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Public involvement in service change has been identified as a key facilitator of health care transformation (Foley et al., 2017) but little is known about how health policy influences whether and how organisations involve the public in change processes. This qualitative study compares policy and practice for involving the public in major service changes across the UK's four health systems (England, Northern Ireland, Wales and Scotland). We analysed policy documents, and conducted interviews with officials, stakeholders, NHS staff and public campaigners (total number of interviewees = 47). Involving the public in major service change was acknowledged as a policy challenge in all four systems. Despite ostensible similarities, there were some clear differences between the four health systems' processes for involving patients and the public in major changes to health services. The extent of central Government oversight, the prescriptiveness of Government guidance, the role for intermediary bodies and arrangements for independent scrutiny of contentious decisions all vary. We analyse how health policy in the four systems has used ‘sticks’ and ‘sermons’ to promote particular approaches, and conclude that both policy and the wider system context within which health care organisations try to effect change are significant, and understudied aspect of contemporary practice.
Norovirus is a predominant cause of infectious gastroenteritis in countries worldwide [1–5]. It accounts for approximately 50% of acute gastroenteritis (AGE) and >90% of viral gastroenteritis outbreaks [6, 7]. The incubation period ranges between 10 and 48 h and illness duration is generally 1–3 days with self-limiting symptoms; however, this duration is often longer (e.g. 4–6 days) in vulnerable populations such as hospital patients or young children [2, 8]. Symptomatic infection of norovirus presents as acute vomiting, diarrhoea, abdominal cramps and nausea, with severe vomiting and diarrhoea (non-bloody) being most common [2, 5, 9].
The European Court of Justice, and courts in general, were key actors in the creation of the European Union (EU). However, they cannot change major policy without political supporters to lobby and litigate for implementation. We argue that part of the resolution of this apparent paradox comes from complementing existing work on the activities of EU courts and litigants with a focus on a third actor: implementing bureaucracies, whose effect on law and politics has not been a focus of studies of EU legal development. Their calculations about whether to pay attention, lobby, and comply shape the impact of the law. Those calculations are variable and patterned; when and how bureaucracies listen to courts varies in predictable ways. We find evidence for this proposition in the case of EU health care services law, both in the secondary literature and in empirical studies of France and Spain.
The United States’ experience with the Ebola virus in 2014 provides a window into US public health politics. First, the United States provided a case study in the role of suasion and executive action in the management of public health in a fragmented multi-level system. The variable capacity of different parts of the United States to respond to Ebola on the level of hospitals or state governments, and their different approaches, show the limitations of federal influence, the importance of knowledge and executive energy, and the diversity of both powerful actors and sources of power. Second, the politics of Ebola in the United States is a case study in the politics of partisan blame attribution. The outbreak struck in the run-up to an election that was likely to be good for the Republican party, and the election dominated interest in and opinions of Ebola in both the media and public opinion. Democratic voters and media downplayed Ebola while Republican voters and media focused on the outbreak. The media was a key conduit for this strategic politicization, as shown in the quantity, timing and framing of news about Ebola. Neither fragmentation nor partisanship appears to be going away, so understanding the politics of public health crises will remain important.
The economic effects of the financial crisis in the eurozone have been much studied, but the impact of political and institutional changes made amidst crisis conditions have been less studied. This article examines the changes in the EU since 2008 through the lens of T.H. Marshall’s concept of citizenship, gauging the effects of different changes in the EU polity on the citizenship rights of individuals. The key changes are in fiscal governance, which includes a new treaty as well as substantial legislation changing the balance of powers within and competencies of the EU institutions, the European Central Bank’s role and the Troika arrangements for countries in crisis. We find that while the EU’s contribution to civil citizenship in Europe is relatively intact, the development of its fiscal governance is bringing serious negative consequences for political and social citizenship in all member states. The EU is adopting policies that entrust more power to less democratically accountable institutions with the objective of fiscal rigour rather than social citizenship.
To assess antimicrobial utilization before and after a change in urine culture ordering practice in adult intensive care units (ICUs) whereby urine cultures were only performed when pyuria was detected.
A 700-bed academic medical center
Patients admitted to any adult ICU
Aggregate data for all adult ICUs were obtained for population-level antimicrobial use (days of therapy [DOT]), urine cultures performed, and bacteriuria, all measured per 1,000 patient days before the intervention (January–December 2012) and after the intervention (January–December 2013). These data were compared using interrupted time series negative binomial regression. Randomly selected patient charts from the population of adult ICU patients with orders for urine culture in the presence of indwelling or recently removed urinary catheters were reviewed for demographic, clinical, and antimicrobial use characteristics, and pre- and post-intervention data were compared.
Statistically significant reductions were observed in aggregate monthly rates of urine cultures performed and bacteriuria detected but not in DOT. At the patient level, compared with the pre-intervention group (n=250), in the post-intervention group (n=250), fewer patients started a new antimicrobial therapy based on urine culture results (23% vs 41%, P=.002), but no difference in the mean total DOT was observed.
A change in urine-culture ordering practice was associated with a decrease in the percentage of patients starting a new antimicrobial therapy based on the index urine-culture order but not in total duration of antimicrobial use in adult ICUs. Other drivers of antimicrobial use in ICU patients need to be evaluated by antimicrobial stewardship teams.
Infect. Control Hosp. Epidemiol. 2016;37(4):448–454
The European Union's (EU) 2011 Directive on cross-border patient mobility codifies the right of any EU citizen to travel abroad for treatment and be reimbursed on the same terms as they would be at home. Governments hoped it would end the string of court cases that had reshaped EU health law but this article argues that it is likely to produce yet more judicial challenges. Patient mobility is an attractive idea with unclear definitions and divergent implementation. In many cases, providers, insurers and governments will not communicate and leave the patient with a bill – almost daring the patient to sue, and the courts to make more policy. Governments should try to prevent this by investing in coordination and alternative redress for patients who might otherwise sue.
Sleep disturbances are persistent residual symptoms following remission of major depressive disorder (MDD) and are associated with an increased risk of MDD recurrence. The purpose of the current study was to examine the effect of exercise augmentation on self-reported sleep quality in participants with non-remitted MDD.
Participants were randomized to receive selective serotonin reuptake inhibitor (SSRI) augmentation with one of two doses of exercise: 16 kilocalories per kilogram of body weight per week (KKW) or 4 KKW for 12 weeks. Depressive symptoms were assessed using the clinician-rated Inventory of Depressive Symptomatology (IDS-C). The four sleep-related items on the IDS-C (Sleep Onset Insomnia, Mid-Nocturnal Insomnia, Early Morning Insomnia, and Hypersomnia) were used to assess self-reported sleep quality.
Significant decreases in total insomnia (p < 0.0001) were observed, along with decreases in sleep onset, mid-nocturnal and early-morning insomnia (p's <0.002). Hypersomnia did not change significantly (p = 0.38). Changes in total, mid-nocturnal and early-morning insomnia were independent of changes in depressive symptoms. Higher baseline hypersomnia predicted a greater decrease in depression severity following exercise treatment (p = 0.0057). No significant moderating effect of any baseline sleep on change in depression severity was observed. There were no significant differences between exercise treatment groups on total insomnia or any individual sleep item.
Exercise augmentation resulted in improvements in self-reported sleep quality in patients with non-remitted MDD. Given the prevalence of insomnia as a residual symptom following MDD treatment and the associated risk of MDD recurrence, exercise augmentation may have an important role in the treatment of MDD.
Shape Memory Alloys (SMA) undergo reversible martensitic transformation in response to changes in temperature or applied stress, exhibiting specific properties of superelasticity and shape memory. At present there is a high scientific and technological interest to develop these properties at small scale, to apply SMA as sensors and actuators in MEMS technologies. In order to study the thermo-mechanical properties of SMA at micro and nano scale, instrumented nano indentation is being widely used for nano compression tests. By using this technique, superelasticity and shape memory at the nano-scale has been demonstrated in micro and nano pillars of Cu-Al-Ni SMA. However the martensitic transformation seems to exhibit a different behavior at small scale than in bulk materials and a size effect on superelasticity has been recently reported. In the present work we will overview the thermo-mechanical properties of Cu-Al-Ni SMA at the nano-scale, with special emphasis on size effects. Finally, the above commented size effects will be discussed on the light of the microscopic mechanisms controlling the martensitic transformation at nano scale.
Turnbull pointed out that good glass formability should correlate with a high reduced glass transition temperature, Trg. The alloy Pd40Ni40P20 has an unusually high Trg of ∼0.66 and indeed it can be formed into a glass at rather low cooling rates (≲ 1 Ks−1 ). In this paper a number of experiments are described which take advantage of the high resistance to crystallization in this alloy to study behavior in the labile temperature range between Tg and Tm. The anomalously low crystal growth velocities arise because the product is a three phase mixture. Nucleation kinetics are derived from crystal size distribution analysis. Heterogeneous nucleation at the surface of melt spun ribbon is characterized; significant surface relief develops on crystallization because of the low number of nuclei. In bulk glass produced by fluxing, good crystal size statistics show that internal nucleation is predominantly also heterogeneous, but with a significant transient time. Measurements of the specific heat of the undercooled liquid reveal that the free energy of crystallization deviates significantly from a linear dependence on undercooling (expected for pure metals) in the way predicted by Dubey and Ramachandrarao.