Heart Failure Spending Function: An Investment Framework for Sequencing and Intensification of Guideline-Directed Medical Therapies

Heart failure with reduced ejection fraction is managed with increasing numbers of guideline-directed medical therapies (GDMT). Benefits tend to be additive. Burdens can also be additive. We propose a heart failure spending function as a conceptual framework for tailored intensification of GDMT that maximizes therapeutic opportunity while limiting adverse events and patient burden. Each patient is conceptualized to have reserve in physiological and psychosocial domains, which can be spent for a future return on investment. Key domains are blood pressure, heart rate, serum creatinine, potassium, and out-of-pocket costs. For each patient, GDMT should be initiated and intensified in a sequence that prioritizes medications with the greatest expected cardiac benefit while drawing on areas where the patient has ample reserves. When reserve is underspent, patients fail to gain the full benefit of GDMT. Conversely, when a reserve is fully spent, addition of new drugs or higher doses that draw upon a domain will lead to patient harm. The benefit of multiple agents drawing upon varied physiological domains should be balanced against cost and complexity. Thresholds for overspending are explored, as are mechanisms for implementing these concepts into routine care, but further health care delivery research is needed to validate and refine clinical use of the spending function. The heart failure spending function also suggests how newer therapies may be considered in terms of relative value, prioritizing agents that draw on different spending domains from existing GDMT.

Regional and age differences in specialised palliative care for patients with pancreatic cancer

Background Despite national recommendations, disparities in specialised palliative care (SPC) admittance have been reported. The aims of this study were to characterize SPC admittance in patients with pancreatic cancer in relation to region of residence and age. Method The data sources were two nationwide databases: Danish Pancreatic Cancer Database and Danish Palliative Care Database. The study population included patients (18+ years old) diagnosed with pancreatic cancer from 2011 to 2018. We investigated admittance to SPC, and time from diagnosis to referral to SPC and first contact with SPC to death by region of residence and age. Results In the study period (N = 5851) admittance to SPC increased from 44 to 63%. The time from diagnosis to referral to SPC increased in the study period and overall, the median time was 67 days: three times higher in Southern (92 days) than in North Denmark Region. The median number of days from diagnosis to referral to SPC was lower in patients ≥70 years (59 days) vs patients < 70 years (78 days), with regional differences between the age groups. Region of residence and age were associated with admittance to SPC; highest for patients in North Denmark Region vs Capital Region (OR = 2.03 (95%CI 1.67–2.48)) and for younger patients (< 60 years vs 80+ years) (OR = 2.54 (95%CI 2.05–3.15)). The median survival from admittance to SPC was 35 days: lowest in Southern (30 days) and highest in North Denmark Region (41 days). The median number of days from admittance to SPC to death was higher in patients < 70 years (40 days) vs ≥ 70 years (31 days), with a difference between age groups in the regions of 1–14 days. Conclusions From 2011 to 2018 more patients with pancreatic cancer than previously were admitted to SPC, with marked differences between regions of residence and age groups. The persistently short period of time the patients are in SPC raises concern that early integrated palliative care is not fully integrated into the Danish healthcare system for patients with pancreatic cancer, with the risk that the referral comes so late that the patients do not receive the full benefit of the SPC.

The Implementation of Action Observation Therapy in Virtual Worlds

<p>Upper limb rehabilitation after stroke is vital to the recovery of a patient’s range of motion, dexterity and strength (Jauch et al, 2010, p. 824). Rehabilitative practises are diverse and met with varying levels of success (Brewer et al, 2012, p. 11). This research is concerned with action observation therapy and its potential for neural reorganization through consistent repetition of prescribed physiotherapy exercises. Action observation utilizes mirror neurons to stimulate neural strengthening and recovery (Ertelt et al, 2007, p. 172). The observation of an expert completion of an action by either the patient, a representation of the patient or someone else fires the corresponding mirror neuron (Fogassi et al, 2005, p. 662). Mirror neurons’ ability to be fired under multiple conditions allow a patient who is unable to complete an action, in this case a physiotherapy exercise, to still receive the neural benefit just by observing the action (Ertelt et al, 2007, p. 165). In collaboration with sensory devices in a virtual medium, action observation will be used to create a dynamic and engaging simulation with the intent of providing a physiotherapy experience that progresses in difficulty. Incremental difficulty will ensure patients are being pushed to their limits in a controlled and monitored environment (IJsselsteijn, 2007, p. 27). Neural reorganization requires a large number of repetitions of exercises over extended periods of time creating rehabilitative experiences that have traditionally been tedious and mundane (Merians et al, 2002, p. 898; O’Dell, Lin & Harrison, 2009, p. 55). Gamification of traditional methods can engage the patient over an extended period of time By masking the repetitive nature of the exercises with a fun experience, patients can receive the full benefit of the treatment while performing enjoyable tasks (Muzzaffa et al, 2013, p. 69).</p>

The Implementation of Action Observation Therapy in Virtual Worlds

<p>Upper limb rehabilitation after stroke is vital to the recovery of a patient’s range of motion, dexterity and strength (Jauch et al, 2010, p. 824). Rehabilitative practises are diverse and met with varying levels of success (Brewer et al, 2012, p. 11). This research is concerned with action observation therapy and its potential for neural reorganization through consistent repetition of prescribed physiotherapy exercises. Action observation utilizes mirror neurons to stimulate neural strengthening and recovery (Ertelt et al, 2007, p. 172). The observation of an expert completion of an action by either the patient, a representation of the patient or someone else fires the corresponding mirror neuron (Fogassi et al, 2005, p. 662). Mirror neurons’ ability to be fired under multiple conditions allow a patient who is unable to complete an action, in this case a physiotherapy exercise, to still receive the neural benefit just by observing the action (Ertelt et al, 2007, p. 165). In collaboration with sensory devices in a virtual medium, action observation will be used to create a dynamic and engaging simulation with the intent of providing a physiotherapy experience that progresses in difficulty. Incremental difficulty will ensure patients are being pushed to their limits in a controlled and monitored environment (IJsselsteijn, 2007, p. 27). Neural reorganization requires a large number of repetitions of exercises over extended periods of time creating rehabilitative experiences that have traditionally been tedious and mundane (Merians et al, 2002, p. 898; O’Dell, Lin & Harrison, 2009, p. 55). Gamification of traditional methods can engage the patient over an extended period of time By masking the repetitive nature of the exercises with a fun experience, patients can receive the full benefit of the treatment while performing enjoyable tasks (Muzzaffa et al, 2013, p. 69).</p>

MECHANISMS FOR INTERACTION BETWEEN LEGAL CLINICS AND GOVERNMENTAL BODIES: LEGAL, ORGANIZATIONAL AND ETHICAL ISSUES

Practice shows that a legal clinic is the most effective element of practical-oriented education in a law school today. Despite the introduction of project activities into curricula, the development of cooperation programs with employers, the harmonization of curricula and teaching materials with employers’ representatives, it is the possibilities of clinical education that enable future lawyers to acquire practical skills even before graduation. Nevertheless, some distance of clinics from employers' practice bases and sites does not allow full benefit of clinical training. Purpose: to examine possible mechanisms for interaction between legal clinics and governmental bodies, primarily courts. Methods: the national and world experience of legal clinics is studied, the level of legislative regulation of their activities and the degree of their involvement in national systems of free legal aid are determined by applying comparative legal, specific legal methods, analysis and synthesis. Results: the author substantiates that the program of clinics should include measures to provide free legal assistance to the public at employers' venues. The opinion is expressed that such work can contribute to the involvement of students in the practice of judicial representation of clients' interests, as the most professional element of free legal aid. The article identifies possible ethical and organizational problems that may arise in the implementation of such interaction, and suggests ways to overcome them on the example of the activities of the legal clinic of the Novgorod State University.

PERCEPTIONS OF CONTINUING MEDICAL EDUCATION PARTICIPANTS REGARDING IMPROVEMENT OF PATIENT CARE THROUGH CONTINUING MEDICAL EDUCATION ACTIVITIES IN LAHORE DISTRICT

Objective: To explore the perceptions of Continuing Medical Education participants about the improvement of patient care through Continuing Medical Education activities and to explore the factors hampering or favouring improvement of patient care through Continuing Medical Education activities. Study Design: Qualitative phenomenological study. Place and Duration of Study: University of Health Sciences, Lahore, from Dec 2016 to May 2017. Methodology: In qualitative phenomenological study conducted at University of Health Sciences, Lahore from Dec 2016 to May 2017, semi structured in-depth interviews were conducted individually from 10 General Practitioners which were audiorecorded and transcribed. Code labels were assigned manually and grouped together into broader themes. Interpretation ofthemes was done after thematic analysis. Results: Two participants were female and ten were male with experience ranging between 20-38 years. Three main themes with sub-themes were identified: (1) positive talk (Affirming the link between Continuing Medical Education and improved patient care), (2) negative talk (perceived hindrances in gaining full benefit from Continuing Medical Education activities), (3) concerns regarding current Continuing Medical Education activities. Conclusion: Participants were found inclined towards Continuing Medical Education activities and felt more confident and comfortable in managing their patients. However, they felt that physicians working in rural areas were dealing directly with all sorts of patients and were more in need of targeted and tailored Continuing Medical Education activities.

Why Hire Veterans?

In order for employers to get the full benefit of hiring military veterans, they need to understand why it is in their best interest to employ and retain these individuals. This chapter presents and expands on the typical understanding of what it means to hire a veteran. It defines the skills and knowledge veterans bring to the organization along with the value associated with decisive efforts to integrate veterans into the civilian workforce. This chapter explores and outlines the subsequent impact of these decisions on a company’s organizational culture and competitive advantage in the marketplace (e.g., how veteran hiring contributes to the corporate bottom line by examining the return on investment of these decisions), looks at the current trends in the marketplace for veteran talent, provides suggestions on hiring veterans, and presents recommendations on how employers can advance the success of veterans in the workplace, including veterans with disabilities and injuries.

Cyber-Physical Systems, Blended Tool Environments, and Playful Creativity

All tools humanity uses are extensions of their physical and/or virtual reach, towards a specific purpose or to fulfill a particular, specified, or dedicated task. The tool is handled, initiated and actively guided to participate in interaction, perception, and/or interpretation of the world around us. Tools mediate in action and interaction, like handling a toothbrush to gain a fresh set of cleaned teeth or to use a hammer to pound nails in a material. The real physicality of these human interactions convey a lot of information and creates knowledge in various levels of insight and understanding. Not only in terms of feeling satisfied in the accomplishment of a task, but also in the experience of tool use and succesful interaction. Furthermore, metacognitive aspects of tool use occur when human beings and tools work together and can be seen as an action-based method of advancing knowledge. In the quotidian, a mixture of tools (i.e. used, embedded) and tool activities occur to directly or indirectly interact with our physical and virtual surroundings, things, or systems. Analogue tools, like e.g. knives, pens, chairs and cars have different complexities, but through communicated ’meaning’ (Dewey, 2005) [9], these artifacts possess a distinct quality and intrinsic interaction of use. Some of these tools have very simple but effective use qualities and therefore are most of the time easy to understand in function and use. Other more sophisticated tools imply more study and demand lots of exercise (i.e. high learning threshold) in order to get the full benefit, function and gain in user experience (UX) and results. In the digital and virtual realms many varieties of computational tools are encountered. As a consequence, many categories and levels of tool use, usage through interaction, usability, user-skills and UX happen. The last decades showed a plethora of tool applications and tool interactions that eluded many users, consequently leading to misinterpretation, misguidance, frustration, reduction and inert mediocrity. Not to speculate that digital innovations and tools are defunct gadgets or not worthy of inclusion in daily life. On the contrary, digital technology plays a crucial role in our understanding of the physical and virtual worlds that co-exists and give us much broader boundless experiences and perspectives than ever before. The problem with most digital tools is, the constructed user interface (UI) and user interaction (UA) between a user and machine, as shown in, for example; Carroll, 1991 [5], Carroll, 2002 [6], Dix, 2009 [10], Hartson, 2003 [16], Piumsomboon et al., 2017 [31], Wendrich, 2016 [44], Rogers, 2011 [33]. This in turn has lead to more study and research being conducted on this subject over the last decades, what somehow lead to more confusion and misapprehension. Incremental improvements in UI have been explored and became a sort of standard, new approaches to UIs and UAs have appeared and wiped others, in some cases e.g. multi-touch sensing surfaces became a next step in interacting with the digital-virtual realms. This in turn lead to a leap in applications software (app) design to create tools that were easy to manipulate and use by swiping fingers across high-definition interactive icons to work the tool. However, how feebly, fleetly or superficial this type of mediated interactions may seem, somehow it became a prefered way of ’doing things.’ Gradually this kind of interaction became the standard, encroached with instant gratification and satisfaction. Eventually, everything is an approximation with human frailty, so is tool use and are tools, Figure 19.1.

IMPLEMENTATION OF COVID-19 VACCINE TEMPERATURE MONITORING AND TRACKING SYSTEM

This paper is concerned with the design and implementation of real-time temperature control, monitoring, and tracking system for COVID-19 Vaccines. COVID-19 Vaccines must be stored properly from the manufacture's time until the administration's time to people. The proper vaccine maintenance during the transportation stage known as the cold chain process. An excellent temperature-controlled supply chain involves all equipment and procedures used in the transportation, storage, and handling of COVID-19 vaccines. By maintaining temperatures recommended by the vaccine manufacture, implementing best storage and handling practices, providers can ensure that patients will get the full benefit of the COVID-19 vaccines they receive. In this project, the Arduino-based controller automatically monitors and preserves the vaccine box's temperature as per the prescribed WHO (World Health Organization) standard and alarming the system if deflection in the standard range happens. The tracking system in this project implement by using another Arduino-based GPSGSM module for the vaccine suppliers or hospitals to track the exact location of the designed Vaccine box. In addition, a portable case solar battery charge design to ensure an uninterrupted power supply during transportation.