This paper analyzes the co-movement and causal linkages between environmental pollution and healthcare expenditure, taking economic growth as a control variable by using wavelet analysis for Taiwan over the period 1995 Q1–2016 Q4. The results show that there exists co-movement and causality between environmental pollution and healthcare expenditure at different frequencies and times. The changes in the relationships of the two variables are observed in certain events such as the period of the expansion stage, the policy of environmental pollution, and the issue of the National Health Insurance Integrated Circuit card (NHI-IC) in Taiwan. In the short-term, positive causality runs from healthcare expenditure to environmental pollution before 2004, while negative causality runs from healthcare expenditure to environmental pollution before 2007 in the long-term. After adding economic growth as a control variable, positive causality runs from healthcare expenditure to environmental pollution in the period 2009–2011 in the short-term, while negative causality running from healthcare expenditure to environmental pollution is shown in 2008 in the long-term. The results indicate that “higher government health expenditure leading to higher demand for environment quality” exists in different sub-periods and the argument may concern the factor of economics in the long-term. The positive healthcare lead in the short-term may be based on economics in the expansion stage. Also, the issue of NHI-IC possibly affects the dynamic relationship between healthcare expenditure and environmental pollution without considering economics. Based on empirical analysis, certain policy and managerial implications are addressed for decision-makers at macroeconomic and microeconomic levels. In recent decades, the relationships between economic growth, environmental deterioration and health spending have received greater focus in literature in the context of both developed and developing nations. These relationships among economic growth, environmental deterioration and health spending are varied, complicated and significant.Increased economic expansion, urbanisation and industrialisation within both developed and developing nations have caused the significant worsening of air quality as a result of the emission of a variety of different air pollutants into the environment . Human a2 emissions on health spending. A limited number of research have specifically concentrated on the bi-directional causality between environmental degradation and health costs. Lastly, based on the pioneering work of Grossman and Kruger [The pairwise relationship that exists among the three issues presented in the study has been examined in the literature. The association between economic growth and health, in particular, has been the focus of numerous studies ,9,10. Thd Kruger , multipld Kruger ,17,18,19Air quality has developed into a significant national problem in Taiwan since the 1990s. It was determined that mobile emissions represent one of the primary contributors to air pollution in this area in comparison to industrial plants. For instance, estimations for 2017 indicated that mobile emissions contributed a total of 74% of the overall carbon monoxide (CO) emissions . AccordiAfter the government introduced the scheme of National Health Insurance in 1995, users, no matter the rich or poor, were able to enjoy the resources in the scheme in which users can undergo health examinations and cures with partial subsidies from the scheme, such that National Health Insurance benefited everyone in the society. The government often subsidises those who are not rich in society; for example, in Taiwan, farmers are endorsed 70% and low-income families are endorsed 100% for the payment . As a reThere is sufficient empirical evidence demonstrating the pairwise association between the three primary issues, namely, environmental pollution and healthcare spending, environmental pollution and economic growth, and healthcare spending and economic expansion. Limited studies have focused on the casualty between environmental pollution and healthcare spending; also, they have investigated the issue utilizing panel data based on a regional context through employing the time series technique ,24. PartTo the best of the authors’ knowledge, the present study represents the first attempt to examine the co-movements between healthcare spending and environmental pollution, where economic growth has been used as the control variable for Taiwan through the application of the time and frequency domain approach. The contribution that this research makes to the literature can be viewed from two perspectives. Firstly, we utilise the wavelet approach, which has the capacity to investigate the dynamics between healthcare spending and environmental pollution, where economic growth is taken as the control variable in both long-term and short-term. The benefit of wavelet analysis is that it takes into account both time and frequency jointly in one structure in the examination of the co-movement in time series of healthcare spending and environmental pollution in a time-frequency band space. From the economic perspective, time-frequency domain techniques allow cyclical data to be extracted from a time series, which can be highly beneficial in the evaluation of the impacts of distinct socio-economic situations in terms of the different positions for environmental and healthcare policies, due to the fact that it provides recommendations in regard to the drive and timing of policy actions that traditional time-series methods are unable to capture completely. Hence, analysis based on the results is comparatively comprehensive in regard to the relationships between the given variables. Secondly, the present study could be particularly beneficial for Taiwanese policymakers responsible for healthcare and environmental issues and will offer a certain degree of imperative understanding to other economies with a level of development and healthcare expenditure similar to Taiwan in both the short and long term.The study is separated into five sections. The aim of this study is to empirically investigate the co-movements among healthcare spending and environmental pollution for Taiwan, where economic growth is taken as the control variable. The pairwise association among the primary study variables will be discussed on the basis of the following strands.First of all, the Environmental Kuznets Curve has been proposed by Grossman and Krueger  who addr2 emissions and GDP in 25 OECD countries through using panel data for the period between 1980 and 2010. Utilising a sample comprising 16 Chinese provinces located in three primary regions for the period 1985–2012, Peng et al. [2 emissions and economic growth in the long run for the G7 nations. In summary, past research has presented opposing evidence in terms of the EKC hypothesis for both individual country and cross-country studies.Hallicioglu  examinedg et al.  exploredSecondly, this section focuses on the relationship between economic growth and health expenditures. Most of the research has focused on measuring the magnitude of the income elasticity of healthcare, in addition to the policy ramification for the funding and the efficiency in the allocation of healthcare resources.Ayuba  utilised2 emissions on healthcare spending. Not so many empirical investigations have investigated the bi-directional causality between the environment and healthcare spending.The third research strand on this issue offers empirical evidence regarding the nexus between the environment and healthcare spending. However, there has been minimal focus within the academic community in terms of this research strand in comparison to the two strands mentioned above. The majority of previous researchers have concentrated on the causal effect of CO2 and other pollutants that impact the environment had a negative effect on human health. In the study conducted by Yazdi et al. [2 and other pollutants to healthcare spending for Iran by utilising cointegration as well as the ARDL approach was investigated. Apergis et al. [2 emissions at the individual state level for 50 states and the resulting effects on healthcare spending. They determined that CO2 had a positive effect on healthcare expenditure and further analysis revealed that this impact was more powerful for states whose healthcare expenditures were higher. Khoshnevis Yazdi and Khanalizadeh [2 emissions and healthcare spending due to the fact that researchers have given this subject less attention. The positive and causal association between healthcare spending and CO2 emissions has been validated by past panel-based research by [In their research focused on 30 Chinese provinces, Lu et al.  determins et al.  studied alizadeh  examinedalizadeh  utilisedalizadeh , the relearch by ,24,31.A minimal number of studies have focused on the relationship between air quality, healthcare spending and economic growth. Chaabouni and Abdnnadher  investigIn summary, the majority of prior research has concentrated on the pairwise association between the three primary issues, namely “environment and economic growth”, “economic growth and healthcare spending” and “environmental quality and healthcare spending”. Additionally, multiple studies have explored the nexus among the three primary issues using the panel cointegration technique based on a regional context. Furthermore, for individual economies, the majority of past studies have investigated the relationship among these variables via the application of time domain methods. Nevertheless, it is evident that in order to examine the three primary issues and to make structured policy recommendations for Taiwan, it is necessary to explore the dynamic association between health spending and environmental pollution, where economic growth is taken as the control variable through wavelet analysis. Wavelet analysis is a time and frequency domain technique. Instead of time domain methods, policy makers employ the time and frequency domain method to comprehensively focus on both long- and short-term analysis.During the mid-1980s, wavelet analysis was developed as another option to the familiar Fourier analysis. Time-localised information is totally ignored in the Fourier transform despite the fact that such analysis may unmask the relationships over various frequencies through spectral methods. Furthermore, the appropriateness of the Fourier analysis is limited to the stationary time series. Contrastingly, we are able, through wavelet analysis, to assess the spectral attributes of a time series (being a time function) and subsequently to remove localised information in frequency areas as well as in time domains . MoreoveIn wavelet analysis, initially, the wavelet transform fragments a time series into extended and transformed types of a specified and well-localised “mother wavelet” within frequency and time areas. This enables the expansion of the series into a time-frequency space where highly-instinctive observations are made of the frequency-varying and time-varying oscillations. There are frequently two wavelet transforms classifications, namely, discrete wavelet transforms (DWT) and continuous wavelet transforms (CWT). The DWT aids data compression as well as noise reduction, whereas the CWT is of greater assistance for data self-similarity recognition and feature extraction ,37. The We can define the CWT of a time series  of time . FurtherIt is necessary for requency . It is oBy using this, we may proceed from a et al. , p. 2868There are many different kinds of mother wavelets for various purposes. These include Daubechies, Haar, Mexican hat and Morlet. The Morlet wavelet, which was introduced by Goupillaud et al. , is the The wavelet power spectrum of a time series s et al.  implemenTo conduct an analysis of the dynamic association between health expenditure and environmental degradation in Taiwan, greater attention ought to be applied to the phase difference and wavelet coherency. The process begins with wavelet coherency, and in order to calculate this, we apply the cross-wavelet spectrum and the auto-wavelet spectra as shown below:S, the squared wavelet coherency produces a quantity between zero and one within a time-frequency space. In wavelet coherency plots, this is indicated by colours, in which red represents a powerful association, whereas blue represents a weak association. Consequently, wavelet coherency enables a three-dimensional analysis which may regard frequency and time components simultaneously in addition to the strength of correlation [We observe, at this point, that the wavelet coherency being studied is shown as a squared type having similarities with past studies ,36,39. Frelation . This coIt is impossible to differentiate between positive and negative links since the wavelet coherency is squared. It is therefore necessary to phase the difference tool to existing positive or negative suggestions for associations and lead-lag links between series. The complexity of the Morlet wavelet function leads to the complexity of the CWT regarding this kind of mother wavelet, which may be separated into a real portion and an imaginary portion. Consequently, according to Bloomfield et al. , we can  Usoskin  and Agui Usoskin , it is aThe phase variations in this paper are shown as arrows in the wavelet coherency plots. Arrows which point to the right-hand direction indicate that and y(t) ,47.Our empirical study uses the quarterly time series data on per capita carbon monoxide (CO) emissions , real GDP per capita, and healthcare expenditure per capita for the 22-year period from 1995 Q1 to 2016 Q4 in Taiwan. The data of CO is from the Environmental Protection Administration in Taiwan. The data of real GDP per capita is from national statistics in Taiwan. Real GDP per capita is measured in New Taiwan Dollars (NTD), considering 2011 prices. The data of healthcare expenditure is from the Ministry of Health and Welfare in Taiwan. We transformed the data including real GDP per capita and healthcare expenditure per capita into natural logarithms. The historical trends of per capita CO emissions, real GDP per capita, and healthcare expenditure per capita for Taiwan are illustrated in The intuition behind such short-term positive causality is that higher government health expenditure positively affects economic performance, for the reason of positive externalities and conflicts between individual and public benefits ; also, EAfter the government introduced the scheme of National Health Insurance in 1995, users, no matter the rich or poor, were able to enjoy the resources in the scheme in which users can undergo health examinations and cures with partial subsidies from the scheme, such that National Health Insurance benefitted everyone in the society. The NHI’s benefits are comprehensive; for example, the insurance includes the fees of inpatient care, daycare for the mentally ill, limited home health care, certain preventive medicines and even expensive treatment for diseases such as HIV/AIDS . The govGovernment spending on healthcare has increased year by year as a result of overuse of medical resources by individuals; for example, users may often perform medical examinations instead of paying attention to their health situations in advance, and the scheme may be taken as the Tragedy of the Commons . In 2003After we add economic growth as a control variable, the stage of expansion in the economic cycle, i.e., the period of 2002 to 2003 and 2009 to 2011, in Taiwan shows that the positive impact of healthcare expenditure per capita on per capita CO emissions. Thus, we confirm that the contribution of externalities to economic growth depends on the stage of the economic cycle. In the period of 2001 to 2002, Taiwan was in recession or early recovery, such that healthcare expenditure per capita and per capita CO emissions do not show significant lead–lag relationships. However, in the period of 2002 to 2003 and 2009 to 2011 in the short run, Taiwan was in an expansion or developing stage, such that healthcare expenditure per capita positively impact on per capita CO emissions based on the applications of positive externalities  and EKT The intuition behind such long-term negative causality is the following two perspectives and is related to the Armey curve.  runs from healthcare expenditure to the environment in the short-term (long-term). This empirical result indicates the launch of the NHI not only shows that the government has put the effort to decrease inequality for residents but also to help the people who possess better physical and mental situations in the middle or bottom of the economic ladder contribute to the economy, such that the positive externalities in the awareness of quality of life are shown in the long-term. The direction of causality between healthcare expenditure and the environment is different in Taiwan and the U.S. states . Taiwan


The outbreak of Severe Acute Respiratory Syndrome is the first severe and readily transmissible disease to emerge in the 21st century. Often one new infection meant tracing of several people to monitor their health conditions as well. In Singapore, several agencies coordinated their efforts to quickly bring the outbreak under control. The current breed of health-care information systems (HCIS) was not sufficient to handle new information-sharing needs during the crisis. In this paper, we take a look at the measures taken during the crisis in Singapore through a knowledge integration perspective. This perspective reveals interesting implications for HCIS. I.The USE of information technologies (IT) in the health-care industry is often restricted to reducing costs and increasing quality of health care Health-care services are generally collaborative work involving many stakeholders Hospitals and various health-care institutions were the battlegrounds where management of this crisis had to be effected. Health-care information systems (HCIS) had to share information effectively to help manage this battleground. Though Singapore already utilizes several strategic applications of IT among health-care institutions In this paper, we narrate the crucial role of IT in coordinating information flow in managing the crisis in Singapore involving several agencies, to draw useful lessons for HCIS through a knowledge integration perspective. Knowledge integration is the ability of an organization to integrate specialist knowledge. Grant discusses efficiency, scope, and flexibility as three characteristics of knowledge integration In II.A.reduced costs and increased quality of service delivery Diverse IT applications in health care are collectively referred to as HCIS, including applications from diverse fields such as medicine, computer science, management science, statistics, biomedical engineering, among others Traditional health-care information systems focus on automation and integration of administrative tasks such as billing and payments collection Clinical information systems (CIS) represent another category of HCIS that is gaining widespread acceptance in the health-care industry B.For the purposes of this paper, we adopt Nonaka and Takeuchi's definition of knowledge as “justified true belief” Drawing on the sociology of knowledge, Alavi and Leidner view organizations as social collectives and knowledge systems and present a framework of knowledge management that comprises four sets of socially enacted processes Knowledge integration is defined as a continuing collective process of creating, expressing, and redefining shared beliefs through social interaction of organizational members Grant identified three characteristics of knowledge integration, namely, efficiency, scope, and flexibility of integration within an organizational setting In this paper, we study these three characteristics of knowledge integration in the context of managing a health-care crisis. Efficient flow of information is necessary in managing an outbreak III.Qualitative research emphasizes processes and meanings that are not easily quantified. It stresses how social experiences are created and given meaning Data for this study was collected from multiple sources for triangulation Data collection and analysis are hard to differentiate in qualitative research DSTA, the lead agency managing the technology support during the crisis, was formed by the Government of Singapore as a statutory board under the Ministry of Defense (MINDEF) in March 2000. DSTA is responsible for implementing defence technology plans, managing defence research and development, acquiring defence material, and developing defence infrastructure for MINDEF. Apart from its defence technology support, DSTA's development work in IT involves various applications that enhance command and control and daily operations of Singapore's Armed Forces. Through its various operations, DSTA has expertise in providing enterprise systems solutions, knowledge engineering, mobility, military command and control, and e-government systems IV.A.In February 2003, several people were diagnosed with a severe form of pneumonia in the Guangdong province of China. The infection spread to Vietnam, traced to a traveller, returning from China and Hong Kong, during the later part of February. Several members of the hospital staff were infected and became critically ill. On the 11th of March, the Prince of Wales hospital in Hong Kong reported several infections and was monitoring several staff with a breakout of fever and respiratory problems.On the 12th of March 2003, the World Health Organization (WHO) issued a global alert on the outbreak of a severe form of pneumonia. Following the alert, Singapore's MOH issued a national alert, requesting doctors to be on the lookout for flu-like symptoms and respiratory problems in patients. It also requested travellers from these regions to consult doctors immediately upon developing any flu-like symptoms. MOH was also monitoring the health of three patients who developed these symptoms and had recently returned from Honk Kong. While two were discharged upon recovery, one patient was under observation and recovering. MOH did some contact-tracing and monitored those who had been exposed to the patient.B.Named SARS by WHO, soon more cases of the disease surfaced, further complicating the spread of the infection. Tracing was also increasingly difficult with over 95 infected patients and 52 discharged. Apart from tracing contacts with suspected carriers, monitoring was established at the airport to help screen passengers as they arrived in Singapore. ICA worked in conjunction with the National Environment Agency (NEA) to help trace passengers who needed to be quarantined such as in the case of the fourth index patient (primary carriers who infect others) who flew into Singapore with symptoms of SARS. The Ministry of Education (MOE) was working with the educational institutions to help trace contacts within institutions and implement screening measures to identify flu-like symptoms early.sinsehs (doctors in Chinese medicine) before visiting a hospital. Increasing index cases and the need to trace and quarantine all contacts of known infected patients led to increased strain on resources. Despite the nation-wide measures taken to help identify early symptoms and isolate patients, the cycle of infection was not broken and every day patients trickled into hospitals with SARS symptoms. On the 19th of April, a new chain of events began, which took the SARS crisis to a new level in Singapore. A cluster of new infections were discovered, and one of them worked in the Pasir Panjang Wholesale Market in Singapore. The new cluster meant the entire wholesale market had to be shutdown and over 700 people contacted to check for symptoms of SARS. Some infected patients had visited several general practitioners and several Contact-tracing had to deal with identifying all visited places, and contact each person to monitor their health. The decision was to play it safe and quarantine even a large number, rather than risk letting potential patients slip through. Close contacts were quarantined and others monitored for appearance of SARS symptoms. All stall holders in the market and their employees were quarantined. Everyone who visited the wholesale market between the 5th and 19th of April were requested to report to the MOH or a hospital to be screened for possible infection.New cases were trickling into the hospitals now, mostly related to the wholesale market. Contact-tracing was in full swing, but with the escalation of contacts to be traced, the system was under severe pressure. In C.During the early outbreak of SARS, the hospital staff traced contacts. This was soon becoming cumbersome since the medical staff was under pressure catering to medical needs of continuously trickling cases and increased precautions during medical care provision. MOH established an operations center together with the NEA to conduct contact-tracing operations. Officers from the NEA managed data on Microsoft Excel-based spreadsheets to monitor data and obtain contact details. Information gathered from contacts was keyed into those spreadsheets. One of the users commented that the spreadsheet was “powerful and caters to all their needs” because it allowed freeform data entry.Reports were prepared based on such information to update MOH on the status of contact-tracing and issuance of Home Quarantine Orders (HQO). MOH contracted CISCO, a statutory board specializing in security services in Singapore, to help in issuing and verifying compliance of HQO. Thus, the complete process of identifying a suspect case, the patient's contacts, and issuance of HQO involved four major agencies, namely, MOH, the hospitals, the NEA, and CISCO. Other agencies were also involved in providing social support such as counselling, food delivery, etc.p.m. every day. CISCO's staff then visited the people on their list and issued HQO. This procedure had to be completed by midnight or early morning in order to ensure compliance with the HQO immediately. Nonissuance or noncompliance only meant a potential increase in people to be traced.When a patient was identified as a suspect SARS case, this information was passed on to the contact-tracing operations center. The MOH did its own follow-up and sometimes obtained information from other relevant agencies . This information was consolidated and sent to the operations center, which was in the process of tracing contacts. This information was consolidated as a complete list of people to be issued with HQO and delivered to CISCO by 8 D.Escalation of the outbreak and the need to contact and trace an entire wholesale market in Singapore prompted MOH to establish contact with the MINDEF to set up a bigger operations room for the growing contact-tracing operations.On the 24th of April 2003, four days after the Pasir Panjang Wholesale Market incident, DSTA was requested to provide their assistance to establish an operations room for contact-tracing. The initial IT infrastructure centered on setting up 120 stations with e-mail, file, and print services and Internet connectivity to the government's e-mail systems. This was established within 48 hours. This capacity was subsequently increased to 250. Due to the nature of the SARS viral transmission, video conferencing became critical connecting MOH and MINDEF. A support team was established, which operated in shifts to provide technical support to the operations center.The chief information officer (CIO) of DSTA oversaw the operations and suggested that the infrastructure would still not help MOH scale-up its operations because their business process was not sufficiently streamlined. “Most of the information was in hardcopies or on spreadsheets with unstructured data. It would be hard to do any sort of analysis based on that data,” reported an informant. Hence, DSTA suggested the use of an information system to cater to the needs of information coordination and flow, thus making the process of tracing contacts efficient.E.DSTA had two weeks to gather information on all processes in tracing contacts, identifying their linkages, and issuing quarantine orders. The system had to be developed to meet the requirements as anticipated by DSTA. To begin this process, DSTA began by assembling a team that was experienced in network technologies, database administration, and systems development. Employees were invited to join the development team, and asked to drop all existing projects to complete the CMS in two weeks.Most of the invited employees began work immediately, recognizing the critical nature of the assignment. The national crisis motivated most team members to contribute their efforts to the project. Another reason cited by developers was the challenge of having to develop a system in such a short time, and gathering development requirements as the system was being written. “It was like being in some kind of extreme programming competition!” suggested a programmer.The project team was assembled, and the nearest system to contact-tracing requirements was identified to help jump-start the development process. DSTA had previously developed a casualty management system for the Singapore Armed Forces. This system was identified as the closest to current requirements and the project managers had prior experience in developing that system. However, this system was insufficient to manage tracing operations, which required analysis of linkages among the infected patients and their contacts. To help in this process, another government agency provided the DSTA with software to study cross-relationships among a set of people.The team quickly went about setting out other requirements for CMS, such as data sources, formats, security, and reports needed from the system. There were no established procedures in the operations room, since data management up to now had been through spreadsheets and individual practices to monitor and manage tracing operations. “People at the operation center had no time to talk to us; they would give us the data and we had to figure out the details. Sometimes they didn't know the complete process!” said a manager. The development team had to identify possible requirements, suggest ways to synchronize their contact-tracing operations, and gather sources of information and user interface layouts. The primary task was to identify sources of data to identify people and their contact information. Sources of information ranged from hospitals, MOE, and MOH, to general medical practitioners and traditional Chinese medicine practitioners. Information from all sources had to be collected into a database, from where the system would perform a case management should someone be identified as suspected or confirmed SARS patient. This database was to be the reference database with as much contact information as could be gathered. In addition, a SARS case-management database connected confirmed cases with suspected and probable cases, to identify potential SARS patients and monitor their health status. This SARS database could also be used to provide exit control with immigration authorities  or with MOE (to isolate students who inadvertently attend schools when they should be quarantined). The databases together were interfaced through CMS and a link analysis system to help in the entire contact-tracing operations.The reference database required data to populate the system. It was ineffective with no data to look up contact information. While DSTA worked with other agencies of the government to populate the database with useful information, technical issues centered on inconsistent data formats, incomplete or outdated information. Inconsistencies had to be resolved and data loaded into the reference database. However, that was a small concern compared to obtaining the data itself. “When one agency offered their contact data for the reference database, they cautioned me that the data was at least three months old. But I was ecstatic because back then I had no data and any data was better than that!” said the CIO.F.Hospitals were an important zone in the battle against SARS. Patients there had to be isolated to prevent further infection, and at the same time, effective medical care provided to those with SARS as well as others in need of other medical services. Every time a patient was identified as a SARS patient, contact-tracing had to be carried out within the hospital to trace the movement of the patient and monitor the health of relevant staff and other inmates. This was a time-consuming process, but it was critical to the efforts in containing the spread of the virus. Most infections arose from index cases who returned to Singapore from travel to the SARS-infected regions in South East Asia.The data gathered at such contact-tracing operations were often ineffective due to lack of knowledge on such procedures. Also, there was immense strain on the medical staff at hospitals due to procedures put in place to deal with the crisis. In some of the data gathered there, fields were incomplete, or lacked basic information to conduct meaningful contact-tracing. However, the hospital staff, with their limited technical expertise innovated through the use of Microsoft Visio to plot the linkages to other contacts. Technology savvy doctors helped establish initial contact-tracing data systems with spreadsheets to help trace patients and their contacts.When DSTA was invited to help MOH with the technical infrastructure, CIOs of health sector agencies had agreed to try a system to tag patients at accident and emergency (A&E) departments of the hospitals since most patients reported to A&E departments when symptoms appeared. One hospital, which was not affected by SARS, ran a trial system with radio-frequency identification (RFID) tags to help trace movements of the patients. DSTA coordinated the trial with a private sector vendor specializing in RFID technologies. Even prior to the outbreak, some hospitals were in the process of trying out RFID systems to help monitor patient movements within hospitals.G.Development and implementation of CMS was completed in two weeks. However, implementation of CMS and conversion of data from spreadsheet-based systems to the new database system highlighted some interesting experiences. The operations center staffed by NEA officers had developed multiple data formats on the spreadsheets. This meant that the new system had virtually 200 different formats to resolve, making data conversion a difficult process. This was because users were using spreadsheets forwarded by MOH or hospitals to trace contacts. This led to varying formats, and clubbing of several fields in a single cell making it difficult to split the data. Populating the SARS case-management database was, thus, a challenge. The database team set about resolving these issues and populated the database with the case data.The implementation team worked on parallel implementation to ease the system to the working environment with minimal disruption to tracing operations. Parallel implementation helped implementers convert data into the new system, as well as train users on system usage without disrupting on-going tracing operations. Intensive system testing was also carried out due to the importance of data accuracy. After running the system parallel to the spreadsheet-based data entry, the operations center finally switched over to CMS.After implementation, DSTA tested and supported the system for three weeks, and was satisfied with its stability. MOH then contracted another agency to continue maintenance and development.H.Relentless efforts were on in Singapore to manage the crisis, and provide a safe and healthy atmosphere in Singapore. The SARS virus had an incubation period of ten days. Singapore was working to break the cycle of infection in order to clear two incubation cycles without new infections and, thus, effectively be rid of the virus. On the 30th of May 2003, Singapore was declared clear of the SARS virus by WHO.On the 9th of September 2003, a new probable SARS case was reported in Singapore. A postdoctoral student was infected while handling virus samples in a laboratory. His fever started on the 26th of August, but was diagnosed as a common viral fever. He had visited doctors several times with persistent fever. Later, within 8 hours of having identified the SARS patient and activating the tracing operations, about 60 people were traced and contacted and some were issued HQOs.V.Organizations value knowledge as a resource, which will give them a competitive advantage by reducing costs, and improving productivity and innovation Health-care activities are knowledge intensive, with an explosion of health-care knowledge, and increased patient awareness on health care The outbreak of communicable disease such as SARS has, thus, highlighted the need for health-care institutions and governments to be prepared for emergencies. Such a crisis may place a new need for sharing, particularly by health-care institutions. In this section, we highlight some of the lessons learned from Singapore's management of the SARS outbreak, through a knowledge-integration perspective for health-care IT.A.Efficiency of competitive advantage depends on how productive firms are in utilizing knowledge stored within individuals The ad hoc system that was managed by NEA's staff was inefficient but was sufficient to cover the magnitude of the task in early days of the infection in Singapore. However, when the need to scale the operations arose, better infrastructure was felt necessary. DSTA was roped in, which proposed a system that went beyond merely scaling hardware infrastructure, thus providing an efficient mechanism for communication.DSTA identified all processes from identifying potential SARS infections to the process of issuing and monitoring HQOs. These processes were built into the system, providing structure to help simplify the process of issuing HQOs. Link analysis of suspected infections helped in understanding the crisis better, even making it easier to compile various reports on the crisis.All agencies were also linked by e-mail through government e-mail systems. This helped in efficient exchange of information, feedback, and suggestions for further actions. “Every night I would go through the e-mails exchanged by various heads in the government and incorporated their suggestions into the system. It was an extremely useful mechanism,” reported the CIO of DSTA. Summaries of other tasks were exchanged among the agencies to keep each other informed on latest developments.Hospitals were an important source of data through the entire crisis. They had no means to share information efficiently, and used nonstandard formats in sharing information through spreadsheets. DSTA consulted with the users and suggested standardized formats, thus making it simpler for other users. Tracing operations which relied on this data were further saved the tedious data cleaning process, and focussing on the task of tracing potential infections.The structuring of processes through DSTA's information system helped the management of the crisis in two ways. It helped coordinate information across several agencies, and it also helped in the accuracy of information dissemination. Coordination among all agencies during the crisis became better because of the information system. The system helped streamline information flow across agencies and the issuing of several HQOs for the same person came under control. This also helped reduce errors in reporting the magnitude of the crisis. This was a key factor since accuracy helped in combating the fear psychosis among the public.It was also suggested that with a system to monitor the processes, the number of quarantined people may be brought down. This is because it is now possible to take a systematic approach to issuing HQOs. This has potential implications for health-care costs during the crisis through reduced social welfare costs in managing quarantined people.B.Scope is the variety of knowledge that is integrated HCIS focuses primarily on administration and patient data management systems The information from the SARS case database was also mapped through a reporting system to help the administrators of the crisis obtain an accurate picture across the nation. The breadth of agencies involved in the use of CMS is presented in C.Flexibility of knowledge integration is the ability to continuously reconfigure existing knowledge and seek new knowledge to achieve a competitive advantage The outbreak of SARS highlighted a shortcoming in the current breed of information systems which cater to health-care requirements. Systems were not geared to an emergency situation, to connect several agencies to coordinate crisis management activities. With an ever present threat of a recurrence of SARS or other outbreaks DSTA's development team gathered requirements from ad hoc procedures and built a complete information system and a reference database in 11 days, extending the design of an older system. DSTAs systems knowledge was suitably used to reinvent existing applications and develop systems to meet the needs of the crisis. Now a necessary part of health-care crisis management, the usefulness of the system was demonstrated during the recurrence of SARS in Singapore. Within 8 h, about 60 people were traced and contacted. This demonstrates that effective knowledge application premeditates an organization's ability to sense, interpret, and respond to new environmental opportunities and threats In Singapore, the contact-tracing operations are designed around interfacing multiple agencies. Though tracing operations are a major aspect of the managing the crisis, the sourcing of data for the system is a significant contributor to the successful use of information systems. The system may eventually be used to continuously monitor appearance of some critical symptoms at various levels of health-care institutions, in order to better detect and react to health-care crises. This would require further development along the lines of MediNet VI.Even as medical knowledge expands rapidly, diffusion of such knowledge to clinicians is slow due to numerous barriers Communication infrastructure with multiple agencies to coordinate the management process of a health-care crisis is an important implication for IT in health care arising from this study. There is a strong case for health-care institutions to share information quickly and efficiently when required Health-care crisis response involves multiple agencies Cost and technology implications are often a major area of research in health-care-related research VII.It is in a position to help organizations manage their health care effectively As innovations in IT increasingly facilitate knowledge management processes, new opportunities arise for solutions that involve a synergistic combination of a science of information, technology, and knowledge to further enhance the quality of health-care delivery


Historically, studies of intracellular membrane trafficking have focused on the secretory and endocytic pathways and their major organelles. However, these pathways are also directly implicated in the biogenesis and function of other important intracellular organelles, the best studied of which are peroxisomes and lipid droplets. There is a large recent body of work on these organelles, which have resulted in the introduction of new paradigms regarding the roles of membrane trafficking organelles. In this review, we discuss the roles of membrane trafficking in the life cycle of lipid droplets. This includes the complementary roles of lipid phase separation and proteins in the biogenesis of lipid droplets from endoplasmic reticulum (ER) membranes, and the attachment of mature lipid droplets to membranes by lipidic bridges and by more conventional protein tethers. We also discuss the catabolism of neutral lipids, which in part results from the interaction of lipid droplets with cytosolic molecules, but with important roles for both macroautophagy and microautophagy. Finally, we address their eventual demise, which involves interactions with the autophagocytotic machinery. We pay particular attention to the roles of small GTPases, particularly Rab18, in these processes. The study of intracellular membrane trafficking has historically concentrated on the movement of proteins and lipids between the membrane-bound compartments of the secretory and endocytic pathways. More recently, relationships have been found between other organelles and membrane trafficking pathways, including melanosomes , peroxisThe existence of adipocytes as a major stores of lipids has been known since the mid-19th century (reviewed in ). The boLDs were originally considered to be static stores of triglycerides and cholesterol esters. However, they are now known to be dynamic organelles which interact extensively with other organelles and numerous regulatory pathways to support the logistics of lipid storage and mobilization. This story was fleshed out with the identification of enzymes, which produced neutral lipids, primarily in the ER, and cytoplasmic lipolytic enzymes which could bind to the surface of the LD. Direct interactions have been found between LDs and other organelles, including notably the ER and mitochondria, which are the organelles with the greatest need for stored lipids. These interactions are regulated by a still poorly understood network of proteins, including tethers and Rabs such as Rab18 that are also found on elements of the secretory and endocytic pathways. More recently, a significant role in autophagy of LDs (lipophagy) has been found for lipolysis of LDs, acting in parallel to cytoplasmic lipases. This review will focus on the interactions between LDs and the secretory and endocytic pathways at different stages of their life cycle, from birth to death, and on commonalities between LDs and the more conventional membrane-bilayer-bound organelles that make up the secretory and endocytic pathways. As a number of distinct topics are covered and the total volume of relevant literature is large, this review is not intended to be comprehensive, but instead to give a broad overview, with a focus on recent findings.There is considerable evidence that LDs arise from the ER in a wide variety of eukaryotic organisms as diverse as mammals, higher plants and yeast. While exit of proteins from the ER via the secretory pathway has been intensively studied, the comparable process of LD production from the ER is still incompletely understood. We will begin by briefly comparing the two processes.Exit of integral membrane proteins from the ER occurs in specialized domains found on the surface of the ER, that are termed ER exit sites or transitional elements ,8. Coat LDs are organized differently to conventional membrane-bound organelles in that their surface is covered by a lipid monolayer rather than a bilayer B, and thThe presence of these enzymes indicated that the ER is a major site of neutral lipid synthesis. Computer simulations and biophysical considerations suggested that neutral lipids produced in the bilayer of ER membranes would remain soluble in the inner hydrophobic portion of the membrane bilayer till a concentration of approximately 3% is reached . At highThese biophysically based hypotheses made a number of predictions which have been verified experimentally. Lens formation could be visualized by electron microscopy of giant unilamellar vesicles  or in th+-ATPase (SERCA), stearoyl-CoA desaturase-1 (SCD1) and Ldo , suggesiewed in . It has iewed in  that appiewed in  and couliewed in  /Scs3 is another protein which plays a key role in LD formation . KnockdoPerilipin family proteins may also favor stabilization of LD lenses or LD budding. Perilipins are a family of cytoplasmic proteins   family of oxysterol binding proteins may play a role in sterol and phospholipid transfer between adjacent membranes. Two members of this family, ORP5 and ORP8, are integral membrane proteins localized to the ER (reviewed in ). Du et The perilipin family member PLIN5, which is localized on the surface of LDs in cells such as skeletal muscle which have high energy demands, has been reported to tether LDs to mitochondria ,76,77,78While LDs often appear to be associated with peroxisomes by electron microscopy, the nature of these associations is not well understood. However, recent work has identified some proteins that appear to link LDs to peroxisomes. Chang et al.  reportedCatabolism of LDs can take place through the action of cytoplasmic lipases, which can bind to the LD surface, or through interactions with the endocytic pathway including macroautophagy (lipophagy) and microautophagy.One important means by which stored lipids can be released is through the action of cytoplasmic lipases. As the body of the LD is primarily made of triglycerides, release of free fatty acid (FFA), which can be used for energy, and glycerol requires three hydrolytic steps. It is primarily the cytoplasmic enzyme ATGL  which inDrosophila, C. elegans, mammalian tissue culture and mammalian in vivo systems .Macroautophagy is a complex multi-step process for targeting cytoplasmic material including organelles to lysosomes. While macroautophagy is still not completely understood, large portions of the process have been characterized, starting with the initial identification of many of the key proteins through yeast genetics . The proThe important role of macroautophagy in the turnover of LDs and in mobilization of stored lipids was not appreciated until after the cytoplasmic enzymes had been characterized. Singh and coworkers  found thRab18 -/- mice developed as a model of Warburg micro syndrome showed macroautophagy defects in this study [The small GTPase Rab18 has been implicated as a regulator of lipophagy. While Lutcke and coworkers  first reis study .Drosophila model system which provided evidence that Vps34 Complex I, which is an important protein complex involved in maturation of autophagosomes to lysosomes, and is an effector of Rab18. In this study, they reported a GTP-dependent interaction between Rab18 and the Atg6 component of the complex. Mutations in Rab18 or the Rab18 exchange factor RAB3GAP2 both resulted in the accumulation of immature autophagosomes which could be mimicked by knockdown of elements of the Vps34 Complex I, but not Vps34 Complex II (which is involved in endosome maturation but not macroautophagy). Another recent study [A recent study suggests the molecular mechanism by which Rab18 could regulate macroautophagy. Takats and coworkers  used a Dnt study  examinedIn mammalian cells, LDs are often larger than lysosomes, potentially complicating autophagy. Schott  providedWhile most studies have concentrated on the roles of macroautophagy in LD catabolism, in which a LD is engulfed in toto, some recent reports have suggested a complementary role for a form of microautophagy in which a portion of a LD’s complement of lipid is drawn into a lysosome and hydrolyzed (While LDs are superficially very different from the membrane-bound intracellular organelles that have historically been considered to constitute secretory and endocytic pathways, their biogenesis and ultimate fate is intimately intertwined with both pathways. Existing evidence indicates that LDs originate from ER membranes through a process that involves phase separation of lipids with an important contribution of regulatory proteins. They can then remain associated with the ER through direct membranous connections, which can allow the diffusion of lipids and a select set of proteins between ER and the LD, or alternatively through protein tethers, or they can more completely but reversibly separate from the ER. The mature LD is also interacting with cytoplasmic factors including lipolytic enzymes, which can release fatty acids and cholesterol when needed. During this phase it can maintain or re-establish connections with the ER although the regulation of this process is still poorly understood. At the end of its life cycle, the LD will interact with elements of the endocytic pathway through both macroautophagy and microphagy. Thus, what was historically considered a static depot of fat is in fact a full member of the secretory/endocytic pathways.


Our institution operates a remote radiation oncology service in Northern Ontario, Canada. Since the start of the coronavirus disease 2019 pandemic, this center has operated without radiation oncologists on site owing to safety precautions, and this study seeks to understand the effect of this shift.Departmental level data reports were used to investigate differences in metrics between April to May of 2019 and April to May 2020. These metrics include the total number of referrals received, average wait time from referral to consult, the number of cases that underwent peer review before beginning treatment, the total number of fractions given over each period, patient-reported outcomes, and patient satisfaction. We also examined the importance of physical examinations and the use of SABR treatment.There was an observed decrease in the number of referrals received, total number of fractions administered, and number of patients providing patient-reported outcomes. We observed no change in patient wait times, cases undergoing peer review before commencing treatment, or overall patient satisfaction. Challenges were identified in the collection of patient- reported outcomes and the conduction of physical examinations.This paper provides proof of concept that a radiation clinic can function entirely virtually in the short term without sacrificing patient satisfaction, efficiency, or safety. Our institution has operated a remote radiation oncology service in Northern Ontario, Canada, since 2010. This program has on site radiation therapists, nurses, and 1 physicist but is operated remotely 3 days per week in terms of radiation oncologists since its inception, with radiation oncologists from the hub center traveling to the satellite center for in-person consults and follow-up visits on the remaining 2 days per week. The coronavirus disease 2019 (COVID-19) pandemic resulted in restrictions that prevented these radiation oncologists from working at multiple health care facilities. As a result, this satellite facility was operated entirely remotely from April until July of 2020. Although the pandemic has brought about changes in the daily operations of radiation clinics globally, with attempts to minimize the time patients spend in the hospital and interacting with staff,This study examines the effect of the COVID-19 global pandemic on the operation of a satellite radiation oncology facility run completely virtually from April to May of 2020. Departmental level data reports from this period were compared with the same months in 2019 when the facility was operating normally These reports contained the necessary data to analyze total number of referrals, average wait time from referral to consult, the number of cases that underwent peer review before beginning treatment, the total number of fractions given over each period, as well as patient satisfaction with their radiation team.Each referral was captured in the Mosaiq oncology information system . This allowed us to compare and determine whether fewer referrals were received during the start of the COVID-19 pandemic. Wait times from referral to consult were then calculated using the date of referral and the date of the patient’s first consult. Internal reports were used to determine the percentage of cases that underwent peer review before the commencement of treatment. The total number of courses of radiation administered was recorded in internal reports as was the number of fractions of radiation administered. Patient satisfaction data were available through internal surveys designed to provide physicians with feedback on the care being provided. Responses were anonymous with no patient identifiers were collected and were further anonymized to ensure the radiation oncologist could not be identified from the information included. We also describe qualitative changes, including the process for obtaining physical examinations and the operation of our SABR program in a remotely operating radiation treatment center.2, Fisher exact) All testing was done using STATA, version 13.Data were initially described graphically and with descriptives and frequencies. Before statistically testing, variables were assessed for normality, and subsequent metric comparisons between 2019 and 2020 were done using nonparametric tests   .Figure 12 = 0.16, P = .67; The number of patients whose cases underwent peer review before beginning radical radiation therapy remained high and increased slightly from the 2019 to the 2020 period. This value remained quite stable with a nonsignificant increase, rising from 97% in April to May of 2019 and 98% in April to May of 2020 (χThe number of patient-reported outcome measures (PROMs) collected, evaluated through the Edmonton Symptom Assessment System (ESAS) tool, dropped substantially between April and May 2019 and 2020. The number of ESAS responses (each patient responds multiple times during a treatment course) over the 2019 period was 1661; however, only 10 responses were accrued over the 2020 period. The PROM scores evaluated by this tool cannot be compared.P = .15). This additional change was produced by the adoption of multiple hypofractionation protocols across multiple tumor sites.There was a reduction of approximately 30% in the number of courses of radiation administered from the 2019 to the 2020 period, dropping from 129 down to 91 . There wP < .001)  .Figure 5Patient satisfaction remained high during each period , and theOur satellite facility has been performing SABR treatment since 2015. Because our facility was already operating virtually 3 days per week, a system was already in place for radiation oncologists and physicists to remotely visualize alignment images. Briefly, a remote-viewing system was built, consisting of a video capture card, virtual private network, and on-site viewing station and was designed to remotely and in real-time allow viewing of the Varian image guided radiation therapy workstation in our satellite facility. This system allows for physicists and radiation oncologists to review and assess the cone beam computed tomography matching process remotely, which is required for our SABR program to meet The American College of Radiology (ACR) and the American Society for Radiation Oncology (ASTRO) SABR guidelines.With the patient work load decreasing due to the use of evidence based hypofractionated radiation treatment schedules and decreases in referrals, fewer staff were required to be onsite on a daily basis. Radiation oncologists, physicists, and radiation therapists (MRTs) were permitted and encouraged to work from home to the furthest extent possible to ensure that the limited and subspecialized staff providing radiation therapy services in Northeastern Ontario was as protected as possible from COVID-19. It was decided to split the MRTs into 2 separate teams rotating between working on site versus at home every 2 weeks. Those working at home had access to the electronic health record in the Mosaiq oncology information system, the Pinnacle radiation treatment planning system , and the hospital network system .The COVID-19 pandemic has substantially affected the world, and radiation oncology is no exception. This pandemic has altered the way radiation departments have functioned in numerous jurisdictions. In Northeastern Ontario, the most evident and significant changes have been seen in our distant cancer center, where, owing to regulations preventing health care providers from working in multiple facilities, we were unable to continue our normal rotation of radiation oncologists and were instead forced to operate the facility without onsite radiation oncologists for over 2 months.As a result of the pandemic, there was disruption in the health care system, limiting the ability of patients to be investigated for various clinical problems, some of which would inevitably be cancer. Many cancer screening services, including mammography and lung cancer screening, ceased.There was no significant increase in wait time from referral to consult despite the need to switch all consults to telemedicine in April and May of 2020, as can be seen in Although a reduction of 30% was seen in the total number of courses of radiation administered during April and May of 2020 compared with 2019, there was a larger observed reduction in the total number of fractions of radiation administered over this period, of approximately 40% . SignifiBecause radiation oncologists were no longer physically present in our satellite center, in the 2020 period there were no in-person visits, with all consults and follow-up appointments occurring via telemedicine. Though there was an initial period of rebooking and rescheduling patients, this shift did not prove to be an insurmountable barrier and was facilitated as the technology for telemedicine visits was in place before the COVID-19 pandemic, with 20.7% of visits having taken place using telemedicine through April and May of 2019 . This teConsistently high patient satisfaction scores across both periods are very encouraging . It demoAn important change that occurred between April and May of 2019 and 2020 was the near absence of ESAS assessment responses in 2020. Because the completion of these surveys presently requires patients to use touch screens in kiosks located in the cancer center lobby, the concern of COVID-19 transmission using this high touch modality necessitated the discouragement of completing the assessments; however, an alternative system for ESAS completion was not put in place during this initial period due to the many other challenges that were being overcome at this time. Additionally, because the majority of virtual visits were conducted directly in the patients’ homes, no alternative system for the completion of these evaluations was rapidly deployed. This has unfortunately resulted in a lack of collection of PROMs, which are considered an important metric in cancer care,One important component of assessment for radiation treatment is physical examinations. With the pandemic preventing physicians from attending our distant cancer center, the oncologists have had to rely on designated community physicians to complete these examinations. We developed an internal mechanism to rerefer patients to specialist community physicians for the purpose of completing and documenting these necessary physical examinations. Results were then reported back to the oncologist. This has been done without major difficulties. The use of local physicians in conducting physical examinations, when warranted, has been functional as an emergency measure during the COVID-19 pandemic; however, it is likely not a long-term option. It is felt to be best practice for the treating radiation oncologist to personally perform a physical examination before the initiation of therapy, which is a standard that has now been reinstated.This shift to remote operations has provided radiation therapists, physicists, and radiation oncologists the opportunity to work from home more frequently. Although there have been challenges associated with this remote system, such as the difficulty in obtaining physical examinations, the shift has not only provided patients with additional safety through reducing contact with hospital facilities but has also helped protect physicians and staff from COVID-19. The reduction of staff present in the cancer center improves the ability to physically distance and reduces the number of sources of exposure to the virus both for other staff members and for patients. Furthermore, physicians are not required to be in as many high-risk situations relating to COVID-19, related to transportation or lodging. Beyond the health benefits of working from home during a pandemic, working from home is reported by the physician group to increase job satisfaction, and some component of at-home work is planned to continue on a permanent basis. It has also decreased demand for clinic space in the cancer center and has the potential to decrease the need for office space as well. Components of these changes are likely permanent and will affect physical infrastructure needs on an ongoing basis.The novel systems developed by our team have allowed SABR treatments to continue despite the fact that it typically requires a radiation oncologist to be present at the first treatment and a physicist on site for all treatments. Because of our remote viewing enhancements to the image guided radiation therapy image matching system, radiation oncologists and physicists are able to review and assess the alignment of computed tomography scans in real-time and provide immediate feedback if necessary. As such, the treatment team can continue to provide this treatment while adhering to the strict ACR-ASTRO guidelines for SABR treatment.Owing to the regular collection and storage of a broad range of performance metrics and patient data, we were able to directly compare a variety of metrics during and 1 year before the COIVD-19 global pandemic, allowing us to appropriately evaluate the effect on our operations during a period where we were required to operate completely virtually with respect to our radiation oncologists. We were able to compare metrics ranging from wait times and number of fractions administered, providing insight into the function of the center at a high level, to patient satisfaction at the individual level, providing us with a more holistic view of how the shift to a completely virtual facility affected operations.One limitation of this study is that it only examined the early response to the pandemic. As the situation has continued to evolve through June and July, it is possible that the results seen here may differ. Additionally, because no alternative system for collecting ESAS data was put into place, resulting in an extreme drop in the number of patients who completed the assessment, we were not able to directly compare PROMs. As such, we cannot determine whether factors like patient fatigue, anxiety, pain, or overall wellbeing were affected as a result of COVID-19 or the changes introduced into the system.The COVID-19 pandemic has altered the way many radiation oncology facilities are functioning. To our knowledge, we report here the operation of the only completely virtual radiation oncology facility in Canada during the COVID-19 pandemic. In all, these results suggest that it is entirely feasible to operate a radiation clinic remotely for a short period of time during a state of emergency. Longer-term operation would require modifications to the operation to increase sustainability. Although these changes were born out of necessity during a worldwide pandemic, they provide a proof of concept that radiation therapy can be delivered in smaller centers closer to patients' homes with a heavy reliance on modern technology to maintain safety, efficiency, and patient satisfaction.


Mobile health  has been shown to be effective in increasing knowledge of sexual health among youth. To date, evaluations mostly refer to interventions delivered via computer, email, and text messages. The possibility of downloading apps on mobile devices has opened up opportunities to develop engaging interventions on safe sexual health promotion. To attract young users and have them engage with a sexual health app, it is important to involve youth in intervention development.This study aimed to obtain input from youth on the content of a mobile phone app intended to promote safe sex and increase condom use among youth in Stockholm.This study was conducted at the Youth Health Clinics (YHC) in Stockholm County, Sweden. A total of 15 individual in-depth interviews and 2 focus group discussions (with youth aged 18-23 years) were conducted at the YHC in Stockholm. Areas explored were: (1) youth perceptions of condom use (advantages and obstacles), (2) perceptions of mHealth to promote safe sexual practices, and (3) content development for a mobile phone app to promote safe sex.Condom Obstacles and Solutions; Quiz; Games; Self-Refection; Challenges; Stories by Peers (stories from peers and information from a doctor); Condom Tips, Pep Talk, and Boosting; and Random Facts.The smartphone app was developed based on the categories that emerged from the data. With regard to content, youth requested sex education, including information on sexually transmitted infections. In addition, condom-specific information, including practical usage technique, advice on how to have the condom talk, and how to decrease shame related to condom use, was requested. Youth suggested different modes to deliver the content, including text messages, movie clips, and push notifications. It was suggested that the tone of the messages delivered should be fun, entertaining, and supportive. The inputs from youth influenced the development of the following sections of the app: It is important to use input from youth when developing a smartphone intervention since the success of the intervention largely depends on the level of engagement and usage by youth. Furthermore, if proven efficient in increasing condom use, it is important that the development, including content and mode, is thoroughly described so that the intervention can be replicated. Likewise, if proven inefficient, it is important to learn from mistakes to improve and adjust the intervention. The effect of this smartphone app on safe sexual practices among youth is being evaluated in a pragmatic randomized controlled trial in Stockholm (ISRCTN13212899) and will be reported separately. Chlamydia trachomatis infections have steadily increased since the mid-90s, and young people aged 15 to 29 years account for 85% of all infections in the country [Sexual risk taking, including multiple sexual partners, sex outside stable relationships, and sex without a condom, has increased among Swedish youth over the past years -3. In ad country . These rMobile health , that is, using mobile devices to address health priorities, has been shown to be effective in promoting elements of sexual health, such as increased broad knowledge regarding sexual health, increased testing for STIs, and condom use, among youth ,6. To daprecontemplation—not ready for a change, contemplation—getting ready for a change, preparation—intends to take action within the foreseeable future and has taken some behavioral steps in this direction, action—changed behavior, and maintenance—adheres to the new behavior. In a subsequent randomized controlled trial (RCT), youth with high-risk sexual behavior will be included. We, therefore, assumed users of the app to be at the precontemplation stage when entering the intervention study. The app was designed to help participants move through the different stages of change toward a new behavior. The second integrated behavioral model (IBM) contains 5 components affecting behavior [behavioral intention, which is determined by attitudes, perceived norms, and personal agency; knowledge and skills to carry out the behavior; importance to the individual, environmental constraints that make behavioral performance difficult; and habit . The IBM was taken into account while developing different self-reflecting exercises in the app.We developed a mobile phone app to increase sexual health and condom use among youth. We used 2 different models of behavioral change. The transtheoretical model (TTM) is a model that conceptualizes the process of intentional behavior change and includes the following different stages of change : precontbehavior : behavioThe objective of this study was to describe exploratory work with youth from Stockholm County to obtain their input on the content of a mobile phone app to promote condom use. Feedback from participants are to be incorporated subsequently into the app, which will then be tested at the Youth Health Clinics (YHC) in Stockholm County.This study was conducted at the YHC in Stockholm County, Sweden. There are 250 clinics in the whole country and 33 in Stockholm County ,15.A total of 15 individual in-depth interviews with youth at the YHC and 2 focus group discussions (FGDs) were conducted. Interviewed participants were selected purposefully using heterogeneous sampling  so that Interviews with youth aged 18 to 23 years were performed from April 2015 to August 2016 . Interviews with youth were performed by the first author (AN) in Swedish. They were recorded and transcribed verbatim. The FGDs were held in October 2016 and November 2016. The first FGD had 4 female participants, whereas the second FGD had 2 females and 4 males. The FGDs, supported by 3 members of the research team, were recorded; notes were taken; and a summary of notes and the recordings were made. Individual interviews were conducted to enable exploration of the sensitive subject of sexual health, and FGDs were held to allow for inspiring exchanges and development of new ideas. All participants stated heterosexual preferences.The questions posed in the interviews and FGDs originated from preknowledge regarding low condom use among youth in Sweden and the current primary and secondary prevention strategies for STIs. The areas explored were as follows:Why do you think condom use is low among Swedish youth?What is positive with condom use?What do you think about mobile phones to reach young people with health messages?Could a smartphone app work to mediate safe sexual practices?What would such an app contain?How could the app be made attractive to youth?Mode and timing of push notifications (message/reminders to engage in activities) in the app.The recordings and transcripts were listened to and read through on several occasions. Data were divided into 3 different categories, which were directly related to the areas explored and the suggestions from youth regarding what the app should contain, how the content should be delivered, and what tone should be used. Subcategories that emerged from the data were organized under each of these main categories as a result of parallel analysis and mutual in-depth discussions between researchers.The intervention duration was intended to be 180 days. This duration was chosen based on previous research that had shown a positive effect on condom use for an mHealth intervention lasting less than 6 months, with decreasing effect over longer follow-up periods .Written informed consent was obtained from each participant. The study was approved by the Stockholm Regional Ethical Board .Skyddslaget or Protection Team) was developed based on the main categories and subcategories that emerged from the data from interviews and FGDs. The main categories were app content, app mode, and app tone. Suggestions for the content, mode, and tone and the subcategories are presented in The team that developed the app had varied backgrounds, including YHC staff working with youth  and in public health, medicine, information technology (IT), and behavioral science. The smartphone app  as well as positive aspects of using protection generated subcategories under app content. For example, youth requested sex education, including STI information, and, additionally, condom-specific information, including practical usage technique. Youth also requested advice on how to have While discussing how the app should be made attractive to youth, study participants suggested different modes to deliver the content, including text messages, movie clips, and push notifications. To retain the interest in the app, new information should be added into the app. Youth suggested that the tone of the messages delivered should be fun, entertaining, and supportive. In addition, youth requested that content from peers should be added.Condom Obstacles and Solutions; Quiz; Games; Self-Refection; Challenges; Stories by Peers (stories from peers and information from a doctor); Condom Tips, Pep Talk, and Boosting; and Random Facts. The different sections of the app were related to the content, mode, and tone requested by participants. For example, in the Condom Obstacles and Solutions section, information on condom technique and exercises on how to suggest a condom to your partner were included. The names of the sections and the material presented in the different sections were developed by the research team. As described, the TTM was chosen as the theoretical framework for intervention development. In the modified TTM, each stage lasted for 30 days and aimed to help youth move from one stage to the next and thereby achieve behavioral change.During the subsequent process, the inputs from youth  influencAt the beginning of the intervention, the precontemplation phase, the messages included general educative information regarding the benefits of safe sexual practices, taking into account that the participants were not yet ready for a change. As the intervention evolved, the content became more oriented toward behavioral change by asking participants to reflect upon individual reasons behind sexual risk taking and benefits of a new behavior. Toward the end, the messages aimed to support the new behavior.ContentInformation regarding sexually transmitted infectionSex educationCondom informationIncrease self-confidence related to condom useCondom techniquePreparation for the condom talkDecrease shame and stigma related to condom useAlcohol and unsafe sexQuestioning norms (sex with condom is not good)Normalizing condomsModeGamesWeekend condom remindersMovie clipImagery (emojis)Text (not heavy)QuizPush notificationsAdding new information to retain interestInteractiveToneFun and entertainingSupportiveContaining pep talkAllowingScaring (the “light version”)Identifying with peersEncouragingCondom Obstacles and Solutions and Self-Reflection categories. Self-reflection was introduced during the preparation and action phases. Identification with peers was strongly suggested by youth and was included in the Stories by Peers category (peers tell their story), and this aimed to create a sense of identification and thereby eliminate possible feelings of shame related to a behavior. On each day of the intervention, at least one condom tip was posted (under the category condom tip). The aim was to inform about different condom types and sizes and to normalize condoms by daily exposure. In addition, push notifications were used to inform users that new content had been added into the app. Every Friday evening, a condom reminder push notification was sent out to participants. The self-reflecting and pedagogical tasks in the app were based on the IBM. These tasks addressed feelings, thoughts, experiences, attitudes, and perceived self-control in relation to condom use and unprotected sex and were mainly found under the Content was added to the app on a daily basis for 180 days. The function and content of the app were initially piloted among 10 users. The pilot users requested more attention to be drawn to the app during the first weeks of usage; this resulted in an increase in the number of push notifications sent to the participants during the first and second week of the intervention. In addition, there were a number of minor technical support issues from the app development side that needed attention. For example, when opening the push notifications, the user was not redirected to the app, and all weekend reminders (N=26) were posted on the first Friday of the intervention.We used the data from FGDs and individual interviews with youth belonging to the target group to develop the content, mode, and tone of a mobile phone app to promote safe sex. Heterogeneous sampling was used, which allowed for input from youth of different backgrounds to be explored. It is important to use input from youth as the success of the intervention largely depends on their level of engagement and usage. The content and the mode of delivery were directly obtained from discussions with youth, which could possibly increase the level of interest among the target group. Input from youth were embedded into existing frameworks that were previously proven to be successful (TTM and IBM) .A program delivered via a mobile phone app is unique as most previously evaluated mHealth interventions for sexual health were delivered via text messages and websites . In addiThis study presents a number of valuable lessons for future app developers. Based on the strengths and limitations of the process we used to develop our app, the following should be taken into consideration:Organize more FGDs so that a variety of views, some possibly divergent, can be obtained. Discussions among the project team members on divergent views better inform intervention development.Be present during interactions with youth to raise the right questions and address limitations of the technology. Health professionals should also be present.Run past iterative versions of the intervention as it is in the process of development with users, so that there are multiple opportunities to test and change. This requires an investment of time over a reasonably long period, which was a constraint during the development of the intervention in this study.Once the intervention has been developed, pilot test for a month with a small closed group to ensure any persisting bugs are removed.MObile phone for SEXual health in Youth trial where the Skyddslaget app was subsequently evaluated in a pragmatic RCT will be reported separately [mHealth interventions are particularly suitable for youth and sexual health promotion as the intervention is delivered in a familiar and discrete way to at-risk population . Analysiparately .


With its increasing incidence, cancer has become one of the main causes of worldwide mortality. In this work, we mainly propose a novel attention-based neural network model named Gated Graph ATtention network (GGAT) for cancer prediction, where a gating mechanism (GM) is introduced to work with the attention mechanism (AM), to break through the previous work’s limitation of 1-hop neighbourhood reasoning. In this way, our GGAT is capable of fully mining the potential correlation between related samples, helping for improving the cancer prediction accuracy. Additionally, to simplify the datasets, we propose a hybrid feature selection algorithm to strictly select gene features, which significantly reduces training time without affecting prediction accuracy. To the best of our knowledge, our proposed GGAT achieves the state-of-the-art results in cancer prediction task on LIHC, LUAD, KIRC compared to other traditional machine learning methods and neural network models, and improves the accuracy by 1% to 2% on Cora dataset, compared to the state-of-the-art graph neural network methods. Global Cancer Statistics 2018  and Cancer_all (including OFN and IFN versions) to verify the effectiveness of our proposed hybrid feature selection algorithm  and training time (seconds) among GGAT and other models. In order to verify the effectiveness and performance of our GGAT model, we also utilised the combined cancer dataset  to investigate the accuracy and training time of the multi-category classification task (3 categories) under large data scale.Evaluation on the GGAT’s Validity and Interpretability. Among these models for comparison, the traditional machine learning methods include K-Nearest Neighbor, Support Vector Machine and Decision Tree, and neural network models include GCN and GAT.All experiments were carried out ten times and the final results were averaged.The cancer prediction task in our work is considered a node classification task, because we built cancer datasets into a graph to predict whether a node (a sample of participant) has cancer or not. We used LIHC (liver cancer), LUAD (lung adenocarcinoma), KIRC  datasets from TCGA and their combination dataset Cancer_all for our experiments.For KIRC, LIHC and LUAD datasets, they are randomly shuffled before being split into training, validation and testing sets. After the shuffle, each of them is then divided into the three sub-sets, proportionally—the top 40% entries of the shuffled dataset become training sets, the latter 20% entries become testing sets, and the rest 20% are appointed as validation sets. We believe that through shuffle, the proportion of cancer samples and normal samples are approximately the identical in the three sets.The feature dimension information of these datasets before and after our hybrid feature selection algorithm is shown in In addition, being aware the fact that Cora is a widely used benchmark dataset for node classification task, we to perform a supplementary experiment on Cora to verify the effectiveness of our proposed model GGAT.All dataset used in our experiments and their details are shown in In order to verify the effectiveness of proposed hybrid feature selection algorithm, experiments were carried out on datasets with different feature dimensions. The experimental results are shown in Accuracy Comparison(1) As is shown in Our hybrid feature selection algorithm has no effect on SVM. We suppose that the way we construct the graph makes the datasets unfriendly to SVM. It has been pointed out in preceding section that we chose the average Euclidean distance to measure whether there is a link between two nodes, whereas the graph constructed by the average value may not be suitable for every model. In the future research, this threshold can be used as a parameter to train and optimize, so as to achieve the value of the specific model, which makes our feature selection algorithm more universal.GCN does not clearly show the advantage of our feature selection algorithm in LIHC. Firstly, we found that the LIHC dataset resulted in more unstable experimental accuracy in multiple models, compared to other datasets: the error rate of which is relatively high (within the acceptable range). Furthermore, there may be the same problems as described in the above point.GAT and GGAT do not highlight the advantages of our feature selection algorithm as well. We hold the belief that feature selection is for better information extraction. However, as a matter of fact, both GAT and GGAT utilise the AM, which is equivalent to feature selection in an indirect manner, that is, the AM in the both models plays the same role as feature selection. In addition, our model introduces GM, which may help to carry out better attention through rigorous information selection and filtering.Training Time Comparison(2) As is shown in Generally speaking, notwithstanding that our feature selection algorithms did not demonstrably improve the efficiency of all models, they could shorten the training time without reducing the performance of the models.We compare the performances of each model on datasets mentioned above with different feature dimensions. The results are as shown in In general, to the best of our knowledge, our proposed model GGAT achieves the best overall results on most of the datasets, which verifies the effectiveness of our model. Specifically, the comparisons on sensitivity and specificity show that our model achieves the stablest effects on predicting three cancer types, among the listed graph convolution models.The previous data processing method and the characteristics of the datasets itself indeed improved the effectiveness of a number of certain algorithms, e.g., SVM on Cancer_all and GAT on KIRC.The more features, the higher effectiveness we found of GAT and GGAT. As is mentioned above, both the GAT and GGAT introduce AM which play the same role as feature selection. Therefore, more information may be selected and aggregated by the AM if more features are given, thus better results may be obtained. In particular, our model introduces gates, which assists to select and filter information that is more important and effective, and to make the node classification more accurate.On the contrary, the more features, the lower efficiency of the traditional algorithm. A conclusion can be drawn that the feature selection algorithm may greatly help the traditional classification algorithms to learn and calculate more effectively, and most importantly, reduce the training time.By analysing the results in To conclude, our aim is to provide a simple and accurate approach to reduce the doctors’ works. It shall be pointed out that our method provides helps to doctors when they are making diagnosis, instead of making diagnosis for doctors. The experiments in this section shows that the prediction accuracy is sufficiently high, despite the fact that no research on pathology and histology is performed.We studied the experiments and further investigated the validity and interpretability of our proposed GGAT model. We point out 2 major claims on the basis of the validity and interpretability study.The gates can help solve the problem of gradient disappearance.(1) In the process of experiments, we noticed that the accuracy of GAT was extremely low in Cancer_all and LIHC(21), while the GGAT displayed a normal performance  As mentioned in In this work, we proposed a novel three-layer GGAT, and used it for cancer prediction tasks. Tradition methods shows that certain methods are suitable for certain types of cancer. However, our proposed GGAT model aims at doing the predicting things better—we tried to increase the accuracy on all types of cancer, moderating the difference of the predicting accuracy among different cancer types. From what can be seen in the experiments, the GGAT is capable of aggregating the information in the 3-hop neighbourhood of every node with different importance. By introducing the GM, the information coming from remote nodes may be selectively filtered. In this way, GGAT can comprehensively mine the semantic information under the graph structure and the association between nodes, and provide a more powerful guarantee for cancer prediction. Through the experimental analysis and comparison on various datasets, GGAT had improved the performance by 1–2%, in the acceptable training time range. Moreover, the validity and interpretability of GGAT were verified. In addition, we also proposed and verified the effectiveness of our hybrid feature selection algorithm. Experiments show that our feature selection algorithms resulted in significant performance in reducing the training time of certain algorithms, without noticeably affecting their accuracy.There are several potential improvements and extensions to our work that could be addressed as future work. We noticed that our ideas of improving the neural network model are based on the graph structure itself, and the semantic information of nodes themselves and additional information outside the graph are temporarily ignored. In the future research, we will focus on the prior knowledge of graph and node attributes, so as to increase the difference between nodes and make the task of nodes on the graph more accurate. In addition, due to the serious imbalance of the positive and negative samples in our datasets, we will also study on the ways to balance data. We are planning to utilise the Generative Adversarial Networks (GAN) and/or other generative models to generate adversarial samples.