1,098 research outputs found
30th European Congress on Obesity (ECO 2023)
This is the abstract book of 30th European Congress on Obesity (ECO 2023
The pharmaco-epidemiology of loop diuretic dispensing and its relationship to the diagnosis of heart failure and to prognosis
Heart failure is a major and growing public health problem associated with poor patient outcomes, including reduced quality of life and high hospitalisation and mortality rates. It is a complex clinical syndrome rather than a single disease, which lacks a practical, universal, and standardised definition. Currently, the definition relies on the identification of symptoms and signs of cardiac dysfunction, such as ankle swelling and breathlessness, which are neither specific nor objective. Many patients are only diagnosed once their symptoms and signs are severe enough to require hospitalisation. Pathophysiologically, heart failure can be defined by the presence of salt and water retention, also known as congestion, associated with cardiac dysfunction. Within the United Kingdom, the pharmacological class of loop diuretics is used primarily for the treatment of congestion due to cardiac dysfunction. The aim of this thesis is to investigate the pharmacoepidemiology of loop diuretic dispensing and its relationship to the diagnosis of heart failure, with a particular focus on patient outcomes.
The first analysis describes the prevalence of repeated loop diuretic dispensing and/or diagnosis of heart failure within the NHS Greater Glasgow & Clyde Health Board population on 1st January 2012, including patient outcomes over the following five years. This research is thought to be the first population-level investigation into the prevalence of repeated loop diuretic dispensing and its prognostic significance in patients with and without a diagnosis of heart failure. The analysis found that an estimated 3.2% of the population received repeated loop diuretic dispensing, while only 1.3% of the population had a diagnosis of heart failure. Hospitalisation rates were higher in those with a loop diuretic (0.99 admissions per patient-year at risk for those with only repeated loop diuretic dispensing and 1.51 admissions per patient-year at risk for those with both) than those with only a diagnosis of heart failure (0.93 admissions patient-year at risk). All-cause mortality followed a similar pattern; adjusting for age, sex, socioeconomic deprivation and comorbidity status, the 5-year hazard ratio and (95% confidence interval) were 1.8 (1.8 - 1.9) for those with those only repeated loop diuretic dispensing and 2.3 (2.2 - 2.4) for those with both, while only 1.2 (2.2 - 2.4) for those with only a diagnosis of heart failure, implying that the presence of repeated loop diuretic dispensing is a marker of serious disease.
The second analysis stepped backwards in ‘patient-time’ to describe the pattern of hospitalisations in the year leading up to the initiation of loop diuretic dispensing or an incident diagnosis of heart failure using network graphs. While the precursors to heart failure are known, this research is thought to be the first to report the common patterns in events leading up to the initiation of loop diuretics. While there was little difference in comorbidity and medication levels 24 months prior, in the year leading up to the initiation, those who received a diagnosis of heart failure were more likely to be admitted for well-recognised contributors to the condition, including ischaemic heart disease in particular, but also atrial fibrillation/flutter and valve disease. In contrast, these patterns were not often seen in those who were only initiated on a loop diuretic, instead with a focus on admissions for non-specific symptoms and signs, most commonly unspecified chest pain.
The third analysis starts where the second leaves off. It assesses the prognostic relationship between the initiation of loop diuretic and diagnosis of heart failure on mortality and whether the sequence of these events matters using semi-Markov multi-state modes, a flexible model for use on longitudinal time data where there is an event-related dependence on outcomes. Those on repeated loop diuretic dispensing without a diagnosis of heart failure were majority women (62%). Many with evidence of left atrial dilation (53%), while those with a diagnosis of heart failure without a repeat loop diuretic were majority men (63%). Many had a history of myocardial infarction (51%). Hospitalisations and mortality were higher in those with a repeat loop diuretic (within the first year per patient-year at risk: hospitalisation, 1.44; mortality, 0.20) compared to those with a diagnosis of heart failure without a repeat loop diuretic (within the first year per patient-year at risk: hospitalisation, 1.47; mortality, 0.14). Rates were higher still in those with both loop diuretic and heart failure (where both events occurred together within the first year per patient-year at risk: hospitalisation, 1.74; mortality, 0.16; or where the diagnosis of HF preceded the initiation of loop diuretic, within the first year per patient-year at risk: hospitalisation, 1.68; mortality, 0.20), with the highest being in those who initiated the loop diuretic in advance of receiving a diagnosis of heart failure (within the first year per patient-year at risk: hospitalisation, 2.26; mortality, 0.28).
The fourth and final analysis subsets the population to investigate the mortality of the 24,921 patients with ischaemic heart disease according to whether or not they have had a repeat loop diuretic and/or diagnosis of heart failure; of whom, 3,806 had only repeat loop diuretic, 2,384 had only a diagnosis of heart failure, and 3,531 had both. This analysis found that after adjusting for age, sex, and other prognostic markers, mortality was associated with the repeat loop diuretic regardless of the patient’s heart failure status. Those with a repeat loop diuretic without a diagnosis of heart failure experienced substantially higher rates of cardiovascular (an estimated 15%) and all-cause mortality (47%) than those with a diagnosis of heart failure without a repeat loop diuretic (an estimated 8% cardiovascular and 19% all-cause mortality), while rates were highest for those with both (an estimated 25% cardiovascular and 57% all-cause mortality).
In conclusion, these analyses found that many more patients are repeatedly treated with loop diuretic than ever receive a diagnosis of heart failure. These patients are at a high risk of hospitalisation and death, and based on their characteristics, many probably have undiagnosed heart failure. From a public health and epidemiological perspective, the current definition of heart failure likely underestimates the true burden on the healthcare system. From the patient’s perspective, with the efficacy of angiotensin receptor-neprilysin inhibitor, sodium-glucose co-transporter-2 inhibitors, and mineralocorticoid receptor antagonistss, a missed diagnosis means a missed opportunity to improve the patient’s outcome and quality of life, regardless of their heart failure phenotype. Even more alarming, if these patients are receiving the loop diuretic inappropriately, the loop diuretic is likely causing these increased hospitalisation and mortality rates. If the loop diuretic can be safely withdrawn, other medications with diuretic properties exist which have good safety profiles. Ultimately, further research is required to determine the optimal strategy for managing these patients
HM 32: New Interpretations in Naval History
Selected papers from the twenty-first McMullen Naval History Symposium held at the U.S. Naval Academy, 19–20 September 2019.https://digital-commons.usnwc.edu/usnwc-historical-monographs/1031/thumbnail.jp
Recognition of and Response to Obstetric Emergencies: Developing A Virtual Competency-Based Orientation Program
In order to improve outcomes in the perinatal setting, the development of a Virtual Competency-Based Orientation Program (CBO) toolkit is vital. Two toolkits, namely the Alliance for Innovation on Maternal Health (AIM) and the California Maternal Quality Care Collaborative (CMQCC), have been identified as effective in enhancing perinatal outcomes. AIM is a national initiative focused on improving maternal health outcomes, promoting safer birth practices, and saving lives through the implementation of best practices. CMQCC is a multi-stakeholder organization in California committed to eliminating preventable morbidity, mortality, and racial disparities in maternity care. Both AIM and CMQCC CBO toolkits incorporate research, quality improvement strategies, bundled care approaches, and collaborative outreach. The utilization of a bundled set of care strategies has been associated with positive outcomes in the maternal newborn setting. These open resource toolkits are designed to facilitate change readiness by engaging stakeholders in understanding the reasons for the proposed changes, gaining leadership support, assembling interprofessional implementation teams, and providing evidence-based information that demonstrates the need for orientation programs while identifying the necessary resources. The CBO outlined in this project serves as a guide for organizations of various backgrounds to effectively prepare, implement, and utilize for the promotion of best practices. The project follows the framework provided by the Centers for Disease Control and Prevention (CDC). Key considerations, including staff training, workflow adjustments, and ongoing evaluation, are crucial to warrant successful implementation and sustainable improvements in practices especially involving maternal hemorrhage and sepsis. Among existing toolkits, the CMQCC and AIM safety bundles have been noted to be exemplary in improving outcomes in the perinatal setting
A human-factors approach to capture medical device safety, performance and usability
Advances in medical technology including computer aided and robotic surgery, digital health and increased use of portable devices have improved patient care in both hospital and home environments. These advancements have brought an increased level of complexity in patient care with new challenges to both patients and clinicians. The available performance data on medical devices (MD) is scarce and of variable quality despite work from regulatory bodies, with multiple associated challenges and lack of effective systems in place for its collection.
This research used human factor methods to address i) the current state of safety and performance data availability for MDs and ii) methods of capturing safety and usability data in hospital and home environments by using human factor methods.
Part A of this thesis concentrated on hospital based devices whilst Part B addressed home use MDs. End user experiences were utilised throughout to gain an understanding of the current system including its challenges and reasons leading to lack of data. Patients, clinicians, manufacturers, human factor specialists and MHRA were involved at all stages of this research.
The studies led to the developments of the pathway map to reporting and information transfer in operating theatres and furthermore the development and initial evaluation of the MD-PRS concept (Medical Device Performance Reporting System) as a single dedicated method of reporting all MD malfunctions/ failures. The My-VID usability tool (My Voice in Design) was developed and evaluated as a method for collecting usability data directly from patients on home use MDs.
In conclusion, this thesis used human factor methods to better understand the current system of data collection, available data sources on MDs and challenges faced prior to developing methods for improvement, based on end user experiences . Finally, methods of applying this research to clinical practice were addressed in the final chapter.Open Acces
ADAPTING AND IMPLEMENTING GROUP POSTPARTUM AND WELL-CHILD CARE AT CLINICS IN BLANTYRE DISTRICT, MALAWI
Background: Persistently elevated rates of maternal and infant mortality and morbidities in Malawi indicate the need for increased quality of maternal and well-child care services. The first-year postpartum sets the stage for long-term health for the childbearing parent and infant. Innovative strategies are needed to advance care models that integrates and addresses both maternal and infant needs. Integrated group postpartum and well-child care offers a promising strategy to improve maternal and infant health outcomes in Malawi. The purpose of this study was to adapt an established program and co-design an integrated group postpartum and well-child care model and evaluate its implementation outcomes in Blantyre District, Malawi.
Methods: We used a mixed methods design and the Human-Centered, Evidence-Driven Adaptive Design (AHEAD) framework to guide this study. Following the five steps of the AHEAD framework we: 1) defined the problem and assembled a team through integrative and scoping reviews of the literature; 2) reviewed the evidence and sought inspiration through interviews with women and health care workers; 3) synthesized the data through rigorous data analyses; 4) developed guiding principles and ideated to co-create a group postpartum and well-child care prototype through incubator sessions with women and health care workers; and 5) evaluated the prototype through pilot sessions of the 6-visit model adapted for the Malawian context through structured observation, surveys, and focus groups evaluating implementation outcomes.
Results: For Step 1 we completed literature reviews which confirmed that group care offers a promising strategy to improve health outcomes for Malawian women and their children. For Steps 2-4 we completed 20 interviews and 6 incubator sessions with women and health care workers. All participants reported a desire for group care in the postpartum period. Health promotion priorities identified by participants were hygiene, breastfeeding, family planning, nutrition, and mental health. Findings from the interviews and incubator sessions guided the development of a 6-visit model prototype to be delivered over the first 12 months postpartum corresponding to the Malawian child vaccination schedule. The prototype included an implementation structure, facilitator’s guide (curriculum), and clinical assessment guidelines. For Step 5 we piloted the prototype and tested each session once at each clinic for a total of 18 pilot sessions with 41 women/infant dyads. Nineteen health care workers across the three clinics co-facilitated group sessions. Both women and health care workers reported group postpartum and well-child care was highly acceptable, appropriate, and feasible across clinics. Fidelity to the group care model was high. Challenges in implementing group sessions were identified.
Conclusions: This integrated group postpartum and well-child care model is a potentially transformative approach to a neglected area of the care continuum by integrating maternal health in to well-child care to meet the needs of Malawian women and infants during the postpartum period. This model has promise for improving multiple maternal and child health outcomes. Due to these promising results, we recommend future research examine the effectiveness of the model on maternal and child health outcomes in Malawi and other low resource settings
The development of a self-directed learning resource for coronary care nurses caring for adult patients with cardiogenic shock
Background: Coronary care nurses require specialized nursing skills and knowledge to care for critically ill cardiovascular patients with cardiogenic shock (CS). Informal discussions with an intentional sample of coronary care nurses outlined a need for more education and resources related to the nursing care of adult patients at risk for and who develop CS. Purpose: The purpose of the practicum project was to develop a self-directed learning resource for nurses providing direct care to adult patients with CS in the coronary care unit at the Health Sciences Centre, Eastern Health (EH). Methods: 1) a literature review, 2) an environmental scan, 3) consultations with nurse educators and nurses, and 4) the development of a self-directed learning resource. Results: The literature review findings supported the belief that nurses have knowledge gaps related to CS nursing care and that a self-directed learning resource is an effective educational strategy for nurses. The environmental scan revealed a variety of learning resources related to CS, but a lack of comprehensive learning resources targeting coronary care nurses was also identified. Consultations supported the development of the resource and informed relevant content for inclusion within the resource. The findings were utilized to develop the self-directed learning resource consisting of four modules: 1) an overview of CS, 2) hemodynamic monitoring and the nursing care of a pulmonary artery catheter, 3) vasoactive medications, and 4) the intra-aortic balloon pump. Conclusion: The self-directed learning resource was developed in a paper format with an implementation plan to create a computer-based resource available on the Learning Management System at EH. The aim is for coronary care nurses to complete the self-directed learning resource to meet their individualized learning needs related to caring for adult patients at risk for and who develop CS
Integration of social values in a multi-agent platform running in a supercomputer
Agent-based modelling is one of the most suitable ways to simulate and analyse complex
problems and scenarios, especially those involving social interactions. Multi-agent systems, consisting
of multiple agents in a simulation environment, are widely used to understand emergent behaviour in
various fields such as sociology, economics and policy.
However, existing multi-agent platforms often face challenges in terms of scalability and
reasoning capacity. Some platforms can scale well in terms of computation, but lack sophisticated
reasoning mechanisms. On the other hand, some platforms employ complex reasoning systems, but
this can compromise their scalability.
In this work, we have extended an existing platform developed at UPC that enables scalable,
parallel HTN planning for complex agents. Our main goal has been to improve the analysis of social
relationships between agents by incorporating moral values.
Building on previous work done by David Marín on the implementation of the platform, we
have made extensions and modifications both formally and in the implementation. We have
formalised the additions to the system model and provided an updated implementation.
Finally, we have presented a complex example scenario that demonstrates all the additions we
have made. This scenario allows us to show how agents' preferences and moral values influence their
decisions and actions in a simulated environment. Through this work, we have sought to improve the
existing platform and fulfil the spirit and purpose of the platform
Generating And Validating A Global Framework Of Pharmaceutical Development Goals And Corresponding Indicators
INTRODUCTION:
The imperative of meeting current global healthcare challenges requires advancing pharmacy practice in a global context. This research aimed to design and develop a valid and consented set of global goal-oriented pharmaceutical development frameworks and corresponding indicators to support and guide systematic practice transformation needed to meet the national and global pharmaceutical healthcare demands of changing population demographics.
METHODS:
Part 1 of the research project
This research used a mixed-methods approach. A series of international expert focus groups were conducted to evaluate the acceptance of a set of proposed global pharmaceutical development goals (PDGs). This was followed by recruiting global pharmacy leaders who participated in a modified nominal group technique to further develop the content of the initial PDGs framework. In a subsequent study, a qualitative modified Delphi approach was employed by a panel of international experts to ensure the credibility and content validity of the framework outputs and generate consensus on a final matrix of the proposed global PDGs.
Part 2 of the research project
A content analysis of the relevant collated data followed by a Delphi process of an international Expert Group was performed to identify and establish initial consensus on potential indicators aligned with the published PDGs framework. Delphi method’s outcomes were used to conduct a global cross-sectional online questionnaire to assess and validate the relevancy and availability of the proposed indicators.
RESULTS:
Part 1 of the research project
A globally validated and consented set of systematic PDGs (systematic framework) for development comprising 21 PDGs along with their descriptions and mechanisms to shape and guide global pharmacy practice transformation.
Part 2 of the research project
A set of correlated and validated transnational evidence-based indicators that will monitor national-level progress and measure the advancement of the 21 PDGs worldwide across workforce/education, practice, and pharmaceutical science.
CONCLUSION:
A systematic and globally consented set of PDGs, along with evidence-based progress indicators, was generated to monitor the sustainable advancement of pharmaceutical practice and support a needs-based roadmap for pharmacy practice transformation
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