Heart failure is a prevalent condition that is generally treated in primary care. The aim of this study was to assess how primary-care physicians think that heart failure should be managed, how they ...implement their knowledge, and whether differences exist in practice between countries.
The survey was undertaken in 15 countries that had membership of the European Society of Cardiology (ESC) between Sept 1, 1999, and May 31, 2000. Primary-care physicians' knowledge and perceptions about the management of heart failure were assessed with a perception survey and how a representative sample of patients was managed with an actual practice survey.
1363 physicians provided data for 11 062 patients, of whom 54% were older than 70 years and 45% were women. 82% of patients had had an echocardiogram but only 51% of these showed left ventricular systolic dysfunction. Ischaemic heart disease, hypertension, diabetes mellitus, atrial fibrillation, and major valve disease were all common. Physicians gave roughly equal priority to improvement of symptoms and prognosis. Most were aware of the benefits of ACE inhibitors and β blockers. 60% of patients were prescribed ACE inhibitors, 34% β blockers but only 20% received these drugs in combination. Doses given were about 50% of targets suggested in the ESC guidelines. If systolic dysfunction was documented, ACE inhibitors were more likely and β blockers less likely to be prescribed than when there was no evidence of systolic dysfunction.
Results from this survey suggest that most patients with heart failure are appropriately investigated, although this finding might be as a result of high rates of hospital admissions. However, treatment seems to be less than optimum, and there are substantial variations in practice between countries. The inconsistencies between physicians' knowledge and the treatment that they deliver suggests that improved organisation of care for heart failure is required.
The European Society of Cardiology (ESC) has published guidelines for the investigation of patients with suspected heart failure and, if the diagnosis is proven, their subsequent management. ...Hospitalisation provides a key point of care at which time diagnosis and treatment may be refined to improve outcome for a group of patients with a high morbidity and mortality. However, little international data exists to describe the features and management of such patients. Accordingly, the EuroHeart Failure survey was conducted to ascertain if appropriate tests were being performed with which to confirm or refute a diagnosis of heart failure and how this influenced subsequent management.
The survey screened consecutive deaths and discharges during 2000-2001 predominantly from medical wards over a 6-week period in 115 hospitals from 24 countries belonging to the ESC, to identify patients with known or suspected heart failure.
A total of 46788 deaths and discharges were screened from which 11327 (24%) patients were enrolled with suspected or confirmed heart failure. Forty-seven percent of those enrolled were women. Fifty-one percent of women and 30% of men were aged >75 years. Eighty-three percent of patients had a diagnosis of heart failure made on or prior to the index admission. Heart failure was the principal reason for admission in 40%. The great majority of patients (>90%) had had an ECG, chest X-ray, haemoglobin and electrolytes measured as recommended in ESC guidelines, but only 66% had ever had an echocardiogram. Left ventricular ejection fraction had been measured in 57% of men and 41% of women, usually by echocardiography (84%) and was <40% in 51% of men but only in 28% of women. Forty-five percent of women and 22% of men were reported to have normal left ventricular systolic function by qualitative echocardiographic assessment. A substantial proportion of patients had alternative explanations for heart failure other than left ventricular systolic or diastolic dysfunction, including valve disease. Within 12 weeks of discharge, 24% of patients had been readmitted. A total of 1408 of 10434 (13.5%) patients died between admission and 12 weeks follow-up.
Known or suspected heart failure comprises a large proportion of admissions to medical wards and such patients are at high risk of early readmission and death. Many of the basic investigations recommended by the ESC were usually carried out, although it is not clear whether this was by design or part of a general routine for all patients being admitted regardless of diagnosis. The investigation most specific for patients with suspected heart failure (echocardiography) was performed less frequently, suggesting that the diagnosis of heart failure is still relatively neglected. Most men but a minority of women who underwent investigation of cardiac function had evidence of moderate or severe left ventricular dysfunction, the main target of current advances in the treatment of heart failure. Considerable diagnostic uncertainty remains for many patients with suspected heart failure, even after echocardiography, which must be resolved in order to target existing and new therapies and services effectively.
Topology optimization consists in finding the spatial distribution of a given total volume of material for the resulting structure to have some optimal property, for instance, maximization of ...structural stiffness or maximization of the fundamental eigenfrequency. In this paper a Genetic Algorithm (GA) employing a representation method based on trees is developed to generate initial feasible individuals that remain feasible upon crossover and mutation and as such do not require any repairing operator to ensure feasibility. Several application examples are studied involving the topology optimization of structures where the objective functions is the maximization of the stiffness and the maximization of the first and the second eigenfrequencies of a plate, all cases having a prescribed material volume constraint.
This work addresses the design optimization of ceramic–metal composite plates with functionally graded material properties, varying through the thickness direction, subjected to thermo-mechanical ...loadings. Constrained multiobjective optimization is performed for mass minimization and material cost minimization as well as the minimization of stress failure criteria or maximization of natural frequency. The optimization problems are constrained by stress based failure criteria among other structural response constraints and manufacturing limitations. The design variables are the index of the power-law distribution in the metal-ceramic graded material and the thicknesses of the graded material and, eventually, also the metal and ceramic faces.
A finite element plate model based on a higher order shear deformation theory, accounting for the transverse shear and transverse normal deformations and considering the temperature dependency of the material properties, is applied for the optimal design of ceramic-metal functionally graded plates. The optimization problems are solved with two direct search derivative-free algorithms: GLODS (Global and Local Optimization using Direct Search) and DMS (Direct MultiSearch). A few multiobjective optimization problems are studied and the results are presented for benchmarking purposes.
A methodology of multiobjective design optimization of ceramic–metal composite plates with functionally graded materials, with properties varying through the thickness direction, obtained by an ...adequate variation of volume fractions of the constituent materials, is presented in this paper. Constrained optimization is conducted for different behavior objectives like the maximization of buckling load or fundamental natural frequency. Mass minimization and material cost minimization are also considered. The optimization problems are constrained by stress based failure criteria and other structural response constraints or manufacturing limitations. The design variables are the index of the power-law distribution in the metal-ceramic graded material and the thicknesses of the graded material and/or the metal and ceramic faces.
An equivalent single layer finite element plate model having a displacement field based on a higher order shear deformation theory, accounting for the temperature dependency of the material properties, was developed and validated for the analysis of through-the-thickness ceramic-metal functionally graded plates. The optimization problems are solved with two direct search derivative-free algorithms: GLODS (Global and Local Optimization using Direct Search) and DMS (Direct MultiSearch). DMS, the multiobjective optimization solver, is started from a set of local minimizers which are initially determined by the global optimizer algorithm GLODS for each one of the objective functions.
This work develops a computational model for topology optimization of linear elastic structures for situations where more than one objective function is required, each one of them with a different ...optimal solution.
The method is thus developed for multi-objective optimization problems and is based on Genetic Algorithms. Its purpose is to evolve an evenly distributed group of solutions (population) to obtain the optimum Pareto set for the given problem.
To reduce computational effort, optimal solutions of each of the single-objective problems are introduced in the initial population.
Two numerical examples are presented and discussed to assess the method.
National surveys suggest that treatment of heart failure in daily practice differs from guidelines and is characterized by underuse of recommended medications. Accordingly, the Euro Heart Failure ...Survey was conducted to ascertain how patients hospitalized for heart failure are managed in Europe and if national variations occur in the treatment of this condition.
The survey screened discharge summaries of 11304 patients over a 6-week period in 115 hospitals from 24 countries belonging to the ESC to study their medical treatment.
Diuretics (mainly loop diuretics) were prescribed in 86.9% followed by ACE inhibitors (61.8%), beta-blockers (36.9%), cardiac glycosides (35.7%), nitrates (32.1%), calcium channel blockers (21.2%) and spironolactone (20.5%). 44.6% of the population used four or more different drugs. Only 17.2% were under the combination of diuretic, ACE inhibitors and beta-blockers. Important local variations were found in the rate of prescription of ACE inhibitors and particularly beta-blockers. Daily dosage of ACE inhibitors and particularly of beta-blockers was on average below the recommended target dose. Modelling-analysis of the prescription of treatments indicated that the aetiology of heart failure, age, co-morbid factors and type of hospital ward influenced the rate of prescription. Age <70 years, male gender and ischaemic aetiology were associated with an increased odds ratio for receiving an ACE inhibitor. Prescription of ACE inhibitors was also greater in diabetic patients and in patients with low ejection fraction (<40%) and lower in patients with renal dysfunction. The odds ratio for receiving a beta-blocker was reduced in patients >70 years, in patients with respiratory disease and increased in cardiology wards, in ischaemic heart failure and in male subjects. Prescription of cardiac glycosides was significantly increased in patients with supraventricular tachycardia/atrial fibrillation. Finally, the rate of prescription of antithrombotic agents was increased in the presence of supraventricular arrhythmia, ischaemic heart disease, male subjects but was decreased in patients over 70.
Our results suggest that the prescription of recommended medications including ACE inhibitors and beta-blockers remains limited and that the daily dosage remains low, particularly for beta-blockers. The survey also identifies several important factors including age, gender, type of hospital ward, co morbid factors which influence the prescription of heart failure medication at discharge.
The golden-striped salamander is a streamside species endemic to the northwestern corner of the Iberian Peninsula. In the first half of the twentieth century, an undisclosed number of individuals of ...this species were reportedly captured in Buçaco, Central Portugal, and deliberately introduced in Sintra Mountains, 170 km south of its native distribution range. The discovery of a breeding population of this salamander in Sintra during 2015 prompted this work: we used neutral genetic markers, the mitochondrial DNA cytochrome b (cytb), and seven microsatellite loci to elucidate on the relict/human-introduced nature of Sintra population, identify the potential source population, and infer the severity of founder effect. Our results support a human-mediated introduction. First, sequencing analysis of cytb showed the presence of a unique haplotype (h31) in Sintra, which was detected only in Buçaco and in two additional populations located close to Mondego river. Second, microsatellite analysis showed that Sintra is more closely related to populations in between Douro and Mondego rivers (Central Portugal), instead of its geographically closest populations (southernmost), as would be expected if Sintra was a relict population isolated in an interglacial refuge. Third, Sintra presents both reduced levels of genetic variability and effective population size when compared to native populations, particularly to those of Central Portugal. Consistent with an isolated population funded by a small number of individuals (inferred herein to be ca. 10–11 salamanders), Sintra forms a geographically coherent genetic unit that is significantly differentiated from the extant native
C. lusitanica
populations. Although our data provide supporting evidence for Buçaco as a likely source population, as documented in the literature, overall, we cannot unequivocally exclude other populations close to Mondego river as a potential source of the introduced individuals in Sintra.
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