A mixed methods study of change processes enabling effective transition to team-based care

Team-based care is considered central to achieving value in primary care, yet results of large-scale primary care transformation initiatives have been mixed. We explore how underlying change processes influence the effectiveness of transition to team-based care. We studied 12 academically-affiliated primary care practices participating in a learning collaborative, using longitudinal staff survey data to measure progress toward team-based care and qualitative interviews with practice staff to understand practice transformation. Transformation efforts focused on team formation and capacity building for quality improvement. Using thematic analysis, we explored types of change processes undertaken and the relationship between change processes and effective team-based care. We identified three prototypical approaches to change: pursuing functional and cultural change processes, functional only, and cultural only. Practice sites prioritizing both change processes formed the most effective teams: simultaneous functional and cultural change spurred a mutually-reinforcing virtuous cycle. We describe implications for research, practice and policyThis research was supported by a grant from the Harvard Medical School Center for Primary Care and CRICO [362121]. MAK was supported by a Harvard Business School doctoral fellowship. ELA was supported by funding from a Wellcome Trust Senior Investigator Award [WT097899M]

Too Many Kates

The poems in this collection were written for the most part during the last two years of the Masters of Fine Arts program at the University of Maryland. They are arranged in five parts to signal the multiplicity of the "many Kates," with a longer poem, a six part elegy, as the collection's center. The elegy as well as many other poems in this collection attempt to think about the problem of autobiography as the emotional and narrative source of poems. Accordingly, the speakers in these poems often manufacture voicesmasksthat subtend or ironize the very experiences they narrate. Similarly, the poems attempt to mix high and low culture. This thesis represents a deepening of poems that rely heavily on voice, wit, narrative and whimsy with an attention to formal control, lyricism and emotional risk

Functional magnetic resonance imaging (fMRI) item analysis of empathy and theory of mind

In contrast to conventional functional magnetic resonance imaging (fMRI) analysis across participants, item analysis allows generalizing the observed neural response patterns from a specific stimulus set to the entire population of stimuli. In the present study, we perform an item analysis on an fMRI paradigm (EmpaToM) that measures the neural correlates of empathy and Theory of Mind (ToM). The task includes a large stimulus set (240 emotional vs. neutral videos to probe empathic responding and 240 ToM or factual reasoning questions to probe ToM), which we tested in two large participant samples (N = 178, N = 130). Both, the empathy-related network comprising anterior insula, anterior cingulate/dorsomedial prefrontal cortex, inferior frontal gyrus, and dorsal temporoparietal junction/supramarginal gyrus (TPJ) and the ToM related network including ventral TPJ, superior temporal gyrus, temporal poles, and anterior and posterior midline regions, were observed across participants and items. Regression analyses confirmed that these activations are predicted by the empathy or ToM condition of the stimuli, but not by low-level features such as video length, number of words, syllables or syntactic complexity. The item analysis also allowed for the selection of the most effective items to create optimized stimulus sets that provide the most stable and reproducible results. Finally, reproducibility was shown in the replication of all analyses in the second participant sample. The data demonstrate (a) the generalizability of empathy and ToM related neural activity and (b) the reproducibility of the EmpaToM task and its applicability in intervention and clinical imaging studies. © 2020 The Authors. Human Brain Mapping published by Wiley Periodicals, Inc

Palliative Care in Africa and the Caribbean

In many of the world's poorest countries, dying is often accompanied by avoidable pain and other distressing symptoms. How can we improve care at the end of life

Is it safe to go back into the water? A systematic review and meta-analysis of the risk of acquiring infections from recreational exposure to seawater

Background: Numerous illnesses are associated with bathing in natural waters, although it is assumed that the risk of illness among bathers exposed to relatively clean waters found in high-income countries is negligible. A systematic review was carried out to quantify the increased risk of experiencing a range of adverse health outcomes among bathers exposed to coastal water compared with non-bathers. Methods: In all 6919 potentially relevant titles and abstracts were screened, and from these 40 studies were eligible for inclusion in the review. Odds ratios (OR) were extracted from 19 of these reports and combined in random-effect meta-analyses for the following adverse health outcomes: incident cases of any illness, ear infections, gastrointestinal illness and infections caused by specific microorganisms. Results: There is an increased risk of experiencing symptoms of any illness [OR = 1.86, 95% confidence interval (CI): 1.31 to 2.64, P = 0.001] and ear ailments (OR = 2.05, 95% CI: 1.49 to 2.82, P < 0.001) in bathers compared with non-bathers. There is also an increased risk of experiencing gastrointestinal ailments (OR = 1.29, 95% CI: 1.12 to 1.49, P < 0.001). Conclusions: This is the first systematic review to evaluate evidence on the increased risk of acquiring illnesses from bathing in seawater compared with non-bathers. Our results support the notion that infections are acquired from bathing in coastal waters, and that bathers have a greater risk of experiencing a variety of illnesses compared with non-bathers

Association of metabolic syndrome and change in Unified Parkinson\u27s Disease Rating Scale scores.

OBJECTIVE: To explore the association between metabolic syndrome and the Unified Parkinson\u27s Disease Rating Scale (UPDRS) scores and, secondarily, the Symbol Digit Modalities Test (SDMT). METHODS: This is a secondary analysis of data from 1,022 of 1,741 participants of the National Institute of Neurological Disorders and Stroke Exploratory Clinical Trials in Parkinson Disease Long-Term Study 1, a randomized, placebo-controlled trial of creatine. Participants were categorized as having or not having metabolic syndrome on the basis of modified criteria from the National Cholesterol Education Program Adult Treatment Panel III. Those who had the same metabolic syndrome status at consecutive annual visits were included. The change in UPDRS and SDMT scores from randomization to 3 years was compared in participants with and without metabolic syndrome. RESULTS: Participants with metabolic syndrome (n = 396) compared to those without (n = 626) were older (mean [SD] 63.9 [8.1] vs 59.9 [9.4] years; p \u3c 0.0001), were more likely to be male (75.3% vs 57.0%; p \u3c 0.0001), and had a higher mean uric acid level (men 5.7 [1.3] vs 5.3 [1.1] mg/dL, women 4.9 [1.3] vs 3.9 [0.9] mg/dL, p \u3c 0.0001). Participants with metabolic syndrome experienced an additional 0.6- (0.2) unit annual increase in total UPDRS (p = 0.02) and 0.5- (0.2) unit increase in motor UPDRS (p = 0.01) scores compared with participants without metabolic syndrome. There was no difference in the change in SDMT scores. CONCLUSIONS: Persons with Parkinson disease meeting modified criteria for metabolic syndrome experienced a greater increase in total UPDRS scores over time, mainly as a result of increases in motor scores, compared to those who did not. Further studies are needed to confirm this finding. CLINICALTRIALSGOV IDENTIFIER: NCT00449865

Patient-Reported Satisfaction and Study Drug Discontinuation: Post-Hoc Analysis of Findings from ROCKET AF.

IntroductionPatient-reported outcomes (PROs) and satisfaction endpoints are increasingly important in clinical trials and may be associated with treatment adherence. In this post hoc substudy from ROCKET AF, we examined whether patient-reported satisfaction was associated with study drug discontinuation.MethodsROCKET AF (n = 14,264) compared rivaroxaban with warfarin for prevention of stroke and systemic embolism in patients with atrial fibrillation. We analyzed treatment satisfaction scores: the Anti-Clot Treatment Scale (ACTS) and Treatment Satisfaction Questionnaire for Medication version II (TSQM II). We compared satisfaction with study drug between the two treatment arms, and examined the association between satisfaction and patient-driven study drug discontinuation (stopping study drug due to withdrawal of consent, noncompliance, or loss to follow-up).ResultsA total of 1577 (11%) patients participated in the Patient Satisfaction substudy; 1181 (8.3%) completed both the ACTS and TSQM II 4 weeks after starting study drug. Patients receiving rivaroxaban did not experience significant differences in satisfaction compared with those receiving warfarin. During a median follow-up of 1.6 years, 448 premature study drug discontinuations occurred (213 rivaroxaban group; 235 warfarin group), of which 116 (26%) were patient-driven (52 [24%] rivaroxaban group; 64 [27%] warfarin group). No significant differences were observed between satisfaction level and rates of patient-driven study drug discontinuation.ConclusionsStudy drug satisfaction did not predict rate of study drug discontinuation. No significant difference was observed between satisfaction with warfarin and rivaroxaban, as expected given the double-blind trial design. Although these results are negative, the importance of PRO data will only increase, and these analyses may inform future studies that explore the relationship between drug-satisfaction PROs, adherence, and clinical outcomes. CLINICALTRIALS.GOV: NCT00403767.FundingThe ROCKET AF trial was funded by Johnson &amp; Johnson and Bayer

Photometry of Kuiper belt object (486958) Arrokoth from New Horizons LORRI

On January 1st 2019, the New Horizons spacecraft flew by the classical Kuiper belt object (486958) Arrokoth (provisionally designated 2014 MU69), possibly the most primitive object ever explored by a spacecraft. The I/F of Arrokoth is analyzed and fit with a photometric function that is a linear combination of the Lommel-Seeliger (lunar) and Lambert photometric functions. Arrokoth has a geometric albedo of p_v = 0.21_(−0.04)^(+0.05) at a wavelength of 550 nm and ≈0.24 at 610 nm. Arrokoth's geometric albedo is greater than the median but consistent with a distribution of cold classical Kuiper belt objects whose geometric albedos were determined by fitting a thermal model to radiometric observations. Thus, Arrokoth's geometric albedo adds to the orbital and spectral evidence that it is a cold classical Kuiper belt object. Maps of the normal reflectance and hemispherical albedo of Arrokoth are presented. The normal reflectance of Arrokoth's surface varies with location, ranging from ≈0.10–0.40 at 610 nm with an approximately Gaussian distribution. Both Arrokoth's extrema dark and extrema bright surfaces are correlated to topographic depressions. Arrokoth has a bilobate shape and the two lobes have similar normal reflectance distributions: both are approximately Gaussian, peak at ≈0.25 at 610 nm, and range from ≈0.10–0.40, which is consistent with co-formation and co-evolution of the two lobes. The hemispherical albedo of Arrokoth varies substantially with both incidence angle and location, the average hemispherical albedo at 610 nm is 0.063 ± 0.015. The Bond albedo of Arrokoth at 610 nm is 0.062 ± 0.015