The prehospital patient pathway and experience of care with acute heart failure: a comparison of two health care systems

Aims This study aimed to analyse community management of patients during the symptomatic period prior to admission with acute decompensated heart failure (ADHF). Methods and results We conducted a prospective, two-centre, two-country observational study evaluating care pathways and patient experience in patients admitted to hospital with ADHF. Quantitative and qualitative data were gathered from patients, carers, and general practitioners (GPs). From the Irish centre, 114 patients enrolled, and from the English centre, 50 patients. Symptom duration longer than 72 h prior to hospitalization was noted among 70.4% (76) Irish and 80% (40) English patients, with no significant difference between those with a new diagnosis of HF [de novo HF (dnHF)] and those with known HF [established HF (eHF)] in either cohort. For the majority, dyspnoea was the dominant symptom; however, 63.3% (31) of these Irish patients and 47.2% (17) of these English patients did not recognize this as an HF symptom, with no significant difference between dnHF and eHF patients. Of the 46.5% (53) of Irish and 38% (19) of English patients reviewed exclusively by GPs before hospitalization, numbers prescribed diuretics were low (11.3%, six; and 15.8%, three, respectively); eHF patients were no more likely to receive diuretics than dnHF patients. Barriers to care highlighted by GPs included inadequate access to basic diagnostics, specialist support and up-to-date patient information, and lack of GP comfort in managing HF. Conclusion The aforementioned findings, consistent across both health care jurisdictions, show a clear potential to intervene earlier and more effectively in ADHF or to prevent the need for hospitalization

Analyse multidimensionnelle interactive de résultats de simulation (aide à la décision dans le domaine de l'agroécologie)

Dans cette thèse, nous nous sommes intéressés à l'analyse des données de simulation issues du modèle agro-hydrologique TNT. Les objectifs consistaient à élaborer des méthodes d'analyse des résultats de simulation qui replacent l'utilisateur au coeur du processus décisionnel, et qui permettent d'analyser et d'interpréter de gros volumes de données de manière efficace. La démarche développée consiste à utiliser des méthodes d'analyse multidimensionnelle interactive. Tout d'abord, nous avons proposé une méthode d'archivage des résultats de simulation dans une base de données décisionnelle (i.e. entrepôt de données), adaptée au caractère spatio-temporel des données de simulation produites. Ensuite, nous avons suggéré d'analyser ces données de simulations avec des méthodes d'analyse en ligne (OLAP) afin de fournir aux acteurs des informations stratégiques pour améliorer le processus d'aide à la prise de décision. Enfin, nous avons proposé deux méthodes d'extraction de skyline dans le contexte des entrepôts de données afin de permettre aux acteurs de formuler de nouvelles questions en combinant des critères environnementaux contradictoires, et de trouver les solutions compromis associées à leurs attentes, puis d'exploiter les préférences des acteurs pour détecter et faire ressortir les données susceptibles de les intéresser. La première méthode EC2Sky, permet un calcul incrémental et efficace des skyline en présence de préférences utilisateurs dynamiques, et ce malgré de gros volumes de données. La deuxième méthode HSky, étend la recherche des points skyline aux dimensions hiérarchiques. Elle permet aux utilisateurs de naviguer le long des axes des dimensions hiérarchiques (i.e. spécialisation / généralisation) tout en assurant un calcul en ligne des points skyline correspondants. Ces contributions ont été motivées et expérimentées par l'application de gestion des pratiques agricoles pour l'amélioration de la qualité des eaux des bassins versants agricoles, et nous avons proposé un couplage entre le modèle d'entrepôt de données agro-hydrologiques construit et les méthodes d'extraction de skyline proposées.This thesis concerns the analysis of simulation data generated by the agrohydrological model TNT. Our objective is to develop analytical methods for massive simulation results. We want to place the user at the heart of the decision-making process, while letting him handle and analyze large amounts of data in a very efficient way. Our first contribution is an original approach N-Catch, relying on interactive multidimensional analysis methods for archiving simulation results in a decisional database (i.e. data warehouse) adapted to the spatio-temporal nature of the simulation data. In addition, we suggest to analyze the simulation data with online analytical methods (OLAP) to provide strategic information for stakeholders to improve the decision making process. Our second contribution concern two methods for computing skyline queries in the context of data warehouses. These methods enable stakeholders to formulate new questions by combining conflicting environmental criteria, to find compromise solutions associated with their expectations, and to exploit the stakeholder preferences to identify and highlight the data of potential interest. The first method EC2Sky, focuses on how to answer efficiently and progressively skyline queries in the presence of several dynamic user preferences despite of large volume of data. The second method HSky, extends the skyline computation to hierarchical dimensions. It allows the user to navigate along the dimensions hierarchies (i.e. specialize / generalize) while ensuring the online computation of associated skylines. Finally, we present the application of our proposals for managing agricultural practices to improve water quality in agricultural watersheds. We propose a coupling between the agro-hydrological data warehouse model N-Catch and the proposed skyline computation methods.RENNES1-Bibl. électronique (352382106) / SudocSudocFranceF

Seasonal prediction skill of winter temperature over North India

This document is the Accepted Manuscript version of the following article: Tiwari, P.R., Kar, S.C., Mohanty, U.C. et al. Theor Appl Climatol (2016) 124: 15. The final publication is available at Springer via https://doi.org/10.1007/s00704-015-1397-y. © Springer-Verlag Wien 2015.The climatology, amplitude error, phase error, and mean square skill score (MSSS) of temperature predictions from five different state-of-the-art general circulation models (GCMs) have been examined for the winter (December–January– February) seasons over North India. In this region, temperature variability affects the phenological development processes of wheat crops and the grain yield. The GCM forecasts of temperature for a whole season issued in November from various organizations are compared with observed gridded temperature data obtained from the India Meteorological Department (IMD) for the period 1982–2009. The MSSS indicates that the models have skills of varying degrees. Predictions of maximum and minimum temperature obtained from the National Centers for Environmental Prediction (NCEP) climate forecast system model (NCEP_CFSv2) are compared with station level observations from the Snow and Avalanche Study Establishment (SASE). It has been found that when the model temperatures are corrected to account the bias in the model and actual orography, the predictions are able to delineate the observed trend compared to the trend without orography correction.Peer reviewedFinal Accepted Versio

Intravenous ferric derisomaltose in patients with heart failure and iron deficiency in the UK (IRONMAN): an investigator-initiated, prospective, randomised, open-label, blinded-endpoint trial.

BACKGROUND: For patients with heart failure, reduced left ventricular ejection fraction and iron deficiency, intravenous ferric carboxymaltose administration improves quality of life and exercise capacity in the short-term and reduces hospital admissions for heart failure up to 1 year. We aimed to evaluate the longer-term effects of intravenous ferric derisomaltose on cardiovascular events in patients with heart failure. METHODS: IRONMAN was a prospective, randomised, open-label, blinded-endpoint trial done at 70 hospitals in the UK. Patients aged 18 years or older with heart failure (left ventricular ejection fraction ≤45%) and transferrin saturation less than 20% or serum ferritin less than 100 μg/L were eligible. Participants were randomly assigned (1:1) using a web-based system to intravenous ferric derisomaltose or usual care, stratified by recruitment context and trial site. The trial was open label, with masked adjudication of the outcomes. Intravenous ferric derisomaltose dose was determined by patient bodyweight and haemoglobin concentration. The primary outcome was recurrent hospital admissions for heart failure and cardiovascular death, assessed in all validly randomly assigned patients. Safety was assessed in all patients assigned to ferric derisomaltose who received at least one infusion and all patients assigned to usual care. A COVID-19 sensitivity analysis censoring follow-up on Sept 30, 2020, was prespecified. IRONMAN is registered with ClinicalTrials.gov, NCT02642562. FINDINGS: Between Aug 25, 2016, and Oct 15, 2021, 1869 patients were screened for eligibility, of whom 1137 were randomly assigned to receive intravenous ferric derisomaltose (n=569) or usual care (n=568). Median follow-up was 2·7 years (IQR 1·8-3·6). 336 primary endpoints (22·4 per 100 patient-years) occurred in the ferric derisomaltose group and 411 (27·5 per 100 patient-years) occurred in the usual care group (rate ratio [RR] 0·82 [95% CI 0·66 to 1·02]; p=0·070). In the COVID-19 analysis, 210 primary endpoints (22·3 per 100 patient-years) occurred in the ferric derisomaltose group compared with 280 (29·3 per 100 patient-years) in the usual care group (RR 0·76 [95% CI 0·58 to 1·00]; p=0·047). No between-group differences in deaths or hospitalisations due to infections were observed. Fewer patients in the ferric derisomaltose group had cardiac serious adverse events (200 [36%]) than in the usual care group (243 [43%]; difference -7·00% [95% CI -12·69 to -1·32]; p=0·016). INTERPRETATION: For a broad range of patients with heart failure, reduced left ventricular ejection fraction and iron deficiency, intravenous ferric derisomaltose administration was associated with a lower risk of hospital admissions for heart failure and cardiovascular death, further supporting the benefit of iron repletion in this population. FUNDING: British Heart Foundation and Pharmacosmos

Two-electron spin correlations in precision placed donors in silicon

Substitutional donor atoms in silicon are promising qubits for quantum computation with extremely long relaxation and dephasing times demonstrated. One of the critical challenges of scaling these systems is determining inter-donor distances to achieve controllable wavefunction overlap while at the same time performing high fidelity spin readout on each qubit. Here we achieve such a device by means of scanning tunnelling microscopy lithography. We measure anti-correlated spin states between two donor-based spin qubits in silicon separated by 16 ± 1 nm. By utilising an asymmetric system with two phosphorus donors at one qubit site and one on the other (2P−1P), we demonstrate that the exchange interaction can be turned on and off via electrical control of two in-plane phosphorus doped detuning gates. We determine the tunnel coupling between the 2P−1P system to be 200 MHz and provide a roadmap for the observation of two-electron coherent exchange oscillations

Quadrature Strategies for Constructing Polynomial Approximations

Finding suitable points for multivariate polynomial interpolation and approximation is a challenging task. Yet, despite this challenge, there has been tremendous research dedicated to this singular cause. In this paper, we begin by reviewing classical methods for finding suitable quadrature points for polynomial approximation in both the univariate and multivariate setting. Then, we categorize recent advances into those that propose a new sampling approach and those centered on an optimization strategy. The sampling approaches yield a favorable discretization of the domain, while the optimization methods pick a subset of the discretized samples that minimize certain objectives. While not all strategies follow this two-stage approach, most do. Sampling techniques covered include subsampling quadratures, Christoffel, induced and Monte Carlo methods. Optimization methods discussed range from linear programming ideas and Newton's method to greedy procedures from numerical linear algebra. Our exposition is aided by examples that implement some of the aforementioned strategies

Agents increasing cyclic GMP amplify 5-HT4-elicited positive inotropic response in failing rat cardiac ventricle

Activation of 5-HT4 receptors in failing ventricles elicits a cAMP-dependent positive inotropic response which is mainly limited by the cGMP-inhibitable phosphodiesterase (PDE) 3. However, PDE4 plays an additional role which is demasked by PDE3 inhibition. The objective of this study was to evaluate the effect of cGMP generated by particulate and soluble guanylyl cyclase (GC) on the 5-HT4-mediated inotropic response. Extensive myocardial infarctions were induced by coronary artery ligation in Wistar rats, exhibiting heart failure 6 weeks after surgery. Contractility was measured in left ventricular preparations. Cyclic GMP was measured by EIA. In ventricular preparations, ANP or BNP displayed no impact on 5-HT4-mediated inotropic response. However, CNP increased the 5-HT4-mediated inotropic response as well as the β1-adrenoceptor (β1-AR)-mediated response to a similar extent as PDE3 inhibition by cilostamide. Pretreatment with cilostamide eliminated the effect of CNP. Inhibition of nitric oxide (NO) synthase and soluble GC by l-NAME and ODQ, respectively, attenuated the 5-HT4-mediated inotropic response, whereas the NO donor Sin-1 increased this response. The effects were absent during PDE3 inhibition, suggesting cGMP-dependent inhibition of PDE3. However, in contrast to the effects on the 5-HT4 response, Sin-1 inhibited whereas l-NAME and ODQ enhanced the β1-AR-mediated inotropic response. cGMP generated both by particulate (NPR-B) and soluble GC increases the 5-HT4-mediated inotropic response in failing hearts, probably through inhibition of PDE3. β1-AR and 5-HT4 receptor signalling are subject to opposite regulatory control by cGMP generated by soluble GC in failing hearts. Thus, cGMP from different sources is functionally compartmented, giving differential regulation of different Gs-coupled receptors

Race discrimination, the politics of knowledge and cultural inequality in England

From the outside, one might assume England’s education system is tolerant of diversity, welcoming and pluralistic. The truth is, to some extent it is. There are thousands of Overseas Trained Teachers (OTTs) and teachers of Black, Asian and Minority Ethnic (BAME) heritage working in schools in England. These two groups of teachers experience one thing in common - race discrimination, built on assumptions of cultural inequality, fuelled by structures that promote a deficit model of difference and a politics of knowledge. For, although thousands of teachers work in English schools, only few from BAME heritage and migrant origin make it to leadership positions, despite having similar aspirations, qualifications and work experience. Drawing on evidence from research on OTTs and teachers of BAME heritage, this chapter will show that five items present as barriers to the progression of OTTs of BAME heritage and teachers of BAME heritage as a whole including: policy, race/racism, institutional practices, group membership and religion (Islam). This chapter also provides a reconceptualisation of promotion, progression for OTTs and teachers of BAME heritage based on three criteria: “Affiliation”, “Appeasement” (or “Adaptation”) and “White sanction”. The chapter considers epistemological and ontological misunderstandings of difference, and highlights the need for courageous and transformative leadership from policy makers and institutions in tackling race inequality in education in England

The role of leptin in the respiratory system: an overview

Since its cloning in 1994, leptin has emerged in the literature as a pleiotropic hormone whose actions extend from immune system homeostasis to reproduction and angiogenesis. Recent investigations have identified the lung as a leptin responsive and producing organ, while extensive research has been published concerning the role of leptin in the respiratory system. Animal studies have provided evidence indicating that leptin is a stimulant of ventilation, whereas researchers have proposed an important role for leptin in lung maturation and development. Studies further suggest a significant impact of leptin on specific respiratory diseases, including obstructive sleep apnoea-hypopnoea syndrome, asthma, COPD and lung cancer. However, as new investigations are under way, the picture is becoming more complex. The scope of this review is to decode the existing data concerning the actions of leptin in the lung and provide a detailed description of leptin's involvement in the most common disorders of the respiratory system