including 96% for the CHB-MIT database and 74% for the European epilepsy database. A 100% sensitivity was reached in 50% of patients, including 79% from the CHB-MIT database and 27% from the European epilepsy database. The median latency from seizure onset to its detection was 17 ± 10 s, with 84% of seizures being detected within 40 s.

SIGNIFICANCE

Personalized EEG signature combined with DTW appears to be a promising method to detect ictal events from a limited number of EEG channels with high sensitivity despite low rate of false alarms, high degree of interpretability, and low computational complexity, compatible with its future use in wearable devices.

A semi-supervised algorithm for improving the consistency of crowdsourced datasets: The COVID-19 case study on respiratory disorder classification

BACKGROUND AND OBJECTIVE

Cough audio signal classification is a potentially useful tool in screening for respiratory disorders, such as COVID-19. Since it is dangerous to collect data from patients with contagious diseases, many research teams have turned to crowdsourcing to quickly gather cough sound data. The COUGHVID dataset enlisted expert physicians to annotate and diagnose the underlying diseases present in a limited number of recordings. However, this approach suffers from potential cough mislabeling, as well as disagreement between experts.

METHODS

In this work, we use a semi-supervised learning (SSL) approach - based on audio signal processing tools and interpretable machine learning models - to improve the labeling consistency of the COUGHVID dataset for 1) COVID-19 versus healthy cough sound classification 2) distinguishing wet from dry coughs, and 3) assessing cough severity. First, we leverage SSL expert knowledge aggregation techniques to overcome the labeling inconsistencies and label sparsity in the dataset. Next, our SSL approach is used to identify a subsample of re-labeled COUGHVID audio samples that can be used to train or augment future cough classifiers.

RESULTS

The consistency of the re-labeled COVID-19 and healthy data is demonstrated in that it exhibits a high degree of inter-class feature separability: 3x higher than that of the user-labeled data. Similarly, the SSL method increases this separability by 11.3x for cough type and 5.1x for severity classifications. Furthermore, the spectral differences in the user-labeled audio segments are amplified in the re-labeled data, resulting in significantly different power spectral densities between healthy and COVID-19 coughs in the 1-1.5 kHz range (p=1.2×10-64), which demonstrates both the increased consistency of the new dataset and its explainability from an acoustic perspective. Finally, we demonstrate how the re-labeled dataset can be used to train a COVID-19 classifier, achieving an AUC of 0.797.

CONCLUSIONS

We propose a SSL expert knowledge aggregation technique for the field of cough sound classification for the first time, and demonstrate how it can be used to combine the medical knowledge of multiple experts in an explainable fashion, thus providing abundant, consistent data for cough classification tasks.

Event-based sampled ECG morphology reconstruction through self-similarity

BACKGROUND AND OBJECTIVE

Event-based analog-to-digital converters allow for sparse bio-signal acquisition, enabling local sub-Nyquist sampling frequency. However, aggressive event selection can cause the loss of important bio-markers, not recoverable with standard interpolation techniques. In this work, we leverage the self-similarity of the electrocardiogram (ECG) signal to recover missing features in event-based sampled ECG signals, dynamically selecting patient-representative templates together with a novel dynamic time warping algorithm to infer the morphology of event-based sampled heartbeats.

METHODS

We acquire a set of uniformly sampled heartbeats and use a graph-based clustering algorithm to define representative templates for the patient. Then, for each event-based sampled heartbeat, we select the morphologically nearest template, and we then reconstruct the heartbeat with piece-wise linear deformations of the selected template, according to a novel dynamic time warping algorithm that matches events to template segments.

RESULTS

Synthetic tests on a standard normal sinus rhythm dataset, composed of approximately 1.8 million normal heartbeats, show a big leap in performance with respect to standard resampling techniques. In particular (when compared to classic linear resampling), we show an improvement in P-wave detection of up to 10 times, an improvement in T-wave detection of up to three times, and a 30% improvement in the dynamic time warping morphological distance.

CONCLUSION

In this work, we have developed an event-based processing pipeline that leverages signal self-similarity to reconstruct event-based sampled ECG signals. Synthetic tests show clear advantages over classical resampling techniques.

Importance of methodological choices in data manipulation for validating epileptic seizure detection models

Epilepsy is a chronic neurological disorder that affects a significant portion of the human population and imposes serious risks in the daily life. Despite advances in machine learning and IoT, small, non-stigmatizing wearable devices for continuous monitoring and detection in outpatient environments are not yet widely available. Part of the reason is the complexity of epilepsy itself, including highly imbalanced data, multimodal nature, and very subject-specific signatures. However, another problem is the heterogeneity of methodological approaches in research, leading to slower progress, difficulty in comparing results, and low reproducibility. Therefore, this article identifies a wide range of methodological decisions that must be made and reported when training and evaluating the performance of epilepsy detection systems. We characterize the influence of individual choices using a typical ensemble random-forest model and the publicly available CHB-MIT database, providing a broader picture of each decision and giving good-practice recommendations, based on our experience, where possible.

A Multimodal Dataset for Automatic Edge-AI Cough Detection

Counting the number of times a patient coughs per day is an essential biomarker in determining treatment efficacy for novel antitussive therapies and personalizing patient care. Automatic cough counting tools must provide accurate information, while running on a lightweight, portable device that protects the patient's privacy. Several devices and algorithms have been developed for cough counting, but many use only error-prone audio signals, rely on offline processing that compromises data privacy, or utilize processing and memory-intensive neural networks that require more hardware resources than can fit on a wearable device. Therefore, there is a need for wearable devices that employ multimodal sensors to perform accurate, privacy-preserving, automatic cough counting algorithms directly on the device in an edge Artificial Intelligence (edge-AI) fashion. To advance this research field, we contribute the first publicly accessible cough counting dataset of multimodal biosignals. The database contains nearly 4 hours of biosignal data, with both acoustic and kinematic modalities, covering 4,300 annotated cough events from 15 subjects. Furthermore, a variety of non-cough sounds and motion scenarios mimicking daily life activities are also present, which the research community can use to accelerate machine learning (ML) algorithm development. A technical validation of the dataset reveals that it represents a wide variety of signal-to-noise ratios, which can be expected in a real-life use case, as well as consistency across experimental trials. Finally, to demonstrate the usability of the dataset, we train a simple cough vs non-cough signal classifier that obtains a 91% sensitivity, 92% specificity, and 80% precision on unseen test subject data. Such edge-friendly AI algorithms have the potential to provide continuous ambulatory monitoring of the numerous chronic cough patients.

Model-Based ISO 14971 Risk Management of EEG-Based Medical Devices

Risk management (RM) is a key component of the development of modern medical devices (MD) to achieve acceptable functional safety and pass the regulatory process. The emerging availability of various techniques, languages, and tools that use model-based system engineering (MBSE) promises to facilitate the development and analysis of complex MD. In this paper, we show how to integrate RM principles and activities recommended in ISO 14971 medical standard into an MBSE-driven MD development process. We propose a method and framework capable of modeling essential RM concepts and performing RM and safety analysis in the early stages of the MD development life cycle. The framework extends OMG RAAML (Object Management Group Risk Analysis and Assessment Modeling Language) to the medical domain according to ISO 14971. We illustrate our approach using a case study of the e-Glass system developed for real-time EEG-based subject monitoring with the intended use of stress monitoring.Clinical Relevance-This facilitates the MD certification process by semi-automation of RM based on ISO 14971 and obtaining safe MD by design.

Approximate zero-crossing: a new interpretable, highly discriminative and low-complexity feature for EEG and iEEG seizure detection

Objective. Long-term monitoring of people with epilepsy based on electroencephalography (EEG) and intracranial EEG (iEEG) has the potential to deliver key clinical information for personalised epilepsy treatment. More specifically, in outpatient settings, the available solutions are not satisfactory either due to poor classification performance or high complexity to be executed in resource-constrained devices (e.g. wearable systems). Therefore, we hypothesize that obtaining high discriminative features is the main avenue to improve low-complexity seizure-detection algorithms.Approach. Inspired by how neurologists recognize ictal EEG data, and to tackle this problem by targeting resource-constrained wearable devices, we introduce a new interpretable and highly discriminative feature for EEG and iEEG, namely approximate zero-crossing (AZC). We obtain AZC by applying a polygonal approximation to mimic how our brain selects prominent patterns among noisy data and then using a zero-crossing count as a measure of the dominating frequency. By employing Kullback-Leiber divergence, leveraging CHB-MIT and SWEC-ETHZ iEEG datasets, we compare the AZC discriminative power against a set of 56 classical literature features (CLF). Moreover, we assess the performances of a low-complexity seizure detection method using only AZC features versus employing the CLF set.Main results. Three AZC features obtained with different approximation thresholds are among the five with the highest median discriminative power. Moreover, seizure classification based on only AZC features outperforms an equivalent CLF-based method. The former detects 102 and 194 seizures, against 99 and 161 for the latter (CHB-MIT and SWEC-ETHZ, respectively). Moreover, the AZC-based method keeps a similar false-alarm rate (i.e. an average of 2.1 and 1.0, against 2.0 and 0.5, per day).Significance. We propose a new feature and demonstrate its capability in seizure classification for both scalp and intracranial EEG. We envision the use of such a feature to improve outpatient monitoring with resource-constrained devices.

M2D2: Maximum-Mean-Discrepancy Decoder for Temporal Localization of Epileptic Brain Activities

Recent years have seen growing interest in leveraging deep learning models for monitoring epilepsy patients based on electroencephalographic (EEG) signals. However, these approaches often exhibit poor generalization when applied outside of the setting in which training data was collected. Furthermore, manual labeling of EEG signals is a time-consuming process requiring expert analysis, making fine-tuning patient-specific models to new settings a costly proposition. In this work, we propose the Maximum-Mean-Discrepancy Decoder (M2D2) for automatic temporal localization and labeling of seizures in long EEG recordings to assist medical experts. We show that M2D2 achieves 76.0% and 70.4% of F1-score for temporal localization when evaluated on EEG data gathered in a different clinical setting than the training data. The results demonstrate that M2D2 yields substantially higher generalization performance than other state-of-the-art deep learning-based approaches.

Adaptive R-Peak Detection on Wearable ECG Sensors for High-Intensity Exercise

OBJECTIVE

Continuous monitoring of biosignals via wearable sensors has quickly expanded in the medical and wellness fields. At rest, automatic detection of vital parameters is generally accurate. However, in conditions such as high-intensity exercise, sudden physiological changes occur to the signals, compromising the robustness of standard algorithms.

METHODS

Our method, called BayeSlope, is based on unsupervised learning, Bayesian filtering, and non-linear normalization to enhance and correctly detect the R peaks according to their expected positions in the ECG. Furthermore, as BayeSlope is computationally heavy and can drain the device battery quickly, we propose an online design that adapts its robustness to sudden physiological changes, and its complexity to the heterogeneous resources of modern embedded platforms. This method combines BayeSlope with a lightweight algorithm, executed in cores with different capabilities, to reduce the energy consumption while preserving the accuracy.

RESULTS

BayeSlope achieves an F1 score of 99.3% in experiments during intense cycling exercise with 20 subjects. Additionally, the online adaptive process achieves an F1 score of 99% across five different exercise intensities, with a total energy consumption of 1.55 ±0.54 mJ.

CONCLUSION

We propose a highly accurate and robust method, and a complete energy-efficient implementation in a modern ultra-low-power embedded platform to improve R peak detection in challenging conditions, such as during high-intensity exercise.

SIGNIFICANCE

The experiments show that BayeSlope outperforms state-of-the-art QRS detectors up to 8.4% in F1 score, while our online adaptive method can reach energy savings up to 38.7% on modern heterogeneous wearable platforms.

Exploration of Hyperdimensional Computing Strategies for Enhanced Learning on Epileptic Seizure Detection

Wearable and unobtrusive monitoring and prediction of epileptic seizures has the potential to significantly increase the life quality of patients, but is still an unreached goal due to challenges of real-time detection and wearable devices design. Hyperdimensional (HD) computing has evolved in recent years as a new promising machine learning approach, especially when talking about wearable applications. But in the case of epilepsy detection, standard HD computing is not performing at the level of other state-of-the-art algorithms. This could be due to the inherent complexity of the seizures and their signatures in different biosignals, such as the electroencephalogram (EEG), the highly personalized nature, and the disbalance of seizure and non-seizure instances. In the literature, different strategies for improved learning of HD computing have been proposed, such as iterative (multi-pass) learning, multi-centroid learning and learning with sample weight ("OnlineHD"). Yet, most of them have not been tested on the challenging task of epileptic seizure detection, and it stays unclear whether they can increase the HD computing performance to the level of the current state-of-the-art algorithms for wearable devices, such as random forests. Thus, in this paper, we implement different learning strategies and assess their performance on an individual basis, or in combination, regarding detection performance and memory and computational requirements. Results show that the best-performing algorithm, which is a combination of multi-centroid and multi-pass, can indeed reach the performance of the random forest model on a highly unbalanced dataset imitating a real-life epileptic seizure detection application.

Machine-Learning Based Monitoring of Cognitive Workload in Rescue Missions with Drones

In search and rescue missions, drone operations are challenging and cognitively demanding. High levels of cognitive workload can affect rescuers' performance, leading to failure with catastrophic outcomes. To face this problem, we propose a machine learning algorithm for real-time cognitive workload monitoring to understand if a search and rescue operator has to be replaced or if more resources are required. Our multimodal cognitive workload monitoring model combines the information of 25 features extracted from physiological signals, such as respiration, electrocardiogram, photoplethysmogram, and skin temperature, acquired in a noninvasive way. To reduce both subject and day inter-variability of the signals, we explore different feature normalization techniques, and introduce a novel weighted-learning method based on support vector machines suitable for subject-specific optimizations. On an unseen test set acquired from 34 volunteers, our proposed subject-specific model is able to distinguish between low and high cognitive workloads with an average accuracy of 87.3% and 91.2% while controlling a drone simulator using both a traditional controller and a new-generation controller, respectively.

Hybrid semiparametric Bayesian networks

This paper presents a new class of Bayesian networks called hybrid semiparametric Bayesian networks, which can model hybrid data (discrete and continuous data) by mixing parametric and nonparametric estimation models. The parametric estimation models can represent a conditional linear Gaussian relationship between variables, while the nonparametric estimation model can represent other types of relationships, such as non-Gaussian and nonlinear relationships. This new class of Bayesian networks generalizes the conditional linear Gaussian Bayesian networks, including them as a special case. In addition, we describe a learning procedure for the structure and the parameters of our proposed type of Bayesian network. This learning procedure finds the best combination of parametric and nonparametric models automatically from data. This requires the definition of a cross-validated score. We also detail how new data can be sampled from a hybrid semiparametric Bayesian network, which in turn can be useful to solve other related tasks, such as inference. Furthermore, we intuitively relate our proposal with adaptive kernel density estimation models. The experimental results show that hybrid semiparametric Bayesian networks are a valuable contribution when dealing with data that do not meet the parametric assumptions that are expected for other models, such as conditional linear Gaussian Bayesian networks. We include experiments with synthetic data and real-world data from the UCI repository which demonstrate the good performance and the ability to extract useful information about the relationship between the variables in the model.

Multi-Centroid Hyperdimensional Computing Approach for Epileptic Seizure Detection

Long-term monitoring of patients with epilepsy presents a challenging problem from the engineering perspective of real-time detection and wearable devices design. It requires new solutions that allow continuous unobstructed monitoring and reliable detection and prediction of seizures. A high variability in the electroencephalogram (EEG) patterns exists among people, brain states, and time instances during seizures, but also during non-seizure periods. This makes epileptic seizure detection very challenging, especially if data is grouped under only seizure (ictal) and non-seizure (inter-ictal) labels. Hyperdimensional (HD) computing, a novel machine learning approach, comes in as a promising tool. However, it has certain limitations when the data shows a high intra-class variability. Therefore, in this work, we propose a novel semi-supervised learning approach based on a multi-centroid HD computing. The multi-centroid approach allows to have several prototype vectors representing seizure and non-seizure states, which leads to significantly improved performance when compared to a simple single-centroid HD model. Further, real-life data imbalance poses an additional challenge and the performance reported on balanced subsets of data is likely to be overestimated. Thus, we test our multi-centroid approach with three different dataset balancing scenarios, showing that performance improvement is higher for the less balanced dataset. More specifically, up to 14% improvement is achieved on an unbalanced test set with 10 times more non-seizure than seizure data. At the same time, the total number of sub-classes is not significantly increased compared to the balanced dataset. Thus, the proposed multi-centroid approach can be an important element in achieving a high performance of epilepsy detection with real-life data balance or during online learning, where seizures are infrequent.

Systematic Assessment of Hyperdimensional Computing for Epileptic Seizure Detection

Hyperdimensional computing is a promising novel paradigm for low-power embedded machine learning. It has been applied on different biomedical applications, and particularly on epileptic seizure detection. Unfortunately, due to differences in data preparation, segmentation, encoding strategies, and performance metrics, results are hard to compare, which makes building upon that knowledge difficult. Thus, the main goal of this work is to perform a systematic assessment of the HD computing framework for the detection of epileptic seizures, comparing different feature approaches mapped to HD vectors. More precisely, we test two previously implemented features as well as several novel approaches with HD computing on epileptic seizure detection. We evaluate them in a comparable way, i.e., with the same preprocessing setup and with identical performance measures. We use two different datasets in order to assess the generalizability of our conclusions. The systematic assessment involved three primary aspects relevant for potential wearable implementations: 1) detection performance, 2) memory requirements, and 3) computational complexity. Our analysis shows a significant difference in detection performance between approaches, but also that the ones with the highest performance might not be ideal for wearable applications due to their high memory or computational requirements. Furthermore, we evaluate a post-processing strategy to adjust the predictions to the dynamics of epileptic seizures, showing that performance is significantly improved in all the approaches and also that after post-processing, differences in performance are much smaller between approaches.

ReLearn: A Robust Machine Learning Framework in Presence of Missing Data for Multimodal Stress Detection from Physiological Signals. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021;2021:535-541. [PMID: 34891350 DOI: 10.1109/embc46164.2021.9630040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Continuous and multimodal stress detection has been performed recently through wearable devices and machine learning algorithms. However, a well-known and important challenge of working on physiological signals recorded by conventional monitoring devices is missing data due to sensors insufficient contact and interference by other equipment. This challenge becomes more problematic when the user/patient is mentally or physically active or stressed because of more frequent conscious or subconscious movements. In this paper, we propose ReLearn, a robust machine learning framework for stress detection from biomarkers extracted from multimodal physiological signals. ReLearn effectively copes with missing data and outliers both at training and inference phases. ReLearn, composed of machine learning models for feature selection, outlier detection, data imputation, and classification, allows us to classify all samples, including those with missing values at inference. In particular, according to our experiments and stress database, while by discarding all missing data, as a simplistic yet common approach, no prediction can be made for 34% of the data at inference, our approach can achieve accurate predictions, as high as 78%, for missing samples. Also, our experiments show that the proposed framework obtains a cross-validation accuracy of 86.8% even if more than 50% of samples within the features are missing.

ReBeatICG: Real-time Low-Complexity Beat-to-beat Impedance Cardiogram Delineation Algorithm

This work presents ReBeatICG, a real-time, low-complexity beat-to-beat impedance cardiography (ICG) delineation algorithm that allows hemodynamic parameters monitoring. The proposed procedure relies only on the ICG signal compared to most algorithms found in the literature that rely on synchronous electrocardiogram signal (ECG) recordings. ReBeatICG was designed with implementation on an ultra-low-power microcontroller (MCU) in mind. The detection accuracy of the developed algorithm is tested against points manually labeled by cardiologists. It achieves a detection Gmean accuracy of 94.9%, 98.6%, 90.3%, and 84.3% for the B, C, X, and O characteristic points, respectively. Furthermore, several hemodynamic parameters were calculated based on annotated characteristic points and compared with values generated from the cardiologists' annotations. ReBeatICG achieved mean error rates of 0.11 ms, 9.72 ms, 8.32 ms, and 3.97% for HR, LVET, IVRT, and relative C-point amplitude, respectively.

MBioTracker: Multimodal Self-Aware Bio-Monitoring Wearable System for Online Workload Detection

Cognitive workload affects operators' performance principally in high-risk or time-demanding situations and when multitasking is required. An online cognitive workload monitoring system can provide valuable inputs to decision-making instances, such as the operator's state of mind and resulting performance. Therefore, it can allow potential adaptive support to the operator. This work presents a new design of a wearable embedded system for online cognitive workload monitoring. This new wearable system consists of, on the hardware side, a multi-channel physiological signals acquisition (respiration cycles, heart rate, skin temperature, and pulse waveform) and a low-power processing platform. Further, on the software side, our wearable embedded system includes a novel energy-aware bio-signal processing algorithm. We also use the concept of application self-awareness to enable energy-scalable embedded machine learning algorithms and methods for online subjects' cognitive workload monitoring. Our results show that this new wearable system can continuously monitor multiple bio-signals, compute their key features, and provide reliable detection of high and low cognitive workload levels with a time resolution of 1 minute and a battery lifetime of 14.58 h in our experimental conditions. It achieves a detection accuracy of 76.6% (2.6% lower than analogous offline computer-based analysis) with a sensitivity of 77.04% and a specificity of 81.75%, on a simulated drone rescue mission task. Moreover, by applying our self-aware monitoring to exploit different energy-scalable modes, we can increase battery lifetime by 51.6% (up to 22.11 hours) while incurring an insignificant accuracy loss of 1.07%.

CAFS: Cost-Aware Features Selection Method for Multimodal Stress Monitoring on Wearable Devices

OBJECTIVE

Today, stress monitoring on wearable devices is challenged by the tension between high-detection accuracy and battery lifetime driven by multimodal data acquisition and processing. Limited research has addressed the classification cost on multimodal wearable sensors, particularly when the features are cost-dependent. Thus, we design a Cost-Aware Feature Selection (CAFS) methodology that trades-off between prediction-power and energy-cost for multimodal stress monitoring.

METHODS

CAFS selects the most important features under different energy-constraints, which allows us to obtain energy-scalable stress monitoring models. We further propose a self-aware stress monitoring method that intelligently switches among the energy-scalable models, reducing energy consumption.

RESULTS

Using CAFS methodology on experimental data and simulation, we reduce the energy-cost of the stress model designed without energy constrains up to 94.37%. We obtain 90.98% and 95.74% as the best accuracy and confidence values, respectively, on unseen data, outperforming state-of-the-art studies. Analyzing our interpretable and energy-scalable models, we showed that simple models that use only heart rate (HR) or skin conductance level (SCL), confidently predict stress for HR >93.30 BPM and non-stress for SCL <6.42S, but, outside these values, a multimodal model using respiration and pulse waves features is needed for confident stress classification. Our self-aware stress monitoring proposal saves10x energy and provides 88.72% of ac-curacy on unseen data.

CONCLUSION

We propose a comprehensive solution for the design of cost-aware stress monitoring addressing the problem of selecting an optimal feature subset considering their cost-dependency and cost-constrains. Significant: Our design framework enables long-term, confident, and accurate stress monitoring on wearable devices.

Personalized Real-Time Federated Learning for Epileptic Seizure Detection

Epilepsy is one of the most prevalent paroxystic neurological disorders. It is characterized by the occurrence of spontaneous seizures. About 1 out of 3 patients have drug-resistant epilepsy, thus their seizures cannot be controlled by medication. Automatic detection of epileptic seizures can substantially improve the patient's quality of life. To achieve a high-quality model, we have to collect data from various patients in a central server. However, sending the patient's raw data to this central server puts patient privacy at risk and consumes a significant amount of energy. To address these challenges, in this work, we have designed and evaluated a standard federated learning framework in the context of epileptic seizure detection using a deep learning-based approach, which operates across a cluster of machines. We evaluated the accuracy and performance of our proposed approach on the NVIDIA Jetson Nano Developer Kit based on the EPILEPSIAE database, which is one of the largest public epilepsy datasets for seizure detection. Our proposed framework achieved a sensitivity of 81.25%, a specificity of 82.00%, and a geometric mean of 81.62%. It can be implemented on embedded platforms that complete the entire training process in 1.86 hours using 344.34 mAh energy on a single battery charge. We also studied a personalized variant of the federated learning, where each machine is responsible for training a deep neural network (DNN) to learn the discriminative electrocardiography (ECG) features of the epileptic seizures of the specific person monitored based on its local data. In this context, the DNN benefitted from a well-trained model without sharing the patient's raw data with a server or a central cloud repository. We observe in our results that personalized federated learning provides an increase in all the performance metric, with a sensitivity of 90.24%, a specificity of 91.58%, and a geometric mean of 90.90%.

Real-Time EEG-Based Cognitive Workload Monitoring on Wearable Devices

OBJECTIVE

Cognitive workload monitoring (CWM) can enhance human-machine interaction by supporting task execution assistance considering the operators cognitive state. Therefore, we propose a machine learning design methodology and a data processing strategy to enable CWM on resource-constrained wearable devices.

METHODS

Our CWM solution is built upon edge computing on a simple wearable system, with only four peripheral channels of electroencephalography (EEG). We assess our solution on experimental data from 24 volunteers. Moreover, to overcome the system's memory constraints, we adopt an optimization strategy for model size reduction and a multi-batch data processing scheme for optimizing RAM memory footprint. Finally, we implement our data processing strategy on a state-of-the-art wearable platform and assess its execution and system battery life.

RESULTS

We achieve an accuracy of 74.5% and a 74.0% geometric mean between sensitivity and specificity for CWM classification on unseen data. Besides, the proposed model optimization strategy generates a 27.5x smaller model compared to the one generated with default parameters, and the multi-batch data processing scheme reduces RAM memory footprint by 14x compared to a single batch data processing. Finally, our algorithm uses only 1.28% of the available processing time, thus, allowing our system to achieve 28.5 hours of battery life.

CONCLUSION

We provide a reliable and optimized CWM solution using wearable devices, enabling more than a day of operation on a single battery charge.

SIGNIFICANCE

The proposed methodology enables real-time data processing on resource-constrained devices and supports real-time wearable monitoring based on EEG for applications as CWM in human-machine interaction.

The COUGHVID crowdsourcing dataset, a corpus for the study of large-scale cough analysis algorithms

Cough audio signal classification has been successfully used to diagnose a variety of respiratory conditions, and there has been significant interest in leveraging Machine Learning (ML) to provide widespread COVID-19 screening. The COUGHVID dataset provides over 25,000 crowdsourced cough recordings representing a wide range of participant ages, genders, geographic locations, and COVID-19 statuses. First, we contribute our open-sourced cough detection algorithm to the research community to assist in data robustness assessment. Second, four experienced physicians labeled more than 2,800 recordings to diagnose medical abnormalities present in the coughs, thereby contributing one of the largest expert-labeled cough datasets in existence that can be used for a plethora of cough audio classification tasks. Finally, we ensured that coughs labeled as symptomatic and COVID-19 originate from countries with high infection rates. As a result, the COUGHVID dataset contributes a wealth of cough recordings for training ML models to address the world's most urgent health crises.

Interpreting deep learning models for epileptic seizure detection on EEG signals

While Deep Learning (DL) is often considered the state-of-the art for Artificial Intel-ligence-based medical decision support, it remains sparsely implemented in clinical practice and poorly trusted by clinicians due to insufficient interpretability of neural network models. We have approached this issue in the context of online detection of epileptic seizures by developing a DL model from EEG signals, and associating certain properties of the model behavior with the expert medical knowledge. This has conditioned the preparation of the input signals, the network architecture, and the post-processing of the output in line with the domain knowledge. Specifically, we focused the discussion on three main aspects: (1) how to aggregate the classification results on signal segments provided by the DL model into a larger time scale, at the seizure-level; (2) what are the relevant frequency patterns learned in the first convolutional layer of different models, and their relation with the delta, theta, alpha, beta and gamma frequency bands on which the visual interpretation of EEG is based; and (3) the identification of the signal waveforms with larger contribution towards the ictal class, according to the activation differences highlighted using the DeepLIFT method. Results show that the kernel size in the first layer determines the interpretability of the extracted features and the sensitivity of the trained models, even though the final performance is very similar after post-processing. Also, we found that amplitude is the main feature leading to an ictal prediction, suggesting that a larger patient population would be required to learn more complex frequency patterns. Still, our methodology was successfully able to generalize patient inter-variability for the majority of the studied population with a classification F1-score of 0.873 and detecting 90% of the seizures.

EpilepsyGAN: Synthetic Epileptic Brain Activities With Privacy Preservation

Epilepsy is a chronic neurological disorder affecting more than 65 million people worldwide and manifested by recurrent unprovoked seizures. The unpredictability of seizures not only degrades the quality of life of the patients, but it can also be life-threatening. Modern systems monitoring electroencephalography (EEG) signals are being currently developed with the view to detect epileptic seizures in order to alert caregivers and reduce the impact of seizures on patients' quality of life. Such seizure detection systems employ state-of-the-art machine learning algorithms that require a large amount of labeled personal data for training. However, acquiring EEG signals during epileptic seizures is a costly and time-consuming process for medical experts and patients. Furthermore, this data often contains sensitive personal information, presenting privacy concerns. In this work, we generate synthetic seizure-like brain electrical activities, i.e., EEG signals, that can be used to train seizure detection algorithms, alleviating the need for sensitive recorded data. Our experiments show that the synthetic seizure data generated with our GAN model succeeds at preserving the privacy of the patients without producing any degradation in performance during seizure monitoring.

ISLPED 2020: An Experience of Virtual Conference during COVID-19 Time

The abstract and full paper deadlines for International Symposium on Low Power Electronics and Design (ISLPED) were March 16th and 23rd, 2020. On March 11, 2020, the World Health Organization (WHO) announced COVID-19 a pandemic and in the following weeks many countries and states immediately issued stay-at-home order. This situation adversely affected the submission to the conference. The conference received 123 legitimate full paper submissions, which is 25% lower than last year. The majority of the submissions were from America (57%), Asia (26%), and Europe (16%). The main contact authors come from 21 different countries. Technical Program Committee consisted of 102 experts from all over the world who reviewed the submissions. The review meeting took place online on May 16, 2020. Each track had its Zoom meeting hosted by the track chair/co-chair. The committee accepted 30 regular papers (~23% acceptance rate) and 12 poster papers (~34% acceptance rate). The acceptance rate is the same as the last year.

Robust Epileptic Seizure Detection on Wearable Systems with Reduced False-Alarm Rate

Epilepsy affects more than 50 million people and ranks among the most common neurological diseases worldwide. Despite advances in treatment, one-third of patients still suffer from refractory epilepsy. Wearable devices for real-time patient monitoring can potentially improve the quality of life for such patients and reduce the mortality rate due to seizure-related accidents and sudden death in epilepsy. However, the majority of employed seizure detection techniques and devices suffer from unacceptable false-alarm rate. In this paper, we propose a robust seizure detection methodology for a wearable platform and validate it on the Physionet.org CHB-MIT Scalp EEG database. It reaches sensitivity of 0.966 and specificity of 0.925, and reducing the false-alarm rate by 34.7%. We also evaluate the battery lifetime of the wearable system including our proposed methodology and demonstrate the feasibility of using it in real time for up to 40.87 hours on a single battery charge.

Real-Time Cognitive Workload Monitoring Based on Machine Learning Using Physiological Signals in Rescue Missions

High levels of cognitive workload decreases human's performance and leads to failures with catastrophic outcomes in risky missions. Today, reliable cognitive workload detection presents a common major challenge, since the workload is not directly observable. However, cognitive workload affects several physiological signals that can be measured non-invasively. The main goal of this work is to develop a reliable machine learning algorithm to identify the cognitive workload induced during rescue missions, which is evaluated through drone control simulation experiments. In addition, we aim to minimize the computing resources usage while maximizing the cognitive workload detection accuracy for a reliable real-time operation. We perform an experiment in which 24 subjects played a rescue mission simulator while respiration, electrocardiogram, photoplethysmogram, and skin temperature signals were measured. State-of-the-art feature-based machine learning algorithms are investigated for cognitive workload characterization using learning curves, data augmentation, and cross-validation techniques. The best classification algorithm is selected, optimized, and the most informative features are selected. Finally, the generalization power of the optimized model is evaluated on an unseen test set. We obtain an accuracy level of 86% on the new unseen datasets using the proposed and optimized eXtreme Gradient Boosting (XGB) algorithm. Then, we reduce the complexity of the machine learning model for future implementation on resource-constrained wearable embedded systems, by optimizing the model and selecting the 26 most important features. Overall, a generalizable and low-complexity machine learning model for cognitive workload detection based on physiological signals is presented for the first time in the literature.

Noninvasive detection of focal seizures in ambulatory patients

Reliably detecting focal seizures without secondary generalization during daily life activities, chronically, using convenient portable or wearable devices, would offer patients with active epilepsy a number of potential benefits, such as providing more reliable seizure count to optimize treatment and seizure forecasting, and triggering alarms to promote safeguarding interventions. However, no generic solution is currently available to reach these objectives. A number of biosignals are sensitive to specific forms of focal seizures, in particular heart rate and its variability for seizures affecting the neurovegetative system, and accelerometry for those responsible for prominent motor activity. However, most studies demonstrate high rates of false detection or poor sensitivity, with only a minority of patients benefiting from acceptable levels of accuracy. To tackle this challenging issue, several lines of technological progress are envisioned, including multimodal biosensing with cross‐modal analytics, a combination of embedded and distributed self‐aware machine learning, and ultra–low‐power design to enable appropriate autonomy of such sophisticated portable solutions.

Multi-Modal Acute Stress Recognition Using Off-the-Shelf Wearable Devices

Monitoring stress and, in general, emotions has attracted a lot of attention over the past few decades. Stress monitoring has many applications, including high-risk missions and surgical procedures as well as mental/emotional health monitoring. In this paper, we evaluate the possibility of stress and emotion monitoring using off-the-shelf wearable sensors. To this aim, we propose a multi-modal machine-learning technique for acute stress episodes detection, by fusing the information careered in several biosignals and wearable sensors. Furthermore, we investigate the contribution of each wearable sensor in stress detection and demonstrate the possibility of acute stress recognition using wearable devices. In particular, we acquire the physiological signals using the Shimmer3 ECG Unit and the Empatica E4 wristband. Our experimental evaluation shows that it is possible to detect acute stress episodes with an accuracy of 84.13%, for an unseen test set, using multi-modal machinelearning and sensor-fusion techniques.

Resource-Aware Distributed Epilepsy Monitoring Using Self-Awareness From Edge to Cloud

The integration of wearable devices in humans' daily lives has grown significantly in recent years and still continues to affect different aspects of high-quality life. Thus, ensuring the reliability of the decisions becomes essential in biomedical applications, while representing a major challenge considering battery-powered wearable technologies. Transferring the complex and energy-consuming computations to fogs or clouds can significantly reduce the energy consumption of wearable devices and result in a longer lifetime of these systems with a single battery charge. In this work, we aim to distribute the complex and energy-consuming machine-learning computations between the edge, fog, and cloud, based on the notion of self-awareness that takes into account the complexity and reliability of the algorithm. We also model and analyze the trade-offs in terms of energy consumption, latency, and performance of different Internet of Things (IoT) solutions. We consider the epileptic seizure detection problem as our real-world case study to demonstrate the importance of our proposed self-aware methodology.

REWARD: Design, Optimization, and Evaluation of a Real-Time Relative-Energy Wearable R-Peak Detection Algorithm. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2019;2019:3341-3347. [PMID: 31946597 DOI: 10.1109/embc.2019.8857226]

Wearable devices are an unobtrusive, cost-effective means of continuous ambulatory monitoring of chronic cardiovascular diseases. However, on these resource-constrained systems, electrocardiogram (ECG) processing algorithms must consume minimal power and memory, yet robustly provide accurate physiological information. This work presents REWARD, the Relative-Energy-based WeArable R-Peak Detection algorithm, which is a novel ECG R-peak detection mechanism based on a nonlinear filtering method called Relative-Energy (Rel-En). REWARD is designed and optimized for real-time execution on wearable systems. Then, this novel algorithm is compared against three state-of-the-art real-time R-peak detection algorithms in terms of accuracy, memory footprint, and energy consumption. The Physionet QT and NST Databases were employed to evaluate the algorithms' accuracy and robustness to noise, respectively. Then, a 32-bit ARM Cortex-M3-based microcontroller was used to measure the energy usage, computational burden, and memory footprint of the four algorithms. REWARD consumed at least 63% less energy and 32% less RAM than the other algorithms while obtaining comparable accuracy results. Therefore, REWARD would be a suitable choice of R-peak detection mechanism for wearable devices that perform more complex ECG analysis, whose algorithms require additional energy and memory resources.

Online Obstructive Sleep Apnea Detection on Medical Wearable Sensors

Obstructive Sleep Apnea (OSA) is one of the main under-diagnosed sleep disorder. It is an aggravating factor for several serious cardiovascular diseases, including stroke. There is, however, a lack of medical devices for long-term ambulatory monitoring of OSA since current systems are rather bulky, expensive, intrusive, and cannot be used for long-term monitoring in ambulatory settings. In this paper, we propose a wearable, accurate, and energy efficient system for monitoring obstructive sleep apnea on a long-term basis. As an embedded system for Internet of Things, it reduces the gap between home health-care and professional supervision. Our approach is based on monitoring the patient using a single-channel electrocardiogram signal. We develop an efficient time-domain analysis to meet the stringent resources constraints of embedded systems to compute the sleep apnea score. Our system, for a publicly available database (PhysioNet Apnea-ECG), has a classification accuracy of up to 88.2% for our new online and patient-specific analysis, which takes the distinct profile of each patient into account. While accurate, our approach is also energy efficient and can achieve a battery lifetime of 46 days for continuous screening of OSA.

Real-Time Event-Driven Classification Technique for Early Detection and Prevention of Myocardial Infarction on Wearable Systems

A considerable portion of government health-care spending is allocated to the continuous monitoring of patients suffering from cardiovascular diseases, particularly myocardial infarction (MI). Wearable devices present a cost-effective means of monitoring patients' vital signs in ambulatory settings. A major challenge is to design such ultra-low energy devices for long-term patient monitoring. In this paper, we present a real-time event-driven classification technique based on the random forest classification scheme, which uses a confidence-related decision-making process. The main goal of this technique is to maintain a high classification accuracy while reducing the complexity of the classification algorithm. We validate our approach on a well-established and complete MI database (Physiobank, PTB Diagnostic ECG database). Our experimental evaluation demonstrates that our real-time classification scheme outperforms the existing approaches in terms of energy consumption and battery lifetime by a factor of 2.60, with no classification quality loss.

Predicted vitamin D status and colon cancer recurrence and mortality in CALGB 89803 (Alliance)

Background

Observational studies suggest that higher levels of 25-hydroxyvitamin D3 (25(OH)D) are associated with a reduced risk of colorectal cancer and improved survival of colorectal cancer patients. However, the influence of vitamin D status on cancer recurrence and survival of patients with stage III colon cancer is unknown.

Patients and methods

We prospectively examined the influence of post-diagnosis predicted plasma 25(OH)D on outcome among 1016 patients with stage III colon cancer who were enrolled in a National Cancer Institute-sponsored adjuvant therapy trial (CALGB 89803). Predicted 25(OH)D scores were computed using validated regression models. We examined the influence of predicted 25(OH)D scores on cancer recurrence and mortality (disease-free survival; DFS) using Cox proportional hazards.

Results

Patients in the highest quintile of predicted 25(OH)D score had an adjusted hazard ratio (HR) for colon cancer recurrence or mortality (DFS) of 0.62 (95% confidence interval [CI], 0.44-0.86), compared with those in the lowest quintile (Ptrend = 0.005). Higher predicted 25(OH)D score was also associated with a significant improvement in recurrence-free survival and overall survival (Ptrend = 0.01 and 0.0004, respectively). The benefit associated with higher predicted 25(OH)D score appeared consistent across predictors of cancer outcome and strata of molecular tumor characteristics, including microsatellite instability and KRAS, BRAF, PIK3CA, and TP53 mutation status.

Conclusion

Higher predicted 25(OH)D levels after a diagnosis of stage III colon cancer may be associated with decreased recurrence and improved survival. Clinical trials assessing the benefit of vitamin D supplementation in the adjuvant setting are warranted.

ClinicalTrials.gov Identifier

NCT00003835.

A Modular Low-Complexity ECG Delineation Algorithm for Real-Time Embedded Systems

This work presents a new modular and low-complexity algorithm for the delineation of the different ECG waves (QRS, P and T peaks, onsets, and end). Involving a reduced number of operations per second and having a small memory footprint, this algorithm is intended to perform real-time delineation on resource-constrained embedded systems. The modular design allows the algorithm to automatically adjust the delineation quality in runtime to a wide range of modes and sampling rates, from a ultralow-power mode when no arrhythmia is detected, in which the ECG is sampled at low frequency, to a complete high-accuracy delineation mode, in which the ECG is sampled at high frequency and all the ECG fiducial points are detected, in the case of arrhythmia. The delineation algorithm has been adjusted using the QT database, providing very high sensitivity and positive predictivity, and validated with the MIT database. The errors in the delineation of all the fiducial points are below the tolerances given by the Common Standards for Electrocardiography Committee in the high-accuracy mode, except for the P wave onset, for which the algorithm is above the agreed tolerances by only a fraction of the sample duration. The computational load for the ultralow-power 8-MHz TI MSP430 series microcontroller ranges from 0.2% to 8.5% according to the mode used.

Energy-aware embedded classifier design for real-time emotion analysis

Detection and classification of human emotions from multiple bio-signals has a wide variety of applications. Though electronic devices are available in the market today that acquire multiple body signals, the classification of human emotions in real-time, adapted to the tight energy budgets of wearable embedded systems is a big challenge. In this paper we present an embedded classifier for real-time emotion classification. We propose a system that operates at different energy budgeted modes, depending on the available energy, where each mode is constrained by an operating energy bound. The classifier has an offline training phase where feature selection is performed for each operating mode, with an energy-budget aware algorithm that we propose. Across the different operating modes, the classification accuracy ranges from 95% - 75% and 89% - 70% for arousal and valence respectively. The accuracy is traded off for less power consumption, which results in an increased battery life of up to 7.7 times (from 146.1 to 1126.9 hours).

Early classification of pathological heartbeats on wireless body sensor nodes

Smart Wireless Body Sensor Nodes (WBSNs) are a novel class of unobtrusive, battery-powered devices allowing the continuous monitoring and real-time interpretation of a subject's bio-signals, such as the electrocardiogram (ECG). These low-power platforms, while able to perform advanced signal processing to extract information on heart conditions, are usually constrained in terms of computational power and transmission bandwidth. It is therefore essential to identify in the early stages which parts of an ECG are critical for the diagnosis and, only in these cases, activate on demand more detailed and computationally intensive analysis algorithms. In this work, we present a comprehensive framework for real-time automatic classification of normal and abnormal heartbeats, targeting embedded and resource-constrained WBSNs. In particular, we provide a comparative analysis of different strategies to reduce the heartbeat representation dimensionality, and therefore the required computational effort. We then combine these techniques with a neuro-fuzzy classification strategy, which effectively discerns normal and pathological heartbeats with a minimal run time and memory overhead. We prove that, by performing a detailed analysis only on the heartbeats that our classifier identifies as abnormal, a WBSN system can drastically reduce its overall energy consumption. Finally, we assess the choice of neuro-fuzzy classification by comparing its performance and workload with respect to other state-of-the-art strategies. Experimental results using the MIT-BIH Arrhythmia database show energy savings of as much as 60% in the signal processing stage, and 63% in the subsequent wireless transmission, when a neuro-fuzzy classification structure is employed, coupled with a dimensionality reduction technique based on random projections.

Automated real-time atrial fibrillation detection on a wearable wireless sensor platform

This paper presents an automated real-time atrial fibrillation (AF) detection approach that relies on the observation of two characteristic irregularities of AF episodes in the electrocardiogram (ECG) signal. The results generated after the analysis of these irregularities are subsequently analyzed in real-time using a new fuzzy classifier. We have optimized this novel AF classification framework to require very limited processing, memory storage and energy resources, which makes it able to operate in real-time on a wearable wireless sensor platform. Moreover, our experimental results indicate that the proposed on-line approach shows a similar accuracy to state-of-the-art off-line AF detectors, achieving up to 96% sensitivity and 93% specificity. Finally, we present a detailed energy study of each component of the target wearable wireless sensor platform, while executing the automated AF detection approach in a real operating scenario, in order to evaluate the lifetime of the overall system. This study indicates that the lifetime of the platform is increased by using the proposed method to detect AF in real-time and diagnose the patient with respect to a streaming application that sends the raw signal to a central coordinator (e.g., smartphone or laptop) for its ulterior processing.

Effects of age, sex, and treatment on weight-loss dynamics in overweight people

The objective of this work was to evaluate how sex, age, and the kind of treatment followed affect weight loss in overweight men and women, as well as to develop an explanation for the evolution of weight-loss dynamics. The study consisted of 119 overweight participants (18-50 years old, body mass index >25 and <29.9 kg·m(-2)), who were randomly assigned to 1 of 4 treatment programs, namely, strength training (n = 30), endurance training (n = 30), a combination of strength training and endurance training (n = 30), and a careful treatment including diet and physical recommendations (n = 29). Each of the training groups exercised 3 times per week for 24 weeks, and their daily diet was restricted to a specific protocol during the testing period and controlled carefully. Body weight changes in the participants were evaluated every 15 days. Based on this study, we developed and validated different sets of equations to accurately capture the weight-loss dynamics. There were no significant differences in terms of global body weight changes from the statistical viewpoint, either regarding the carried out treatment or the individuals' ages. However, significant differences in weight-loss tendency were found depending on participant sex. We concluded that the effectiveness of different possible treatments for weight loss varies by sex and, based on our experimental observations, a quadratic function provides the most accurate model for capturing specific weight-loss dynamics. This trial is registered at Clinical Trials Gov.: number NCT01116856.

[A new species of amphipod crustacean of the genus Amphilochus (Crustacea, Amphipoda, Amphilochidae) from Venezuela]

A new species of amphipod Crustacea (Gammaridea, Amphilochidae) of the genus Amphilochus Bate, 1862, is described. The species was collected in Phallusia nigra (Savigny, 1816) at depths between 0 and 2 m, in the pier piles of the Marina El Ancla and Los Manglares gas station in Morrocoy National Park (Falcón State, Venezuela), during the months of June and July 1998. The main differences between A. ascidicola new species and all others species of the genus recorded from the Gulf of Mexico and the Caribbean Sea, are given.

Severe diabetic retinopathy after cataract surgery

We retrospectively compared the visual acuity and degree of background diabetic retinopathy in 32 consecutive patients with diabetes who had cataract surgery in one eye (study group) and compared them with the visual acuity and degree of diabetic retinopathy in 32 patients with diabetes who had not had cataract surgery (control group) to determine if the retinopathy was asymmetric and worse in the operated-on eye. Twenty-three (72%) of the 32 study patients had asymmetric retinopathy (with the more severe retinopathy in the eye that underwent cataract surgery in each case) compared with three (9%) of the control group (P < .0005). The eyes that had cataract surgery did poorly in terms of visual acuity with no eyes achieving 20/20 or 20/25, only three eyes achieving 20/30 or 20/40, and 16 achieving 20/100 or worse.