Electronic Health Record-Triggered Research Infrastructure Combining Real-world Electronic Health Record Data and Patient-Reported Outcomes to Detect Benefits, Risks, and Impact of Medication:Development Study

BACKGROUND: Real-world data from electronic health records (EHRs) represent a wealth of information for studying the benefits and risks of medical treatment. However, they are limited in scope and should be complemented by information from the patient perspective. OBJECTIVE: The aim of this study is to develop an innovative research infrastructure that combines information from EHRs with patient experiences reported in questionnaires to monitor the risks and benefits of medical treatment. METHODS: We focused on the treatment of overactive bladder (OAB) in general practice as a use case. To develop the Benefit, Risk, and Impact of Medication Monitor (BRIMM) infrastructure, we first performed a requirement analysis. BRIMM’s starting point is routinely recorded general practice EHR data that are sent to the Dutch Nivel Primary Care Database weekly. Patients with OAB were flagged weekly on the basis of diagnoses and prescriptions. They were invited subsequently for participation by their general practitioner (GP), via a trusted third party. Patients received a series of questionnaires on disease status, pharmacological and nonpharmacological treatments, adverse drug reactions, drug adherence, and quality of life. The questionnaires and a dedicated feedback portal were developed in collaboration with a patient association for pelvic-related diseases, Bekkenbodem4All. Participating patients and GPs received feedback. An expert meeting was organized to assess the strengths, weaknesses, opportunities, and threats of the new research infrastructure. RESULTS: The BRIMM infrastructure was developed and implemented. In the Nivel Primary Care Database, 2933 patients with OAB from 27 general practices were flagged. GPs selected 1636 (55.78%) patients who were eligible for the study, of whom 295 (18.0% of eligible patients) completed the first questionnaire. A total of 288 (97.6%) patients consented to the linkage of their questionnaire data with their EHR data. According to experts, the strengths of the infrastructure were the linkage of patient-reported outcomes with EHR data, comparison of pharmacological and nonpharmacological treatments, flexibility of the infrastructure, and low registration burden for GPs. Methodological weaknesses, such as susceptibility to bias, patient selection, and low participation rates among GPs and patients, were seen as weaknesses and threats. Opportunities represent usefulness for policy makers and health professionals, conditional approval of medication, data linkage to other data sources, and feedback to patients. CONCLUSIONS: The BRIMM research infrastructure has the potential to assess the benefits and safety of (medical) treatment in real-life situations using a unique combination of EHRs and patient-reported outcomes. As patient involvement is an important aspect of the treatment process, generating knowledge from clinical and patient perspectives is valuable for health care providers, patients, and policy makers. The developed methodology can easily be applied to other treatments and health problems

Pharmacist-Led Self-management Interventions to Improve Diabetes Outcomes:A Systematic Literature Review and Meta-Analysis

Background: Treatment of diabetes requires a strict treatment scheme which demands patient self-management. Pharmacists are in a good position to provide self-management support. This review examines whether pharmacist-led interventions to support self-management in diabetes patients improve clinical and patient-reported outcomes.Methods: This review was conducted according to the PRISMA guidelines. An extended literature search was conducted with the keywords “pharmacist,” “diabetes,” and “self-management” using the electronic databases Pubmed, Embase, CINAHL, PsycINFO, Web of Science, and the Cochrane Library from the beginning of the database through September 2017. In addition reference lists of systematic reviews and included studies were searched. Eligibility criteria included; self-management intervention tested with an RCT, performed in an ambulatory care setting, led by a pharmacist and reporting at least one clinical- or patient-reported outcome. Primary outcomes were HbA1c (—as this is a clinical parameter for long-term diabetes follow-up), self-management and components of intervention. Secondary outcomes were blood glucose, blood pressure, BMI, lipids, adherence to medication, quality of life, and diabetes knowledge. For the meta-analysis HbA1c values were pooled with a random-effects model in Revman 5.3. Risk of bias was assessed with the Cochrane Risk of Bias tool.Results: Twenty-four studies representing 3,610 patients were included. Pharmacist-led self-management interventions included education on diabetes complications, medication, lifestyle, and teaching of self-management skills. Some studies focused on patient needs through a tailored intervention. No key components for a successful self-management intervention could be identified. Pharmacist-led self-management interventions improve HbA1c levels with a mean of 0.71% (CI −0.91, −0.51; overall effect P < 0.0001) and had a positive effect on blood pressure (SBP −5.20 mm Hg [−7.58; −2.92], DBP −3.51 mmHg [−6.00; −1.01]), BMI (−0.49 kg/m2 [−0.79; −0.19]), lipids (total cholesterol −0.19 mmol/l [−0.33; −0.05], LDL-C mmol/l −0.16 [−0.26; −0.06], HDL-C 0.32 mmol/l [0.02; 0.61]), self-management skill development, and adherence to medication.Conclusion: Pharmacist-led self-management interventions significantly improve HbA1c values in diabetes patients. These results underline the added value of pharmacists in patient-related care. Pharmacists should offer self-management support to diabetes patients in order to improve diabetes outcomes

Scalability of effective adherence interventions for patients using cardiovascular disease medication:A realist synthesis-inspired systematic review

Upscaling of medication adherence interventions to routine care is still challenging. This realist theory-inspired review aimed to assess which intervention aspects are potentially important for the scalability of effective cardiovascular disease (CVD) medication adherence interventions and how they are reported in effectiveness studies. A total of 4097 articles from four databases were screened of which ultimately 31 studies were included. Relevant information on scalability was extracted using a theoretic framework based on the scalability assessment tool used in the QUALIDEC study for the following domains: (i) innovation, (ii) implementers and patients, (iii) adopting organizations and health system, and (iv) socio-political context. Extracted articles were analysed for themes and chains of inference, which were grouped based on commonality and source of evidence to form new hypotheses. Six different domains relevant for scalability of adherence interventions were identified: (1) Complexity of the intervention; (2) training; (3) customization of the intervention; (4) drivers of the intervention; (5) technical interventions; and (6) stakeholder involvement. These six domains might be useful for the development of more scalable interventions by bridging the gap between research and practice. Data relevant for scalability is not well reported on in effectiveness trials for CVD medication adherence interventions and only limited data on scalability has been published in additional papers. We believe the adoption and reach of effective CVD medication adherence interventions will improve with increased awareness for the necessity of scalability in all phases of intervention development

Determinants of delay in the head and neck oncology care pathway:The next step in value-based health care

Objective Head and neck squamous cell carcinomas (HNSCC) are relatively fast-growing tumours, and delay of treatment is associated with tumour progression and adverse outcomes. The aim of this study is to identify determinants of delay in a head and neck oncology centre. Methods This cohort study with prospectively collected data investigated associations between patient (including geriatric assessment at first consultation), tumour and treatment characteristics and treatment delay. Two quality indicator intervals assessing value-based healthcare were studied: care pathway interval (CPI, interval between first visit in an HNOC and treatment initiation) and time-to-treatment initiation (TTI, interval between histopathological confirmation of HNSCC and treatment initiation), using regression analyses. Results Stage-IV tumours and initial radiotherapy were independent predictors of delay in CPI. Initial radiotherapy was associated with delay in TTI. Overall, 37% of the patients started treatment within 30 days after first consultation (67% in case of initial surgical treatment and 11.5% if treated with (chemo)radiation, p <0.001). Geriatric assessment outcomes were not associated with delay. Indicators for delay in initial surgery patients were stage-IV tumours (CPI). Conclusion The majority of HNSCC patients encounter delay in treatment initiation, specifically in patients with advanced-stage tumours or when radiotherapy is indicated

Схема когенерации с размещением противодавленческой и гидропаровой турбин на общем валу с газопоршневой установкой

Показана перспективність використання когенераційних технологій для підвищення рентабельності вугільних підприємств. Розглянуто схему з розміщенням турбіни з противотиском і гідропарової турбіни на одному валу з газопоршневою установкою. Використання даної схеми для утилізації надлишкового тепла шахтних енергокомплексів дозволить отримати коефіцієнт корисної дії 64 % та зменшити витрати палива.In this paper the perspective use of cogeneration technology enhance the profitability of coal enterprises was discussed. The scheme with setting back-pressures and steam-water turbines on one shaft of gas engine was considered. Using this scheme for utilization of surplus heat mine energy complexes will provide efficiency of 64% and reduce fuel

Влияние механической активации гидрида титана на его взаимодействие с азотом и кислородом

Показано, что размол гидрида титана в планетарной мельнице приводит к повышению удельной поверхности порошка, росту микроискажений кристаллической решетки, уменьшению содержания в нем водорода и повышению химической активности, что позволяет получать нитрид титана из него в среде азота уже при температуре 500 °С. За счет кислорода, адсорбирован ного механически активированным порошком при нагревании в атмосфере азота, происходят реакции окисления атомов титана, в результате чего образуется низший оксид Tі2О.Показано, що подрібнення гідриду титану в планетарному млині приводить до підвищення питомої поверхні порошку, зростанню дефектів кристалічної ґратки, зменшенню вмісту в ній водню і підвищенню хімічної активності. Це дає змогу досягти повного перетворення механічно активованого гідриду в нітрид титану вже за температури 500 °С і витримці упродовж однієї години в середовищі азоту. За рахунок кисню, адсорбованого механічно активованим порошком при нагрівання в атмосфері азоту, проходять реакції окиснення, в результаті чого утворюється нижчий оксид Ti2O.Milling of titanium hydride in planetary mill is shoun to increase the speci surface area of powder, to decrease the hydrogen content in it and to intensity chemical activity. This makesit possible to obtain titanium nitride from the titanium hydride in a nitrogen atmosphere at as low temperature as 500 °C . Thanks to the presence of oxygen adsorbed by mechanically activated powder under heating in a nitrogen atmosphere? Reaction of intramolecular oxidation -reduction, of titanium takes place, which results in forming the lower oxide Ti2O

Bioelectrical Impedance Analysis and Mid-Upper Arm Muscle Circumference Can Be Used to Detect Low Muscle Mass in Clinical Practice

Identification of low muscle mass becomes increasingly relevant due to its prognostic value in cancer patients. In clinical practice, mid-upper arm muscle circumference (MAMC) and bioelectrical impedance analysis (BIA) are often used to assess muscle mass. For muscle-mass assessment, computed tomography (CT) is considered as reference standard. We investigated concordance between CT, BIA, and MAMC, diagnostic accuracy of MAMC, and BIA to detect low muscle mass and their relation with the clinical outcome malnutrition provided with the Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF). This cross-sectional study included adult patients with advanced esophageal and gastrointestinal cancer. BIA, MAMC, and PG-SGA-SF were performed. Routine CT-scans were used to quantify psoas muscle index (PMI) and skeletal muscle area. Good concordance was found between CT(PMI) and both BIA(FFMI (fat free mass index)) (ICC 0.73), and BIA(ASMI (appendicular skeletal muscle index)) (ICC 0.69) but not with MAMC (ICC 0.37). BIA(FFMI) (94%), BIA(ASMI) (86%), and MAMC (86%) showed high specificity but low sensitivity. PG-SGA-SF modestly correlated with all muscle-mass measures (ranging from −0.17 to −0.43). Of all patients with low muscle mass, 62% were also classified with a PG-SGA-SF score of ≥4 points. Although CT remains the first choice, since both BIA and MAMC are easy to perform by dieticians, they have the potential to be used to detect low muscle mass in clinical practice

Screening av nye PFAS-stoffer 2018

This screening project has focused on the occurrence of conventional andemerging PFASs in terrestrial and marine environments, including the Arctic. Conventional PFASs were found to be wide-spread in the environment and for the first time in Norway reported in wolf, a top predator from the terrestrial environment.Otters living in close proximity to human settlements and preying on the marine food chain,are heavily contaminated with PFASs. Areas where ski-testing activitiesare common are a potential “hotspot” where PFASs can enter the food chain. The difference in PFAS-profile between the samples indicatesthat the diversity in samples are necessary to reveal the complete picture of PFASs in the environment