Efficacy and Safety of Ticagrelor for Long-term Secondary Prevention of Atherothrombotic Events in Relation to Renal Function: Insights from the PEGASUS TIMI-54 trial

Aims: We evaluated the relationship of renal function and ischaemic and bleeding risk as well as the efficacy and safety of the P2Y12 platelet receptor inhibitor ticagrelor in stable patients with prior myocardial infarction (MI). Methods & Results: Patients with a history of MI 1-3 years prior from the Prevention of Cardiovascular Events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin (PEGASUS)-TIMI 54 were stratified based on estimated glomerular filtration rate (eGFR), with<60 ml/min/1.73m2 prespecified for analysis of the effect of ticagrelor on the primary efficacy composite of cardiovascular death, MI, or stroke (MACE) and the primary safety endpoint of TIMI major bleeding. Of 20,898 patients, those with eGFR<60 (N=4,849, 23.2%) had a greater risk of MACE at 3 years relative to those without, which remained significant after multivariable adjustment (HRadj 1.54, 95% CI 1.27–1.85, p<0.001). The relative risk reduction in MACE with ticagrelor was similar in those with eGFR<60 (ticagrelor pooled vs. placebo: HR 0.81; 95% CI 0.68–0.96) vs. ≥60 (HR 0.88; 95% CI 0.77–1.00, pinteraction=0.44). However, due to the greater absolute risk in the former group, the absolute risk reduction with ticagrelor was higher: 2.7% vs. 0.63%. Bleeding tended to occur more frequently in patients with renal dysfunction. The absolute increase in TIMI major bleeding with ticagrelor was similar in those with and without eGFR<60 (1.19% vs. 1.43%), whereas the excess of minor bleeding tended to be more pronounced (1.93% vs. 0.69%). Conclusion: In patients with a history of MI, patients with renal dysfunction are at increased risk of MACE and consequently experience a particularly robust absolute risk reduction with long-term treatment with ticagrelor.

A COMUNICAÇÃO PODE SALVAR VIDAS: ALERTAS ANTECIPADOS DE EMERGÊNCIAS CLIMÁTICAS PELA TELEVISÃO DIGITAL INTERATIVA BRASILEIRA

Alertas Antecipados de Emergência são elementos importantes na redução de riscos de desastres, evitando a perda de vidas e reduzindo seu impacto econômico e material. Dentre os meios de comunicação mais eficazes para geração de alertas antecipados, a televisão digital com sua capacidade de emissão de um para muitos e ainda com suas possibilidades de gerar informações reativas com dados enviados pelo mesmo sinal de TV é, no momento, o estado da arte para ajudar a população em situações de risco, comprovado através de estudos comparativos entre os sistemas de alerta de emergência existentes hoje em todo o mundo. Neste trabalho são comparados os sistemas japonês e norte-americano, sendo que os referenciais teóricos apresentados focalizam o processo comunicacional de uma informação de emergência, a partir de diversas teorias que fundamentam o processo de comunicação em situações de crise, com os quais chegou-se à conclusão de que a tecnologia de televisão Digital Brasileira, juntamente com a infraestrutura essencial para detecção de riscos e confiabilidade para a geração de alertas antecipados já existente, dispõe de todo o ferramental necessário para a criação de um sistema nacional. Por fim são apresentadas as indicações iniciais para a criação de um modelo para uma comunicação eficaz e efetiva de informações de emergência destinado à população brasileira.

Patients’ and physicians’ experiences of atrial fibrillation and anticoagulation therapy:a qualitative journey

Background: Oral anticoagulation (OAC) reduces stroke risk in patients with atrial fibrillation (AF) however it is often underutilized and sometimes refused by patients. This programme of work included a meta-synthesis and two inter-linking studies aiming to explore patients’ and physicians’ experiences of AF and OAC. Methods: A meta-synthesis of qualitative evidence was conducted which informed the empirical work. Semi-structured individual interviews were utilised. Study 1: Three AF patient sub-groups were interviewed; accepted (n=4), refused (n=4), or discontinued (n=3) warfarin. Study 2: Four physician sub-groups (n=4 each group) prescribing OAC to AF patients were interviewed: consultant cardiologists, consultant general physicians, general practitioners and cardiology registrars. Data was analysed using interpretative phenomenological analysis. Results: Study 1: Three over-arching themes comprised patients’ experiences: (1) the initial consultation, (2) life after the consultation, and (3) patients’ reflections. Patients commented on the relief and reassurance experienced during the consultation but they perceived the decision making process mostly led by the physician. Lack of education and take-home materials distributed during the initial consultation was highlighted. Patients who had experienced stroke themselves or were caregivers, were more receptive to education aimed towards stroke risk reduction rather than bleeding risk. Warfarin monitoring was challenging for patients, however some patients perceived it as beneficial as it served to enhance patient-physician relationship. Study 2: Two over-arching themes emerged from physicians’ experiences: (1) communicating information and (2) challenges with OAC prescription for AF. Physicians’ approach to the consultation style shifted through a continuum of compliance-adherence-concordance during the consultation. They aimed for concordance, however challenges such as time and the perceived patient trust in them as the expert, led to physicians adopting a paternalistic approach. Physicians also pointed out challenges associated with guideline adherence and the need to adopt a multi-disciplinary approach, where other health professionals could provide on-going education. Conclusion: This programme of work has illustrated the benefit of taking an in depth phenomenological approach to understanding the lived experience of the physician-patient consultation. Together with the meta-synthesis, this work has strengthened the evidence base and demonstrated that there is a need to target patients' and physicians' ability to communicate with each other in a comprehensible way.

Evaluation of vulnerability factors for cyclones : the case of Patuakhali, Bangladesh

Tropical cyclones are considered as the most severe natural disasters in Bangladesh; they cause extensive damage, create losses in the country׳s economy, and affect social settings. The impact of natural disasters has been further intensified due to various vulnerability factors within the Bangladeshi community such as low income; shortages of food; lack of assets such as land and permanent housing; dense population, illiteracy. This study evaluates the vulnerability factors for cyclones in the community based in the Patuakhali region of south western Bangladesh. The bottom-up research approach was adopted for the study, whereby the local community was consulted for their viewpoints by using focus group interviews and semi-structured interviews. Different community groups and social categories including both men and women, from different age groups and livelihoods, participated in the study. The study revealed how the community׳s vulnerability to cyclones has been further aggravated by socio-economic factors such as social status, political influences and economic conditions. The majority of the community in Patuakhali has been “knowingly” vulnerable to cyclone disaster as a result of the lack of alternatives especially in terms of their livelihood patterns. The vulnerability of women, due to their lack of authority, domestic work, and fear of exposure within the society was also highlighted. The study revealed how vulnerability factors are interlinked with each other making them further difficult to manage. This calls for multi-faceted disaster risk reduction strategies that targets vulnerability factors deriving from different origins and root causes.

Evaluation of vulnerability factors for cyclones:the case of Patuakhali, Bangladesh

Tropical cyclones are considered as the most severe natural disasters in Bangladesh; they cause extensive damage, create losses in the country[U+05F3]s economy, and affect social settings. The impact of natural disasters has been further intensified due to various vulnerability factors within the Bangladeshi community such as low income; shortages of food; lack of assets such as land and permanent housing; dense population, illiteracy. This study evaluates the vulnerability factors for cyclones in the community based in the Patuakhali region of south western Bangladesh. The bottom-up research approach was adopted for the study, whereby the local community was consulted for their viewpoints by using focus group interviews and semi-structured interviews. Different community groups and social categories including both men and women, from different age groups and livelihoods, participated in the study. The study revealed how the community[U+05F3]s vulnerability to cyclones has been further aggravated by socio-economic factors such as social status, political influences and economic conditions. The majority of the community in Patuakhali has been "knowingly" vulnerable to cyclone disaster as a result of the lack of alternatives especially in terms of their livelihood patterns. The vulnerability of women, due to their lack of authority, domestic work, and fear of exposure within the society was also highlighted. The study revealed how vulnerability factors are interlinked with each other making them further difficult to manage. This calls for multi-faceted disaster risk reduction strategies that targets vulnerability factors deriving from different origins and root causes. © 2014 Elsevier Ltd.

Reliability modelling and verification of manufacturing processes based on process knowledge management

Reliability modelling and verification is indispensable in modern manufacturing, especially for product development risk reduction. Based on the discussion of the deficiencies of traditional reliability modelling methods for process reliability, a novel modelling method is presented herein that draws upon a knowledge network of process scenarios based on the analytic network process (ANP). An integration framework of manufacturing process reliability and product quality is presented together with a product development and reliability verification process. According to the roles of key characteristics (KCs) in manufacturing processes, KCs are organised into four clusters, that is, product KCs, material KCs, operation KCs and equipment KCs, which represent the process knowledge network of manufacturing processes. A mathematical model and algorithm is developed for calculating the reliability requirements of KCs with respect to different manufacturing process scenarios. A case study on valve-sleeve component manufacturing is provided as an application example of the new reliability modelling and verification procedure. This methodology is applied in the valve-sleeve component manufacturing processes to manage and deploy production resources.

Motivations for servitization:the impact of product complexity

Purpose – The purpose of this paper is to identify the commonalities and differences in manufacturers’ motivations to servitise. Design/methodology/approach – UK study based on interviews with 40 managers in 25 companies in 12 sectors. Using the concept of product complexity, sectors were grouped using the Complex Products and Systems (CoPS) typology: non-complex products, complex products and systems. Findings – Motivations to servitise were categorised as competitive, demand based (i.e. derived from the customer) or economic. Motivations to servitise vary according to product complexity, although cost savings and improved service quality appear important demand-based motivations for all manufacturers. Non-complex product manufacturers also focus on services to help product differentiation. For CoPS manufacturers, both risk reduction and developing a new revenue stream were important motivations. For uniquely complex product manufacturers, stabilising revenue and increased profitability were strong motivations. For uniquely systems manufacturers, customers sought business transformation, whilst new service business models were also identified. Research limitations/implications – Using the CoPS typology, this study delineates motivations to servitise by sector. The findings show varying motivations to servitise as product complexity increases, although some motivational commonality existed across all groups. Manufacturers may have products of differing complexity within their portfolio. To overcome this limitation the unit of analysis was the strategic business unit. Practical implications – Managers can reflect on and benchmark their motivation for, and opportunities from, servitisation, by considering product complexity. Originality/value – The first study to categorise servitisation motivations by product complexity. Identifying that some customers of systems manufacturers seek business transformation through outsourcing.

Environmental Management Accounting - Estimating the Benefit Side

The presentation focuses on estimating benefits of environmental projects and achievements like image improvement, gaining an environmental award, profit from environmentally benign products, risk reduction benefits, etc. The paper integrates the results and experience gained in three different fields: EMA, evaluation of natural resources and working as a consultant