The suitability of care pathways for integrating processes and information systems in healthcare

Purpose: This paper examines the suitability of current care pathway modelling techniques for supporting business improvement and the development of information systems. This is in the light of current UK government policies advocating the use of care pathways as part of the £12.4 billion programme for IT and as a key strategy to reducing waiting times. Approach: We conducted a qualitative analysis of the variety in purpose, syntax and semantics in a selection of existing care pathways. Findings: Care pathways are typically modelled in an ad-hoc manner with little reference to formal syntax or semantics. Research limits: The research reviews a small selection of existing pathways. The feature set used for evaluation could be further refined. Future research should examine the suitability of applying existing process modelling techniques to care pathways and explore the motivations for modelling care pathways in an ad-hoc manner. Practical implications: The development of care pathways can aid process improvement and the integration of information systems. However, while syntax and semantics are not standardised the impact of care pathways in the work of Department of Health agencies, in particular Connecting for Health, is likely to be limited. Value: The results provide insight into the limitations of the state of the art in care pathway models. This highlights a significant omission in the Department of Health’s approach and identifies an important direction for further development that will aid Connecting for Health, healthcare organisations and healthcare professionals to deliver more effective services

Human Immunodeficiency Virus Infection in Young Adults: Treatment of Substance Use Disorders as a Priority Component of HIV Prevention, Care and Treatment in Low and Middle Income Countries

Young adults comprise roughly one-quarter of the global population and are at the developmental stage where personal life goals are formulated and personal independence is obtained. It is also the time of sexual debut and exposure to illicit drug and alcohol use. Thus, young adulthood is a time of high-risk for HIV transmission due to drug and alcohol use in the context of sexual activity. Social-networking, gender norms, economic, educational, familial, personal identity and development factors, among others, play a role in illicit drug and alcohol use and HIV infection in young adults. It is estimated that young adults account for 42% of new HIV infections globally, and that 4 million young adults living with HIV reside in sub-Saharan Africa. In Central Asia, Eastern Europe and the United States key populations are important subpopulations of young adults at high-risk for living with HIV. Subpopulations of young adults, particularly key populations, consume illicit drugs and alcohol with high-risk sexual and injection activity, thereby establishing connections between substance use/injection drug use/substance use disorders and HIV infection. Globally, interventions that comprise evidence-based prevention, care and treatment of substance use disorders targeting young adults and prioritizing treatment of substance use disorders as part of HIV care and treatment are vital to reduce the transmission of HIV infection and promote good clinical outcomes for young adults at-risk for and living with HIV

Analysis of fouling and breakthrough of process related impurities during depth filtration using confocal microscopy

Titer improvement has driven process intensification in mAb manufacture. However, this has come with the drawback of high cell densities and associated process related impurities such as cell debris, host cell protein (HCP), and DNA. This affects the capacity of depth filters and can lead to carryover of impurities to protein A chromatography leading to early resin fouling. New depth filter materials provide the opportunity to remove more process related impurities at this early stage in the process. Hence, there is a need to understand the mechanism of impurity removal within these filters. In this work, the secondary depth filter Millistak+ X0HC (cellulose and diatomaceous earth) is compared with the X0SP (synthetic), by examining the breakthrough of DNA and HCP. Additionally, a novel method was developed to image the location of key impurities within the depth filter structure under a confocal microscope. Flux, tested at 75, 100, and 250 LMH was found to affect the maximal throughput based on the max pressure of 30 psi, but no significant changes were seen in the HCP and DNA breakthrough. However, a drop in cell culture viability, from 87% to 37%, lead to the DNA breakthrough at 10% decreasing from 81 to 55 L/m2 for X0HC and from 105 to 47 L/m2 for X0SP. The HCP breakthrough was not affected by cell culture viability or filter type. The X0SP filter has a 30%–50% higher max throughput depending on viability, which can be explained by the confocal imaging where the debris and DNA are distributed differently in the layers of the filter pods, with more of the second tighter layer being utilized in the X0SP

High-resolution imaging of depth filter structures using X-ray computed tomography

A multiple length scale approach to the imaging and measurement of depth filters using X-ray computed tomography is described. Three different filter grades of varying nominal retention ratings were visualized in 3D and compared quantitatively based on porosity, pore size and tortuosity. Positional based analysis within the filters revealed greater voidage and average pore sizes in the upstream quartile before reducing progressively through the filter from the center to the downstream quartile, with these results visually supported by voidage distance maps in each case. Flow simulation to display tortuous paths that flow may take through internal voidage were examined. Digital reconstructions were capable of identifying individual constituents of voidage, cellulose and perlite inside each depth filter grade, with elemental analysis on upstream and downstream surfaces confirming perlite presence. Achieving an appropriate pixel size was of particular importance when optimizing imaging conditions for all grades examined. A 3 µm pixel size was capable of representing internal macropores of each filter structure; however, for the finest grade, an improvement to a 1 µm pixel size was required in order to resolve micropores and small perlite shards. Enhancing the pixel size resulted in average porosity measurements of 70% to 80% for all grades. Graphical abstract: [Figure not available: see fulltext.

TOPOGRAPHIC WAVES IN OPEN DOMAINS .2. BAY MODES AND RESONANCES

The topographic wave equation is solved in a domain consisting of a channel with a terminating bay zone. For exponential depth profiles the problem reduces to an algebraic eigenvalue problem. In a flat channel adjacent to a shelf–like bay zone the solutions form a countably infinite set of orthogonal bay modes: the spectrum of eigenfrequencies is purely discrete. A channel with transverse topography allows wave propagation towards and away from the bay: the spectrum has a continuous part below the cutoff frequency of free channel waves. Above this cutoff frequency a finite number (possibly zero) of bay-trapped solutions occur. Bounds for this number are given. At particular frequencies below the cutoff the system is in resonance with the incident wave. These resonances are shown to be associated with bay modes

THE TRAPPING AND SCATTERING OF TOPOGRAPHIC WAVES BY ESTUARIES AND HEADLANDS

This paper extends recent theoretical work on sub-inertial trapped modes in bays to consider trapping of energy in the neighbourhood of estuary mouths on coastal shelves. The qualitative form of the theoretical predictions accords well with recent observations on the Scotian Shelf that show energy trapped near the Laurentian Channel at a frequency higher than that of the propagating waves on the shelf.The trapping and scattering of shelf waves is modelled for a shelf-estuary or shelf-headland system by considering barotropic waves in a straight, infinite channel with an attached rectangular estuary or interrupted by a rectangular headland. Taking the depth to increase exponentially with distance from the coast and expanding in cross-shelf modes reduces the problem to a system of real linear algebraic equations.Trapped modes with frequencies above the cutoff frequency of propagating waves are found near the mouth of the estuary. Waves propagating towards the estuary are strongly scattered and, for particular frequencies, incident energy can be either perfectly transmitted or totally reflected. An incident wave can be in resonance with the estuary causing energy to penetrate the estuary. Bounds on the frequencies of trapped and resonant solutions are given and allow an easy modal interpretation.If the frequency of an incident wave is sufficiently high, waves cannot propagate past a headland. Energy at these frequencies can however tunnel through the region and appear as an attenuated wave on the far side. For particular frequencies all energy passes the headland and none is reflected. For headlands long compared with the incident wave, transmission coefficients for single-mode scattering follow from spatially one-dimensional wave mechanics

Analytical tools for monitoring changes in physical and chemical properties of chromatography resin upon reuse

Protein A resins are often reused for multiple cycles to improve process economy during mAb purification. Significant reduction in binding capacity and product recovery are typically observed due to the presence of unwanted materials (foulants) deposited on the resin upon reuse. In this paper, we have used a wide spectrum of qualitative and quantitative analytical tools (particle size analysis, HPLC, fluorescence, SEM, MS, and FTIR) to compare the strengths and shortcomings of different analytical tools in terms of their capability to detect the fouling of the resin and relate it to chromatographic cycle performance. While each tool offers an insight into this complex phenomena, fluorescence is the only one that can be used for real‐time monitoring of resin fouling. A correlation could be established between fluorescence intensity and the process performance attributes (like yield or binding capacity) impacted upon resin reuse. This demonstration of the application of fluorescence for real‐time monitoring correlated empirically with process performance attributes and the results support its use as a PAT tool as part of a process control strategy. While the focus of this paper is on fouling of protein A chromatography resin, the approach and strategy are pertinent to other modes of chromatography as well

Packed bed compression visualisation and flow simulation using an erosion-dilation approach

X-ray computed tomography has been demonstrated to be capable of imaging 1 mL (5 mm diameter, 50 mm height) chromatography packed beds under compression, visualising the 3D structure and measuring changes to geometry of the packing. 1 mL pre-packed columns did not exhibit any structural changes at vendor specified flow rate limits, however cellulose beds did compress at higher flow rates that were imaged before, during and after flow. This was used to visualise and quantitate changes to porosity, tortuosity and permeability based on simulation of flow through the packed bed structure using the imaging data. When using a high flow rate it was found that a decrease in porosity could be measured during compression before reverting after flow had ceased, with corresponding changes to tortuosity and permeability also occurring. X-ray CT imaging of packed beds and individual beads exposed to foulant-rich process streams resulted in considerable image quality loss, associated with residual biological material. In order to address this, digital processing using an erosion-dilation method was applied at bead and bed scales to computationally alter the porosity by adding or removing material from the existing surface to calculate the impact upon tortuosity factor. The eroded and dilated bead volumes of agarose, cellulose and ceramic materials were used to simulate diffusivity whilst mimicking internal bead pore constriction and blocking mechanisms

X-ray computed tomography of packed bed chromatography columns for three dimensional imaging and analysis

Physical characteristics critical to chromatography including geometric porosity and tortuosity within the packed column were analysed based upon three dimensional reconstructions of bed structure in-situ. Image acquisition was performed using two X-ray computed tomography systems, with optimisation of column imaging performed for each sample in order to produce three dimensional representations of packed beds at 3μm resolution. Two bead materials, cellulose and ceramic, were studied using the same optimisation strategy but resulted in differing parameters required for X-ray computed tomography image generation. After image reconstruction and processing into a digital three dimensional format, physical characteristics of each packed bed were analysed, including geometric porosity, tortuosity, surface area to volume ratio as well as inter-bead void diameters. Average porosities of 34.0% and 36.1% were found for ceramic and cellulose samples and average tortuosity readings at 1.40 and 1.79 respectively, with greater porosity and reduced tortuosity overall values at the centre compared to the column edges found in each case. X-ray computed tomography is demonstrated to be a viable method for three dimensional imaging of packed bed chromatography systems, enabling geometry based analysis of column axial and radial heterogeneity that is not feasible using traditional techniques for packing quality which provide an ensemble measure

A meta-analytic review of stand-alone interventions to improve body image

Objective Numerous stand-alone interventions to improve body image have been developed. The present review used meta-analysis to estimate the effectiveness of such interventions, and to identify the specific change techniques that lead to improvement in body image. Methods The inclusion criteria were that (a) the intervention was stand-alone (i.e., solely focused on improving body image), (b) a control group was used, (c) participants were randomly assigned to conditions, and (d) at least one pretest and one posttest measure of body image was taken. Effect sizes were meta-analysed and moderator analyses were conducted. A taxonomy of 48 change techniques used in interventions targeted at body image was developed; all interventions were coded using this taxonomy. Results The literature search identified 62 tests of interventions (N = 3,846). Interventions produced a small-to-medium improvement in body image (d+ = 0.38), a small-to-medium reduction in beauty ideal internalisation (d+ = -0.37), and a large reduction in social comparison tendencies (d+ = -0.72). However, the effect size for body image was inflated by bias both within and across studies, and was reliable but of small magnitude once corrections for bias were applied. Effect sizes for the other outcomes were no longer reliable once corrections for bias were applied. Several features of the sample, intervention, and methodology moderated intervention effects. Twelve change techniques were associated with improvements in body image, and three techniques were contra-indicated. Conclusions The findings show that interventions engender only small improvements in body image, and underline the need for large-scale, high-quality trials in this area. The review identifies effective techniques that could be deployed in future interventions