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ispartof: INTENSIVE CARE MEDICINE vol:47 issue:3 pages:344-348 ispartof: location:United States status: published

This article presents technical debt (TD) impediments, decision factors, enabling practices, and actions diagrams for TD management in agile software projects. By analyzing diagrams, professionals can avoid the pitfalls, and increase their capacity, for better TD management.

Background The SARS-CoV-2/COVID-19 pandemic has claimed nearly 900,000 lives worldwide and infected more than 27 million people. Researchers worldwide are studying ways to decrease SARS-CoV-2 transmission and COVID-19 related deaths. Several studies found altitude having a negative association with both COVID-19 incidence and deaths. Ecuadorian data was used to explore the relationship between altitude and COVID-19. Methods This is an ecological study examining province-level data. To explore a relationship between altitude and COVID-19, this study utilized publicly available COVID-19 data and population statistics. ANOVA, correlation statistics, and a multivariate linear model explored the relationship between different Ecuadorian altitudes against incidence, mortality, and case-fatality rates. Population statistics attributed to COVID-19 were included in the linear model to control for confounding factors. Results Statistically significant differences were observed in the regions of Amazónica, Sierra, Costa of Ecuador for incidence, mortality, and case fatality rates, suggesting an association between altitude and SARS-CoV-2 transmission and COVID-19 disease severity (p-value ≤0.05). In univariate analysis, altitude had a negative association to mortality rate with a 1-unit change in altitude resulting in the decrease of 0.006 units in mortality rate (p-value = 0.03). The multiple linear models adjusted for population statistics showed a statistically significant negative association of altitude with mortality rate (p-value = 0.01) with a 1-unit change in altitude resulting in the decrease in mortality rate by 0.015 units. Overall, the model helped in explaining 50% (R2 = 0.4962) of the variance in mortality rate. Conclusion Altitude may have an effect on COVID-19 mortality rates. However, based on our model and R2 value, the relationship between our variables of interest and COVID-19 mortality may be nonlinear. More research is needed to understand why altitude may have a protective effect against COVID-19 mortality and how this may be applicable in a clinical setting.

Technical debt (TD) can be injected at any stage of software development, spreading across other phases and causing various problems. This article presents a model for conceptualizing TD causes, effects, payment practices, and reasons for payment avoidance, with a prioritization schema for technical and nontechnical roles.

BackgroundWe evaluated prevaccine pandemic period COVID-19 death risk factors among nursing home (NH) residents.MethodsIn a retrospective cohort study covering Medicare fee-for-service beneficiaries aged ≥65 years residing in US NHs, we estimated adjusted hazard ratios (HRs) using multivariate Cox proportional hazards regressions.ResultsAmong 608251 elderly NH residents, 57398 (9.4%) died of COVID-19–related illness 1 April to 22 December 2020; 46.9% (26893) of these deaths occurred without prior COVID-19 hospitalizations. We observed a consistently increasing age trend for COVID-19 deaths. Racial/ethnic minorities shared similarly high risk of NH COVID-19 deaths with whites. NH facility characteristics for-profit ownership and low health inspection ratings were associated with higher death risk. Resident characteristics (male [HR, 1.69], end-stage renal disease [HR, 1.42], cognitive impairment [HR, 1.34], and immunocompromised status [HR, 1.20]) were death risk factors. Other individual-level characteristics were less predictive of death than in community-dwelling population.ConclusionsLow NH health inspection ratings and private ownership contributed to COVID-19 death risks. Nearly half of NH COVID-19 deaths occurred without prior COVID-19 hospitalization and older residents were less likely to get hospitalized with COVID-19. No substantial differences were observed by race/ethnicity and socioeconomic status for NH COVID-19 deaths.

BackgroundShingrix (recombinant zoster vaccine) was licensed to prevent herpes zoster, dispensed as 2 doses given 2–6 months apart among adults aged ≥50 years. Clinical trials yielded efficacy of >90% for confirmed herpes zoster, but post-market performance has not been evaluated. Efficacy of a single dose and a delayed second dose and efficacy among persons with autoimmune or immunosuppressive conditions have not been studied. We aimed to assess post-market vaccine effectiveness of Shingrix.MethodsWe conducted a cohort study among Medicare Part D community-dwelling beneficiaries aged >65 years. Herpes zoster was identified using a medical office visit diagnosis with treatment, and postherpetic neuralgia was identified using a validated algorithm. We used inverse probability of treatment weighting to improve cohort balance and marginal structural models to estimate hazard ratios.ResultsWe found a vaccine effectiveness of 70.1% (95% confidence interval [CI], 68.6–71.5) and 56.9% (95% CI, 55.0–58.8) for 2 and 1 doses, respectively. The 2-dose vaccine effectiveness was not significantly lower for beneficiaries aged >80 years, for second doses received at ≥180 days, or for individuals with autoimmune conditions. The vaccine was also effective among individuals with immunosuppressive conditions. Two-dose vaccine effectiveness against postherpetic neuralgia was 76.0% (95% CI, 68.4–81.8).ConclusionsThis large real-world observational study of the effectiveness of Shingrix demonstrates the benefit of completing the 2-dose regimen. Second doses administered beyond the recommended 6 months did not impair effectiveness. Our effectiveness estimates were lower than the clinical trials estimates, likely due to differences in outcome specificity.

BackgroundThe current study was performed to evaluate risk factors for severe coronavirus disease 2019 (COVID-19) outcomes among Medicare beneficiaries during the pandemic’s early phase.MethodsIn a retrospective cohort study covering Medicare fee-for-service beneficiaries, we separated out elderly residents in nursing homes (NHs) and those with end-stage renal disease (ESRD) from the primary study population of individuals age ≥65 years. Outcomes included COVID-19 hospital encounters and COVID-19-associated deaths. We estimated adjusted odds ratios (ORs) using logistic regression.ResultsWe analyzed 25 333 329 elderly non-NH beneficiaries without ESRD, 653 966 elderly NH residents, and 292 302 patients with ESRD. COVID-related death rates (per 10 000) were much higher among elderly NH residents (275.7) and patients with ESRD (60.8) than in the primary study population (5.0). Regression-adjusted clinical predictors of death among the primary population included immunocompromised status (OR, 1.43), frailty index conditions such as cognitive impairment (3.16), and other comorbid conditions, including congestive heart failure (1.30). Demographic-related risk factors included male sex (OR, 1.77), older age (3.09 for 80- vs 65-year-olds), Medicaid dual-eligibility status (2.17), and racial/ethnic minority. Compared with whites, ORs were higher for blacks (2.47), Hispanics (3.11), and Native Americans (5.82). Results for COVID-19 hospital encounters were consistent.ConclusionsFrailty, comorbid conditions, and race/ethnicity were strong risk factors for COVID-19 hospitalization and death among the US elderly.

Background Approximately 50 000 influenza-associated deaths occur annually in the United States, overwhelmingly among individuals aged ≥65 years. Although vaccination is the primary prevention tool, investigations have shown low vaccine effectiveness (VE) in recent years, particularly among the elderly. We analyzed the relative VE (RVE) of all influenza vaccines among Medicare beneficiaries aged ≥65 years to prevent influenza hospital encounters during the 2019–2020 season. Methods Retrospective cohort study using Poisson regression and inverse probability of treatment weighting (IPTW). Exposures included egg-based high-dose trivalent (HD-IIV3), egg-based adjuvanted trivalent (aIIV3), egg-based standard dose (SD) quadrivalent (IIV4), cell-based SD quadrivalent (cIIV4), and recombinant quadrivalent (RIV4) influenza vaccines. Results We studied 12.7 million vaccinated beneficiaries. Following IPTW, cohorts were well balanced for all covariates and health-seeking behavior indicators. In the adjusted analysis, RIV4 (RVE, 13.3%; 95% CI, 7.4–18.9%), aIIV3 (RVE, 8.2%; 95% CI, 4.2–12.0%), and HD-IIV3 (RVE, 6.8%; 95% CI, 3.3–10.1%) were significantly more effective in preventing hospital encounters than the reference egg-based SD IIV4, while cIIV4 was not significantly more effective than IIV4 (RVE, 2.8%; 95% CI, −2.8%, 8.2%). Our results were consistent across all analyses. Conclusions In this influenza B-Victoria and A(H1N1)–dominated season, RIV4 was moderately more effective than other vaccines, while HD-IIV3 and aIIV3 were more effective than the IIV4 vaccines, highlighting the contributions of antigen amount and adjuvant use to VE. Egg adaptation likely did not substantially affect our RVE evaluation. Our findings, specific to the 2019–2020 season, should be evaluated in other studies using virological case confirmation.

What started as a cluster of patients with a mysterious respiratory illness in Wuhan, China, in December 2019, was later determined to be coronavirus disease 2019 (COVID-19). The pathogen severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel Betacoronavirus, was subsequently isolated as the causative agent. SARS-CoV-2 is transmitted by respiratory droplets and fomites and presents clinically with fever, fatigue, myalgias, conjunctivitis, anosmia, dysgeusia, sore throat, nasal congestion, cough, dyspnea, nausea, vomiting, and/or diarrhea. In most critical cases, symptoms can escalate into acute respiratory distress syndrome accompanied by a runaway inflammatory cytokine response and multiorgan failure. As of this article's publication date, COVID-19 has spread to approximately 200 countries and territories, with over 4.3 million infections and more than 290,000 deaths as it has escalated into a global pandemic. Public health concerns mount as the situation evolves with an increasing number of infection hotspots around the globe. New information about the virus is emerging just as rapidly. This has led to the prompt development of clinical patient risk stratification tools to aid in determining the need for testing, isolation, monitoring, ventilator support, and disposition. COVID-19 spread is rapid, including imported cases in travelers, cases among close contacts of known infected individuals, and community-acquired cases without a readily identifiable source of infection. Critical shortages of personal protective equipment and ventilators are compounding the stress on overburdened healthcare systems. The continued challenges of social distancing, containment, isolation, and surge capacity in already stressed hospitals, clinics, and emergency departments have led to a swell in technologically-assisted care delivery strategies, such as telemedicine and web-based triage. As the race to develop an effective vaccine intensifies, several clinical trials of antivirals and immune modulators are underway, though no reliable COVID-19-specific therapeutics (inclusive of some potentially effective single and multi-drug regimens) have been identified as of yet. With many nations and regions declaring a state of emergency, unprecedented quarantine, social distancing, and border closing efforts are underway. Implementation of social and physical isolation measures has caused sudden and profound economic hardship, with marked decreases in global trade and local small business activity alike, and full ramifications likely yet to be felt. Current state-of-science, mitigation strategies, possible therapies, ethical considerations for healthcare workers and policymakers, as well as lessons learned for this evolving global threat and the eventual return to a 'new normal' are discussed in this article.

Community-acquired pneumonia (CAP) is a common infection with significant morbidity and mortality. In January 2017, Poland introduced pneumococcal conjugate vaccine (PCV) into their national immunisation programme to protect children against invasive pneumococcal disease. This study was designed to investigate pneumonia-related hospitalisation rates and trends from 2009 to 2016 prior to the introduction of nationally funded PCV vaccination.Using national public statistic data available from the National Institute of Public Health - National Institute of Hygiene, annual hospitalisation rates for pneumonia were analysed, categorised by aetiology and age (2, 2-3, 4-5, 6-19, 20-59, 60+ years). Trends over time were assessed, as well as in-hospital mortality.The overall hospitalisation rate due to pneumonia varied between 325.9 and 372.2/100,000 population. Higher rates of hospitalisation were seen in older adults and children ≤5 years. Trends were observed when analysing hospitalisations by pneumonia aetiology within age groups: between 2009 and 2016, Streptococcus pneumoniae hospitalisations significantly increased for children aged2, 2-3, and 4-5 years, from 5.3 to 12.4, 5.2 to 8.2, and 1.9 to 4.6/100,000 population respectively. Whereas hospitalisations due to Haemophilus influenzae pneumonia decreased significantly from 7.8 to 1.8 and 4.8 to 1.9/100,000 children aged2 and 2-3 years respectively. The numbers of in-hospital deaths increased from 5578 in 2009 to 8149 in 2016, with85% of deaths in the 60+ age group.This is the first national study of pneumonia hospitalisations in Poland, providing the baseline data from which to investigate the impact of the change in vaccination policy on pneumonia hospitalisations in Poland.

Key Points Question What was the COVID-19 vaccination coverage and estimated mRNA COVID-19 vaccine effectiveness (VE) among US veterans in the first 3 months following vaccine rollout? Findings In this case-control study including 6 647 733 veterans, 23% of veterans received at least 1 COVID-19 vaccination during the first 3 months of vaccine rollout. VE against infection was estimated to be 95% for full vaccination; estimated VE against COVID-19-related hospitalization was 91%, and there were no COVID-19–related deaths among fully vaccinated veterans. Meaning These findings suggest that early vaccination rollout for veterans was efficient, and estimated VE was high for this diverse US population., This case-control study describes the scope of the mRNA COVID-19 vaccination rollout and estimates the association between vaccination and reductions in SARS-CoV-2 infections among veterans during the first 3 months of vaccine rollout., Importance Effectiveness of mRNA vaccinations in a diverse older population with high comorbidity is unknown. Objectives To describe the scope of the COVID-19 vaccination rollout among US veterans, and to estimate mRNA COVID-19 vaccine effectiveness (VE) as measured by rates of SARS-CoV-2 infection. Design, Setting, and Participants This matched test–negative case-control study was conducted using SARS-CoV-2 test results at Veterans Health Administration sites from December 14, 2020, to March 14, 2021. Vaccine coverage was estimated for all veterans. VE against SARS-CoV-2 infection and COVID-19–related hospitalization and death were estimated using electronic health records from veterans who routinely sought care at a VHA facility and had a test result positive for SARS-CoV-2 (cases) or negative for SARS-CoV-2 (controls). Cases and controls were matched on time of test and geographic region. Data were analyzed from May to July 2021. Exposures Vaccination status, defined as unvaccinated, partially vaccinated (≥14 days after first dose until second dose), or fully vaccinated (≥14 days after second dose), at time of test. Main Outcomes and Measures The main outcome of interest was a positive result for SARS-CoV-2 on a polymerase chain reaction or antigen test. Secondary outcomes included COVID-19–related hospitalization and death, defined by discharge data and proximity of event to positive test result. VE was estimated from odds ratios for SARS-CoV-2 infection with 95% CIs. Results Among 6 647 733 veterans included (3 350 373 veterans [50%] aged ≥65 years; 6 014 798 [90%] men and 632 935 [10%] women; 461 645 Hispanic veterans of any race [7%], 1 102 471 non-Hispanic Black veterans [17%], and 4 361 621 non-Hispanic White veterans [66%]), 1 363 180 (21%) received at least 1 COVID-19 vaccination by March 7, 2021. In this period, during which the share of SARS-CoV-2 variants Alpha, Epsilon, and Iota had started to increase in the US, estimates of COVID-19 VE against infection, regardless of symptoms, was 95% (95% CI, 93%-96%) for full vaccination and 64% (95% CI, 59%-68%) for partial vaccination. Estimated VE against COVID-19–related hospitalization for full vaccination was 91% (95% CI 83%-95%); there were no deaths among veterans who were fully vaccinated. VE against infection was similar across subpopulations (non-Hispanic Black, 94% [95% CI, 88%-97%]; Hispanic [any race], 83% [95% CI, 45%-95%]; non-Hispanic White, 92% [95% CI 88%-94%]; rural, 94% [95% CI, 89%-96%]; urban, 93% 95% CI, 89%-95%]). Conclusions and Relevance For veterans of all racial and ethnic subgroups living in urban or rural areas, mRNA vaccination was associated with substantially decreased risk of COVID-19 infection and hospitalization, with no deaths among fully vaccinated veterans.

Enhancing the trust of machine learning-based classifiers with large input spaces is a desirable goal; however, due to high labeling costs and limited resources, this is a challenging task. One solution is to use test input prioritization techniques that aim to identify and label only the most effective test instances. These prioritized test inputs can then be used with some popular testing techniques e.g., Metamorphic testing (MT) to test and uncover implementation bugs in computationally complex machine learning classifiers that suffer from the oracle problem. However, there are certain limitations involved with this approach, (i) using a small number of prioritized test inputs may not be enough to check the program correctness over a large variety of input scenarios, and (ii) traditional MT approaches become infeasible when the programs under test exhibit a non-deterministic behavior during training e.g., Neural Network-based classifiers. Therefore, instead of using MT for testing purposes, we propose a metamorphic relation to solve a data generation/labeling problem; that is, enhancing the test inputs effectiveness by extending the prioritized test set with new tests without incurring additional labeling costs. Further, we leverage the prioritized test inputs (both source and follow-up data sets) and propose a statistical hypothesis testing (for detection) and machine learning-based approach (for prediction) of faulty behavior in two other machine learning classifiers (Neural Network-based Intrusion Detection Systems). In our case, the problem is interesting in the sense that injected bugs represent the high accuracy producing mutated program versions that may be difficult to detect by a software developer. The results indicate that (i) the proposed statistical hypothesis testing is able to identify the induced buggy behavior, and (ii) Random Forest outperforms and achieves the best performance over SVM and k-NN algorithms.

Importance The scope of vaccination rollout and effectiveness of mRNA SARS-CoV-2 vaccines in the United States (US), and US Veterans specifically, has not been fully assessed. Objective To estimate receipt of SARS-CoV-2 vaccines, and vaccine effectiveness (VE) against SARS-CoV-2 infection, subsequent disease-related severity and mortality. Design, Setting, and Participants First, receipt of any SARS-CoV-2 vaccine by March 7, 2021 was described for all enrolled and alive Veterans within the Veterans Health Administration (VHA). Second, to evaluate mRNA SARS-CoV-2 VE, a matched test negative case-control evaluation was conducted across all VHA facilities utilizing SARS-CoV-2 positive (cases [n=16,690]) and negative (controls [n=61,610]) tests from Veterans aged ≥18 years old who routinely sought care at a VHA facility and were tested for SARS-CoV-2 from December 14, 2020, through March 14, 2021. Exposures Vaccination histories were obtained from pharmacy and medical records to determine if patients were unvaccinated, partially vaccinated (from 7 days after first dose until day of second dose of mRNA SARS-CoV-2 vaccine), or fully vaccinated (from 7 days after second dose of mRNA SARS-CoV-2 vaccine) at time of SARS-CoV-2 test. Main Outcome Measures Primary outcomes were (1) vaccine receipt among Veterans and specific subpopulations, (2) VE calculated from odds ratios (ORs) with 95% confidence intervals (95% CI) for the association between SARS-CoV-2 infection and full vs. no vaccination, and (3) VE against infection for partial vs. no vaccination. VE against COVID-19-related hospitalization and death were also estimated. Results By March 7, 2020, among 6,170,750 Veterans, 1,547,045 (23.1%) received at least one SARS-CoV-2 vaccine. Based on the analysis of mRNA SARS-CoV-2 vaccines, VE against infection was 93.7% (95% CI 92.0-95.0) and 57.7% (95% CI 53.5-61.5) for full and partial vaccination (vs. no vaccination), respectively. VE was similar for subpopulations. VE against COVID-19-related hospitalization and death for full vs. no vaccination was 90.7% (95% CI 90.0-91.3) and 94.7% (95% CI 91.3-98.1), respectively. Conclusion and Relevance Vaccines are effective in reducing SARS-CoV-2 infections and disease-related severity and mortality in the Veteran population. Effective vaccine, as well as their efficient and equitable distribution, are important for reducing COVID-19 disease burden among Veterans. Key Points Question What is the scope of VHA vaccination rollout and the impact of mRNA SARS-CoV-2 vaccination among Veterans? Findings Vaccination rollout reached all Veteran subpopulations in the first three months. Effectiveness of full vaccination with mRNA SARS-CoV-2 vaccines was 93.7% for preventing infection, comparable to that demonstrated in clinical trials. Effectiveness was similarly high for the elderly, ethnic and racial minorities, individuals with low income, homeless persons, and immunocompromised Veterans. Meaning Effective vaccines and their efficient and equitable distribution helped the VHA to reduce COVID-19 disease burden and disparities among Veterans within the first three months of vaccine distribution.

Background Guillain-Barre syndrome (GBS) is a serious acute demyelinating disease, an increased risk of which was found after the 1976 swine flu vaccinations. The U.S. Food and Drug Administration, in collaboration with the Centers for Medicare & Medicaid Services, has been conducting active surveillance for GBS after influenza vaccinations of Medicare Fee-For-Service beneficiaries since 2009. Methods We conducted active surveillance for GBS claims in the 2015–2016 and 2016–2017 influenza seasons using the Updating Sequential Probability Ratio Test (USPRT) to monitor for signals of GBS risk. We performed self-controlled risk interval (SCRI) analyses at the end of both seasons, including chart confirmation in the 2015–2016 season, to estimate the odds ratio of GBS risk. We used 1–42 and 8–21 days post-vaccination as primary and secondary risk windows, respectively, and 43–84 days post-vaccination as the control window. Results Over 13 million beneficiaries were vaccinated in each season. USPRT found a low magnitude signal for GBS in both seasons. SCRI analyses did not find excess GBS risk following any influenza vaccine for days 1–42 post-vaccination in either season. In the 2015–2016 season, for the 8–21 day window, our chart-confirmation showed an attributable GBS risk of 0.87 (95% CI: 0.16, 1.49) and 1.68 (95% CI: 0.69, 2.41) cases per million vaccinees after all seasonal and high dose (HD) vaccines, respectively, an elevated GBS risk for beneficiaries aged ≥75 years following all seasonal vaccines (OR: 2.25; 95% CI: 1.15, 4.39) and HD vaccine (OR: 3.67, 95% CI: 1.52, 8.85), and an elevated GBS risk for males who received seasonal vaccines (OR: 2.18; 95% CI: 1.15, 4.15) and HD vaccine (OR: 3.33; 95% CI: 1.35, 8.20). The finding of elevated GBS risk with advancing age and in males is consistent with literature; however, a distinction between HD and SD was a new finding. In the 2016–17 season, for the 8–21 day window, attributed cases showed an attributable GBS risk of 0.87 (95% CI: 0.03, 1.61) and 1.11 (95% CI: 0.00, 2.01) cases per million vaccinees after all seasonal and HD vaccines, respectively. We found no excess GBS risk for standard dose vaccines in the 8–21 day window in either season. Conclusions Our primary analysis finding of no excess GBS risk during both seasons was reassuring. The slightly elevated GBS risk, although in the expected range, in the 8–21 day window after all seasonal and high dose vaccines, but not after standard dose vaccines is hypothesis-generating because the difference may be due to vaccine factors such as antigen amount or strains in various seasons or due to host factors.

Background: No head-to-head studies are currently available comparing pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) with 13-valent pneumococcal conjugate vaccine (PCV-13). This study explored the feasibility of using network meta-analysis (NMA) to conduct an indirect comparison of the relative efficacy or effectiveness of the two vaccines. Methods: A systematic literature search was conducted for published randomized controlled trials (RCTs) and non-RCT studies reporting data on vaccine efficacy or effectiveness against invasive pneumococcal disease in children aged

La microcuenca del río Chimborazo, de la Parroquia San Juan, Cantón Riobamba, Provincia de Chimborazo, es la principal productora y abastecedora del recurso hídrico para las comunidades asentadas en sus alrededores, que son alrededor de 5425 hab. En la actualidad, el pago que se realiza por la distribución del servicio de agua no internaliza los aspectos ambientales para la protección de la zona de importancia hídrica y la conservación de la biodiversidad. En este sentido, en esta investigación se presentan los resultados de la valoración económica del servicio de provisión hídrica, desde una adaptación de las metodologías de Barrantes y Villavicencio, aplicada a un sistema de páramo, donde se estimó un valor real igual a $0.26 /m3. El valor real fue calculado a través de la sumatoria del valor de captación ($0.114 /m3), del valor de protección ($1.33 x 10-6 /m3), del valor de recuperación ($9.3 x 10-2 / m3), del valor del agua como insumo a la producción ($1.19 x 10-4 ha /m3); y de los costos operativos y de administración ($0.054/ m3). La implementación de un reajuste tarifario considerando el valor real generaría mecanismos de compensación para la conservación y protección del servicio ambiental hídrico en la zona de estudio.

Purpose Medicare claims can provide real-world evidence (RWE) to support the Food and Drug Administration's ability to conduct postapproval studies to validate products' safety and effectiveness. However, Medicare claims do not contain comprehensive information on some important sources of bias. Thus, we piloted an approach using the Medicare Current Beneficiary Survey (MCBS), a nationally representative survey of the Medicare population, to (a) assess cohort balance with respect to unmeasured confounders in a herpes zoster vaccine (HZV) effectiveness claims-based study and (b) augment Medicare claims with MCBS data to include unmeasured covariates. Methods We reanalyzed data from our published HZV effectiveness Medicare analysis, using linkages to MCBS to obtain information on impaired mobility, education, and health-seeking behavior. We assessed survey variable balance between the matched cohorts and selected imbalanced variables for model adjustment, applying multiple imputation by chained equations (MICE) to impute these potential unmeasured confounders. Results The original HZV effectiveness study cohorts appeared well balanced with respect to variables we selected from the MCBS. Our imputed results showed slight shifts in HZV effectiveness point estimates with wider confidence intervals, but indicated no statistically significant differences from the original study estimates. Conclusions Our innovative use of linked survey data to assess cohort balance and our imputation approach to augment Medicare claims with MCBS data to include unmeasured covariates provide potential solutions for addressing bias related to unmeasured confounding in large database studies, thus adding new tools for RWE studies.

Isabel Hernández,1,2 Julio Barzallo,3 Simón Beltrán,4 Alberto Castillo,5 Nelson Cevallos,6 Patricio Hernández,7 Camilo López,8 Rita Vera,9 Gabriela Yerovi,10 Alejandra Mendoza,1 Santiago Terán,1 Andres Izurieta,11 Enrique Teran11Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Ecuador; 2Facultad de Enfermería, Pontificia Universidad Católica del Ecuador, Quito, Ecuador; 3Hospital Teofilo Dávila, Ministerio de Salud Pública, Machala, Ecuador; 4Hospital Carlos Andrade Marín, Instituto Ecuatoriano de Seguridad Social, Quito, Ecuador; 5Hospital Eugenio Espejo, Ministerio de Salud Pública, Quito, Ecuador; 6Hospital Enrique Garcés, Ministerio de Salud Pública, Quito, Ecuador; 7Hospital de Infectología Dr. José Daniel Rodríguez Maridueña, Ministerio de Salud Pública, Guayaquil, Ecuador; 8Hospital Teodoro Maldonado Carbo, Instituto Ecuatoriano de Seguridad Social, Guayaquil, Ecuador; 9Hospital Abel Gilbert Pontón, Ministerio de Salud Pública, Guayaquil, Ecuador; 10Programa Nacional para Control del VIH, Ministerio de Salud Pública, Quito, Ecuador; 11Department of Computer Engineering, College of Engineering, University of South Florida, Tampa, FL, USAIntroduction: Besides the well-known increased risk of developing HIV-related infectious comorbidities; compared with the general population, people living with HIV (PLHIV) may also have an increased risk of developing noninfectious comorbidities (NICMs). This is the first study intended to determine the NICMs rates affecting PLHIV who were under cART regimen in Ecuador.Methods: A total of 503 HIV-positive patients were evaluated during the period June 2015-November 2016 and included in a multicenter retrospective, cross-sectional study conducted in seven main government and nongovernment community-based hospitals in Ecuador.Results: The average age of the participants was 39.2±11.9 years old and the majority of them were male (67.2%). The average age at HIV diagnosis was 34.1 years old and cART in average was started 15.9 months after HIV-diagnosis. Recruited patients were receiving cART for an average of 59.2±40.2 months. Only 9.9% (n=50) of the patients did not show any NICMs. Diabetes and pre-diabetes was found in 6% (n=30) and 16.3% (n=82) patients, respectively; however, dyslipidemia and overweight/obesity was frequent, as they affected 41.4% (n=208) and 36.4% (n=183) patients, respectively. Sixty patients (11.9%) were diagnosed with depression and 28.2% (n=142) of the studied subjects were found to have other NICMs.Conclusion: Prevalence of NICMs among subjects under cART was greater than that reported among the Ecuadorian general population, therefore specific public health actions are required to make patients aware of and prevent NICMs among PLHIV in Ecuador.Keywords: HIV noninfectious comorbidities, people living with HIV, HIV combined antiretroviral therapy, HIV diagnosis, HIV treatment, HIV in developing countries, HIV in Ecuador

Background: Mexican Americans are at increased risk of developing mild cognitive impairment (MCI) and Alzheimer’s disease compared to non-Hispanic whites. This study sought to examine the relationship between vascular risk, depression, and cognition in Mexican American elders. Methods: Data from 470 (390 normal controls, 80 MCI patients) Mexican Americans enrolled in the Health and Aging Brain among Latino Elders (HABLE) study were used. The cardiovascular risk was assessed by the Framingham Risk Score. Cognition was assessed with a neuropsychological battery, and depression was assessed based on scores from the Geriatric Depression Scale (GDS). ANOVAs were utilized to determine the differences in neuropsychological scores of normal controls with and without depression and CVD risk (low vs. high). Follow-up logistic regression was conducted to determine MCI risk. Results: The results of this study indicated that comorbid depression and a high CVD risk were associated with poorer cognitive performance in Mexican Americans. Depressed women with high CVD risk were more likely to have executive dysfunction, language deficits, and poorer global cognition than nondepressed women with a high CVD risk. In Mexican American men, those with a high vascular risk and depression were more likely to have executive dysfunction and poorer immediate memory than the nondepressed high-risk group. Higher GDS scores (OR = 1.10; 95% CI 1.02–1.10, p = 0.001) and higher vascular risk scores (OR = 1.05; 95% CI 1.02–1.10, p = 0.001) significantly predicted MCI status in Mexican Americans. Conclusion: The results of this study indicated that comorbid depression and a high CVD risk were associated with poorer cognitive performance and increased risk of MCI in Mexican Americans.

Background The low influenza vaccine effectiveness (VE) observed during the A(H3N2)-dominated 2017–2018 season may be due to vaccine virus adaptation to growth in eggs. We compared the effectiveness of cell-cultured and egg-based vaccines among Medicare beneficiaries. Methods Retrospective cohort study on Medicare beneficiaries aged ≥65 years who received an influenza vaccine (cell-cultured, egg-based quadrivalent; egg-based high-dose, adjuvanted, or standard-dose trivalent) during the 2017–2018 season. We used Poisson regression to evaluate relative VE (RVE) in preventing influenza-related hospital encounters. Results Of >13 million beneficiaries, RVE for cell-cultured vaccines relative to egg-based quadrivalent vaccines was 10% (95% confidence interval [CI], 7%–13%). In a midseason interim analysis, this estimate was 16.5% (95% CI, 10.3%–22.2%). In a 5-way comparison, cell-cultured (RVE, 11%; 95% CI, 8%–14%) and egg-based high-dose (RVE, 9%; 95% CI, 7%–11%) vaccines were more effective than egg-based quadrivalent vaccines. Conclusions The modest VE difference between cell-cultured and egg-based vaccines only partially explains the low overall VE reported by the Centers for Disease Control and Prevention, suggesting that egg adaptation was not the main contributor to the low VE found among individuals aged ≥65 years. The midseason interim analysis we performed demonstrates that our methods can be used to evaluate VE actively during the influenza season.

Context: The technical debt (TD) metaphor helps to conceptualize the pending issues and trade-offs made during software development. Knowing TD causes can support in defining preventive actions and having information about effects aids in the prioritization of TD payment. Goal: To investigate the impact of the experience level on how practitioners perceive the most likely causes that lead to TD and the effects of TD that have the highest impacts on software projects. Method: We approach this topic by surveying 227 practitioners. Results: While experienced software developers focus on human factors as TD causes and external quality attributes as TD effects, low experienced developers seem to concentrate on technical issues as causes and internal quality issues and increased project effort as effects. Missing any of these types of causes could lead a team to miss the identification of important TD, or miss opportunities to preempt TD. On the other hand, missing important effects could hamper effective planning or erode the effectiveness of decisions about prioritizing TD items. Conclusion: Having software development teams composed of practitioners with a homogeneous experience level can erode the team's ability to effectively manage TD.

Background There are theoretical concerns that angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) could increase the risk of severe Covid-19. Objective To determine if ACEIs and ARBs are associated with an increased risk of Covid-19 hospitalization overall, or hospitalization involving intensive care unit (ICU) admission, invasive mechanical ventilation, or death. Design Observational case-control study. Participants Medicare beneficiaries aged ≥ 66 years with hypertension, treated with ACEIs, ARBs, calcium channel blockers (CCBs), or thiazide diuretics. Main Measures Adjusted odds ratios (OR) and 95% confidence intervals (CI) for the outcomes of Covid-19 hospitalization, or hospitalization involving ICU admission, invasive mechanical ventilation, or death. Results A total of 35,300 cases of hospitalized Covid-19 were matched to 228,228 controls on calendar date and neighborhood of residence. The median age of cases was 79 years, 57.4% were female, and the median duration of hospitalization was 8 days (interquartile range 5–12). ACEIs and ARBs were associated with a slight reduction in Covid-19 hospitalization risk compared with treatment with other first-line antihypertensives (OR for ACEIs 0.95, 95% CI 0.92–0.98; OR for ARBs 0.94, 95% CI 0.90–0.97). Similar results were obtained for hospitalizations involving ICU admission, invasive mechanical ventilation, or death. There were no meaningful differences in risk for ACEIs compared with ARBs. In an analysis restricted to monotherapy with a first-line agent, CCBs were associated with a small increased risk of Covid-19 hospitalization compared with ACEIs (OR 1.09, 95% CI 1.04–1.14), ARBs (OR 1.10, 95% CI 1.05–1.15), or thiazide diuretics (OR 1.11, 95% CI 1.03–1.19). Conclusions ACEIs and ARBs were not associated with an increased risk of Covid-19 hospitalization or with hospitalization involving ICU admission, invasive mechanical ventilation, or death. The finding of a small increased risk of Covid-19 hospitalization with CCBs was unexpected and could be due to residual confounding. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-021-07155-z.

Context: Knowing the effects of technical debt (TD) can support software development teams in the prioritization of TD items to pay off. However, little is known about the relations between the effects of TD and TD payment practices. Having this knowledge can provide valuable information for decision making about which payment practice can be applied given the presence of specific effects of TD. Aims: To investigate, from the point of view of software practitioners, (i) which TD payment practices have been used when certain effects of the presence of debt are felt in software projects and (ii) the reasons for not paying debt items despite the effects they are causing to the project. Method: We analyze quantitatively and qualitatively data collected from a survey with 432 practitioners across four countries. Results: Among the identified relations, the practice "code refactoring" is commonly used to pay debt items off when the effects "delivery delay" and "rework" are felt in software projects. On the other hand, when practitioners face the TD effects "low external quality" and "delivery delay", ，they commonly justify the non- payment of the debt items indicating the need of "focusing on short term goals". Conclusion: We organize the relationship between TD effects, and payment practices and reasons for not eliminating debt items. All this information is structured in an alluvial diagram, which can facilitate the visualization of the identified relations.

Under-detection of HIV/AIDS still burdens many low- and middle-income countries (LMICs). Our randomized trial investigated the effects of financial incentives and a behavioral nudge to induce HIV testing and learning HIV status in Ecuador. In the control group, 12.2% of participants agreed to testing, and 5.3% learned results. A financial incentive paid at testing increased the fraction of participants tested by 50.1 percentage points (95% CI 38.8 to 61.4) and the fraction who learned their status by 8.9 percentage points (95% CI 5.3 to 12.5); the nudge had no effect. The HIV-positive rate was 1.2% in the control group, and incentives prompted a 4.7 percentage point (95% CI 0.5 to 8.9) higher proportion of HIV-positive detection. Incentives also induced earlier testing, suggesting reduced procrastination. This suggests that information with appropriately timed small financial incentives can improve HIV testing and detection of new cases in the general population in LMIC settings.

The worldwide implementation of pneumococcal conjugate vaccines (PCVs) in children has reduced the overall pneumococcal disease burden. Two PCVs are widely available for infant vaccination: the pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) and the 13-valent PCV (PCV13). While these PCVs differ in serotype composition (PCV13 includes polysaccharides of serotypes 3, 6A and 19A; PHiD-CV does not), their impact on the overall pneumococcal disease burden in children is comparable. This commentary summarizes the evidence of comparability between PHiD-CV and PCV13 and explores why differences in serotype composition may not necessarily translate into a differential clinical impact. Both vaccines confer similarly high protection against disease caused by vaccine serotypes and lead to a partial replacement by non-vaccine serotypes. PHiD-CV does not protect against serotype 3 disease (not included in the vaccine) and PCV13's effect on this serotype has been inconsistent. PHiD-CV provides some cross-protection against disease caused by vaccine-related serotype 19A but neither vaccine has fully controlled 19A disease. While protection against 19A is higher for PCV13 than PHiD-CV, replacement by non-PCV13 serotypes in settings with a PCV13 program appears to compensate for this difference. This results in a similar residual overall disease burden with both vaccines.

—As technical debt (TD) potentially occurs as a result of poor decisions that affect software development tasks, one might expect that practitioners following different process models, such as agile, hybrid or traditional, will perceive and manage the effects of TD differently. This study investigates the potential relationship between development process models and TD effects and their management by surveying 432 practitioners from software organizations in Brazil, Chile, Colombia, and the United States. Results indicate that, although opinions about debt prevention and repayment are the same regardless of the process model, there are differences in how practitioners monitor and feel the effects of TD. Development teams can use our findings to have a clearer view of the possible effects and managerial influence of TD in their projects for each type of process model.

International health security (IHS) encompasses any natural or anthropogenic occurrence that can threaten the safety of human health and well-being. The American College of Academic International Medicine IHS Consensus Group (ACAIM-CG) developed a summative assessment highlighting the main issues that can impact IHS including emerging infectious diseases; chronic health conditions; bioterrorism; planetary changes (volcanic eruptions, earthquakes, wildfires, and climate change); nuclear incidents; information and cyber health; industrialization; globalization; pharmaceutical production; and communication platforms (social media). These concerns can directly and indirectly impact IHS both in the long and short term. When considering IHS, we aim to emphasize the utility of applying a predefined framework to effectively approach health security threats. This framework comprises of prevention, detection, assessment, reporting, response, addressing needs, and the perpetual repetition of the above cycle (inclusive of appropriate mitigation measures). It is hoped that this collective work will provide a foundation for further research within the redefined, expanded scope of IHS.

Streptococcus pneumoniae is a major cause of morbidity and mortality, especially amongst young children and the elderly. Childhood implementation of pneumococcal conjugate vaccines (PCVs) significantly reduced the incidence of invasive pneumococcal disease (IPD), while several nonvaccine serotypes remained substantial. Although there is evidence of the impact of higher-valent PCVs on serotype 19A, 19A IPD burden and antibiotic resistance remain a major concern post-vaccination. We performed a systematic literature review to analyze the frequency and clonal distribution of serotype 19A isolates in the pre– and post-PCV era worldwide providing a scientific background on the factors that influence multidrug resistance in pneumococcal isolates. Serotype 19A IPD incidence increased in all regions following the introduction of the 7-valent PCV. The higher-valent PCVs have reduced the rates of 19A IPD isolates, but several circulating strains with diverse antibiotic resistance prevailed. Heterogeneous clonal distribution in serotype 19A was observed within countries and regions, irrespective of higher-valent PCV used. An increase of 19A isolates from pre- to post-vaccination periods were associated with frequently occurring serotype switching events and with the prevalence of multidrug resistant strains. Rational antibiotic policies must be implemented to control the emergence of resistance. Plain Language Summary What is the context? Streptococcus pneumoniae is a major cause of pneumococcal diseases especially amongst young children and the elderly. Vaccination with pneumococcal conjugate vaccines has significantly reduced the incidence of invasive pneumococcal disease worldwide. However, the invasive pneumococcal disease remains an important health problem due to the increase of nonvaccine serotypes. Serotype 19A is predominant in many countries worldwide. Factors contributing to its prevalence include serotype replacement, the emergence of clones with multidrug resistance due to antibiotic overuse, and potential bacteria adaptation in response to the vaccine. What is new? We performed a systematic literature review to 1) analyze the incidence and clonal distribution of serotype 19A isolates pre- and post-vaccination worldwide, and to collect data evaluating antimicrobial resistance patterns displayed by the clones of serotype 19A. We found that 1) clonal distribution in serotype 19A was heterogeneous within countries and regions, irrespective of the vaccine used; 2) the diversity of 19A isolates increased after vaccination. It was associated with frequent serotype switching events and with the prevalence of multidrug resistant strains. What is the impact? Implementation of policies to educate on sustainable antibiotic use and infectious prevention measures may help control the emergence of antibiotic resistance. High-quality active surveillance and future molecular epidemiology studies are needed to understand rapid genetic changes.

Alcohol abuse has been identified as a risk factor for contracting human immunodeficiency virus (HIV) and accelerating disease progression. Our study aims to determine alcohol consumption rates among Ecuadorian HIV positive (HIV+) patients prior to diagnosis to evaluate its impact as an independent risk factor for contracting HIV. Additionally, we will examine post-diagnosis consumption rates among the HIV+ population. We provided anonymous questionnaires to 300 HIV+ patients and 600 internal medicine patients at 3 hospitals in Quito, Ecuador. Questionnaires quantified alcohol usage prior to HIV diagnosis, at time of diagnosis, and post-diagnosis while accounting for other potential HIV risk factors. We then determined frequencies of alcohol consumption and confounding variables. Finally, we performed a multivariable logistic regression controlling for confounders to determine the statistical significance of alcohol consumption as an independent risk factor for HIV. Our results showed increased odds for contracting HIV among those who drank daily (OR 5.3, CI 2.0–14.0) and those who consumed 6 or more alcoholic beverages on days they drank (OR 5.0, CI 3.1–8.2). Through multivariable analysis, we found that abstaining from binge drinking was a protective factor with an OR 0.5 (0.3–0.96). The percentage of HIV+ patients abstaining from alcohol increased from 30% twelve months prior to diagnosis to 57% after diagnosis. Our results show that alcohol abuse significantly increases the risk of contracting HIV. We found that prior to diagnosis, HIV patients consistently drank more frequently and a greater amount than the control group. Alcohol use significantly decreased among HIV+ patients after diagnosis.

Leishmaniasis is a major neglected tropical disease which contributes a huge economic burden on already meager economic resources. The World Health Organization (WHO) has estimated an annual incidence of 700,000--1,000,000 patients and about 20,000–30,000 deaths per year. Approximately 66,941 patients of cutaneous leishmaniasis are reported annually in the Americas. In recent years, Nicaragua has presented alarmingly high numbers of patients and elevated incidence rates. Unfortunately, there are no detailed spatial descriptions on the epidemiological situation of leishmaniasis in this country. The objective of this study is to present descriptive data about the epidemiology of leishmaniasis in Nicaragua in the context of the distribution of this neglected tropical disease (NTD) in the Americas. This paper also provides an epidemiological update on different forms of leishmaniasis found in the three administrative regions of Nicaragua and its municipalities. Health authorities from the Ministry of Health of Nicaragua (MINSA) provided the entomological and epidemiological information for the different forms of the disease from 2001 to 2018. Prevalence, incidence rates, clinical classification of disease, age groups, sex, and geographic distribution by municipality and department are described in this study. Approximately 90%–95% of the national patients corresponded to CL and 5–10% correspond to MCL. The disease is distributed in the three regions of the country, with a higher burden in the Departments of Jinotega, Matagalpa and Atlántico Norte. The municipalities with the highest proportion of patients were El Cuá (23.92%), Waslala (14.16), Santa Maria de Pantasma (9.62%), Rancho Grande (9.03%) and Siuna (7.67%). There is an expansion of spatial distribution of CL and MCL in the North Central and South Atlantic regions of the country. These results could inform interventional strategies to address the burden of leishmaniasis in Nicaragua, which would improve the likelihood of meeting the goals for the Leishmaniasis Plan of Action for the Americas.

Background or Objectives: HIV/AIDS transmission in Ecuador is considered a concentrated epidemic; therefore, there are some studies on high risk groups but there is limited published data regarding the HIV/AIDS risk factors among adolescents of African descent. In this study, we sought to explore the determinants of HIV/AIDS-related knowledge and behavior among afro-descendant youths attending schools in the city of Esmeraldas, Ecuador. Methods: A cross-sectional survey among school-attending youths was conducted in Esmeraldas, Ecuador in 2010. Our target population was afro-descendant youths attending the last two years of high school. Thirty public high schools enrolling students in junior and senior years were identified. Outcome data were analyzed in the form of three composite variables. A multivariate linear regression model was built for each outcome. Results: A total of 213 school-attending afro-descendant youths aged 14 to 21 years old were enrolled in this study. Gender distribution was almost equal with a 1:1.17 male to female ratio. Overall, students in this population scored well in comprehensive knowledge of HIV with 88% having medium or higher knowledge. Conclusion and Global Health Implications: Knowledge of HIV and its determinants was medium to high, but knowledge of sexually transmitted diseases was low among afro-descendant Ecuadorian adolescents in our study. Results of this study might be instrumental in facilitating decision-making processes related to the planning, implementation, and evaluation of HIV/AIDS prevention and control strategies in this specific population. Key words: • Afro-descendant • Adolescents • HIV/AIDS • Ecuador • Condom use • Risk factors• Epidemiology • Youths • Sexually transmitted infections • Transmission Copyright © 2020 Hernandez et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0)which permits unre-stricted use, distribution, and reproduction in any medium, provided the original work, first published in this journal, is properly cited.

Background: Little is known about the practices used for technical debt (TD) payment. The study of payment practices, as well as the reasons for not applying them, can help practitioners to control and manage TD items. Aims: To investigate, from the point of view of software practitioners, if TD items have been paid off in software projects, the practices that have been used to pay off TD and the reasons that hamper the implementation of these practices. Method: We analyzed - both quantitatively and qualitatively - a corpus of responses from a survey of 432 practitioners, from four countries, about the possibility of TD payment. Results: We found that, for most of the cases, TD items have not been eliminated from software projects. The main reasons for not paying off TD are lack of organizational interest, low priority on the debt, focus on short-term goals, cost, and lack of time. On the other hand, we identified that code refactoring, design refactoring, and update system documentation are the most used practices for TD payment. Practitioners also cited practices related to the prevention, prioritization, and creation of a favorable setting as part of TD payment initiatives. Conclusion: This paper summarizes the identified practices and reasons for not paying off debt items in a map. Our map reveals that the majority of payment practices are of a technical nature while the majority of reasons for not paying off debts are associated with non-technical issues.

Background: Preventive measures and interventions for obesity in young adults are urgently needed. However, evidence-based guidelines for interventional programs in this generation have not been established worldwide because of limited access to data on this group. To establish effective methods of obesity prevention in young adults, we analyzed the relationship between nutrient intake and obesity-related metabolic factors in each body mass index (BMI) group among Japanese university students. Methods: A cross-sectional analysis was performed using annual health checkup data, which is conducted mandatory for all students according to the School Health and Safety Act in Japan, from Gifu University’s incoming class of 2017. Nutrient intake information was obtained from the brief-type self-administered diet history questionnaire (BDHQ), which has been adjusted and validated for the Japanese population. Inclusion criteria were aged 18-30 years and completed the all examination items including BDHQ. From a total of 1277 students’ data, 1202 satisfied and were included in the analyses (participation rate: 94.1%). Nutrition and metabolic data were compared among BMI groups (lean

El presente artículo, se suscribe en la modalidad de ensayo, el cual tiene como propósito realizar una contribución crítica y reflexiva en torno a la educación ambiental como herramienta estratégica para fomentar el turismo sostenible en la ciudad de Manta Ecuador, dicho recorrido discursivo inicia con una mirada hacia los aportes y preceptos que han realizado los organismos internacionales en torno a la temática, de allí que se aprecia que el turismo sostenible es crucial para el desarrollo, no solo porque encierra el potencial de contribuir al crecimiento económico, sino que también puede ejercer una influencia positiva en las comunidades locales; preservar el patrimonio, la biodiversidad y los recursos naturales. En este sentido se asume que la educación ambiental es una herramienta para mejorar las relaciones de los seres humanos con su medio y, por lo tanto, debe incidir en la prevención y resolución de problemas ambientales. Como reflexión, es imperativo que se asuma un currículo educativo contextualizado, que incluya la educación ambiental como la herramienta para impulsar el turismo sostenible, donde los docentes desarrollen estrategias con mayores niveles de concreción y con una postura socio crítica más cónsona con las demandas sociales y ambientales de la localidad.

Background: Preventing the occurrence of technical debt (TD) in software projects can be cheaper than its payment. Prevention practices also help in catching inexperienced developers' 'not-so-good' solutions. However, little is known on how to prevent the occurrence of TD. Aims: To investigate, from the point of view of software practitioners, preventive actions that can be used to curb the occurrence of TD and the impediments that hamper the use of those actions. Method: We use data from the InsighTD Project, a family of industrial surveys specifically designed to study software engineering TD. We use a corpus of answers from 207 practitioners across different geographic locations to identify and analyze - both quantitatively and qualitatively - the TD preventive actions most used in practice. Results: We found that project planning, adoption of good practices, well-defined requirements, creating tests, and training are the most cited preventive actions that curb TD in software projects. We also identified seven preventive action categories and defined relationships among them and TD types. On the other hand, the main impediments to prevent TD are related to inappropriate project planning and lack of expertise of the team. Conclusions: Our list of preventive actions and impediments can help practitioners to implement policies for the sector and guide TD researches in a problem-driven way.

[Context and Motivation] It is common for teams to take shortcuts during software development that, in the future, will lead to maintainability issues and affect productivity and development cost. Different types of technical debt may affect software projects, including those associated with software documentation. Although there are many studies on technical debt, few focus on documentation debt in an industrial environment. [Question/Problem] We aimed to identify how software practitioners perceive the occurrence of documentation debt in their projects. We present a combined analysis of the results from two complementary studies: a survey (InsighTD) and an interview-based case study. [Principal Ideas/Results] We provide a list of causes and effects of documentation debt, along with practices that can be used to deal with it during software development projects. [Contribution] We find that documentation debt is strongly related to requirements issues. Moreover, we propose a theoretical framework, which provides a comprehensive depiction of the documentation debt phenomenon.

Meta-analysis can be especially useful for evaluation of vaccine safety, since individual studies often have limited power to detect an increase in safety risk. In order to gain a perspective on the current state of utilization of the technique of meta-analysis for evaluation of vaccine safety and to assess the methodological characteristics of these meta-analyses, we conducted a systematic review of published meta-analyses. We identified 61 meta-analyses of vaccine safety. Safety outcomes for influenza and human papillomavirus (HPV) vaccines were most frequently meta-analysed. The most studied safety outcomes were local and systemic reactions, as well as Serious Adverse Events. Most meta-analyses were literature based. Differences in the definitions of safety outcomes across the different studies and the poor reporting of safety in the published literature were described as challenges when conducting a meta-analysis of vaccine safety. A way to overcome these challenges is through the implementation of standardized safety outcomes definitions and reporting. A prospectively conducted meta-analysis, i.e. a meta-analysis planned prior to the conduct of the trials, as well as implementation of subject-level meta-analysis techniques can also reduce or eliminate the impact of these difficulties.

A highly integrated process aiming electrical and heating power supply is proposed. Ethanol, water and air at atmospheric conditions are considered as feedstocks. Main focus is put in process intensification through the use of parallel-plate and membrane reactors allowing the combination of different process operations within the units. The electric power is generated by means of a PEM fuel cell, which is fed with pure hydrogen produced by ethanol steam reforming with subsequent purification. Appropriate thermal integration is achieved both in the parallel-plate units as well as in the membrane reactor. The high temperature of the streams exiting the reformer allows preheating the air to the combustion sections and the sweep gas to the membrane reactor improving the process integration and achieving an electrical production of 2.5 kW. In addition, a hot water stream is used to produce the cogeneration heat, increasing the total thermal efficiency up to 56.3%. Fil: Izurieta, Eduardo Miguel. Universidad Nacional del Sur. Departamento de Ingeniería Química; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Bahía Blanca. Planta Piloto de Ingeniería Química. Universidad Nacional del Sur. Planta Piloto de Ingeniería Química; Argentina Fil: Adrover, María Esperanza. Universidad Nacional del Sur. Departamento de Ingeniería Química; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Bahía Blanca. Planta Piloto de Ingeniería Química. Universidad Nacional del Sur. Planta Piloto de Ingeniería Química; Argentina Fil: Pedernera, Marisa Noemi. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Bahía Blanca. Planta Piloto de Ingeniería Química. Universidad Nacional del Sur. Planta Piloto de Ingeniería Química; Argentina Fil: Lopez, Eduardo. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Bahía Blanca. Planta Piloto de Ingeniería Química. Universidad Nacional del Sur. Planta Piloto de Ingeniería Química; Argentina

The technical debt (TD) metaphor describes actions made during various stages of software development that lead to a more costly future regarding system maintenance and evolution. According to recent studies, on average 25% of development effort is spent, i.e. wasted, on TD caused issues in software development organizations. However, further research is needed to investigate the relations between various software development activities and TD. The objective of this study is twofold. First, to get empirical insight on the understanding and the use of the TD concept in the IT industry. Second, to contribute towards precise conceptualization of the TD concept through analysis of causes and effects. In order to address the research objective a family of surveys was designed as a part of an international initiative that congregates researchers from 12 countries -- InsighTD. At country level, national teams ran survey replications with industry practitioners from the respective countries. In total 653 valid responses were collected from 6 countries. Regarding the prevalence of the TD concept 22% of practitioners have only theoretical knowledge about it, and 47% have some practical experiences with TD identification or management. Further analysis indicated that senior practitioners who work in larger organizations, larger teams, and on larger systems are more likely to be experienced with TD management. Time pressure or deadline was the single most cited cause of TD. Regarding the effects of TD: delivery delay, low maintainability, and rework were the most cited. InsighTD is the first family of surveys on technical debt in software engineering. It provided a methodological framework that allowed multiple replication teams to conduct research activities and to contribute to a single dataset. Future work will focus on more specific aspects of TD management., Comment: Journal of Systems and Software

Introduction: Pneumococcal conjugate vaccine (PCV) impact studies have reported substantial reductions in the incidence of invasive pneumococcal disease (IPD) after implementation of childhood PCV programs. Heterogeneity in surveillance systems, local epidemiology and PCV programs hampers comparisons between studies. We aimed to better understand the impact of childhood PCV programs on overall IPD and serotype distribution. Areas covered: We analyzed the impact of PCV programs on the incidence of overall IPD, and the distribution of vaccine serotypes (VT) and non-vaccine serotypes (NVT) in children Expert commentary: After introduction of pediatric PCV programs, the residual overall IPD burden in children was low and in a narrow range across countries with high vaccination coverage, irrespective of differences in PCV programs and pneumococcal epidemiology. Effects on overall IPD were more variable in the elderly. Whereas IPD was mainly due to VTs before PCV introduction, NVTs are the major contributor today in children and adults. Read the transcript Watch the video on Vimeo

Background The objective of this study was to evaluate creatine as an anti-nociceptive compound in an animal model of thermal and inflammatory pain. Creatine has the structural potential to interact with acid-sensing ion channels (ASIC), which have been involved in pain sensation modulation. The hypothesis evaluated in this study was that creatine will interact with ASICs leading to decreased nociception. Methods Male and female C57BL/6J mice were fed with either a control diet or the control diet supplemented with creatine (6.25 g/kg diet). After one week on the diet, the mice were tested for thermal hyperalgesia and inflammatory pain response. Results The latency to withdraw the tail during the thermal hyperalgesia test was unaffected by sex or diet. During the formalin test, males and females responded differently to the stimulus, and the female mice supplemented with creatine seemed to recover faster than the controls. To determine whether ASICs mediate the action of creatine, GMQ, an ASIC3 agonist, was injected in one paw and pain response was quantified. Females responded more strongly to GMQ injections, and all mice fed creatine had a decreased response to GMQ. Conclusions These preliminary data suggest a potential effect of creatine on inflammation-based nociception that may be mediated via ASIC3. While preliminary, this study warrants further research on the potential of creatine as an analgesic and can serve as a stepping stone for the development of ASIC-based therapeutics.

BACKGROUND Over 34 million residents of the United States aged 65 years and older are also Medicare prescription drug beneficiaries. Medical claims records for this age group potentially provide a wealth of data for better understanding influenza epidemiology. OBJECTIVE The purpose of this study was to evaluate data on oseltamivir dispensing extracted from medical claims records as an indicator of influenza activity in the United States for the 2010-11 through 2014-15 influenza seasons. METHODS We used Centers for Medicare and Medicaid Services (CMS) medical claims data to evaluate the weekly number of therapeutic oseltamivir prescriptions dispensed following a rapid influenza diagnostic test among beneficiaries 65 years old and older as an indicator of influenza timing and intensity. We compared the temporal changes in this indicator to changes in the proportion of influenza-like illnesses among outpatient visits in the US Outpatient Influenza-like Illness Surveillance Network (ILINet) by administrative regions defined by the US Department of Health and Human Services. Using the moving epidemic method, we determined intensity thresholds and categorized the severity of seasons for both CMS and ILINet data. RESULTS Centers for Medicare and Medicaid Services oseltamivir data and ILINet data were strongly correlated by administrative region (median Spearman's ρ = 0.78; interquartile range = 0.73-0.80). CMS oseltamivir data and ILINet data substantially agreed (Cohen's weighted κ = 0.62) as to the seasonal severity across administrative regions. CONCLUSIONS Our results support the use of oseltamivir dispensing in medical claims data as an indicator of US influenza activity.

Context: Architectural decisions are considered one of the most common sources of technical debt (TD). Thus, it is necessary to understand how TD is perceived by software architects, particularly, the practices supporting the elimination of debt items from projects, and the practices used to reduce the chances of TD occurrence. Objective: This paper investigates the most commonly used practices to pay off TD and to prevent debt occurrence in software projects from the architect’s point of view. Method: We used the available data from InsighTD, which is a globally distributed family of industrial surveys on the causes, effects, and management of TD. We analyze responses from a corpus of 72 software architects from Brazil, Chile, Colombia, and the United States. Results: Results showed that refactoring (30.2%) was the main practice related to TD payment, followed by design improvements (14.0%). Refactoring, design improvements, and test improvements are the most cited payment practices among cases of code, design and test debt. Concerning the TD preventive practices, we find that having a well-defined architecture and design is the most cited practice (13.6%), followed by having a well-defined scope and requirements. This last practice is the most cited one for expert software architects. Finally, when comparing preventive practices among the three major roles derived from the survey (software architects, engineer roles, and management roles), we found that none of the roles shared the most cited practice, meaning that each role had its worries and focus on different strategies to reduce TD’s presence in the software. Conclusion: The lists of TD payment and prevention practices can guide software teams by having a catalog of practices to keep debt controlled or reduced.

Clinicians often encounter patients with apparently discordant echocardiographic findings, severe aortic stenosis (SAS) defined by aortic valve area (AVA) despite a low mean gradient. A new classification according to flow state and pressure gradient has been proposed. We sought to assess the prevalence, characteristics and outcomes of patients with asymptomatic SAS with preserved left-ventricular ejection fraction (LVEF) according to flow and gradient.In total 442 patients with SAS (AVAi0.6 cm2/m2) and LVEF ≥50% (mean age 80+11years, 54,5% female) were included. Patients were classified according to flow state (≥ or35ml/mOur study confirms the high prevalence and worse prognosis of LF/LG SAS. Clinicians must be aware of this entity to ensure appropriate patient management.