Cognitive behavioral therapy for insomnia (CBT-I) is an effective treatment in adults. However, access to care is limited. One potential solution is telemedicine. Though synchronous video-based telemedicine CBT-I has been shown to be non-inferior to in-person treatment, there is no study to date that evaluates patient and provider experiences with video-based treatment. Our study team evaluated patient and provider perceptions of CBT-I delivered via telemedicine versus an in-person format. As part of a larger randomized control trial, we interviewed patients and providers in both arms of the study (in-person and via telemedicine). 20 minute interviews were conducted over the phone and were transcribed and coded to identify themes. While patients shared initial concerns about telemedicine CBT-I, including privacy and technological issues, they were satisfied with the approach and had similar experiences as the patients receiving in-person treatment. Providers shared concerns about challenges establishing a strong therapeutic alliance, patient engagement, and accountability in CBT-I, but felt these did not interfere with their overall ability to deliver care. Patients and providers were satisfied with CBT-I treatment delivered via telemedicine when compared to those being treated in-person. Patients in both arms noted that virtual care could increase access and provide convenience. © 2022 The Author(s). This open access article is distributed under a Creative Commons Attribution (CC-BY) 4.0 license.
Climate change is impacting marine seascapes against a backdrop of multiple anthropogenic stressors. These current impacts are projected to increase in the future with increasing warming, acidification, oxygen loss, and sea level rise. Marine Protected Areas (MPAs) have been established to protect features in the ocean, traditionally with a focus to reduce fishing pressures and infrastructure placements. These MPAs are static in nature and are rarely considering climate change; therefore, their potential adaptation effectiveness as local adaptation measures for conservation in response to climate change are not clear. Here we discuss the challenges to Marine Protected Areas as conservation tools and for adaptation to climate change threats. We use two case studies from the UK to ask how climate change resilience could be included in MPA management to future-proof these conservation measures. We conclude that the resilience of MPAs to climate change would be better supported when adaptive management measures and an ecosystem-based approaches are adopted. We emphasise the need to increase the recognition in the primary legislation of MPAs and the monitoring of sites to better understand climate change as it becomes more pronounced, and impacts emerge.
Demand is frequently found to react differently to price increases than to price decreases. This finding is usually attributed to psychological phenomena such as loss aversion or to the different pace with which price changes become known to potential buyers leading to a kinked demand curve. This kink is often invoked in explaining why prices are sticky, especially in the downward direction. We analyse the presence of and the causes for asymmetric price elasticities of demand for the London Underground. Studying public transport demand offers unique advantages: the service cannot be stored and must be consumed at the point of purchase, and the consumption of public transport cannot be preponed or postponed. During the period that we study some nominal fares on the network have increased while others have decreased, offering a unique opportunity to observe price elasticities for both cases. Comparing changes in price elasticities after a price decrease to changes after a price increase, we find that demand is more sensitive to price increases than to decreases (by 0.5 to 1.0 percentage points). We also find that loss aversion contributes to this asymmetry at least on the intensive margin of transport demand.
The enduring link between the annual cash bonus and safety metrics that is common practice across the oil and gas industry, and in some other domains, is in part due to job market pressures, and possibly supported by a self-reinforcing belief system. The current study aims to investigate the contemporary annual cash bonus practice in the oil and gas industry from the perspective of the employees and managers, regarding both the perceived value of bonus payments and the influence these have on safety. Forty-eight employees participated in semi-structured interviews in which they described their sense of the impact of the bonus scheme on safety and what could be improved. The results of the case study indicate that only a minority of the frontline properly appear to understand the link between safety performance and their annual bonus payment. Even for those with an understanding, positive safety behaviours are not directly encouraged by the bonus since the incentives are linked to the absence of incidents and are not relevant to the workers’ daily activities. There is strong evidence for a negative impact on incident reporting, both through under-reporting and reclassification of incidents. However, the current practice is considered valuable by the respondents as it signals the importance of safety alongside production and profit. Taken together, the results suggest that the contemporary annual cash bonus practice should be discontinued in the long term because of the limited influence on safety behaviour and potential adverse effect on safety outcomes, simultaneously ensuring that the commitment to safety is communicated through alternative means.
This paper studies the relationship between early mental health episodes and early homelessness, focusing on depression and anxiety amongst disadvantaged Australians. Using data from the Australian Journeys Home survey, we investigate whether the early onset of mental health conditions make a first transition into homelessness more likely. Similarly, we analyze whether early experiences of homelessness increase the likelihood of early onset of depression or anxiety. We perform our analysis separately for men and women since there are gender differences in rates of both mental health diagnosis and homelessness. After accounting for the effects of joint observed and unobserved determinants, we find that a person's first episode of depression makes a transition to homelessness more likely for both men and women. In contrast, anxiety disorders have no effect on the likelihood of experiencing homelessness. In addition, people's first experience of homelessness has no effect on the likelihood of developing depression, but does increase the likelihood of anxiety disorders for men only.
Context: CARTITUDE-2 (NCT04133636) Cohort B is evaluating cilta-cel in patients with MM and early relapse after initial therapy. These patients have functionally high-risk disease and unmet medical needs, as early relapse post-ASCT is associated with a poor prognosis. Objective: To present updated results from CARTITUDE-2 Cohort B. Design: Phase 2, multicohort study. Patients: Eligible patients had MM, 1 prior LOT (PI and IMiD required), disease progression per IMWG, and no previous treatment with CAR-T/anti-BCMA therapies. Intervention: Single cilta-cel infusion (target dose 0.75×106 CAR+ viable T-cells/kg) post lymphodepletion. Main outcome measures: Safety and efficacy were evaluated. Primary endpoint was MRD negativity at 10-5. Management strategies were used to reduce the risk of movement/neurocognitive AEs (MNTs). Assessments included pharmacokinetics (PK) (Cmax, Tmax of CAR+ T-cell transgene levels in blood), CRS-related cytokine (eg, IL-6) levels over time, peak cytokine levels by response and CRS, association of cytokine levels with ICANS, and CAR+ T-cell CD4/CD8 ratio by response, CRS, and ICANS. Results: As of January 2022 (median follow-up 13.4 months), 19 patients (median age 58.0 years; 74% male; 79% with prior ASCT) received cilta-cel. ORR was 100% (90% ≥CR and 95% ≥VGPR). Median time to first response was 0.95 months and median time to best response was 5.1 months. Median DOR was not reached. Of 15 MRD-evaluable patients, 14 (93%) achieved MRD 10-5 negativity. At 12 months, the event-free rate was 88.9% and PFS rate was 90%. CRS occurred in 16 (84.2%) patients (1 gr 4); median time to onset was 8 days. CRS resolved in all patients. 1 patient had ICANS (gr 1); 1 patient had MNT (gr 3; previously reported). 1 death occurred post-cilta-cel due to progressive disease (day 158). Preliminary PK data showed CAR-T cell peak expansion on day 13.1 and median persistence was 76.9 days. Conclusions: A single cilta-cel infusion resulted in deep and durable responses and manageable safety in functionally high-risk patients with MM and early clinical relapse/treatment failure to initial therapy. We will present updated and detailed PK/cytokine/CAR-T subset analyses and clinical correlations to provide novel insights into biological correlates of efficacy/safety in this population.
Context: CARTITUDE-2 (NCT04133636) Cohort A is assessing cilta-cel in lenalidomide-refractory patients with progressive MM after 1-3 prior LOT. Objective: To present updated results from CARTITUDE-2 Cohort A. Design: Phase 2, multicohort study. Patients: Lenalidomide-refractory patients with progressive MM after 1-3 prior LOT (PI and IMiD included) and no previous exposure to BCMA-targeting agents. Interventions: Single cilta-cel infusion (target dose 0.75×106 CAR+ viable T-cells/kg) after lymphodepletion Main Outcome Measures: Primary endpoint was minimal residual disease (MRD) negativity at 10-5. Management strategies were used to reduce risk of movement/neurocognitive adverse events (MNTs). Pharmacokinetics (PK) (Cmax/Tmax of CAR+T-cell transgene levels), cytokine release syndrome (CRS)-related cytokines over time, peak cytokine levels by response/CRS, association of cytokine levels with immune effector cell-associated neurotoxicity syndrome (ICANS), and CAR+T-cell CD4/CD8 ratio by response/CRS/ICANS are being evaluated. Results: As of January 2022 (median follow-up [MFU] 17.1 months), 20 patients (65% male; median age 60 years; median 2 prior LOT; 95% refractory to last LOT) received cilta-cel. Overall response rate was 95% (90% ≥complete response; 95% ≥very good partial response). Median times to first and best response were 1.0 month and 2.6 months, respectively. All 16 MRD-evaluable patients achieved MRD negativity at 10-5. Median duration of response was not reached. At 12 months, event-free rate was 79% and progression-free survival rate was 75%. 95% of patients had CRS (gr3/4 10%); median time to onset was 7 days and median duration was 3 days. Neurotoxicity was reported in 30% of patients (5 gr1/2; 1 gr3/4) and ICANS in 15% (all 3 gr1/2); 1 patient had gr2 facial paralysis. No MNTs were observed. 1 death occurred due to COVID-19 (treatment-related), 2 due to progressive disease, and 1 due to sepsis (not treatment-related). Preliminary PK analyses showed peak CAR-T cell expansion at day 10.5; median persistence was 153.5 days. Conclusions: At MFU of 17.1 months, a single cilta-cel infusion resulted in deep and durable responses in lenalidomide-refractory MM patients with 1-3 prior LOT. We will present updated PK/cytokine/CAR-T subset analyses and clinical correlation to provide novel insights into biological correlates of efficacy/safety in this population.
Context: Zandelisib is a selective PI3Kδ inhibitor administered orally at 60 mg once daily (QD) for 2 cycles (response induction), then intermittent dosing (ID) on days 1-7 of subsequent 28-day cycles for maintenance, while potentially enabling regulatory T-cell recovery to reduce risk of immune adverse events (irAEs) seen with continuous PI3Kδ inhibition. In a phase Ib study of zandelisib in 37 R/R FL patients, the overall response rate (ORR) was 87% (78% single agent; 95% with rituximab), with only 8% discontinuations due to irAEs (Pagel ICML 2021). Objective: Topline results from the fully enrolled FL population from TIDAL, a global phase II study evaluating zandelisib in R/R indolent lymphomas (NCT03768505). Patients: Age ≥18y with FL Grade I-IIIA, progressive disease after ≥2 prior therapies, and no prior PI3K inhibitor. Consent required. FL sample size (planned): 120 patients. Primary efficacy population (PEP): first 91 patients treated. Intervention: Zandelisib 60 mg QD for 2 cycles, followed by ID during cycle 3+. Main outcome measure: IRC-assessed ORR (Lugano criteria) after a minimum 6-month follow-up. Results: 91 FL patients in PEP (of 121 enrolled): median 3 prior therapies (range, 2-8), 21 (23%) prior stem cell transplant, 42 (46%) refractory to last therapy, 31 (34%) tumors ≥5 cm, 51 (56%) POD24. ORR was 70.3% (64/91; 95% CI: 59.8%, 79.5%) and complete response (CR) rate was 35.2% (32/91; 95% CI: 25.4%, 45.9%). Responses occurred early: 87.5% (56/91) occurred at end of Cycle 2, 75% (24/91) of CRs at end of Cycle 4. Data still immature for accurate duration of response (DOR) estimation. With median follow-up of 9.4 months (range, 0.8-24) for all 121 patients, 12 (9.9%) discontinued due to any treatment-related AE. Grade 3 AEs of special interest (AESI) included diarrhea (6/121; 5%), colitis (2/121; 1.7%), rash (4/121; 3.3%), stomatitis (3/121; 2.5%), and AST and ALT elevation and non-infectious pneumonitis (1/121 each; 0.8%). Most Grade 3 AESIs (15 [83%]) occurred during daily dosing (cycles 1-3). Conclusions: Zandelisib on ID led to high ORR and CR rates in heavily pretreated FL patients and was associated with a low rate of grade 3 AESI and discontinuations due to treatment-related AEs.
The Jizan region of southwest Saudi Arabia contains large industrial point sources of CO2 and potentially the capacity to dispose substantial quantities of this gas by the subsurface mineralization of local basaltic rocks. Significant volumes of basaltic magma were erupted within an Oligo-Miocene continental rift valley that preceded the formation of the Red Sea. These igneous rocks consist of lava flows and volcaniclastics intruded by dikes and shallow plutons. The volcanic rocks are densely fractured and variably altered to chlorite-epidote-calcite assemblages. Dissolution rate measurements performed at 25 °C of four variably altered basaltic rock samples from the region demonstrate their ability to increase fluid pH and liberate substantial Ca and Mg to the fluid phase. Reaction path calculations suggest that CO2-charged water will readily carbonate when interacting with the basaltic rocks at both 25 and 100 °C. Reactive transport calculations, however, suggest that while such carbonation reactions will be slow at 25 °C, these would fix more than 95% of injected water-dissolved CO2 within five years at 100 °C. Monte Carlo estimates suggest that the total CO2 mineralization capacity of the Oligocene basaltic rocks is ∼4.2 Gt CO2, which is sufficient to store all of the carbon emissions from the Jizan region industrial facilities for in excess of one hundred years. Taken together, the results of this study indicate the likely success of large-scale subsurface carbon storage efforts through the subsurface carbonation of basaltic rocks in the Jizan region.
In this chapter, we will conclude the case study used for the illustration of a typical business analytics consulting for an SME by presenting the details of the engagement phase for the case study in question. The post-engagement phase is left out as the implementation of the recommendations is determined by the systems and procedures of the business. It is important to note that the consulting steps can be customized for any business (particularly small businesses). The whole steps described in Chapters 9 and 10 have been made simple for understanding, though in real-life business applications, there might be a need to iterate the process until satisfactory results have been obtained. This is because you constantly need to incorporate feedback from the stakeholders and domain experts.
In this chapter, we will explore the popular techniques used for prediction, particularly in the retail business. The approach used in explaining these techniques is to use them in solving a business problem. The business problem to be addressed is the sales prediction problem which is common in the retail business. The chapter first explains the fundamental concept of prediction techniques; next, we look at how such techniques are evaluated. After this, we describe the business problem we intend to solve. We then pick each of the selected techniques one by one and explain the algorithms involved and how they can be used to solve the problem described. The prediction techniques used are the multiple linear regression, the regression trees, and the neural network. To conclude the chapter, we compare the results of the three algorithms and conclude on the problem in question. In this chapter, therefore, the analytics product offered is the sales prediction problem for small retail businesses.
This chapter is the beginning part of the major consulting case study for this book. We will explain a typical business analytics consulting project and create a road map or an example of how to navigate a business analytics consulting project. We start with a description of the SME ecommerce environment generally, since this is the business environment of our selected case study; we then talk about the sources of data for analytics peculiar to this environment. Next, we describe the business to be used as a case study briefly, followed by the analytics road map peculiar to consulting for this business. This chapter ends with the results of the initial analysis and pre-engagement phase which forms the basis for the detailed analytics and implementation phase in Chapter 10.
In this chapter, even though there are several classification techniques, we will explore the popular ones used for classification in the business domain. In doing this, we will use the third business problem centered on customer loyalty using neural networks, classification trees, and random forest algorithms. In solving this problem, we are particular about how to get and retain more customers for our small business. We will also introduce some other classification-based techniques such as K-nearest neighbor and logistic regression. In using these techniques to solve the problem, we explain the fundamental concepts in the chosen algorithms and use them to demonstrate how these problem solving processes can be adopted in real business scenarios.
In this chapter, we will look at the various sources of data generally and in small business. This is important because the major challenge of consulting for small business is the lack of data or quality data for analysis. This chapter will therefore detail the sources of data for analysis explaining first the type or form that data exists and some general ideas of how to collect such data. It gives an overview on data quality and integrity issues and touches on data literacy. In addition, we will explain typical data preparation procedures for data analytics techniques. To conclude, we look at data visualization, particularly toward preparing data for various analytics tasks as explained in Section 1.3.
Introduction/Background Embedding research into clinical practice has many benefits, with research-active healthcare settings reporting better clinical outcomes and improved staff recruitment and retention. This is recognised by the NHS who aim to ‘build the capacity and capability of our current and future workforce to embrace and actively engage with research’. In spite of this, clinical academic capacity across the NHS remains challenging; the number of consultants working in clinical academia has declined in recent years and there is concern about lack of academic progression for non-medical professions. Reported barriers include clinical pressures and lack of dedicated time, individual skill and confidence. Description/Method Our aim was to gather information about research exposure across the Paediatric Rheumatology multidisciplinary team (MDT), including paediatric trainees (rheumatology grid, rheumatology spin and level 2 trainees), clinical nurse specialists (CNS), advanced nurse practitioners (ANPs) and Allied Health Professionals (AHPs). We initially sought to identify if trainees were receiving adequate research opportunities during their training. A pilot questionnaire was distributed, and results collated and presented at the Spring Clinical Studies Group (CSG) annual meeting. Feedback was received from both questionnaire respondents and the CSG. Following this, we modified and broadened the scope of the questionnaire to include the Paediatric Rheumatology MDT, with the aim of comparing experiences across the MDT. This was developed using an online survey platform with the link distributed via email and messaging groups for trainees, AHPs and CNSs. The aims of the modified questionnaire were to; 1. Understand the current research experience across the paediatric rheumatology MDT and identify barriers and ways to support participation in research. 2. Identify if individuals wanted more exposure to research and what specific research skills they would like to develop. Discussion/Results There were 34 respondents: 14 (41%) paediatric trainees (7 grid, 2 spin, 2 post-CCT fellows, 3 level-2 trainees), 14 (41%) CNS, 4 (12%) AHPs and 2(6%) ANPs. Across the MDT, 19 respondents (56%) agreed they had adequate opportunity to be involved in research, of which 7 (21%) strongly agreed. In terms of research exposure, 22 (65%) have undertaken postgraduate degrees, 5 (15%) PhD, 9 (26%) MSc, 5 (15%) diploma and 6 (18%) postgraduate certificate. Eight-respondents (24%) had taken time out to develop research skills. Research experience: 18 respondents (53%) have been on the delegation-log for clinical trials. 20 (59%) have contributed to data collection for National Registries. 23 (68%) have given a poster/oral presentation at national/international conferences and 15 (44%) have published in peer-reviewed journals - the majority trainees (n = 11,73%). Research training: 51% report adequate training in critical appraisal, 48% in literature review and 40% in consent; fewer reported adequate training in designing research projects (21%), ethics applications (21%) and statistical analysis (23%). Further training would be desirable in: • designing research projects (68%); • discussing research with patients (65%); • statistical analysis (49%); • critical appraisal (40%); • literature search (37%). Future research involvement: 94% would like more opportunities to be involved in research. In the future, 63% would like allocated research time, 6% to be mainly academic (1 CNS, 1 trainee) and 12% to be full-time clinical (1 spin, 1 level-2 trainee, 2 CNS). Barriers to research: Free text answers were used to gather information and common themes identified included lack of: • time/heavy clinical commitment (60%); • supervision/support from seniors (9%); • local resources (9%); • research funding (9%); • awareness of projects (12%); • research skills (9%). Encourage participation in research: Common suggestions included: • protected research time during training/career (35%); • further research training (21%); • earlier awareness of projects/trials (18%); • Increased support from more experienced colleagues (15%); • improved collaboration/networking (12%). Key learning points/Conclusion This survey provides an interesting insight into the research experience throughout the Paediatric Rheumatology MDT. It is encouraging that within the Rheumatology MDT 56% of respondents reported that they have had adequate opportunities to be involved in research and the majority have presented or published their research. However, 94% have reported they would like more opportunities to be involved in research. Lack of time was reported as the most common barrier to research involvement; this finding is consistent with the British Society for Rheumatology’s 2019 ‘Paediatric State of Play’ report. Additionally, significant numbers report they would like further training in research skills. Academic writing for publication was noted as a particular area of concern for nurses and AHPs. We advocate for further research opportunities throughout the MDT. For Rheumatology trainees, it was suggested that research skills be incorporated into the curriculum, with dedicated time allocated to gain experience and contribute to research. All members of the MDT may benefit from research skills training courses, although this would need to be carefully considered, given lack of time and resources were common barriers reported by respondents. Several professionals reported lack of support or supervision from seniors and suggested the benefit of mentoring networks. A weakness of this study is the relatively low number of respondents; the survey remains open and we intend to collect further data to maximise representation across the MDT. Additionally, there is potential bias, with individuals with a research interest possibly more likely to contribute, meaning research experience may be over-represented by this sample of the MDT. Also, representation from AHPs was limited compared to paediatric trainees and CNS. Further work is needed to understand research experience across the MDT, however this initial survey is a valuable first step in encouraging discussion of MDT participation in research.
Introduction/Background The Barbara Ansell National Network for Adolescent Rheumatology (BANNAR) was established in 2012. Survey results from within the paediatric and adolescent rheumatology community at this time, highlighted the lack of young people’s involvement in rheumatology research, beyond the role of study participant. Following research to determine the young person’s perspective of research and how they wanted to be involved, Your Rheum, a national young person’s advisory group, for 11-24 year olds diagnosed with a rheumatic condition, was formed in 2016. Description/Method Aim: to assess the current involvement of young people in rheumatology research and service delivery. A questionnaire was created using Microsoft Office online forms and emailed to all BANNAR members (n = 105). Topics included demographics, youth involvement panels and Your Rheum. Discussion/Results 23 responses were received (21% response rate), representing 18 rheumatology centres across the UK including 15 tertiary paediatric and adolescent rheumatology centres. The majority of respondents were Consultants (n = 18). Over half of respondents (n = 16) work in centres involved in rheumatology research. 15 centres reported having a hospital-wide youth forum/advisory panel, which they promote amongst young people within their services. However, nearly all respondents reported no specific youth advisory panel for rheumatology services. Young people are actively involved in a number of areas within clinical rheumatology services (table 1), however patient satisfaction surveys were the most commonly reported. Moreover, young people are involved in aspects of rheumatology research (table 1), although this was primarily as research participants. Over half of respondents (n = 14) have not worked with Your Rheum. Most recruit young people to get involved in the group (n = 16), however, only three respondents said they do this routinely. Common barriers to promoting Your Rheum were: lack of time in consultations; forgetting; lack of interest from the young person(s); no designated member in clinic to discuss Your Rheum with young people. Key learning points/Conclusion There remains a need to support youth involvement strategies at a local level as well as nationally via Your Rheum. The recent introduction of a Your Rheum animation (https://bit.ly/yourRHEUM) will hopefully support future recruitment.
Poster session 3, September 23, 2022, 12:30 PM - 1:30 PM Background: The advent of COVID-19 has meant that patients with chronic diseases needed to shield, however, investigations were needed to guide continual management of their disease. Remote monitoring options were evaluated to ensure the standard of care is not compromised. Purpose and Hypothesis: The aim was to validate remote (return-posted) capillary triazole blood testing and evaluate the potential role of remote TDM in chronic antifungal therapy. Materials and Methods: A single-center prospective cross-sectional study of remote finger prick capillary blood testing compared with gold standard venesection was performed. Remote finger prick capillary blood testing was validated compared to local standard venesection using comparative statistical analysis Comparative statistical analysis: Paired t-test, correlation and Bland-Altman were used to determine if there was agreement or association between the sampling methods. Results A total of 66 patients receiving triazole therapy were recruited and 57 pooled pairs of remote capillary and venous triazole concentrations and metabolites were prospectively analyzed, with the rest of the blood samples not being analyzed due to insufficient sample, hemolysis, or undetectable triazole level of <0.2 mg/l. There was a significant difference in the comparison of the two methods of sampling with paired t-test at P <.0001. Bland-Altman analysis yielded wide bias (−49.07%) and wide limits of agreement (−85.5% to −12.64%). On average capillary triazole, concentrations were 37% lower than venous concentrations (Fig. 1). There was however a very strong correlation between capillary and venous tests (Pearson's correlation coefficient r = 0.9219, P <.0001, Fig. 2). Conclusions: Remote capillary triazole sampling does not appear interchangeable with venous sampling, but being strongly correlated and on average 2/3rd of the venous value, could be a predictor of venous triazole level, or be useful for intra-patient longitudinal monitoring. When incorporated into an outpatient clinical pathway it can improve shared decision-making and patient experience. Further research is required to determine appropriate target reference ranges if the new lower capillary levels can be used routinely, especially in the climate of COVID-19 where social distancing measures limit patient access to hospitals and clinics for routine investigations.
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