Disease management projects and the Chronic CareModel in action: Baseline qualitative research

Background: Disease management programs, especially those based on the Chronic Care Model (CCM),are increasingly common in the Netherlands. While disease management programs have beenwell-researched quantitatively and economically, less qualitative research has been done. Theoverall aim of the study is to explore how disease management programs are implementedwithin primary care settings in the Netherlands; this paper focuses on the early developmentand implementation stages of five disease management programs in the primary care setting,based on interviews with project leadership teams. Methods: At the five sites, eleven semi-structured interviews were conducted at the five selected siteswith sixteen professionals interviewed; all project leaders were interviewed. The interviewsfocused on each project's chosen chronic illness (diabetes, eating disorders, COPD, multimorbidity,CVRM) and project plan, barriers to development and implementation, the projectleaders' action and reactions, as well as their roles and responsibilities, and diseasemanagement strategies. Analysis was inductive and interpretive, based on the content of theinterviews. After analysis, the results of this research on disease management programs andthe Chronic Care Model are viewed from a traveling technology framework. Results: This analysis uncovered four themes that can be mapped to disease management and theChronic Care Model: (1) changing the health care system, (2) patient-centered care, (3)technological systems and barriers, and (4) integrating projects into the larger system. Projectleaders discussed the paths, both direct and indirect, for transforming the health care systemto one that addresses chronic illness. Patient-centered care was highlighted as needed and aparadigm shift for many. Challenges with technological systems were pervasive.

Development of a human model for the study of effects of hypoxia, exercise, and sildenafil on cardiac and vascular function in chronic heart failure

Background: Pulmonary hypertension is associated with poor outcome in patients with chronic heart failure (CHF) and may be a therapeutic target. Our aims were to develop a noninvasive model for studying pulmonary vasoreactivity in CHF and characterize sildenafil's acute cardiovascular effects. Methods and Results: In a crossover study, 18 patients with CHF participated 4 times [sildenafil (2 × 20 mg)/or placebo (double-blind) while breathing air or 15% oxygen] at rest and during exercise. Oxygen saturation (SaO2) and systemic vascular resistance were recorded. Left and right ventricular (RV) function and transtricuspid systolic pressure gradient (RVTG) were measured echocardiographically. At rest, hypoxia caused SaO2 (P = 0.001) to fall and RVTG to rise (5 ± 4 mm Hg; P = 0.001). Sildenafil reduced SaO2 (−1 ± 2%; P = 0.043), systemic vascular resistance (−87 ± 156 dyn·s−1·cm−2; P = 0.034), and RVTG (−2 ± 5 mm Hg; P = 0.05). Exercise caused cardiac output (2.1 ± 1.8 L/min; P < 0.001) and RVTG (19 ± 11 mm Hg; P < 0.0001) to rise. The reduction in RVTG with sildenafil was not attenuated by hypoxia. The rise in RVTG with exercise was not substantially reduced by sildenafil. Conclusions: Sildenafil reduces SaO2 at rest while breathing air, this was not exacerbated by hypoxia, suggesting increased ventilation–perfusion mismatching due to pulmonary vasodilation in poorly ventilated lung regions. Sildenafil reduces RVTG at rest and prevents increases caused by hypoxia but not by exercise. This study shows the usefulness of this model to evaluate new therapeutics in pulmonary hypertension

The management of cardiovascular disease in the Netherlands: analysis of different programmes

Background: Disease management programmes are increasingly used to improve the efficacy and effectiveness of chronic care delivery. But, disease management programme development and implementation is a complex undertaking that requires effective decision-making. Choices made in the earliest phases of programme development are crucial, as they ultimately impact costs, outcomes and sustainability. Methods: To increase our understanding of the choices that primary healthcare practices face when implementing such programmes and to stimulate successful implementation and sustainability, we compared the early implementation of eight cardiovascular disease management programmes initiated and managed by healthcare practices in various regions of the Netherlands. Using a mixed-methods design, we identified differences in and challenges to programme implementation in terms of context, patient characteristics, disease management level, healthcare utilisation costs, development costs and health-related quality of life. Results: Shifting to a multidisciplinary, patient-centred care pathway approach to disease management is demanding for organisations, professionals and patients, and is especially vulnerable when sustainable change is the goal. Funding is an important barrier to sustainable implementation of cardiovascular disease management programmes, although development costs of the individual programmes varied considerably in relation to the length of the development period. The large number of professionals involved in combination with duration of programme development was the largest cost drivers. While Information and Communication Technology systems to support the new care pathways did not directly contribute to higher costs, delays in implementation indirectly did. Conclusions: Developing and implementing cardiovascular disease management programmes is time-consuming and challenging. Multidisciplinary, patient-centred care demands multifaceted changes in routine care. As care pathways become more complex, they also become more expensive. Better preparedness and training can prevent unnecessary delays during the implementation period and are crucial to reducing costs

Association of copy number variation across the genome with neuropsychiatric traits in the general population

Copy number variants (CNVs) are associated with psychiatric conditions in clinical populations. The relationship between rare CNV burden and neuropsychiatric traits in young, general populations is underexplored. 6807 children from the Avon Longitudinal Study of Parents and Children (ALSPAC) were studied. CNVs were inferred from SNP-array data using PennCNV. After excluding children with known candidate CNVs for schizophrenia, rare (<1%) CNV burden (total number of genes affected by CNVs, total length of CNVs, and largest CNV carried) was analysed in relation to: psychotic experiences (PEs) and anxiety/depression in adolescence; autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD), ASD and ADHD traits, and cognitive measures during childhood. Outcomes were also assessed in relation to known schizophrenia CNVs. The number of genes affected by rare CNVs was associated with a continuous measure of ASD: the standardised mean difference [SMD] per gene affected was increased by 0.018 [95%CI 0.011,0.025], p=3e-07 for duplications and by 0.021 [95%CI 0.010, 0.032], p=1e-04 for deletions. In line with published results on educational attainment in ALSPAC, IQ was associated with CNV burden: the SMD per gene affected was -0.017 [95%CI -0.025,-0.008] p=1e-04 for duplications and -0.023 [95%CI -0.037, -0.009], p=0.002 for deletions. Associations were also observed for measures of coherence, attention, memory, and social cognition. Schizophrenia-associated deletions were associated with IQ (SMD: -0.617 [95%CI -0.936,-0.298], p=2e-04), but not with PEs or other traits. We found that rare CNV burden and known schizophrenia candidate CNVs are associated with neuropsychiatric phenotypes in a non-clinically ascertained sample of young people

Evaluatie van disease management programma's in Nederland

In het ZonMw programma ‘Disease Management Chronische Ziekten’ (DMCZ) zijn 22 praktijkprojecten ontwikkeld, gevolgd en geëvalueerd. Deze ZonMw-praktijkprojecten hadden een looptijd van ongeveer drie jaar. Gedurende deze periode zijn de projecten systematisch gevolgd op een aantal proces- en effectmaten en kosten-effectiviteit. De verwachting is dat disease management programma's gebaseerd op Ed Wagner's chronische zorgmodel bijdragen aan betere kwaliteit van chronische zorgverlening. Inzicht in de korte en lange termijn effecten van implementatie van dit type programma's voor verschillende chronische aandoeningen is echter nog schaars. [...

The Lick AGN Monitoring Project 2011: Dynamical Modeling of the Broad Line Region in Mrk 50

We present dynamical modeling of the broad line region (BLR) in the Seyfert 1 galaxy Mrk 50 using reverberation mapping data taken as part of the Lick AGN Monitoring Project (LAMP) 2011. We model the reverberation mapping data directly, constraining the geometry and kinematics of the BLR, as well as deriving a black hole mass estimate that does not depend on a normalizing factor or virial coefficient. We find that the geometry of the BLR in Mrk 50 is a nearly face-on thick disk, with a mean radius of 9.6(+1.2,-0.9) light days, a width of the BLR of 6.9(+1.2,-1.1) light days, and a disk opening angle of 25\pm10 degrees above the plane. We also constrain the inclination angle to be 9(+7,-5) degrees, close to face-on. Finally, the black hole mass of Mrk 50 is inferred to be log10(M(BH)/Msun) = 7.57(+0.44,-0.27). By comparison to the virial black hole mass estimate from traditional reverberation mapping analysis, we find the normalizing constant (virial coefficient) to be log10(f) = 0.78(+0.44,-0.27), consistent with the commonly adopted mean value of 0.74 based on aligning the M(BH)-{\sigma}* relation for AGN and quiescent galaxies. While our dynamical model includes the possibility of a net inflow or outflow in the BLR, we cannot distinguish between these two scenarios.Comment: Accepted for publication in ApJ. 8 pages, 6 figure

Fashionable curiosities: extreme footwear as wearable fantasies

This paper considers an aspect of the material culture fashion, focusing on shoes. Like clothes, shoes are used every day: they are essential objects that primarily allow people to perform daily and socially accepted activities, walk comfortably and adorn the body in a fashionable way. Furthermore, shoes are associated with the idea of individuality and can be highly practical or decorative, depending on their design and fashion style. With regard to their style, one phenomenon emerging in high fashion is that of the “impossible-to-wear shoes”: exhibitions and fashion shows staging designers’ bizarre shoes are becoming more frequent. During these shows, the spectators are presented with an unusual variety of footwear (e.g. heelless shoes; shoes without soles; fish-shaped shoes). These shoes are not made to fit the individual. On the contrary, their shape and forms are imposed on the individuals. This paper explores the extreme, impossible-to-wear shoes and considers the visual statements they make about contemporary society, women and femininity. I will argue that impossible-to-wear shoes are puzzling yet charming objects, epitomizing a spectacle-centered society: they are part of unexpected and personal performances, which blend the boundaries of fashion and art and allow the wearers to shift from an ordinary “self” to the extraordinary “other”

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy