Entire Journey Research Articles

Development of Assessment and Screening Tool to Assist with Prevention and Identification of Charcot Foot in Type 2 Diabetics

Development of Assessment and Screening Tool to Assist with Prevention and Identification of Charcot Foot in Type 2 Diabetics by Louise Wade MSN, RN MS, West Texas AM an additional goal was to develop practice guidelines for practitioners to assist in the early recognition, treatment, and referral of adult diabetic patients at risk for Charcot foot. Lippitt’s theory of change was used to guide the project. An interdisciplinary team of stakeholders was assembled to guide development of the tool, algorithm, and practice guidelines. Products were developed in accordance with evidence in current peer-reviewed literature and American Diabetes Association recommendations for Charcot foot diagnosis, treatment, and referral. Content was validated using a scale content validation instrument process to obtain input from experts in the care of Charcot foot. An implementation plan was developed to guide introduction of the products into practice, and an evaluation plan created to determine the extent to which intermediate term outcomes are met using these products. The project may contribute to social change by identifying patients at risk for Charcot foot prior to the onset of the complication, therefore preventing further injury, deformity, or amputation in populations that are often unable to afford quality healthcare. Development of Assessment and Screening Tool to Assist with Prevention and Identification of Charcot Foot in Type 2 Diabetics by Louise Wade MSN, RN MS, West Texas AM Dr. Stoerm Anderson for his constant support and encouragement throughout the project and for being a positive role model in my life; Dr. Deborah Lewis for her support and suggestions for a successful project completion and finally, Dr. Sandra Cadena as serving as the URR on this project and providing positive comments and encouragement. This entire journey would not have been possible without the encouragement and support of each of these people and I am eternally grateful.

Psychometric Validation of the BODY-Q in Danish Patients Undergoing Weight Loss and Body Contouring Surgery.

A well-developed patient-reported outcome instrument is needed for use in Danish bariatric and body contouring patients. The BODY-Q is designed to measure changes in important patient outcomes over the entire patient journey, from obesity to post-body contouring surgery. The current study aims to psychometrically validate the BODY-Q for use in Danish patients. The process consisted of 3 stages: translation and linguistic validation, field-test, and data analysis. The translation was performed in accordance with the International Society for Pharmacoeconomics and Outcomes Research and World Health Organization guidelines, and field-test data were collected in 4 departments in 2 different hospitals. Field-test data were analyzed using Rasch Measurement Theory. A total of 495 patients completed the Danish BODY-Q field-test 1-4 times, leading to a total of 681 assessments with an overall response rate at 76%. Cronbach α values were ≥ 0.90, and person separation index values were in general high. The Rasch Measurement Theory analysis provided broad support for the reliability and validity of the Danish version of the BODY-Q scales. Item fit was outside the criteria for 34 of 138 items, and of these, 21 had a significant chi-square P value after Bonferroni adjustment. Most items (128 of 138) had ordered thresholds, indicating that response options worked as intended. The Danish version of the BODY-Q is a reliable and valid patient-reported outcome instrument for use in Danish bariatric and body contouring patients.

Patient-Reported Outcomes in Weight Loss and Body Contouring Surgery: A Cross-Sectional Analysis Using the BODY-Q.

Health-related quality of life and satisfaction with appearance are important outcomes in bariatric and body contouring surgery. To investigate these outcomes, scientifically sound and clinically meaningful patient-reported outcome instruments are needed. The authors measured health-related quality of life and appearance in a cohort of Danish patients at different phases in the weight loss journey: before bariatric surgery, after bariatric surgery, before body contouring surgery, and after body contouring surgery. From June of 2015 to June of 2016, a cross-sectional sample of 493 bariatric and body contouring patients were recruited from four different hospital departments. Patients were asked to fill out the BODY-Q, a new patient-reported outcomes instrument designed specifically to measure health-related quality of life and appearance over the entire patient journey, from obesity to the post-body contouring surgery period. Data were collected using REDCap, and analyzed using SPSS software. For all appearance and health-related quality-of-life scales, the mean score was significantly lower in the pre-bariatric surgery group compared with the post-body contouring group. Furthermore, the correlation between body mass index and mean scores was significant for all appearance and health-related quality-of-life scales, with higher scores associated with lower body mass index. The mean score for the group reporting no excess skin compared with the group reporting a lot of excess skin was significantly higher for five of seven appearance scales and four of five health-related quality-of-life scales. This study provides evidence to suggest that body contouring plays an important role in the weight loss patient's journey and that patients need access to treatments.

Challenges experienced during rehabilitation after traumatic multiple rib fractures: a qualitative study

Background: People with multiple rib fractures rarely receive rehabilitation aimed specifically at their chest wall injuries. This research explores patient perceptions of rehabilitation and recovery.Materials and methods: A qualitative study exploring how a purposive sample of 15 people with traumatic multiple rib fractures at a Major Trauma Centre in the United Kingdom make sense of their recovery. Data collected during one-to-one interviews 4 to 9 months after injury. Transcripts analysed using Interpretative Phenomenological Analysis.Results: Struggling with breathing and pain: Difficulties with breathing and pain were initially so severe ?it takes your breath away? and people felt scared they may not survive. These symptoms gradually improved but feeling “out of puff” often persisted.Life on hold: Healing was considered a natural process which people couldn't influence, creating frustration whilst waiting for injuries to heal. Many believed they would never fully recover and accepted limitations.Lucky to be alive: All participants expressed a sense of feeling lucky to be alive. The seriousness of injury prompted a change in attitude to make the most of life.Conclusion: Rib fractures can be painful, but also frightening. A rehabilitation intervention promoting pain management, normalises trauma and restores physical activity may improve recovery.Implications for RehabilitationPatients identified challenges with rehabilitation throughout the entire recovery journey, and their rehabilitation needs evolved with time.People find it difficult to regain pre-injury fitness even after their fractures heal and pain subsides.A belief there is nothing that can be done to help rib fractures contributed to people lowering their expectations of achieving a full recovery and developing a sense of “making do”.Rehabilitation and patient education after traumatic multiple rib fractures should focus on improving pain management, respiratory fitness and emotional well-being.

The Energy-Efficient Operation Problem of a Freight Train Considering Long-Distance Steep Downhill Sections

With the energy consumption rising in rail transport, the railway sector is showing increasing interest in the energy-efficient operation of freight trains. Freight trains require more complicated driving strategies than ordinary passenger trains do due to their heavy loads, especially in the long-distance steep downhill (LDSD) sections that are very common in freight rail lines in China. This paper studies the energy-efficient operation of a freight train considering LDSD sections. An optimal control model including regenerative and pneumatic braking is developed for the freight train. Then, when a train leaves/enters the LDSD section, we verify the uniqueness of control transitions and discuss the speed profile linkage between LDSD and its adjacent sections, which indicates that the periodic braking should be applied on LDSD sections for optimality. Additionally, given the same running time for the entire journey, our analysis shows that electrical braking-full braking strategy is more energy-efficient than coasting-full braking strategy on LDSD sections. Finally, a numerical algorithm for the optimal driving solution is proposed. The simulation results demonstrate that the driving strategies generated by the proposed algorithm performs better than those from fuzzy predictive control and field operation regarding energy saving.

Troubleshooting Cardiac Resynchronization Therapy in Nonresponders

Heart failure (HF) is a critical health issue. Despite the advancements in pharmacotherapy, HF-related morbidity and mortality remains high. Cardiac resynchronization therapy (CRT) has been revolutionary in medically refractory, symptomatic HF patients with reduced ejection fraction and a prolonged, abnormal QRS complex. Although CRT affects electromechanical dys-synchrony resulting in favourable ventricular remodelling, improved functional capacity and clinical outcomes with fewer HF hospitalizations and better survival, the response to CRT is not uniform. A reported 20%-40% of patients, depending on the criteria used, are considered CRT nonresponders. Identifying a cause for nonresponse is challenging and often multifactorial and therefore requires a complete approach involving the entire patient journey. Effort to improve response includes careful consideration of selected patients, optimal therapy delivery, and comprehensive postimplantation care. Because of the prevalence of HF and generally poor prognosis, CRT provides an important treatment option, however, further research is needed to better understand reasons for CRT nonresponse and potential solutions.

Integrated Funding: Connecting the Silos for the Healthcare We Need

Once held in high esteem worldwide, Canadian healthcare has taken a drubbing in recent international comparisons, posting repeated poor showings against similarly high-spending OECD peers. The erosion in the worldwide status of Canadian healthcare has been attributed to the failure of the provinces to adapt their aging health systems to the changing face of healthcare demand. Since the late 1950s, the provinces have only tinkered at the margins of the Canadian healthcare delivery silos – a system that is arbitrarily divided among hospitals, specialists, and the provision of prescription drugs, primary care, and home and community care.This Commentary provides an overview of current payment models for provincial health services, focusing especially on areas where there is misalignment among the methods. Then, turning our attention beyond Canada, we examine a diverse range of international integrated payment reforms – defined here as models that distribute single payments or funding envelopes across groups of once disparately remunerated providers in order to foster shared financial incentives.A series of emerging policy reforms in the United States, the Netherlands, England, and Germany has attracted attention from international policymakers for going beyond the silos of traditional payment reforms in healthcare to introduce new financial flows that bridge sectors and settings. New models such as bundled payments and accountable-care organizations disburse single payments across groups of provider entities, offering shared financial incentives to improve coordination, efficiency, and effectiveness across a patient’s entire journey. Although still in their infancy, early evaluations have found compelling evidence of the potential for some of these models to reduce healthcare costs while maintaining or improving the quality of care.With a still relatively new federal government and the recent success of the pan-Canadian Pharmaceutical Alliance in providing a potential template for cross-provincial collaboration, the time appears ripe for collaboration on integrated payment reforms and greater sharing of experiences and expertise. Federal players such as Health Canada and the Canadian Institute for Health Information can have a strong role in facilitating this Canada-wide collaboration, with funding to facilitate transition, analytic tools that generate insights across the continuum, and information brokering among provinces.

TOWARDS SEAMLESS PASSENGER TRANSPORT: PERFORMANCE OF INTERMODAL APPROACHES

The growing demand for mobility in general and for air transport in particular puts increasing pressure on today’s transportation providers. Supplying sufficient capacity, hence alleviating potential congestion of the entire system, and ensuring seamless and efficient operation of the overall transport system are two of the main challenges for the future. The integration of transport modes along the entire passenger journey can help to streamline the current system and, thus, increase existing capacities as well as passenger comfort level. Today, there are already some approaches in place that interlink different transport modes by providing single ticketing, or specially dedicated interchange platforms. Four such intermodal transport models are assessed within this paper. For this purpose, a set of key performance indicators is developed and applied to evaluate the intermodal transport performance of each concept. Aspects such as journey time and costs as well as baggage through-handling are considered and data for each concept acquired. Based on the evaluation, the AIRail concept is ranked highest since it best meets the criteria of a seamless passenger journey. However, the results show that there is potential for improvement within each investigated concept.

Integrating Satisfaction and Cultural Background in the Customer Journey: A Method Development and Test

ABSTRACTThe purpose of this study was to develop and test a method to map the customer journey along the service process, integrating customer satisfaction and cultural background, and to improve the managerial applications of the customer journey method. This research applied a sequential mixed-method approach, with 34 clients participating in an observation technique and 6 customers participating in a semi-structured interview to define the restaurant customer journey and the influence of the Brazilian culture. Based on the results, an internet-mediated questionnaire was conducted among 131 participants to measure the customer satisfaction of the entire customer journey.

Striking the Optimal Solubility-Permeability Balance in Oral Formulation Development for Lipophilic Drugs: Maximizing Carbamazepine Blood Levels.

The purpose of this research was to investigate the performance of cosolvent based solubility-enabling formulations in oral delivery of lipophilic drugs, accounting for the gastrointestinal tract (GIT) luminal solubilization processes, the solubility-permeability interplay, and the overall in vivo systemic absorption. The poorly soluble antiepileptic agent carbamazepine was formulated in three cosolvent-based formulations: 20%, 60%, and 100% PEG-400, and the apparent solubility and rat permeability of the drug in these formulations were evaluated. The performance of the formulations in the dynamic GIT environment was assessed utilizing the biorelevant pH-dilution method. Then, the overall in vivo drug exposure was investigated following oral administration to rats. The three formulations showed dramatic solubility and permeability differences; the 100% PEG-400 provided the highest solubility enhancement and the 20% the poorest, while the exact opposite was evident from the permeability point of view. The dissolution results indicated that the 20% PEG-400 formulation crashes quickly following oral administration, but both the 60% and the 100% PEG-400 formulations allowed full solubilization of the dose throughout the entire GIT-like journey. The best in vivo performing formulation was the 60% PEG-400 (Fsys > 90%), followed by the 100% PEG-400 (Fsys = 76%), and the 20% PEG-400 formulation (Fsys ≈ 60%). In conclusion, this work demonstrates the in vivo solubility-permeability trade-off in oral delivery of lipophilic drugs; when a solubility-enabling formulation is developed, minimal threshold solubility should be targeted, that is just enough to allow solubilization of the drug dose throughout the GIT, while excess solubilizer should be avoided.

Picture of health: An artist’s journey through disease as told in his photographs

Abstract This is a phenomenological study of a photographer who used his artistic sensibilities to deal with a life-threatening illness, which became a life-changing journey. As J. was diagnosed with end-stage liver disease, knew he would die if he did not get a new liver, waited for that liver, went through the transplant surgery and subsequent surgeries, and recovered, he chronicled the entire journey with photographs. When diagnosed with a terminal illness, J. faced mortality and went through stages of grief and loss, as well as experiencing trauma, and used his photography to cope with this. J. also went through a process of transformation, whereby the patient moves through a five-stage trajectory of receiving the transplant, improving in hospital, improving at home, feeling well again, and reciprocating. J. continues on that journey with a commitment to health and life. Literature is reviewed regarding the stages of grief, loss, trauma and emotional state of transplant patients.

A new look at the rate of change of energy consumption with respect to journey time on an optimal train journey

We present a new derivation of a key formula for the rate of change of energy consumption with respect to journey time on an optimal train journey. We use a standard mathematical model (Albrecht et al., 2015b; Howlett, 2000; Howlett et al., 2009; Khmelnitsky, 2000; Liu and Golovitcher, 2003) to define the problem and show by explicit calculation of switching points that the formula also applies for all basic control subsequences within the optimal strategy on appropriately chosen fixed track segments. The rate of change was initially derived as a known strictly decreasing function of the optimal driving speed in a text edited by Isayev (1987, Section 14.2, pp 259–260) using an empirical resistance function. An elegant derivation by Liu and Golovitcher (2003, Section 3) with a general resistance function required an underlying assumption that the optimal strategy is unique and that the associated optimal driving speed is a strictly decreasing and continuous function of journey time. An earlier proof of uniqueness (Khmelnitsky, 2000) showed that the optimal driving speed decreases when journey time increases. A subsequent constructive proof (Albrecht et al., 2013a, 2015c) used a local energy minimization principle to find optimal switching points and show explicitly that the optimal driving speed is a strictly decreasing and continuous function of journey time. Our new derivation of the key formula also uses the local energy minimization principle and depends on the following observations. If no speed limits are imposed the optimal strategy consists of a finite sequence of phases with only five permissible control modes. By considering all basic control subsequences and subdividing the track into suitably chosen fixed segments we show that the key formula is valid on each individual segment. The formula is extended to the entire journey by summation. The veracity of the formula is demonstrated with an elementary but realistic example.

Improving Disruption Management With Multimodal Collaborative Decision-Making: A Case Study of the Asiana Crash and Lessons Learned

Transportation networks constitute a critical infrastructure enabling the transfers of passengers and goods, with a significant impact on the economy at different scales. Transportation modes are coupled and interdependent. The frequent occurrence of perturbations on one or several modes disrupts passengers' entire journeys, directly and through ripple effects. Collaborative decision-making has shown significant benefits at the airport level, both in the U.S. and in Europe. This paper examines how it could be extended to the multimodal network level, discusses the supporting evidence, and provides recommendations for implementation. A case study on the disruption management following the Asiana Crash at San Francisco International Airport is presented. The crash led to a large number of flight diversions to many airports, such as Oakland, Los Angeles, but also Seattle for instance, disrupting the journeys of thousands of passengers. Passenger reaccommodation varied greatly from airline to airline and airport to airport. First, a passenger-centric reaccommodation scheme is developed to balance costs and delays, for each diversion airport. Second, assuming better information sharing and collaborative decision-making, we show that there was enough capacity at the neighboring airports, Oakland and San Jose, to accommodate most of the diverted flights and reoptimize the allocation of flight diversions to the Bay Area airports. Based on this case study, recommendations for the adoption of multimodal CDM are elaborated. This paper paves the way for further data-driven research for increased resilience of passenger door-to-door journeys.

A multi-phase DES modelling framework for patient-centred care

We provide a framework for simulating the entire patient journey across different phases (such as diagnosis, treatment, rehabilitation and long-term care) and different sectors (such as GP, hospital, social and community services), with the aim of providing better understanding of such processes and facilitating evaluation of alternative clinical and care strategies. A phase-type modelling approach is used to promote better modelling and management of the specific elements of a patient pathway, using performance measures such as clinical outcomes, patient quality of life, and cost. The approach is illustrated using stroke disease. Approximately 5% of the United Kingdom National Health Service budget is spent treating stroke disease each year. There is an urgent need to assess whether existing services are cost-effective or new interventions could increase efficiency. This assessment can be made using models across primary and secondary care; in particular we evaluate the cost-effectiveness of thrombolysis (clot busting therapy), using discrete event simulation. Using our model, patient quality of life and the costs of thrombolysis are compared under different regimes. In addition, our simulation framework is used to illustrate the impact of internal discharge queues, which can develop while patients are awaiting placement. Probabilistic Sensitivity Analysis of the value parameters is also carried out.

Training practitioners in activity-based funding best practice

The provision of hospital and healthcare services occurs in one of the most complex organisational structures, which, while embracing continuing change in clinical practice, has concomitantly resisted change in the management functions of those services. The introduction of activity-based funding (ABF) has provided a significant challenge to healthcare management teams, which, faced with continuing budget restrictions and spiralling healthcare provision costs, have been forced to reconsider the design of healthcare management systems. The basis for ABF is the management of activity in the most efficient manner possible across the entire organisation. This requires a whole team approach that extends beyond the clinical service delivery team. Healthcare funding models are complex and there are few (if any) people in the organisation who have a full understanding of the entire patient journey through the system and who can conceptually relate that information to the design and implementation of that funding model. Clearly, in addition to a whole team approach to the challenges of health reform, organisations must invest in education and training. Using an ABF best practice model, this paper discusses how we can better educate the whole team, build skills required in each specialty domain and how we can work together in the identification of opportunities for improvement, from their initial analysis, through to practice change planning, implementation and monitoring.

Asymmetrical Processing of Olfactory Input in the Piriform Cortex Mediates "Activation" of the Avian Navigation Circuitry.

The role of odors in the long-distance navigation of birds has elicited intense debate for more than half a century. Failure to resolve many of the issues fueling this debate is due at least in part to the absence of controls for a variety of non-specific effects that odors have on the navigational process. The present experiments were carried out to investigate whether the olfactory inputs are involved only in "activation" of neuronal circuitry involved in navigation or are also playing a role in providing directional information. Experienced adult pigeons were exposed to controlled olfactory stimuli during different segments of the journey (release site vs. displacement + release site). Protein levels of IEGs (immediate early genes used to mark synaptic activity) were analyzed in areas within the olfactory/navigation avian circuitry. The results indicate that 1) exposure to natural odors at the release site (and not before) elicit greater activation across brain regions than exposure to filtered air, artificial odors, and natural odors along the entire outward journey (from home to the release site, inclusive); 2) activation of the piriform cortex in terms of odor discrimination is lateralized; 3) activation of the navigation circuitry is achieved by means of lateralized activation of piriform cortex neurons. Altogether, the findings provide the first direct evidence that activation of the avian navigation circuitry is mediated by asymmetrical processing of olfactory input occurring in the right piriform cortex.

A combinatorial problem on a directed graph

We consider two options for a particle’s entire journey through a certaindirectedgraph. Both options involve a random assignment to the journey route to be followed. We are interested in the option that offers, on average, the shortest route. Therefore, we determine the average journey length for each of the two options. As part of our analysis, we provesome combinatorial identities that appear to be new. Some suggestions for further work are given.

Curriculum and Learning the Course World Civilization at Bangladesh Islami University, Bangladesh

Pedagogy is critical aspect of classroom teaching at all educational levels and particularly in tertiary level. Globally there has no unique teaching style to educate undergrad students, despite most universities basically follow the old-fashioned lecturing style. To assess students’ learning, written examinations, assignments, presentation and field work are still followed while main emphasis put on formal examinations. World Civilization as a 100-mark mandatory course involving three credit for the third year law students in Bangladesh Islami University outlines wide coverage of the entire journey of human civilization that encompasses from the beginning of the universe to recent phenomena. The course vastly helps the students to extend their knowledge of different ancient, medieval and modern civilizations, major religions that immensely contributed the world, major wars that accelerated civilization growth and recent phenomena of world politics. This article about the pedagogy what I follow to educate undergrad students in and out of the classroom, curriculum what the department prescribed for them to understand the civilization and the assessment style what the university stipulated.

Living with uncertainty: Mapping the transition from pre-diagnosis to a diagnosis of dementia

Across the world, an early and timely diagnosis of dementia is seen to be a policy and practice imperative and a necessary step in order to live well with the condition. However, limited understanding exists regarding the personal and relational meanings attributed to the diagnostic experience. Drawn from the findings of a larger multi-site study conducted in four areas of England, this article presents a subset of the data where five participants and their carers and two people living alone initially presented themselves at a memory clinic for diagnostic testing, with this presentation eventually resulting in a confirmed, and shared, diagnosis of dementia. All 12 participants were interviewed at two time points in the study: at the time of first presentation to the memory clinic and shortly after the diagnosis had been shared with them. Informed by the grounded theory method, constant comparative analysis was applied to the data and this process resulted in a four-phase sequential model of diagnostic transition: (1) becoming self-aware→seeking outside help; (2) being referred→receiving a clinic appointment; (3) undergoing tests→being told what's wrong; and (4) adjusting to the diagnosis→negotiating everyday expectations. Running through each phase was the core category of ‘living with uncertainty’ which summarised the entire diagnostic journey for all study participants. Findings suggest a need for better awareness and information for people living with dementia at all phases and time points in the condition, which may be fostered by embedding these in early clinical encounters.

Multimodal Impact Analysis of an Airside Catastrophic Event: A Case Study of the Asiana Crash

Transportation networks constitute a critical infrastructure enabling the transfers of passengers and goods, with a significant impact on the economy at different scales. Transportation modes, whether air, road, or rail, are intrinsically coupled through passenger transfers and are interdependent. The frequent occurrence of perturbations on one or several modes disrupts passengers' entire journeys, directly and through ripple effects. This paper provides a case report of the Asiana crash in San Francisco International Airport (SFO) on July 6, 2013, and its repercussions on the multimodal transportation network. It studies the resulting propagation of disturbances on the transportation infrastructure in the USA, particularly on the U.S. air transport network and the ground transportation in the Bay Area. The perturbation takes different forms and varies in scale and time frame: cancelations and delays snowball in the airspace, with up to 86% of cancelations in the U.S. due to the SFO crash; highway traffic near the airport is impacted by congestion in previously not congested locations, with low speed and high delays on US 101; and transit passenger demand exhibits unusual traffic peaks in between airports in the Bay Area, with up to 180 passengers more per hour between SFO and Oakland International Airport Bay Area Rapid Transit stations. This paper also investigated the effect of the crash on the social media Twitter. This paper, through a case study, aims at stressing the importance of further data-driven research on interdependent infrastructure networks. The end goal is to form the basis for optimization models behind providing more reliable passenger door-to-door journeys and improved transport network resilience.