Monitoring Of Individuals Research Articles

Evaluation of community pharmacist follow-up supported by the use of healthcare technology for type 2 diabetes patients

BackgroundPrevalence of type 2 diabetes is high in Belgium (estimated at over 10%, 1 patient out of 3 being unaware of their diagnosis). Management based on a change of lifestyle and the adoption of health-promoting behaviors, supplemented when needed with drug treatment, prevents complications, improves the patient's quality of life and reduces mortality. Multidisciplinary patient support is essential. In this, pharmacists have a key role, e.g. through therapeutic patient education activities, in which they are increasingly involved. Moreover, research suggests that the use of mobile technologies can be a useful tool for helping patients with their daily life and disease management. ObjectivesThis study aims at exploring the benefits of community pharmacist follow-up supported by the use of mobile technologies in the monitoring of individuals with type 2 diabetes. The presented intervention aimed to reinforce the patients' willingness to actively participate in the management of their disease and to adopt favorable health behaviors, in order to increase their level of medication adherence. MethodsA quantitative quasi-experimental study was conducted in community pharmacies throughout Belgium over a 6-month period with 3 data collection periods (before, during and after the intervention). Primary outcomes, related to the level of medication adherence, and secondary outcomes, considered as markers of the patient's overall health, were analyzed. In addition, qualitative data concerning participants' opinions on their experience were collected. Results66 patients participated in the study, with 50 remaining after 3 months and 46 completing the entire study. Statistical analyses did not show an improvement in the level of medication adherence. This parameter was high from the beginning, reflecting patients with controlled diabetes. However, statistically significant results were observed for systolic blood pressure and waist circumference (both improved), while other outcomes showed a positive trend or remained stable. Patient follow-up by the pharmacist was a positive experience for both parties which noted their interest and satisfaction for the project. ConclusionsAlthough clinical results are not conclusive, patients were motivated and the attrition rate was low. Participants showed their interest in participating in this kind of project, opening up opportunities for further studies in the community pharmacy setting. As front-line health professionals, community pharmacists certainly have a key-role to play in therapeutic patient education and mobile technologies could be additional tools in this process.

National institutions to limit the spread of drugs in Iraq after 2003

Each country seeks, through its internal policies, to combat any crime or phenomenon that occurs on its territory or in areas under its sovereignty, including the drug phenomenon. The responsibility for confronting this problem, treating it, and finding effective solutions lies with the state and its political system. The government's control over all areas, as well as the strict monitoring of individuals, leads to reducing the risk of this problem, and this is clearly evident in Iraq as a result of the political situation and the security chaos that was reflected in the role of successive governments after 2003 in finding relevant measures to address this phenomenon and develop appropriate solutions to it. In this research, we will discuss the most important treatments at the security, health, media and awareness levels of the drug phenomenon

Asymptomatic infection with clade 2.3.4.4b highly pathogenic avian influenza A(H5N1) in carnivore pets, Italy, April 2023.

In April 2023, an outbreak of clade 2.3.4.4b highly pathogenic avian influenza A(H5N1) viruses carrying the T271A mammalian adaptive mutation in the PB2 protein was detected in a backyard poultry farm in Italy. Five domestic dogs and one cat living on the premises had seroconverted in the absence of clinical signs. Virological and serological monitoring of individuals exposed to the virus proved the absence of human transmission, however, asymptomatic influenza A(H5N1) infections in mammalian pets may have important public health implications.

Increased Risk of Thyroid Eye Disease Following Covid-19 Vaccination.

SARS-CoV-2 infection and Covid-19 vaccines have been associated with thyroid disorders. We analyzed the risk of thyroid eye disease (TED) following Covid-19 vaccination. This was a self-controlled case series study at a tertiary referral center for TED. A total of 98 consecutive patients with newly developed (n = 92) or reactivated (n = 6) TED occurring between January 1, 2021, and August 31, 2022, were included. TED was assessed in patients undergoing Covid-19 vaccination. Person-days were defined as exposed if TED occurred 1 to 28 days after vaccination, and unexposed if occurring outside this time window. Conditional Poisson regression models were fitted to calculate incidence rate ratio (IRR) and 95% CI of exposed vs unexposed. Sensitivity analyses were conducted considering different exposed periods, and effect modification by potential TED risk factors. Covid-19 vaccines were administered in 81 people, 25 (31%) of whom developed TED in exposed and 56 (69%) in unexposed periods. The IRR for TED was 3.24 (95% CI 2.01-5.20) and 4.70 (95% CI 2.39-9.23) in patients below 50 years of age. Sex, smoking, and radioiodine treatment did not modify the association between TED and vaccination. TED risk was unrelated to the number of vaccine doses, and progressively decreased over time following vaccination (P trend = .03). The risk of TED was significantly increased after Covid-19 vaccination, especially in people below 50 years of age. Possible mechanisms include spike protein interaction with the angiotensin-converting enzyme II receptor, cross-reactivity with thyroid self-proteins, and immune reactions induced by adjuvants. We suggest monitoring of individuals undergoing Covid-19 vaccination, especially if young and at risk for autoimmunity.

Model and Empirical Data-Based Cost-Utility Studies of Continuous Glucose Monitoring in Individuals with Type 1 Diabetes: A Protocol of a Systematic Review on Methodology and Quality.

This review aims to critically appraise differences in methodology and quality of model-based and empirical-data-based cost-utility studies to address key limitations, opportunities, and challenges to inform future cost-utility analyses of continuous glucose monitoring (CGM) in type 1 diabetes. This protocol is registered at PROSPERO (CRD42023391284). The review will be conducted in accordance with the PRISMA guideline for systematic reviews. Searches will be conducted in MEDLINE, Embase, Web of Science, Cochrane Library, and Econlit from 2000 to January 2023. Model and empirical data-based studies evaluating the cost-utility of any CGM system in type 1 diabetes will be considered for inclusion. Studies that only report on cost per life year or any other clinical outcome, or reporting only costs or only clinical outcomes studies in type 2 diabetes populations, and studies on bi-hormonal closed loops and do-it-yourself hybrid closed loop devices will be excluded. Two reviewers will independently screen each study for inclusion. Data on the intervention, population, model settings (such as perspective, time horizon), model type and structure, clinical outcomes used to populate the model, validation, and uncertainty will be extracted and qualitatively synthesised. Quality will be assessed using the Philips etal. 2006 (model-based studies) or Consensus Health Economic Criteria (empirical data-based studies) checklists. Model validation will be assessed using the AdViSHE checklist. Now that CGM is being used more broadly in practice, critical appraisal of existing cost-utility methodology and quality is important to inform future cost-utility analyses of CGM in type 1 diabetes in various settings.

Coverage for Continuous Glucose Monitoring for Individuals with Type 2 Diabetes Treated with Nonintensive Therapies: An Evidence-Based Approach to Policymaking.

Numerous studies have demonstrated the clinical benefits of continuous glucose monitoring (CGM) in individuals with type 1 diabetes (T1D) and type 2 diabetes (T2D) who are treated with intensive insulin regimens. Based on this evidence, CGM is now a standard of care for individuals within these diabetes populations and widely covered by commercial and public insurers. Moreover, recent clinical guidelines from the American Diabetes Association and American Association of Clinical Endocrinology now endorse CGM use in individuals treated with nonintensive insulin regimens. However, despite increasing evidence supporting CGM use for individuals treated with less-intensive insulin therapy or noninsulin medications, insurance coverage is limited or nonexistent. This narrative review reports key findings from recent randomized, observational, and retrospective studies investigating use of CGM in T2D individuals treated with basal insulin only and/or noninsulin therapies and presents an evidence-based rationale for expanding access to CGM within this population.

Residual β-Cell Function Is Associated With Longer Time in Range in Individuals With Type 1 Diabetes.

Little is known about the influence of residual islet function on glycemic control in type 1 diabetes (T1D). We investigated the associations between residual β-cell function and metrics of continuous glucose monitoring (CGM) in individuals with T1D. In this cross-sectional cohort comprising 489 individuals (64% female, age 41.0 ± 14.0 years), T1D duration was 15.0 (interquartile range [IQR] 6.0-29.0) years. Individuals had a time in range (TIR) of 66% (IQR 52-80%) and a urinary C-peptide-to-creatinine ratio (UCPCR) of 0.01 (IQR 0.00-0.41) nmol/mmol. To assess β-cell function, we measured UCPCR (detectable >0.01 nmol/mmol), and to assess α-cell function, fasting plasma glucagon/glucose ratios were measured. CGM was used to record TIR (3.9-10 mmol/L), time below range (TBR) (<3.9 mmol/L), time above range (TAR) (>10 mmol/L), and glucose coefficient of variance (CV). For CGM, 74.7% used FreeStyle Libre 2, 13.8% Medtronic Guardian, and 11.5% Dexcom G6 as their device. The percentage of patients with T1D who had a detectable UCPCR was 49.4%. A higher UCPCR correlated with higher TIR (r = 0.330, P < 0.05), lower TBR (r = -0.237, P < 0.05), lower TAR (r = -0.302, P < 0.05), and lower glucose CV (r = -0.356, P < 0.05). A higher UCPCR correlated negatively with HbA1c levels (r = -0.183, P < 0.05) and total daily insulin dose (r = -0.183, P < 0.05). Glucagon/glucose ratios correlated with longer TIR (r = 0.234, P < 0.05). Significantly longer TIR, shorter TBR and TAR, and lower CV were observed in individuals with greater UCPCR-assessed β-cell function. Therefore, better CGM-derived metrics in individuals with preserved β-cell function may be a contributor to a lower risk of developing long-term complications.

Systemic Arterial Oxygen Levels Differentiate Pre- and Post-capillary Predominant Hemodynamic Abnormalities During Exercise in Undifferentiated Dyspnea on Exertion

Whether systemic oxygen levels (SaO2) during exercise can provide a window into invasively derived exercise hemodynamic profiles in patients with undifferentiated dyspnea on exertion is unknown. We performed cardiopulmonary exercise testing with invasive hemodynamic monitoring and arterial blood gas sampling in individuals referred for dyspnea on exertion. Receiver operator analysis was performed to distinguish heart failure with preserved ejection fraction from pulmonary arterial hypertension. Among 253 patients (mean ± SD, age 63 ± 14 years, 55% female, arterial O2 [PaO2] 87 ± 14 mmHg, SaO2 96% ± 4%, resting pulmonary capillary wedge pressure [PCWP] 18 ± 4mmHg, and pulmonary vascular resistance [PVR] 2.7 ± 1.2 Wood units), there was no exercise PCWP threshold, measured up to 49 mmHg, above which hypoxemia was consistently observed. Exercise PaO2 was not correlated with exercise PCWP (rho = 0.04; P = 0.51) but did relate to exercise PVR (rho = -0.46; P < 0.001). Exercise PaO2 and SaO2 levels distinguished left-heart-predominant dysfunction from pulmonary-vascular-predominant dysfunction with an area under the curve of 0.89 and 0.89, respectively. Systemic O2 levels during exercise distinguish relative pre- and post-capillary pulmonary hemodynamic abnormalities in patients with undifferentiated dyspnea. Hypoxemia during upright exercise should not be attributed to isolated elevation in left heart filling pressures and should prompt consideration of pulmonary vascular dysfunction.

Updated consensus guidelines on the management of Phelan-McDermid syndrome.

Phelan-McDermid syndrome (PMS) is a genetic condition caused by SHANK3 haploinsufficiency and characterized by a wide range of neurodevelopmental and systemic manifestations. The first practice parameters for assessment and monitoring in individuals with PMS were published in 2014; recently, knowledge about PMS has grown significantly based on data from longitudinal phenotyping studies and large-scale genotype-phenotype investigations. The objective of these updated clinical management guidelines was to: (1) reflect the latest in knowledge in PMS and (2) provide guidance for clinicians, researchers, and the general community. A taskforce was established with clinical experts in PMS and representatives from the parent community. Experts joined subgroups based on their areas of specialty, including genetics, neurology, neurodevelopment, gastroenterology, primary care, physiatry, nephrology, endocrinology, cardiology, gynecology, and dentistry. Taskforce members convened regularly between 2021 and 2022 and produced specialty-specific guidelines based on iterative feedback and discussion. Taskforce leaders then established consensus within their respective specialty group and harmonized the guidelines. The knowledge gained over the past decade allows for improved guidelines to assess and monitor individuals with PMS. Since there is limited evidence specific to PMS, intervention mostly follows general guidelines for treating individuals with developmental disorders. Significant evidence has been amassed to guide the management of comorbid neuropsychiatric conditions in PMS, albeit mainly from caregiver report and the experience of clinical experts. These updated consensus guidelines on the management of PMS represent an advance for the field and will improve care in the community. Several areas for future research are also highlighted and will contribute to subsequent updates with more refined and specific recommendations as new knowledge accumulates.

Barriers to and Facilitators of Using Remote Measurement Technology in the Long-Term Monitoring of Individuals With ADHD: Interview Study.

Remote measurement technology (RMT) has the potential to address current research and clinical challenges of attention-deficit/hyperactivity disorder (ADHD) symptoms and its co-occurring mental health problems. Despite research using RMT already being successfully applied to other populations, adherence and attrition are potential obstacles when applying RMT to a disorder such as ADHD. Hypothetical views and attitudes toward using RMT in a population with ADHD have previously been explored; however, to our knowledge, there is no previous research that has used qualitative methods to understand the barriers to and facilitators of using RMT in individuals with ADHD following participation in a remote monitoring period. We aimed to evaluate the barriers to and facilitators of using RMT in individuals with ADHD compared with a group of people who did not have a diagnosis of ADHD. We also aimed to explore participants' views on using RMT for 1 or 2 years in future studies. In total, 20 individuals with ADHD and 20 individuals without ADHD were followed up for 10 weeks using RMT that involved active (questionnaires and cognitive tasks) and passive (smartphone sensors and wearable devices) monitoring; 10 adolescents and adults with ADHD and 12 individuals in a comparison group completed semistructured qualitative interviews at the end of the study period. The interviews focused on potential barriers to and facilitators of using RMT in adults with ADHD. A framework methodology was used to explore the data qualitatively. Barriers to and facilitators of using RMT were categorized as health-related, user-related, and technology-related factors across both participant groups. When comparing themes that emerged across the participant groups, both individuals with and without ADHD experienced similar barriers and facilitators in using RMT. The participants agreed that RMT can provide useful objective data. However, slight differences between the participant groups were identified as barriers to RMT across all major themes. Individuals with ADHD described the impact that their ADHD symptoms had on participating (health-related theme), commented on the perceived cost of completing the cognitive tasks (user-related theme), and described more technical challenges (technology-related theme) than individuals without ADHD. Hypothetical views on future studies using RMT in individuals with ADHD for 1 or 2 years were positive. Individuals with ADHD agreed that RMT, which uses repeated measurements with ongoing active and passive monitoring, can provide useful objective data. Although themes overlapped with previous research on barriers to and facilitators of engagement with RMT (eg, depression and epilepsy) and with a comparison group, there are unique considerations for people with ADHD, for example, understanding the impact that ADHD symptoms may have on engaging with RMT. Researchers need to continue working with people with ADHD to develop future RMT studies for longer periods.

134-LB: Real-World Impact of Intermittently Scanned Continuous Glucose Monitoring on Hemoglobin A1c in People with Type 2 Diabetes in Canada That Use Basal Insulin—A Prospective Chart Review

The change in HbA1c after initiating FreeStyle Libre or FreeStyle Libre 2 Flash Glucose Monitoring System (FSL and FSL2) in adults with type 2 diabetes (T2D) in a real-world setting was evaluated over a 3-6 month period. Nine sites in Canada collected medical record data prospectively for adults who had started FSL or FSL2 in the last 3 months and with the following criteria: a basal insulin regimen with or without additional glucose lowering medications, and HbA1c 8.0-12.0%. Preliminary data were analysed from 79/138 medical records (n=138; 6 records ineligible, 53 no follow up, ineligible HbA1c or had stopped FSL or FSL2). Participants had the following baseline characteristics (mean±SD): HbA1c 8.9%±0.8, age 67.3±11.5 years (57% ≥65 years), BMI 30.1±6.2 (n=65), insulin use duration 5.3±3.9 years, and 54% were males. The most commonly used non-insulin glucose lowering medications included metformin (87.3%), sodium-glucose co-transporter-2 (SGLT2) inhibitors (62.0%) and sulphonylureas (46.8%). By the end of the study (3-6 months after the index date), mean HbA1c was reduced by 0.6%±1.1 to 8.3%±1.0 (p&amp;lt;0.0001). Observed changes in antihyperglycemic medications from baseline included increased use of GLP-1 agonists from 44.3% to 51.9% and decreased use of DPP4i from 24.1% to 16.5%. This prospective chart review study found that initiating intermittently scanned continuous glucose monitoring in individuals with T2D treated with basal insulin plus other glucose lowering medications was associated with significantly improved HbA1c over a 3-6 month period. Disclosure A. Abitbol: Advisory Panel; Abbott Diabetes, Lilly Diabetes, Dexcom, Inc., Novo Nordisk Canada Inc., Janssen Pharmaceuticals, Inc., Research Support; Abbott Diabetes, Lilly Diabetes, Zucara Therapeutics, Novo Nordisk Canada Inc., Moderna, Inc., Senseonics, Speaker's Bureau; Boehringer Ingelheim (Canada) Ltd., Lilly Diabetes, Amgen Canada, Dexcom, Inc., Novo Nordisk Canada Inc., HLS Therapeutics Inc., Janssen Pharmaceuticals, Inc., Merck &amp; Co., Inc., Sanofi. A. B. Jain: Advisory Panel; Abbott, Amgen Canada, Dexcom, Inc., AstraZeneca, Novo Nordisk, Bayer Inc., Insulet Corporation, Takeda Canada, Boehringer Ingelheim (Canada) Ltd., Eli Lilly and Company, Research Support; Abbott, Amgen Canada, Novo Nordisk, Speaker's Bureau; Abbott, Amgen Canada, Dexcom, Inc., AstraZeneca, Novo Nordisk, Bausch Health, Canada, Boehringer Ingelheim (Canada) Ltd., Eli Lilly and Company, Pfizer Inc. M. Tsoukas: Speaker's Bureau; Novo Nordisk Canada Inc., Boehringer Ingelheim (Canada) Ltd., Eli Lilly and Company, Janssen Scientific Affairs, LLC, AstraZeneca, Sanofi. J. Sigalas: None. B. P. Galm: Advisory Panel; Abbott, Boehringer Ingelheim (Canada) Ltd., Novo Nordisk Canada Inc., Pfizer Inc., Research Support; Abbott, Speaker's Bureau; Abbott, Dexcom, Inc., Pfizer Inc. J. Lee: Advisory Panel; Amgen Canada, Research Support; Novo Nordisk, Lilly, Abbott, Speaker's Bureau; Amgen Canada, Canadian Collaborative Research Network, AstraZeneca, Pfizer Inc. K. S. Qureshy: Advisory Panel; Novo Nordisk, Other Relationship; Novo Nordisk, Novo Nordisk, Research Support; Abbott Diagnostics, Novo Nordisk, Speaker's Bureau; AstraZeneca. C. Collins: None. V. C. Woo: Advisory Panel; Abbott, Speaker's Bureau; Dexcom, Inc. Funding Abbott Diabetes Care

1273-P: Guidance to Persons Who Screen Positive for Islet Autoantibodies and Their Health Care Providers—Ask the Experts

Objective: Detecting early-stage type 1 diabetes (T1D) by screening for islet autoantibodies (IA) can prevent serious morbidity at clinical onset and allow for a trial prevention, e.g., FDA-approved teplizumab therapy. The Ask the Experts program provides confirmation of positive screening results, monitoring, and education for individuals who screen positive for IA as well as their families and health care providers (HCPs). Methods: Individuals and HCPs concerned for T1D (e.g., screen positive for IA) can enroll in Ask the Experts via phone, e-mail or website. We recommend and facilitate screening or confirmation of IA status and collect demographic and clinical data. When IA positivity is confirmed, we partner with HCPs to provide early T1D training and collaborative follow-up, customized to HCP interest and clinical capacity. Results: We have enrolled 71 participants to date, mostly youth (83%), aged 1 to 62 years (61% female; 79% non-Hispanic white). Most referrals were for confirmation of IA results (52%) or HCP concern for early T1D based on dysglycemic HbA1c or glucose (30%). IA were measured at 6 commercial laboratories, including the Barbara Davis Center Autoantibody Laboratory with 53% screening positive for a single IA and 47% for multiple IA. The most common IA detected was insulinoma antigen-2 IA (48%) with glutamic decarboxylase 65 and insulin IAs both present in 41% of those who screened positive. Of those who presented with one or more IA on screening, 66% were negative for all four major IA on confirmation testing completed at the Barbara Davis Center Autoantibody Laboratory. 80% of individuals confirmed IA positive have engaged in remote monitoring while 20% have been followed by their local HCP with our training and support. Conclusion: Persons who screen positive for IA should have confirmation testing completed given the discordance between screening and confirmation results. HCPs require support for following screening detected individuals. Disclosure K.M.Simmons: Advisory Panel; Provention Bio, Inc., Consultant; Dexcom, Inc., Provention Bio, Inc., Research Support; Novartis. K.A.Bautista: None. C.Geno rasmussen: None. R.Karban: None. H.K.O'donnell: None. B.I.Frohnert: Advisory Panel; Provention Bio, Inc. A.Steck: None. M.Rewers: Research Support; Provention Bio, Juvenile Diabetes Research Foundation (JDRF), Hemsley Charitable Trust, Dexcom, Inc., Janssen Research &amp; Development, LLC. Funding The Leona M. and Harry B. Helmsley Charitable Trust

Assessing the Influential Factors Associated with Medication Non-adherence and Self-care Practices Among Type 2 Diabetes Mellitus Patients in Tripoli, Libya

Influential factors causing poor adherence to antidiabetic medications and self-care practices among type 2 diabetes mellitus (T2DM) patients have not been reported before in Libya. To assess such factors that contribute to non-adherence, a single health facility, cross-sectional descriptive study was carried out on T2DM patients attending the NCDE in Tripoli/ Libya; using a pre-tested questionnaire. Crude odds ratios in the binary logistic regression were used to describe the associations between medication adherence and various independent factors using SPSS version 26. Adjusted odds ratios with their corresponding 95% confidence intervals were further generated in the multivariable analysis, to determine variables which were independently associated with medication adherence and were considered significant at a p-value of &lt;0.05. Of the 380 study participants, only 225(67.1%) were adherent. 159(41.8%) were non-adherence to physician recommendations and were careless when taking their medication, 200(52.6%) found difficulty maintaining recommended dietary restrictions, 211(55.5%) and 97(25.5%) didn’t adhere to regular exercise or blood glucose monitoring; respectively. Factors significant association with non-adherence were; medication being taken; especially patients who were prescribed OHA and insulin ([AOR] [95% CI] = 0.214[0.073-0.632]), being careless and not taking prescribed medication as recommended ([AOR] [95% CI] = 2.880 [1.387- 5.983]), forgetfulness ([AOR] [95% CI] =0.199 [0.070- 0.570], stop taking prescribed antidiabetic medication when feeling well ( [AOR] [95% CI] = 0.153[0.058- 0.402], medications side effects ( [AOR] [95% CI]=0.382 [0.181- 0.809] and unawareness of the consequences of not adhering to medication as recommended and the consequences skipping doses ([AOR] [95% CI] = 0.146 [0.037- 0.581]). Adherence to recommended medication and self-care practices in Libya is unsatisfactory. Diabetes education, awareness programs, and regular monitoring of T2DM individuals’ medication adherence and self-care practices are vitally required.

#6672 THE DEVELOPMENT OF A COMMUNITY-NEPHROLOGY, MULTI-DISCIPLINARY SERVICE

Abstract Background and Aims The Walsall Together clinical and operational leads constructed a collaborative initiative between nephrology and community services. Driven to provide multi-agency, patient-focused care. The aim of the community nephrology MDT service is to identify and optimally manage individuals with acute nephrological presentations and optimally manage individuals with secondary complications of chronic kidney disease (CKD) at home, while maximally utilising outpatient community services to prevent hospital admissions. Method Nephrology and community teams, including rapid-response, complex-case management, enhanced-care and frailty teams devised a MDT service for individuals with either community-acquired acute kidney injury (AKI) or complications of CKD. The MDT can consist of; a nephrologist, community-CKD nurse, a member from each of the above teams, a community pharmacist and an MDT coordinator. Patients are identified from the MDT attendee's caseload, from the community heart failure and the community geriatrician patient cohort. A weekly MDT meeting is held on Microsoft Teams, this allows for efficient working across a large geographical area. The MDT coordinator is essential for the efficient performance of the community nephrology MDT. They are responsible for: organising meetings, producing minutes, requesting laboratory investigations (including urine album in creatinine ratio), chasing results from clinical investigations and finally ensuring that the actions generated from the MDT are completed. The community pharmacist is an independent prescriber and immediately actions any medication changes. The community teams consist of advanced clinical practitioners or band 7/above nurse prescribers. All clinical staff perform home visits and fully utilise outpatient services including ambulatory-care-unit services for medical assessment, urgent imaging and intravenous electrolyte replacement. The medical-day-case unit services for the administration of blood transfusions. The community outpatient access team services for intravenous iron therapy and antibiotic therapy. Results Currently, the community nephrology MDT is actively managing over 60 patients. This excludes patients who have been successfully managed and discharged from the community MDT service. The multimorbid, patient cohort with recurrent hospital admissions appear to have benefited the most. A reduction and/or cessation is noted, in hospital admissions after the introduction of interventions from the community nephrology MDT. The service allows the nephrology team to easily monitor and manage housebound, individuals with CKD. This reduces the number of admissions related to secondary complications of CKD. Furthermore, by managing acute illness in the community, the service reduces the number of individuals admitted to hospital with community acquired AKI. Finally, in the unfortunate event of terminal, irreversible pathology, the MDT service allows for advanced care planning and referral to community palliative care services. Conclusion The Walsall Together collaboration has demonstrated that utilising a multi-agency approach to managing acute and chronic renal disease, can result in a reduction in hospital admissions. Furthermore, the cooperative multi-speciality approach, has led to improved monitoring and management of housebound individuals with CKD.

Frailty in Kingdom of Saudi Arabia-Prevalence and Management, Where Are We?

A recent report from the United Nations state that the percentage of elderly individuals in the Kingdom of Saudi Arabia (KSA) will witness a sharp increase in the next three decades (5.6% in 2017 to 23% by 2050). This situation will lead to an increased prevalence of comorbidities and hence, will require close monitoring and constant care of such individuals who are prone to suffer from complications such as arthritis, cardiovascular disorders, diabetes, neurological disorders, etc. Frailty is one such age-related phenomenon which enhances the risk of falling, functional restrictions and greater vulnerability to adverse consequences, which tend to lead to institutionalization. Such factors highlight the importance of the urgent awareness for circumventing the progression of frailty toward a compromised health status. This concise report is an attempt to sum up the relevant research articles published with regard to frailty and concomitant diseases in the last 5 years. It also sums up the research on frailty in the KSA elderly population, till date. This article reflects the opinions of an author on tackling such issues through a well-directed mechanism involving interdisciplinary transitional care and geriatric co-management.

ASSOCIATION OF AMBULATORY AND HOME BLOOD PRESSURE VARIABILITY FOR CARDIOVASCULAR OUTCOMES

Objective: Although blood pressure (BP) variability (BPV) is reportedly associated with cardiovascular prognosis, there is no evidence that either ambulatory BPV (ABPV) or home BPV (HBPV) is a superior clinical marker. Design and method: We analyzed the association of ABPV and HBPV with cardiovascular prognosis in 1,319 hypertensive outpatients who underwent both home and ambulatory BP measurements in the Japan Morning Surge-Home Blood Pressure (J-HOP) study. BPV is evaluated by standard deviation (SD), coefficient of variation (CV), and average real variability (ARV) of 24-h ambulatory and average morning and evening home systolic BP. Results: During the median 6.9 years of follow-up, 109 cardiovascular events occurred. All SD, CV, and ARV of HBPV were significantly associated with cardiovascular risk even after adjusted by ABPV (1-SD of HR [95%CI] in SD, CV, and ARV of HBPV: 1.47 [1.23–1.75]; 1.48 [1.24–1.75]; and 1.33 [1.14–1.54]). In the model improvement using goodness-of-fit, HBPV values significantly improved the model predictability when adding to the model including confounding factors and mean 24-h ambulatory SBP and ABPV values. However, these relationships were not shown in ABPV parameters. Conclusions: Based on the findings from this study using both ambulatory and home BP monitoring in the same individuals, HBPV, i.e., day-to-day BPV, was suggested to have superiority in predicting for cardiovascular incidence compared to ABPV, i.e., short-term BPV through 24-hours.

The use of a new ECG patch for exercise and prolonged monitoring: usability, evaluation of signal quality and utility to detect arrhythmias

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): ITEA. Background Accurate detection of myocardial ischemia and arrhythmia’s during free-living exercise could play a pivotal role in optimizing screening and monitoring of individuals with underlying cardiovascular disease. Although remote electrocardiogram (ECG) solutions are emerging rapidly, these applications are generally not designed nor validated for continuous use during vigorous exercise. Purpose In this proof-of-concept study, we evaluated the usability, signal quality and arrhythmia detection of a new self-adhesive dry electrode ECG patch, the Nighthawk Vital Signs patch, during exercise and prolonged continuous ECG monitoring in individuals with chronic coronary syndrome (CCS). Methods Six consecutive CCS patients scheduled for an exercise stress test as part of routine cardiac follow-up were recruited. The traditional 12-lead exercise ECG was combined with monitoring with the 1-lead patch. Following the exercise test, the subjects continuously wore the sensor for five days. Intraclass correlation coefficients (ICC) and Wilcoxon signed-rank tests were used to assess the utility to detect arrhythmias with the patch. Signal quality for ECG recording was evaluated by using a signal quality indicator (SQI) based on the average QRS complex. Connection time and signal-to-noise ratio (SNR) were additionally calculated for prolonged ECG monitoring. Comfort and usability of the patch were evaluated by an online questionnaire. Results Six male patients with CCS (mean age 69.8 ± 6.2 years) completed the protocol. The mean time the patch was worn, was 118.3 hours (SD 5.6). The level of agreement between the patch and the 12-lead ECG was excellent for amount of premature atrial contractions (PAC’s) and premature ventricular contractions (PVC’s) during exercise stage, recovery stage and total test duration (ICC = 0.998, 0.998, 1.000, 1.000, 0.998, 1.000). There were no significant differences in the total amount of PAC’s and PVC’s detected with both methods during the exercise test (p = 0.785 and 0.180, respectively). One episode of atrial fibrillation was detected identically on both recorded ECG’s. Signal quality based on average QRS SQI during exercise did decrease slightly during (sub)maximal effort. Total connection time during recording was above 88% in all subjects and the SNR was above the target limit of 18dB. There were no reports on skin irritation, erythema or pain. Conclusion The Nighthawk Vital Signs ECG patch based on self-adhesive dry electrodes technology can be used for accurate arrhythmia detection during vigorous exercise. The sensor is also usable for prolonged ECG monitoring in free-living conditions and can therefore be of potential use in cardiac rehabilitation and telemonitoring for prevention of exercise-related cardiovascular events. However, more research is needed in order to analyze the signal quality over time together with a larger-scale validation study focusing on both arrhythmia and ischemia detection.

Legal and human rights issues in the use of electronic monitoring (using GPS 'tracking' technology) in forensic mental health settings in the UK.

Electronic monitoring (EM) of individuals has been used by the criminal justice system for the past thirty years, and in the UK, use is on the increase. Its use has been justified as an alternative to prison to reduce recidivism and allowing early release of prisoners, however, the evidence base for this remains mixed. In 2010, it was employed for the first time in a forensic psychiatry setting. A study investigating the effects of EM on leave episodes concluded that EM may improve the speed of patient progress and reduce the length of admission, leading to reduced costs and increased public safety. However, the intervention generated considerable controversy and sparked discussion about ethical concerns. Here, we consider specifically legal and human rights issues that emerge from use of EM in forensic healthcare settings, scrutinising its use in the context of the Mental Health Act and the Human Rights Act. We conclude that EM is legal and justifiable, providing it is used judiciously and with due consideration of concerns for the individual and the given context.

Wrist ballistocardiography and invasively recorded blood pressure in healthy volunteers during reclining bike exercise.

Objective: Ballistocardiogram (BCG) features are of interest in wearable cardiovascular monitoring of cardiac performance. We assess feasibility of wrist acceleration BCG during exercise for estimating pulse transit time (PTT), enabling broader cardiovascular response studies during acute exercise and improved monitoring in individuals at risk for cardiovascular disease (CVD). We also examine the relationship between PTT, blood pressure (BP), and stroke volume (SV) during exercise and posture interventions. Methods: 25 participants underwent a bike exercise protocol with four incremental workloads (0W, 50W, 100W, and 150W) in supine and semirecumbent postures. BCG, invasive radial artery BP, tonometry, photoplethysmography (PPG) and echocardiography were recorded. Ensemble averages of BCG signals determined aortic valve opening (AVO) timings, combined with peripheral pulse wave arrival times to calculate PTT. We tested for significance using Wilcoxon signed-rank test. Results: BCG was successfully recorded at the wrist during exercise. PTT exhibited a moderate negative correlation with systolic BP (ρSup = -0.65, ρSR = -0.57, ρAll = -0.54). PTT differences between supine and semirecumbent conditions were significant at 0W and 50W (p < 0.001), less at 100W (p = 0.0135) and 150W (p = 0.031). SBP and DBP were lower in semirecumbent posture (p < 0.01), while HR was slightly higher. Echocardiography confirmed association of BCG features with AVO and indicated a positive relationship between BCG amplitude and SV (ρ = 0.74). Significance: Wrist BCG may allow convenient PTT and possibly SV tracking during exercise, enabling studies of cardiovascular response to acute exercise and convenient monitoring of cardiovascular performance.

Explainable Activity Recognition for Smart Home Systems

Smart home environments are designed to provide services that help improve the quality of life for the occupant via a variety of sensors and actuators installed throughout the space. Many automated actions taken by a smart home are governed by the output of an underlying activity recognition system. However, activity recognition systems may not be perfectly accurate, and therefore inconsistencies in smart home operations can lead users reliant on smart home predictions to wonder “Why did the smart home do that?” In this work, we build on insights from Explainable Artificial Intelligence (XAI) techniques and introduce an explainable activity recognition framework in which we leverage leading XAI methods (Local Interpretable Model-agnostic Explanations, SHapley Additive exPlanations (SHAP), Anchors) to generate natural language explanations that explain what about an activity led to the given classification. We evaluate our framework in the context of a commonly targeted smart home scenario: autonomous remote caregiver monitoring for individuals who are living alone or need assistance. Within the context of remote caregiver monitoring, we perform a two-step evaluation: (a) utilize Machine Learning experts to assess the sensibility of explanations and (b) recruit non-experts in two user remote caregiver monitoring scenarios, synchronous and asynchronous, to assess the effectiveness of explanations generated via our framework. Our results show that the XAI approach, SHAP, has a 92% success rate in generating sensible explanations. Moreover, in 83% of sampled scenarios users preferred natural language explanations over a simple activity label, underscoring the need for explainable activity recognition systems. Finally, we show that explanations generated by some XAI methods can lead users to lose confidence in the accuracy of the underlying activity recognition model, while others lead users to gain confidence. Taking all studied factors into consideration, we make a recommendation regarding which existing XAI method leads to the best performance in the domain of smart home automation and discuss a range of topics for future work to further improve explainable activity recognition.