The Challenges of Multimorbidity from the Patient Perspective

BACKGROUND Although multiple co-occurring chronic illnesses within the same individual are increasingly common, few studies have examined the challenges of multimorbidity from the patient perspective. OBJECTIVE The aim of this study is to examine the self-management learning needs and willingness to see non-physician providers of patients with multimorbidity compared to patients with single chronic illnesses. DESIGN. This research is designed as a cross-sectional survey. PARTICIPANTS Based upon ICD-9 codes, patients from a single VHA healthcare system were stratified into multimorbidity clusters or groups with a single chronic illness from the corresponding cluster. Nonproportional sampling was used to randomly select 720 patients. MEASUREMENTS Demographic characteristics, functional status, number of contacts with healthcare providers, components of primary care, self-management learning needs, and willingness to see nonphysician providers. RESULTS Four hundred twenty-two patients returned surveys. A higher percentage of multimorbidity patients compared to single morbidity patients were "definitely" willing to learn all 22 self-management skills, of these only 2 were not significant. Compared to patients with single morbidity, a significantly higher percentage of patients with multimorbidity also reported that they were "definitely" willing to see 6 of 11 non-physician healthcare providers. CONCLUSIONS Self-management learning needs of multimorbidity patients are extensive, and their preferences are consistent with team-based primary care. Alternative methods of providing support and chronic illness care may be needed to meet the needs of these complex patients.US Department of Veterans Affairs (01-110, 02-197); Agency for Healthcare Research and Quality (K08 HS013008-02

Quantifying Implications of Deposit Aging from Crude Refinery Preheat Train Data

Heat exchanger fouling has been studied for some time in the petroleum industry. As understanding of fouling dynamics and mitigation methods improves, refinery fouling mitigation strategies are changing. The implications of deposit aging in refinery units have not been addressed in detail: aging refers to where the deposit undergoes physical and chemical conversion over time. In the 2009 Heat Exchanger Fouling and Cleaning conference, Wilson et al. [Ageing: Looking back and looking forward] presented a simple framework illustrating how deposit aging impacts heat exchanger thermal and hydraulic performance. This paper presents insights into deposit aging gained from analysis of refinery monitoring data. Two case studies are presented: (i) one from the Preem refinery in Sweden where stream temperature, flow and gauge pressure measurements indicated a higher deposit thermal conductivity in exchangers located in the hotter section of the preheat train. (ii) US refinery stream temperature, flow and plant cleaning log data, showing an increased resistance to cleaning when deposits are exposed to high temperature for a prolonged period. The use of deposit aging analysis to improve exchanger operation is discussed.I am a co-author on this paper. The work reported was undertaken for a Swedish company by another company, HTRI.I advised on the results

Study protocol to investigate the effects of testosterone therapy as an adjunct to exercise rehabilitation in hypogonadal males with chronic heart failure

BACKGROUND: Testosterone deficiency is a common occurrence in men with chronic heart failure (CHF) and may underpin features of advanced disease, including reduced skeletal muscle mass and fatigue. It is positively correlated with cardiac output and exercise capacity in patients with CHF, whereas a significant improvement in both these parameters has been observed following testosterone replacement therapy. Testosterone therapy has also been shown to reduce circulating levels of inflammatory markers, (TNF-α, sICAM-1 and sVCAM-1) in patients with established coronary artery disease and testosterone deficiency. This pilot study will assess the feasibility of a combined exercise rehabilitation and adjunctive testosterone therapy intervention for evoking improvements in exercise capacity, circulating inflammatory markers, cardiac and skeletal muscle function, indices of psychological health status and quality of life in hypogonadal males with chronic heart failure. METHODS/DESIGN: Following ethical approval, 36 patients will be randomly allocated to one of two groups: testosterone or placebo therapy during exercise rehabilitation. A combined programme of moderate intensity aerobic exercise and resistance (strength) training will be used. The primary outcome measure is exercise capacity, assessed using an incremental shuttle walk test. Secondary outcome measures include measures of peak oxygen uptake, cardiac function, lower-limb skeletal muscle contractile function and oxygenation during exercise, circulating inflammatory markers, psychological health status and quality of life. DISCUSSION: Exercise rehabilitation can safely increase exercise capacity in stable CHF patients but there is a need for studies which are aimed at evaluating the long-term effects of physical training on functional status, morbidity and mortality. This pilot study will provide valuable preliminary data on the efficacy of testosterone therapy as an adjunct to exercise rehabilitation on a range of functional, physiological and health-related outcomes in this patient population. Preliminary data will be used in the design of a large-scale randomised controlled trial, aimed at informing clinical practice with respect to optimisation of exercise rehabilitation in this patient group

Marital interaction theory: some implications for research

This project examines specific basic areas of marital interaction theory. Individual chapters are developed around the following themes: historical development of the theory of interaction; a theoretical discussion of selected concepts; personality as a determinant of interaction; communication in marriage; marital interaction patterns; methodology pertaining to research findings; and finally some implications for research which became apparent as this project developed. The project lays the conceptual groundwork for a series of empirical studies that will use the interactional approach as a theoretical base. The immediate purpose of this project therefore is to describe the important dimensions of the interactional approach as these pertain to marital interaction. Interaction is defined as a reciprocal relationship in which each person may produce effects upon the other. Here the essence of marriage is interaction; thus marital interaction is critical in its effect on the spouses and the continuity of the marriage. Some of the basic concepts of George Mead are described and it is suggested that they are essential elements of the interactional approach. The major assumptions of this approach are that a) human behavior cannot be derived or inferred from nonhuman forms, b) the social act is the primary analytic unit for an understanding of society and the personality, c) the human infant is potentially social, and d) the human being is actor as well as reactor. Personality is discussed as a determinant of the quality and quantity of marital interaction. The issue of personal competence is explored, particularly in respect to verbal ability. Communication, the process of influence, is defined for marital interaction and the consequent formation of patterns. Identification and classification of marital interaction patterns are limited to a description of selected examples from family research and the observations of clinicians. Patterns tend to be defined in psychological terms although communicative behavior is stressed. The absence of common criteria and terminology is noted. Description of dysfunctional patterns predominates. Two methods frequently used in recent studies of marital interaction are direct observation and analysis of reports from marital partners. It is suggested that a combination of these techniques could increase the quantity of information about marital interaction. Research questions focus on the problem of adult socialization, its implications for the establishment of marital interaction patterns, and the need to determine the relation between the interaction process and the functional or dysfunctional quality of the resultant pattern. An inseparable part of the aforementioned research areas is the function of communication. It is suggested that investigation of verbal communication might yield significant data for the understanding of the interaction process as it affects the personalities of the spouses and the formation of patterns

Integrated Clinical-Molecular Classification of Colorectal Liver Metastases: A Biomarker Analysis of the Phase 3 New EPOC Randomized Clinical Trial

IMPORTANCE: Personalized treatment approaches for patients with oligometastatic colorectal liver metastases are critically needed. We previously defined 3 biologically distinct molecular subtypes of colorectal liver metastases: (1) canonical, (2) immune, and (3) stromal. OBJECTIVE: To independently validate these molecular subtypes in the phase 3 New EPOC randomized clinical trial. DESIGN, SETTING, AND PARTICIPANTS: This retrospective secondary analysis of the phase 3 New EPOC randomized clinical trial included a bi-institutional discovery cohort and multi-institutional validation cohort. The discovery cohort comprised patients who underwent hepatic resection for limited colorectal liver metastases (98% received perioperative chemotherapy) from May 31, 1994, to August 14, 2012. The validation cohort comprised patients who underwent hepatic resection for liver metastases with perioperative chemotherapy (fluorouracil, oxaliplatin, and irinotecan based) with or without cetuximab from February 26, 2007, to November 1, 2012. Data were analyzed from January 18 to December 10, 2021. INTERVENTIONS: Resected metastases underwent RNA sequencing and microRNA (miRNA) profiling in the discovery cohort and messenger RNA and miRNA profiling with microarray in the validation cohort. MAIN OUTCOMES AND MEASURES: A 31-feature (24 messenger RNAs and 7 miRNAs) neural network classifier was trained to predict molecular subtypes in the discovery cohort and applied to the validation cohort. Integrated clinical-molecular risk groups were designated based on molecular subtypes and the clinical risk score. The unique biological phenotype of each molecular subtype was validated using gene set enrichment analyses and immune deconvolution. The primary clinical end points were progression-free survival (PFS) and overall survival (OS). RESULTS: A total of 240 patients were included (mean [range] age, 63.0 [56.3-68.0] years; 151 [63%] male), with 93 in the discovery cohort and 147 in the validation cohort. In the validation cohort, 73 (50%), 28 (19%), and 46 (31%) patients were classified as having canonical, immune, and stromal metastases, respectively. The biological phenotype of each subtype was concordant with the discovery cohort. The immune subtype (best prognosis) demonstrated 5-year PFS of 43% (95% CI, 25%-60%; hazard ratio [HR], 0.37; 95% CI, 0.20-0.68) and OS of 63% (95% CI, 40%-79%; HR, 0.38; 95% CI, 0.17-0.86), which was statistically significantly higher than the canonical subtype (worst prognosis) at 14% (95% CI, 7%-23%) and 43% (95% CI, 32%-55%), respectively. Adding molecular subtypes to the clinical risk score improved prediction (the Gönen and Heller K for discrimination) from 0.55 (95% CI, 0.49-0.61) to 0.62 (95% CI, 0.57-0.67) for PFS and 0.59 (95% CI, 0.52-0.66) to 0.63 (95% CI, 0.56-0.70) for OS. The low-risk integrated group demonstrated 5-year PFS of 44% (95% CI, 20%-66%; HR, 0.38; 95% CI, 0.19-0.76) and OS of 78% (95% CI, 44%-93%; HR, 0.26; 95% CI, 0.08-0.84), superior to the high-risk group at 16% (95% CI, 10%-24%) and 43% (95% CI, 32%-52%), respectively. CONCLUSIONS AND RELEVANCE: In this prognostic study, biologically derived colorectal liver metastasis molecular subtypes and integrated clinical-molecular risk groups were highly prognostic. This novel molecular classification warrants further study as a possible predictive biomarker for personalized systemic treatment for colorectal liver metastases. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN22944367

Effect of vessel wettability on the foamability of "ideal" surfactants and "real-world" beer heads

The ability to tailor the foaming properties of a solution by controlling its chemical composition is highly desirable and has been the subject of extensive research driven by a range of applications. However, the control of foams by varying the wettability of the foaming vessel has been less widely reported. This work investigates the effect of the wettability of the side walls of vessels used for the in situ generation of foam by shaking aqueous solutions of three different types of model surfactant systems (non-ionic, anionic and cationic surfactants) along with four different beers (Guinness Original, Banks’s Bitter, Bass No 1 and Harvest Pale). We found that hydrophilic vials increased the foamability only for the three model systems but increased foam stability for all foams except the model cationic system. We then compared stability of beer foams produced by shaking and pouring and demonstrated weak qualitative agreement between both foam methods. We also showed how wettability of the glass controls bubble nucleation for beers and champagne and used this effect to control exactly where bubbles form using simple wettability patterns

Patterns of primary care and mortality among patients with schizophrenia or diabetes: a cluster analysis approach to the retrospective study of healthcare utilization

Abstract Background Patients with schizophrenia have difficulty managing their medical healthcare needs, possibly resulting in delayed treatment and poor outcomes. We analyzed whether patients reduced primary care use over time, differentially by diagnosis with schizophrenia, diabetes, or both schizophrenia and diabetes. We also assessed whether such patterns of primary care use were a significant predictor of mortality over a 4-year period. Methods The Veterans Healthcare Administration (VA) is the largest integrated healthcare system in the United States. Administrative extracts of the VA's all-electronic medical records were studied. Patients over age 50 and diagnosed with schizophrenia in 2002 were age-matched 1:4 to diabetes patients. All patients were followed through 2005. Cluster analysis explored trajectories of primary care use. Proportional hazards regression modelled the impact of these primary care utilization trajectories on survival, controlling for demographic and clinical covariates. Results Patients comprised three diagnostic groups: diabetes only (n = 188,332), schizophrenia only (n = 40,109), and schizophrenia with diabetes (Scz-DM, n = 13,025). Cluster analysis revealed four distinct trajectories of primary care use: consistent over time, increasing over time, high and decreasing, low and decreasing. Patients with schizophrenia only were likely to have low-decreasing use (73% schizophrenia-only vs 54% Scz-DM vs 52% diabetes). Increasing use was least common among schizophrenia patients (4% vs 8% Scz-DM vs 7% diabetes) and was associated with improved survival. Low-decreasing primary care, compared to consistent use, was associated with shorter survival controlling for demographics and case-mix. The observational study was limited by reliance on administrative data. Conclusion Regular primary care and high levels of primary care were associated with better survival for patients with chronic illness, whether psychiatric or medical. For schizophrenia patients, with or without comorbid diabetes, primary care offers a survival benefit, suggesting that innovations in treatment retention targeting at-risk groups can offer significant promise of improving outcomes.http://deepblue.lib.umich.edu/bitstream/2027.42/78274/1/1472-6963-9-127.xmlhttp://deepblue.lib.umich.edu/bitstream/2027.42/78274/2/1472-6963-9-127.pdfPeer Reviewe

Analisis Pemetaan dan Pengembangan Potensi Komoditas Tanaman Obat di Kabupaten Pacitan

: This aims of this study are determining the commodity of medicinal plants base and non-base in Pacitan Regency with LQ (Location Quotient) analysis and formulating alternative and priorities development strategies of medicinal plants base commodity in Pacitan Regency with AHP (Analytical Hierarchy Process) analysis. Location were selected in Pacitan Regency as one potential area ofmedicinal plants commodity development. This study was using descriptive method. The data collections were using primary and secondary data. The data were analyzed by LQ and AHP. The study shown that medicinal plants commodity with value of LQ base for 3 consecutive years in 2011-2013 amounted to 1,545; 1,329 and 1,099 in Pacitan Regency is ginger commodity. AHP analysis formulating alternative and priorities development strategies of ginger commodity in Pacitan Regency through five criteria: production, capital, technology, price and market linkages. Alternative and priorities development strategies of ginger commodity in Pacitan Regency are 1) procuring and improving of capital aid that right on target and support appropriate technologies with a priority value of 0,33; 2) increasing availability of adequate market information with a priority value of 0,27;3) increasing ginger commodity processing skills and expanding market of ginger products processed with a priority value of 0,22; 4) improving quality of ginger harvest through the seeds certification process that evenly distributed throughout ginger producers region with a priority value of 0,20

Polynomial diffeomorphisms of C^2, IV: The measure of maximal entropy and laminar currents

This paper concerns the dynamics of polynomial automorphisms of ${\bf C}^2$. One can associate to such an automorphism two currents $\mu^\pm$ and the equilibrium measure $\mu=\mu^+\wedge\mu^-$. In this paper we study some geometric and dynamical properties of these objects. First, we characterize $\mu$ as the unique measure of maximal entropy. Then we show that the measure $\mu$ has a local product structure and that the currents $\mu^\pm$ have a laminar structure. This allows us to deduce information about periodic points and heteroclinic intersections. For example, we prove that the support of $\mu$ coincides with the closure of the set of saddle points. The methods used combine the pluripotential theory with the theory of non-uniformly hyperbolic dynamical systems

A Comprehensive Resource for Induced Pluripotent Stem Cells from Patients with Primary Tauopathies.

Primary tauopathies are characterized neuropathologically by inclusions containing abnormal forms of the microtubule-associated protein tau (MAPT) and clinically by diverse neuropsychiatric, cognitive, and motor impairments. Autosomal dominant mutations in the MAPT gene cause heterogeneous forms of frontotemporal lobar degeneration with tauopathy (FTLD-Tau). Common and rare variants in the MAPT gene increase the risk for sporadic FTLD-Tau, including progressive supranuclear palsy (PSP) and corticobasal degeneration (CBD). We generated a collection of fibroblasts from 140 MAPT mutation/risk variant carriers, PSP, CBD, and cognitively normal controls; 31 induced pluripotent stem cell (iPSC) lines from MAPT mutation carriers, non-carrier family members, and autopsy-confirmed PSP patients; 33 genome engineered iPSCs that were corrected or mutagenized; and forebrain neural progenitor cells (NPCs). Here, we present a resource of fibroblasts, iPSCs, and NPCs with comprehensive clinical histories that can be accessed by the scientific community for disease modeling and development of novel therapeutics for tauopathies