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To describe the process by which the 12 community-based primary health care (CBPHC) research teams worked together and fostered cross-jurisdictional collaboration, including collection of common indicators with the goal of using the same measures and data sources.
A pan-Canadian mechanism for common measurement of the impact of primary care innovations across Canada is lacking. The Canadian Institutes for Health Research and its partners funded 12 teams to conduct research and collaborate on development of a set of commonly collected indicators.
A working group representing the 12 teams was established. They undertook an iterative process to consider existing primary care indicators identified from the literature and by stakeholders. Indicators were agreed upon with the intention of addressing three objectives across the 12 teams: (1) describing the impact of improving access to CBPHC; (2) examining the impact of alternative models of chronic disease prevention and management in CBPHC; and (3) describing the structures and context that influence the implementation, delivery, cost, and potential for scale-up of CBPHC innovations.
Nineteen common indicators within the core dimensions of primary care were identified: access, comprehensiveness, coordination, effectiveness, and equity. We also agreed to collect data on health care costs and utilization within each team. Data sources include surveys, health administrative data, interviews, focus groups, and case studies. Collaboration across these teams sets the foundation for a unique opportunity for new knowledge generation, over and above any knowledge developed by any one team. Keys to success are each team’s willingness to engage and commitment to working across teams, funding to support this collaboration, and distributed leadership across the working group. Reaching consensus on collection of common indicators is challenging but achievable.
Abnormalities in reward learning in psychotic disorders have been proposed to be linked to dysregulated subcortical dopaminergic (DA) neurotransmission, which in turn is a suspected mechanism for predisposition to psychosis. We therefore explored the striatal dopaminergic modulation of reward processing and its behavioral correlates in individuals at familial risk for psychosis.
We performed a DA D2/3 receptor [18F]fallypride positron emission tomography scan during a probabilistic reinforcement learning task in 16 healthy first-degree relatives of patients with psychosis and 16 healthy volunteers, followed by a 6-day ecological momentary assessment study capturing reward-oriented behavior in the everyday life.
We detected significant reward-induced DA release in bilateral caudate, putamen and ventral striatum of both groups, with no group differences in its magnitude nor spatial extent. In both groups alike, greater extent of reward-induced DA release in all regions of interest was associated with better performance in the task, as well as in greater tendency to be engaged in reward-oriented behavior in the daily life.
These findings suggest intact striatal dopaminergic modulation of reinforcement learning and reward-oriented behavior in individuals with familial predisposition to psychosis. Furthermore, this study points towards a key link between striatal reward-related DA release and pursuit of ecologically relevant rewards.
In 2009, the Australian federal government decided to fund the construction of the National Broadband Network, or NBN. At a total projected cost of A$44 billion, it was the largest engineering and public infrastructure project in Australia's history, with the intention of laying 200 000 km of fibre optic cable to the doors of 93 per cent of Australian premises. For the remaining 7 per cent of people, who lived in rural and remote areas, wireless and satellite would replace fibre. However, in 2013, this fibre-tothe- premises [FttP] model was subsequently replaced by a much slower, hybrid model that used a mix of optic-fibre, co-axial cable and copper infrastructures alongside wireless and satellite in regional and remote areas (see Arnold et al. 2014 for installation history).
One of the stated key goals of the various plans for high speed broadband networks in Australia is to overcome the challenges of distance and the concomitant difficulties for transport implicit in distance. For example, in the initial scheme, the then Minister for Broadband, Communications and the Digital Economy, Stephen Conroy, signalled broadband-enabled benefits relating to social inclusion, economic productivity and geographic connectivity. He stated that ‘every person and business in Australia, nomatter [sic] where they are located, will have access to affordable, fast broadband at their fingertips’, and that high speed broadband [HSB] ‘will help drive Australia's productivity, improve education and health service delivery and connect our big cities and regional centres’ (2009). Australian geography has had a major impact on the history of telecommunications in the nation (see, for example, Given 2010). The National Broadband Network [NBN] has been promoted as a way of overcoming the ‘tyranny of distance’ experienced by people in remote and rural regions (Swan & Conroy 2011).
In this chapter, we seek to examine the dynamics of this process, exploring what high speed broadband infrastructure means for overcoming (or ameliorating the effects of) the ‘tyranny of distance’ for those living in regional and remote areas, and what HSB means for the social and material significance of these places.
We evaluated the QX200 Droplet Digital PCR (ddPCR™, Bio-Rad) system and protocols for the detection of the tick-borne pathogens Borrelia burgdorferi and Borrelia miyamotoi in Ixodes scapularis nymphs and adults collected from North Truro, Massachusetts. Preliminary screening by nested PCR determined positive infection levels of 60% for B. burgdorferi in these ticks. To investigate the utility of ddPCR as a screening tool and to calculate the absolute number of bacterial genome copies in an infected tick, we adapted previously reported TaqMan®-based qPCR assays for ddPCR. ddPCR proved to be a reliable means for detection and absolute quantification of control bacterial DNA with precision as low as ten spirochetes in an individual sample. Application of this method revealed the average carriage level of B. burgdorferi in infected I. scapularis nymphs to be 2291 spirochetes per nymph (range: 230–5268 spirochetes) and 51 179 spirochetes on average in infected adults (range: 5647–115 797). No ticks naturally infected with B. miyamotoi were detected. The ddPCR protocols were at least as sensitive to conventional qPCR assays but required fewer overall reactions and are potentially less subject to inhibition. Moreover, the approach can provide insight on carriage levels of parasites within vectors.
United Nations policy forbids its peacekeepers and other personnel from engaging in transactional sex (the exchange of money, favors, or gifts for sex), but we find the behavior to be very common in our survey of Liberian women. Using satellite imagery and GPS locators, we randomly selected 1,381 households and randomly sampled 475 women between the ages of eighteen and thirty. Using an iPod in private to preserve the anonymity of their responses, these women answered sensitive questions about their sexual histories. More than half of them had engaged in transactional sex, a large majority of them (more than 75 percent) with UN personnel. We estimate that each additional battalion of UN peacekeepers caused a significant increase in a woman's probability of engaging in her first transactional sex. Our findings raise the concern that the private actions of UN personnel in the field may set back the UN's broader gender-equality and economic development goals, and raise broader questions about compliance with international norms.
Organisational culture of institutions providing care for older people is increasingly recognised as influential in the quality of care provided. There is little research, however, that specifically examines the processes of care home culture and how these may be associated with quality of care. In this paper we draw from an empirical study carried out in the United Kingdom (UK) investigating the relationship between care home culture and residents' experience of care. Eleven UK care homes were included in an in-depth comparative case study design using extensive observation and interviews. Our analysis indicates how organisational cultures of care homes impact on the quality of care residents receive. Seven inter-related cultural elements were of key importance to quality of care. Applying Schein's conceptualisation of organisational culture, we examine the dynamic relationship between these elements to show how organisational culture is locally produced and shifting. A particular organisational culture in a care home cannot be achieved simply by importing a set of organisational values or the ‘right’ leader or staff. Rather, it is necessary to find ways of resolving the everyday demands of practice in ways that are consistent with espoused values. It is through this everyday practice that assumptions continuously evolve, either consistent with or divergent from, espoused values. Implications for policy makers, providers and practitioners are discussed.
Early findings from a national study of discharges from 32 National
Health Service medium secure units revealed that nearly twice as many
patients than expected were discharged back to prison.
To compare the characteristics of those discharged back to prison with
those discharged to the community, and consider the implications for
ongoing care and risk.
Prospective cohort follow-up design. All forensic patients discharged
from 32 medium secure units across England and Wales over a 12-month
period were identified. Those discharged to prison were compared with
those who were discharged to the community.
Nearly half of the individuals discharged to prison were diagnosed with a
serious mental illness and over a third with schizophrenia. They were a
higher risk, more likely to have a personality disorder, more symptomatic
and less motivated than those discharged to the community.
Findings suggest that alternative models of prison mental healthcare
should be considered to reduce risks to the patient and the public.
We quantify the scientific potential for exoplanet imaging with the mid-infrared E-ELT Imager and Spectrograph (METIS) foreseen as one of the instruments of the European Extremely Large Telescope (E-ELT). We focus on two main science cases: (1) the direct detection of known gas giant planets found by radial velocity (RV) searches; and (2) the direct detection of small (1–4 R⊕) planets around the nearest stars. Under the assumptions made in our modelling, in particular on the achievable inner working angle and sensitivity, our analyses reveal that within a reasonable amount of observing time METIS is able to image >20 already known, RV-detected planets in at least one filter. Many more suitable planets with dynamically determined masses are expected to be found in the coming years with the continuation of RV-surveys and the results from the GAIA astrometry mission. In addition, by extrapolating the statistics for close-in planets found by Kepler, we expect METIS might detect ≈10 small planets with equilibrium temperatures between 200 and 500 K around the nearest stars. This means that (1) METIS will help constrain atmospheric models for gas giant planets by determining for a sizable sample their luminosity, temperature and orbital inclination; and (2) METIS might be the first instrument to image a nearby (super-) Earth-sized planet with an equilibrium temperature near that expected to enable liquid water on a planet surface.
A small-scale excavation, undertaken in advance of building works at Faraday Road, Newbury, Berkshire, encountered an apparently intact Early Mesolithic layer containing abundant worked flint directly associated with animal bones. The site lay on the floodplain of the River Kennet in an area already well-known for Mesolithic remains and certainly represents an extension of the site found at nearby Greenham Dairy Farm in 1963. The flint assemblage was dominated by obliquely-blunted microlithic forms accompanied by a restricted range of other items. The animal bones were, unusually, dominated by wild pig with clear evidence of both primary butchery and food waste. Spatial analysis of the bone and flint assemblages indicated discrete activity areas, possibly associated with hearths. Both pollen and molluscan data were recovered which, together with the results of soil micromorphological examination, confirmed an Early Holocene date for the formation of the Mesolithic layer. Radiocarbon dates place the site in the late 10th–early 9th millennium BP. The paper re-examines the nature of known Early Mesolithic activity in this part of the Kennet valley, with particular reference to the specific environmental conditions that seem to have prevailed. It is concluded that the Faraday Road site represents one part of a continuum of Early Mesolithic occupation that stretches along a considerable length of the floodplain, with each focus of activity witnessing repeated, but intermittent, occupation spanning a period of more than a millennium.
The goal of this study was to quantify the impact of the suggested education correction on the sensitivity and specificity of the Montreal Cognitive Assessment (MoCA).
Twenty-five outpatients with dementia and 39 with amnestic mild cognitive impairment (aMCI) underwent a diagnostic evaluation, which included the MoCA. Thirty-seven healthy controls also completed the MoCA and psychiatric, medical, neurological, functional, and cognitive difficulties were ruled out.
For the total MoCA score, unadjusted for education, a cut-off score of 26 yielded the best balance between sensitivity and specificity (80% and 89% respectively) in identifying cognitive impairment (people with either dementia or aMCI, versus controls). When applying the education correction, sensitivity decreased from 80% to 69% for a small specificity increase (89% to 92%). The cut-off score yielding the best balance between sensitivity and specificity for the education adjusted MoCA score fell to 25 (61% and 97%, respectively).
Adjusting the MoCA total score for education had a detrimental effect on sensitivity with only a slight increase in specificity. Clinically, this loss in sensitivity can lead to an increased number of false negatives, as education level does not always correlate to premorbid intellectual function. Clinical judgment about premorbid status should guide interpretation. However, as this effect may be cohortspecific, age and education corrected norms and cut-offs should be developed to help guide MoCA interpretation.
Vitamin D and folate are associated with decreased colorectal cancer risk and their association with colorectal cancer prognosis is under investigation. We assessed the levels of plasma 25-hydroxyvitamin D3 (25(OH)D3), folate and vitamin B12 in an international pilot study in order to determine variability of these biomarkers based on geographical location. Plasma 25(OH)D3, folate and vitamin B12 concentrations were measured in 149 invasive, newly diagnosed colorectal cancer cases from Heidelberg (Germany), Seattle (WA, USA), and Tampa (FL, USA) and in ninety-one age- and sex-matched controls. Their associations with potential predictors were assessed using multivariate linear regression analyses. Plasma 25(OH)D3, folate and vitamin B12 concentrations differed by location. Other predictors were season for 25(OH)D3 and tumour stage (vitamin B12). Season-corrected average 25(OH)D3 concentrations were higher in Heidelberg (31·7 ng/ml; range 11·0–83·0 ng/ml) than in Seattle (23·3 ng/ml; range 4·0–80·0 ng/ml) and Tampa (21·1 ng/ml; range 4·6–51·6 ng/ml). In Heidelberg, a strong seasonal variation was observed. Folate (11·1 ng/ml) and vitamin B12 (395 pg/ml) concentrations in Heidelberg were lower than those in Seattle (25·3 ng/ml and 740 pg/ml, respectively) and Tampa (23·8 ng/ml and 522 pg/ml, respectively). Differences in plasma 25(OH)D3 and folate concentrations between Heidelberg and the US sites were observed, probably reflecting variation in outdoor activities and sun-avoidance behaviour during summer as well as in folic acid fortification and supplement use. Intra-site differences at each study location were greater than between-location variability, suggesting that individual health behaviours play a significant role. Nevertheless, the intra-site differences we observed may be due to chance because of the limited sample size. Our pilot study illustrates the value of an international cohort in studying colorectal cancer prognosis to discern geographical differences in a broad range of exposures.
Lipoprotein-associated phospholipase A2 (Lp-PLA2) is an independent risk factor for CVD and has been proposed as a marker of vascular inflammation. Polyunsaturated n-3 fatty acids (FA) and several n-6 FA are known to suppress inflammation and may influence Lp-PLA2 mass and activity. The associations of n-3 and n-6 plasma FA with Lp-PLA2 mass and activity were analysed using linear regression analysis in 2246 participants of the Multi-Ethnic Study of Atherosclerosis; statistical adjustments were made to control for body mass, inflammation, lipids, diabetes, and additional clinical and demographic factors. Lp-PLA2 mass and activity were significantly lower in participants with the higher n-3 FA EPA (β = − 4·72, P< 0·001; β = − 1·53; P= 0·023) and DHA levels (β = − 4·47, β = − 1·87; both P< 0·001). Those in the highest quintiles of plasma EPA and DHA showed 12·71 and 19·15 ng/ml lower Lp-PLA2 mass and 5·7 and 8·90 nmol/min per ml lower Lp-PLA2 activity than those in the first quintiles, respectively. In addition, lower Lp-PLA2 mass and activity were associated with higher levels of n-6 arachidonic acid (β = − 1·63, β = − 1·30; both P< 0·001), while γ-linolenic acid was negatively associated with activity (β = − 27·7, P= 0·027). Lp-PLA2 mass was significantly higher in participants with greater plasma levels of n-6 linoleic (β = 0·828, P= 0·011) and dihomo-γ-linolenic acids (β = 4·17, P= 0·002). Based on their independent associations with Lp-PLA2 mass and activity, certain n-3 and n-6 FA may have additional influences on CVD risk. Intervention studies are warranted to assess whether these macronutrients may directly influence Lp-PLA2 expression or activity.
Studies suggest a role for cardiovascular fitness in the prevention of
To determine whether cardiovascular fitness at age 18 is associated with
future risk of serious affective illness.
Population-based Swedish cohort study of male conscripts
(n = 1 117 292) born in 1950–1987 with no history of
mental illness who were followed for 3–40 years. Data on cardiovascular
fitness at conscription were linked with national hospital registers to
calculate future risk of depression (requiring in-patient care) and
In fully adjusted models low cardiovascular fitness was associated with
increased risk for serious depression (hazard ratios (HR)=1.96, 95%, CI
1.71–2.23). No such association could be shown for bipolar disorder
(HR=1.11, 95% CI 0.84–1.47).
Lower cardiovascular fitness at age 18 was associated with increased risk
of serious depression in adulthood. These results strengthen the theory
of a cardiovascular contribution to the aetiology of depression.