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Part 1 of this three-part series on integrated care discussed the drivers for change in healthcare delivery in England set out in the NHS Long Term Plan. This second part explores the evolution of mental health services within the wider National Health Service (NHS), and describes important relevant legislation and policy over the past decade, leading up to the 2019 Long Term Plan. We explain the implications of this, including the detail of emerging structures such as integrated care systems (ICSs) and primary care networks (PCNs), and conclude with challenges facing these novel systems. Part 3 will address the practical local implementation of integrated care.
To evaluate the Child and Adult Care Food Program (CACFP) rule that allows a meat/meat alternative to replace the breakfast grain requirement three times per week.
A 5-week menu including breakfast, lunch and snack was developed with meat/meat alternative replacing the breakfast grain requirement three times per week. Menu nutrients based on the minimum requirements were compared with reference values representing the Acceptable Macronutrient Distribution Range for fat and a range of reference values representing two-thirds the Dietary Reference Intake for 3-year-olds and 4–5-year-olds. The meal pattern minimum requirements were compared with two-thirds of those recommended by the Dietary Guidelines for Americans (DGA).
Evaluation took place between April and June 2019.
Human subjects were not utilized.
The CACFP minimum grain requirement is well below the DGA reference value (0·5–1·5 v. 3·33 ounce-equivalents). Energy (2208·52 kJ) was below the reference values (3126·83–4362·53 kJ). Protein (34·43 g) was above the reference values (9·87–10·81 g). Carbohydrate (76·65 g), fibre (7·46 g) and vitamin E (1·69 mg) were below their reference values of 86·67 g, 10·46–14·60 g and 4–4·76 mg, respectively. Fat (22·57 %) was below the reference range (25–40 %).
The CACFP rule which allows a meat/meat alternative to replace the breakfast grain requirement three times per week may result in meal patterns low in energy, carbohydrate, fat, fibre and vitamin E, while providing an excessive amount of protein.
A non-parametric Gaussian process regression model is developed in the three-dimensional equilibrium reconstruction code V3FIT. A Gaussian process is a normal distribution of functions that is uniquely defined by specifying a mean function and covariance kernel function. Gaussian process regression assumes that an unknown profile belongs to a particular Gaussian process and uses Bayesian analysis to select the function the give the best fit to measured data. The implementation in V3FIT uses a hybrid representation where Gaussian processes are used to infer some of the equilibrium profiles and standard parametric techniques are used to infer the remaining profiles. The implementation of the Gaussian process is tested using both synthetic data and experimental data from multiple machines.
There is a worldwide epidemic of non-communicable diseases (NCDs), including cardiovascular disease (CVD), type 2 diabetes, chronic lung disease, and some forms of cancer; predisposition to these is linked to obesity. This is despite efforts by individuals to modify their diet and lifestyle, and government and global programs aimed at promoting healthy eating or increased physical activity. Some initiatives have begun to target childhood eating and activity. But a strong and international body of scientific and epidemiological data suggests that health interventions should be focused on a much earlier period of development: pregnancy. Expectant couples are often focused on the immediate result of their pregnancy – a viable baby. It may come as a surprise to many of them to hear that the finer details of building a baby are in fact the foundation of lifelong health.
The concerns and corporate practice of business ethics have evolved over the past sixty years. But none of the changes of the past are as great as those that will occur in the next ten years as artificial intelligence (AI) and machine learning become ubiquitous tools in American society. This chapter presents a concise history of corporate attention to business ethics over this historical period in order to identify how “next-generation business ethics” will demonstrate both continuity with and divergence from past attention to business ethics.
Can artworks be morally good or bad? Many philosophers have thought so. Does this moral goodness or badness bear on how good or bad a work is as art? This is very much a live debate. Autonomists argue that moral value is not relevant to artistic value; interactionists argue that it is. In this paper, I argue that the debate between interactionists and autonomists has been conducted unfairly: all parties to the debate have tacitly accepted a set of constraints which prejudices the issue against the interactionist. I identify two demands which are routinely placed on arguments seeking to establish interaction and argue that they are, in fact, mutually conflicting.
There are two upshots. First, in light of this, it is unsurprising that arguments for interaction have failed to meet with everybody’s satisfaction. The constraints are such that no argument can meet them. Second, recognizing this helps us uncover a new, promising, but hitherto overlooked strategy for establishing artistic-ethical interaction.
There is strong public belief that polyunsaturated fats protect against and ameliorate depression and anxiety.
To assess effects of increasing omega-3, omega-6 or total polyunsaturated fat on prevention and treatment of depression and anxiety symptoms.
We searched widely (Central, Medline and EMBASE to April 2017, trial registers to September 2016, ongoing trials updated to August 2019), including trials of adults with or without depression or anxiety, randomised to increased omega-3, omega-6 or total polyunsaturated fat for ≥24 weeks, excluding multifactorial interventions. Inclusion, data extraction and risk of bias were assessed independently in duplicate, and authors contacted for further data. We used random-effects meta-analysis, sensitivity analyses, subgrouping and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment.
We included 31 trials assessing effects of long-chain omega-3 (n = 41 470), one of alpha-linolenic acid (n = 4837), one of total polyunsaturated fat (n = 4997) and none of omega-6. Meta-analysis suggested that increasing long-chain omega-3 probably has little or no effect on risk of depression symptoms (risk ratio 1.01, 95% CI 0.92–1.10, I2 = 0%, median dose 0.95 g/d, duration 12 months) or anxiety symptoms (standardised mean difference 0.15, 95% CI 0.05–0.26, I2 = 0%, median dose 1.1 g/d, duration 6 months; both moderate-quality evidence). Evidence of effects on depression severity and remission in existing depression were unclear (very-low-quality evidence). Results did not differ by risk of bias, omega-3 dose, duration or nutrients replaced. Increasing alpha-linolenic acid by 2 g/d may increase risk of depression symptoms very slightly over 40 months (number needed to harm, 1000).
Long-chain omega-3 supplementation probably has little or no effect in preventing depression or anxiety symptoms.
Declaration of interest
L.H. and A.A. were funded to attend the World Health Organization Nutrition Guidance Expert Advisory Group (NUGAG) Subgroup on Diet and Health meetings and present review results. The authors report no other conflicts of interest.
To develop a physiological data-driven model for early identification of impending cardiac arrest in neonates and infants with cardiac disease hospitalised in the cardiovascular ICU.
We performed a single-institution retrospective cohort study (11 January 2013–16 September 2015) of patients ≤1 year old with cardiac disease who were hospitalised in the cardiovascular ICU at a tertiary care children’s hospital. Demographics and diagnostic codes of cardiac arrest were obtained via the electronic health record. Diagnosis of cardiac arrest was validated by expert clinician review. Minute-to-minute physiological monitoring data were recorded via bedside monitors. A generalized linear model was used to compute a minute by minute risk score. Training and test data sets both included data from patients who did and did not develop cardiac arrest. An optimal risk-score threshold was derived based on the model’s discriminatory capacity for impending arrest versus non-arrest. Model performance measures included sensitivity, specificity, accuracy, likelihood ratios, and post-test probability of arrest.
The final model consisting of multiple clinical parameters was able to identify impending cardiac arrest at least 2 hours prior to the event with an overall accuracy of 75% (sensitivity = 61%, specificity = 80%) and observed an increase in probability of detection of cardiac arrest from a pre-test probability of 9.6% to a post-test probability of 21.2%.
Our findings demonstrate that a predictive model using physiologic monitoring data in neonates and infants with cardiac disease hospitalised in the paediatric cardiovascular ICU can identify impending cardiac arrest on average 17 hours prior to arrest.
This chapter explores the popular organizing that arose in Mexico’s southwest state of Guerrero during the Cold War. It concludes that the movement’s identification with the language of nationalism and economic and social expectations that arose with the revolution of 1910 distinguishes it from many of the contemporary Marxist-inspired movements in Latin America. Following a series of government assaults on peaceful protesters demanding democratic inclusion, the teacher-activists who had led the initial opposition – Genaro Vázquez Rojas and Lucio Cabañas – each founded an armed guerrilla movement. While these both remained small, the chapter argues that they enjoyed the support of a broader base that hid them, fed them, and suffered the consequences of unrestrained government violence. Guerrero was, ultimately, the site of Mexico’s guerra sucia. This history also helps us understand the disappearance of Ayotzinapa’s teachers-in-training in 2014. Those students attended a school distinguished for producing radical opposition leaders since its post-revolutionary inception, including, during the Cold War, Lucio Cabañas.
The Roman military presence at Dalswinton is reassessed using a range of remote sensing techniques (geophysical survey, LiDAR and aerial photography). At Bankfoot the absence of internal buildings suggests the postulated vexillation fortress was a more temporary structure; while numerous pits/ovens were identified across the interior of the large Stracathro-type camp. The primary fort at Bankhead was provided with in-turned entrances and two small annexes attached to the north-west and south-east quadrants of the fort. A third much larger annexe extended southwards down to the river. Only pits and furnaces were recorded within the annexes, two of which were expanded in Phase 2. Various buildings, including legionary and auxiliary barracks, were identified in the expanded fort of Phase 2, whose orientation remained unchanged. A mixed garrison of legionaries and auxiliary cavalry is indicated for both periods of occupation. Finally, the fort was deliberately demolished. The Roman attribution of the three nearby enclosures at Butterhole Brae can no longer be supported.
Calls for a return to a traditional method of lawmaking known as “regular order” have proliferated as unorthodox lawmaking has grown more dominant in Congress. Proponents claim regular order enhances deliberation on legislation. This chapter examines deliberation under one form of regular order: open rules permitting unlimited amending in the House of Representatives. We find evidence of substantial minority influence on the inputs and outputs of the appropriations process. Regular order gives the minority party members the opportunity to present and win adoption of their policy proposals. Our evidence also shows that ideological extremists play an outsized role in debate. They offer more amendments than other members, and their amendments tend to win less support and face defeat more often than moderates. The paradox of regular order is that it simultaneously offers the opportunity for bipartisan deliberation over legislation while exposing the majority party to problems that may make its management of the floor more difficult.
Although there has been considerable scholarly interest in the nature of ancient cities, it has been difficult to identify and explore quantitative patterns in their design and amenities. Here, the authors offer a model for the relationship between the population size and infrastructural area of settlements, before testing it against measures of urban form in the Roman Empire. They advocate a more consistent approach to the investigation of settlements that is capable of not only incorporating sites with divergent physical forms and historical trajectories into the same model, but also able to expose their similarities and differences.