Implementation Of Optimal Strategy Research Articles

The LAIs Are Coming! Implementation Science Considerations for Long-Acting Injectable Antiretroviral Therapy in the United States: A Scoping Review.

Long-acting injectable antiretroviral therapy (LAI-ART) is one of the latest advancements in HIV control with the potential to overcome oral ART barriers to adherence. The objective of this article is to anticipate and examine implementation considerations for LAI-ART using components of the PRISM model, a Practical, Robust Implementation and Sustainability Model for integrating research findings into practice. We conducted a scoping review from January to August 2020 of the growing literature on LAI-ART implementation and other fields using LAI therapies. Key considerations regarding LAI-ART were parsed from the searches and entered into the PRISM implementation science framework. The PRISM framework posed multiple questions for consideration in the development of an optimal implementation strategy for LAI-ART in the United States. These questions revealed the necessity for more data, including acceptability of LAI-ART among many different subgroups of people living with HIV (PLWH), cost effectiveness, patient satisfaction, and patient-reported outcomes, as well as more detailed information related to the external environment for optimal LAI-ART implementation. Ethical considerations of LAI-ART will also need to be considered. The anticipation of, and excitement for, LAI-ART represent the hope for a new direction for HIV treatment that reduces adherence barriers and improves prognoses for PLWH. We have a unique window of opportunity to anticipate implementation considerations for LAI-ART, so this new therapy can be used to its fullest potential. Outstanding questions remain, however, that need to be addressed to help achieve HIV suppression goals in diverse populations.

A rapid pre-implementation evaluation to inform a family engagement navigator program during COVID-19

BackgroundInnovative models of family engagement and support are needed in the intensive care unit (ICU) during times of restricted visitation such as the COVID-19 pandemic. Limited understanding of the factors affecting the uptake and outcomes of different family support models hinders the implementation of best practices. We aimed to conduct a rapid pre-implementation evaluation of stakeholder-perceived facilitators and barriers to design implementation strategies to support a novel program using medical students to facilitate family-centered care in the ICU.MethodsWe conducted a 2-step process. In step 1, we gathered contextual data via interview-style open-ended questions sent to clinicians and navigator stakeholders via email. We used electronic data collection due to the physical distancing requirements, the need to prioritize brief data collection for respondent burden, and the need for rapid knowledge gain. A codebook based on the Consolidated Framework for Implementation Research (CFIR), an integrated framework from the field of implementation science, was used to analyze the findings. In step 2, a pilot of the intervention was implemented with 3 navigators over 2 weeks. Implementation strategies were developed to target barriers identified by the pre-implementation evaluation.ResultsFourteen (70%) of the identified stakeholders responded to the survey. Ten constructs encompassing all five CFIR domains were present in responses as implementation influencers, with the Intervention domain most frequently represented. Through these results and operational feedback from navigators during the pilot period, stakeholders selected multiple implementation strategies: audit and provide feedback, develop educational materials, conduct ongoing training, promote adaptability, assess and redesign workflow, identify and prepare champions, and engage community resources.ConclusionsWe demonstrated how a conceptually based pre-implementation program evaluation can be used to rapidly inform optimal implementation strategies. We report key factors to inform design and implementation strategies for a novel ICU family engagement navigator program that may be useful to others wishing to adopt similar programs.

Higher patient doses through X-ray imaging procedures.

Medical imaging using X-rays has been one of the most popular imaging modalities ever since the discovery of X-rays 125years ago. With unquestionable benefits, concerns about radiation risks have frequently been raised. Computed tomography (CT) and fluoroscopic guided interventional procedures have the potential to impart higher radiation exposure to patients than radiographic examinations. Despite technological advances, there have been instances of increased doses per procedure mainly because of better diagnostic information in images. However, cumulative dose from multiple procedures is creating new concerns as effective doses >100mSv are not uncommon. There is a need for action at all levels. Manufacturers must produce equipment that can provide a quality diagnostic image at substantially lesser dose and better implementation of optimization strategies by users. There is an urgent need for the industry to develop CT scanners with sub-mSv radiation dose, a goal that has been lingering. It appears that a new monochromatic X-ray source will lead to replacement of X-ray tubes all over the world in coming years and will lead to a drastic reduction in radiation doses. This innovation will impact all X-ray imaging and will help dose reduction. For interventional procedures, the likely employment of robotic systems in practice may drastically reduce radiation exposures to operators- but patient exposure will still remain an issue. Training needs always need to be emphasized and practiced.

THE TACTICS OF ANTIVIRAL THERAPY FOR CHRONIC VIRAL HEPATITIS B IN PREGNANT WOMEN

The aim of the study.Analysis of tactics of antiviral therapy for chronic viral hepatitis b in pregnant women. Methods. Theoretical analysis of scientific literature; analysis and generalization. Statistics and comparisons. Classification of theoretical material and development of recommendations. Research results.Today, there are about 2 billion people in the world ill with a chronic infection caused by the hepatitis B virus, 350 million of whom suffer from chronic hepatitis B, and most are asymptomatic carriers of the Australian antigen (HBsAg). Up to 50 % of all new cases of hepatitis B virus infection are due to vertical infection. Despite the lack of increase in viral load during pregnancy, alanine aminotransferase tends to increase in late pregnancy and in the postpartum period. A sharp drop in postpartum corticosteroids may create favourable conditions for hepatitis B virus activation. It is emphasized that the current treatment of hepatitis B virus includes the use of antiviral drugs, where Peg-IFN is absolutely contraindicated in pregnancy, lamivudine and entecavir are classified by the FDA as category C, and tenofovir and telbivudine are classified as category B. During pregnancy, it is recommended to use mainly category B drugs. Conclusions. The use of antiviral therapy in combination with immunoprophylaxis of new-borns is the optimal strategy for implementation as a universal program, as the success of such an intervention can make a significant contribution to achieving the ultimate goal of global elimination of hepatitis B virus.

Aspirin should be targeted to those who need it.

Low dose aspirin, for the prevention of early onset pre-eclampsia is an established antenatal intervention; it is safe, effective, cheap and accessible in many health care settings. Optimal implementation strategies including dose, timing and screening are currently debated. The evidence supports starting aspirin early (before 16 weeks), prescribe at night, give up to 150mg and continue until at least 36 weeks gestation ((Poon et al. Int J Gynaecol Obstet. 2019 May;145 Suppl 1(Suppl 1):1-33). From the women's perspective, many may not be happy to routinely medicate an apparently normal pregnancy, to prevent an unknown or unfamiliar disease.

Risk management for mine closure: A cloud model and hybrid semi-quantitative decision method

Mine closure is associated with many negative impacts on society and the environment. If these effects are not rationally addressed, they would pose risks of mine closure. Thus, a risk management method is needed to mitigate these adverse impacts and address mine-closure issues. An integral framework for mine-closure risk management that includes risk assessment and risk treatment was proposed. Given the fuzziness and randomness of the transformation between qualitative and quantitative knowledge in the risk assessment process, a novel risk assessment method based on the cloud model was presented, which fully considers the uncertainty in risks themselves and in the reasoning process. Closed mine reutilization is an effective risk treatment option in response to the identified high risks, but it requires selecting optimal reutilization strategies for the successful implementation of the reuse plan. To this end, a hybrid semi-quantitative decision method is proposed to optimize decision-making. The results of a case study showed that this risk management methodology can help budget planning for risk treatment and provide an instructional framework to effectively reduce the negative effects of closed mines.

Patterns of Cystatin C Uptake and Use Across and Within Hospitals

ObjectiveTo characterize the use of cystatin C (cysC) across and within hospitals. Patients and MethodsThis 2-part study first evaluated access to cysC testing across 129 hospitals in the state of Minnesota, using a telephone-based survey. Second, granular data from a single center (Mayo Clinic) with on-site, rapid-turnaround testing (<1 day) and automated estimated glomerular filtration rate (eGFR) reporting was used to describe temporal patterns. The characteristics of hospitals that offered cysC testing and of patients who underwent rapid cysC testing at Mayo Clinic between January 1, 2011, and March 31, 2018, were described. Poisson regression analyzed temporal trends in cysC testing. ResultsOf the 114 hospitals (88%) that responded to the statewide survey, cysC was available in 91 (80%), but only 3 of 91 (3%) reported a turnaround time of <1 day. At Mayo Clinic, cysC use increased from 0.74 tests per 1000 patient-days in 2011 to 14 tests per 1000 patient-days in 2018 (P=.004). Of the 3774 patients with cysC tests, the mean first available eGFR was 46 mL/min per 1.73 m2 using cysC and 59 mL/min per 1.73 m2 using serum creatinine (P<.001). CysC testing was used across all intensities of care and was ordered by a variety of specialties. Nephrology was consulted in only 42% of cases. ConclusionIn the hospital, rapid-turnaround cysC testing is necessary for practical use but was not widely available in Minnesota. When available, a marked increase in cysC testing was observed over the study timeframe. Additional research is needed to determine optimal strategies for implementation of cysC within hospitals.

An EMR-Based Alert with Brief Provider-Led ART Adherence Counseling: Promising Results of the InfoPlus Adherence Pilot Study Among Haitian Adults with HIV Initiating ART.

To promote HIV antiretroviral therapy (ART) outcomes in Haiti, we developed a culturally relevant intervention (InfoPlus Adherence) that combines an electronic medical record alert identifying patients at elevated risk of treatment failure and provider-delivered brief problem-solving counseling. We conducted a quasi-experimental mixed-methods study among 146 patients at two large ART clinics in Haiti with 728 historical controls. We conducted quantitative assessments of patients at baseline and intervention completion (6months) as well as focus groups with health workers and exit interviews with patients. The primary quantitative outcome measures were HIV viral suppression according to medical record and ART adherence in terms of ≥ 90% for "proportion of days covered" (PDC) according to pharmacy dispensing data. Results indicated that the proportion of intervention patients with suppressed VL during the study/historical periods was 80.0%/86.0% and 76.8%/87.4% for controls. In a difference-in-differences (DID) analytic model, the adjusted relative risk for viral suppression with the intervention was 1.15 (95% CI 0.92-1.45, p = 0.21), representing favorable but non-significant association between the intervention and the trajectory of VL outcomes. PDC ≥ 90% during the study/historical periods was 30.9%/11.0% among intervention participants and 16.9%/19.4% among controls. In the adjusted DID model, the relative risk for of PDC ≥ 90% with the intervention was 4.00 (95% CI 1.91-8.38, p < 0.001), representing a highly favorable association between the intervention and the trajectory of PDC outcomes. Qualitative data affirmed acceptability of the intervention, although providers reported some challenges consistently implementing it. Future research is needed to demonstrate efficacy and explore optimal implementation strategies.

Mailed fecal immunochemical test outreach for colorectal cancer screening: Summary of a Centers for Disease Control and Prevention-sponsored Summit.

Uptake of colorectal cancer screening remains suboptimal. Mailed fecal immunochemical testing (FIT) offers promise for increasing screening rates, but optimal strategies for implementation have not been well synthesized. In June 2019, the Centers for Disease Control and Prevention convened a meeting of subject matter experts and stakeholders to answer key questions regarding mailed FIT implementation in the United States. Points of agreement included: 1) primers, such as texts, telephone calls, and printed mailings before mailed FIT, appear to contribute to effectiveness; 2) invitation letters should be brief and easy to read, and the signatory should be tailored based on setting; 3) instructions for FIT completion should be simple and address challenges that may lead to failed laboratory processing, such as notation of collection date; 4) reminders delivered to initial noncompleters should be used to increase the FIT return rate; 5) data infrastructure should identify eligible patients and track each step in the outreach process, from primer delivery through abnormal FIT follow-up; 6) protocols and procedures such as navigation should be in place to promote colonoscopy after abnormal FIT; 7) a high-quality, 1-sample FIT should be used; 8) sustainability requires a program champion and organizational support for the work, including sufficient funding and external policies (such as quality reporting requirements) to drive commitment to program investment; and 9) the cost effectiveness of mailed FIT has been established. Participants concluded that mailed FIT is an effective and efficient strategy with great potential for increasing colorectal cancer screening in diverse health care settings if more widely implemented.

Barriers to and facilitators of the implementation of multi-disciplinary care pathways in primary care: a systematic review

BackgroundCare pathways (CPWs) are complex interventions that have the potential to reduce treatment errors and optimize patient outcomes by translating evidence into local practice. To design an optimal implementation strategy, potential barriers to and facilitators of implementation must be considered.The objective of this systematic review is to identify barriers to and facilitators of the implementation of CPWs in primary care (PC).MethodsA systematic search via Cochrane Library, CINAHL, and MEDLINE via PubMed supplemented by hand searches and citation tracing was carried out. We considered articles reporting on CPWs targeting patients at least 65 years of age in outpatient settings that were written in the English or German language and were published between 2007 and 2019. We considered (non-)randomized controlled trials, controlled before-after studies, interrupted time series studies (main project reports) as well as associated process evaluation reports of either methodology. Two independent researchers performed the study selection; the data extraction and critical appraisal were duplicated until the point of perfect agreement between the two reviewers. Due to the heterogeneity of the included studies, a narrative synthesis was performed.ResultsFourteen studies (seven main project reports and seven process evaluation reports) of the identified 8154 records in the search update were included in the synthesis. The structure and content of the interventions as well as the quality of evidence of the studies varied.The identified barriers and facilitators were classified using the Context and Implementation of Complex Interventions framework. The identified barriers were inadequate staffing, insufficient education, lack of financial compensation, low motivation and lack of time. Adequate skills and knowledge through training activities for health professionals, good multi-disciplinary communication and individual tailored interventions were identified as facilitators.ConclusionsIn the implementation of CPWs in PC, a multitude of barriers and facilitators must be considered, and most of them can be modified through the careful design of intervention and implementation strategies. Furthermore, process evaluations must become a standard component of implementing CPWs to enable other projects to build upon previous experience.Trial registrationPROSPERO 2018 CRD42018087689.

The Long-Term Efficacy of Working Memory Training in Healthy Older Adults: A Systematic Review and Meta-Analysis of 22 Randomized Controlled Trials.

The long-lasting efficacy of working memory (WM) training has been a controversial and still ardently debated issue. In this meta-analysis, the authors explored the long-term effects of WM training in healthy older adults on WM subdomains and abilities outside the WM domain assessed in randomized controlled studies. A systematic literature search of PubMed, Web of Science, PsycINFO, Cochrane Library, ProQuest, clinicaltrials.gov, and Google Scholar was conducted. Random-effects models were used to quantitatively synthesize the existing data. Twenty-two eligible studies were included in the meta-analysis. The mean participant age ranged from 63.77 to 80.1 years. The meta-synthesized long-term effects on updating were 0.45 (95% confidence interval = 0.253-0.648, <6 months: 0.395, 0.171-0.619, ≥6 months: 0.641, 0.223-1.058), on shifting, 0.447 (0.246-0.648, <6 months: 0.448, 0.146-0.75, ≥6 months: 0.446, 0.176-0.716); on inhibition, 0.387 (0.228-0.547, <6 months: 0.248, 0.013-0.484, ≥6 months: 0.504, 0.288-0.712); on maintenance, 0.486 (0.352-0.62, <6 months: 0.52, 0.279-0.761, ≥6 months: 0.471, 0.31-0.63). The results showed that WM training exerted robust long-term effects on enhancing the WM system and improving processing speed and reasoning in late adulthood. Future studies are needed to use different tasks of the same WM construct to evaluate the WM training benefits, to adopt more ecological tasks or tasks related to daily life, to improve the external validity of WM training, and to identify the optimal implementation strategy for WM training.

The dance of knowledge management strategies in libraries: The case of the libraries of the Iranian universities of medical science

The success of any organization is highly dependent on choosing the right strategic orientation. The main objectives of the present study were to identify appropriate knowledge management strategies and their subsystems in the libraries of Iranian universities of medical science, and to examine their level of strategic alignment. The study population consisted of 55 managers and 225 librarians working at 33 central libraries in Iranian universities of medical science. In order to carry out the research, two questionnaires were initially designed to collect information about the dominant system strategies and knowledge management subsystems. Then, the means of the sum of the items that were planned for each strategy were calculated, the highest means in each group were considered as the basis for determining the dominant strategy, and the levels of alignment between the different strategies were assessed. The results showed that, with regard to the degree of dynamism, maintaining the status quo was the dominant strategy of the knowledge management system in the selected academic libraries, and with regard to the knowledge acquisition and identification subsystem, passive was the dominant strategy. Externalization was the dominant strategy related to the knowledge creation and transfer subsystem, and static was the dominant strategy related to the knowledge application subsystem. As for the level of alignment between the strategies, the results revealed that the strategic alignment is at an average level. Based on the findings, improving the existing conditions in these libraries requires a transition from traditional knowledge management approaches towards more modern approaches, as well as the selection of optimal implementation strategies for the knowledge management system and subsystems.

Adherence to remote versus clinic-based collection of patient-reported outcomes in patients with advanced lung cancer.

e14109 Background: Routine collection of patient-reported outcomes (PROs) is an evidence-based practice to improve communication, symptom management, and health outcomes in cancer care. However, optimal implementation strategies are poorly understood. Previous studies have mostly assessed PROs collected during clinic visits, which may be less actionable and more subject to recall bias than those collected in real time. Behavioral economics-informed digital approaches have shown increasing promise as sustainable and scalable strategies for remote patient monitoring. We compared remote text-messaging versus usual clinic-based PRO collection approaches. Methods: Between September 2018 and May 2019, we conducted a prospective pilot feasibility study of remote PRO monitoring via text-messaging among 20 patients with advanced non-small cell lung cancer (NSCLC). Pilot participants consented to enroll in a HIPAA-compliant, bidirectional text-messaging platform, which allowed for direct reporting of PRO measures at home. Data were integrated into the electronic health record in real time, and clinicians were notified of severe or escalating symptoms. We compared patient-level adherence over 12 weeks among: 1) pilot participants and 2) patients with advanced NSCLC reporting via usual clinic-based collection methods. We identified predictors of adherence using multivariable logistic regression, and surveyed pilot participants on feasibility outcomes. Results: During the study period, 20 patients with advanced NSCLC participated in the remote text-messaging pilot study (mean age, 63y; 60% male; 85% white), and 328 patients with advanced NSCLC participated in usual clinic-based PRO collection (mean age, 66y; 48% male; 69% white). Baseline characteristics were similar between groups. Mean adherence was 88.4% for remote text-messaging vs 71.2% for clinic-based collection (p &lt; 0.001). Pilot participation predicted &gt; 80% adherence after adjusting for age, sex, race, and marital status (OR 3.5, p = 0.029). Pilot participants reported high levels of usability (97%) and satisfaction (96%) with text-messaging, and 90% noted that text messages reminded them to report symptoms to their clinical team. Conclusions: Among patients with advanced NSCLC, remote PRO monitoring via text-messaging was feasible and enabled significantly higher adherence to reporting than usual clinic-based collection. These results are based on a small pilot study, and further research on text messaging as a PRO implementation strategy is warranted. Clinical trial information: NCT03616522.

Study protocol: a cluster randomized trial to evaluate the effectiveness and implementation of onsite GeneXpert testing at community health centers in Uganda (XPEL-TB)

BackgroundDelays in diagnosis and treatment of tuberculosis (TB) remain common in high-burden countries. To improve case detection, substantial investments have been made to scale-up Xpert MTB/RIF (Xpert), a cartridge-based nucleic acid amplification test that can detect TB within 2 hours, as a replacement for sputum smear microscopy. However, the optimal strategy for implementation of Xpert testing remains unclear.MethodsThe Xpert Performance Evaluation for Linkage to Tuberculosis Care (XPEL-TB) trial uses an ultra-pragmatic, hybrid type II effectiveness-implementation design to assess the effectiveness and implementation of a streamlined strategy for delivery of Xpert testing in real-world settings. Twenty health centers with TB microscopy units were selected to participate in the trial, with ten health centers randomized to the intervention strategy (onsite molecular testing using GeneXpert Edge, process redesign to facilitate same-day TB diagnosis and treatment, and performance feedback) or routine care (onsite sputum smear microscopy plus referral of sputum samples to Xpert testing sites). The primary outcome is the number of patients with microbiologically confirmed TB who were initiated on treatment within 14 days of presentation to the health center, which reflects successful completion of the TB diagnostic evaluation process. Secondary outcomes include health outcomes (6-month vital status), as well as measures of the reach, adoption, and implementation of the intervention strategy.DiscussionThe design elements and implementation approach for the XPEL-TB trial were intentionally selected to minimize disruptions to routine care procedures, with the goal of limiting their influence on key primary and secondary outcomes. Trial findings may result in increased support and funding for rapid, onsite molecular testing as the standard-of-care for all patients being evaluated for TB.Trial registrationUS National Institutes of Health’s ClinicalTrials.gov, NCT03044158. Registered 06 February 2017.Pan African Clinical Trials Registry, PACTR201610001763265. Registered 03 September 2016.

Ending the HIV epidemic in the USA: an economic modelling study in six cities

The HIV epidemic in the USA is a collection of diverse local microepidemics. We aimed to identify optimal combination implementation strategies of evidence-based interventions to reach 90% reduction of incidence in 10 years, in six US cities that comprise 24·1% of people living with HIV in the USA. In this economic modelling study, we used a dynamic HIV transmission model calibrated with the best available evidence on epidemiological and structural conditions for six US cities: Atlanta (GA), Baltimore (MD), Los Angeles (CA), Miami (FL), New York City (NY), and Seattle (WA). We assessed 23 040 combinations of 16 evidence-based interventions (ie, HIV prevention, testing, treatment, engagement, and re-engagement) to identify combination strategies providing the greatest health benefit while remaining cost-effective. Main outcomes included averted HIV infections, quality-adjusted life-years (QALYs), total cost (in 2018 US$), and incremental cost-effectiveness ratio (ICER; from the health-care sector perspective, 3% annual discount rate). Interventions were implemented at previously documented and ideal (90% coverage or adoption) scale-up, and sustained from 2020 to 2030, with outcomes evaluated until 2040. Optimal combination strategies providing health benefit and cost-effectiveness contained between nine (Seattle) and 13 (Miami) individual interventions. If implemented at previously documented scale-up, these strategies could reduce incidence by between 30·7% (95% credible interval 19·1-43·7; Seattle) and 50·1% (41·5-58·0; New York City) by 2030, at ICERs ranging from cost-saving in Atlanta, Baltimore, and Miami, to $95 416 per QALY in Seattle. Incidence reductions reached between 39·5% (26·3-53·8) in Seattle and 83·6% (70·8-87·0) in Baltimore at ideal implementation. Total costs of implementing strategies across the cities at previously documented scale-up reached $559 million per year in 2024; however, costs were offset by long-term reductions in new infections and delayed disease progression, with Atlanta, Baltimore, and Miami projecting cost savings over the 20 year study period. Evidence-based interventions can deliver substantial public health and economic value; however, complementary strategies to overcome social and structural barriers to HIV care will be required to reach national targets of the ending the HIV epidemic initiative by 2030. National Institutes of Health.

Towards self-optimisation in fog computing environments

In recent years, the number of smart devices has grown exponentially. However, the computational demand for latency-sensitive applications has grown and the traditional model of cloud computing is no longer able to meet alone all the needs of this type of application. In this direction, a new paradigm of computation was introduced, it is called Fog Computing. Many challenges need to be overcome, especially those regarding issues such as security, power consumption, high latency in communication with critical IoT applications, and need for QoS. We have presented a container migration mechanism to Fog and the cloud computing that supports the implementation of optimisation strategies to achieve different objectives and solutions to problems of resources allocation. In addition, our work emphasises the performance and latency optimisation, through an autonomic architecture based on the MAPE-K control loop, and provides a foundation for the analysis and optimisation architectures design to support IoT applications.

Postpartum hemorrhage care bundles to improve adherence to guidelines: A WHO technical consultation.

ObjectiveTo systematically develop evidence‐based bundles for care of postpartum hemorrhage (PPH).MethodsAn international technical consultation was conducted in 2017 to develop draft bundles of clinical interventions for PPH taken from the WHO's 2012 and 2017 PPH recommendations and based on the validated “GRADE Evidence‐to‐Decision” framework. Twenty‐three global maternal‐health experts participated in the development process, which was informed by a systematic literature search on bundle definitions, designs, and implementation experiences. Over a 6‐month period, the expert panel met online and via teleconferences, culminating in a 2‐day in‐person meeting.ResultsThe consultation led to the definition of two care bundles for facility implementation. The “first response to PPH bundle” comprises uterotonics, isotonic crystalloids, tranexamic acid, and uterine massage. The “response to refractory PPH bundle” comprises compressive measures (aortic or bimanual uterine compression), the non‐pneumatic antishock garment, and intrauterine balloon tamponade (IBT). Advocacy, training, teamwork, communication, and use of best clinical practices were defined as PPH bundle supporting elements.ConclusionFor the first response bundle, further research should assess its feasibility, acceptability, and effectiveness; and identify optimal implementation strategies. For the response to refractory bundle, further research should address pending controversies, including the operational definition of refractory PPH and effectiveness of IBT devices.

Implementation Science Using Proctor's Framework and an Adaptation of the Multiphase Optimization Strategy: Optimizing a Financial Incentive Intervention for HIV Treatment Adherence in Tanzania.

Ambitious targets have been set to end the HIV epidemic by 2030. Such targets assume that tools to end HIV exist and are successfully being deployed across populations, albeit unequally. Implementation science approaches are needed to understand the drivers of disparities and how to bring effective interventions to those most in need. We describe a hybrid implementation science approach, adapting a strategy to facilitate retention and viral suppression (VS) among people living with HIV/AIDS in Tanzania. We used Proctor framework and the multiphase optimization strategy to optimize a cash transfer to improve antiretroviral therapy adherence and VS among people living with HIV/AIDS in Tanzania. This involved 3 trials. The first trial tested the efficacy of cash and food assistance compared with the standard of care in improving antiretroviral therapy adherence among treatment initiators. Cash transfers were superior to the standard of care and noninferior, less expensive, and logistically simpler to implement compared with food. The second trial is dose-finding: identifying the optimal amount of cash for a 20% improvement in VS at 6 months. Before this, components were simplified to maximize reach, align with local policies, and reduce staff time. We assessed implementation science constructs to understand barriers to uptake and sustainability. Trial 3 is a cluster randomized controlled trial, testing the effectiveness of the optimized intervention in multiple settings. Our process illustrates the utility of applying multiple implementation science frameworks to arrive at an optimal implementation strategy to bridge the know-do gap with data to show efficacy and maximum potential for scalability and sustainability.

Inhibition factors and kinetic model for anaerobic ammonia oxidation in a granular sludge bioreactor with Candidatus Brocadia

Varying pH and high levels of nitrite have major inhibitory effects on anaerobic ammonium oxidizing bacteria (AnAOB) and are known to interfere with the anaerobic ammonia oxidation (Anammox) process. In this study, we evaluated the effect of pH and nitrite on Anammox process performance through a predictive kinetic model. A series of batch experiments were performed in a stably operating Anammox sequencing batch reactor system with “Candidatus Brocadia” as the dominant AnAOB taxon (>95%), by varying the nitrite concentration from 40 to 378 mg/L and the pH from 6.7 and 8.5, while maintaining the NH4+-N concentration at 54.6 ± 5.6 mg/L. Dual substrate kinetics including a pH inhibition function was able to predict Anammox activity at higher NO2−-N concentrations, with a nitrite inhibition constant of 210 mg/L. A synergistic negative effect on Anammox activity was observed when combining pH and nitrite stressors. Anammox activity was completely lost at low (6.7) and high (8.5) pH conditions, but resumed after adjusting to an optimal pH (7.5 ± 0.2). We found that AnAOB bacteria are susceptible to both high nitrite concentrations and fluctuating pH levels. Based on experimental evidence and modeling, pH mediates nitrite inhibition in the Anammox process due to the accumulation of free nitrous acid. Our model can predict the outcome of different operating scenarios and help select optimal operational strategies for Anammox implementation.

Predesign Considerations for the DC Link Voltage Level of the CENTRELINE Fuselage Fan Drive Unit

Electric propulsion (EP) systems offer considerably more degrees of freedom (DOFs) within the design process of aircraft compared to conventional aircraft engines. This requires large, computationally expensive design space explorations (DSE) with coupled models of the single components to incorporate interdependencies during optimization. The purpose of this paper is to exemplarily study these interdependencies of system key performance parameters (KPIs), e.g., system mass and efficiency, for a varying DC link voltage level of the power transmission system considering the example of the propulsion system of the CENTRELINE project, including an electric motor, a DC/AC inverter, and the DC power transmission cables. Each component is described by a physically derived, analytical model linking specific subdomains, e.g., electromagnetics, structural mechanics and thermal analysis, which are used for a coupled system model. This approach strongly enhances model accuracy and simultaneously keeps the computational effort at a low level. The results of the DSE reveal that the system KPIs improve for higher DC link voltage despite slightly inferior performance of motor and inverter as the mass of the DC power transmission cable has a major share for a an aircraft of the size as in the CENTRELINE project. Modeling of further components and implementation of optimization strategies will be part of future work.