Stroke Reduction in Elderly Patients With Atrial Fibrillation Through Utilization of an Anticoagulation Toolkit in the Primary Care Setting

Patients, especially those older than 65-years-old, do not receive adequate assessment or management of atrial fibrillation, resulting in higher ischemic stroke rates and worse outcomes related to strokes. Oral anticoagulation is recommended indefinitely for patients with atrial fibrillation and a moderate to high risk of stroke; yet this population is not receiving oral anticoagulation consistently. Factors such as overexaggerated bleeding risk in the elderly, the lack of head-to-head studies comparing anticoagulants, cost, patient compliance, safety, lab monitoring, and reversal agents convolute the process of prescribing anticoagulation for atrial fibrillation. Variations exist with assessing bleeding risk and stroke risk for every patient through reliable tools such as HAS-BLED and CHA2DS2-VASc scores, respectively, and translating these scores into practice. Due to these inconsistencies and the lack of a comprehensive, universal guideline for assessment and management of atrial fibrillation, this topic was selected for a capstone project. A retrospective chart review was completed on 100 patients to assess the current practice of diagnosing atrial fibrillation and treating with anticoagulation in the primary care setting. Through utilization of two rounds of the Delphi method, expert opinion, and the recommendations of national and international guidelines, an evidence-based anticoagulation toolkit was created and modified to guide primary care providers on improving diagnosis of atrial fibrillation and enhanced initiation and maintenance of oral anticoagulation to reduce the incidence of stroke in elderly patients with atrial fibrillation. The Anticoagulation for Atrial Fibrillation Toolkit is a four-step, simplified guideline to guide providers on improved diagnosis and treatment of AF; it is supported by four algorithms: CHA2DS-VASc score, HAS-BLED score, comparison of anticoagulants, and patient specific factors influencing selection of anticoagulant. Additionally, this toolkit offers in one document a summary of additional information and resources for providers to improve the overall management of atrial fibrillation. The chart reviews demonstrated gaps between evidence and practice, predominantly a lack of utilization of CHA2DS2 VASc and HAS-BLED scores to assess for stroke and bleeding risk, respectively, in patients with atrial fibrillation, poor continued monitoring of AF in the primary care setting, a disconnect between the treatment plan and providers, and the absence of consistently diagnosing an irregular pulse as AF through an EKG. Round 1 of the Delphi survey assessed providers’ comfort level and expertise with prescribing anticoagulants and diagnosing and managing AF and Round 2 evaluated the anticoagulation toolkit and how its incorporation could influence practice. Results from Round 1 were utilized to revise the evidence-based anticoagulation toolkit; data analysis concluded 70% consensus was achieved on at least 6 of the 10 questions. Even without 70% consensus, the researcher incorporated provider expertise, suggestions, and requests into the anticoagulation toolkit. In Round 2, data analysis of greater than 70% consensus suggested the Anticoagulation for Atrial Fibrillation Toolkit was evidence based, user-friendly, promoted safety and efficacy of anticoagulation, and could positively impact practice; however, the toolkit was too extensive and lengthy. A thorough evaluation concluded this capstone project successfully addressed the following problem statement: In adult patients with atrial fibrillation older than 65 years old and a moderate to high risk of stroke, how effective is an anticoagulation toolkit in guiding primary care providers on (a) diagnosing atrial fibrillation and (b) initiating and maintaining oral anticoagulation safely, to reduce the incidence of ischemic stroke? The comprehensive literature review not only provided extensive background information on atrial fibrillation and anticoagulation but also highlighted key references to first compare evidence to practice (analyze patient chart reviews) and then utilize these identified gaps to translate evidence into practice (create the anticoagulation toolkit). Furthermore, the PARIHS framework and RE-AIM model evaluated the ability to effectively facilitate the results from this research project into practice. Additionally, this capstone project met all five criteria of the EC as PIE model, concluding this was a successful Doctor of Nursing Practice capstone project. A future extension of this project suggests evaluation of patient outcomes with AF, predominantly stroke incidence, subsequent to implementation of this toolkit in the primary care setting

Modeling Subdiffusion Using Reaction Diffusion Systems

In many types of media, and in particular within living cells or within their membranes, diffusing species do not follow Fick's laws, but instead show transient subdiffusive behavior. Formulating spatiotemporal models that take this behavior into account is a delicate matter, as one is faced with the choice of resorting either to fractional calculus or to microscopic descriptions. In this article, we provide an alternative designed to be easier to tackle analytically and numerically than the existing approaches. Specifically, starting from the Continuous Time Random Walk model, we construct linear reaction diffusion systems that can be used as components within such a model, and which capture the defining properties of subdiffusion. We show how to impose physically relevant parameters, and prove stability and mass conservation. While applications to cellular biology are our main motivation, our approach is abstract, and should thus be applicable to any situation where anomalous subdiffusion is observed

A new fictitious domain method in shape optimization

The present paper is concerned with investigating the capability of the smoothness preserving fictitious domain method from [22] to shape optimization problems. We consider the problem of maximizing the Dirichlet energy functional in the class of all simply connected domains with fixed volume, where the state equation involves an elliptic second order differential operator with non-constant coefficients. Numerical experiments in two dimensions validate that we arrive at a fast and robust algorithm for the solution of the considered class of problems. The proposed method keeps applicable for three dimensional shape optimization problems

Formaldehyde-free curing of cotton cellulose fabrics in anhydrous media

The effect of formaldehyde-free curing on standard cotton cellulose fabrics in anhydrous media is studied. Different crosslinkers are applied via (1) a pad-cure-dry process (solid/liquid) and (2) in a vapor chamber (solid/gas). The performance of each crosslinker and set of conditions is assessed by measuring dry crease recovery angles, DCRAs. We find that in control samples (treatment without crosslinker) the DCRAs are altered depending on the solvent. Using DMF, carbonyldiimidazole shows the best DCRA (160.1°, 15° higher than the non-treated fabrics). In ethyl acetate, triglycidyl isocyanurate shows the highest DCRA (22° higher than the control). The most promising crosslinkers are applied with selected catalysts known from literature. Here, trigycidyl isocyanurate in combination with the superbase P4-t-Bu gives the best DCRA (35° higher than the control). Using the vapor-chemical finishing, divinylsulfone as crosslinker increases the DCRA to 162.7° (18° higher than non-treated fabrics). Hence, cotton cellulose fabrics can be successfully finished in anhydrous conditions. © 2019 The Authors. Journal of Applied Polymer Science published by Wiley Periodicals, Inc. J. Appl. Polym. Sci. 2020, 137, 48371. © 2019 The Authors. Journal of Applied Polymer Science published by Wiley Periodicals, Inc

Investigating the effectiveness of different forms of mineral resources governance in meeting the objectives of the UK petroleum fiscal regime

After 40 years of oil investments, the UK is now a mature oil province. During these 40 years or so, the UK Government has changed the type of governance it uses to manage its petroleum resources. This paper introduces the theoretical background to two models of mineral resource governance: the so-called proprietorial and nonproprietorial regimes. It investigates the adoption of these two models by the UK Government and their effect on the overall tax take from the UK`s petroleum resources. The analysis tracks the changes in the UK petroleum taxation system since establishment up until 2010. It assesses how these tax changes have affected the overall petroleum average tax rate (ATR). The study concludes that the UK Government adopted a proprietorial type of mineral governance during the period 1975-1982, before changing to a non-proprietorial regime in the period 1983-2000. Since 2000 it has begun to move back towards a proprietorial style of governance. This change is still in its early stages, however; the evidence shows that although there has been an increase in fiscal revenues, this increase has been small

Anion-induced reversible actuation of squaramide-crosslinked polymer gels

NWOSupramolecular & Biomaterials Chemistr