Case of the Veterans Health Administration Telehealth Expansion

Thesis (S.M.)--Massachusetts Institute of Technology, Dept. of Aeronautics and Astronautics, 2013.This thesis was scanned as part of an electronic thesis pilot project.Cataloged from PDF version of thesisIncludes bibliographical references (p. 164-169).This research applies an implementation framework derived from enterprise systems thinking to the Veterans Health Administration (VHA) Telehealth Expansion in order to characterize and evaluate the implementation methods used to expand Telehealth nation-wide. An in-depth, multi-disciplinary literature review was conducted to identify how enterprise-wide implementations are characterized in the literature and then was used to inform the development of a baseline enterprise implementation framework, the Timeline Implementation Framework. Said framework aims to characterize enterprise-wide implementations over time, from conceptualization to evaluation and sustainment, by breaking down an implementation into four phases (Enterprise Analysis, Implementation Planning, Implementation Execution and Innovation Evaluation) based on the nature of the activities and concepts that occur during each phase. The Timeline Implementation Framework was then applied to the VHA Telehealth Expansion. The framework guided study methods and facilitated analysis of a Clinical Video Telehealth clinic implementation. Further analysis was conducted in order to understand the VHA Telehealth expansion by considering an enterprise perspective of Telehealth's impact on VHA, and vice versa. Data collection included qualitative and quantitative evidence sources (e.g., interviews, observation, internal documents, and archival records) in order to gather information required to populate the developed framework. Fifteen interviews were conducted with VHA employees to allow for various perspectives emerging from multiple stakeholders with different roles across the enterprise. Conclusions aim to improve VHA implementation strategies in three key ways. First, by applying the framework to a Telehealth clinic, study findings help depict Telehealth expansion at a facility level. Second, results are used to provide constructive recommendations regarding implementation strategies throughout VHA. Third, this study tests the generalizability of the framework before applying it in further implementations.by Julie C. Andren.S.M

The effects of aetiology on outcome in patients treated with cardiac resynchronization therapy in the CARE-HF trial

Aims: Cardiac dyssynchrony is common in patients with heart failure, whether or not they have ischaemic heart disease (IHD). The effect of the underlying cause of cardiac dysfunction on the response to cardiac resynchronization therapy (CRT) is unknown. This issue was addressed using data from the CARE-HF trial.Methods and resultsPatients (n = 813) were grouped by heart failure aetiology (IHD n = 339 vs. non-IHD n = 473), and the primary composite (all-cause mortality or unplanned hospitalization for a major cardiovascular event) and principal secondary (all-cause mortality) endpoints analysed. Heart failure severity and the degree of dyssynchrony were compared between the groups by analysing baseline clinical and echocardiographic variables. Patients with IHD were more likely to be in NYHA class IV (7.5 vs. 4.0; P = 0.03) and to have higher NT-proBNP levels (2182 vs. 1725 pg/L), indicating more advanced heart failure. The degree of dyssynchrony was more pronounced in patients without IHD (assessed using mean QRS duration, interventricular mechanical delay, and aorta-pulmonary pre-ejection time). Left ventricular ejection fraction and left ventricular end-systolic volume improved to a lesser extent in the IHD group (4.53 vs. 8.50 and -35.68 vs. -58.52 cm 3). Despite these differences, CRT improved all-cause mortality, NYHA class, and hospitalization rates to a similar extent in patients with or without IHD.ConclusionThe benefits of CRT in patients with or without IHD were similar in relative terms in the CARE-HF study but as patients with IHD had a worse prognosis, the benefit in absolute terms may be greater

Pancreatitis-diabetes-pancreatic cancer: summary of an NIDDK-NCI workshop

A workshop sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the National Cancer Institute (NCI) on "Pancreatitis-Diabetes-Pancreatic Cancer" focused on the risk factors of chronic pancreatitis (CP) and diabetes mellitus (DM) on the development of pancreatic ductal adenocarcinoma (PDAC). Sessions were held on (a) an overview of the problem of PDAC; (b) CP as a risk factor of PDAC; (c) DM as a risk factor of PDAC; (d) pancreatogenic, or type 3c, DM; (e) genomic associations of CP, DM, and PDAC; (f) surveillance of high-risk populations and early detection of PDAC; and (g) effects of DM treatment on PDAC. Recent data and current understandings of the mechanisms of CP- and DM-associated factors on PDAC development were discussed, and a detailed review of the possible risks of DM treatment on the development of PDAC was provided by representatives from academia, industry, and the Food and Drug Administration. The current status of possible biomarkers of PDAC and surveillance strategies for high-risk populations were discussed, and the gaps in knowledge and opportunities for further research were elucidated. A broad spectrum of expertise of the speakers and the discussants provided an unusually productive workshop, the highlights of which are summarized in the accompanying article

Quantifying the checks and balances of collaborative governance systems for adaptive carnivore management

Recovering or threatened carnivore populations are often harvested to minimise their impact on human activities, such as livestock farming or game hunting. Increasingly, harvest quota decisions involve a set of scientific, administrative and political institutions operating at national and sub-national levels whose interactions and collective decision-making aim to increase the legitimacy of management and ensure population targets are met. In practice, however, assessments of how quota decisions change between these different actors and what consequences these changes have on population trends are rare. We combine a state-space population modelling approach with an analysis of quota decisions taken at both regional and national levels between 2007 and 2018 to build a set of decision-making models that together predict annual harvest quota values for Eurasian lynx (Lynx lynx) in Norway. We reveal a tendency for administrative decision-makers to compensate for consistent quota increases by political actors, particularly when the lynx population size estimate is above the regional target. Using population forecasts based on the ensemble of decision-making models, we show that such buffering of political biases ensures lynx population size remains close to regional and national targets in the long term. Our results go beyond the usual qualitative assessment of collaborative governance systems for carnivore management, revealing a system of checks and balances that, in the case of lynx in Norway, ensures both multi-stakeholder participation and sustainable harvest quotas. Nevertheless, we highlight important inter-regional differences in decision-making and population forecasts, the socio-ecological drivers of which need to be better understood to prevent future population declines. Synthesis and applications. Our work analyses the sequence of decisions leading to yearly quotas for lynx harvest in Norway, highlighting the collaborative and structural processes that together shape harvest sustainability. In doing so, we provide a predictive framework to evaluate participatory decision-making processes in wildlife management, paving the way for scientists and decision-makers to collaborate more widely in identifying where decision biases might lie and how institutional arrangements can be optimised to minimise them. We emphasise, however, that this is only possible if wildlife management decisions are documented and transparent

The undatables : Quantifying uncertainty in a highly expanded Late Glacial-Holocene sediment sequence recovered from the deepest Baltic Sea basin-IODP Site M0063

Laminated, organic-rich silts and clays with high dissolved gas content characterize sediments at IODP Site M0063 in the Landsort Deep, which at 459 m is the deepest basin in the Baltic Sea. Cores recovered from Hole M0063A experienced significant expansion as gas was released during the recovery process, resulting in high sediment loss. Therefore, during operations at subsequent holes, penetration was reduced to 2 m per 3.3 m core, permitting expansion into 1.3 m of initially empty liner. Fully filled liners were recovered from Holes B through E, indicating that the length of recovered intervals exceeded the penetrated distance by a factor of > 1.5. A typical down-core logarithmic trend in gamma density profiles, with anomalously low-density values within the upper similar to 1 m of each core, suggests that expansion primarily occurred in this upper interval. Thus, we suggest that a simple linear correction is inappropriate. This interpretation is supported by anisotropy of magnetic susceptibility data that indicate vertical stretching in the upper similar to 1.5 m of expanded cores. Based on the mean gamma density profiles of cores from Holes M0063C and D, we obtain an expansion function that is used to adjust the depth of each core to conform to its known penetration. The variance in these profiles allows for quantification of uncertainty in the adjusted depth scale. Using a number of bulk C-14 dates, we explore how the presence of multiple carbon source pathways leads to poorly constrained radiocarbon reservoir age variability that significantly affects age and sedimentation rate calculations.Peer reviewe

Activity Patterns of Eurasian Lynx Are Modulated by Light Regime and Individual Traits over a Wide Latitudinal Range

The activity patterns of most terrestrial animals are regarded as being primarily influenced by light, although other factors, such as sexual cycle and climatic conditions, can modify the underlying patterns. However, most activity studies have been limited to a single study area, which in turn limit the variability of light conditions and other factors. Here we considered a range of variables that might potentially influence the activity of a large carnivore, the Eurasian lynx, in a network of studies conducted with identical methodology in different areas spanning latitudes from 49 degrees 7'N in central Europe to 70 degrees 00'N in northern Scandinavia. The variables considered both light conditions, ranging from a day with a complete day-night cycle to polar night and polar day, as well as individual traits of the animals. We analysed activity data of 38 individual free-ranging lynx equipped with GPS-collars with acceleration sensors, covering more than 11, 000 lynx days. Mixed linear additive models revealed that the lynx activity level was not influenced by the daily daylight duration and the activity pattern was bimodal, even during polar night and polar day. The duration of the active phase of the activity cycle varied with the widening and narrowing of the photoperiod. Activity varied significantly with moonlight. Among adults, males were more active than females, and subadult lynx were more active than adults. In polar regions, the amplitude of the lynx daily activity pattern was low, likely as a result of the polycyclic activity pattern of their main prey, reindeer. At lower latitudes, the basic lynx activity pattern peaked during twilight, corresponding to the crepuscular activity pattern of the main prey, roe deer. Our results indicated that the basic activity of lynx is independent of light conditions, but is modified by both individual traits and the activity pattern of the locally most important prey

Mass spectrometry imaging of cassette-dosed drugs for higher throughput pharmacokinetic and biodistribution analysis

Cassette dosing of compounds for preclinical drug plasma pharmacokinetic analysis has been shown to be a powerful strategy within the pharmaceutical industry for increasing throughput while decreasing the number of animals used. Presented here for the first time is data on the application of a cassette dosing strategy for label-free tissue distribution studies. The aim of the study was to image the spatial distribution of eight nonproprietary drugs (haloperidol, bufuralol, midazolam, clozapine, terfenadine, erlotinib, olanzapine, and moxifloxacin) in multiple tissues after oral and intravenous cassette dosing (four compounds per dose route). An array of mass spectrometry imaging technologies, including matrix-assisted laser desorption ionization mass spectrometry imaging (MALDI MSI), liquid extraction surface analysis tandem mass spectrometry (LESA-MS/MS), and desorption electrospray ionization mass spectrometry (DESI-MS) was used. Tissue analysis following intravenous and oral administration of discretely and cassette-dosed compounds demonstrated similar relative abundances across a range of tissues indicating that a cassette dosing approach was applicable. MALDI MSI was unsuccessful in detecting all of the target compounds; therefore, DESI MSI, a complementary mass spectrometry imaging technique, was used to detect additional target compounds. In addition, by adapting technology used for tissue profiling (LESA-MS/MS) low spatial resolution mass spectrometry imaging (∼1 mm) was possible for all targets across all tissues. This study exemplifies the power of multiplatform MSI analysis within a pharmaceutical research and development (R&D) environment. Furthermore, we have illustrated that the cassette dosing approach can be readily applied to provide combined, label-free pharmacokinetic and drug distribution data at an early stage of the drug discovery/development process while minimizing animal usage