Perspectives in measuring organisational performance in public Child and Adolescent Mental Health Services (CAMHS)

As part of the public health system in Australia and internationally, the Child and Adolescent Mental Health Services (CAMHS) setting is a small, specialised, and unique environment – sharing the developmental context of paediatric health and the clinical mental health service delivery domains with adult and aged person’s psychiatric services (Kelvin, 2005; Ford, 2007). CAMHS services are grappling with a set of expectations imposed by a stressed social welfare system to manage the sequelae of extreme trauma, challenging behaviour and the impact of family violence and trauma on children and adolescents in their care (Wolpert et al., 2014; Bor et al., 2014). CAMHS settings are subject to a pervasive set of expectations emerging from elected government regimes linked with the voting community regarding accountability, efficiency, and effectiveness. The rise of the transparency and accountability agenda within the public sector has been documented extensively (Armstrong, 2005; Gaventa & McGee, 2013; Van Belle & Mayhew, 2016). In such a paradigm, accountability is neatly and simplistically measured by the articulation of the task of the organisation and the application of metrics to assess performance against that task. The current study aimed to explore and better understand differences in assumptions, perceptions, and experiences of the organisation of public Child and Adolescent Mental Health Services (CAMHS). Further, the implications these differences have for clinical care, management, and leadership within the organisation itself but also for government in its performance-monitoring role of CAMHS services more broadly are also examined and described. The current study sought to highlight individual perspectives and experiences as they relate to measuring organisational performance beyond finance, activity, and outcomes towards sustainability, process, emotional climate, culture, and organisational dynamics. Thus, the current study aimed to critically review current frameworks for measuring organisational performance and, through analyses of theoretical constructs and qualitative methodologies, to explore experiences, processes, and meaning. A framework is then proposed for considering organisational performance in public CAMHS that takes account of these new meanings and proposes the measurement of organisational performance across a range of domains. The focus of interest was in what personal experience might convey about broader shared issues and themes at an organisational level, and the key data collection tool used was semi-structured in-depth interviews. To elicit data on personal experience, participants who were stakeholders of CAMHS as clients, families, referrers, clinicians, managers, policy leaders, and collaborative partners were the focus of sampling. The data was initially segmented and filtered across broad themes and then coded and gathered into more detailed categories. Themes emerged relating to the expectations and impressions of CAMHS, the clients themselves and their stories of complexity and trauma, the experience of CAMHS clinicians, barriers to accessing services, the experience of services provided once ‘in’ the system, issues related to the interface between CAMHS and other services and stakeholders, and impressions on what factors might make a ‘good’ CAMHS. Overall, the findings underlined the view that CAMHS services should take an integrated multi-theoretical perspective, support wisdom in leadership, be accessible, and have sophisticated collaborative capacity. Furthermore a theme of shared power in decision making across a team including children, young people and their families, and other services emerged. Overall the findings are indicative of the fact that a performance framework that adequately addresses these complexities works against the risk that authenticity is lost when measures of organisational performance are reduced to one or two examples. Recommendations for a performance framework for CAMHS are proposed. This includes a robust synthesis of the policy environment, a developmental lens across infant, child, adolescent and youth age groups, a clear definition of the primary task for CAMHS along with an understanding of the target client group, directly addressing the broadly conflicted interface between CAMHS and child protection services, attending to the organisational climate within CAMHS, and defining appropriate accountability measures. Future research must focus on defining the target group for CAMHS, the best and most efficacious treatment models and clients experience of care. It is further recommended that future research explore models for understanding and leading or managing the unique organisational climate in CAMHS settings and particularly on the roles of clinical staff and leaders in the CAMHS settings. A particular area of focus should be in relation to the inherent stress of working in this setting, noting that this is not seen as weakness or poor performance, but rather as a a natural consequence of engagement in the task. A key strength of the current study was that it sought to highlight individual perspectives and experiences as they related to measuring organisational performance and to explicitly place the roles and perspective of the researcher into this frame. The focus of interest was in what personal experience might convey about broader shared issues and themes at an organisational level. In terms of limitations, the most significant was the fact that no child informants could be sourced, and that the time frame and design limited the number of participants and therefore possible perspectives. The qualitative research design did not use a mixed methods model to confirm findings and the generalizability is thought to be limited. The narrow theoretical lens for the research may be also considered a limitation (Chowdery, 2017). However, the theoretical model was chosen carefully as a sound platform on which to consider the complex issues presented from an organisational perspective. In summary, the thesis seeks to make recommendations for a performance framework for CAMHS, and in doing so the author has sought to draw together the key elements emerging from the findings supported by the research community. If the comprehensive network of elements identified in the current thesis were all adequately addressed, it would have the potential to reliably bind public child and adolescent mental health services with a unique clarity of purpose in a community of care for children, adolescents, and their families

Adoptive T-cell immunotherapy for ganciclovir-resistant CMV disease after lung transplantation

Infections with cytomegalovirus (CMV) can induce severe complications after solid organ transplantation (SOT). The prognosis for ganciclovir-resistant CMV infection and disease is particularly poor. Whereas adoptive transfer of CMV-specific T cells has emerged as a powerful tool in hematopoietic stem cell transplant patients, its translation into the SOT setting remains a significant challenge as underlying immunosuppression inhibits the virus-specific T-cell response in vivo. Here, we demonstrate successful expansion and adoptive transfer of autologous CMV-specific T cells from a seronegative recipient of a seropositive lung allograft with ganciclovir-resistant CMV disease, resulting in the long-term reconstitution of protective anti-viral immunity, CMV infection, disease-free survival and no allograft rejection.Chien-Li Holmes-Liew, Mark Holmes, Leone Beagley, Peter Hopkins, Daniel Chambers Corey Smith and Rajiv Khann

Pre-emptive and therapeutic adoptive immunotherapy for nasopharyngeal carcinoma: Phenotype and effector function of T cells impact on clinical response

published_or_final_versio

Gas-phase structures of sterically crowded disilanes studied by electron diffraction and quantum chemical methods : 1,1,2,2-tetrakis(trimethylsilyl) disilane and 1,1,2,2-tetrakis(trimethylsilyl)dimethyldisilane

The gas-phase structures of the disilanes 1,1,2,2-tetrakis(trimethylsilyl) disilane [(Me3Si)2HSiSiH(SiMe3)2] (1) and 1,1,2,2-tetrakis(trimethylsilyl)dimethyldisilane [(Me 3Si)2MeSiSiMe(SiMe3)2] (2) have been determined by density functional theoretical calculations and by gas electron diffraction (GED) employing the SARACEN method. For each of 1 and 2 DFT calculations revealed four C2-symmetric conformers occupying minima on the respective potential-energy surfaces; three conformers were estimated to be present in sufficient quantities to be taken into account when fitting the GED data. For (Me3Si)2RSiSiR(SiMe3)2 [R = H (1), CH3 (2)] the lowest energy conformers were found by GED to have RSiSiR dihedral angles of 87.7(17)° for 1 and -47.0(6)° for 2. For each of 1 and 2 the presence of bulky and flexible trimethylsilyl groups dictates many aspects of the geometric structures in the gas phase, with the molecules often adopting structures that reduce steric strain

Structures of tetrasilylmethane derivatives (XMe2Si)2C(SiMe3)2 (X = H, Cl, Br) in the gas phase, and their dynamic structures in solution

The structures of the molecules (XMe2Si)2C(SiMe3)2, where X = H, Cl, Br, have been determined by gas electron diffraction (GED) using the SARACEN method of restraints, with all analogues existing in the gas phase as mixtures of C1- and C2-symmetric conformers. Variable temperature 1H and 29Si solution-phase NMR studies, as well as 13C NMR and 1H/29Si NMR shift correlation and 1H NMR saturation transfer experiments for the chlorine and bromine analogues, are reported. At low temperatures in solution there appear to be two C1 conformers and two C2 conformers, agreeing with the isolated-molecule calculations used to guide the electron diffraction refinements. For (HMe2Si)2C(SiMe3)2 the calculations indicated six conformers close in energy, and these were modeled in the GED refinement

TLR2, but Not TLR4, Is Required for Effective Host Defence against Chlamydia Respiratory Tract Infection in Early Life

Chlamydia pneumoniae commonly causes respiratory tract infections in children, and epidemiological investigations strongly link infection to the pathogenesis of asthma. The immune system in early life is immature and may not respond appropriately to pathogens. Toll-like receptor (TLR)2 and 4 are regarded as the primary pattern recognition receptors that sense bacteria, however their contribution to innate and adaptive immunity in early life remains poorly defined. We investigated the role of TLR2 and 4 in the induction of immune responses to Chlamydia muridarum respiratory infection, in neonatal wild-type (Wt) or TLR2-deficient (−/−), 4−/− or 2/4−/− BALB/c mice. Wt mice had moderate disease and infection. TLR2−/− mice had more severe disease and more intense and prolonged infection compared to other groups. TLR4−/− mice were asymptomatic. TLR2/4−/− mice had severe early disease and persistent infection, which resolved thereafter consistent with the absence of symptoms in TLR4−/− mice. Wt mice mounted robust innate and adaptive responses with an influx of natural killer (NK) cells, neutrophils, myeloid (mDCs) and plasmacytoid (pDCs) dendritic cells, and activated CD4+ and CD8+ T-cells into the lungs. Wt mice also had effective production of interferon (IFN)γ in the lymph nodes and lung, and proliferation of lymph node T-cells. TLR2−/− mice had more intense and persistent innate (particularly neutrophil) and adaptive cell responses and IL-17 expression in the lung, however IFNγ responses and T-cell proliferation were reduced. TLR2/4−/− mice had reduced innate and adaptive responses. Most importantly, neutrophil phagocytosis was impaired in the absence of TLR2. Thus, TLR2 expression, particularly on neutrophils, is required for effective control of Chlamydia respiratory infection in early life. Loss of control of infection leads to enhanced but ineffective TLR4-mediated inflammatory responses that prolong disease symptoms. This indicates that TLR2 agonists may be beneficial in the treatment of early life Chlamydia infections and associated diseases

The Coupled Model Intercomparison Project (CMIP)

The Coupled Model Intercomparison Project (CMIP) was established to study and intercompare climate simulations made with coupled ocean-atmosphere-cryosphere-land GCMs. There are two main phases (CMIP1 and CMIP2), which study, respectively, 1) the ability of models to simulate current climate, and 2) model simulations of climate change due to an idealized change in forcing (a 1% per year CO2 increase). Results from a number of CMIP projects were reported at the first CMIP Workshop held in Melbourne, Australia, in October 1998. Some recent advances in global coupled modeling related to CMIP were also reported. Presentations were based on preliminary unpublished results. Key outcomes from the workshop were that 1) many observed aspects of climate variability are simulated in global coupled models including the North Atlantic oscillation and its linkages to North Atlantic SSTs, El Niño-like events, and monsoon interannual variability; 2) the amplitude of both high- and low-frequency global mean surface temperature variability in many global coupled models is less than that observed, with the former due in part to simulated ENSO in the models being generally weaker than observed, and the latter likely to be at least partially due to the uncertainty in the estimates of past radiative forcing; 3) an El Niño-like pattern in the mean SST response with greater surface warming in the eastern equatorial Pacific than the western equatorial Pacific is found by a number of models in global warming climate change experiments, but other models have a more spatially uniform or even a La Niña-like, response; 4) flux adjustment, by definition, improves the simulation of mean present-day climate over oceans, does not guarantee a drift-free climate, but can produce a stable base state in some models to enable very long term (1000 yr and longer) integrations-in these models it does not appear to have a major effect on model processes or model responses to increasing CO2; and 5) recent multicentury integrations show that a stable surface climate can be attained without flux adjustment (though still with some systematic simulation errors)

Group II Introns Break New Boundaries: Presence in a Bilaterian's Genome

Group II introns are ribozymes, removing themselves from their primary transcripts, as well as mobile genetic elements, transposing via an RNA intermediate, and are thought to be the ancestors of spliceosomal introns. Although common in bacteria and most eukaryotic organelles, they have never been reported in any bilaterian animal genome, organellar or nuclear. Here we report the first group II intron found in the mitochondrial genome of a bilaterian worm. This location is especially surprising, since animal mitochondrial genomes are generally distinct from those of plants, fungi, and protists by being small and compact, and so are viewed as being highly streamlined, perhaps as a result of strong selective pressures for fast replication while establishing germ plasm during early development. This intron is found in the mtDNA of an annelid worm, (an undescribed species of Nephtys), where the complete sequence revealed a 1819 bp group II intron inside the cox1 gene. We infer that this intron is the result of a recent horizontal gene transfer event from a viral or bacterial vector into the mitochondrial genome of Nephtys sp. Our findings hold implications for understanding mechanisms, constraints, and selective pressures that account for patterns of animal mitochondrial genome evolutio

Assessing the impact of shipping emissions on air pollution in the Canadian Arctic and northern regions: current and future modelled scenarios

A first regional assessment of the impact of shipping emissions on air pollution in the Canadian Arctic and northern regions was conducted in this study. Model simulations were carried out on a limited-area domain (at 15&thinsp;km horizontal resolution) centred over the Canadian Arctic, using the Environment and Climate Change Canada's on-line air quality forecast model, GEM-MACH (Global Environmental Multi-scale – Modelling Air quality and CHemistry), to investigate the contribution from the marine shipping emissions over the Canadian Arctic waters (at both present and projected future levels) to ambient concentrations of criteria pollutants (O3, PM2.5, NO2, and SO2), atmospheric deposition of sulfur (S) and nitrogen (N), and atmospheric loading and deposition of black carbon (BC) in the Arctic. Several model upgrades were introduced for this study, including the treatment of sea ice in the dry deposition parameterization, chemical lateral boundary conditions, and the inclusion of North American wildfire emissions. The model is shown to have similar skills in predicting ambient O3 and PM2.5 concentrations in the Canadian Arctic and northern regions, as the current operational air quality forecast models in North America and Europe. In particular, the model is able to simulate the observed O3 and PM components well at the Canadian high Arctic site, Alert. The model assessment shows that, at the current (2010) level, Arctic shipping emissions contribute to less than 1&thinsp;% of ambient O3 concentration over the eastern Canadian Arctic and between 1 and 5&thinsp;% of ambient PM2.5 concentration over the shipping channels. Arctic shipping emissions make a much greater contributions to the ambient NO2 and SO2 concentrations, at 10&thinsp;%–50&thinsp;% and 20&thinsp;%–100&thinsp;%, respectively. At the projected 2030 business-as-usual (BAU) level, the impact of Arctic shipping emissions is predicted to increase to up to 5&thinsp;% in ambient O3 concentration over a broad region of the Canadian Arctic and to 5&thinsp;%–20&thinsp;% in ambient PM2.5 concentration over the shipping channels. In contrast, if emission controls such as the ones implemented in the current North American Emission Control Area (NA ECA) are to be put in place over the Canadian Arctic waters, the impact of shipping to ambient criteria pollutants would be significantly reduced. For example, with NA-ECA-like controls, the shipping contributions to the population-weighted concentrations of SO2 and PM2.5 would be brought down to below the current level. The contribution of Canadian Arctic shipping to the atmospheric deposition of sulfur and nitrogen is small at the current level, &lt;&thinsp;5&thinsp;%, but is expected to increase to up to 20&thinsp;% for sulfur and 50&thinsp;% for nitrogen under the 2030 BAU scenario. At the current level, Canadian Arctic shipping also makes only small contributions to BC column loading and BC deposition, with &lt;&thinsp;0.1&thinsp;% on average and up to 2&thinsp;% locally over the eastern Canadian Arctic for the former, and between 0.1&thinsp;% and 0.5&thinsp;% over the shipping channels for the latter. The impacts are again predicted to increase at the projected 2030 BAU level, particularly over the Baffin Island and Baffin Bay area in response to the projected increase in ship traffic there, e.g., up to 15&thinsp;% on BC column loading and locally exceeding 30&thinsp;% on BC deposition. Overall, the study indicates that shipping-induced changes in atmospheric composition and deposition are at regional to local scales (particularly in the Arctic). Climate feedbacks are thus likely to act at these scales, so climate impact assessments will require modelling undertaken at much finer resolutions than those used in the existing radiative forcing and climate impact assessments.</p