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This paper examines how care home managers in England conceptualised the approach to delivering personalised care in the homes they managed. We conducted interviews with care home managers and mapped the approaches they described on two distinct characterisations of personalised care prominent in the research and practitioner literature: the importance of close care relationships and the degree of resident choice and decision-making promoted by the care home. We derived three ‘types’ of personalised care in care homes. These conceptualise the care home as an ‘institution’, a ‘family’ and a ‘hotel’. We have added a fourth type, the ‘co-operative’, to propose a type that merges proximate care relationships with an emphasis on resident choice and decision-making. We conclude that each approach involves trade-offs and that the ‘family’ model may be more suitable for people with advanced dementia, given its emphasis on relationships. While the presence of a range of diverse approaches to personalising care in a care home market may be desirable as a matter of choice, access to care homes in England is likely to be constrained by availability and cost.
Competition and cooperation are the two fundamental mechanisms of service procurement in the NHS and represent the tools for ‘getting things done’. This chapter presents empirical findings from a longitudinal, qualitative case study research project into the use of competition and cooperation by local NHS commissioners following the HSCA 2012.
As outlined in Chapter 2, the economics of markets (and their opposite, hierarchies) in conjunction with more sophisticated theories of cooperation underpin the analysis of competition and cooperation in the NHS quasi-market. For a market to operate competitively, there needs to be sufficient numbers of buyers and sellers of goods and services. A key assumption is that purchasers have sufficient information about the goods or services to make rational choices and maximise their utility. The market will produce value for money by allocating resources to the best use at the most efficient price (Allen, 2013).
Competition in the NHS is realised through several models. Competition for the market is a result of tendering processes whereby different providers compete to deliver a particular service and one provider wins the whole market. Competition within the market exists when a number of providers are accredited to provide a particular service and they compete to attract patients. An example of the competition for the market is tendering out of community health services, and an example of competition within the market is the patient choice of elective secondary or community-based care.
In order to analyse cooperation the theory of ‘co-opetition’ and the work of Elinor Ostrom (2005) are utilised. Co-opetition suggests that organisations can compete and cooperate simultaneously to mutual benefit (Brandenburger and Nalebuff, 1996). Ostrom suggests that individuals can self-organise to solve collective problems, without direct control by the government, and can establish and enforce rules limiting the appropriation of common pool resources.
In terms of defining cooperation, there are a number of closely related terms such as collaboration, coordination, integrated care, networking and partnership. Integrated care implies the coordination of separate but interconnected components which should function together to perform a shared task (Kodner and Spreeuwenberg, 2002).
The main objective of “Lifebrain” is to identify the determinants of brain, cognitive and mental (BCM) health at different stages of life. By integrating, harmonising and enriching major European neuroimaging studies across the life span, we will merge fine-grained BCM health measures of more than 5000 individuals. Longitudinal brain imaging, genetic and health data are available for a major part, as well as cognitive and mental health measures for the broader cohorts, exceeding 27,000 examinations in total. By linking these data to other databases and biobanks, including birth registries, national and regional archives, and by enriching them with a new online data collection and novel measures, we will address the risk factors and protective factors of BCM health. We will identify pathways through which risk and protective factors work and their moderators. Exploiting existing European infrastructures and initiatives, we hope to make major conceptual, methodological and analytical contributions towards large integrative cohorts and their efficient exploitation. We will thus provide novel information on BCM health maintenance, as well as the onset and course of BCM disorders. This will lay a foundation for earlier diagnosis of brain disorders, aberrant development and decline of BCM health, and translate into future preventive and therapeutic strategies. Aiming to improve clinical practice and public health we will work with stakeholders and health authorities, and thus provide the evidence base for prevention and intervention.
Iron deficiency is common in pregnant and lactating women and is associated with reduced cognitive development of the offspring. Since iron affects lipid metabolism, the availability of fatty acids, particularly the polyunsaturated fatty acids required for early neural development, was investigated in the offspring of female rats fed iron-deficient diets during gestation and lactation. Subsequent to the dams giving birth, one group of iron-deficient dams was recuperated by feeding an iron-replete diet. Dams and neonates were killed on postnatal days 1, 3 and 10, and the fatty acid composition of brain and stomach contents was assessed by gas chromatography. Changes in the fatty acid profile on day 3 became more pronounced on day 10 with a decrease in the proportion of saturated fatty acids and a compensatory increase in monounsaturated fatty acids. Long-chain polyunsaturated fatty acids in the n-6 family were reduced, but there was no change in the n-3 family. The fatty acid profiles of neonatal brain and stomach contents were similar, suggesting that the change in milk composition may be related to the changes in the neonatal brain. When the dams were fed an iron-sufficient diet at birth, the effects of iron deficiency on the fatty acid composition of lipids in both dam’s milk and neonates’ brains were reduced. This study showed an interaction between maternal iron status and fatty acid composition of the offspring’s brain and suggests that these effects can be reduced by iron repletion of the dam’s diet at birth.
In 2012, the Government invited local councils in England to participate in a pilot programme to test direct payments in residential care. While the programme was set up to allow for comprehensive summative evaluation, the uptake of direct payments in residential care was substantially lower than anticipated, with only 40 people in receipt of one at the end of the programme. Drawing on qualitative data collected for the evaluation, this paper aims to understand better the barriers to implementing direct payments in residential care. Evidence from the use of direct payments in domiciliary care identified gatekeeping by council frontline staff as a major barrier for service users to access direct payments. Our findings suggest that, whilst selectivity of both service users and providers was an integral part of the programme design, gatekeeping does not fully explain the poor take-up. Other factors played a part, such as lack of clarity about the benefits of direct payments for care home residents, the limited range and scope of choice of services for residents, and concerns from care providers about the financial impact of direct payments on their financial sustainability.
Vitamin D deficiency is emerging worldwide and many studies now suggest its role in the development of several chronic diseases. Due to the low level of vitamin D naturally occurring in food there is a need for supplementation and use of vitamin D-enhanced products. The aim of the present study was to determine if daily consumption of vitamin D2-enhanced mushrooms increased vitamin D status in free-living healthy adults or affected markers of the metabolic syndrome. A total of ninety volunteers (aged 40–65 years) were randomly assigned to one of two 4-week studies: mushroom study (15 µg vitamin D2 or placebo mushroom powder) and capsule study (15 µg vitamin D3 or placebo capsules). Consumption of vitamin D2-enhanced mushrooms increased serum 25-hydroxyvitamin D2 (25(OH)D2) by 128 % from baseline (3·9 (sd 1·9) nmol/l; P < 0·05). Serum 25(OH)D3 increased significantly in the vitamin D3 capsule group (a 55 % increase from a baseline of 44.0 (sd 17·1) nmol/l; P < 0·05). Vitamin D status (25(OH)D) was affected only in the vitamin D3 group. Plasminogen activator inhibitor-1 was lowered by vitamin D2 intake. Vitamin D2 from enhanced mushrooms was bioavailable and increased serum 25(OH)D2 concentration with no significant effect on 25(OH)D3 or total 25(OH)D.
The cognitive profile of early onset Parkinson’s disease (EOPD) has not been clearly defined. Mutations in the parkin gene are the most common genetic risk factor for EOPD and may offer information about the neuropsychological pattern of performance in both symptomatic and asymptomatic mutation carriers. EOPD probands and their first-degree relatives who did not have Parkinson’s disease (PD) were genotyped for mutations in the parkin gene and administered a comprehensive neuropsychological battery. Performance was compared between EOPD probands with (N = 43) and without (N = 52) parkin mutations. The same neuropsychological battery was administered to 217 first-degree relatives to assess neuropsychological function in individuals who carry parkin mutations but do not have PD. No significant differences in neuropsychological test performance were found between parkin carrier and noncarrier probands. Performance also did not differ between EOPD noncarriers and carrier subgroups (i.e., heterozygotes, compound heterozygotes/homozygotes). Similarly, no differences were found among unaffected family members across genotypes. Mean neuropsychological test performance was within normal range in all probands and relatives. Carriers of parkin mutations, whether or not they have PD, do not perform differently on neuropsychological measures as compared to noncarriers. The cognitive functioning of parkin carriers over time warrants further study. (JINS, 2011, 17, 1–10)
Bioactive glass powder in the MgO-CaO-P2O5-SiO2 system was mixed with water to create a bioactive glass paste. The paste was then placed in 8 cavities in molars of Sinclair mini-pigs, isolated using a light-cure composite filling, and left in vivo for 4 weeks. Additionally, 4 controls were run where the bioactive glass was placed in an inert polymer substrate and then incubated at 37°C for 4 weeks. Specimens were cut longitudinally in two halves and prepared for chemical and x-ray analyses. Qualitative results showed that the paste in the molars stayed intact while there was little or no paste left in the polymer substrate after cutting. This observation suggested that the paste in the natural tissue had structural integrity which could be caused by chemical changes and/or mineralization encouraged by contact with dentinal tubule fluid. X-ray analysis did not reveal any crystallinity in the paste at 4 weeks, but chemical alterations were confirmed by electron microprobe analysis. The chemical inhomogeneity of the individual elemental maps revealed the formation of Ca-P-rich/Si-poor areas. These distinct chemical variations were not seen in chemical analyses run on the bioactive glass paste in its initial state.
Drying or curing of a coating after vitrification or gelation is accompanied by stress development. Evaporation of solvent, polymerization, cross-linking, and cooling all cause shrinkage, but adhesion of the coating to the substrate prevents shrinkage to a stress-free state. The interaction of shrinkage and restraint creates strain and stress. If the local stress grows above the local strength of the coating, it can produce cracking, delamination, or other defects.
A large deformation elastic model based on the Galerkin/finite element method is developed to analyze stress development in coatings subject to uniform shrinkage. The model is used to analyze effects of delamination and surface cracks. The strain energy release rates in both delamination and surface cracking are computed at different crack lengths. In both cases, results show that thicker coatings have larger energy release rates and are more vulnerable to cracking. A key conclusion of this modeling is that a crack can propagate only from an inherent flaw greater than a certain size. If the coating is thin enough so that the maximum energy release rate is less than the crack growth resistance, then no inherent flaws in the coating can grow into a crack, and so the coating remains crack-free. The model also shows how to calculate a critical coating thickness, i.e., the maximum thickness of a coating that can remain crack-free.
In an effort to determine the optimal balance of electrical and mechanical performance for electrically conductive polymer composites, three figures of merit were evaluated. All three figures of merit displayed peaks and/or discontinuities at a particular filler loading. These loadings appear to correspond to the critical pigment volume concentration for a given system. Composite systems based upon latex as the matrix starting material showed peaks in the figures of merit at very low carbon black concentrations (10 vol%), while composites prepared with polymer solutions or melts had peaks above 20 vol% carbon black. These differences in behavior are attributed to differences in microstructural evolution that occur with filler loading.
The results of modulus measurements, on carbon black-filled poly(N-vinylpyrrolidone), using dynamic mechanical analysis and nanoindentation were compared. It was shown that beyond the critical pigment volume concentration for this composite system (∼ 25 vol% carbon black), the storage modulus, obtained with dynamic mechanical analysis, decreased with increasing filler concentration. This dropping modulus was due to porosity that developed in the composite films when the critical pigment volume concentration had been exceeded. Elastic modulus obtained with nanoindentation showed the opposite trend, with modulus increasing with additional carbon black loading. An analysis of the method used to calculate modulus based upon indentation data was performed and a mechanism was proposed to explain the disparity between the moduli obtained using these two different methods of measurement.
The effect of carbon black content on the mechanical and electrical properties of carbon-black-filled poly(vinylpyrrolidone) composites was determined. Experimental data show a drop in modulus when the volume of carbon black exceeds 25%, coincident with pore formation documented by scanning electron microscopy. This behavior is consistent with surpassing the critical pigment volume concentration. Electrical conductivity, however, does not show a discontinuous change in behavior at 25 vol% carbon black and continues to increase through a carbon black loading of 35 vol%. A qualitative model of microstructural evolution is presented to explain the observed differences in electrical and mechanical behavior.
Atomic force microscopy (AFM) has been used to image the surface atomic structure of hydroxyapatite [Ca10(PO4)6 (OH)2], HA, and brushite [CaHPO4 · 2H2O], DCPD. Compared to HA, the surface of DCPD was found to be much less complex. Identification has been made of one crystal plane of DCPD that has atoms commensurate with those of one of the observed crystal planes of HA.