•Application of an inertia-based control device for building structures is investigated.•Experimental results are used to verify the derived equations for the gyromass damper.•Using various ...approaches, performance of GMDs in different configurations is examined.•Seismic effectiveness of GVBs is shown through numerical simulations.
A gyro-mass damper (GMD) is an inertia-based passive control device. It has a gear assembly that amplifies the rotational inertias developed in the gears and generates a resultant resisting force that is proportional to the relative acceleration at the end terminals of the GMD. The amplification provided by the gear assembly can be adjusted by changing the gear masses or the gear ratios of the compound gears. Although similar inertia-based devices have been successfully used for vibration mitigation of motor vehicles and optical tables, there are only a few studies that investigated their application in building structures. This number is even lower for the particular type of inertial damper that has been considered in this study, i.e., GMD. Unlike other types of inertial dampers, the supplemental energy dissipation component of GMDs is not built-in to the device and can be independently attached as an external component. This allows the design engineers to use this cost-effective device and select any available energy dissipation device to use in parallel. In this study, using a small-scale GMD, by considering the rotational inertias of the intermediate gears, characteristic equation which describes the relationship between the applied relative acceleration and the resulting resisting force is derived and experimentally verified. For the introduction of GMDs into building structures, three different configurations are evaluated: (i) stand-alone GMD, (ii) GMD-brace system, and (iii) GMD–Viscous damper–Brace (GVB) system. The structure-GMD interaction, considering these three configurations, is investigated in frequency domain and in time domain through energy balance equations and time history analyses. It is shown that by selecting the system parameters properly, GVB systems with nonlinear viscous dampers can effectively improve the seismic behaviour of the structure. This is discussed in more detail when the effects of the damper nonlinearities, as well as the various GMD equivalent mass, brace stiffness, damping values and selected ground motions are investigated. The key findings related to the design, implementation and performance considerations of these systems are provided.
Background: Guidelines for breaking bad news are largely directed at and validated in oncology patients, based on expert opinion, and neglect those with other diagnoses. We sought to determine ...whether existing guidelines for breaking bad news, particularly SPIKES, are consistent with patient preferences across patient populations. Methods: Patients from an online community responded to 5 open-ended and 11 Likert-scale questions identifying their preferences in having bad news delivered. Patient participants received a diagnosis of cancer, lupus, amyotrophic lateral sclerosis, multiple sclerosis, HIV/AIDS, or Parkinson's disease. Additionally, we surveyed all 14 English-curriculum Canadian medical schools regarding resources used to teach breaking bad news. Results: Ten of 12 responding schools used the SPIKES model. Preferences of 1337 patients were consistent with the recommendations of SPIKES. There was one exception: Most patients disagree that empathetic physical touch is important and some described apprehension. Responses were consistent across disease states. Content analysis of 220 open-ended patient responses revealed 16 patient-important themes. Themes were largely addressed by the SPIKES guidelines, but five were not: ensuring timely follow-up is planned; offering informational sheets about the diagnosis; offering contact information of support organizations, with some patients preferring patient support groups while others preferring counselors; and conveying a sense of determination to aid the patient through the diagnosis. The four most patient-important components of SPIKES were physicians conveying empathy, taking their time, explaining the diagnosis and its implications, and asking the patient if they understand. Conclusion: SPIKES is the most commonly taught framework for breaking bad news in Canadian medical schools. This is the first work to demonstrate that the existing guidelines in breaking bad news such as SPIKES largely reflect the perspectives of many patient groups, as assessed by quantitative and qualitative measures. We highlight the most important components of SPIKES to patients and identify five additional suggestions to aid clinicians in breaking bad news.
Time to discontinuation of biologic therapy may be related to mechanism of action. We aimed to compare discontinuation of tumor necrosis factor inhibitors (TNFi) versus non-TNFi in an observational ...rheumatoid arthritis cohort.
Patients enrolled in the Ontario Best Practices Research Initiative (OBRI) starting biologic agents on or after 1st January 2010 were included. Time to discontinuation due to (1) any reason, (2) any of lack/loss of response, adverse events (AEs), physician, or patient decision, (3) lack/loss of response, and (4) AEs were assessed using Kaplan-Meier survival and Cox proportional hazards regression analysis.
A total of 932 patients were included of whom 174 (18.7%) received non-TNFi and 758 (81.3%) received TNFi. Over a median follow-up of 1.7 years, discontinuation was reported for 416 (44.6%) due to any reason, 367 (39.4%) due to any of lack/loss of response, AEs, physician, or patient decision, 192 (20.6%) due to lack/loss of response, and 102 (10.9%) due to AEs. After adjusting for propensity score, there was no significant difference in discontinuation between the two classes due to any reason HR 1.14 (0.90–1.46), p = 0.28, lack/loss of response HR: 1.01 (0.70–1.47), p = 0.95, and AEs HR: 1.06 (0.64–1.73), p = 0.83. Similar results were found in biologic naïve patients.
This analysis demonstrates that discontinuation of therapy is similar in patients started on TNFi and non-TNFi therapies. There was also no significant difference in stopping due to lack/loss of response or AEs, suggesting that these reasons should not drive the selection of one treatment over another.
Objective Patient engagement is critical to clinical practice guideline (CPG) development. This work presents our approach to ascertaining patients’ values and preferences to inform the American ...College of Rheumatology guidelines for screening, monitoring, and treatment of interstitial lung disease (ILD) in people with systemic autoimmune rheumatic diseases (SARDs). Methods We conducted a cross‐sectional qualitative study of a purposefully sampled Patient Panel using a modified content analytic approach. The study team reviewed text transcripts from the Patient Panel discussion to identify themes and develop a clustered thematic schema. Results Twenty‐one patients (75% women) participated, with a mean age of 53 years (range 33–73). Patients had one or more SARDs: systemic sclerosis (38%), Sjögren disease (38%), idiopathic inflammatory myopathy (33%), rheumatoid arthritis (24%), and mixed connective tissue disease (10%). We identified 10 themes in 4 thematic clusters: communication, screening and monitoring, treatment goals, and treatment adverse effects. Patients prioritized recognizing ILD symptoms, importance of ILD screening and close monitoring, goals of survival and improving quality of life, and willingness to accept treatment risks provided that there is close communication with providers. Patient representatives shared patients’ priorities and insight at the Voting Panel meeting, influencing multiple guideline recommendations. Conclusion Patient engagement fosters a holistic approach to CPG development, leading to recommendations aiming for the best clinical outcomes while prioritizing outcomes important for patients. The patient‐identified themes played a critical role in ILD guideline development and provide core elements for shared decision‐making as clinicians make management and therapeutic decisions with patients with SARD‐associated ILD. image
Trustworthy clinical practice guidelines represent a fundamental tool to summarize relevant evidence regarding a set of clinical choices and provide guidance for making optimal clinical decisions. ...Clinicians must differentiate between guidelines that provide trustworthy evidence guidance and those that do not. We present six questions clinicians should ask when evaluating a guideline's trustworthiness. (1) Are the recommendations clear?; (2) Have the panelists considered all alternatives?; (3) Have the panelists considered all patient-important outcomes?; (4) Is the recommendation based on an up-to-date systematic review?; (5) Is the strength of the recommendation compatible with the certainty of the evidence?; (6) Might conflicts of interest influence the recommendations? If yes, were they managed? Once the conclude they are dealing with a trustworthy guideline, clinicians must gain an understanding of the transparent evidence summary that the guideline will offer, and judge the applicability of trustworthy recommendations to their patients and settings. Consideration of the circumstances and values and preferences of patients will be crucial for all weak or conditional recommendations.
We conceptualize patient values and preferences as the relative importance of health outcomes (RIO) which are often obtained through utility elicitation research. A transparent and structured ...approach to present synthesized RIO evidence and the certainty of this evidence is needed. This study aims to adapt the summary of findings (SoF) table to describe the RIO.
We performed three interactive workshops with a protype version of the SoF table for RIO, evidence adapted from the SoF table for intervention effects. We then tested the new format through semi-structured interviews with professionals who interpret RIO evidence (e.g., systematic review authors and guideline developers).
We adapted the SoF table for the presentation of RIO evidence. This SoF table may be easy to use, but bears one risk: some participants misunderstood the utility information and the variability around the RIO. We added a visual analogue scale to clarify the concept of utilities.
Through a multi-stage process including brainstorming sessions and interviews, we adapted the SoF table to present RIO evidence. This table may enhance understanding of evidence synthesis of values and preferences, facilitating the incorporation of this type of evidence in decision-making.
Flow stagnation and residence time (RT) are important features of diseased arterial flows that influence biochemical transport processes and thrombosis. RT calculation methods are classified into ...Eulerian and Lagrangian approaches where several measures have been proposed to quantify RT. Each of these methods has a different definition of RT, and it is not clear how they are related. In this study, image-based computational models of blood flow in an abdominal aortic aneurysm and a cerebral aneurysm were considered and RT was calculated using different methods. In the Lagrangian methods, discrete particle tracking of massless tracers was used to calculate particle residence time and mean exposure time. In the Eulerian methods, continuum transport models were used to quantify RT using Eulerian RT and virtual ink approaches. Point-wise RT and Eulerian indicator RT were also computed based on measures derived from velocity. A comparison of these methods is presented and the implications of each method are discussed. Our results highlight that most RT methods have a conceptually distinct definition of RT and therefore should be utilized depending on the specific application of interest.
Objective We provide evidence‐based recommendations regarding screening for interstitial lung disease (ILD) and the monitoring for ILD progression in people with systemic autoimmune rheumatic ...diseases (SARDs), specifically rheumatoid arthritis, systemic sclerosis, idiopathic inflammatory myopathies, mixed connective tissue disease, and Sjögren disease. Methods We developed clinically relevant population, intervention, comparator, and outcomes questions related to screening and monitoring for ILD in patients with SARDs. A systematic literature review was performed, and the available evidence was rated using the Grading of Recommendations, Assessment, Development, and Evaluation methodology. A Voting Panel of interdisciplinary clinician experts and patients achieved consensus on the direction and strength of each recommendation. Results Fifteen recommendations were developed. For screening people with these SARDs at risk for ILD, we conditionally recommend pulmonary function tests (PFTs) and high‐resolution computed tomography of the chest (HRCT chest); conditionally recommend against screening with 6‐minute walk test distance (6MWD), chest radiography, ambulatory desaturation testing, or bronchoscopy; and strongly recommend against screening with surgical lung biopsy. We conditionally recommend monitoring ILD with PFTs, HRCT chest, and ambulatory desaturation testing and conditionally recommend against monitoring with 6MWD, chest radiography, or bronchoscopy. We provide guidance on ILD risk factors and suggestions on frequency of testing to evaluate for the development of ILD in people with SARDs. Conclusion This clinical practice guideline presents the first recommendations endorsed by the American College of Rheumatology and American College of Chest Physicians for the screening and monitoring of ILD in people with SARDs.
Objective We provide evidence‐based recommendations regarding the treatment of interstitial lung disease (ILD) in adults with systemic autoimmune rheumatic diseases (SARDs). Methods We developed ...clinically relevant population, intervention, comparator, and outcomes questions. A systematic literature review was then performed, and the available evidence was rated using the Grading of Recommendations, Assessment, Development, and Evaluation methodology. A panel of clinicians and patients reached consensus on the direction and strength of the recommendations. Results Thirty‐five recommendations were generated (including two strong recommendations) for first‐line SARD‐ILD treatment, treatment of SARD‐ILD progression despite first‐line ILD therapy, and treatment of rapidly progressive ILD. The strong recommendations were against using glucocorticoids in systemic sclerosis–ILD as a first‐line ILD therapy and after ILD progression. Otherwise, glucocorticoids are conditionally recommended for first‐line ILD treatment in all other SARDs. Conclusion This clinical practice guideline presents the first recommendations endorsed by the American College of Rheumatology and American College of Chest Physicians for the treatment of ILD in people with SARDs.
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