Current legal and institutional issues in the commercialization of phosphoric acid fuel cells

Legal and institutional factors affecting the development and commercial diffusion of phosphoric acid fuel cells are assessed. Issues for future research and action are suggested. Perceived barriers and potential opportunities for fuel cells in central and dispersed utility operations and on-site applications are reviewed, as well as the general concept of commercialization as applied to emerging energy technologies

Orthostatic Hypotension and Antiparkinsonian Drugs: A Systematic Review and Meta-analysis

BACKGROUND: Orthostatic hypotension (OH) is multifactorial in Parkinson's disease (PD). Antiparkinsonian medication can contribute to OH, leading to increased risk of falls, weakness and fatigue. METHODS: We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) of antiparkinsonian drugs associated with OH as an adverse effect, compared to placebo. We searched EMBASE, MEDLINE and Web of Science databases until November 2020. Analysis used fixed-effects models and the GRADE tool to rate quality of evidence. Meta-analysis was performed if 3 or more studies of a drug group were available. RESULTS: Twenty-one RCTs including 3783 patients were included comparing 6 PD drug groups to placebo (MAO-B inhibitors, dopamine agonists, levodopa, COMT inhibitors, levodopa and adenosine receptor antagonists). OH was recorded as an adverse event or measurement of vital signs, without further specification on how this was defined or operationalised. Meta-analysis was performed for MAO-B inhibitors and dopamine agonists, as there were 3 or more studies for these drug groups. In this analysis, compared with placebo, neither MAO-B inhibitors or dopamine agonists were associated with increased risk of OH, (OR 2.28 [95% CI:0.81-6.46]), (OR 1.39 [95% CI:0.97-1.98]). CONCLUSIONS: Most studies did not specifically report OH, or reporting of OH was limited, including how and when it was measured. Furthermore, studies specifically reporting OH included participants that were younger than typical PD populations without multimorbidity. Future trials should address this, for example,, by including individuals over the age of 75, to improve estimations of how antiparkinsonian medications affect risk of OH

Drug-induced orthostatic hypotension: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND: Drug-induced orthostatic hypotension (OH) is common, and its resulting cerebral hypoperfusion is linked to adverse outcomes including falls, strokes, cognitive impairment, and increased mortality. The extent to which specific medications are associated with OH remains unclear. METHODS AND FINDINGS: We conducted a systematic review and meta-analysis to evaluate the extent to which specific drug groups are associated with OH. EMBASE, MEDLINE, and Web of Science databases were searched from inception through 23 November 2020. Placebo-controlled randomised controlled trials (RCTs) on any drug reporting on OH as an adverse effect in adults (≥18 years) were eligible. Three authors extracted data on the drug, OH, dose, participant characteristics, and study setting. The revised Cochrane risk-of-bias tool for randomised trials (RoB 2) was used to appraise evidence. Summary odds ratios (ORs) were estimated for OH using fixed effects Mantel-Haenszel statistics. We conducted subgroup analysis on validity of OH measurement, drug dose, risk of bias, age, and comorbidity. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool was used to summarise the certainty of evidence. Of 36,940 citations, 69 eligible RCTs were included in the meta-analysis comprising 27,079 participants. Compared with placebo, beta-blockers and tricyclic antidepressants were associated with increased odds of OH (OR 7.76 [95% CI 2.51, 24.03]; OR 6.30 [95% CI 2.86, 13.91]). Alpha-blockers, antipsychotics, and SGLT-2 inhibitors were associated with up to 2-fold increased odds of OH, compared to placebo. There was no statistically significant difference in odds of OH with vasodilators (CCBs, ACE inhibitors/ARBs, SSRIs), compared to placebo. Limitations of this study are as follows: data limited to placebo-controlled studies, (excluding head-to-head trials), many RCTs excluded older participants; therefore results may be amplified in older patients in the clinical setting. The study protocol is publicly available on PROSPERO (CRD42020168697). CONCLUSIONS: Medications prescribed for common conditions (including depression, diabetes, and lower urinary tract symptoms) were associated with significantly increased odds of OH. Drugs causing sympathetic inhibition were associated with significantly increased odds of OH, while most vasodilators were associated with small nonsignificant differences in odds of OH, compared to placebo. Drugs targeting multiple parts of the orthostatic blood pressure (BP) reflex pathway (e.g. sympathetic inhibition, vasodilation, cardio-inhibitory effects) may carry cumulative risk, suggesting that individuals with polypharmacy could benefit from postural BP monitoring

Experiences of advance care planning in Parkinson’s disease and atypical Parkinsonian disorders: a mixed methods systematic review

Background and purpose: Advance care planning allows people to plan for their future care needs and can include medical, psychological and social aspects. However, little is known on the use, experience of and attitudes towards advance care planning in patients with parkinsonian disorders, their family carers and healthcare professionals. Methods: A systematic search of online databases was conducted in April 2019 using a narrative synthesis approach with thematic analysis and tabulation to synthesize the findings. Results: In all, 507 articles were identified and 27 were included. There were five overarching themes: (i) what is involved in advance care planning discussions, (ii) when and how advance care planning discussions are initiated, (iii) barriers to advance care planning, (iv) the role of healthcare professionals and (v) the role of the family carer. This evidence was used to highlight eight effective components to support optimal advance care planning in parkinsonian disorders: advance care planning discussions should be individualized in content, timing and approach; patients should be invited to discuss advance care planning early and regularly; palliative care services should be introduced early; a skilled professional should deliver advance care planning; support to family carers should be offered in the advance care planning process; healthcare professionals should be educated on parkinsonian disorders and palliative care; advance care planning should be clearly documented and shared with relevant services; and healthcare professionals should be enabled to conduct effective advance care planning. Conclusions: These components can inform best practice in advance care planning in patients with parkinsonian disorders

Medical student mentoring programs: current insights

Medical school mentoring programs incorporate a wide range of objectives. Clinical mentoring programs help to develop students' clinical skills and can increase interest in under-subscribed specialties. Those that focus on teaching professionalism are integrated into medical school curriculums in order to overcome the "hidden curriculum". Positive mentoring plays a part in reversing the decline of academic medicine, by sparking interest through early research experiences. It also has an important role in encouraging recruitment of under-represented minority groups into the medical profession through widening access programs. The aim of our review of the literature, is to analyze current trends in medical student mentoring programs, taking into account their objectives, execution, and evaluation. We outline the challenges encountered, potential benefits, and key future implications for mentees, mentors, and institutions

Exploring the co-occurrence of depression, anxiety and insomnia symptoms, diagnoses and treatments in primary care: observational study using UK primary care data.

BACKGROUND: Depression, anxiety and insomnia often co-occur. However, there is a lack of research regarding how they cluster and how this is related to medication used to treat them. AIMS: To describe the frequencies and associations between depression, anxiety and insomnia, and treatment for these conditions in primary care. METHOD: A retrospective cohort study using UK electronic primary care records. We included individuals aged between 18 and 99 years old with one or more records suggesting they had a diagnosis, symptom or drug treatment for anxiety, depression or insomnia between 2015 and 2017. We report the conditional probabilities of having different combinations of diagnoses, symptoms and treatments recorded. RESULTS: There were 1 325 960 records indicative of depression, anxiety or insomnia, for 739 834 individuals. Depression was the most common condition (n = 106 117 records), and SSRIs were the most commonly prescribed medication (n = 347 751 records). Overall, individuals with a record of anxiety were most likely to have co-occurring symptoms and diagnoses of other mental health conditions. For example, of the individuals with a record of generalised anxiety disorder (GAD), 24% also had a diagnosis of depression. In contrast, only 0.6% of those who had a diagnosis of depression had a diagnosis or symptom of GAD. Prescribing of more than one psychotropic medication within the same year was common. For example, of those who were prescribed an SNRI (serotonin-norepinephrine reuptake inhibitor), 40% were also prescribed an SSRI (selective serotonin reuptake inhibitor). CONCLUSIONS: The conditional probabilities of co-occurring anxiety, depression and insomnia symptoms, diagnoses and treatments are high

Intervention components in the self-management of Parkinson's: a mixed-methods synthesis of qualitative and quantitative evidence.

INTRODUCTION: Self-management interventions consist of multiple components to support people in the management of medical, emotional, and behavioural aspects of their condition, and aim to improve quality of life, function, and other outcomes. A systematic review of self-management interventions in Parkinson's showed no conclusive evidence for effectiveness of specific self-management approaches in Parkinson's to date but identified several potentially useful components. AIM: To identify the key required components for self-management in people with Parkinson's by synthesising evidence from a body of primary qualitative evidence and systematic reviews, and to explore which of these key components should be incorporated into trials of self-management in Parkinson's. METHOD: A mixed-methods synthesis was conducted. We combined data from two primary qualitative studies and a systematic review of qualitative studies that focused on self-management in Parkinson's to identify key intervention components. These were then mapped onto the results of a systematic review of Randomised Controlled Trials (RCTs) using matrices. First, data were extracted from the qualitative studies with people with Parkinson's and healthcare professionals on the key self-management components in this population. Second, a matrix table was created to map the identified Parkinson's specific self-management components against potential effectiveness from published RCTs of self-management interventions. RESULTS: Synthesis of qualitative data identified 15 potential self-management components. These 15 components included components needed to start self-managing (e.g., information, skill acquirement) and components needed to maintain self-managing (e.g., self-motoring, increasing motivation). From 18 RCTs, interventions varied in how many components were included (range 1-10). Trials reporting significant beneficial effects of their intervention included a higher number of components (4 or more self-management components) than trials without significant findings (1-3 self-management components). CONCLUSION: Fifteen key self-management components were identified that should be incorporated into interventions or programs of self-management in Parkinson's. No current trial has incorporated all aspects, but a higher number of these key components appears to make trials of self-management interventions more likely to be successful

Defining Mental Health Conditions Within Primary Care Data: A Validation Study With a Mixed Qualitative and Quantitative Approach.

OBJECTIVES: To validate codelists for defining a range of mental health (MH) conditions with primary care data, using a mixed qualitative and quantitative approach and without requiring external data. METHODS: We validated Read codelists, selecting and classifying them in three steps. The qualitative step included an in-depth revision of the codes by six doctors. Simultaneously, the quantitative step performed on UK primary care data included an exploratory factor analysis to cluster Read codes in MH conditions to obtain an independent classification. The statistical results informed the qualitative conclusions, generating a final selection and classification. RESULTS: From a preselected list of 2007 Read codes, a total of 1638 were selected by all doctors. Later, they agreed on classifying these codes into 12 categories of MH disorders. From the same preselected list, a total of 1364 were quantitatively selected. Using data from 497,649 persons who used these Read codes at least once, we performed the exploratory factor analysis, retaining five factors (five categories). Both classifications showed good correspondence, while discrepancies informed decisions on reclassification. CONCLUSIONS: We produced a comprehensive set of medical codes lists for 12 MH conditions validated by a combination of clinical consensus panel and quantitative cluster analysis with cross-validation

Remote Consultations for People With Parkinson Disease and Cognitive Impairment: Interview Study With Patients, Caregivers, and Health Care Professionals

Background: The COVID-19 pandemic led to many consultations being conducted remotely. Cognitive impairment is recognized as a potential barrier to remote health care interactions and is common and heterogeneous in Parkinson disease. Studies have shown remote consultations in Parkinson disease to be feasible, but little is known about real-life experience, especially for those with cognitive impairment. We explored the experiences and perceptions of remote consultations for people with Parkinson disease and cognitive impairment. Objective: This study aimed to explore the experiences of remote consultations for people with Parkinson disease and cognitive impairment from the perspective of service users and professionals and investigate considerations for future service delivery. Methods: Semistructured interviews were conducted remotely with 11 people with Parkinson disease and cognitive impairment, 10 family caregivers, and 24 health care professionals (HCPs) between 2020 and 2021. Purposive sampling was used. Interviews were audio-recorded, transcribed, and analyzed using reflexive thematic analysis. Results: Overall, four themes were identified: “the nature of remote interactions,” “challenges exacerbated by being remote,” “expectation versus reality,” and “optimizing for the future.” Remote consultations were considered as “transactional” and less personal, with difficulties in building rapport, and considered to play a different role from that of in-person consultations. The loss of nonverbal communication and ability of HCPs to sense led to remote consultations being perceived as riskier by all groups. Issues arising from communication and cognitive impairment, balancing the voices of the person with Parkinson disease and the caregiver, and discussions of the future affect this population specifically. Remote consultations were reported to have been more successful than anticipated in all 3 groups. Obstacles were not always as expected; for example, age was less of a barrier than predicted. Video consultations were perceived as being preferable to telephone consultations by many participants, but not accessible to all people with Parkinson disease. With widespread expectation of ongoing remote consultations, potential improvements for these 3 groups and health care services were identified, including practice, preparation, increased awareness of issues, expectation management by HCPs, and more time and flexibility for consultations. Conclusions: Advantages and challenges of remote consultations for this population are identified. Consultations could be improved with increased support, practice, preparation, awareness of issues, and more time and flexibility within services