Design Optimization of Piezocomposites Using a Homogenization Model: From Analytical Model to Experimentation.

In the process of activating non-conductive smart-structures using piezoelectric patches, one possible method is to add a conductive layer to ensure electrical contact of both electrodes of the ceramic. Therefore, depending on the stiffness and the thickness of this layer, changes in the overall piezoelectric properties lead to a loss in the electromechanical coupling that can be implemented. The purpose of this work is to study the impact of this added electrode layer depending on its thickness. A model of the effect of this layer on the piezoelectrical coefficients has been derived from the previous approach of Hashimoto and Yamagushi and successfully compared to experimental data. This global model computes the variation of all the piezoelectric coefficients, and more precisely of k31 or d31 for various brass electrode volumes relative to the ceramic volume. A decrease in the lateral electromechanical coupling factor k31 was observed and quantified. NAVY II PZT piezoelectric transducers were characterized using IEEE standard methods, with brass electrode thicknesses ranging from 50 to 400 microns. The model fits very well as shown by the results, leading to good expectations for the use of this design approach for actuators or sensors embedded in smart-structures.

Haptic Feedback Device Using 3D-Printed Flexible, Multilayered Piezoelectric Coating for In-Car Touchscreen Interface.

This study focuses on the development of a piezoelectric device capable of generating feedback vibrations to the user who manipulates it. The objective here is to explore the possibility of developing a haptic system that can replace physical buttons on the tactile screen of in-car systems. The interaction between the user and the developed device allows completing the feedback loop, where the user's action generates an input signal that is translated and outputted by the device, and then detected and interpreted by the user's haptic sensors and brain. An FEM (finite element model) via ANSYS multiphysics software was implemented to optimize the haptic performance of the wafer structure consisting of a BaTiO3 multilayered piezocomposite coated on a PET transparent flexible substrate. Several parameters relating to the geometric and mechanical properties of the wafer, together with those of the electrodes, are demonstrated to have significant impact on the actuation ability of the haptic device. To achieve the desired vibration effect on the human skin, the haptic system must be able to drive displacement beyond the detection threshold (~2 µm) at a frequency range of 100-700 Hz. The most optimized actuation ability is obtained when the ratio of the dimension (radius and thickness) between the piezoelectric coating and the substrate layer is equal to ~0.6. Regarding the simulation results, it is revealed that the presence of the conductive electrodes provokes a decrease in the displacement by approximately 25-30%, as the wafer structure becomes stiffer. To ensure the minimum displacement generated by the haptic device above 2 µm, the piezoelectric coating is screen-printed by two stacked layers, electrically connected in parallel. This architecture is expected to boost the displacement amplitude under the same electric field (denoted E) subjected to the single-layered coating. Accordingly, multilayered design seems to be a good alternative to enhance the haptic performance while keeping moderate values of E so as to prevent any undesired electrical breakdown of the coating. Practical characterizations confirmed that E=20 V/µm is sufficient to generate feedback vibrations (under a maximum input load of 5 N) perceived by the fingertip. This result confirms the reliability of the proposed haptic device, despite discrepancies between the predicted theory and the real measurements. Lastly, a demonstrator comprising piezoelectric buttons together with electronic command and conditioning circuits are successfully developed, offering an efficient way to create multiple sensations for the user. On the basis of empirical data acquired from several trials conducted on 20 subjects, statistical analyses together with relevant numerical indicators were implemented to better assess the performance of the developed haptic device.

Holistic needs assessment in outpatient cancer care: a randomised controlled trial.

DESIGN: Analyst blinded, parallel, multi-centre, randomised controlled trial (RCT). PARTICIPANTS: People with confirmed diagnoses of cancer (head and neck, skin or colorectal) attending follow-up consultation 3 months post-treatment between 2015 and 2020. INTERVENTION: Holistic needs assessment (HNA) or care as usual during consultation. OBJECTIVE: To establish whether incorporating HNA into consultations would increase patient participation, shared decision making and postconsultation self-efficacy. OUTCOME MEASURES: Patient participation in the consultations examined was measured using (a) dialogue ratio (DR) and (b) the proportion of consultation initiated by patient. Shared decision making was measured with CollaboRATE and self-efficacy with Lorig Scale. Consultations were audio recorded and timed. RANDOMISATION: Block randomisation. BLINDING: Audio recording analyst was blinded to study group. RESULTS: 147 patients were randomised: 74 control versus 73 intervention. OUTCOME: No statistically significant differences were found between groups for DR, patient initiative, self-efficacy or shared decision making. Consultations were on average 1 min 46 s longer in the HNA group (respectively, 17 m 25 s vs 15 min 39 s). CONCLUSION: HNA did not change the amount of conversation initiated by the patient or the level of dialogue within the consultation. HNA did not change patient sense of collaboration or feelings of self-efficacy afterwards. HNA group raised more concerns and proportionally more emotional concerns, although their consultations took longer than treatment as usual. IMPLICATIONS FOR PRACTICE: This is the first RCT to test HNA in medically led outpatient settings. Results showed no difference in the way the consultations were structured or received. There is wider evidence to support the roll out of HNA as part of a proactive, multidisciplinary process, but this study did not support medical colleagues facilitating it. TRIAL REGISTRATION NUMBER: NCT02274701.

Healthcare providers and patients: an essay on the importance of professional assertiveness in healthcare today.

Professional assertiveness can enable the healthcare provider to confidently share their expertise without seeming authoritarian to the patient. Professional assertiveness is an interpersonal communication skill that helps express opinions or knowledge while respecting similar competencies in others. For healthcare providers, this compares to sharing scientific or professional knowledge with their patients while respecting their person, ideas, and autonomy. Professional assertiveness also connects the patient's beliefs and values with actual scientific evidence and healthcare system constraints. The definition of professional assertiveness might be easy to understand, but it remains challenging to apply in clinical practice. In this essay, we hypothesize that the practical difficulties healthcare providers encounter with assertive communication stem from their misunderstanding of this style.

Design for a Virtual Peer-to-Peer Knowledge to Action Platform for Type 2 Diabetes.

Many patients with Type 2 Diabetes (T2D) have difficulty in controlling their disease despite wide-spread availability of high-quality guidelines, T2D education programs and primary care follow-up programs. Current diabetes education and treatment programs translate knowledge from bench to bedside well, but underperform on the 'last-mile' of converting that knowledge into action (KTA). Two innovations to the last-mile problem in management of patients with T2D are introduced. 1) Design of a platform for peer-to-peer groups where patients can solve KTA problems together in a structured and psychologically safe environment using all the elements of the Action Cycle phase of the KTA framework. The platform uses Self-Determination Theory as the behavior change theory. 2) A novel patient segmentation method to enable the formation of groups of patients who have similar behavioral characteristics and therefore who are more likely to find common cause in the fight against diabetes.

Applying a multidimensional approach to understanding clinical conversations: A deprescribing case study in primary care.

OBJECTIVE: To describe and evaluate the contribution of multiple coding approaches applied to a clinical conversation on deprescribing in primary care (PC). METHODS: Seven distinct coding approaches were applied to one audiotaped consultation. Only exchanges related to deprescribing a benzodiazepine (BZD) were coded for: content, interaction, arguments, connectors, transitions, orientation towards deprescribing and concordance with a deprescribing algorithm. A discursive map presents the unfolding of the exchanges. RESULTS: The deprescribing conversation was broken down into 31 utterances divided into three segments: opening (n = 6), development (n = 16) and closing (n = 9). The family physician dominated the last two segments and most of her utterances were favorable to BZD deprescribing while the patient's utterances were generally unfavorable in the first two segments. The number of distinct codes assigned to utterances varied according to the coding approach. The map illustrates how each utterance can be viewed through different lenses revealing the dynamics and complexity of the deprescribing conversation. CONCLUSION: This multidimensional methodological approach with its proposed way of presenting results, either quantitatively or qualitatively, and its map offer a comprehensive evaluation of the deprescribing process in this PC setting. PRACTICE IMPLICATIONS: This novel multidimensional coding approach has potential to be applied to a range of other topics in clinical communications.

I am ready to see you now, Doctor! A mixed-method study of the Let's Discuss Health website implementation in Primary Care.

BACKGROUND: Let's Discuss Health (LDH) is a website that encourages patients to prepare their health-care encounters by providing communication training, review of topics and questions that are important to them. OBJECTIVE: To describe LDH implementation during primary care (PC) visits for chronic illnesses. METHODS: Design: Descriptive mixed-method study. SETTING: 6 PC clinics. PARTICIPANTS: 156 patients and 51 health-care providers (HCP). INTERVENTION: LDH website implementation. OUTCOME MEASURES: Perceived quality and usefulness of LDH; perceived quality of HCP-patient communication; patient activation; LDH integration in routine PC practices and barriers to its use. RESULTS: Patients reported a positive perception of the website in that it helped them to adopt an active role in the encounters; recall their visit agenda and reduce encounter-related stress; feel more confident to ask questions, feel more motivated to prepare their future medical visits and improve their chronic illness management. However, a certain disconnect emerged between HCP and patient perceptions as to the value of LDH in promoting a sense of partnership and collaboration. The main barriers to the use of LDH are HCP lack of interest, limited access to technology, lack of time and language barriers. CONCLUSION: Our findings indicate that it is advantageous for patients to prepare their medical encounters. However, the study needs to be replicated in other medical environments using larger and more diverse samples. PATIENT AND PUBLIC CONTRIBUTION: Patient partners were involved in the conduct of this study.

Syntheses of Methyl Jasmonate and Analogues.

This account corresponds to the presentation given by the main author on the occasion of the 2nd Swiss Industrial Symposium in Basel (October 19th , 2018). After a short historical introduction to methyl-jasmonate and methyl-epijasmonate, it essentially focuses on the reported more promising industrial approaches devoted to the synthesis of these naturally occurring odorants isolated from jasmine flowers. Some attempts to simplify these approaches, as well as independent unreported strategies are also presented. Several asymmetric methodologies are also discussed such as Xie hydrogenation, Corey-CBS reduction, enzymatic resolution, and 1,4-addition.

Deprescribing conversations: a closer look at prescriber-patient communication.

BACKGROUND: Little is known about the initiation, style and content of patient and healthcare provider communication around deprescribing. We report the findings from a content analysis of audio-recorded discussions of proton pump inhibitor (PPI) and benzodiazepine deprescribing in primary care. METHODS: Participants were healthcare providers (n = 13) from primary care practices (n = 3) and patients aged ⩾65 (n = 24) who were chronic users of PPIs or benzodiazepines. The EMPOWER educational brochures were distributed prior to (n = 15) or after (n = 9) the patient's usual healthcare provider appointment. Conversations were audio-recorded and coded using MEDICODE to analyze who initiated different themes, whether they followed a monologue or dialogue style, and to what extent the thematic content addressed issues pertaining to: 'dosage/instructions,' 'medication action and efficacy,' 'risk/adverse effects,' 'attitudes/emotions,' 'adherence' and 'follow up.' Descriptive analysis of the conversations was performed with comparison between patients who received the EMPOWER brochure before or after their appointments. RESULTS: Patients were mostly women (67%) with a mean age of 74 ± 6 years. For PPI users, prior education resulted in a greater proportion of themes initiated by patients (44% versus 17%) and maintaining dialogue-style conversations (48% versus 28%). Among benzodiazepine users, conversation initiation (52% versus 47%) and conversation style was similar between both groups. The content of deprescribing conversations for PPIs revealed that patients and their healthcare providers focused less on 'dosage/instructions,' and more on the 'medication action and efficacy' and the necessity for 'follow up.' Conversations about stopping benzodiazepines were more likely to stagnate on the 'if' rather than the 'how.' CONCLUSION: The initiation, style and content of the conversations varied between PPI and benzodiazepine users, suggesting that healthcare providers will need to tailor deprescribing conversations accordingly.

The impact of a patient web communication intervention on reaching treatment suggested guidelines for chronic diseases: A randomized controlled trial.

OBJECTIVE: Examine the impact of a PACE (Prepare, Ask, Check, Express) inspired web-based communication intervention alone or combined with a workshop on reaching treatment goals for patients suffering from chronic diseases (CDs), compared to usual care. METHODS: Three arm single-blind RCT in community primary care (PC) practices. PC practitioners (n=18) had a CD patient caseload, and practicing >5 years. Patients >40 years old, English speaking, computer literate, not reaching treatment goals for hypertension, type II diabetes, and/or dyslipidemia. INTERVENTIONS: (1) web-intervention and (2) web intervention and nurse facilitated workshop and (3) usual care. OUTCOME: Proportion of patients meeting all treatment suggested guidelines for the diagnoses they were enrolled for. RESULTS: Patients (n=322) were randomized, and of these 221 returned for follow up. Patients in the web group were 1.42 times more likely to meet targets compared to usual care [95% CI: 1.00-2.00], a statistical difference not seen in the combined group. Sensitivity analyses were performed to mitigate bias due to loss to follow up. CONCLUSIONS: Training patients in communication skills using a website positively affects reaching treatment goals for hypertensive, diabetic and dyslipidemic patients. PRACTICE IMPLICATIONS: Web communication interventions are an effective tool that can be used in primary care.

Communication and patient participation influencing patient recall of treatment discussions.

CONTEXT: Patient recall of treatment information is a key variable towards chronic disease (CD) management. It is unclear what communication and patient participation characteristics predict recall. OBJECTIVES: To assess what aspects of doctor-patient communication predict patient recall of medication information. To describe lifestyle treatment recall, in CD primary care patients. DESIGN: Observational study within a RCT. SETTING & PARTICIPANTS: Community-based primary care (PC) practices. Family physicians (n=18): practicing >5 years, with a CD patient caseload. Patients (n=159): >40 years old, English speaking, computer literate, off-target hypertension, type II diabetes and/or dyslipidaemia. MAIN VARIABLES: Patient characteristics: age, education, number of CDs. Information characteristics: length of encounter, medication status, medication class. Communication variables: socio-emotional utterances, physician dominance and communication control scores and PACE (ask, check and express) utterances, measured by RIAS. Number of medication themes, dialogue and initiative measured by MEDICODE. MAIN OUTCOME MEASURES: Recall of CD, lifestyle treatment and medication information. RESULTS: Frequency of lifestyle discussions varied by topic. Patients recalled 43% (alcohol), 52% (diet) to 70% (exercise) of discussions. Two and a half of six possible medication themes were broached per medication discussion. Less than one was recalled. Discussing more themes, greater dialogue and patient initiative were significant predictors of improved medication information recall. DISCUSSION: Critical treatment information is infrequently exchanged. Active patient engagement and explicit conversations about medications are associated with improved treatment information recall in off-target CD patients followed in PC. CONCLUSION: Providers cannot take for granted that long-term off-target CD patients recall information. They need to encourage patient participation to improve recall of treatment information.

The impact of a primary care e-communication intervention on the participation of chronic disease patients who had not reached guideline suggested treatment goals.

OBJECTIVE: To evaluate the efficacy of two web-based educational approaches on doctor-patient communication. The study focused on chronic disease (CD) patients in a lengthy relationship with their family physician (FP) who had not reached guideline suggested treatment goals (off-target) for their CDs. METHODS: 322 hypertensive, diabetic, or dyslipidemic patients of 18 FPs were randomised into three groups: Usual Care (UC), e-Learning (e-L) and e-Learning+Workshop (e-L+W). Interventions were based on Cegala's PACE system: Prepare, Ask questions, Check understanding, Express concerns. Communication was evaluated using the Roter Interaction Analysis System (RIAS), MEDICODE and questionnaires. RESULTS: Encounter length was similar across groups. RIAS showed that e-L+W group engaged in more socio-emotional talk and PACE-like utterances. MEDICODE showed that interventions increased frequency, initiative and dialogue for selected CD medication themes. Quality of communication was perceived as satisfactory at baseline and did not change. CONCLUSION: Following interventions, CD patients were more activated even in well-established doctor-patient relationships. PRACTICE IMPLICATIONS: PACE web-based interventions are accessible and effective at increasing CD patients' participation. They increase legitimacy to express the patient experience. FPs should present this type of training to CD patients as an integral part of their routine practice and consider referring patients to complete it.

Evaluating holistic needs assessment in outpatient cancer care--a randomised controlled trial: the study protocol.

INTRODUCTION: People living with and beyond cancer are vulnerable to a number of physical, functional and psychological issues. Undertaking a holistic needs assessment (HNA) is one way to support a structured discussion of patients' needs within a clinical consultation. However, there is little evidence on how HNA impacts on the dynamics of the clinical consultation. This study aims to establish (1) how HNA affects the type of conversation that goes on during a clinical consultation and (2) how these putative changes impact on shared decision-making and self-efficacy. METHODS AND ANALYSIS: The study is hosted by 10 outpatient oncology clinics in the West of Scotland and South West England. Participants are patients with a diagnosis of head and neck, breast, urological, gynaecological and colorectal cancer who have received treatment for their cancer. Patients are randomised to an intervention or control group. The control group entails standard care--routine consultation between the patient and clinician. In the intervention group, the patient completes a holistic needs assessment prior to consultation. The completed assessment is then given to the clinician where it informs a discussion based on the patient's needs and concerns as identified by them. The primary outcome measure is patient participation, as determined by dialogue ratio (DR) and preponderance of initiative (PI) within the consultation. The secondary outcome measures are shared decision-making and self-efficacy. It is hypothesised that HNA will be associated with greater patient participation within the consultation, and that shared decision-making and feelings of self-efficacy will increase as a function of the intervention. ETHICS AND DISSEMINATION: This study has been given a favourable opinion by the West of Scotland Research Ethics Committee and NHS Research & Development. Study findings will be disseminated through peer-reviewed publications and conference attendance. TRAIL REGISTRATION NUMBER: Clinical Trials.gov NCT02274701.

Relationship between beta-blocker and angiotensin-converting enzyme inhibitor dose and clinical outcome following acute myocardial infarction.

BACKGROUND: Benefit of ß-blockers (BB) and angiotensin-converting-enzyme inhibitors (ACEI) on mortality following acute myocardial infarction (MI) is well demonstrated. This study assessed the impact of BB and ACEI doses administered following ST-elevation MI on mortality and outcome up to 1 year. METHODS AND RESULTS: The French prospective observational cohort "RIMA" included 1,461 MI patients. Dosing of BB and ACEI given at 24 h and at time of discharge was assessed as follows: no treatment; <50% of target dose; or ≥50% of target dose. For in-hospital mortality, after MI, the use of BB in the first 24 h, but not ACEI, was associated with significantly lower event rate on multivariate analysis (OR, 5.78; 95% CI: 2.62-12.76, P<0.001). In contrast at 1 year, use of higher doses of ACEI, but not BB, was associated with significantly lower CV mortality, readmission for heart failure and the composite of CV mortality and readmission for heart failure (HR, 2.65; 95% CI: 1.32-5.31, P=0.006 for absence of ACEI at discharge). CONCLUSIONS: Prescription of BB in the first 24 h was independently associated with a lower in-hospital mortality following MI. There appeared to be a significant dose effect on outcome with regard to <50% vs. ≥50% of target dose, which requires confirmation in further large-scale clinical studies.

Healthcare professionals' adoption and use of a clinical information system (CIS) in primary care: insights from the Da Vinci study.

UNLABELLED: Given the increasing prevalence of multimorbidity in primary care (PC), interdisciplinary PC teams supported by appropriate clinical information systems (CIS) are needed in order to deal with the complexity of multimorbid patients' care. Our team has developed such a system, called the Da Vinci system. However, despite the expected benefits, evidence suggests generally low rates of CIS adoption. To optimize adoption in PC settings, a better understanding of the implementation process of such systems is crucial. PURPOSE: To identify user profiles, investigate the drivers of and barriers to adoption and use of the Da Vinci system, a PC tailored CIS, and understand the dynamics of the CIS adoption for each profile. METHODS: Using a longitudinal approach, we conducted a qualitative study (individual interviews, documentation and observation) based on the Diffusion of Innovation theory. It included 31 participants (primary care physicians, staff or residents, nurses, pharmacists) from two Family Medicine Groups in Quebec (Canada). RESULTS: The different user profiles drawn from the dynamics of implementation are linked to different sets of perceived drivers and barriers that evolve over time. Certain factors favour the decision of adopting Da Vinci early on: e.g. user skills and the system's expected ease of use and usefulness. Certain concerns hinder its adoption: e.g. perceived negative impact on the doctor-patient relationship. Over time, 5 factors appear to be related to more advanced exploitation of the system's functionalities: user skills, ease of use, comfort using the system in front of patients, support from colleagues and, more importantly, perceived positive impacts. CONCLUSIONS: A better understanding of the dynamics of CIS implementation provides insight into how best to encourage clinicians to adopt and make full use of such systems to improve the quality of care for multimorbid patients followed in PC settings.

Macromolecular synthesis inhibitors perturb glucocorticoid receptor trafficking.

The ability of inhibitors of transcription and translation to prevent glucocorticoid-induced apoptosis has been interpreted to indicate that the cell death machinery requires de novo protein synthesis. The transcriptional inhibitors actinomycin D (Act D) and DRB as well as the translational inhibitors CHX and puromycin inhibited early loss of mitochondrial membrane integrity in a dose-dependent manner. This effect was not observed with the transcriptional inhibitor α-amanitin suggesting they may have additional effects. Their role in the glucocorticoid receptor (GR) intracellular trafficking was therefore investigated. Here, we show that Act D and CHX reduced glucocorticoid binding, GR turnover and impaired GR nuclear translocation. We performed the same experiments in different thymocyte subpopulations of Balb/c mice. At the highest dose tested, actinomycin D and cycloheximide abolished glucocorticoid-induced cell death of CD4+CD8+ and CD4+CD8-. In all subsets, Act D, DRB, as well as CHX and puromycin prevented receptor nuclear translocation, indicating a general alteration of GR trafficking. Overall, our data support a direct effect of macromolecular inhibitors on GR activation and trafficking. Finally, direct alterations of the functional properties of the glucocorticoid receptor might be responsible for cell death prevention by actinomycin D, DRB, cycloheximide and puromycin.

Medication discussion between nurse prescribers and people with diabetes: an analysis of content and participation using MEDICODE.

AIM: This paper is a report of a study to identify the content of, and participation in, medicine discussion between nurse prescribers and people with diabetes in England. BACKGROUND: Diabetes affects 246 million people worldwide and effective management of medicines is an essential component of successful disease control. There are now over 20,000 nurse independent prescribers in the UK, many of whom frequently prescribe for people with diabetes. With this responsibility comes a challenge to effectively communicate with patients about medicines. National guidelines on medicines communication have recently been issued, but the extent to which nurse prescribers are facilitating effective medicine-taking in diabetes remains unknown. METHODS: A purposive sample of 20 nurse prescribers working with diabetes patients audio-recorded 59 of their routine consultations and a descriptive analysis was conducted using a validated coding tool: MEDICODE. Recordings were collected between January and July 2008. The unit of analysis was the medicine. RESULTS: A total of 260 instances of medicine discussion identified in the audio-recordings were analysed. The most frequently raised themes were 'medication named' (raised in 88·8% of medicines), 'usage of medication' (65·4%) and 'instructions for taking medication' (48·5%). 'Reasons for medication' (8·5%) and 'concerns about medication' were infrequently discussed (2·7%). Measures of consultation participation suggest largely dyadic medicine discussion initiated by nurse prescribers. CONCLUSION: MEDICODE discussion themes linked to principles of recent guidelines for effective medicine-taking were infrequently raised. Medicine discussion was characterized by a one statement-one response style of communication led by nurses. Professional development is required to support theoretically informed approaches to effective medicines management.

The content of talk about health conditions and medications during appointments involving interpreters.

INTRODUCTION: Interpreters often join immigrants and physicians to permit communication. OBJECTIVE: To describe the content of talk about health problems and medications during clinical encounters involving interpreters [professionals (PI) or family members (FI)]. METHODS: We analysed one regularly scheduled encounter for each of 16 adult patients with his family physician and their usual interpreter (10 with a PI and 6 with a FI). A different PI, not involved in the consultations, translated the non-English or French parts. We coded all utterances about each medical problem and each medication using six health problem and 16 medication topics from MEDICODE, a validated coding scheme. RESULTS: Physicians and patients addressed an average of 3.6 problems and 3 medications per encounter. No psychosocial problems were discussed in encounters involving FIs. On average, three topics were discussed per problem. In order of frequency, they were follow-up, explanations of the condition, non-drug management, consequences, self-management and emotions about the problem. Encounters involving PIs were more likely than encounters with FIs to include discussions of emotions about the problem (42% versus 4%, P = 0.001) and indications for follow-up (88% versus 28%, P < 0.001). An average of 6.5 topics was discussed per medication. Commonest topics discussed were medication class, how the drug was being used, achieved effect and expected effect. CONCLUSIONS: One can address multiple problems and share vital information even in the presence of a language barrier. When FIs are interpreting, physicians would do well to make a particular effort to bring the patient's psychological and emotional issues into the interaction.