Advanced Program Research Articles

Drug-induced cholestasis (DIC) predictions based on in vitro inhibition of major bile acid clearance mechanisms.

Drug-induced cholestasis (DIC) is recognized as a major safety concern in drug development, as it represents one of the three types of drug-induced liver injury (DILI). Cholestasis is characterized by the disruption of bile flow, leading to intrahepatic accumulation of toxic bile acids. Bile acid regulation is a multifarious process, orchestrated by several hepatic mechanisms, namely sinusoidal uptake and efflux, canalicular secretion and intracellular metabolism. In the present study, we developed a prediction model of DIC using in vitro inhibition data for 47 marketed drugs on nine transporters and five enzymes known to regulate bile acid homeostasis. The resulting model was able to distinguish between drugs with or without DILI concern (p-value = 0.039) and demonstrated a satisfactory predictive performance, with the area under the precision-recall curve (PR AUC) measured at 0.91. Furthermore, we simplified the model considering only two processes, namely reversible inhibition of OATP1B1 and time-dependent inhibition of CYP3A4, which provided an enhanced performance (PR AUC = 0.95). Our study supports literature findings suggesting a contribution not only from a single process inhibition, but a rather synergistic effect of the key bile acid clearance processes in the development of cholestasis. The use of a quantitative model in the preclinical investigations of DIC is expected to reduce attrition rate in advanced development programs and guide the discovery and development of safe medicines.

The barriers and enablers to completing the RPS core advanced pharmacist credentialing programme via the CPPE/RPS pilot programme

Abstract Introduction The RPS and CPPE launched a pilot programme in March 2023 to support 300 pharmacists to evidence their advanced practice via an e-portfolio aligned to the RPS Core Advanced curriculum1 in a 12-week period. Successful pharmacists are credentialed as Advanced Pharmacists. The pilot involved CPPE education supervisors (ESs) support, an online learning platform and small group learning and support. Aim To ascertain barriers and enablers to completing an advanced e-portfolio and to identify how to improve the on-going programme. Methods The invitation to complete the anonymous survey in May 2024 was administered via www.onlinesurveys.ac.uk and developed linking to key performance indicators around education supervision support, to understand why candidates were deferring cohorts and to ascertain additional support accessed by candidates. Ethical approval was not required as study is service evaluation. Candidates who responded included those who successfully submitted their e-portfolio ‘submitted candidates’ n=10, candidates who are resubmitting their portfolio after not passing ‘resubmission candidates’ n=8, pharmacists currently completing their portfolio ‘current candidates’ n=44 and those who started but left without submitting ‘attrition candidates’ n=13. Results All submitted candidates scored ES support as very good/excellent; 60% agreed strongly they would not have submitted their portfolio without this support. Each cohort had two small-group tutorials where candidates accessed peer support and joined WhatsApp groups. Only 38% of resubmission candidates, compared to 80% of portfolio submitted candidates attended both group tutorials. Resubmission candidates were less likely to access additional peer support (38% for resubmission candidates vs 60% for submitted candidates) or to join the cohort WhatsApp group (75% for resubmission candidates vs 90% for submitted candidates). Resubmission candidates rated the remedial SMART action planning support highly. Submitted candidates would have found it easier to complete their portfolio with more comprehensive (60%) and timely responses (70%) from their collaborators. This compares to 55% and 59% of current candidates recognising the same issues. Submitted candidates wanted more allocated time during working hours to support completion of the portfolio (60% rising to 80% for current candidates). There is a notable increase for current candidates wanting a longer period to complete their portfolio (75% compared to 40% of submitted candidates). Half of submitted candidates (50%) reported spending more than 5 hours (average) each week on their portfolio compared to 18% of current candidates. Top reasons for attrition include too busy with work, family responsibilities, personal health challenges and no support from the workplace. Candidates across all groups suggested programme improvement ideas including more evidence examples, making the RPS platform less difficult to navigate and use, and more education supervisor support. Motivating factors for completion include recognition of advanced level working and preparation for the consultant portfolio. Conclusion Enablers include education supervision, CPPE resources/facilitated support events, peer support, WhatsApp groups, recognition and career progression. Key barriers include needing more time and lack of dedicated time at work to complete e-portfolio, lack of timely and comprehensive support from collaborators and finding the RPS e-portfolio platform difficult to navigate. Limitations – low numbers and response rate. Data collection is on-going. Reference 1. Royal Pharmaceutical Society, Core Advanced Pharmacist Curriculum, 2022 https://www.rpharms.com/Portals/0/Credentialing/RPS%20-%20Core%20Advanced%20curriculumFINAL.pdf?ver=8gc3s2aE9t1nZN37CSU7Lw%3d%3d (Accessed 28 May 2024)

Treatment Outcomes in Awake Endoscopy With Advanced Programming in Hypoglossal Nerve Stimulation.

Hypoglossal nerve stimulation (HNS) is a treatment option for patients with moderate-to-severe obstructive sleep apnea. In the post-implant period, awake endoscopy with advanced programming (AEAP) can be employed to improve apnea hypopnea index (AHI) reduction and/or patient comfort. This study describes response patterns to HNS after AEAP as well as patient-specific patterns in our patient population. Retrospective evaluation of 17 consecutive patients who underwent AEAP between June 2019 and December 2022. Post-AEAP AHIs were used to create 2 response groups, which facilitated analysis of patient-based characteristics. AHI reporting, deemed non-titration AHI (NT-AHI), is the whole-night AHI resulting from non-titration studies. Chi-squared, Pearson correlation coefficient, and independent samples t-test were used to determine significance deemed as P < .05. Fifteen of 17 patients (88.2%) presented for failed NT-AHI reduction, and 2/17 (11.8%) presented for comfort measures. Eleven patients (65%) showed an improvement in post-AEAP NT-AHI; 6 (35%) patients failed to improve. Four patients with either lateral wall collapse or concentric wall collapse at the tongue base failed to improve NT-AHI compared to a single patient who showed an improved NT-AHI (P = .017). Of the 2 patients who presented with discomfort, patient 1/2 demonstrated improvement in device usage, and patient 2/2 reported improved comfort while maintaining average device usage. AEAP is a powerful tool that offers the ability to identify settings conducive to increased therapy efficacy and improved treatment tolerability. Airway phenotypes are closely correlated with treatment efficacy, and as such, careful anatomical consideration of the upper airway must be performed when titrating therapy. Amongst the different treatment options for obstructive sleep apnea, hypoglossal nerve stimulation has been shown to be effective in positive-airway-pressure intolerant patients. This article explores response patterns to AEAP and highlights the importance of careful anatomical considerations of the upper airway. Level 3.

Using Multi-Sensor Data Fusion Techniques and Machine Learning Algorithms for Improving UAV-Based Yield Prediction of Oilseed Rape

Accurate and timely prediction of oilseed rape yield is crucial in precision agriculture and field remote sensing. We explored the feasibility and potential for predicting oilseed rape yield through the utilization of a UAV-based platform equipped with RGB and multispectral cameras. Genetic algorithm–partial least square was employed and evaluated for effective wavelength (EW) or vegetation index (VI) selection. Additionally, different machine learning algorithms, i.e., multiple linear regression (MLR), partial least squares regression (PLSR), least squares support vector machine (LS-SVM), back propagation neural network (BPNN), extreme learning machine (ELM), and radial basis function neural network (RBFNN), were developed and compared. With multi-source data fusion by combining vegetation indices (color and narrow-band VIs), robust prediction models of yield in oilseed rape were built. The performance of prediction models using the combination of VIs (RBFNN: Rpre = 0.8143, RMSEP = 171.9 kg/hm2) from multiple sensors manifested better results than those using only narrow-band VIs (BPNN: Rpre = 0.7655, RMSEP = 188.3 kg/hm2) from a multispectral camera. The best models for yield prediction were found by applying BPNN (Rpre = 0.8114, RMSEP = 172.6 kg/hm2) built from optimal EWs and ELM (Rpre = 0.8118, RMSEP = 170.9 kg/hm2) using optimal VIs. Taken together, the findings conclusively illustrate the potential of UAV-based RGB and multispectral images for the timely and non-invasive prediction of oilseed rape yield. This study also highlights that a lightweight UAV equipped with dual-image-frame snapshot cameras holds promise as a valuable tool for high-throughput plant phenotyping and advanced breeding programs within the realm of precision agriculture.

Novelty in Intelligent Controlled Oscillations in Smart Structures

Structural control techniques can be used to protect engineering structures. By computing instantaneous control forces based on the input from the observed reactions and adhering to a strong control strategy, intelligent control in structural engineering can be achieved. In this study, we employed intelligent piezoelectric patches to reduce vibrations in structures. The actuators and sensors were implemented using piezoelectric patches. We reduced structural oscillations by employing sophisticated intelligent control methods. Examples of such control methods include H-infinity and H2. An advantage of this study is that the results are presented for both static and dynamic loading, as well as for the frequency domain. Oscillation suppression must be achieved over the entire frequency range. In this study, advanced programming was used to solve this problem and complete oscillation suppression was achieved. This study explored in detail the methods and control strategies that can be used to address the problem of oscillations. These techniques have been thoroughly described and analyzed, offering valuable insights into their effective applications. The ability to reduce oscillations has significant implications for applications that extend to various structures and systems such as airplanes, metal bridges, and large metallic structures.

Assessing students' confidence in prescribing: contributing facilitators and constraints.

There is a growing number of non-medical prescribers in the UK. Practitioners working in advanced and specialist roles access university-based non-medical prescribing programmes to enhance their clinical practice. Despite this clinical and cultural shift, there is a paucity of literature and evidence on this issue. Using a mixed-methods approach of a focus group and the Likert survey, this study explored the experiences of specialist practice district nursing students undertaking non-medical prescribing. The findings of the study suggested that while the students felt supported by their teams, university and peers, there were limitations to the supervisors available and supervised prescribing opportunities, with a variance in the experiences of prescribing supervision. Further exploration into the experiences of prescribing supervision is warranted, as is the experience of prescribing students across multiple care settings.

Multi-parametric Analysis for Mixed Integer Linear Programming: An Application to Transmission Upgrade and Congestion Management

Upgrading the capacity of existing transmission lines is essential for meeting the growing energy demands, facilitating the integration of renewable energy, and ensuring the security of the transmission system. This study focuses on the selection of lines whose capacities and by how much should be expanded from the perspective of the Independent System Operators (ISOs) to minimize the total system cost. We employ advanced multi-parametric programming and an enhanced branch-and-bound algorithm to address complex mixed-integer linear programming (MILP) problems, considering multi-period time constraints and physical limitations of generators and transmission lines. To characterize the various decisions in transmission expansion, we model the increased capacity of existing lines as parameters within a specified range. This study first relaxes the binary variables to continuous variables and applies the Lagrange method and Karush-Kuhn-Tucker (KKT) conditions to obtain optimal solutions and identify critical regions associated with active and inactive constraints. Moreover, we extend the traditional branch-and-bound (B&B) method by determining the problem’s upper and lower bounds at each node of the B&B decision tree, helping to manage computational challenges in large-scale MILP problems. We compare the difference between the upper and lower bounds to obtain an approximate optimal solution within the decision-makers’ tolerable error range. In addition, the first derivative of the objective function on the parameters of each line is used to inform the selection of lines for easing congestion and maximizing social welfare. Finally, the capacity upgrades are selected by weighing the reductions in system costs against the expense of upgrading line capacities. The findings are supported by numerical simulations and provide transmission-line planners with decision-making guidance.

Creating a Model for Advanced Practice Provider Mentorship.

Advanced practice providers (APPs), widely considered essential to the delivery of healthcare, are one of the fastest-growing workforces in the United States. However, the APP role is evolving, and professional growth and advancement programs for APPs are still emerging at many institutions. Professional mentorship has been long embraced by other healthcare disciplines and numerous organizations because of the benefits gained from helping employees increase knowledge, enhance skills, and achieve scholarly goals, such as retention. Thus, there is a dearth of evidence on building effective APP mentorship models. This article details the development of an APP mentorship model and program designed to support both the mentor and mentee across the career trajectory.

Enhancing social skills: the impact of advanced physical education program development

Background: The cultivation of social behaviour during childhood and adolescence holds paramount importance, serving as a cornerstone for the establishment of robust interpersonal connections in subsequent stages of life, whether transitioning from adolescence to adulthood. Research Objective: This research aims to assess how implementing enhanced physical education influences social interactions and behaviour among adolescents. Methods: The study employed a pretest-posttest control group design, involving experimental and control groups randomly selected from high school students in the City of Aceh. The study’s population was drawn from class X students at a public high school in Aceh City, encompassing 4 classes with a total of 124 students. Cluster random sampling was employed as the sampling technique. The researcher randomly selected one class as the experimental group and another as the control group. The participants included two classes: 30 students from class 10B as the experimental group and 30 students from class 10D as the control group. Thus, the study involved a total of 60 participants. Social behaviour was evaluated using standardised questionnaires measuring various dimensions. The pre-test and post-test data analysis techniques were analysed using a homogeneity test, a normality test, and a Mann-Whitney test using SPSS version 22, with a significance threshold set at p &lt; 0.05. Finding/Result: The results indicate significant improvements in social behaviour among adolescents who underwent the enhanced physical education, sports, and health program compared to the control group. Conclusion: The findings underscore the importance of integrating comprehensive physical education into high school curricula to foster positive social development among adolescents.

A flexible programming and verification methodology for reconfigurable CNC woodworking machine

An advanced flexible programming methodology for CNC woodworking machines was developed. As the research starting base, a three-axis CNC woodworking machine was used. The developed methodology is proposed for programming, simulation, postprocessing, and machining by woodworking machine. This flexible programming method integrates the standard programming based on CAD, CAD/CAM systems, and STEP-NC protocol through different output files, enabling data interoperability during the realization of the machining tasks. The control system for the machine is configured based on the open-architecture software LinuxCNC to verify the flexible programming method and the results obtained. Programming verification was realized by simulation on a configured virtual machine in different programming environments and finally on a virtual machine integrated with the control system. The results obtained from the study were evaluated comparatively.

Integrated market scheduling with flexibility options

This work presents a generic optimization framework using advanced mixed-integer programming techniques to integrate day-ahead and balancing markets with distributed energy resources such as storage, electric vehicles, demand response, and Transmission and Distribution System Operators' coordination schemes. The day-ahead model determines optimal initial energy scheduling, while the balancing model optimizes energy and reserve products for three market designs with varying Transmission and Distribution System Operators’ coordination. The framework is applied to the interconnected Greek-Bulgarian-Romanian power system, considering 2030 installed capacities.The model outputs illustrate market coupling scenarios among Romania, Bulgaria, and Greece, highlighting clear price signals and distributed energy resources flexibility. Results reveal the significance of a diverse energy mix for energy security and show that Transmission and Distribution System Operators’ coordination significantly influences ancillary service prices, with reductions of up to 80 % in certain scenarios. Net demand values determine electricity flow direction. Flexibility providers like storage can cover up to 100 % of the upward congestion management requirements and 11 % of upward balancing energy, helping smooth energy allocation from intermittent renewables. The impact of electric vehicle penetration on generation scheduling is minimal. The proposed model offers valuable insights for system operators, market participants, and policymakers, enabling them to provide accurate price signals and optimize resource allocation.The integrated day-ahead and balancing market models support efficient renewable energy integration, emissions reduction, enhanced grid stability, and investment in low-carbon technologies. This aligns with the United Nations Framework Convention on Climate Change goals, contributing to the development of sustainable and resilient energy systems.

Clinical Simulation Program for the Training of Health Profession Residents in Confidentiality and the Use of Social Networks.

In the transition to a professional learning environment, healthcare professionals in their first year of specialized postgraduate clinical training (known as residents in Spain) are suddenly required to handle confidential information with little or no prior training in the safe and appropriate use of digital media with respect to confidentiality issues. The aims of this study were: (1) to explore the usefulness of an advanced clinical simulation program for educating residents from different healthcare disciplines about confidentiality and the dissemination of clinical data or patient images; (2) to explore the use of social networks in healthcare settings; and (3) to explore participants' knowledge and attitudes on current regulations regarding confidentiality, image dissemination, and the use of social networks; Methods: This was a cross-sectional study. Data were collected from all 49 first-year residents of different health professions at a Spanish hospital between June and August 2022. High-fidelity clinical simulation sessions designed to address confidentiality and health information dissemination issues in hospital settings, including the use of social networks, were developed and implemented. Data were assessed using a 12-item ad hoc questionnaire on confidentiality and the use of social media in the healthcare setting. Descriptive of general data and chi-square test or Fisher's exact test were performed using the SPSS 25.0 software; Results: All the participants reported using the messaging application WhatsApp regularly during their working day. A total of 20.4% of the participants stated that they had taken photos of clinical data (radiographs, analyses, etc.) without permission, with 40.8% claiming that they were unaware of the legal consequences of improper access to clinical records. After the course, the participants reported intending to modify their behavior when sharing patient data without their consent and with respect to how patients are informed; Conclusions: The use of advanced simulation in the training of interprofessional teams of residents is as an effective tool for initiating attitudinal change and increasing knowledge related to patient privacy and confidentiality. Further follow-up studies are needed to see how these attitudes are incorporated into clinical practice.

Three Types of Uncertainty: A Qualitative Study of Family Medicine Residents.

Many past studies have focused on uncertainty in medical practice, yet it is still not well understood in the field of family medicine, especially among residents. The aim of this study was to examine situations in which residents experience uncertainty and the coping strategies they use to deal with it. The results may have implications for advanced training programs and the specialist training in family medicine. We conducted semistandardized interviews with 15 residents and young family doctors from Hesse, Germany and asked them to describe cases in which they experienced uncertainty. In total, 40 cases were reported. Using established methods, we derived a coding system with different categories. Uncertainty occurred in a broad and heterogenous range of cases, and it often involved complex interaction of biomedical, interpersonal, and psychosocial factors. The participants described various strategies that were helpful in dealing with the three different types of uncertainty. To deal with biomedical uncertainty, the residents primarily found information-seeking and consulting more experienced colleagues to be useful. In dealing with interpersonal and psychosocial uncertainty, they applied reflective strategies. Participants suggested open communication and honest dialogue about uncertainty and the thematization of the topic at much earlier stages (eg, during medical studies). Family medicine residents experience uncertainty as an important part of their daily work. They do not necessarily interpret it as a negative phenomenon. Instead, uncertain situations often accompany learning effectiveness and an increase of self-confidence.

The Impact of Social Media Marketing on Consumer Purchase Intention and Customer Loyalty on E-commerce Websites

Thailand’s e-commerce industry has significantly improved in recent years, driven by widespread Internet access and smartphone adoption. The diverse online marketplace caters to the changing needs and preferences of Thai consumers. However, the impact of social media marketing on consumer purchase intention and loyalty to e-commerce sites has not received sufficient attention. This study focuses on online shopping platforms in Thailand to investigate the role of social media marketing in influencing consumer purchase intention and loyalty to e-commerce platforms. For this purpose, 400 online questionnaires were required for data collection and used for testing the hypothesis, based on the suitable statistics through the advanced statistical program. The findings indicated that demographic factors, consumer behavior, and social media engagement have significantly influenced consumer purchase intention. This research also highlighted implications for how e-commerce sites can enhance their marketing strategies and foster customer loyalty to their products. Keywords: social media marketing, purchase intention, customer loyalty

RELEVANCE OF COMPETENCE DEVELOPMENTAND ADVANCED TRAINING PROGRAMMES FOR PHYSICAL THERAPISTS WORKING IN PAEDIATRICS

Physical therapists in Ukraine complete six years of study (4 years of first (bachelor's) degree and 2 years of second (master's) degree) to obtain a speciality and diploma of physical therapist, which involves the acquisition of a number of professional competencies described in the relevant educational standards and curricula. These educational standards and the vast majority of educational programmes contain a minimum amount of paediatric physical therapy component. Therefore, additional training based on the competency-based approach in paediatrics is needed to enable physical therapists to provide effective, qualified services to children. The aim of the study is to substantiate the need to develop a list of competencies to improve the training of physical therapists in Ukraine who will specialise in paediatrics. Materials and methods. The study was conducted by questionnaire survey of physical therapists working in paediatrics from 1 to 14 September 2023. The questionnaire was developed to assess the need for advanced training programmes for physical therapists working in paediatrics, as well as to assess the areas of clinical activity and the level of competencies of specialists. Results. The survey involved 82 physical therapists working in paediatrics. Of the 82 physical therapists, 59 (71.9%) were representatives of public institutions, 13 - private, and 10 respondents did not indicate the type of institution. In 80.4% of physical therapists, the total length of service is equal to the length of service in paediatrics. Only 10.97% of the surveyed physical therapists agree with the statement that university education in Ukraine is sufficient to start an effective practice in paediatrics. 6.10% believe that there are sufficient opportunities for advanced training in paediatric physical therapy in Ukraine, while 21.95% disagree with this statement. The majority of respondents provide services on an outpatient basis, only 25.60% - in acute rehabilitation. Among the proposed areas of physical therapy in paediatrics, most physical therapists work with patients with musculoskeletal disorders (79.26%). The next area in terms of the number of physical therapists working in it is physical therapy in neurology (70.73%). Almost not covered areas in physical therapy for children were assistance in neonatal intensive care (only 8.53% of respondents work in this area) and assistance in intensive care units (only 12.19% gave an affirmative answer to the question about this area). Only 4.87% of respondents work with burns, 7.32% - with amputations, 24.4% - with cardiovascular and respiratory disorders. Few specialists are engaged in physical therapy for such complex conditions as Spina bifida (24.4%), spinal cord injury (21.95%) and traumatic brain injury (24.9%). In addition, 14.63% of the surveyed physical therapists indicated other areas of clinical activity. The total number of educational components in paediatric physical therapy is very low compared to the total number of all disciplines in educational and professional programmes. Conclusions. Practicing physical therapists believe that university education in Ukraine does not sufficiently develop professional competencies for work in paediatrics. It is advisable to form the competencies of a physical therapist in paediatrics, which would be the basis for improving university curricula, educational components and the development of postgraduate training programmes.

Midwives’ account of virtual reality childbirth education

In Finland, prenatal clinics and birthing hospitals struggle with resources to provide expectant parents with childbirth education (CBE) and a tour of the hospital birthing unit. Not preparing for birth is common, and not knowing how and where to give birth causes parents unnecessary stress during pregnancy. One new possibility to complement CBE is using virtual reality (VR) to deliver content. The aim of this study is to describe midwives' views of the status of parents' preparation for birth and provide information on the VR CBE program's advantages and challenges from the midwife's perspective. The study consisted of two focus group sessions with seven participants. Participants were midwives with experience from a hospital birthing ward and had provided childbirth education. The data was analysed using a thematic content analysis approach. According to the midwives, the parents do not prepare for birth well enough. Preparing for birth affects the parents' knowledge about childbirth, their cooperation with the healthcare personnel, and how they trust the birthing process, themselves, and the healthcare personnel. Preparation can also have adverse effects if the birthing person is trying to give birth with a detailed plan or has false expectations. Parents should focus on knowledge, attitude, and mental and physical exercise in preparing for childbirth. By preparing from trusted sources, parents can make informed decisions. They have the skills to stay calm, relaxed, and open-minded during labour and birth. Physical and mental exercise will help them cope with labour and relax their mind and bodies during birth. Midwives see VR as offering great potential for concrete, realistic, and flexible childbirth education that can address current challenges. They were also worried that VR could replace face-to-face contact. However, since there is minimal such contact in the current CBE, VR could enhance childbirth education and offer a realistic and concrete image of birth and a hospital tour. Midwives want families to prepare better for birth and work on their knowledge, attitude, and exercise. By preparing, parents understand childbirth, trust themselves, the birthing process, and the midwives; cooperation works better. Midwives see VR as an excellent addition to childbirth education by offering realistic and concrete online childbirth education. VR should not replace face-to-face contact.

Impact of advanced endoscopy training on colonoscopy quality and efficiency.

Few reports have detailed improvements in the quality of colonoscopies with continuous training post-fellowship completion. We examined the changes in colonoscopy performance among trainees during our advanced endoscopy training program. Screening or surveillance colonoscopies performed by 11 trainees who participated in our 3-year advanced endoscopy training program between April 2015 and March 2020 were retrospectively analyzed. Quality and efficiency metrics of colonoscopies were evaluated annually. Altogether, 297, 385, and 438 colonoscopies were enrolled in the first, second, and third training years, respectively. The mean insertion times were 8.6, 7.6, and 6.9 min in the first, second, and third training years, respectively, with significant improvement from the first to second year (p = 0.03) and from the first to third year (p < 0.01). The adenoma detection rate, proximal adenoma detection rate, and mean number of adenomas per patient exhibited a tendency to improve annually; however, the difference was not significant. Polypectomy efficiency was 10.5%, 11.2%, and 13.0%, with significant improvements from the first to third year (p < 0.01) and from the second to third year (p = 0.02). Insertion time and polypectomy efficiency showed significant improvements, especially among trainees experienced with <500 colonoscopies. Through our advanced endoscopy training program, there has been an improvement in the quality and efficiency of colonoscopy for trainees who have completed their fellowships, particularly those with <500 colonoscopies.

Impact of a pilot advanced provider-based comprehensive management program to support patients with immunotoxicity-related adverse events in a cancer care setting.

31 Background: Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of many types of cancers. Despite the clinical benefits of the targeted therapy, its use is associated with a spectrum of autoimmune side effects known as immune-related adverse events (irAEs). Toxicities are distinct from those associated with standard chemotherapy, and, if unrecognized and not managed aggressively, can become life-threatening. Early recognition and management of these toxicities, as well as approaches toward cautious retreatment following resolution is essential in clinical practice. Methods: As part of larger effort to provide efficient and proactive care to patients, advanced provider-based comprehensive management program was established in an academic hospital ambulatory setting to identify and manage the full spectrum of unique toxicities of patients receiving standard-of-care ICIs. The goal of the program was to manage patients with severe toxicity including seamless transitions of care between outpatient and inpatient settings to obviate the need for future acute care utilizations. The program provided real-time guidance to providers with clinical questions on use of ICIs, actively navigated patients with suspected immunotherapy toxicity and assessed ongoing education needs for both outpatient and inpatient services. A retrospective analysis of 2-year post implementation of the program was performed with inpatient to outpatient referrals as primary outcome and median length of stay and 30-day readmission rate as secondary outcomes. Results: A total of 388 inpatient admissions (222 Year-1 and 166 Year-2) were included. Preliminary analysis revealed a 25% decrease in immunotoxicity related inpatient admissions (admission rate decreased from 2.8 to 1.9) while patients treated with immunotherapy increased by 7%. The number of ambulatory encounters with the navigator increased by 40% (362 vs 509). The median length of stay for those on the dedicated program decreased by 27.3% (5.5 vs. 4 days) and the 30-day readmission rate decreased by 15.8% (24.3 vs. 20.5) from Year 1 to Year 2. Conclusions: Preliminary analysis suggests the program improved patient care, provided timelier follow-up and management, and reduced the delay to return to anti-cancer treatment. The ambulatory program provided proactive intervention, diagnosis, and management of immunotherapy related toxicities, preventing hospitalization and readmission to the hospital. Although initial findings suggest improved preliminary outcomes, further analysis is required to make any causal inference on the true and sustainable impact of the intervention.

Blue Thinking. Notas sobre um programa de formação avançada para a valorização dos recursos hídricos e a promoção da sustentabilidade social e ambiental através do design.

Blue Thinking is the concept and methodology behind the Blue Design Alliance. A new advanced higher education programme focused on the enhancement of water, ocean and river resources, as well as social and environmental sustainability through the application of design tools and methodologies. ESAD - Escola Superior de Artes e Design is promoting the Blue Design Alliance - an alliance between four higher education institutions dedicated to one of our planet's most precious resources: water. This programme presents a funded and innovative training offer, using design as a driver for a more sustainable life. The proximity of the sea, the growing concern about climate change and the urgent need to adopt more sustainable and responsible practices were the main reasons for the creation of the Blue Design Alliance, whose mission is to contribute to the training of skills linked to the blue economy. In this article, we describe its practical-orientated methodology, geared towards the professional career of trainees, with a clear concern for the sustainability of ecosystems.

Modelling the front dynamics of invasive plant pathogens through the analysis of spatial gradients

AbstractVariables of phytopathological interest correlated to the impact of plant diseases, such as incidence and severity, may display a spatial pattern resulting from an underlying, yet unknown gradient. Along the main direction of the gradient the variable assessed at the site level either increases, or decreases. Spatial gradients may also arise because of the movement of a front of invasion, an imaginary moving contour separating areas already infested by a plant pathogen from those still pathogen-free. Adequate geostatistical tools may shed light on gradients directional properties, as well as on the direction the front of invasion is coming from or moving to. Tools currently available for that may be impractical due to the advanced computational and programming skills required for their application. Hence, the goals of this study were: (I) to develop, test and validate a new user-friendly geostatistical tool named DirGrad (Direction of Gradient) aimed at analyzing spatial gradients resulting from the impact of plant diseases; (II) to build an algorithm able to run DirGrad on R, one the most widespread open source software for statistics; and (III) to apply DirGrad for the ex post modelling of the invasion front dynamics. The designed algorithm was successfully validated both in silico and in the field by using data from real case studies such as those of the invasive fungal pathogens Heterobasidion irregulare and Ophiostoma novo-ulmi in a forest stand of Central Italy and across the Swedish island of Gotland, respectively. The algorithm is released as a user-friendly open-source script.