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Multistage sequential decision-making scenarios are commonly seen in the healthcare diagnosis process. In this paper, an active learning-based method is developed to actively collect only the necessary patient data in a sequential manner. There are two novelties in the proposed method. First, unlike the existing ordinal logistic regression model which only models a single stage, we estimate the parameters for all stages together. Second, it is assumed that the coefficients for common features in different stages are kept consistent. The effectiveness of the proposed method is validated in both a simulation study and a real case study. Compared with the baseline method where the data is modeled individually and independently, the proposed method improves the estimation efficiency by 62\%-1838\%. For both simulation and testing cohorts, the proposed method is more effective, stable, interpretable, and computationally efficient on parameter estimation. The proposed method can be easily extended to a variety of scenarios where decision-making can be done sequentially with only necessary information.

No current data exists regarding the occurrence of pathological results when using Whole Exome Sequencing (WES) analysis in a subgroup of fetuses with minor abnormalities and normal Chromosomal Microarray Analysis (CMA) results.Our study aimed to report our experience with in-utero WES abnormal results, found in fetuses with minor anomalies after a normal CMA result.A retrospective study conducted in a single tertiary center, during four years, included collating data regarding fetuses with minor structural abnormalities, normal CMA results, and abnormal triple WES test results.Eleven fetuses were included in the study. Eight were with cardiovascular and lymphatic drainage alterations. Two fetuses developed late third-trimester macrocephaly (head circumference ≥ +2 standard deviations), and one fetus had unilateral mildly short and bowed femur bone. In seven cases (63.6%) the parents opted to terminate the pregnancy as a result of the WES analysis results.Our case series raises the possibility that fetuses with even minor structural alterations and normal CMA results can have genetic variants revealable only by WES analysis which can provide critical information regarding pregnancy management.

The core feature of parliamentary democracy is government responsibility to the legislature. The most important instrument by which parliament can express its lack of support for the government is ...

Placenta accreta spectrum constitutes one of the most complicated challenges in modern obstetrics. Given the conflicting data regarding the added value of MRI in the diagnosis of invasive placentation, we aim to assess individual and combined ability of multiple sonographic and MRI signs to diagnose placenta accreta spectrum in suspected cases.We assessed 28 cases of suspected placenta accreta spectrum in the third trimester. All cases underwent ultrasound assessment as well as MRI scan. Diagnosis was confirmed during surgery. The value of sonographic and MRI signs in the detection of placenta accreta spectrum was assessed.A total of 23 cases were diagnosed with placenta accreta spectrum during cesarean delivery. Overall, ultrasound was found to be more sensitive and specific compared to MRI (sensitivity of 0.96 and specificity of 0.6 in ultrasound vs. sensitivity of 0.83 and specificity of 0.4 in MRI). However, the use of a post-hoc structured model improved MRI performance to a similar level of ultrasound (sensitivity of 0.96 and specificity of 0.6).Ultrasound is superior to MRI in the detection of placenta accreta spectrum. However, MRI performance can be greatly improved by the use of a structured scoring system.

Levantine adaptive water subsistence and exploitative water management studies concerning late pre- and proto-history have intensified since 2000. This comes in the wake of findings concerning dome...

Earlier ascending/descending trust spirals were explained by the job-discretion allowed to employees by managers; few studied such spirals as it required bi-directional longitudinal framework. Such a framework used ethnographies of managers who “jumped” from other organizations and suffered gaps of knowledge that curbed their psychological safety for gap-exposing vulnerable involvement in locals’ deliberations required for trust building; mostly they were detached or autocratic and generated descending trust spirals which barred locals’ knowledge-sharing. In their ignorance they used immoral subterfuge, furthered distrust, shaped low-trust cultures, and mismanaged. However, detached/autocratic “jumpers” often managed mediocrely by “riding” on the successes of trusted vulnerably-involved mid-levelers. Only a few “jumpers” generated ascending trust spirals by vulnerable involvement, learned from and with locals, and succeeded by high-trust innovation-prone cultures. Contextual factors helped explain choices of practicing/avoiding vulnerable involvement and generating ascending/ descending trust spirals. Further study of these choices and these factors is suggested.

Myeloablative doses of busulfan (Bu) with fludarabine (Flu) have reduced toxicity, however, limited by an increased relapse rate. We aimed to improve outcome of Flu-Bu regimen by augmentation with thiotepa (TT) (10 mg/kg). Eighty-nine patients with AML, 44 patients conditioned with Flu-Bu (group 1), and 45 patients augmented with TT (Flu-Bu-TT, group 2), were retrospectively analyzed. Primary objectives were toxicity and outcomes. Major toxicities were comparable: mucositis (p = 1.0), sepsis (p = .7), severe venocclusive disease of liver (VOD) (p = 1.0), and non-relapse mortality (NRM) (22 vs. 22%, p = .7). Five-year disease-free survival was significantly better in group 2 compared to group 1 (62 vs. 38%, p = .02). Five-year overall survival (OS) showed trend toward benefit in group 2 (62 vs. 42%, p = .06). Lower relapse rate in group 2 (14 vs. 46%, p = .005) contributed to better outcomes. Augmented regimen has better disease-free survival (DFS) (mainly due to reduced relapse rate) and similar toxicities as compared to Flu-Bu. Key points Assessing the addition of TT to myeloablative conditioning (Flu, Bu) in patients undergoing allogeneic stem cell transplant for acute myeloid leukemia with regard to relapse rate, disease-free survival and toxicity. Addition of thiotepa improves disease-free survival and shows trend toward benefit in overall survival, by reducing relapses without additional toxicity.

Objectives: To assess if measurement of the head progression distance (PD) during the first stage of labor in nulliparous women can predict the delivery method.Methods: A prospective study was cond...

The COVID-19 outbreak caused persons to be reluctant to seek medical care due to fear of contracting the infection.To evaluate the effect of the COVID-19 pandemic on admission rates to the delivery room and the feto-maternal unit, and to assess the effect on the nature of presenting obstetrical complaints to the emergency department.A retrospective cohort study in one medical center. The population was women20 weeks pregnant who presented to the obstetrical emergency department with self-complaints during 29 days at the peak of the pandemic outbreak, and a matched group during the exact period in the previous year. We compared between the groups: clinical, obstetrical, and demographic data, including age, area of residence, gravidity, parity, previous cesarean deliveries, high-risk pregnancy follow-up, the last 30 days admissions to the obstetrical emergency department, gestational age, chief complaints, cervical dilatation, cervical effacement, admissions to the delivery room or feto-maternal unit, time from admissions to the delivery room to birth, if applicable, and acute obstetrical complications diagnosed at the emergency department.During the pandemic outbreak, 398 women met study inclusion criteria, compared to 544 women in the matched period of the previous year. During the COVID-19 period, women visited the obstetrical emergency department at a more advanced mean gestational age (37.6 ± 3.7 vs. 36.7 ± 4.6,The pandemic outbreak of COVID-19 caused a behavioral change among women who presented to the obstetrical emergency department. This was characterized by delayed arrival to the obstetrical emergency department and the delivery room, which led to a significant increase in urgent and acute interventions. The change in behavior did not affect the rates of maternal and neonatal morbidity.

Pigmentary retinal dystrophy and macular dystrophy have been previously reported in Heimler syndrome due to mutations in PEX1. Here we reported the ocular manifestations in Heimler syndrome due to mutations in PEX6.Medical records were reviewed to identify patient demographics, ophthalmic and systemic findings, and results of diagnostic testing including whole genome sequencing.Patient 1 is 12-year-old boy with a novel mutation c.275TG (p.Val92Gly) and known mutation c.1802GA (p.Arg601Gln) in PEX6. Patient 2 is a 7-year-old girl with the same known c.1802GA (p.Arg601Gln) mutation and another novel missense mutation c.296GT (p.Arg99Leu). Both patients exhibited a pigmentary retinopathy. Visual acuity in patient 1 was 20/80 and 20/25 following treatment of intraretinal cystoid spaces with carbonic anhydrase inhibitors, while patient 2 had visual acuity of 20/20 in both eyes without intraretinal cysts. Fundus autofluorescence showed a multitude of hyperfluorescent deposits in the paramacular area of both eyes. OCTs revealed significant depletion of photoreceptors in both patients and macular intraretinal cystoid spaces in one patient. Full field electroretinograms showed normal or abnormal photopic but normal scotopic responses. Multifocal electroretinograms were abnormal.Heimler syndrome due to biallelic PEX6 mutations demonstrates a macular dystrophy with characteristic fundus autofluorescence and may be complicated by intraretinal cystoid spaces.

Mechanical designers strive to create a simple design that will reduce product's cost and increase its reliability. This paper presents an experimental method for measuring the simplicity of a mechanical design. It also presents a quantitative metric for evaluating the simplicity of product design based on quantifiable design parameters. The simplicity metric was developed by using experts’ evaluations of functionally equivalent products. The dominant parameter for predicting an expert's simplicity rating is the number of features required to fully define the examined computer-aided design (CAD) model. This parameter is highly correlated with two additional measured design parameters: number of parts and number of interfaces between parts.

PEGylated asparaginase (pegaspargase) can be administered via intramuscular (IM) injection or intravenous (IV) infusion with a hypersensitivity reaction (HSR) incidence ranging 3–41%. We evaluated grade ≥3 HSRs when given IM vs. IV on six Children’s Oncology Group (COG) leukemia trials (2003–2015) to determine differences in HSR rates. 54,280 doses were administered to 16,534 patients. Considering all doses of pegaspargase during induction, consolidation, and delayed intensification, grade ≥3 HSR rate with IM injection was 5.4% (n = 482/8981) compared to 3.2% for IV (n = 245/7553) (p < .0001). If only the second and third doses of pegaspargase were analyzed, where the majority of grade ≥3 HSRs occur, the rate following IM injection was 10.1% (n = 459/4534) compared to 5.0% (n = 222/4443) for IV (p < .0001). On standardized treatment protocols conducted by the COG during 2003–2015, grade ≥3 HSR rates to pegaspargase occurred less frequently with IV infusion than IM injection.

Technologies for the detection of minimal residual disease (MRD) in leukemia and our understanding of the prognostic implications of MRD at different phases of treatment have significantly improved over the past decade. As a result, definitions of treatment failure based on bone marrow morphology by light microscopy are becoming increasingly inadequate for clinical care and trial design. In addition, novel therapies that may have increased efficacy and decreased toxicity in the setting of MRD compared to overt disease are changing clinical practice and challenging investigators to redefine treatment failure, the role of disease surveillance in remission, and clinical trial eligibility in the era of MRD.

The purpose of this study is to describe the morphological characteristics of fetal MRIs and outcome of prenatally-detected abnormal width of the CSP (cavum septum pellucidum).A retrospective study of cases with abnormal width of the CSP demonstrated prenatally on MRI. Data collected included: prenatal history, MRI features, sonographic follow up, and neurodevelopmental outcome.Most of the cases referred (34/39) had an abnormal CSP on MRI. Thirty cases had an abnormal width: 23 had narrow CSP and seven had wide CSP. Only three out of 12 cases that were referred with US diagnosis of absent CSP were confirmed by MRI, the rest had narrow CSP. Follow up was performed in 24 out of 30 cases with an abnormal CSP width; all had normal neurodevelopment.To the best of our knowledge, this is the first study to examine the outcome in narrow and wide CSPs detected prenatally. An abnormal width of the CSP prenatally, without an associated fetal abnormality such as aneuploidy, appears to have normal outcome. MRI should be offered when an absence of the CSP is suspected on US to rule out narrow CSP, which seems to be a benign finding.

The objective of this study is to determine the clinical significance of maternal and fetal ultrasound Doppler flow indices in postdates pregnancies.This prospective study comprised 120 low-risk pregnant women beyond 40 weeks of gestation. All participants underwent Doppler assessment including of fetal middle cerebral artery (MCA), umbilical, and uterine arteries. Perinatal outcomes were recorded and evaluated for possible associations with Doppler flow values. Adverse perinatal outcomes were defined as umbilical cord arterial pH7.1, Apgar score7 at 5 min, neonatal admission to a neonatal intensive care unit, and emergency cesarean section due to abnormal intrapartum cardiotocogram Results: Adverse perinatal outcome rate was 17.5% (n = 21). Doppler indices of umbilical artery, MCA, uterine artery and the cerebroplacental ratio (CPR) did not differ significantly between pregnant women with and without adverse perinatal outcomes. Neonatal birth weight was found to correlate negatively with umbilical artery Doppler indices, including the peak systolic to end diastolic ratio (p = .04), the resistance index (p = .02), and the pulsatility index (p = .01). Doppler values of the uterine artery, MCA and CPR did not correlate with neonatal birth weight.The contribution of maternal and fetal ultrasound Doppler to the prediction of adverse perinatal outcomes in low-risk postdates pregnancies is low. Hence, performing routine Doppler examination as part of postdates pregnancy assessments is unlikely to yield significant clinical benefit.

To investigate the correlation between the angle of progression and the clinical fetal head station (FHS) during the second stage of labor, and to build reference range.A prospective, observational study was conducted. Women carrying singleton term pregnancies were enrolled during the second stage of labor. FHS was assessed manually by a senior obstetrician, while the angle of progression (AOP) was assessed by transperineal ultrasound (TPU). Both examiners were blinded to each others results. The correlation between the sonographic AOP and the clinical FHS was analyzed.Seventy patients comprised the study group. Clinical FHS demonstrated an excellent correlation with the sonographic measurement of AOP (Pearson's Correlation 0.642, p 0.001). This correlation was best described by a cubic regression according to the formula: 123.800 + 10.290 × FHS -2.889 * FHS +0.910, (rOur results demonstrate a significant correlation between the clinical FHS and the TPU measured AOP. These standardized sonographic values may serve the obstetrician as a reliable, objective auxiliary tool for the evaluation of the FHS during the second stage of labor.

No study thus far has evaluated the LUS thickness in active labor. In this study, we endeavored to assess the LUS during active labor.Using transabdominal sonography in the mid-sagittal position with a full urinary bladder, the thickness of the LUS was measured during active labor phase in women with or without a history of a previous cesarean section.A total of 28 women with a previous cesarean delivery were compared to 29 women without a history of uterine surgery. The median LUS was significantly thinner in women with a uterine scar both during (4 versus 5 mm, p = .001) and between contractions (5 versus 7 mm, p = .011). Paired comparison of LUS thickness between and during contractions within each group showed that thinning of LUS during contraction was significant for both the previous CS group (p .001) and the control group (p .001). We found no correlation between LUS thickness and chances of successful TOLAC.In this study, we characterized for the first time the LUS during active labor. We found that LUS was significantly thinner in women after a previous CS and that the LUS was significantly thinner during contraction.

The aim of our study was to assess the agreement between pre- and post-natal measurements in prenatal isolated ventriculomegaly.Ninety-two women were referred for lateral ventricular abnormality and followed prospectively. Cases with at least one dilated lateral ventricle ≥10 mm and a normal work up (serological tests, detailed anatomical scan, fetal brain MR imaging, genetic counseling, and amniocentesis) were considered idiopathic ventriculomegaly and comprised the study group for post-natal follow up. Prenatal measurements were performed by ultrasound and MR imaging. Post-natal measurements were performed by cranial sonography at age of 1-3 months. Measurements were performed in the customary plane for each modality. Paired Student's t test was used to assess the mean difference between pre- and postnatal measurements.Forty three cases comprised the study group for post-natal measurements. A statistically significant decrease in ventricular width (p .001) was observed between pre- and post-natal measurements. On clinical follow up for 24 months, all cases were normal except three who demonstrated very mild neurological deficits.Our study indicates statistically significant regression of prenatal isolated ventriculomegaly in the post-natal period.

To assess the mid-trimester triple test biomarkers among women diagnosed with vasa previa (VP).The study included 43 singleton pregnancies diagnosed with vasa previa between the years 1988 and 2011. The mid-gestation screening test for Down syndrome was calculated from the combination of triple serum markers and maternal age, and expressed as a multiple of the gestation specific normal mean (MoM). Reference MoM values were calculated from the local population. The levels of mid-gestation maternal serum alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and unconjugated estriol (uE3) of patients with VP were compared with control reference group.The mean hCG and αFP levels of women diagnosed with VP was significantly higher compared to control reference group (1.42 versus 0.99 MoM; p .002 and 1.24 versus1.01 MoM; p .001, respectively). In contrast, there was no significant difference in uEOur findings suggest that increased mid-gestation hCG and AFP were found among pregnancies complicated with VP. Clinicians should consider targeted scanning of pregnant women with risk factors for VP, including unexplained high maternal levels of hCG and αFP of the triple test, while conducting mid-gestation anomaly scan.

An artificial pacemaker is a small medical device that uses electrical impulses, delivered by electrodes contracting the heart muscles, to regulate the beating of the heart. The pacemaker is implanted under the skin, and uses for many years regular non-rechargeable batteries. However, the demand for rechargeable batteries in pacemakers increased, and the aim of this work is to design an efficient charging system for pacemakers.

The purpose of this study was to describe fetal brain anomalies identified during nuchal translucency (NT) examination and their clinical management.In this retrospective study, we evaluated charts of pregnant women performed the first trimester scan (FTS) between 1.1.2011 and 31.12.14 in a tertiary referral center. Study population consisted of 952 patients scheduled for routine NT scan for aneuploidy screening between 11.0 and 13.6 gestational weeks, and 32 referred patients due to suspicious CNS finding during previous NT scan. Targeted brain assessment was performed according to clinical judgment during routine scans and in all referred cases. Patients with suspicious CNS findings were referred to pregnancy termination or further evaluation including genetic consultation and second trimester anatomical scan.Thirty-one fetuses were diagnosed with variable brain anomalies. Acrania/anencephaly was the most common defect (nine cases) while the rarest findings were inter-hemispheric cyst, microcephaly, and Walker-Warburg Syndrome (one case each). Genetic testing revealed variable results. Twenty-six (83.9%) couples decided to terminate their pregnancies.The current report highlights the evolving ability to detect CNS malformation during NT scan. FTS novel findings expand our embryological understanding of early fetal development. While severe anomalies can be managed by early termination, other defects necessitate comprehensive evaluation and repetitive imaging.

Business tax reform is coming? But even as various inequities are ironed out, will it result in major tax cuts for business? Is that justified? And reform could also be used to raise tax revenues.

Patients with severe atopic dermatitis (AD) may require potent immunosuppressive therapy to control their disease. Mycophenolate mofetil (MMF) has been suggested as a safe and effective drug in these cases.To investigate effectiveness and tolerability of oral MMF in adult patients with severe recalcitrant AD.During the years 2010-2017 oral MMF 2-3 g/day was administered to adult patients with severe recalcitrant AD who failed other major systemic drugs, or where other drugs, including cyclosporine (CSA), methotrexate, and azathioprine, were contraindicated.Of 9 consecutive adult patients, 4 (44%) responded completely, 2 (22%) had partial response, and 3 (33%) did not respond at all. The MMF therapy was continued for 5-36 months (average 21 months) without major side effects.Oral MMF may be an effective drug in AD. Due to its good safety profile, it may be recommended as a first-line systemic therapy, or successive to CSA in the long term.

To date, most studies of the Bengal tiger (Panthera tigris) are of biological research, techniques, conservation, population modeling, or tiger– human conflicts. Few studies have attempted to understand the rural population that share a region with the tigers, and some of the villages are even displaced in the name of conservation. Hence, we undertook a survey of 10 villages that are located in the buffer zone of the Bor Tiger Reserve (BTR). Most of the villagers interviewed had encountered tigers, most considered them a boon and beneficial to their livelihood, and almost all displayed environmental awareness and stressed the necessity to conserve tigers in order to ensure their own continued survival. Some stressed the religious connotation and significance because the tiger is the animal of transport of the Goddess Durga. A minority expressed a negative attitude that resulted not from damages incurred by the tigers, but from discontent following inept handling of property losses by the authoriti...

Objective: The objective of this study is to evaluate the relevance of Lp-PLA2 to risk prediction among coronary heart disease (CHD) patients. Methods: Lp-PLA2 activity was measured in 2538 CHD patients included in the Bezafibrate Infarction Prevention (BIP) study. Results: Adjusting for patient characteristics and traditional risk factors, 1 standard deviation of Lp-PLA2 was associated with a hazard ratio (HR) of 1.12 (95% confidence interval (CI): 1.00–1.25) for mortality and 1.03 (0.93–1.14) for cardiovascular events. Lp-PLA2 did not significantly improve model discrimination, or calibration nor result in noteworthy reclassification. Conclusions: Our results do not support added value of Lp-PLA2 for predicting cardiovascular events or mortality among CHD patients beyond traditional risk factor.

This article analyzes the dynamics of the 2015 Israeli elections by examining the movement of votes within ideological blocs and the manifestation of multiple identities in the electoral campaigns. The premature collapse of Netanyahu’s government led Israel to general elections only two years and two months after the previous elections. The elections were portrayed as a horse race between the Likud and the Zionist Union. Indeed, both parties gained some support in comparison to the previous elections, yet almost all of their electoral gains were from parties in their own bloc. The politics of multiple identities steered these two parties to appeal to voters within their blocs, and also clearly defined the borders of these blocs. An exception was the new centrist Kulanu, which succeeded in capturing the strategic pivotal position. Likud’s clear-cut “victory” over the Zionist Union led Kulanu to join the Likud’s right-wing religious coalition.

The reverence for Stalinism by the main kibbutz movements, which through revolutionary rhetoric helped perpetuate leaders who had reached the dysfunctional phase, was wrongly interpreted. Historians missed leaders’ efforts to induce reverence and its use for their domination, while social researchers missed its enhancement of oligarchic rule. These are explained by the suppression of critics at the hands of a co-opted functionalist scientific coalition, by ethnographers missing the impact of inter-kibbutz organizations, and by the differentiation of disciplines. Multiple ethnographies of kibbutzim (pl. of kibbutz) and inter-kibbutz organizations and the integration of various findings by a good theory exposed these failures. They point to the required integration of disciplines and to the need for reform of scientific publication decision-making aimed at preventing such failures.