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Safety and pharmacokinetics of a single 1500-mg dose of famciclovir in adolescents with recurrent herpes labialis. Antiviral treatment and other therapeutic interventions for herpes simplex virus epithelial keratitis. Herpes simplex virus resistance to acyclovir and penciclovir after two decades of antiviral therapy. Survey of acyclovir-resistant herpes simplex virus in the Netherlands: prevalence and characterization. Resistant herpes simplex virus type 1 infection: an emerging concern after allogeneic stem cell transplantation. Oral antiviral therapy for prevention of genital herpes outbreaks in immunocompetent and nonpregnant patients. Acyclovir susceptibility and genetic characteristics of sequential herpes simplex virus type 1 corneal isolates from patients with recurrent herpetic keratitis. In the United States, it is most highly endemic in the Ohio and Mississippi river valleys. Infections in regions in which histoplasmosis is not endemic often result from travel to endemic regions within and outside the United States. Because yeast forms of the fungus may remain viable within granulomas formed after successful treatment or spontaneous resolution of infection, late relapse can occur if cellular immune function wanes, although the magnitude of this risk appears very low. Because of greater airway pliability in children, airway obstruction from mediastinal lymphadenopathy is more common in children. Histoplasmin skin tests are no longer available and were not useful in diagnosing disseminated disease. However, urine antigen concentrations in serious infections frequently exceed this value. In these instances, serum specimens should be followed because maximum serum concentrations are lower than those in urine and thus more likely to be in a range in which differences can be accurately measured. After resolution of the antigenemia, urine concentrations can be followed to monitor the effectiveness of treatment and, thereafter, to identify relapse. Urine antigen is detectable in 75% to 81% of immunocompetent hosts with acute, primary pulmonary infection. This occurs early in infection, reflecting the primary fungemia that is aborted by an effective cellular immune response. Prevention Recommendations Preventing Exposure Most infections occur without a recognized history of exposure to a high-risk site or activity. Therefore, complete avoidance of exposure in histoplasmosis-endemic regions is not possible. Sites and conditions sometimes implicated in high-risk exposure and point-source outbreaks include disturbances of contaminated areas resulting in aerosolization of spores. These include soil contaminated with bird or bat droppings, older urban and rural structures, decaying vegetation or trees, and caves. Dry and windy conditions, excavation, demolition, renovation, gardening, and agricultural activities often predispose to aerosolization of spores. If not feasible, reducing the release of spores by wetting soil, renovation sites, and other potentially contaminated areas, and use of protective respiratory devices,25 should be recommended. A trial in adults26 demonstrated that induction with liposomal amphotericin B was associated with less toxicity and improved survival, compared with induction using amphotericin B deoxycholate. The interval needed to achieve desired serum concentrations can be shortened if the recommended dose is administered 3 times daily for the first 3 days of therapy. Itraconazole solution is preferred to the capsule formulation because it is better absorbed and serum concentrations are 30% higher than those achieved with the capsules. Fluconazole is less effective than itraconazole and has been associated with development of drug resistance. Chest radiographs may show mediastinal adenopathy with or without focal pulmonary infiltrate and/or a diffuse miliary-like pattern in high-inoculum exposure; radiographic findings may mimic those of tuberculosis.

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She routinely presents to various bar-related groups on mindfulness, leadership and cultural competence, and has chaired numerous all day programs at several State Bar of Arizona conventions. Javoyne Hicks is a member of the State Bar of Georgia and presently serves as chair of the Wellness Committee and as a member of the Board of Governors. In her regular capacity, she serves as the DeKalb County State and Magistrate Courts clerk. She is responsible for the management of public records for civil lawsuits, garnishments, eviction proceedings, personal property foreclosures, domestic violence hearings, traffic violations, ordinance violations and criminal misdemeanor cases. She supervised and expanded the operations of several diversion programs designed to give first time and youthful offenders and those with special circumstances a second chance at opportunities to avoid criminal prosecution. Hicks returned to DeKalb County after serving the federal government as the chief of staff of the Environmental Protection Agency, Region 4. Hicks focused on Environmental Justice and Sustainability and led the region in its ability to meet critical deadlines while managing the overall health and maintenance of the organization and its people. Hicks is a past president of the DeKalb Bar Association and served on the boards of Georgia Association of Black Women Attorneys and Leadership Georgia. Hodges has previously served as treasurer and president-elect of the State Bar and as a member of the Executive Committee and Board of Governors. On May 22, 2018, Hodges won a statewide election to serve on the Court of Appeals of Georgia and will assume that role in January 2019. Currently, he focuses his law practice on criminal defense and civil litigation, including but not limited to personal injury, commercial litigation and civil rights cases. Hodges spent 15 years as a prosecutor, including 12 as district attorney of the Dougherty Judicial Circuit. Born and raised in Albany, he is a graduate of Emory University and the University of Georgia School of Law. He is also a past president of the Sertoma Club; past board chair of Easter Seals of Southwest Georgia and has served on the boards of the American Heart Association in Albany, the Albany Civil Rights Institute (formerly Albany Civil Rights Museum) the Albany Chamber of Commerce and the Georgia Chamber of Commerce. He is also a graduate of Leadership Albany and a graduate and board member of Leadership Georgia. Kauffman has assisted many clients in the sale, acquisition and financing of commercial and residential development projects all over Georgia. He has worked extensively with lenders, developers and owners, steering them through commercial financing and the numerous legal issues that naturally arise in the areas of development, sales and leasing. In addition to his transactional practice, Kauffman has helped numerous clients form their business entities, buy and sell businesses, and assists with a wide range of business issues. Principal-Marketplace Initiative Mercer University-Center for Theology and Public Life Paul E. As an attorney his primary practice area is intellectual property, where he excels in both litigation and prosecution. These successes came with additional, unique stresses that demand to be navigated. The role of executive leader comes with additional burdens and stresses that must be faced, reshaped and turned to advantages. Leveraging his personal and professional successes, he is pleased to share his experiences of addressing the stresses of our honorable profession for the benefit of as many State Bar members as possible. Tom Morgan is a full time professor at Western Carolina University where he teaches criminal law and ethics. Morgan has dedicated his career to being an outstanding trial attorney and an outspoken champion for children and youth. He is an experienced trial attorney specializing in criminal defense and general civil litigation. During his career, he has tried more than 100 jury trials and successfully argued before the Court of Appeals and Supreme Court of Georgia. He is licensed to practice in Georgia and North Carolina and is admitted to practice before all Georgia and North Carolina state courts, the U. Prior to being elected district attorney in 1992, Morgan served as an assistant district attorney in DeKalb County for nine years and was the first prosecutor in Georgia to specialize in the prosecution of crimes against children.


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This significantly reduces the time traditionally spent sending water samples for laboratory testing and lowers the cost of certain automated systems (Leider, 2018). In a similar fashion, remote sensing from meteorological sensors, combined with geographic information systems, has been used to measure and analyze air pollution patterns in space and over time. In another approach to understanding environmental factors, images of Google Street View have been analyzed using deep learning mechanisms to analyze urban greenness as a predictor and enabler of exercise. Robots can replace human labor in highly dangerous or tedious jobs that are fatiguing and could represent health risks to workers-reducing injuries and fatalities. Some of these robotic deployments are replacing human labor; in other instances, humans collaborate with robots to carry out such tasks. Hence, the deployment of robots requires workers to develop new skills in directing and managing robots and managing interactions between different types of robots or equipment, all operating in dynamic work environments. It involves the patient, providers, health care facilities, laboratories, hospitals, pharmacies, benefit administrators, payers, and others. Before, during, and after a patient encounter, administrative coordination occurs around scheduling, billing, and payment. Collectively, we call this the administration of care, or administrative workflow. The use of deep learning is particularly powerful in a workflow where a trained professional reviews narrative data and makes a decision about a clear action plan. Textual information used for prior authorization can be used for training a deep learning model that reaches or even exceeds the ability of human reviewers, but will likely require "human in the loop" review. Most health plans and pharmacy benefit managers require prior authorization of devices, durable equipment, labs, and procedures. The process includes the submission of patient information along with the proposed request, along with justification. Automating this process, with human review, can reduce biased decisions and improve speed, consistency, and quality of decisions. Automation of prior authorization as above could reduce administrative costs, frustration, and idle time for provider and payer alike. Ultimately, such a process could lead to fewer appeals as well, which is a costly outcome of any prior authorization decision. A prior authorization model would need to work in near real time, because the required decisions are typically time sensitive. It is a human-labor-intensive process that requires an understanding of language, expertise in clinical terminology, and a nuanced, expert understanding of administrative coding of medical care. Of note, codes are often deleted and added, and their assignment to particular medical descriptions often changes. Proximity and other methods are used to identify appropriate codes to assist or pre-populate manual coding. The accuracy of coding is very important, and the process of assigning an unspecified number of multiple labels to an event is a complex one. False positives may lead to overcharges, compliance issues, and excess cost to payers. Because of the complexity of multilabel prediction, humans will have to supervise and review the process for the foreseeable future. This also increases the need for transparency in the algorithmic outputs as part of facilitating human review. Transparency will also be helpful for monitoring automated processes because treatments and medical standards change over time and algorithms have to be retrained. In the long term, increasing automation may be achieved for some or many types of encounters/hospitalizations. This automation will be reliant upon data comprehensiveness, lack of bias, public acceptance, algorithm accuracy, and appropriate regulatory frameworks. To narrow this massive landscape, we focus our discussion on research institutions with medical training facilities. Deep Learning Deep learning algorithms rely on the large quantities of data and massive computer resources, both of which are newly possible in this era. Deep learning can identify underlying patterns in data well beyond the pattern-perceiving capacities of humans. Deep learning and its associated techniques have become popular in many data-driven fields of research. This "unsupervised feature extraction" sometimes permits highly accurate predictions.

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Post-retirement: Those who look most forward to retirement and have plans are those who anticipate adequate income (Erber & Szuchman, 2015). This is especially true for males who have worked consistently and have a pension and/or adequate savings. Many of these individuals chose to pursue additional training to improve skills to return to work in a second career. For some older students who no longer are focus on financial reasons, returning to school is intended to enable them to pursue work that is personally fulfilling. Attending college in late adulthood is also a great way for seniors to stay young and keep their minds sharp. Even if an elder chooses not to attend college for a degree, there are many continuing education programs on topics of Source interest available. In 1975, a nonprofit educational travel organization called Elderhostel began in New Hampshire with five programs for several hundred retired participants (DiGiacomo, 2015). This program combined college classroom time with travel tours and experiential learning experiences. In 2010 the organization changed its name to Road Scholar, and it now serves 100,000 people per year in the U. Academic courses, as well as practical skills such as computer classes, foreign languages, budgeting, and holistic medicines, are among the courses offered. Older adults who have higher levels of education are more likely to take continuing education. However, offering more educational experiences to a diverse group of older adults, including those who are institutionalized in nursing homes, can bring enhance the quality of life. Those 60 and older now spend more than half of their daily leisure time (4 hours and 16 minutes) in front of screens. Screen time has increased for those in their 60s, 70s, 80s and beyond, and across genders and education levels. This rise in screen time coincides with significant growth in the use of digital technology by older Americans. In 2000, 14% of those aged 65 and older used the Internet, and now 73% are users and 53% own smartphones. Alternatively, the time spent on other recreational activities, such as reading or socializing, has gone Source down slightly. People with less education spend more of their leisure time on screens and less time reading compared with those with more education. Less educated adults also spend less time exercising: 12 minutes a day for those with a high school diploma or less, compared with 26 minutes for college graduates. These stereotypes are reflected in everyday conversations, the media, and even in greeting cards (Overstreet, 2006). Age is not revered in the United States, and so laughing about getting older in birthday cards is one way to get relief. The negative attitudes people have about those in late adulthood are examples of ageism, or prejudice based on age. The term ageism was first used in 1969, and according to Nelson (2016), ageism remains one of the most institutionalized forms of prejudice today. In contrast, older individuals in cultures, such as China, that held more positive views on aging did not demonstrate cognitive deficits. This is known as stereotype threat, and it was originally used to explain race and gender differences in academic achievement (Gatz et al. Stereotype threat research has demonstrated that older adults who internalize the aging 411 stereotypes will exhibit worse memory performance, worse physical performance, and reduced self-efficacy (Levy, 2009). In terms of physically taking care of themselves, those who believe in negative stereotypes are less likely to engage in preventative health behaviors, less likely to recover from illnesses, and more likely to feel stress and anxiety, which can adversely affect immune functioning and cardiovascular health (Nelson, 2016). Additionally, individuals who attribute their health problems to their age, had a higher death rate. Similarly, doctors who believe that illnesses are just natural consequence of aging are less likely to have older adults participate in clinical trials or receive life-sustaining treatment.

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Home visits by school authorities to assess educational environment and child welfare a minimum of two times per year, with more visits or an order to enroll in school triggered by evidence of problems. If deemed appropriate based on suspected problems, visits shall be without prior warning and without consent. School authorities must be charged with enforcement of above requirements, including by orders transferring children to public school based on inadequate compliance, inadequacy of education, or other problems. Specific Requirements to Ensure Adequate Protection Against Abuse and Neglect School officials with mandatory reporting responsibilities should be designated for the required home visits noted above. Costs of the Proposed Restrictive Regime There would be costs associated with the proposed regime. Public schools in this country, especially those serving the most disadvantaged children, are plagued with problems, triggering reform efforts that regularly fail to provide cures. Many schools provide little in the way of civic preparation or exposure to alternative perspectives. However, problematic school authorities may use their discretion to implement the proposed regime wrongfully. This danger could be minimized by delegating the decision as to whether to grant exceptions to a higher school authority than the local school district, or by providing an appeal mechanism. Nonetheless, the costs for children in a system of restrictive regulation are limited. Most children will do all right in public schools, even if some of them might do better if homeschooled. And parents will be free to make up at home what their children are not getting at school. Also, to the degree public schools are seriously deficient, our society should work on improving them, rather than simply allowing some parents to escape. This provides no solution for the children condemned to attend inadequate schools. Some would say there are also costs in terms of the values at the heart of the historic Meyer and Pierce cases. Parents would retain enormous control over children, even if children were required to attend regular school throughout the period of compulsory education. Parents could still raise these children at home with total control over their lives from infancy until kindergarten. They could still dominate the lives of children enrolled full-time in school, with total control during a huge proportion of their waking hours. Private School Reform Some private schools pose problems of the same nature as homeschooling. Private schooling is a large and complicated world with some important differences from homeschooling, both factually and legally. New York State is currently engaged in a struggle to impose some control over yeshiva education. One legal difference is that the Supreme Court has clearly held private schools are protected by the Federal Constitution. Children in private schools are at least exposed to a number of different adults and children, who are likely to provide at least some range of alternative views. Courts upholding differential treatment of homeschooling as compared to private schools have relied on a range of indicators that private schools might more reliably provide an adequate education, 472 including the fact that states can supervise private schools far more easily and at far less expense than homeschooling. A New Political and Legal Reality Regulatory reform along the lines sketched above should be possible, if legislators made decisions based on weighing the pros and cons of homeschooling and balancing the interests at stake. But the reality is that regulatory reform along these lines will not happen without a political and legal sea change. Severe critics of homeschooling regularly express pessimism about their recommendations for far more limited regulatory reform being adopted. It has all been in the direction of legitimation, deregulation, and rejection of proposed restrictions. It has grown evermore expansive in reach, now combining forces with other parental rights groups in the child protection area and beyond. There are many thoughtful critics of homeschooling who have called for significant reform, as discussed above. They have formed no organizations capable of resisting the organized political force of the homeschooling movement.


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In addition, some programs have begun to integrate dieticians into the treatment team, given the nutritional challenges that exist for many individuals with serious mental illness (Teasdale et al. Other nonpharmacological approaches that have been studied include exercise and cognitive-behavioral therapy approaches (Bonfioli et al. Of the pharmacological treatments that have been assessed, metformin has been studied most often. It has been shown to be safe in individuals without hyperglycemia, shows modest benefits on weight (with 109 average weight loss of 3-4 kg), and can reverse metabolic abnormalities in patients with obesity or other metabolic problems (Das et al. However, most studies have been small and follow-up periods have not been longer than six months. Modest benefit has also been seen in several studies of glucagon-like peptide-1 receptor agonists (Siskind et al. Other medications have been examined in small trials or case series with less consistent findings (Mizuno et al. This limited evidence and modest benefit of these pharmacological treatments needs to be considered in light of potential adverse effects. Another consideration for a patient who has experienced significant weight gain with antipsychotic treatment is to change or augment treatment with a medication with lower weight-gain liability (Vancampfort et al. In any patient with weight gain, it is also important to assess for other contributors to metabolic syndrome (Mitchell et al. Nevertheless, many individuals with schizophrenia do not engage in physical activity (Stubbs et al. Balancing of Potential Benefits and Harms in Rating the Strength of the Guideline Statement Benefits Use of an antipsychotic medication in the treatment of schizophrenia can improve positive and negative symptoms of psychosis (high strength of research evidence) and can also lead to reductions in depression and improvements in quality of life and functioning (moderate strength of research evidence). Meta-analysis of double-blind, randomized, placebo-controlled trials showed a medium effect size for overall efficacy (Leucht et al. The rates of achieving any response or a good response were also significantly greater in those who received an antipsychotic medication. In addition, the proportion of individuals who dropped out of treatment for any reason and for lack of efficacy was significantly less in those who were treated with an antipsychotic medication. Research evidence from head-to-head comparison studies and network meta-analysis 110 (McDonagh et al. Harms the harms of using an antipsychotic medication in the treatment of schizophrenia include sedation, side effects mediated through dopamine receptor blockade. Clozapine has additional harms associated with its use including sialorrhea, seizures, neutropenia (which can be severe and life-threatening), myocarditis, and cardiomyopathy. Among the antipsychotic medications, there is variability in the rates at which each of these effects occurs and no specific medication appears to be devoid of possible side effects. Patient Preferences Clinical experience suggests that many patients are cooperative with and accepting of antipsychotic medications as part of a treatment plan. A survey of patient preferences reported that patients viewed an ability to think more clearly and an ability to stop hallucinations or paranoia as important efficacyrelated reasons to take an antipsychotic medication (Achtyes et al. However, patients also reported concerns about side effects, particularly weight gain, sedation, and restlessness as reasons that they may not wish to take antipsychotic medications. Some patients may also choose not to take an antipsychotic medication when they are feeling well or if they do not view themselves as having a condition that requires treatment. Some patients may also prefer one medication over another medication on the basis of prior treatment experiences or other factors. Harms of treatment can be mitigated by selecting medications based on individual characteristics and preferences of patients as well as by choosing a medication based on its side effect profile, pharmacological characteristics, and other factors. Each guideline also recommends the need for monitoring during the course of treatment to assess therapeutic response and treatment-related side effects. Quality Measurement Considerations In clinical practice, almost all individuals with schizophrenia are offered an antipsychotic medication. Thus, a quality measure is unlikely to enhance outcomes if it only examines whether an individual with schizophrenia is offered or receives an initial prescription for antipsychotic treatment.

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A longitudinal look at the use of mental health services by persons with serious mental illness: Do Spanish-speaking Latinos di er from English-speaking Latinos and Caucasians. Mini-Mental State: A practical method for grading the cognitive state of patients for the clinician. Evidence-based psychological treatments for distress in family caregivers of older adults. Adult day service use and reductions in caregiving hours: E ects on stress and psychological well-being for dementia caregivers. Respite for dementia caregivers: e e ects of adult day service use on caregiving hours and care demands. A prescribing cascade involving cholinesterase inhibitors and anticholinergic drugs. Sedative hypnotics in older people with insomnia: meta-analysis of risks and bene ts. Family caregivers as case managers: A statewide model for enhancing consumer choice. Amnestic mild cognitive impairment: diagnostic outcomes and clinical prediction over a two-year time period. Making decisions about tube feeding for severely demented patients at the end of life: Clinical, legal, and ethical considerations. Hormone replacement therapy to maintain cognitive function in women with dementia. Dementia care: critical interactions among primary care physicians, patients and caregivers. Personality counts for a lot: predictors of mental and physical health of spouse caregivers in two disease groups. Improvement of agitation and anxiety in demented patients a er psychoeducative group intervention with their caregivers. Working with American Indian families: Collaboration with families for the care of older American Indians with memory loss. Nonpharmacological interventions for wandering of people with dementia in the domestic setting. A sociocultural stress and coping model for mental health outcomes among African American caregivers in Southern California. Naturalistic study of intramuscular ziprasidone versus conventional agents in agitated elderly patients: retrospective ndings from a psychiatric emergency service. Anticonvulsants for the treatment of behavioral and psychological symptoms of dementia: a literature review. Psychosocial intervention for individuals with dementia: An integration of theory, therapy, and a clinical understanding of dementia. E ective electroconvulsive therapy in a -year-old dementia patient with psychotic feature. Assessing self-maintenance: Activities of daily living, mobility, and instrumental activities of daily living. Systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia. Evidence-based psychological treatments for disruptive behaviors in individuals with dementia. Comparison of risperidone and placebo for psychosis and behavioral disturbances associated with dementia: A randomized, double-blind trial. Position statement of the American Association for Geriatric Psychiatry regarding principles of care for patients with dementia resulting from Alzheimer disease. Outcomes of family involvement in care intervention for caregivers of individuals with dementia. Nonpharmacologic management of agitated behaviors in persons with Alzheimer Disease and other chronic dementing conditions. Comparison of rapidly acting intramuscular olanzapine, lorazepam, and placebo: a double-blind, randomized study in acutely agitated patients with dementia. Meta-analysis: high-dosage vitamin E supplementation may increase all-cause mortality.

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In addition, providers can suggest that family, friends, and other potential recovery supports. See Medication-Assisted Treatment for Opioid Addiction: Facts for Families and Friends (ttp://mha. Treatment Planning or Referral Making Decisions About Treatment Start by sharing the diagnosis with patients and hearing their feedback. A great deal of time is spent in activities to obtain the opioid, use the opioid, or recover from its effects. Recurrent opioid use resulting in a failure to fulfll major role obligations at work, school, or home. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of opioids. A need for markedly increased amounts of opioids to achieve intoxication or desired effect b. A markedly diminished effect with continued use of the same amount of an opioid 11. The same-or a closely related-substance is taken to relieve or avoid withdrawal symptoms *This criterion is not met for individuals taking opioids solely under appropriate medical supervision. Whether to access potentially benefcial mental health, recovery support, and other ancillary services, whether or not they choose pharmacotherapy. Understanding Treatment Settings and Services Support patient preferences for treatment settings and services. Many patients initially form a preference for a certain treatment without knowing all the risks, benefts, and alternatives. Providers should ensure that patients understand the risks and benefts of all options. Exploring what patients already know about treatment options and dispelling misconceptions. Offering information on medications and their side effects, benefts, and risks (Exhibit 2. Additional methadone take-home doses are possible at every 90 days of demonstrated progress in treatment. Develop a treatment plan to determine where patients will receive continuing care (see the "Treatment Planning" section). Some programs also offer case management, peer support, medical services, mental disorder treatment, and other services. Some residential programs require patients to discontinue these medications to receive residential treatment, which could destabilize patients and result in opioid overdose. These programs range from low intensity (individual or group counseling once to a few times a week) to high intensity (2 or more hours a day of individual and group counseling several days a week). Providing a naloxone prescription and overdose prevention information is appropriate. Drug Addiction Treatment Act of 2000 legislation requires that buprenorphine prescribers be able to refer patients to counseling, but making referrals is not mandatory. New prescribers can beneft from mentorship from experienced providers in their practice or community. Preventing opioid overdose (see the "Preventing Opioid-Related Overdose" section). For information about all forms of naloxone, Refer patients to syringe exchange sites. The North American Syringe Exchange Network provides options (see the "Syringe Exchange" section). Use a small "test dose" if returning to opioid use after a period of abstinence, if the substance appears altered, or if it has been acquired from an unfamiliar source.

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Development and validation of a deep learning algorithm for detection of diabetic retinopathy in retinal fundus photographs. Best Care at Lower Cost: the Path to Continuously Learning Health Care in America. Adapting to artificial intelligence: Radiologists and pathologists as information specialists. The Enemy of Good: Estimating the Cost of Waiting for Nearly Perfect Autonomous Vehicles. Smartphone-based conversational agents and responses to questions about mental health, interpersonal violence, and physical health. This health startup won big government deals-but inside, doctors flagged problems. Populationlevel prediction of type 2 diabetes from claims data and analysis of risk factors. A general reinforcement learning algorithm that masters chess, Shogi, and Go through self-play. Counterfactual normalization: Proactively addressing dataset shift and improving reliability using causal mechanisms. Effect of an intensive outpatient program to augment primary care for high-need veterans affairs patients: A randomized clinical trial. The concepts discussed here apply to the development and validation of an algorithmic agent (or, plainly, an algorithm) that is used to diagnose, prognose, or recommend actions for preventive care as well as patient care in outpatient and inpatient settings. Overall, Chapters 5, 6, and 7 represent the process of use case and needs assessment, conceptualization, design, development, validation, implementation, and maintenance within the framework of regulatory and legislative requirements. Her primary care physician must diagnose and treat the acute illness, but also manage the risks associated with her chronic diseases. Ideally, decisions regarding if to treat are guided by risk stratification tools, and decisions of how to treat are guided by evidencebased guidelines. For example, best practices to manage blood pressure come from randomized controlled trials enrolling highly homogeneous populations (Cushman et al. Moreover, there are care delivery gaps from clinical inertia, provider familiarity with treatments, and patient preferences that result in the lack of management or undertreatment of many conditions. Even for well-understood clinical situations, such as the monitoring of surgical site infections, current care delivery falls woefully short. Such automation can significantly increase the capacity of a care team to provide quality care or, at the very least, free up their time from the busy work of reporting outcomes. Below, additional examples are discussed regarding applications driving the use of algorithms to classify, predict, and treat, which can guide users in figuring out for whom to take action and when. These applications may be driven by needs of providers, payers, or patients and their caregivers (see Table 5-1). Doing so requires an assessment of utility, feasibility given available data, implementation costs, deployment challenges, clinical uptake, and maintenance over time. This chapter focuses on the process necessary to develop and validate a model, and Chapter 6 covers the issues of implementation, clinical use, and maintenance. Factors affecting the clinical utility of a predictive model may include lead time offered by the prediction, the existence of a mitigating action, the cost and ease of intervening, the logistics of the intervention, and incentives (Amarasingham et al. For example, if Vera was suspected of having atrial fibrillation based on a personalized risk estimate (Kwong et al. During this assessment process, there are several key conceptual questions that must be answered (see Box 5-1). Quantitative answers to these questions can drive analyses for optimizing the desired outcomes, adjusting components of the expected utility formulation and fixing variables that are difficult to modify. After the potential utility has been established, there are some key choices that must be made prior to actual model development. Both model developers and model users are needed at this stage in order to maximize the chances of succeeding in model development because many modeling choices are dependent on the context of use of the model. Although clinical validity is discussed in Chapter 6, we note here that the need for external validity depends on what one wishes to do with the model, the degree of agency ascribed to the model, and the nature of the action triggered by the model. These types of systems make use of established biomedical knowledge, conventions, and relationships. Inexpensive data storage, fast processors, and advancements in machine learning techniques have made it feasible to use large datasets, which can uncover previously unknown relationships.

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The age and temperament of the child, along with concerns about the reaction of the ex-spouse, may also influence when parents reveal their romantic relationships to their children. Rates of remarriage: the rate for remarriage, like the rate for marriage, has been declining overall. This represents a 44% decline since 1990 and a 16% decline since 2008 (Payne, 2015). Brown and Lin (2013) found that the rate of remarriage dropped more for younger adults than middle aged and older adults, and Livingston (2014) found that as we age we are more likely to have remarried (see Figure 8. This is not surprising as it takes some time to marry, divorce, and then find someone else to marry. However, Livingston found that unlike those younger than 55, those 55 and up are remarrying at a higher rate than in the past. In 2013, 67% of adults 55-64 and 50% of adults 65 and older had remarried, up from 55% and 34% in 1960, respectively. Livingston (2014) reported that in 2013, 64% of divorced or widowed men compared with 52% of divorced or widowed women had remarried. This gender gap has closed mostly among young and middle aged adults, but still persists among those 65 and older. In 2012, Whites who were previously married were more likely to remarry than were other racial and ethnic groups (Livingston, 2014). Moreover, the rate of remarriage has increased among Whites, while the rate of remarriage has declined for other racial and ethnic groups. This increase is driven by White women, whose rate of remarriage has increased, while the rate for White males has declined. Success of Remarriage: Reviews are mixed as to the happiness and success of remarriages. While some remarriages are more successful, especially if the divorce motivated the adult to engage in self-improvement and personal growth (Hetherington & Kelly, 2002), a number of divorced adults end up in very similar marriages the second or third time around (Hetherington & Kelly, 2002). Remarriages have challenges that are not found in first marriages that may create additional stress in the marital relationship. There can often be a general lack of clarity in family roles and expectations when trying to incorporate new kin into the family structure, even determining the appropriate terms for these kin, along with their roles can be a challenge. All of this may lead to greater dissatisfaction and even resentment among family members. Even though remarried couples tend to have more realistic expectations for marriage, they tend to be less willing to stay in unhappy situations. The rate of divorce among remarriages is higher than among first marriages (Payne, 2015), which can add additional burdens, especially when children are involved. There is also some evidence that individuals who participated in a stepfamily while growing up may feel better prepared for stepfamily living as adults. Goldscheider and Kaufman (2006) found that having experienced family divorce as a child is associated with a greater willingness to marry a partner with children. When children are present after divorce, one of the challenges the adults encounter is how much influence the child will have when selecting a new partner. Greene, Anderson, Hetherington, Forgatch, and DeGarmo (2003) identified two types of parents. In contrast, the adult-focused parent expects that their child can adapt and should accommodate to parental wishes. Anderson and Greene (2011) found that divorced custodial mothers identified as more Source adult focused tended to be older, more educated, employed, and more likely to have been married longer. Additionally, adult focused mothers reported having less rapport with their children, spent less time in joint activities with their children, and the child reported lower rapport with their mothers. Lastly, when the child and partner were resisting one another, adultfocused mothers responded more to the concerns of the partner, while the child focused mothers responded more to the concerns of the child. Understanding the implications of these two differing perspectives can assist parents in their attempts to repartner.


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