The Box-eHealth in the Outpatient Clinic Follow-up of Patients With Acute Myocardial Infarction: Cost-Utility Analysis.

BACKGROUND: Smartphone compatible wearables have been released on the consumers market, enabling remote monitoring. Remote monitoring is often named as a tool to reduce the cost of care. OBJECTIVE: The primary purpose of this paper is to describe a cost-utility analysis of an eHealth intervention compared to regular follow-up in patients with acute myocardial infarction (AMI). METHODS: In this trial, of which clinical results have been published previously, patients with an AMI were randomized in a 1:1 fashion between an eHealth intervention and regular follow-up. The remote monitoring intervention consisted of a blood pressure monitor, weight scale, electrocardiogram device, and step counter. Furthermore, two in-office outpatient clinic visits were replaced by e-visits. The control group received regular care. The differences in mean costs and quality of life per patient between both groups during one-year follow-up were calculated. RESULTS: Mean costs per patient were €2417±2043 (US $2657±2246) for the intervention and €2888±2961 (US $3175±3255) for the control group. This yielded a cost reduction of €471 (US $518) per patient. This difference was not statistically significant (95% CI -€275 to €1217; P=.22, US $-302 to $1338). The average quality-adjusted life years in the first year of follow-up was 0.74 for the intervention group and 0.69 for the control (difference -0.05, 95% CI -0.09 to -0.01; P=.01). CONCLUSIONS: eHealth in the outpatient clinic setting for patients who suffered from AMI is likely to be cost-effective compared to regular follow-up. Further research should be done to corroborate these findings in other patient populations and different care settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT02976376; https://clinicaltrials.gov/ct2/show/NCT02976376. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/resprot.8038.

Nonparametric D-R1-R2 distribution MRI of the living human brain.

Diffusion-relaxation correlation NMR can simultaneously characterize both the microstructure and the local chemical composition of complex samples that contain multiple populations of water. Recent developments on tensor-valued diffusion encoding and Monte Carlo inversion algorithms have made it possible to transfer diffusion-relaxation correlation NMR from small-bore scanners to clinical MRI systems. Initial studies on clinical MRI systems employed 5D D-R1 and D-R2 correlation to characterize healthy brain in vivo. However, these methods are subject to an inherent bias that originates from not including R2 or R1 in the analysis, respectively. This drawback can be remedied by extending the concept to 6D D-R1-R2 correlation. In this work, we present a sparse acquisition protocol that records all data necessary for in vivo 6D D-R1-R2 correlation MRI across 633 individual measurements within 25 min-a time frame comparable to previous lower-dimensional acquisition protocols. The data were processed with a Monte Carlo inversion algorithm to obtain nonparametric 6D D-R1-R2 distributions. We validated the reproducibility of the method in repeated measurements of healthy volunteers. For a post-therapy glioblastoma case featuring cysts, edema, and partially necrotic remains of tumor, we present representative single-voxel 6D distributions, parameter maps, and artificial contrasts over a wide range of diffusion-, R1-, and R2-weightings based on the rich information contained in the D-R1-R2 distributions.

Effect of Smartphone-Enabled Health Monitoring Devices vs Regular Follow-up on Blood Pressure Control Among Patients After Myocardial Infarction: A Randomized Clinical Trial.

Importance: Smart technology via smartphone-compatible devices might improve blood pressure (BP) regulation in patients after myocardial infarction. Objectives: To investigate whether smart technology in clinical practice can improve BP regulation and to evaluate the feasibility of such an intervention. Design, Setting, and Participants: This study was an investigator-initiated, single-center, nonblinded, feasibility, randomized clinical trial conducted at the Department of Cardiology of the Leiden University Medical Center between May 2016 and December 2018. Two hundred patients, who were admitted with either ST-segment elevation myocardial infarction or non-ST-segment acute coronary syndrome, were randomized in a 1:1 fashion between follow-up groups using smart technology and regular care. Statistical analysis was performed from January 2019 to March 2019. Interventions: For patients randomized to regular care, 4 physical outpatient clinic visits were scheduled in the year following the initial event. In the intervention group, patients were given 4 smartphone-compatible devices (weight scale, BP monitor, rhythm monitor, and step counter). In addition, 2 in-person outpatient clinic visits were replaced by electronic visits. Main Outcomes and Measures: The primary outcome was BP control. Secondary outcomes, as a parameter of feasibility, included patient satisfaction (general questionnaire and smart technology-specific questionnaire), measurement adherence, all-cause mortality, and hospitalizations for nonfatal adverse cardiac events. Results: In total, 200 patients (median age, 59.7 years [interquartile range, 52.9-65.6 years]; 156 men [78%]) were included, of whom 100 were randomized to the intervention group and 100 to the control group. After 1 year, 79% of patients in the intervention group had controlled BP vs 76% of patients in the control group (P = .64). General satisfaction with care was the same between groups (mean [SD] scores, 82.6 [14.1] vs 82.0 [15.1]; P = .88). The all-cause mortality rate was 2% in both groups (P > .99). A total of 20 hospitalizations for nonfatal adverse cardiac events occurred (8 in the intervention group and 12 in the control group). Of all patients, 32% sent in measurements each week, with 63% sending data for more than 80% of the weeks they participated in the trial. In the intervention group only, 90.3% of patients were satisfied with the smart technology intervention. Conclusions and Relevance: These findings suggest that smart technology yields similar percentages of patients with regulated BP compared with the standard of care. Such an intervention is feasible in clinical practice and is accepted by patients. More research is mandatory to improve patient selection of such an intervention. Trial Registration: ClinicalTrials.gov Identifier: NCT02976376.

Flipping The Practice Based Pathology Laboratory-Can It Support Development Of Practitioner Capability For Trainee Pathologists in Gynaecological Cytopathology?

This study investigated the role of 'flipping', the practice-based pathology laboratory and classroom to support the development of trainee pathologist practitioners' in the field of gynaecological cytopathology, addressing development of their knowledge and practical application in the clinical setting. Content-rich courses traditionally involve lecture led delivery which restricts tutors from adopting approaches that support greater student engagement in the topic area and application of knowledge to practice. We investigated the role of 'flipping', the practice-based pathology laboratory and classroom where 'virtual lectures' were accessed outside of 'class time' allowing more time for students to engage in active learning under the supervision of a consultant histopathologist. 'Flipping' was used to support two gynaecological cytopathology training courses with cohorts of eight trainee pathologists on the first course and six on the second. Lectures were made available to the trainees to watch before attending the workshops. The workshops consisted of group activities and individual practical exercises allowing trainees to review and report on patient practice cases with the support of their peers and tutors. Focus group sessions were held after each course, allowing trainee pathologists to reflect on their experiences. Discussions were transcribed and thematic analysis was used to capture key themes discussed by the trainees. Trainees' identified that 'flipping' provided them with more time during face-to-face sessions, enabling a greater depth of questioning and engagement with the consultant histopathologists. Having already watched the lectures, trainees were able to attend the sessions having identified areas in which they needed additional support and development. Trainee pathologists reported they had more time to concentrate on developing their skills and practise under the guidance of the consultant histopathologists so developing their capability in gynaecological cytopathology. The role of alternative methods of delivery such as 'flipping' is suggested for short courses designed to support practitioner capability and continued professional development.

Benchmark ab Initio Conformational Energies for the Proteinogenic Amino Acids through Explicitly Correlated Methods. Assessment of Density Functional Methods.

The relative energies of the YMPJ conformer database of the 20 proteinogenic amino acids, with N- and C-termination, have been re-evaluated using explicitly correlated coupled cluster methods. Lower-cost ab initio methods such as MP2-F12 and CCSD-F12b actually are outperformed by double-hybrid DFT functionals; in particular, the DSD-PBEP86-NL double hybrid performs well enough to serve as a secondary standard. Among range-separated hybrids, ωB97X-V performs well, while B3LYP-D3BJ does surprisingly well among traditional DFT functionals. Treatment of dispersion is important for the DFT functionals; for the YMPJ set, D3BJ generally works as well as the NL nonlocal dispersion functional. Basis set sensitivity for DFT calculations on these conformers is weak enough that def2-TZVP is generally adequate. For conformer corrections to heats of formation, B3LYP-D3BJ and especially DSD-PBEP86-D3BJ or DSD-PBEP86-NL are adequate for all but the most exacting applications. The revised geometries and energetics for the YMPJ database have been made available as Supporting Information and should be useful in the parametrization and validation of molecular mechanics force fields and other low-cost methods. The very recent dRPA75 method yields good performance, without resorting to an empirical dispersion correction, but is still outperformed by DSD-PBEP86-D3BJ and particularly DSD-PBEP86-NL. Core-valence corrections are comparable in importance to improvements beyond CCSD(T*)/cc-pVDZ-F12 in the valence treatment.

Assessment of CCSD(T)-F12 Approximations and Basis Sets for Harmonic Vibrational Frequencies.

We consider basis set convergence and the effect of various approximations to CCSD(T)-F12 for a representative sample of harmonic frequencies (the HFREQ2014 set). CCSD(T*)(F12*)/cc-pVDZ-F12 offers a particularly favorable compromise between accuracy and computational cost: its RMSD <3 cm(-1) from the valence CCSD(T) limit is actually less than the remaining discrepancy with the experimental value at the valence CCSD(T) limit (about 5 cm(-1) RMSD). CCSD(T)-F12a and CCSD(T)-F12b appear to benefit from error compensation between CCSD and (T).

The melatonin conformer space: benchmark and assessment of wave function and DFT methods for a paradigmatic biological and pharmacological molecule.

Reference quality conformational energies have been obtained for the 52 unique conformers of melatonin by means of explicitly correlated ab initio methods as well as the ccCA composite method. These data have then been used to evaluate more approximate methods, including a variety of density functionals both on their own and paired with various empirical dispersion corrections. Owing to the presence of internal contacts of the C-H···O and C-H···N variety, basis set convergence is much slower than for alkane conformers, for example, and basis sets of aug-cc-pVQZ or def2-QZVP quality seem to be required to obtain firm estimates of the basis set limit. Not just HF, but also many DFT functionals, will transpose the two lowest conformers unless empirical dispersion corrections are added. Somewhat surprisingly, many DFT functionals reproduce the reference data to fairly high accuracy when combined with the D3BJ empirical dispersion correction or the "nonlocal" Vydrov-Van Voorhis dispersion model. The two best performers including dispersion corrections are the double hybrids DSD-PBEP86-D3BJ and B2GP-PLYP-D; if no such correction is permitted, then M06-2X puts in the best performance. Of lower-cost ab initio-like models, MP2.5 yields the best performance, followed by SCS-MP2.

Assessment of subjective workload in an anaesthesia simulator environment: reliability and validity.

BACKGROUND AND OBJECTIVE: For the subjective assessment of workload, Borg's Rating of Perceived Exertion (RPE) scale is a global measure of perceived workload during anaesthesia induction, maintenance and emergence in the real workplace. In the present study, validity and reliability of the RPE scale were analysed for a full-scale simulator environment using scenarios of induction of general anaesthesia with and without critical incidents. METHODS: Seventeen anaesthetists (professional experience 1-30 years) participated in this randomised cross-over trial. Each participant rated their workload using the RPE scale after three different simulator sessions. No critical incident was simulated in the 1st session. In a randomised order, workload was increased by simulation of a critical incident in the 2nd or 3rd session. For the analysis of validity and reliability, univariate and multivariate regression analysis and the concordance correlation coefficient were used. RESULTS: RPE scores were significantly increased after managing a simulated critical incident [13.0, 95% confidence interval (CI) 11.6-14.5] compared to normal anaesthesia induction (9.4, 95% CI 8.2-10.6; P < 0.001). Reliability was moderate (concordance correlation coefficient = 0.55; 95% CI 0.13-0.80) for uneventful sessions. CONCLUSION: RPE scores were significantly increased after critical incidents during simulated anaesthesia induction and indicate good construct validity. Reliability may be impaired by the fact that the first session was announced to be without a critical incident. The RPE scale is easy to administer and a valid tool for subjective workload assessment in simulator settings. Reliability is moderate.

Economical post-CCSD(T) computational thermochemistry protocol and applications to some aromatic compounds.

To achieve a kilojoules-per-mole level of accuracy consistently in computational thermochemistry, the inclusion of post-CCSD(T) correlation effects cannot be avoided. Such effects are included in the W4 and HEAT computational thermochemistry protocols. The principal bottleneck in carrying out such calculations for larger systems is the evaluation of the T(3)-(T) term. We propose a cost-effective empirical approximation for this term that does not entail any reliance on experimental data. For first-row molecules, our W3.2lite protocol yields atomization energies with a 95% confidence interval of approximately 0.4 kcal/mol at the expense of introducing two such parameters. W3.2lite has been successfully applied to aromatic and aliphatic hydrocarbons such as benzene, fulvene, phenyl radical, pyridine, furan, benzyne isomers, trans-butadiene, cyclobutene, [1.1.1]propellane, and bicyclo[1.1.1]pentane. The W3.2lite predictions for fulvene, phenyl radical, cyclobutene, and [1.1.1]propellane are impossible to reconcile with experiment and suggest that remeasurement may be in order.

Basis set limit coupled cluster study of h-bonded systems and assessment of more approximate methods.

Hydrogen bonds are of utmost importance in both chemistry and biology. As the applicability of density functional theory and ab initio methods extends to ever larger systems and to liquids, an accurate description of such interactions is desirable. However, reference data are often lacking, and ab initio calculations are only possible and done in very small basis sets. Here, we present high level [CCSD(T)] ab initio reference calculations at the basis set limit on a large set of hydrogen-bonded systems and assess the accuracy of second-order perturbation theory (MP2). The possibilities of using basis set extrapolations for geometries and dissociation energies are discussed as well as the results of R12 methods and density functional and local correlation methods.

Social and economic impact of inflammatory arthritis.

The inflammatory arthritides place a substantial burden on society with direct healthcare costs and indirect costs due to reduced productivity and social function. These progressive conditions cause significant pain, joint destruction, and reduced function, and therefore also place a substantial disease burden on affected patients and their families. This article reviews the epidemiology, social impact, and disease costs associated with 3 common inflammatory arthritides--rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis.

Culturally competent care for Latino elders in long-term care settings.

The decision to place a family member in a long-term care (LTC) facility results in a variety of experiences for families. The experience of Latino families can be particularly problematic for the different relatives involved in the process. Placing a loved one in an LTC facility goes against cultural norms for Hispanic families that can lead to problems for both the family and the facility staff. Information about the cultural norms that are violated along with ways that the care providers and administrative staff can make adjustments in the environment to assist these residents will improve outcomes and meet the needs of diverse health care consumers.