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Emotion recognition in doctor-patient interactions from real-world clinical video database: Initial development of artificial empathy

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Computer Methods and programs in Biomedicine 2023年 233卷 107480-107480页

作者： Huang, Chih-Wei Wu, Bethany C.Y. Nguyen, Phung Anh Wang, Hsiao-Han Kao, Chih-Chung Lee, Pei-Chen Rahmanti, Annisa Ristya Hsu, Jason C. Yang, Hsuan-Chia Li, Yu-Chuan Jack Taipei Medical University Taipei Taiwan Taipei Medical University Ringgold standard institution - Center for Simulation in Medical Education Taipei 116 Taiwan National Taiwan University Children and Family Research Center Sponsored by CTBC Charity Foundation Taipei Taiwan Clinical Data Center Office of Data Science Taipei Medical University Taipei Taiwan Clinical Big Data Research Center Taipei Medical University Hospital Taipei Taiwan Graduate Institute of Biomedical Informatics College of Medical Science and Technology Taipei Medical University TMU Da'an Campus 15 F No. 172-1 Kee lung Road Section 2 Da-an District Taipei Taiwan Research Center of Big Data and Meta-analysis Wanfang Hospital Taipei Medical University Taipei Taiwan Department of Dermatology Wanfang Hospital Taipei Medical University Taiwan Department of Dermatology School of Medicine College of Medicine Taipei Medical University Taipei Taiwan Delta Research Center Taipei Taiwan Department of Health Policy and Management Faculty of Medicine Public Health and Nursing Universitas Gadjah Mada Yogyakarta Indonesia International PhD Program in Biotech and Healthcare Management College of Management Taipei Medical University Taipei Taiwan Research Center of Data Science on Healthcare Industry College of Management Taipei Medical University Taipei Taiwan

Background and objective: The promising use of artificial intelligence (AI) to emulate human empathy may help a physician engage with a more empathic doctor-patient relationship. This study demonstrates the application of artificial empathy based on facial emotion recognition to evaluate doctor-patient relationships in clinical practice. Methods: A prospective study used recorded video data of doctor-patient clinical encounters in dermatology outpatient clinics, Taipei Municipal Wanfang Hospital, and Taipei Medical University Hospital collected from March to December 2019. Two cameras recorded the facial expressions of four doctors and 348 adult patients during regular clinical practice. Facial emotion recognition was used to analyze the basic emotions of doctors and patients with a temporal resolution of 1 second. In addition, a physician-patient satisfaction questionnaire was administered after each clinical session, and two standard patients gave impartial feedback to avoid bias. Results: data from 326 clinical session videos showed that (1) Doctors expressed more emotions than patients (t [326] > = 2.998, p © 2023

关键词： Emotion Recognition

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Low rates of chronic graft-versus-host disease with ruxolitinib maintenance following allogeneic HCT

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Blood 2025年第20期145卷 2312-2316页

作者： DeFilipp, Zachariah Kim, Haesook T. Knight, Laura W. Dhaver, Shilton E. White, Meghan Dholaria, Bhagirathbhai Schroeder, Mark A. Vasu, Sumithira Abedin, Sameem Chung, Jooho El-Jawahri, Areej Frigault, Matthew J. McAfee, Steven Newcomb, Richard A. Spitzer, Thomas R. Chen, Yi-Bin Hobbs, Gabriela S. Hematopoietic Cell Transplant and Cellular Therapy Program Massachusetts General Hospital Boston MA United States Department of Data Science Dana-Farber Cancer Institute and Harvard T.H. Chan School of Public Health Boston MA United States Cancer Center Protocol Office Massachusetts General Hospital Boston MA United States Department of Hematology-Oncology and Stem Cell Transplantation Vanderbilt University Medical Center Nashville TN United States Bone Marrow Transplantation and Leukemia Section Division of Oncology Washington University School of Medicine in Saint Louis Saint Louis MO United States Division of Hematology Department of Internal Medicine The Ohio State University Columbus OH United States Division of Hematology/Oncology Department of Medicine Medical College of Wisconsin Milwaukee WI United States Center for Leukemia Massachusetts General Hospital Boston MA United States

Despite recent advances in graft-versus-host disease (GVHD) prophylaxis, novel approaches to effective prevention of chronic GVHD (cGVHD) remain of high importance. In this prospective, multicenter, phase 2 trial, ruxolitinib, an oral inhibitor of Janus kinase (JAK) 1 and 2, was administered as maintenance therapy after reduced-intensity allogeneic hematopoietic cell transplantation (HCT). GVHD prophylaxis consisted of tacrolimus and methotrexate. Ruxolitinib began between day +30 to 100 and was administered continuously in 28-day cycles for up to 24 cycles. Seventy-eight participants were enrolled before HCT;63 participants received the intervention. The median start date of ruxolitinib after HCT was day +45. The most common grade ≥3 adverse events were neutropenia, thrombocytopenia, and anemia. Seven participants experienced grade ≥3 infectious events. GVHD-free, relapse-free survival at 1 year after HCT, the primary end point, was 70%. Grade 3 to 4 acute GVHD at 6 months was 4.8%, and moderate-severe cGVHD at 2 years was 16%. cGVHD requiring systemic therapy was 9.5% at 1 year and 13% at 2 years. Overall survival and progression-free survival at 2 years were 76% and 68%, respectively. Prolonged administration of ruxolitinib following HCT is associated with low rates of clinically significant cGVHD. The incorporation of JAK inhibition into GVHD prevention approaches warrants further investigation. This trial was registered at *** as #NCT03286530. © 2025 American Society of Hematology

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Wait, but Tylenol is Acetaminophen… Investigating and Improving Language Models' Ability to Resist Requests for Misinformation

arXiv

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arXiv 2024年

作者： Chen Gao, Mingye Sasse, Kuleen Hartvigsen, Tom Anthony, Brian Fan, Lizhou Aerts, Hugo Gallifant, Jack Bitterman, Danielle Program Mass General Brigham Harvard Medical School BostonMA United States Department of Radiation Oncology Brigham and Women’s Hospital Dana-Farber Cancer Institute BostonMA United States Computational Health Informatics Program Boston Children’s Hospital Harvard Medical School BostonMA United States Massachusetts Institute of Technology CambridgeMA United States Johns Hopkins University BaltimoreMD United States Department of Data Science University of Virginia CharlottesvilleVA United States Radiology and Nuclear Medicine GROW & CARIM Maastricht University Netherlands

Background: Large language models (LLMs) are trained to follow directions, but this introduces a vulnerability to blindly comply with user requests even if they generate wrong information. In medicine, this could accelerate the generation of misinformation that impacts human well-being. Objectives/Methods: We analyzed compliance to requests to generate misleading content about medications in settings where models know the request is illogical. We investigated whether in-context directions and instruction-tuning of LLMs to prioritize logical reasoning over compliance reduced misinformation risk. Results: While all frontier LLMs complied with misinformation requests, both prompt-based and parameter-based approaches can improve the detection of logic flaws in requests and prevent the dissemination of medical misinformation. Conclusion: Shifting LLMs to prioritize logic over compliance could reduce risks of exploitation for medical misinformation. © 2024, CC BY-NC-ND.

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Artificial intelligence for modelling infectious disease epidemics

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Nature 2025年第8051期638卷 623-635页

作者： Kraemer, Moritz U. G. Tsui, Joseph L.-H. Chang, Serina Y. Lytras, Spyros Khurana, Mark P. Vanderslott, Samantha Bajaj, Sumali Scheidwasser, Neil Curran-Sebastian, Jacob Liam Semenova, Elizaveta Zhang, Mengyan Unwin, H. Juliette T. Watson, Oliver J. Mills, Cathal Dasgupta, Abhishek Ferretti, Luca Scarpino, Samuel V. Koua, Etien Morgan, Oliver Tegally, Houriiyah Paquet, Ulrich Moutsianas, Loukas Fraser, Christophe Ferguson, Neil M. Topol, Eric J. Duchêne, David A. Stadler, Tanja Kingori, Patricia Parker, Michael J. Dominici, Francesca Shadbolt, Nigel Suchard, Marc A. Ratmann, Oliver Flaxman, Seth Holmes, Edward C. Gomez-Rodriguez, Manuel Schölkopf, Bernhard Donnelly, Christl A. Pybus, Oliver G. Cauchemez, Simon Bhatt, Samir Pandemic Sciences Institute University of Oxford Oxford United Kingdom Department of Biology University of Oxford Oxford United Kingdom Department of Electrical Engineering and Computer Science University of California Berkeley Berkeley CA United States UCSF UC Berkeley Joint Program in Computational Precision Health Berkeley CA United States Division of Systems Virology Department of Microbiology and Immunology The Institute of Medical Science The University of Tokyo Tokyo Japan Section of Epidemiology Department of Public Health University of Copenhagen Copenhagen Denmark Oxford Vaccine Group University of Oxford and NIHR Oxford Biomedical Research Centre Oxford United Kingdom Department of Epidemiology and Biostatistics Imperial College London London United Kingdom Department of Computer Science University of Oxford Oxford United Kingdom School of Mathematics University of Bristol Bristol United Kingdom MRC Centre for Global Infectious Disease Analysis School of Public Health Imperial College London London United Kingdom Department of Statistics University of Oxford Oxford United Kingdom Doctoral Training Centre University of Oxford Oxford United Kingdom Institute for Experiential AI Northeastern University MA Boston Thailand Santa Fe Institute Santa Fe NM United States World Health Organization Regional Office for Africa Brazzaville Congo WHO Hub for Pandemic and Epidemic Intelligence Health Emergencies Programme World Health Organization Berlin Germany Centre for Epidemic Response and Innovation (CERI) School for Data Science and Computational Thinking Stellenbosch University Stellenbosch South Africa African Institute for Mathematical Sciences (AIMS) South Africa Muizenberg Cape Town South Africa Genomics England London United Kingdom Scripps Research La Jolla CA United States Department of Biosystems Science and Engineering ETH Zürich Basel Switzerland Swiss Institute of Bioinformatics Lausanne Switzerland The Ethox Centre Nuffield

Infectious disease threats to individual and public health are numerous, varied and frequently unexpected. Artificial intelligence (AI) and related technologies, which are already supporting human decision making in economics, medicine and social science, have the potential to transform the scope and power of infectious disease epidemiology. Here we consider the application to infectious disease modelling of AI systems that combine machine learning, computational statistics, information retrieval and data science. We first outline how recent advances in AI can accelerate breakthroughs in answering key epidemiological questions and we discuss specific AI methods that can be applied to routinely collected infectious disease surveillance data. Second, we elaborate on the social context of AI for infectious disease epidemiology, including issues such as explainability, safety, accountability and ethics. Finally, we summarize some limitations of AI applications in this field and provide recommendations for how infectious disease epidemiology can harness most effectively current and future developments in AI. © Springer Nature Limited 2025.

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Confronting the Challenges of Computational and Social Perspectives of the data Continuum

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data and Information Management 2020年第2期4卷 119-126页

作者： Murillo, Angela P. Curty, Renata G. Jeng, Wei He, Daqing School of Informatics and Computing Indiana University-Purdue University Indianapolis IndianapolisIN United States Data Curation Program — UCSB Library University of California Santa Barbara United States Department of Library and Information Science National Taiwan University Taipei China School of Computing and Information University of Pittsburgh PittsburghPA United States

As the availability of data is increasing everyday, the need to reflect on how to make these data meaningful and impactful becomes vital. Current data paradigms have provided data life cycles that often focus on data acumen and data stewardship approaches. In an effort to examine the convergence, tensions, and harmonies of these two approaches, a group of researchers participated in an interactive panel session at the Association of Information science and Technology Annual meeting in 2019. The panel presenters described their various research activities in which they confront the challenges of the computational and social perspectives of the data continuum. This paper provides a summary of this interactive panel. © 2020 Angela P. Murillo et al., published by Sciendo

关键词： Life cycle

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Eye tracking data analytics in virtual reality training: Application in Deepwater Horizon oil drilling operation 64th

Eye tracking data analytics in virtual reality training: App...

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64th International Annual Meeting of the Human Factors and Ergonomics Society, HFES 2020

作者： Kang, Ziho Jeon, Jiwon Salehi, Saeed Industrial and Systems Engineering University of Oklahoma NormanOK United States Data Science and Analytics Program University of Oklahoma NormanOK United States Petroleum and Geological Engineering University of Oklahoma NormanOK United States

Virtual reality (VR) enable us to train in a safe environment using computer-generated simulations. One such simulated environment is the Deepwater Horizon operation, and VR enables us to evaluate trainees’ and operators’ situation awareness (SA) in a non-hazardous environment. One unobtrusive and viable SA evaluation method might be the use of eye movements, specifically the time-ordered visual scan paths. In this research, we investigated how SA can be associated with visual scan paths in an anomaly detection task within the oil drilling rig virtual reality simulator. The results show that the trainees having lower SA tended to create random visual scan paths whereas the trainees having higher SA tended to create concentrated and refined visual scan paths. The results show promise in developing timely intervention methods through analyzing the visual scan path characteristics of the trainees. © 2020 by Human Factors and Ergonomics Society. All rights reserved.

关键词： Eye tracking

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Fabrication a sustainable adsorbent nanocellulose-mesoporous hectorite bead for methylene blue adsorption

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Case Studies in Chemical and Environmental Engineering 2024年 10卷

作者： Holilah Asranudin El Messaoudi, Noureddine Ulfa, Maria Hamzah, Amir Hamid, Zuratul Ain Abdul Ramadhani, Dini Viandi Suryanegara, Lisman Mahardika, Melbi Melenia, Alvina Tata Pratama, Agus Wedi Prasetyoko, Didik Research Center for Biomass and Bioproducts National Research and Innovation Agency of Indonesia (BRIN) Research Collaboration Center for Nanocellulose BRIN-Andalas University Research Collaboration Center for Biomass and Biorefinery Between BRIN and Universitas Padjadjaran Laboratory of Applied Chemistry and Environment Faculty of Sciences Ibn Zohr University Chemistry Education Study Program Faculty of Teacher Training and Education Sebelas Maret University Deputy for Infrastructure Research and Innovation National Research and Innovation Agency of Indonesia (BRIN) School of Materials & Mineral Resources Engineering Universiti Sains Malaysia Department of Biology Faculty of Science and Data Analytics Institut Teknologi Sepuluh Nopember Department of Chemistry Faculty of Science and Data Analytics Institut Teknologi Sepuluh Nopember (ITS) Kampus ITS Sukolilo

In this study, fabrication of mesoporous nanocellulose-hectorite-alginate bead (B-NcH) composites and their application for adsorption of MB from water was carried out. The synthesis of nanocellulose (NC) was conducted from mangosteen waste peel (Garcinia mangostana L.). Garcinia mangostana L. peel had 58.9 ± 0,41 % content of cellulose. NCs was successfully isolated using the acid hydrolysis method. NC from Garcinia mangostana L. peel had a diameter of 24.5 ± 0.2 nm and a length of 381.2 ± 10.4 nm. The superabsorbent was composed of nanocrystalline cellulose, mesoporous hectorite, and alginate. The functional group, phase, and morphology of composite was investigated. The composite with 5 % NC had excellent mechanical strength. The B-NcH5 showed a high adsorption capacity of methylene blue (MB), reaching 98.64 % at an adsorbent dose of 30 mg for 90 min. The presence of hectorite can increase the adsorption ability compared to NCs-alginate. The equilibrium adsorption data followed the Freundlich isotherm;however, the kinetics of adsorption showed the usefulness of adopting the PSO kinetic model. The highest adsorption capacity of B-NcH5 for MB was determined to be 57.59 mg/g. For thermodynamic studies, it was revealed that the adsorption of MB on BNcH-5 is a spontaneous and endothermic process. The removal efficiency was observed in six consecutive cycles, indicating at the favorable reusability of this adsorbent. These results validate the potential use of this B-NcH5 adsorbent for water treatment applications. © 2024

关键词： Adsorption Bead Hectorite Methylene blue Nanocellulose Water treatment

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Risks of liver cirrhosis,hepatocellular carcinoma,hepatic-related complications,and mortality in patients with type 2 diabetes in Taiwan

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World Journal of Diabetes 2025年第5期16卷 202-215页

作者： Hua-Fen Chen Yung-Yueh Chang Peter Chen Xiao-Han Shen Chin-Huan Chang Wan-Lun Hsu Department of Endocrinology Far Eastern Memorial HospitalNew Taipei City 220TaiwanChina School of Medicine College of MedicineFu Jen Catholic UniversityNew Taipei City 242TaiwanChina Department of Public Health College of MedicineFu Jen Catholic UniversityNew Taipei City 242TaiwanChina Institute of Epidemiology and Preventive Medicine College of Public HealthNational Taiwan UniversityTaipei City 100TaiwanChina Department of Gastroenterology Choninn HospitalChoninn Medical GroupNew Taipei City 220TaiwanChina Master Program of Big Data in Medical Healthcare Industry College of MedicineFu Jen Catholic UniversityNew Taipei City 242TaiwanChina Data Science Center Fu Jen Catholic UniversityNew Taipei City 242TaiwanChina

BACKGROUND Hepatitis B and C and alcoholic liver disease are the principal causes of hepaticrelated morbidity and ***,evidence of the associations between diabetes without the above risk factors and hepatic-related study endpoints is not well *** addition,the effects of associated metabolic dysfunction and exercise on hepatic outcomes are still not *** To investigate the incidence and relative hazards of cirrhosis of the liver,hepato cellular carcinoma(HCC),hepatic-related complications and mortality in patients with type 2 diabetes(T2D)who were nonalcoholic and serologically negative for hepatitis B and C in *** A total of 33184 T2D patients and 648746 nondiabetic subjects selected from Taiwan’s adult preventive health care service were linked to various National Health Insurance databases,cancer registry,and death registry to identify cirrhosis of the liver,HCC,hepatic-related complications,and *** Poisson assumption and Cox proportional hazard regression model were used to estimate the incidences and relative hazards of all hepatic-related study endpoints,*** also compared the risk of hepatic outcomes stratified by age,sex,associated metabolic dysfunctions,and regular exercise between T2D patients and nondiabetic *** Compared with nondiabetic subjects,T2D patients had a significantly greater incidence(6.32 vs 17.20 per 10000 person-years)and greater risk of cirrhosis of the liver[adjusted hazard ratio(aHR)1.45;95%CI:1.30-1.62].The aHRs for HCC,hepatic complications,and mortality were 1.81,1.87,and 2.08,*** older age,male sex,obesity,hypertension,and dyslipidemia further increased the risks of all hepatic-related study endpoints,and regular exercise decreased the risk,irrespective of diabetes *** Patients with T2D are at increased risk of cirrhosis of the liver,HCC,hepatic-related complications,and mortality,and associated metabolic dysfunctions provide additional

关键词： Type 2 diabetes mellitus Liver cirrhosis Hepatocellular carcinoma Hepatic-related complications Mortality Metabolic dysfunction-associated steatotic liver disease Metabolic dysfunction-associated steatohepatitis

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Survival analysis of Kasturi tobacco plants in Jember district using the stratified cox and extended cox models.

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MethodsX 2025年 14卷

作者： Pratama, Angga Iryanto Rantini, Dwi Ningrum, Ratih Ardiati Ramadan, Arip Othman, Fazidah Data Science Technology Study Program Faculty of Advanced Technology and Multidiscipline Universitas Airlangga Surabaya 60115 Indonesia Research Group of Data-Driven Decision Support System Faculty of Advanced Technology and Multidiscipline Universitas Airlangga Surabaya 60115 Indonesia Information System Study Program School of Industrial and System Engineering Telkom University Surabaya Campus Surabaya 60231 Indonesia Department of Computer System and Technology Faculty of Computer Science and Information Technology University of Malaya Malaya Malaysia

In 2022, tobacco was the top export commodity, generating $106.3 million in sales. East Java Province contributes significantly to Indonesia's tobacco production, with an annual output of 188.6 thousand tons. Jember Regency is the area in East Java Province which is a Kasturi tobacco cultivation area. The productivity of Kasturi tobacco continues to decrease due to several factors that can affect the survival of the tobacco. This study aims to analyze the survival of Kasturi tobacco by creating stratified Cox and extended Cox models in order to handle factors that cannot fulfill the proportional hazard assumption. Based on the results of the analysis, the stratified Cox model is the best model with AIC and BIC values of 798.108 and 805.5748 respectively, while the extended Cox has AIC and BIC values of 840.2186 and 850.1732 respectively. Variables that can significantly affect the survival of Kasturi tobacco are the variable concentration of ZA fertilizer, pesticide concentration. The addition of ZA fertilizer must be appropriate, because if excessive it can cause poisoning of tobacco plants. Likewise with pesticides, if excessive it will cause damage to the leaves. This policy can increase the productivity of Kasturi tobacco. Then, Jember Regency contributes greater export capacity. • This paper aims to determine the factors that affect the survival of Kasturi tobacco plants in Jember • By using the extended Cox model, the best one is obtained using the Heaviside function with AIC and BIC values of 840.2186 and 850.1732, respectively • The stratified Cox model is better than the extended Cox model, which has AIC and BIC values of 798.108 and 805.5748, respectively © 2025 The Author(s)

关键词： Cox proportional hazard Extended cox Kasturi tobacco Productive agriculture Stratified cox

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Frailty and Other Factors Associated With Early Outcomes in Middle-to Older Age Trauma Patients: A Prospective Cohort Study

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American Journal of Geriatric Psychiatry 2024年第2期32卷 244-255页

作者： Yeh, Tian-Shin Kang, Jiunn-Horng Littlejohns, Thomas J. Wu, Chia-Chieh Chen, Jin-Hua Piravej, Krisna Chiu, Wen-Ta Lam, Carlos Department of Physical Medicine and Rehabilitation School of Medicine College of Medicine Taipei Medical University Taipei Taiwan Department of Physical Medicine and Rehabilitation Wan Fang Hospital Taipei Medical University Taipei Taiwan Department of Epidemiology and Nutrition Harvard T. H. Chan School of Public Health Harvard University Boston MA United States Department of Physical Medicine and Rehabilitation National Taiwan University Hospital Taipei Taiwan Department of Physical Medicine and Rehabilitation College of Medicine National Taiwan University Taipei Taiwan Department of Physical Medicine and Rehabilitation Taipei Medical University Hospital Taipei Taiwan Graduate Institute of Nanomedicine and Medical Engineering College of Biomedical Engineering Taipei Medical University Taipei Taiwan International Ph.D. Program in Medicine College of Medicine Taipei Medical University Taipei Taiwan Professional Master Program in Artificial Intelligence in Medicine College of Medicine Taipei Medical University Taipei Taiwan Nuffield Department of Population Health University of Oxford Oxford United Kingdom Emergency Department Wan Fang Hospital Taipei Medical University Taipei Taiwan Department of Emergency School of Medicine College of Medicine Taipei Medical University Taipei Taiwan Graduate Institute of Data Science College of Management Taipei Medical University Taipei Taiwan Institutional Research Center Office of Data Science Taipei Medical University Taipei Taiwan Biostatistics Center Department of Medical Research Wan Fang Hospital Taipei Medical University Taipei Taiwan Department of Rehabilitation Medicine Faculty of Medicine Chulalongkorn University Bangkok Thailand Department of Chula Neuroscience Center King Chulalongkorn Memorial Hospital Bangkok Thailand Graduate Institute of Injury Prevention and Control College of Public Health Taipei Medical University Taipei Taiwan AHMC Health System Alhambra CA United States

Objectives: To prospectively investigate associations of frailty and other predictor variables with functional recovery and health outcomes in middle-aged and older patients with trauma. Design: Single-center prospective cohort study. Setting: Emergency department of Wan Fang Hospital in Taiwan. Participants: Trauma patients aged 45 and older. Measurements: Frailty was assessed with the Clinical Frailty Scale (CFS). Injury mechanisms, pre-existing diseases, and fracture locations were recorded at baseline. The primary outcome was functional recovery assessed using the Barthel Index (BI). Secondary outcomes were new care needs, unscheduled return visits, and falls 3 months postinjury. Results: A total of 588 participants were included in the final analysis. For every one-point increase in the CFS, the multivariable-adjusted odds ratio (OR, 95% confidence interval [CI]) of failure to retain the preinjury BI was 1.34 (1.16–1.55);associations were consistent across levels of age and injury severities. Significant joint associations of frailty and age with poor functional recovery were observed. CFS was also associated with new care needs (OR for every one-point increase, 1.36, 95% CI, 1.17–1.58), unscheduled return visits (OR 1.26, 95% CI, 1.04–1.51), and falls (OR 1.23, 95% CI, 1.01–1.51). Other variables associated with failure to retain preinjury BI included road traffic accident and presence of hip fracture. Conclusion: Frailty was significantly associated with poor functional and health outcomes regardless of injury severity in middle-aged and older patients with trauma. Injury mechanisms and fracture locations were also significant predictors of functional recovery postinjury. © 2023 American Association for Geriatric Psychiatry

关键词： Clinical Frailty Scale Frailty functional recovery injury middle-to older age

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