Understanding innovators' experiences of barriers and facilitators in implementation and diffusion of healthcare service innovations: A qualitative study

This article is made available through the Brunel Open Access Publishing Fund - Copyright @ 2011 Barnett et al.Background: Healthcare service innovations are considered to play a pivotal role in improving organisational efficiency and responding effectively to healthcare needs. Nevertheless, healthcare organisations encounter major difficulties in sustaining and diffusing innovations, especially those which concern the organisation and delivery of healthcare services. The purpose of the present study was to explore how healthcare innovators of process-based initiatives perceived and made sense of factors that either facilitated or obstructed the innovation implementation and diffusion. Methods: A qualitative study was designed. Fifteen primary and secondary healthcare organisations in the UK, which had received health service awards for successfully generating and implementing service innovations, were studied. In-depth, semi structured interviews were conducted with the organisational representatives who conceived and led the development process. The data were recorded, transcribed and thematically analysed. Results: Four main themes were identified in the analysis of the data: the role of evidence, the function of inter-organisational partnerships, the influence of human-based resources, and the impact of contextual factors. "Hard" evidence operated as a proof of effectiveness, a means of dissemination and a pre-requisite for the initiation of innovation. Inter-organisational partnerships and people-based resources, such as champions, were considered an integral part of the process of developing, establishing and diffusing the innovations. Finally, contextual influences, both intra-organisational and extra-organisational were seen as critical in either impeding or facilitating innovators' efforts. Conclusions: A range of factors of different combinations and co-occurrence were pointed out by the innovators as they were reflecting on their experiences of implementing, stabilising and diffusing novel service initiatives. Even though the innovations studied were of various contents and originated from diverse organisational contexts, innovators' accounts converged to the significant role of the evidential base of success, the inter-personal and inter-organisational networks, and the inner and outer context. The innovators, operating themselves as important champions and being often willing to lead constructive efforts of implementation to different contexts, can contribute to the promulgation and spread of the novelties significantly.This research was supported financially by the Multidisciplinary Assessment of Technology Centre for Healthcare (MATCH)

Marginalization of end-use technologies in energy innovation for climate protection

Mitigating climate change requires directed innovation efforts to develop and deploy energy technologies. Innovation activities are directed towards the outcome of climate protection by public institutions, policies and resources that in turn shape market behaviour. We analyse diverse indicators of activity throughout the innovation system to assess these efforts. We find efficient end-use technologies contribute large potential emission reductions and provide higher social returns on investment than energy-supply technologies. Yet public institutions, policies and financial resources pervasively privilege energy-supply technologies. Directed innovation efforts are strikingly misaligned with the needs of an emissions-constrained world. Significantly greater effort is needed to develop the full potential of efficient end-use technologies

Training Humans for the Human Domain

Experience from Afghanistan and Iraq has demonstrated the vital nature of understanding human terrain, with conclusions relevant far beyond counterinsurgency operations in the Islamic world. Any situation where adversary actions are described as “irrational” demonstrates a fundamental failure in understanding the human dimension of the conflict. It follows that where states and their leaders act in a manner which in the U.S. is perceived as irrational, this too betrays a lack of human knowledge. This monograph offers principles for operating in the human domain which can be extended to consideration of other actors which are adversarial to the United States, and whose decisionmaking calculus sits in a different framework to our own — including such major states as Russia and China. This monograph argues that the human dimension has become more, not less, important in recent conflicts and that for all the rise in technology future conflicts will be as much defined by the participants’ understanding of culture, behavior, and language as by mastery of technology.https://press.armywarcollege.edu/monographs/1434/thumbnail.jp

A Macroscope for Global History. Seshat Global History Databank: a methodological overview

This is a pre-copyedited, author-produced PDF of an article accepted for publication in Digital Humanities Quarterly following peer review. The final published version is available online at: http://www.digitalhumanities.org/dhq/vol/10/4/000272/000272.html This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 LicenseThis article introduces the ‘Seshat: Global History’ project, the methodology it is based upon and its potential as a tool for historians and other humanists. The article describes in detail how the Seshat methodology and platform can be used to tackle big questions that play out over long time scales whilst allowing users to drill down to the detail and place every single data point both in its historic and historiographical context. Seshat thus offers a platform underpinned by a rigorous methodology to actually do 'longue durée' history and the article argues for the need for humanists and social scientists to engage with data driven ‘longue durée' history. The article argues that Seshat offers a much needed infrastructure in which different skills sets and disciplines can come together to analyze the past using long timescales. In addition to highlighting the theoretical and methodological underpinnings, the potential of Seshat is demonstrated by showcasing three case studies. Each of these case studies is centred around a set of long standing questions and historiographical debates and it is argued that the introduction of a Seshat approach has the potential to radically alter our understanding of these questions.Peer reviewedFinal Accepted Versio

Biophysical Mechanisms of Early Heart Morphogenesis

The heart is the first functioning organ in the developing embryo. Initially, the heart is a relatively straight tube created by folding and fusion of the cardiogenic fields, which lie bilaterally within the blastoderm. Shortly after formation, the primitive heart tube (HT) undergoes the morphogenetic process of c-looping as it bends and twists into a c-shaped tube. All these transformations require physical forces, which remain poorly understood. The aim of this dissertation is to elucidate some of the biophysical mechanisms that create and shape the early HT. Our work involves a combination of ex ovo experiments and computational modeling. Experiments were performed on embryonic chicken hearts, which are morphologically similar to human hearts during development. First, we explored a somewhat puzzling aspect of early heart development. Previous studies have shown that myosin-II-based cytoskeletal contraction is required for fusion of the heart fields before looping begins, but not as these tissues continue to fuse and extend the length of the HT during subsequent c-looping. To investigate this fundamental change in behavior, we focused on the tissues around the anterior intestinal portal (AIP), where fusion takes place. Our results indicate that stiffness and tangential tension decreased bilaterally with distance from the embryonic midline along the AIP. The stiffness and tension gradients increased to peaks at Hamburger-Hamilton (HH) stage 9 and decreased immediately afterward. Along with experimental results of contraction inhibition, finite-element models indicate that the measured mechanical gradients are consistent with a relatively uniform contraction of the endoderm along the AIP. Taken together, these results suggest that, before looping begins at HH10, cytoskeletal contraction pulls the bilateral cardiogenic fields toward the midline where they begin to fuse to create the HT. By HH10, however, the fusion process is far enough along to enable apposing cardiac progenitor cells to subsequently undergo filopodia-mediated “zippering” without the continuing need for contraction. Next, in light of recently published data, we examined the possible role of differential hypertrophic growth in driving the bending component of c-looping. Using cultured isolated hearts, which bend without the complicating effects of external loads, we found that myocardial growth patterns correlate with bending. We also developed finite-element models that include previously measured regional changes in myocardial growth during c-looping. The simulations show that differential growth alone can produce results that agree reasonably well with trends in our experimental data, including changes in HT morphology and tissue strains and stresses. Incorporating other mechanisms into the model, such as active changes in myocardial cell shape, provides closer agreement. These results suggest that regional difference in hypertrophic myocardial growth is the primary cause of the bending component of c-looping, with other mechanisms playing lesser roles. Finally, we extended the model of the previous study to explore the physical plausibility of a hypothesis for the entire process of c-looping. According to our hypothesis, bending is driven primarily by differential hypertrophic growth in the myocardium, torsion is mainly caused by compressive loads exerted by the overlying splanchnopleuric membrane, and looping direction is determined by asymmetric regional growth in the omphalomesenteric veins at the caudal end of the HT. Our model includes both bending and torsion of the HT, realistic 3D geometry, and loads exerted by neighboring tissues. The behavior of the model is in reasonable agreement with available experimental data from control and mechanically perturbed embryos, offering support for our hypothesis. The results also suggest, however, that several other mechanisms contribute secondarily to normal looping, and we speculate that these mechanisms play backup roles when looping is perturbed. In summary, studies of this dissertation address several important questions during early cardiac development. The results should enrich our understanding of the underlying biophysical mechanisms

Diffusion-Augmented Depth Prediction with Sparse Annotations

Depth estimation aims to predict dense depth maps. In autonomous driving scenes, sparsity of annotations makes the task challenging. Supervised models produce concave objects due to insufficient structural information. They overfit to valid pixels and fail to restore spatial structures. Self-supervised methods are proposed for the problem. Their robustness is limited by pose estimation, leading to erroneous results in natural scenes. In this paper, we propose a supervised framework termed Diffusion-Augmented Depth Prediction (DADP). We leverage the structural characteristics of diffusion model to enforce depth structures of depth models in a plug-and-play manner. An object-guided integrality loss is also proposed to further enhance regional structure integrality by fetching objective information. We evaluate DADP on three driving benchmarks and achieve significant improvements in depth structures and robustness. Our work provides a new perspective on depth estimation with sparse annotations in autonomous driving scenes.Comment: Accepted by ACM MM'202

Uncovering the Role of Stress In Craniosynosostosis

Craniosynostosis is the premature fusion of one or more of the cranial sutures resulting in skull deformity and possible brain dysfunction. It occurs in roughly 1 in 2,000 live births.1 It may be associated with syndromes or occur sporadically. Any cranial suture may be involved. The descriptions of the skull dysmorphologies have led to numerous hypotheses regarding the developmental trajectory of the synostosed skull, including the role of the cranial vault and cranial base. As proposed originally by Virchow (1851),2 the shape of the skull in craniosynostosis is usually attributed to a lack of local growth perpendicular to the fused suture with compensatory growth occurring at adjacent patent sutures. This change in growth vectors is a variation on the highly coordinated adjustment required of the normally developing head. The reasons these growth vectors change may be directly related to changes in applied stress. However, the question still remains as to why the suture fuses prematurely. The cause of premature fusion of cranial sutures has been speculated to be either due to physical constraint (i.e. stress)3,4 or to genetic mutation.5-8 Although some genetic mutations have been identified in individuals with craniosynostosis, the role of these mutations in pathways regulating suture patency and/or skull growth has not been characterized. To date, only coronal suture craniosynostosis has been found to be associated with a specific genetic mutation. Even still screens of non-syndromic patients with coronal craniosynostosis have found varied expression of this mutation, P250R a fibroblast growth factor receptor (FGFR) 3.9-12 In fact, only 50% of isolated cases of coronal synostosis have been shown to carry the mutation.9-12 Current consensus is that the FGFR3 mutation causes a particular syndrome (Muenke syndrome) with variable expressivity and incomplete penetrance.11-12 As for the remaining majority of craniosynostosis cases no consensus exists. The influence of physical constraint, or stress, is currently poorly understood. Despite studies suggesting that in utero constraint leads to craniosynostosis,13,3,4 other studies concluded that constraint leads only to deformation of the skull while sutures remain patent.14,15 Thus, we have a very limited understanding of the relationship between physical stress to suture fusion. Genetic mutation and/or physical stress may play a role in causing premature suture fusion, but neither can affect the ontogenetic pathway of skull and sutures without having an impact on the entire craniofacial system. The osseous elements of the skull do not develop in isolation; rather the post-natal skull, brain, and dura mater develop in intimate physical and biochemical contact with one another. The precise nature of the interactions is unclear. Many studies have demonstrated that the presence of dura mater is necessary to maintain suture patency, and further, that the signal mediating suture fusion involves soluble factors, rather than biomechanical factors or cell-cell interactions.16-18 Additionally, studies have hypothesized that complex cell signaling from dura to osteogenic cell populations is responsible for patency of the suture.16-20 However, the biomechanical/biochemical mechanisms necessary for production of cranial vault phenotypes in craniosynostosis are not elucidated by these findings. A functional approach to the study of skull form was introduced by van der Klaauw (1948-1952)21 and expanded on by Moss and colleagues.22,23 In particular, Moss and Young (1960)22 presented a functional analysis to neurocranial growth, proposing that the size and shape of the cranial vault is determined by the form and orientation of the dura mater, which in turn is a direct reflection of the form of the brain. Citing Popa (1936),24 Moss and Young (1960)22 point out that the brain is encapsulated by the dura mater, which is firmly attached to the chondrocranium from its initiation. Since the dura mater and skull base are so firmly integrated at specific sites, a system of forces is produced by the growing brain, placing pressure against this capsule formed by the dura and skull tissues surrounding the brain. The dural folds produced by these attachments sites underlie the calvarial sutures and this relationship is proposed as playing a part in normal suture closure. Moss and Young (1960)22 suggested biomechanical forces produced by growth of the brain as the means of communication between adjacent tissues. The role of biomechanical forces in signaling diffusion of growth factors in communication among tissues has been supported experimentally,25-31 suggesting both biochemical and biomechanical influences on the craniofacial phenotype. Whatever the mechanism for communication we know that a change in the growth trajectory of one of these tissue units influences changes in the trajectory of the others. For example, mechanical forces acting on the external neurocranium, such as binding of immature heads32,33 or a habitual sleeping position,34,35 changes the shape of the endocranium and neural mass. In fact, Babler and Persing et al. demonstrated that suture fusion shortly after birth via application of adhesive to the sagittal suture of rabbits causes both deformation of the basicranial and facial dimensions.36 Likewise, changes in arrangement of dural attachment sites by way of cranial base deformation (experimentally or naturally produced) alter the shape of the outer skull and the neural mass.37,38 So, too changes in brain volume such as hydrocephalus, anencephaly, and microcephaly result in adjustments in neurocranial shape.39-42 In summary, one of the primary goals in the study of craniosynostosis is to determine the cause of premature suture fusion and its relationship to observed craniofacial dysmorphology. Beyond understanding the genetic mechanisms potentially underlying premature suture fusion, determination of the cause of craniosynostosis requires knowledge of the development of the entire craniofacial complex prior to, during, and following suture fusion. By the time children are diagnosed with craniosynostosis, the suture has already fused and the associated dysmorphology is well established. Thus, the data required to test directly hypotheses related to the cause of suture fusing is not available in humans and must be sought in animal models. Studies of human data are constrained to the more modest goal of acquiring a quantitative depiction of the phenotypes associated with suture fusion. Within this context, morphology and growth can be evaluated in individuals with craniosynostosis and the findings compared to perform clearer hypotheses to be tested in the appropriate animal models. In this report, a new in vitro model (Microdistractor) is defined (Chapter 3) wherein a linear stress can be applied to a system. Our data suggests the Microdistractor device as effective for studying the cellular response to distraction stresses. As such a murine suture is stressed in this system and the histologic and gene expression changes are noted (Chapter 1). The application of oscillatory stress to cranial sutures results in fusion of both the posterior frontal and the normally patent sagittal suture. However, distractile stress did not cause fusion. This later finding is a likely result of the existence of a range of acceptable stresses. Thus, the stress applied to the suture in distraction caused the two calvarial halves to undergo too great of separation for bony bridging to occur. Both stressed groups however, did demonstrate the same gene expression relative to control: significantly increased expression of the bone differentiation markers Runx2 and the late marker AP with nearly no expression of Noggin, a bone inhibitor. Thus, mechanical stress influenced the cells involved in sutural fusion and stimulated them to undergo osteogenic differentiation. These findings were then compared with an animal (rabbit) model that spontaneously develops craniosynostosis in utero (Chapter 2). Our results suggest that pathologic rabbit coronal sutures progress toward complete suture fusion in vitro. Furthermore, the expression patterns of Noggin, Runx-2, and AP for a fusing suture paralleled that of our stressed model (Chaper 1). Thus, Noggin expression was decreased and Runx-2 and AP were increased in craniosynostosis. Finally, pre-osteoblasts were biomechanically stressed within a collagen gel using the Microdistractor model (Chapter 4). Proliferative changes and genes of osteogenic differentiation were monitored. Cells undergoing linear distraction experienced rapid proliferation with a delayed expression of markers of osteogenic differentiation; whereas, cells undergoing oscillation had a rapid expression of osteogenic markers, but a cellular proliferation pattern indistinguishable from that of unstressed controls. These findings may help to explain the factors that occur in patients with craniosynostosis. For instance if a constant stress similar to distraction were to be applied a proliferative response would occur, when the stress is removed or oscillated the proliferated populations of cells may osteodifferentiate and lead to fusion. At the end of this series we conclude that stress induces the same gene expression patterns as craniosynostosis and the particular pattern of stress application is crucial in determining the cellular response

Is India Fit for a Role in Global Governance? The Predicament of Fragile Domestic Structures and Institutions

How do emerging powers cooperate at the global level? The government of India-one such power-has let it be known that it is seeking an enhanced role in global governance. Is Indian society ready for this new, global role? This paper analyses the impact of domestic factors on India's foreign-policy ambitions. It begins by examining the country's paradoxical social and economic development and the problems it faces in the realm of internal security. Section 2 looks at a number of socio-cultural and political factors that may help to explain India's new, globally oriented approach to foreign policy: 1. Indian society's capacity to merge tradition and modernity, resulting in the creation of resilient institutions; 2. the amorphous nature of Indian society and its distinctive capacity to exploit vagueness and improvisation in resolving problems; and 3. the competition and cooperation between political actors at national and federal level, which has resulted in the emergence of a functioning federal system but has also complicated centre-state relations. The paper concludes that, overall, the question of whether India's social structures and political institutions are robust enough to allow it to assume a global role is not one that can be answered unambivalently. The government has undertaken major reforms and the country's institutions are strong, resilient, adaptive, and keen on global cooperation. On the other hand, Indian society is still bedeviled by incoherent economic development in which phenomenal growth is found alongside appalling poverty and inequality

Independent Origins of New Sex-Linked Chromosomes in the melanica and robusta Species Groups of Drosophila

<p>Abstract</p> <p>Background</p> <p>Recent translocations of autosomal regions to the sex chromosomes represent important systems for identifying the evolutionary forces affecting convergent patterns of sex-chromosome heteromorphism. Additions to the sex chromosomes have been reported in the <it>melanica </it>and <it>robusta </it>species groups, two sister clades of <it>Drosophila</it>. The close relationship between these two species groups and the similarity of their rearranged karyotypes motivates this test of alternative hypotheses; the rearranged sex chromosomes in both groups are derived through a common origin, or the rearrangements are derived through at least two independent origins. Here we examine chromosomal arrangement in representatives of the <it>melanica </it>and the <it>robusta </it>species groups and test these alternative hypotheses using a phylogenetic approach.</p> <p>Results</p> <p>Two mitochondrial and two nuclear gene sequences were used to reconstruct phylogenetic relationships of a set of nine ingroup species having fused and unfused sex chromosomes and representing a broad sample of both species groups. Different methods of phylogenetic inference, coupled with concurrent cytogenetic analysis, indicate that the hypothesis of independent origins of rearranged sex chromosomes within each species group is significantly more likely than the alternative hypothesis of a single common origin. An estimate tightly constrained around 8 My was obtained for the age of the rearranged sex chromosomes in the <it>melanica </it>group; however, a more loosely constrained estimate of 10–15 My was obtained for the age of the rearrangement in the <it>robusta </it>group.</p> <p>Conclusion</p> <p>Independent acquisition of new chromosomal arms by the sex chromosomes in the <it>melanica </it>and <it>robusta </it>species groups represents a case of striking convergence at the karyotypic level. Our findings indicate that the parallel divergence experienced by newly sex-linked genomic regions in these groups represents an excellent system for studying the tempo of sex chromosome evolution.</p