The illness experiences of patients and their family members living with congestive heart failure

Purpose. To investigate and understand the illness experiences of patients and their family members living with congestive heart failure (CHF). ^ Design. Focused ethnographic design. ^ Setting. One outpatient cardiology clinic, two outpatient heart failure clinics, and informants' homes in a large metropolitan city located in southeast Texas. ^ Sample. A purposeful sampling technique was used to select a sample of 28 informants. The following somewhat overlapping, sampling strategies were used to implement the purposeful method: criterion; typical case; operational construct; maximum variation; atypical case; opportunistic; and confirming and disconfirming case sampling. ^ Methods. Naturalistic inquiry consisted of data collected from observations, participant observations, and interviews. Open-ended semi-structured illness narrative interviews included questions designed to elicit informant's explanatory models of the illness, which served as a synthesizing framework for the analysis. A thematic analysis process was conducted through domain analysis and construction of data into themes and sub-themes. Credibility was enhanced through informant verification and a process of peer debriefing. ^ Findings. Thematic analysis revealed that patients and their family members living with CHF experience a process of disruption, incoherence, and reconciling. Reconciling emerged as the salient experience described by informants. Sub-themes of reconciling that emerged from the analysis included: struggling; participating in partnerships; finding purpose and meaning in the illness experience; and surrendering. ^ Conclusions. Understanding the experiences described in this study allows for a better understanding of living with CHF in everyday life. Findings from this study suggest that the experience of living with CHF entails more than the medical story can tell. It is important for nurses and other providers to understand the experiences of this population in order to develop appropriate treatment plans in a successful practitioner-patient partnership. ^

Ambulatory blood pressure and physical activity in heart failure

Background. Ambulatory blood pressure (ABP) measurement is a means of monitoring cardiac function in a noninvasive way, but little is known about ABP in heart failure (HF) patients. Blood pressure (BP) declines during sleep as protection from consistent BP load, a phenomenon termed "dipping." The aims of this study were (1) to compare BP dipping and physical activity between two groups of HF patients with different functional statuses and (2) to determine whether the strength of the association between ambulatory BP and PA is different between these two different functional statuses of HF. ^ Methods. This observational study used repeated measures of ABP and PA over a 24-hour period to investigate the profiles of BP and PA in community-based individuals with HF. ABP was measured every 30 minutes by using a SpaceLabs 90207, and a Basic Motionlogger actigraph was used to measure PA minute by minute. Fifty-six participants completed both BP and physical activity for a 24-hour monitoring period. Functional status was based on New York Heart Association (NYHA) ratings. There were 27 patients with no limitation of PA (NYHA class I HF) and 29 with some limitation of PA but no discomfort at rest (NYHA class II or III HF). The sample consisted of 26 men and 30 women, aged 45 to 91 years (66.96 ± 12.35). ^ Results. Patients with NYHA class I HF had significantly greater dipping percent than those with NYHA class II/III HF after controlling their left ventricular ejection fraction (LVEF). In a mixed model analysis (PROC MIXED, SAS Institute, v 9.1), PA was significantly related to ambulatory systolic and diastolic BP and mean arterial pressure. The strength of the association between PA and ABP readings was not significantly different for the two groups of patients. ^ Conclusions. These preliminary findings demonstrate differences between NYHA class I and class II/III of HF in BP dipping status and ABP but not PA. Longitudinal research is recommended to improve understanding of the influence of disease progression on changes in 24-hour physical activity and BP profiles of this patient population. ^ Key Words. Ambulatory Blood Pressure; Blood Pressure Dipping; Heart Failure; Physical Activity. ^

Financial services and the Transatlantic Trade and Investment Partnership. CEPS Policy Brief No. 302, 20 November 2013

Given the size of the financial markets on both sides of the Atlantic and the symmetry in the follow-up of the G-20 standards, Karel Lannoo argues in this Policy Brief that the Transatlantic Trade and Investment Partnership (TTIP) provides a good opportunity to put in place a more institutionalised framework. He finds that both blocs have reacted in similar ways to the financial crisis in strengthening their regulatory and supervisory frameworks and incorporating the G-20 recommendations into federal law. He also notes that consumer protection has been reinforced, certainly in the US, with the creation of the Consumer Financial Protection Bureau. And on the EU side, the Single Supervisory Mechanism (SSM) will radically change banking supervision. In his view, inclusion of financial services could also be an opportunity to strengthen prudential rules and consumer protection provisions on both sides. Rather than leading to a reduction of consumer protection, as had been feared in the post-crisis environment, it could lead to an examination, exchange and recognition of best practices in regulation and enforcement. Finally, he concludes that inclusion of financial services would make it part of the permanent regulatory dialogue that will be established as a result of a successful TTIP.

Performance partnership agreement /

"Illinois Environmental Protection Agency, Environmental Policy" -- Cover.

The Heart of the Sangamon : an inventory of the region's resources.

"A project of the Critical Trends Assessment Program."

International trade law, plain packaging and tobacco industry political activity:the Trans-Pacific Partnership

Tobacco companies are increasingly turning to trade and investment agreements to challenge measures aimed at reducing tobacco use. This study examines their efforts to influence the Trans-Pacific Partnership (TPP), a major trade and investment agreement which may eventually cover 40% of the world's population; focusing on how these efforts might enhance the industry's power to challenge the introduction of plain packaging. Specifically, the paper discusses the implications for public health regulation of Philip Morris International's interest in using the TPP to: shape the bureaucratic structures and decision-making processes of business regulation at the national level; introduce a higher standard of protection for trademarks than is currently provided under the Agreement on Trade Related Aspects of Intellectual Property Rights; and expand the coverage of Investor-State Dispute Settlement which empowers corporations to litigate directly against governments where they are deemed to be in breach of investment agreements. The large number of countries involved in the TPP underlines its risk to the development of tobacco regulation globally.

A közérdek védelmének intézményei Public-Private Partnership esetében = Institutional approaches to protecting public interest in Public-Private Partnership projects

A tanulmány a Public-Private Partnership (PPP) egyik nagy kérdésének megközelítéseit vizsgálja: miként védhető a közérdek e projektekben. Piaci és nem piaci megoldásokat tesz az elemzés mérlegre, valamint kitér arra, hogy miért különleges a PPP projektek esetében a közérdek védelmének kérdése. A szabályozott verseny körülményeinek kialakítása több megközelítésben is perdöntő kérdés a PPP értéknövelésének előmozdításához, bár a létező megoldások nem mentesek anomáliáktól. A képviseleti demokrácia intézményi működésének támogatására pedig a társadalmi részvétel megoldásait javasolja az irodalom. E megközelítés is több formájában, többféle céllal és szintén kihívásokkal segítheti az értéknövelő PPP projekteket. A tanulmány az elvi lehetőségek értékelő elemzését követően a megvalósítás realitásait is mérlegre teszi. = This study focuses on a key issue in Public-Private Partnership (PPP) projects: how may public interest be protected. It assesses market based and non market based approaches, and also explains why PPP projects are peculiar when addressing the protection of public interest. Setting up the conditions for simulated competition is of paramount importance for different reasons in order to enable value creating PPP projects. Existing solutions however are not without anomalies. To promote the institutions of democracy, participatory solutions are recommended in the literature. That approach may help value creating PPP projects in various forms, with a range of objectives and challenges. The study concludes the analytical assessment of options by highlighting the realistic conditions of implementation.

Risk factors of coronary heart disease and correlates of type 2 diabetes among Cuban Americans

Cuban Americans, a minority Hispanic subgroup, have a high prevalence of type 2 diabetes. Persons with diabetes experience a higher rate of coronary heart disease (CHD) compared to those without diabetes. The objectives of the National Institute of Diabetes and Digestive and Kidney Disease (NIDDK) are to investigate the risk factors of CHD and the etiology of diabetes among diabetics of minority ethnic populations. No information is available on the etiology of CHD risks for Cuban Americans. ^ This cross-sectional study compared Cuban Americans with (N = 79) and without (N = 80) type 2 diabetes residing in South Florida. Data on risk factors of CHD and type 2 diabetes were collected using sociodemographics, smoking habit, Rose Angina, Modifiable Activity, and Willet's food frequency questionnaires. Anthropometrics and blood pressure (BP) were recorded. Glucose, glycated hemoglobin, lipid profile, homocysteine, and C-reactive protein were assessed in fasting blood. ^ Diabetics reported a significantly higher rate of angina symptoms than non-diabetics (P = 0.008). After adjusting for age and gender, diabetics had significantly (P < 0.001) larger waist circumference and higher systolic BP than non-diabetics. There was no significant difference in major nutrient intakes between the groups. One quarter of subjects, both diabetics and non-diabetics, exceeded the intake of percent calories from total fat and almost 60% had cholesterol intake >200 mg/d and more than 60% had fiber intake <20 gm/d. The pattern of physical activity did not differ between groups though, it was much below the recommended level. After adjusting for age and gender, diabetics had significantly (P < 0.001) higher levels of blood glucose, glycated hemoglobin, triglycerides, and homocysteine than non-diabetics. In contrast, diabetics had significantly (P < 0.01) lower levels of high-density lipoprotein cholesterol (HDL-C). ^ Multivariate logistic regression analyses showed that increasing age, male gender, large waist circumference, lack of acculturation, and high levels of triglycerides were independent risk factors of type 2 diabetes. In contrast, moderate alcohol consumption conferred protection against diabetes. ^ The study identified several risk factors of CHD and diabetes among Cuban Americans. Health care providers are encouraged to practice ethno-specific preventive measures to lower the burden of CHD and diabetes in Cuban Americans. ^

Dialogue, partnership and empowerment for network and information security:the changing role of the private sector from objects of regulation to regulation shapers

The protection of cyberspace has become one of the highest security priorities of governments worldwide. The EU is not an exception in this context, given its rapidly developing cyber security policy. Since the 1990s, we could observe the creation of three broad areas of policy interest: cyber-crime, critical information infrastructures and cyber-defence. One of the main trends transversal to these areas is the importance that the private sector has come to assume within them. In particular in the area of critical information infrastructure protection, the private sector is seen as a key stakeholder, given that it currently operates most infrastructures in this area. As a result of this operative capacity, the private sector has come to be understood as the expert in network and information systems security, whose knowledge is crucial for the regulation of the field. Adopting a Regulatory Capitalism framework, complemented by insights from Network Governance, we can identify the shifting role of the private sector in this field from one of a victim in need of protection in the first phase, to a commercial actor bearing responsibility for ensuring network resilience in the second, to an active policy shaper in the third, participating in the regulation of NIS by providing technical expertise. By drawing insights from the above-mentioned frameworks, we can better understand how private actors are involved in shaping regulatory responses, as well as why they have been incorporated into these regulatory networks.

Predictive Analytics and Decision Support for Heart Failure patients

Thesis (Master's)--University of Washington, 2016-08

Unmet health needs in patients with coronary heart disease: implications and potential for improvement in caring services

BACKGROUND: Improving the quality of health care services requires tailoring facilities to fulfil patients' needs. Satisfying patients' healthcare needs, listening to patients' opinions and building a closer provider-user partnership are central to the NHS. Few published studies have discussed cardiovascular patients' health needs, but they are not comprehensive and fail to explore the contribution of outcome to needs assessment. METHOD: A comprehensive self-administered health needs assessment (HNA) questionnaire was developed for concomitant use with generic (Short Form-12 and EuroQOL) and specific (Seattle Angina Questionnaire) health-related quality of life (HRQL) instruments on 242 patients admitted to the Acute Cardiac Unit, Nottingham. RESULTS: 38% reported difficulty accessing health facilities, 56% due to transport and 32% required a travelling companion. Mean HRQOL scores were lower in those living alone (P < 0.05) or who reported unsatisfactory accommodation. Dissatisfaction with transport affected patients' ease of access to healthcare facilities (P < 0.001). Younger patients (<65 y) were more likely to be socially isolated (P = 0.01). Women and patients with chronic disease were more likely to be concerned about housework (P < 0.05). Over 65 s (p < 0.05) of higher social classes (p < 0.01) and greater physical needs (p < 0.001) had more social needs, correlating moderately (0.32 < r < 0.63) with all HRQL domains except SAQ-AS. Several HRQL components were highly correlated with the HNA physical score (p < 0.001). CONCLUSIONS: Patients wanted more social (suitable accommodation, companionship, social visits) and physical (help aids, access to healthcare services, house work) support. The construct validity and intra-class reliability of the HNA tool were confirmed. Our results indicate a gap between patients' health needs and available services, highlighting potential areas for improvement in the quality of services

The Use of Cryogenic Air in Supplied Air Respiratory Protection

The Mine Improvement and New Emergency Response (MINER) Act of 2006 implemented new regulations in the underground coal mining industry that allow for the certification of non-compressed gas equipment for respiratory protection in underground coal mines. NASA’s Kennedy Space Center (KSC) Biomedical Research and Engineering Laboratory (BRL) is investigating the potential to expand cryogenic air supply systems into the mining and general industries. These investigations have, so far, resulted in four separate comparison and hardware development programs. The Propellant Handlers Ensemble (PHE) and Level “A” Ensemble Comparison (LAE): This study compared worker thermal stress while using the industry standard Level A hazardous material handling ensemble as opposed to using the similarly protective Propellant Handler’s Ensemble (PHE) that utilizes a cryogenic air supply pack, known as an Environmental Control Unit (ECU) as opposed to the compressed air Self Contained Breathing Apparatus (SCBA) used in the LAE. The research found that, in a 102°F environment, test subjects experienced significantly decreased body temperature increases, significantly decreased heart rate increases, and decreased sweat loss while performing a standard work routine while using the PHE, compared to the same test subjects performing the same routine while using the LAE. The Cryogenic Refuge Alternative Supply System (CryoRASS) project: The MINER Act of 2006 requires the operators of underground coal mines to provide refuge alternatives that can provide a safe atmosphere for workers for up to 96 hours in the event of a mine emergency. The CryoRASS project retrofitted an existing refuge chamber with a liquid air supply instead of the standard compressed air supply system and performed a 96 hour test. The CryoRASS system demonstrated that it provided a larger air supply in a significantly smaller footprint area, provided humidity and temperature control, and maintained acceptable oxygen and carbon dioxide levels in the chamber for the required amount of time. SCBA and Mine Rescue System (CryoBA/CryoASFS) Another requirement of the MINER Act is that additional emergency breathing equipment must be staged along evacuation routes to supplement the Self Contained/Self Rescue (SCSR) devices that are now required. The BRL has developed an SCBA known as the Cryogenic Breathing Apparatus (CryoBA), that has the ability to provide 2 hours of breathing air, a refill capability, and some cooling for the user. Cryogenic Air Storage and Filling Stations (CryoASFS) would be positioned in critical areas to extend evacuation time. The CryoASFS stations have a significantly smaller footprint and larger air storage capacity to similar compressed air systems. The CryoBA pack is currently undergoing NIOSH certification testing. Technical challenges associated with liquid breathing air systems: Research done by the BRL has also addressed three major technical challenges involved with the widespread use of liquid breathing air. The BRL developed a storage Dewar fitted with a Cryorefrigerator that has stored liquid air for four months with no appreciable oxygen enrichment due to differential evaporation. Testing of liquid breathing air was material and time intensive. A BRL contract developed a system that only required 1 liter of air and five minutes of time compared to the 10 liters of air and 75 minutes of time required by the old method. The BRL also developed a simple and cost effective method of manufacturing liquid air that joins a liquid oxygen tanker with a liquid nitrogen tanker through an orifice controlled “Y” fitting, mixing the two components, and depositing the mixed breathing air in a separate tanker.

Toxoplasma gondii Infection in Hunted Wild Boars (Sus scrofa): Heart Meat Juice as an Alternative Sample to Serum for the Detection of Antibodies

Toxoplasmosis is a global zoonosis caused by the protozoan parasite Toxoplasma gondii. Detection of antibodies to T. gondii in serum samples from hunted animals may represent a key step for public health protection. It is also important to assess the circulation of this parasite in wild boar population. However, in hunted animals, collection of blood is not feasible and meat juice may represent an alternative sample. The purpose of the present study was to evaluate heart meat juice of hunted wild boars as an alternative sample for post-mortem detection of antibodies to T. gondii by modified agglutination test (MAT). The agreement beyond chance between results from meat juice assessed with Cohen’s kappa coefficient revealed that the 1:20 meat juice dilution provided the highest agreement. McNemars’s test further revealed 1:10 as the most suitable meat juice dilution, as the proportion of positive paired samples (serum and meat juice from the same animal) did not differ at this dilution. All together, these results suggest a reasonable accuracy of heart meat juice to detect antibodies to T. gondii by MAT and support it as an alternative sample in post-mortem analysis in hunted wild boars.

WIPO and the Reinforcement of the Nagoya Protocol: Towards Effective Implementation of an Access and Benefit Sharing Regime for the Protection of Traditional Knowledge Associated with Genetic Resources

Traditional knowledge associated with genetic resources (TKaGRs) is acknowledged as a valuable resource. Its value draws from economic, social, cultural, and innovative uses. This value places TK at the heart of competing interests as between indigenous peoples who hold it and depend on it for their survival, and profitable industries which seek to exploit it in the global market space. The latter group seek, inter alia, to advance and maintain their global competitiveness by exploiting TKaGRs leads in their research and development activities connected with modern innovation. Biopiracy remains an issue of central concern to the developing world and has emerged in this context as a label for the inequity arising from the misappropriation of TKaGRs located in the South by commercial interests usually located in the North. Significant attention and resources are being channeled at global efforts to design and implement effective protection mechanisms for TKaGRs against the incidence of biopiracy. The emergence and recent entry into force of the Nagoya Protocol offers the latest example of a concluded multilateral effort in this regard. The Nagoya Protocol, adopted on the platform of the Convention on Biological Diversity (CBD), establishes an open-ended international access and benefit sharing (ABS) regime which is comprised of the Protocol as well as several complementary instruments. By focusing on the trans-regime nature of biopiracy, this thesis argues that the intellectual property (IP) system forms a central part of the problem of biopiracy, and so too to the very efforts to implement solutions, including through the Nagoya Protocol. The ongoing related work within the World Intellectual Property Organization (WIPO), aimed at developing an international instrument (or a series of instruments) to address the effective protection of TK, constitutes an essential complementary process to the Nagoya Protocol, and, as such, forms a fundamental element within the Nagoya Protocol’s evolving ABS regime-complex. By adopting a third world approach to international law, this thesis draws central significance from its reconceptualization of biopiracy as a trans-regime concept. By construing the instrument(s) being negotiated within WIPO as forming a central component part of the Nagoya Protocol, this dissertation’s analysis highlights the importance of third world efforts to secure an IP-based reinforcement to the Protocol for the effective eradication of biopiracy.

[health Protection For Rural Workers: The Need To Standardize Techniques For Quantifying Dermal Exposure To Pesticides].

Quantification of dermal exposure to pesticides in rural workers, used in risk assessment, can be performed with different techniques such as patches or whole body evaluation. However, the wide variety of methods can jeopardize the process by producing disparate results, depending on the principles in sample collection. A critical review was thus performed on the main techniques for quantifying dermal exposure, calling attention to this issue and the need to establish a single methodology for quantification of dermal exposure in rural workers. Such harmonization of different techniques should help achieve safer and healthier working conditions. Techniques that can provide reliable exposure data are an essential first step towards avoiding harm to workers' health.