Protocol for an evaluation of the initiation of an integrated longitudinal outpatient care model for severe chronic non-communicable diseases (PEN-Plus) at secondary care facilities (district hospitals) in 10 lower-income countries

INTRODUCTION

The Package of Essential Noncommunicable Disease Interventions-Plus (PEN-Plus) is a strategy decentralising care for severe non-communicable diseases (NCDs) including type 1 diabetes, rheumatic heart disease and sickle cell disease, to increase access to care. In the PEN-Plus model, mid-level clinicians in intermediary facilities in low and lower middle income countries are trained to provide integrated care for conditions where services traditionally were only available at tertiary referral facilities. For the upcoming phase of activities, 18 first-level hospitals in 9 countries and 1 state in India were selected for PEN-Plus expansion and will treat a variety of severe NCDs. Over 3 years, the countries and state are expected to: (1) establish PEN-Plus clinics in one or two district hospitals, (2) support these clinics to mature into training sites in preparation for national or state-level scale-up, and (3) work with the national or state-level stakeholders to describe, measure and advocate for PEN-Plus to support development of a national operational plan for scale-up.

METHODS AND ANALYSIS

Guided by Proctor outcomes for implementation research, we are conducting a mixed-method evaluation consisting of 10 components to understand outcomes in clinical implementation, training and policy development. Data will be collected through a mix of quantitative surveys, routine reporting, routine clinical data and qualitative interviews.

ETHICS AND DISSEMINATION

This protocol has been considered exempt or covered by central and local institutional review boards. Findings will be disseminated throughout the project's course, including through quarterly M&E discussions, semiannual formative assessments, dashboard mapping of progress, quarterly newsletters, regular feedback loops with national stakeholders and publication in peer-reviewed journals.

Realigning noncommunicable disease monitoring with health systems priorities in the Africa region

The African region of the World Health Organization (WHO) recently adopted a strategy aimed at more comprehensive care for noncommunicable diseases (NCDs) in the region. The WHO's World Health Assembly has also newly approved several ambitious disease-specific targets that raise the expectations of chronic care and plans to revise and update the NCD-Global Action Plan. These actions provide a critically needed opportunity for reflection and course correction in the global health response to NCDs. In this paper, we highlight the status of the indicators that are currently used to monitor progress towards global goals for chronic care. We argue that weak health systems and lack of access to basic NCD medicines and technologies have prevented many countries from achieving the level of progress required by the NCD epidemic, and current targets do little to address this reality. We identify gaps in existing metrics and explore opportunities to realign the targets with the pressing priorities facing today's health systems.

Feasibility of Telemonitoring Blood Pressure in Patients With Kidney Disease (Oxford Heart and Renal Protection Study-1): Observational Study

Background

Blood pressure (BP) is a key modifiable risk factor for patients with chronic kidney disease (CKD), with current guidelines recommending strict control to reduce the risk of progression of both CKD and cardiovascular disease. Trials involving BP lowering require multiple visits to achieve target BP, which increases the costs of such trials, and in routine care, BP measured in the clinic may not accurately reflect the usual BP.

Objective

We sought to assess whether a telemonitoring system for BP (using a Bluetooth-enabled BP machine that could transmit BP measurements to a tablet device installed with a bespoke app to guide the measurement of BP and collect questionnaire data) was acceptable to patients with CKD and whether patients would provide sufficient BP readings to assess variability and guide treatment.

Methods

A total of 25 participants with CKD were trained to use the telemonitoring equipment and asked to record BP daily for 30 days, attend a study visit, and then record BP on alternate days for the next 60 days. They were also offered a wrist-worn applanation tonometry device (BPro) which measures BP every 15 minutes over a 24-hour period. Participants were given questionnaires at the 1- and 3-month time points; the questionnaires were derived from the System Usability Scale and Technology Acceptance Model. All eligible participants completed the study.

Results

Mean participant age was 58 (SD 11) years, and mean estimated glomerular filtration rate was 36 (SD 13) mL/min/1.73m2. 13/25 (52%) participants provided >90% of the expected data and 18/25 (72%) provided >80% of the expected data. The usability of the telemonitoring system was rated highly, with mean scores of 84.9/100 (SE 2.8) after 30 days and 84.2/100 (SE 4.1) after 90 days. The coefficient of variation for the variability of systolic BP telemonitoring was 9.4% (95% CI 7.8-10.9) compared with 7.9% (95% CI 6.4-9.5) for the BPro device, P=.05 (and was 9.0% over 1 year in a recently completed trial with identical eligibility criteria), indicating that most variation in BP was short term.

Conclusions

Telemonitoring is acceptable for patients with CKD and provides sufficient data to inform titration of antihypertensive therapies in either a randomized trial setting (comparing BP among different targets) or routine clinical practice. Such methods could be employed in both scenarios and reduce costs currently associated with such activities.

Trial Registration

International Standard Randomized Controlled Trial Number ISRCTN13725286; http://www.isrctn.com/ISRCTN13725286 (Archived by WebCite at http://www.webcitation.org/74PAX51Ji).

Lights and shadows about health claims: analysis of food labels in a field survey in Florence

BACKGROUND

Health claims (HC) are those statements on food labels that state, suggest, or imply that a relationship exists between a food category, a food product, or one of its constituents, and health of consumer. The European legislation on the use of HC aims to encourage responsible consumption by people. The aim of this study is to assess the adherence of HC to EU norms in foodstuffs sold in the large-scale retail distribution in Florence.

METHODS

Two independent researchers have separately selected and assessed the foodstuffs with HC sold in at least two of four supermarkets identified randomly in Florence. Each selected product was assessed by a checklist with seven macro-criteria, extrapolated from the 'Specific Conditions' and 'Restrictions of Use' provided by EU regulations, rating the adherence of the chosen foods to the legislation.

RESULTS

Seventy-seven products were assessed. Only a limited number of products show full compliance to all the criteria. Specifically, noncompliance related to Criterion 3 ("the amount of the food and pattern of consumption required to obtain the claimed beneficial effect are reported") is the most significant: the absence of indications about the maximum amount to be consumed or the modality of consumption could represent a risk of overconsumption and, consequently, a risk for health.

CONCLUSION

According to the results, we hypothesize a lack of knowledge of the EU norms on the part of the manufacturer. A great deal of work is still to be done to assess and manage these products in the right way, as well as to communicate the right messages to the consumers.

A qualitative study exploring women's journeys to becoming smokers in the social context of urban India

In India, the prevalence of smoking among women is increasing, and the reasons behind this are unclear. We aimed to study the factors leading to initiation and maintenance of the smoking habit in women in Pune, India. Twenty-seven urban women smokers, ranging from 21 to 60 years of age (31.96 ± 10.70 years), were interviewed between September 2015 and February 2016. The in-depth interviews consisted of questions on pre-decided categories, including initiation, motivation to continue smoking, and risk perception. Thematic analysis revealed that peer pressure, curiosity, fascination, experimentation, and belonging to a group were factors that led to initiation, while lack of alternatives for stress relief, work environments, and lack of leisure time activities provided circumstances to continue smoking. Participants recognized a sense of liberation and independence from smoking cigarettes and perceived health risks as minor and distant. These findings can be used to develop or modify interventions to prevent and control smoking among urban Indian women.

Micronucleus test on Triturus carnifex as a tool for environmental biomonitoring

The amphibian micronucleus test has been widely used during the last 30 years to test the genotoxic properties of several chemicals and as a tool for ecogenotoxic monitoring. The vast majority of these studies were performed on peripheral blood of urodelan larvae and anuran tadpoles and to a lesser extent adults were also used. In this study, we developed protocols for measuring micronuclei in adult shed skin cells and larval gill cells of the Italian crested newt (Triturus carnifex). Amphibians were collected from ponds in two protected areas in Italy that differed in their radon content. Twenty-three adult newts and 31 larvae were captured from the radon-rich pond, while 20 adults and 27 larvae were taken from the radon-free site. The animals were brought to the laboratory and the micronucleus test was performed on peripheral blood and shed skins taken from the adults and on larval gills. Samples from the radon-rich site showed micronucleus frequencies higher than those from the radon-free site and the difference was statistically significant in gill cells (P < 0.00001). Moreover, the larval gills seem to be more sensitive than the adult tissues. This method represents an easy (and noninvasive in the case of the shed skin) application of the micronucleus assay that can be useful for environmental studies in situ.

Innovative self management system for guided cardiac rehabilitation

This paper describes the design and development of a system for cardio rehabilitation of patients that suffered a myocardial infarction. The proposed solution focuses on exercise prescriptions and the encouragement of healthy behaviors. The innovative strategy of the design takes into account health promotion models to provide safe, assistive exercise training sessions, personalized feedbacks, and educational contents.

Integration of heterogeneous biomedical sensors into an ISO/IEEE 11073 compliant application

Current trends in healthcare technology include mobile-based applications. Relevant advances in the integration of vital signs monitoring devices with mobile platforms are widely reported nowadays. In this context, conceiving and designing an interoperable application is essential due to the growing necessity of integrating a huge and heterogeneous amount of biomedical data, coming from a wide range of devices and sensors. In this paper the key research issues associated with such integration are presented as well as a specific proposal to solve these problems. It is based on a middleware architecture for the integration of biomedical sensors with mobile devices, derived from the ISO/IEEE 11073 standards family. The application has been developed in the framework of an EU-funded R&D project called METABO.

A system to promote self-behaviors of patients with coronary heart disease

Personalized health devices are the novel paradigm to reduce healthcare costs and to improve the quality of health services. At the same time, health interventions and promotion of self behaviors generate benefits to healthcare and allow citizens to be more involved in their own health management. This paper describes the process followed in HeartCycle project to design education and coaching services to promote self-behaviors in a closed loop monitoring system for patients with coronary heart diseases that suffered a myocardial infarction.

Numerical modeling of continuous flow microwave heating: a critical comparison of COMSOL and ANSYS

Numerical models were developed to simulate temperature profiles in Newtonian fluids during continuous flow microwave heating by one way coupling electromagnetism, fluid flow, and heat transport in ANSYS 8.0 and COMSOL Multiphysics v3.4. Comparison of the results from the COMSOL model with the results from a pre-developed and validated ANSYS model ensured accuracy of the COMSOL model. Prediction of power Loss by both models was in close agreement (5-13% variation) and the predicted temperature profiles were similar. COMSOL provided a flexible model setup whereas ANSYS required coupling incompatible elements to transfer load between electromagnetic, fluid flow, and heat transport modules. Overall, both software packages provided the ability to solve multiphysics phenomena accurately.

Wearable and mobile system to manage remotely heart failure

Cardiovascular diseases (CVDs) account for 45% of all deaths in the western world according to the 2004 World Health Organization statistics report. Heart failure (HF), CVD's primary paradigm, mainly affects people older than 65. The European MyHeart Project's mission is to empower citizens to fight CVD by leading a preventative lifestyle and allowing early diagnosis. This paper presents the iterative design and development of the HF management system, part of MyHeart Project. The system daily measures vital body signals to assess HF. The methodology applied herein has involved stakeholders in an iterative process: concept validation, feasibility, efficiency, patients' experience, and patients' acceptance. The final solution allows patient self-management of their chronic condition.

User interaction design and development of a heart failure management system based on wearable and information technologies

In the Western World, cardiovascular diseases (CVD) are the leading source of death. Only in Europe, they cause 45% of all deaths. Besides heart failure, the paradigm of CVD, affects mainly people older than 65. Facing this reality, the European Union has funded MyHeart Project, whose mission is empowering citizens to fight CVD by means of a preventive lifestyle and an early diagnosis. This paper presents the design and development of the user interaction for a heart failure management system. This system consists on wearable and mobile technologies which monitors the vital body signals in a daily basis, providing a continuous assessment of this chronic disease.

Organic solvent extraction as a versatile procedure to identify hydrophobic chloroplast membrane proteins

As a complementary approach to genome projects, proteomic analyses have been set up to identify new gene products. One of the major challenges in proteomics concerns membrane proteins, especially the minor ones. A procedure based on the differential extraction of membrane proteins in chloroform/methanol mixtures, was tested on the two different chloroplast membrane systems: envolope and thylakoid membranes. Combining the use of classical sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and mass spectrometry analyses, this procedure enabled identification of hydrophobic proteins. The propensity of hydrophobic proteins to partition in chloroform/methanol mixtures was directly correlated with the number of amino acid residues/number of putative transmembrane regions (Res/TM ratio). Regardless of the particular case of some lipid-interacting proteins, chloroform/methanol extractions allowed enrichment of hydrophobic proteins and exclusion of hydrophilic proteins from both membrane systems, thus demonstrating the versatility of the procedure.

Selectivity of endotoxin-induced defect in endothelial calcium mobilization

BACKGROUND

We hypothesized that endotoxin (LPS) would impair bradykinin (BK)-induced calcium (Ca2+) mobilization in aortic endothelial cells, perhaps due to cytotoxicity or via stimulation of nitric oxide (NO) synthesis. As well, we sought to define contributions of LPS-stimulated Ca2+ mobilization to these effects.

METHODS

LPS- or BK-induced increments of intracellular Ca2+ were assessed by microspectrofluorimetry with fura-2 in passaged bovine aortic endothelial cells. Time- and dose-dependent effects of LPS exposure (+/- inhibitors of NO or prostaglandin synthesis) on subsequent BK-induced Ca2+ mobilization and on attached cell counts were determined.

RESULTS

LPS (0.1 to 1.0 mg/ml) led to rapid increments of Ca2+, while Ca2+ responses were delayed following LPS (1 to 10 microg/ml) and lower doses were without effect. By contrast, LPS more potently (1.0 pg to 1.0 microg/ml) led to dose- and time-dependent impairment of subsequent BK-induced Ca2+ mobilization, with peak effect at four to six hours, persisting for at least 18 hours. This delayed effect on BK-response was unaltered by inhibition of either NO synthase or cyclooxygenase. The effect of LPS on BK-responsivity depended importantly on cell confluence, as it was not observed in subconfluent cells. By contrast, LPS-induced cell detachment, which was observed only at doses > or = 1.0 microg/ml, did not depend on confluence.

CONCLUSIONS

Different mechanisms lead to endothelial cytotoxicity and to impaired BK-response following LPS. Only the former effect, occurring at higher doses, might depend on initial LPS-induced Ca2+ mobilization.

Androgen up-regulates epidermal growth factor receptor expression and binding affinity in PC3 cell lines expressing the human androgen receptor

Androgens are required for the optimal growth and development of both the normal prostate and steroid-sensitive prostate cancer. PC3 prostate cancer cell lines stably expressing the human androgen receptor (AR) and possessing an androgen-sensitive phenotype (PC3-hAR) were used to examine the role of the epidermal growth factor receptor (EGFR) in androgen-stimulated prostate cancer cell growth. Epidermal growth factor (EGF) and dihydrotestosterone (DHT) independently induced the growth of PC3-hAR cells. Moreover, EGF and DHT in combination exerted a synergistic effect on PC3-hAR cell growth. DHT-exposed PC3-hAR cells expressed a greater than 2-fold increase in EGFR mRNA and 50% more EGFR protein than controls. Time course radioligand-binding assays confirmed these findings by showing an elevation in EGF binding in the DHT-exposed PC3-hAR cells. In addition, radioligand competition-binding studies revealed a 2-fold increase in EGFR-EGF binding affinity in the PC3-hAR cells after DHT treatment. However, no enhancement of transforming growth factor alpha or EGF expression was detected because DHT did not affect the levels of these cytokines in the PC3-hAR cell lysate or conditioned media. Our observations suggest that DHT increases both EGFR number and receptor-ligand affinity in androgen-sensitive prostate cancer cells and that these effects correlate with increased EGF binding and an enhanced mitogenic response to EGF.

Language use in intergroup contexts: the linguistic intergroup bias

Three experiments examine how the type of language used to describe in-group and out-group behaviors contributes to the transmission and persistence of social stereotypes. Two experiments tested the hypothesis that people encode and communicate desirable in-group and undesirable out-group behaviors more abstractly than undesirable in-group and desirable out-group behaviors. Experiment 1 provided strong support for this hypothesis using a fixed-response scale format controlling for the level of abstractness developed from Semin and Fiedler's (1988a) linguistic category model. Experiment 2 yielded the same results with a free-response format. Experiment 3 demonstrated the important role that abstract versus concrete communication plays in the perpetuation of stereotypes. The implications of these findings and the use of the linguistic category model are discussed for the examination of the self-perpetuating cycle of stereotypes in communication processes.

Language use in intergroup contexts: The linguistic intergroup bias

Three experiments examine how the type of language used to describe in-group and out-group behaviors contributes to the transmission and persistence of social stereotypes. Two experiments tested the hypothesis that people encode and communicate desirable in-group and undesirable out-group behaviors more abstractly than undesirable in-group and desirable out-group behaviors. Experiment 1 provided strong support for this hypothesis using a fixed-response scale format controlling for the level of abstractness developed from Semin and Fiedler's (1988a) linguistic category model. Experiment 2 yielded the same results with a free-response format. Experiment 3 demonstrated the important role that abstract versus concrete communication plays in the perpetuation of stereotypes. The implications of these findings and the use of the linguistic category model are discussed for the examination of the self-perpetuating cycle of stereotypes in communication processes.

Effects of high-calcium and/or high-sodium diet on basal and angiotensin II-stimulated blood pressure in the spontaneously hypertensive rat

Direct conscious blood pressure (BP) was measured via indwelling femoral cannula to evaluate the effects of chronic diet supplements with Na, Ca or both, offered to 3-week-old weanling spontaneously hypertensive rats (SHR). Despite similar food intakes, body weights were reduced within 1-2 weeks on high-Ca diets. Blood pressure was unchanged by 5.5 weeks of diet treatments. However, irrespective of concomitant Na supplement, more prolonged treatment with the high-Ca diet completely abolished the further increase in BP between the 9th and 12th weeks of age, which was noted in the rats fed the normal or high-Na diets. Angiotensin-stimulated BP was attenuated by high-Ca diets regardless of diet Na, similar to basal readings. These weight and pressure effects of Ca were not reproduced by high-Na diet alone. For all four groups, BP was directly and significantly correlated with body weight, both at 9 and 12 weeks of age. These studies demonstrate the potential role of growth retardation in the antihypertensive action of oral Ca loading in young rats.