Instrumental variable methods to assess quality of care the marginal effects of process-of-care on blood pressure change and treatment costs

Background: Hypertension is poorly controlled. Team-based care and changes in the process of care have been proposed to address these quality problems. However, assessing care processes is difficult because they are often confounded even in randomized behavioral studies by unmeasured confounders based on discretion of health care providers. Objective: To evaluate the effects of process measures including number of counseling sessions about lifestyle modification and number of antihypertensive medications on blood pressure change and payer-perspective treatment costs. Methods: Data were obtained from two prospective, cluster randomized controlled clinical trials (Trial A and B) implementing physician-pharmacist collaborative interventions compared with usual care over six months in community-based medical offices in the Midwest. Multivariate linear regression models with both instrumental variable methods and as-treated methods were utilized. Instruments were indicators for trial and study arms. Models of blood pressure change and costs included both process measures, demographic variables, and clinical variables. Results: The analysis included 496 subjects. As-treated methods showed no significant associations between process and outcomes. The instruments used in the study were insufficient to simultaneously identify distinct process effects. However, the post-hoc instrumental variable models including one process measure at a time while controlling for the other process demonstrated significant associations between the processes and outcomes with estimates considerably larger than as-treated estimates. Conclusions: Instrumental variable methods with combined randomized behavioral studies may be useful to evaluate the effects of different care processes. However, substantial distinct process variation across studies is needed to fully capitalize on this approach. Instrumental variable methods focusing on individual processes provided larger and stronger outcome relationships than those found using as-treated methods which are subject to confounding

Responding to the needs of people who have learning disabilities and have been raped : co-prooduction in action

Purpose The paper discusses a project that explored why mainstream rape support services are still failing to meet the needs of women with learning disabilities. Principles of co-production and action learning enabled a group of women, including women with learning disabilities, to share knowledge and skills and develop easy-read information leaflets. Design/methodology/approach The project included representatives from a University, a Third sector Organisation and a Rape Crisis Centre. Action learning methods were used to bring together a broad range of experience and expertise. The project was co-led by a woman with a learning disability and a lecturer in social work with people with learning disabilities. Findings Three organisations had been toiling with a similar issue, that of responses to women with learning disabilities who had been raped. Each had previously examined the problem from their own perspective. An action learning process enabled them to explore the issues from a range of experiences, sharing knowledge and expertise and enabling them to begin to develop better service responses. Co-production of knowledge highlights competing priorities in and between organisations. It can also provide the means of managing these tensions. Social implications The project demonstrates the importance of co-production. By working together each organisation learned about the needs of the other. This resulted in shared understanding of the barriers experienced by women with learning disabilities who experience rape and of the challenges experienced by workers who aim to support them. This shared understanding enabled the Action Learning Set to develop bespoke training and literature. Originality value All of the participants shared the goal of developing more accessible services for women with learning disabilities who had experienced rape. The project included people with learning disabilities from inception. It was based on expressed need of a group of women with learning disabilities who had been raped and experienced other forms of domestic violence. The project demonstrates the importance of working with people with learning disabilities in order to develop services that truly meet their needs. Key words Learning disability, action-learning, easy -read information, domestic violence, co-production, organisational identity

GRB optical and IR rapid follow-up with the 2 m Liverpool Robotic Telescope

The Liverpool Telescope, owned and operated by Liverpool John Moores University and situated at Roque de los Muchachos, La Palma, is the first 2-m, fully instrumented robotic telescope. We plan to use the LT in conjunction with Gamma Ray Observatories (HETE-2, INTEGRAL, Swift) to study GRB physics. A special over-ride mode will enable observations commencing less than a minute after the GRB alert, including optical and near infrared imaging and spectroscopy. These observations, together with systematic monitoring of the burst through the afterglow, will help to unravel the nature of prompt optical flashes, short bursts, optically dark bursts, redshift distribution, GRB - supernova connection and other questions related to the GRB phenomenon. In particular, the combination of aperture, instrumentation and rapid automated response makes the Liverpool Telescope excellently suited to the investigation of optically dark bursts and currently optically unstudied short bursts

Appointing Women to Boards: Is There a Cultural Bias?

Companies that are serious about corporate governance and business ethics are turning their attention to gender diversity at the most senior levels of business (Institute of Business Ethics, Business Ethics Briefing 21:1, 2011). Board gender diversity has been the subject of several studies carried out by international organizations such as Catalyst (Increasing gender diversity on boards: Current index of formal approaches, 2012), the World Economic Forum (Hausmann et al., The global gender gap report, 2010), and the European Board Diversity Analysis (Is it getting easier to find women on European boards? 2010). They all lead to reports confirming the overall relatively low proportion of women on boards and the slow pace at which more women are being appointed. Furthermore, the proportion of women on corporate boards varies much across countries. Based on institutional theory, this study hypothesizes and tests whether this variation can be attributed to differences in cultural settings across countries. Our analysis of the representation of women on boards for 32 countries during 2010 reveals that two cultural characteristics are indeed associated with the observed differences. We use the cultural dimensions proposed by Hofstede (Culture’s consequences: International differences in work-related values, 1980) to measure this construct. Results show that countries which have the greatest tolerance for inequalities in the distribution of power and those that tend to value the role of men generally exhibit lower representations of women on boards

The Plasmodium falciparum, Nima-related kinase Pfnek-4: a marker for asexual parasites committed to sexual differentiation

<b>Background</b> Malaria parasites undergo, in the vertebrate host, a developmental switch from asexual replication to sexual differentiation leading to the formation of gametocytes, the only form able to survive in the mosquito vector. Regulation of the onset of the sexual phase remains largely unknown and represents an important gap in the understanding of the parasite's complex biology. <b>Methods:</b> The expression and function of the Nima-related kinase Pfnek-4 during the early sexual development of the human malaria parasite Plasmodium falciparum were investigated, using three types of transgenic Plasmodium falciparum 3D7 lines: (i) episomally expressing a Pfnek-4-GFP fusion protein under the control of its cognate pfnek-4 promoter; (ii) episomally expressing negative or positive selectable markers, yeast cytosine deaminase-uridyl phosphoribosyl transferase, or human dihydrofolate reductase, under the control of the pfnek-4 promoter; and (iii) lacking a functional pfnek-4 gene. Parasite transfectants were analysed by fluorescence microscopy and flow cytometry. In vitro growth rate and gametocyte formation were determined by Giemsa-stained blood smears. <b>Results:</b> The Pfnek-4-GFP protein was found to be expressed in stage II to V gametocytes and, unexpectedly, in a subset of asexual-stage parasites undergoing schizogony. Culture conditions stimulating gametocyte formation resulted in significant increase of this schizont subpopulation. Moreover, sorted asexual parasites expressing the Pfnek-4-GFP protein displayed elevated gametocyte formation when returned to in vitro culture in presence of fresh red blood cells, when compared to GFP- parasites from the same initial population. Negative selection of asexual parasites expressing pfnek-4 showed a marginal reduction in growth rate, whereas positive selection caused a marked reduction in parasitaemia, but was not sufficient to completely abolish proliferation. Pfnek-4- clones are not affected in their asexual growth and produced normal numbers of stage V gametocytes. <b>Conclusions:</b> The results indicate that Pfnek-4 is not strictly gametocyte-specific, and is expressed in a small subset of asexual parasites displaying high rate conversion to sexual development. Pfnek-4 is not required for erythrocytic schizogony and gametocytogenesis. This is the first study to report the use of a molecular marker for the sorting of sexually-committed schizont stage P. falciparum parasites, which opens the way to molecular characterization of this pre-differentiated subpopulation

Kerr-CFT From Black-Hole Thermodynamics

We analyze the near-horizon limit of a general black hole with two commuting killing vector fields in the limit of zero temperature. We use black hole thermodynamics methods to relate asymptotic charges of the complete spacetime to those obtained in the near-horizon limit. We then show that some diffeomorphisms do alter asymptotic charges of the full spacetime, even though they are defined in the near horizon limit and, therefore, count black hole states. We show that these conditions are essentially the same as considered in the Kerr/CFT corresponcence. From the algebra constructed from these diffeomorphisms, one can extract its central charge and then obtain the black hole entropy by use of Cardy's formula.Comment: 19 pages, JHEP3, no figures. V2: References added, small typos fixe

Experimental evaluation of beef breed utilization strategies

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GPs’ strategies in exploring the preschool child’s wellbeing in the paediatric consultation

Background: Although General Practitioners (GPs) are uniquely placed to identify children with emotional, social, and behavioural problems, they succeed in identifying only a small number of them. The aim of this article is to explore the strategies, methods, and tools employed by GPs in the assessment of the preschool child’s emotional, mental, social, and behavioural health. We look at how GPs address parental care of the child in general and in situations where GPs have a particular awareness of the child. Method: Twenty-eight Danish GPs were purposively selected to take part in a qualitative study which combined focus-group discussions, observation of child consultations, and individual interviews with GPs. Results: Analysis of the data suggests that GPs have developed a set of methods, and strategies to assess the preschool child and parental care of the child. They look beyond paying narrow attention to the physical health of the child and they have expanded their practice to include the relations and interactions in the consultation room. The physical examination of the child continues to play a central role in doctor-child communication. Conclusion: The participating GPs’ strategies helped them to assess the wellbeing of the preschool child but they often find it difficult to share their impressions with parents

Participant recruitment into a randomised controlled trial of exercise therapy for people with multiple sclerosis

The success of a clinical trial is often dependant on whether recruitment targets can be met in the required time frame. Despite an increase in research into the benefits of exercise in people with multiple sclerosis (PwMS), no trial has reported detailed data on effective recruitment strategies for large-scale randomised controlled trials. The main purpose of this report is to provide a detailed outline of recruitment strategies, rates and estimated costs in the Exercise Intervention for Multiple Sclerosis (ExIMS) trial to identify best practices for future trials involving multiple sclerosis (MS) patient recruitment