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Existing mass vaccination clinic guidance calls for staffing and resource requirements that may not be achievable in smaller settings. Practical and scalable solutions to these problems were developed by a volunteer group of continuous improvement professionals, working to assist 2 non-governmental organizations engaged in coordinating refugee health services: the Somali Health Board of Seattle, WA and Community Health Services Inc. of Rochester, MN. Our shared goal was to get more shots in arms by bringing vaccines to small communities through pop-up clinics that are quick to set-up and require minimal resources. The clinics were developed using continuous improvement methods, thereby yielding a 2-minute vaccine administration time and an 8-fold improvement in productivity as a result of Federal Emergency Management Agency (FEMA) guidance. This report details our field-tested methods and achieved results. The relevance and benefits of this approach deserve attention as pandemic response needs continue to evolve and vaccines become more globally available.
Young people with social disability and severe and complex mental health problems have poor outcomes, frequently struggling with treatment access and engagement. Outcomes may be improved by enhancing care and providing targeted psychological or psychosocial intervention.
We aimed to test the hypothesis that adding social recovery therapy (SRT) to enhanced standard care (ESC) would improve social recovery compared with ESC alone.
A pragmatic, assessor-masked, randomised controlled trial (PRODIGY: ISRCTN47998710) was conducted in three UK centres. Participants (n = 270) were aged 16–25 years, with persistent social disability, defined as under 30 hours of structured activity per week, social impairment for at least 6 months and severe and complex mental health problems. Participants were randomised to ESC alone or SRT plus ESC. SRT was an individual psychosocial therapy delivered over 9 months. The primary outcome was time spent in structured activity 15 months post-randomisation.
We randomised 132 participants to SRT plus ESC and 138 to ESC alone. Mean weekly hours in structured activity at 15 months increased by 11.1 h for SRT plus ESC (mean 22.4, s.d. = 21.4) and 16.6 h for ESC alone (mean 27.7, s.d. = 26.5). There was no significant difference between arms; treatment effect was −4.44 (95% CI −10.19 to 1.31, P = 0.13). Missingness was consistently greater in the ESC alone arm.
We found no evidence for the superiority of SRT as an adjunct to ESC. Participants in both arms made large, clinically significant improvements on all outcomes. When providing comprehensive evidence-based standard care, there are no additional gains by providing specialised SRT. Optimising standard care to ensure targeted delivery of existing interventions may further improve outcomes.
A collaborative research approach was used to co-develop patient reported outcome measures or PROMS. One of our PROMS (SURE) assesses recovery from alcohol and other drug problems, and another (SUSS) assesses sleep problems. People using SURE and SUSS reported that they would like to complete them on their mobile phones and tablet computers so that they could record and refer back to their scores. This chapter describes the collaborative research process used to co-design a mobile application (app) called SURE Recovery, including the experiences of working with a diverse team of people with lived experience of addiction, researchers, app developers, and clinicians. The chapter also provides reflections on the challenges encountered and the lessons learned. Insights and advice for others are offered who might be interested in developing similar recovery-oriented apps in the future.
The criteria for objective memory impairment in mild cognitive impairment (MCI) are vaguely defined. Aggregating the number of abnormal memory scores (NAMS) is one way to operationalise memory impairment, which we hypothesised would predict progression to Alzheimer’s disease (AD) dementia.
As part of the Australian Imaging, Biomarkers and Lifestyle Flagship Study of Ageing, 896 older adults who did not have dementia were administered a psychometric battery including three neuropsychological tests of memory, yielding 10 indices of memory. We calculated the number of memory scores corresponding to z ≤ −1.5 (i.e., NAMS) for each participant. Incident diagnosis of AD dementia was established by consensus of an expert panel after 3 years.
Of the 722 (80.6%) participants who were followed up, 54 (7.5%) developed AD dementia. There was a strong correlation between NAMS and probability of developing AD dementia (r = .91, p = .0003). Each abnormal memory score conferred an additional 9.8% risk of progressing to AD dementia. The area under the receiver operating characteristic curve for NAMS was 0.87 [95% confidence interval (CI) .81–.93, p < .01]. The odds ratio for NAMS was 1.67 (95% CI 1.40–2.01, p < .01) after correcting for age, sex, education, estimated intelligence quotient, subjective memory complaint, Mini-Mental State Exam (MMSE) score and apolipoprotein E ϵ4 status.
Aggregation of abnormal memory scores may be a useful way of operationalising objective memory impairment, predicting incident AD dementia and providing prognostic stratification for individuals with MCI.
Demands placed on informal caregivers can result in an increased likelihood of experiencing common mental health difficulties that may affect their ability to undertake the caring role. Currently, however, few evidence-based interventions have been specifically developed for informal caregivers and available interventions are difficult to access. The Improving Access to Psychological Therapies (IAPT) programme aims to improve access to evidence-based psychological therapies for all groups and may therefore present an opportunity to meet informal caregiver needs. Located within the MRC Complex Intervention Framework, a Phase II feasibility randomised controlled trial (RCT) examines key methodological, procedural and clinical uncertainties associated with running a definitive Phase III RCT of an adapted written cognitive behavioural therapy (CBT) self-help intervention for informal caregivers of stroke survivors. Recruitment was low despite different recruitment strategies being adopted, highlighting significant challenges moving towards a Phase III RCT until resolved. Difficulties with study recruitment may reflect wider challenges engaging informal caregivers in psychological interventions and may have implications for IAPT services seeking to improve access for this group. Further attempts to develop a successful recruitment protocol to progress to a Phase III RCT examining effectiveness of the adapted CBT self-help intervention should be encouraged.
Key learning aims
After reading this article, readers should be able to:
(1) Consider key feasibility issues with regard to recruitment and attrition when running a randomised controlled trial of an adapted written cognitive behavioural therapy (CBT) self-help intervention for informal caregivers of stroke survivors.
(2) Understand potential barriers experienced by an informal caregiving population to accessing psychological interventions.
(3) Appreciate implications for clinical practice to enhance access to IAPT services and low-intensity CBT working with an informal caregiver population.
We describe an ultra-wide-bandwidth, low-frequency receiver recently installed on the Parkes radio telescope. The receiver system provides continuous frequency coverage from 704 to 4032 MHz. For much of the band (
), the system temperature is approximately 22 K and the receiver system remains in a linear regime even in the presence of strong mobile phone transmissions. We discuss the scientific and technical aspects of the new receiver, including its astronomical objectives, as well as the feed, receiver, digitiser, and signal processor design. We describe the pipeline routines that form the archive-ready data products and how those data files can be accessed from the archives. The system performance is quantified, including the system noise and linearity, beam shape, antenna efficiency, polarisation calibration, and timing stability.
It was consistent with both humanism and the growth of political bureaucracy that humanisticallyeducated ‘new men’ took roles as counsellors in the courts of both early Tudor kings. This chapter explores the role of the counsellor in the work of three leading Renaissance humanists: Erasmus, More and Castiglione. Each accepted that good counsel should, to varying degrees, rule the prince. At the heart of their writings remains, however, a question about the efficacy of counsel in a hereditary monarchy. Often overlooked in this debate is importance of Seneca, who provides the basis for the discussion of the effectiveness of counsel in all three writers’ works, contrasting principles learned through instruction from precepts gathered through counsel.
By abandoning the focus on virtue and replacing it with a focus on preservation by means of occasional deception, the Machiavellian discourse throws suspicion on the role of the counsellor, and especially problematises his powerful role in relation to the monarch. This is especially the case in late Tudor England, ruled by monarchs perceived to be ‘weakened’ by their age or gender. Whereas the Henrician humanists had advocated counsellors who ruled their princes, the threat of Machiavellianism and weak monarchs renders such arguments threatening, and the counsellor falls under greater suspicion for his perceived usurpation of power. At the same time – and by contrast – there is a view that such weak monarchs require strong counsel to guide them. If this cannot come from individuals, as they are likely to be self-interested, then it must come different, ‘dis-interested’, sources. Whereas single private counsellors will be self-interested and thus ought not to rule a monarch, especially a female one, assemblies such as parliament will guide the prince according to the good of the commonwealth. For this reason, they need to have a share in the government. Command becomes ‘bridled’ by this source of counsel.
The Introduction sets out the ‘problem’ and ‘paradox’ of counsel in regard to the ‘monarchy of counsel’ in England between the end of the Wars of the Roses and the English Civil War. On the one hand, it was a long-standing requirement that monarchs receive counsel in order to legitimize their rule. On the other, this condition had the potential to undermine their authority if the monarch was required to act on the counsel given. In other words, if counsel is obligatory, it impinges upon sovereignty. If it is not, it then becomes irrelevant and futile. The Introduction also provides justification of the scope of the study by providing some classical and medieval background.
The introduction of Machiavellian political thought into the context of an England weakened by perceived monarchical instability – the reign of a minor and two women – opens a new chapter in the history of the English discourse of counsel. Machiavelli, in The Prince, offers a reversal of the traditional humanist model of counsel; the prince’s prudence is what determines the quality of the counsel he receives. Counsellors, given Machiavelli's pessimistic account of self-interest in The Prince, are not likely to demonstrate the civic spirit that the humanist took to be foundational to their image of the counsellor. Thus, they need to be held in suspicion, and cannot be given any real power.
Reason of state discourses see a renewed preoccupation with the divide between public and private. Even as there is an increased understanding of the need to keep state secrets, there are likewise increasing attempts to peer into hearts and minds of rulers. At the centre of this tension is the counsellor, whose position between public and private remains in contention. It is the emerging language of ‘interests’ which shows this tension most clearly. The counsellor is to advise according to the interest of the state, and not his own private interest. The more public a counsellor can be, the more likely he is to give advice in line with this state interest. Three problems emerge from this model, however. First, how can the counsellor be both secretive and public? Second, how can a private individual abandon his personal interests? And, third, a recurring issue, what if the counsellor knows the state’s interests better than the monarch: should his counsel then become command? These are the issues which come to the fore in the mid-seventeenth century, born of tensions apparent in the reason of state tradition.
In the Machiavellian literature on counsel, the distinction between private and public prudence becomes more pointed, leading to a distinction between a private sphere ruled by morality, and a public sphere in which moral flexibility, or even amoralism, is appropriate. As Machiavellian principles spread, such a view became accepted even amongst self-described anti-Machiavellians, especially in considering ‘policy’ and political deliberation. Counsellors must weigh both private and public expectations, offering advice that takes into account necessity and advantage politically but with an awareness of traditional expectations, embracing the skill of redescription when occasion, still in the tradition of kairos, calls for the employment of vice. Not only does this redefinition of prudence establish a separate sphere of morality (or lack thereof) for politics, it also introduces a language of contingency and exceptionalism, which becomes associated with the counsellor. In contrast with earlier writings on the topic, in this tradition the counsellor must mitigate not the tyranny of the prince, but of fortune.
The events of the Henrician Reformation served to put pressure on the problem of counsel and especially on its proposed timely solution. A second generation of English humanists took on this question, thinking more deeply about what the opportune moment was and how it related to the question of frank counsel. Thomas Starkey makes this issue central to his Dialogue Between Pole and Lupset, criticizing More’s approach, though he never resolves the problem fully. It is Thomas Elyot, in his works published in 1531 and 1533, who writes at length on the issue of right-timing and counsel, like Starkey coming to a critique of the ‘silence until kairos’ strategy espoused by Erasmus and More. These writers are also directly concerned with the relationship between counsel and command. In the context of the late 1520s and 1530s, theirs is a concern that counsel does not have enough authority over command, and that it will need to be supported or bolstered in some fashion to have its proper influence.