PROJECTING THE IMPACT OF DEMOGRAPHIC CHANGE ON THE DEMAND FOR AND DELIVERY OF HEALTH CARE IN IRELAND. RESEARCH SERIES NUMBER 13 OCTOBER 2009

Primary care is often the first point of contact with the health care system for people requiring care. Primary care is often thought synonymous with general practitioners, but actually encompasses a large range of different professionals and services including nurses/midwives; physiotherapists; occupational therapists; dentists; opticians; chiropodists; psychologists and pharmacists. The list is not exhaustive, but still gives an indication of the wide range of services that can be grouped under the general heading of primary care. Nonetheless, GPs do have a core part to play in primary care as well as performing the role of ‘gate keeper’ to other health services such as accident and emergency or outpatient care in hospitals. The balance of treatment and referral between general practice and secondary care is, therefore, a very important issue and it has been argued that the under development of primary care services in Ireland in recent decades has contributed, and indeed, may be the most important reason, for the over-crowding of accident and emergency services and long waiting lists for elective procedures in Irish health care (Layte et al., 2007b; Tussing and Wren, 2006)

Connective auxin transport contributes to strigolactone-mediated shoot branching control independent of the transcription factor BRC1

The shoot systems of plants are built by the action of the primary shoot apical meristem, established during embryogenesis. In the axil of each leaf produced by the primary meristem, secondary axillary shoot apical meristems are established. The dynamic regulation of the activity of these axillary meristems gives shoot systems their extraordinary plasticity of form. The ability of plants to activate or repress these axillary meristems appropriately requires communication between meristems that is environmentally sensitive. The transport network of the plant hormone auxin has long been implicated as a central player in this tuneable communication system, with other systemically mobile hormones, such as strigolactone and cytokinin, acting in part by modulating auxin transport. Until recently, the polar auxin transport stream, which provides a high conductance auxin transport route down stems dominated by the auxin export protein PIN-FORMED1 (PIN1), has been the focus for understanding long range auxin transport in the shoot. However, recently additional auxin exporters with important roles in the shoot have been identified, including PIN3, PIN4 and PIN7. These proteins contribute to a wider less polar stem auxin transport regime, which we have termed connective auxin transport (CAT), because of its role in communication across the shoot system. Here we present a genetic analysis of the role of CAT in shoot branching. We demonstrate that in Arabidopsis, CAT plays an important role in strigolactone-mediated shoot branching control, with the triple pin3pin4pin7 mutant able to suppress partially the highly branched phenotype of strigolactone deficient mutants. In contrast, the branchy phenotype of mutants lacking the axillary meristem-expressed transcription factor, BRANCHED1 (BRC1) is unaffected by pin3pin4pin7. We further demonstrate that mutation in the ABCB19 auxin export protein, which like PIN3 PIN4 and PIN7 is widely expressed in stems, has very different effects, implicating ABCB19 in auxin loading at axillary bud apices.Gatsby Charitable Foundatio

The Impact of Games on Wellbeing in Autism

This thesis begins with a systematic literature review exploring the experiences of autistic individuals who engage in multiplayer online gaming. A systematic search of the literature identified 11 papers for inclusion. The papers identified were analysed and synthesised using a meta-ethnographic approach. Four themes emerged from the analysis: 1) Relationships in multiplayer online games are built through a platform of opportunity, 2) Multiplayer online games are a platform to practise and develop communication skills with reduced barriers, 3) Emotional recognition, regulation and expression is facilitated through multiplayer online games, and 4) A sense of belonging and self-esteem contributes to increased wellbeing. The review highlighted that multiplayer online games provide opportunities for players to interact in a way that feels less pressured than the face-to-face world. Additionally, players learn skills that contribute to increased self-esteem and improved wellbeing. It is hoped that findings from this review could be used to help psychologists to think about how they can adapt their work to be more suitable for autistic individuals. The research paper explores the impact of table-top board games on wellbeing and functioning in autistic adults. Ten autistic adults volunteered to participate in semi-structured interviews. Verbatim interview transcripts were analysed following the principles of Grounded Theory. Results identified three main themes: the cycle of board game engagement, impact on aspects of autism, impact on wellbeing and functioning. Content of these themes interacted in a variety of ways, represented in a theoretical model. Limitations for the research, along with areas for future research and clinical implications, have been considered. The critical appraisal section of this work pulls together the two pieces of work and discuss how they are related. The processes of qualitative research have also been discussed, along with personal reflections. Future directions for the work have been identified

The relationship between pain, analgesics and survival in patients with advanced cancer; a secondary data analysis of the international European palliative care Cancer symptom study.

Purpose: Opioids reduce cancer-related pain but an association with shorter survival is variably reported. Aim: To investigate the relationship between pain, analgesics, cancer and survival within the European Palliative Care Cancer Symptom (EPCCS) study to help inform clinical decision making. Methods: Secondary analysis of the international prospective, longitudinal EPCCS study which included 1739 adults with advanced, incurable cancer receiving palliative care. In this secondary analysis, for all participants with date of death or last follow up, a multilevel Weibull survival analysis examined whether pain, analgesics, and other relevant variables are associated with time to death. Results: Date of death or last follow-up was available for 1404 patients (mean age 65.7 [SD:12.3];men 50%). Secondary analysis of this group showed the mean survival from baseline was 46.5 (SD:1.5) weeks (95% CI:43.6–49.3). Pain was reported by 76%; 60% were taking opioids, 51% non-opioid analgesics and 24% co-analgesics. Opioid-use was associated with decreased survival in the multivariable model (HR = 1.59 (95% CI:1.38–1.84), p < 0.001). An exploratory subgroup analysis of those with C-reactive protein (CRP) measures (n = 219) indicated higher CRP was associated with poorer survival (p = 0.001). In this model, the strength of relationship between survival and opioid-use weakened (p = 0.029). Conclusion: Opioid-use and survival were associated; this relationship weakened in a small sensitivity-testing subgroup analysis adjusting for CRP. Thus, the observed relationship between survival and opioid-use may partly be due to tumour-related inflammation. Larger studies, measuring disease activity, are needed to confirm this finding to more accurately judge the benefits and risks of opioids in advanced progressive disease

Implementing person-centred outcome measures in palliative care: An exploratory qualitative study using Normalisation Process Theory to understand processes and context

© The Author(s) 2020. Background: Despite evidence demonstrating the utility of using Person-Centred Outcome Measures within palliative care settings, implementing them into routine practice is challenging. Most research has described barriers to, without explaining the causal mechanisms underpinning, implementation. Implementation theories explain how, why, and in which contexts specific relationships between barriers/enablers might improve implementation effectiveness but have rarely been used in palliative care outcomes research. Aim: To use Normalisation Process Theory to understand and explain the causal mechanisms that underpin successful implementation of Person-Centred Outcome Measures within palliative care. Design: Exploratory qualitative study. Data collected through semi-structured interviews and analysed using a Framework approach. Setting/participants: 63 healthcare professionals, across 11 specialist palliative care services, were purposefully sampled by role, experience, seniority, and settings (inpatient, outpatient/day therapy, home-based/community). Results: Seven main themes were developed, representing the causal mechanisms and relationships underpinning successful implementation of outcome measures into routine practice. Themes were: Subjectivity of measures; Frequency and version of Integrated Palliative care Outcome Scale; Training, education, and peer support; Building and sustaining community engagement; Electronic system readiness; The art of communication; Reinforcing use through demonstrating value. Conclusions: Relationships influencing implementation resided at individual and organisational levels. Addressing these factors is key to driving the implementation of outcome measures into routine practice so that those using palliative care services can benefit from the systematic identification, management, and measurement of their symptoms and concerns. We provide key questions that are essential for those implementing and using outcome measures to consider in order to facilitate the integration of outcome measures into routine palliative care practice

The Northeast Water Polynya, Greenland: Climatology, atmospheric forcing and ocean response

The Northeast Water Polynya is a significant annually recurring summertime Arctic polynya, located off the coast of Northeast Greenland. It is important for marine wildlife and affects local atmospheric and oceanic processes. In this study, over 40 years of observational and reanalysis products (ERA5 and ORAS5) are analyzed to characterize the polynya's climatology and ascertain forcing mechanisms. The Northeast Water Polynya has high spatiotemporal variability; its location, size and structure vary interannually, and the period for which it is open is changing. We show this variability is largely driven by atmospheric forcing. The polynya extent is determined by the direction of the near-surface flow regime, and the relative locations of high and low sea-level pressure centers over the region. The surface conditions also impact the oceanic water column, which has a strong seasonal cycle in potential temperature and salinity, the amplitude of which decreases with depth. The ocean reanalyses also show a significant warming trend at all depths and a freshening near the surface consistent with greater ice melt, but salinification at lower depths (∼200 m). As the Arctic region changes due to anthropogenic forcing, the sea-ice edge is migrating northwards and the Northeast Water Polynya is generally opening earlier and closing later in the year. This could have significant implications for both the atmosphere and ocean in this complex and rapidly changing environment

Specific Induction of Double Negative B Cells During Protective and Pathogenic Immune Responses

Double negative (DN) (CD19(+)CD20(low)CD27(-)IgD(-)) B cells are expanded in patients with autoimmune and infectious diseases;however their role in the humoral immune response remains unclear. Using systematic flow cytometric analyses of peripheral blood B cell subsets, we observed an inflated DN B cell population in patients with variety of active inflammatory conditions: myasthenia gravis, Guillain-Barre syndrome, neuromyelitis optica spectrum disorder, meningitis/encephalitis, and rheumatic disorders. Furthermore, we were able to induce DN B cells in healthy subjects following vaccination against influenza and tick borne encephalitis virus. Transcriptome analysis revealed a gene expression profile in DN B cells that clustered with naive B cells, memory B cells, and plasmablasts. Immunoglobulin VH transcriptome sequencing and analysis of recombinant antibodies revealed clonal expansion of DN B cells that were targeted against the vaccine antigen. Our study suggests that DN B cells are expanded in multiple inflammatory neurologic diseases and represent an inducible B cell population that responds to antigenic stimulation, possibly through an extra-follicular maturation pathway

Weight Gain Prevention Outcomes From a Pragmatic Digital Health Intervention With Community Health Center Patients: Randomized Controlled Trial

BACKGROUND: The prevalence of obesity and its associated comorbidities continue to rise in the United States. Populations who are uninsured and from racial and ethnic minority groups continue to be disproportionately affected. These populations also experience fewer clinically meaningful outcomes in most weight loss trials. Weight gain prevention presents a useful strategy for individuals who experience barriers to weight loss. Given the often-limited weight management resources available to patients in primary care settings serving vulnerable patients, evaluating interventions with pragmatic designs may help inform the design of comprehensive obesity care delivered in primary care. OBJECTIVE: This study aims to evaluate the effectiveness of Balance, a 2-arm, 12-month pragmatic randomized controlled trial of a digital weight gain prevention intervention, delivered to patients receiving primary care within federally qualified community health centers. METHODS: Balance was a 2-arm, 12-month pragmatic randomized controlled trial of a digital weight gain prevention intervention delivered to individuals who had a BMI of 25-40 kg/m2, spoke English or Spanish, and were receiving primary care within a network of federally qualified community health centers in North Carolina. The Balance intervention was designed to encourage behavioral changes that result in a slight energy deficit. Intervention participants received tailored goal setting and tracking, skills training, self-monitoring, and responsive health coaching from registered dietitians. Weight was measured at regular primary care visits and documented in the electronic health record. We compared the percentage of ≤3% weight gain in each arm at 24 months after randomization-our primary outcome-using individual empirical best linear unbiased predictors from the linear mixed-effects model. We used individual empirical best linear unbiased predictors from participants with at least 1 electronic health record weight documented within a 6-month window centered on the 24-month time point. RESULTS: We randomized 443 participants, of which 223 (50.3%) participants were allocated to the intervention arm. At baseline, participants had a mean BMI of 32.6 kg/m2. Most participants were Latino or Hispanic (n=200, 45.1%) or non-Latino or Hispanic White (n=115, 26%). In total, 53% (n=235) of participants had at least 1 visit with weight measured in the primary time window. The intervention group had a higher proportion with ≤3% weight gain at 6 months (risk ratio=1.12, 95% CI 0.94-1.28; risk difference=9.5, 95% CI -4.5 to 16.4 percentage points). This difference attenuated to the null by 24 months (risk ratio=1.00, 95% CI 0.82-1.20; risk difference=0.2, 95% CI -12.1 to 11.0 percentage points). CONCLUSIONS: In adults with overweight or obesity receiving primary care at a community health center, we did not find long-term evidence to support the dissemination of a digital health intervention for weight gain prevention. TRIAL REGISTRATION: ClinicalTrials.gov NCT03003403; https://clinicaltrials.gov/study/NCT03003403. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12889-019-6926-7

Correction: Weight Gain Prevention Outcomes From a Pragmatic Digital Health Intervention With Community Health Center Patients: Randomized Controlled Trial

[This corrects the article DOI: 10.2196/50330.]

Neuropsychological Assessment, Neuroimaging, and Neuropsychiatric Evaluation in Pediatric and Adult Patients with Sickle Cell Disease (SCD)

Traditionally, neuropsychological deficits due to Sickle Cell Disease (SCD) have been understudied in adults. We have begun to suspect, however, that symptomatic and asymptomatic Cerebrovascular Events (CVE) may account for an alarming number of deficits in this population. In the current brief review, we critically evaluated the pediatric and adult literatures on the neurocognitive effects of SCD. We highlighted the studies that have been published on this topic and posit that early detection of CVE via neurocognitive testing, neuropsychiatric evaluations, and neuroimaging may significantly reduce adult cognitive and functional morbidities