Investigating whether the Johns Hopkins ACG case-mix system explains variation in UK general practice

This thesis describes the first large-scale studies in the United Kingdom to adjust for diagnostic-based morbidity when examining variation in home visits, specialist referrals and prescribing patterns in general practice. The Johns Hopkins ACG Case-Mix System was used since each patient’s overall morbidity is a better predictor of health service resource use than individual diseases. A literature review showed large variations in resource use measures such as consultations, referrals and prescribing practice patterns in general practice both in the UK and elsewhere and highlighted inappropriate use of statistical methodology that has the potential to produce misleading and erroneous conclusions. The review presents a strong argument for adjusting for diagnostic based morbidity when comparing variation in general practice outcomes in the UK. Multilevel models were used to take account of clustering within general practices and partition variation in general practice outcomes into between and within practice variation. Statistical measures for appropriately dealing with the challenging\ud methodological issues were explored with the aim of producing results that could be more easily communicated to policy makers, clinicians, and other healthcare professionals. The datasets used contained detailed patient demographic, social class and diagnostic information from the Morbidity Statistics in General Practice Survey and the General Practice Research Database. This research shows that a combination of measures is required to quantify the effect of model covariates on variability between practices. Morbidity explains a small proportion of total variation between general practices for the home visit and referral outcomes but substantially more for the prescribing outcome compared to age and sex. Most of the variation was within rather than between practices

Biostatistical Analysis of the Schistosomiasis Control Initiative Programme on Schistosoma Prevalence, Intensity and Associated Morbidity

Background: Schistosomiasis remains one of the most prevalent parasitic diseases in developing countries. Goal and objectives: The potential relationship between Schistosoma mansoni and anaemia, was examined using Schistosomiasis Control Initiative (SCI) data on Ugandan children and a randomized clinical trial implemented by colleagues from the London School of Hygiene and Tropical Medicine (LSHTM) in Western Kenya. The impact of large-scale administration of chemotherapy on Schistosoma haematobium infection and associated morbidity was also evaluated using SCI data on Burkinabe children. Evaluation and validation of field applicable tools, such as ultrasound, for the cost-effective diagnosis of schistosomiasis morbidity using SCI baseline data from Malian children was another aim of this thesis. Furthermore, in combination with the ultrasound scans, microscopic examination of urine for detection of S. haematobium eggs, dipsticks for detection of haematuria, tests for circulating antigens and serology tests were examined for the cost-effective assessment of S. haematobium prevalence in an adult’s dataset from Ghana. Methods: Biostatistical analysis of afore mentioned data was applied. Principal findings: Results from SCI and LSHTM studies suggest that anaemia is associated with schistosomiasis in African children, and that such anaemia shows a significant improvement following chemotherapy. Results from the SCI study in Burkina Faso suggested that even a single round of mass chemotherapy can have a substantial impact on S. haematobium infection and its associated morbidity in children. Microscopy and haematuria dipsticks were suggested as sensitive and specific indicators of prevalence of S. haematobium infection in Ghanaian adults. Furthermore, ultrasound global scores were demonstrated to be valuable markers in children for morbidity caused by S. haematobium infection, but ultrasonographic examination is not a reasonable substitute for microscopy or dipsticks for determining the prevalence of this infection. Significance: Finally, the key findings from all the studies presented, emphasizing how these relate to one another, are discussed

Becoming a moral self through a community of ethical enquiry: a study of a class group from middle to late childhood in an Irish primary school

This qualitative research study examines moral responsiveness and thinking in a mixed gender class of primary school children over a period o f four and a half years. It sets out to track development in children’s moral awareness, looking at gains and losses from middle to late childhood, and focusing on cognitive skills, notions of moral rectitude, and interpersonal relationships and friendship. The first part of the study is designed to offer a theoretical background to inform interpretation of the data in the second part. It examines major issues in morality and moral education in the context of significant recent debates across several disciplines, including developmental psychology, philosophy, sociology and education; it also offers a theoretical perspective on children’s ability to think together about morality in a community of enquiry and on related issues of pedagogy. Through interpretation of transcripts, the second part o f the study analyses the children’s thinking, in response to a wide range of content, on issues of justice, freedom and responsibility, rights and duties, inclusiveness, and friendship. Gender differences, most notably the reticence of girls to express themselves in a mixed gender group after about age ten, are also examined. The study demonstrates how, through participation in a community of ethical enquiry such as Thinking Time - Philosophy with Children, children become more thoughtful and develop respect and responsiveness to others as well as other traits of character that are central to democratic citizenship

Social identity emergence in attitude interactions and the identity strengthening effects of cumulative attitude agreement

The social identity approach asserts that self-categorization is fluid and created anew in context. Despite this, research often conceptualizes identities as being based on static categories. In this article, we assess: how attitudes may be relevant attributes used to categorize the self and others, and therefore have the potential to foster social identification; how such categories/identities can be updated with new attitudinal information; and how attitudes have greater impact when socially expressed. Across three preregistered computer-mediated interactive experiments (N = 3087), involving attitudes relating to the Ukraine-Russia conflict of 2022, we find, identities can be updated with the introduction of new attitudes in interaction; cumulative attitude congruence strengthens identification; attitudinal interaction strengthens opinion-based group identification and activism intentions, and ingroups can strategically align their attitudes. We conclude that to fully understand identity formation, we must acknowledge the fluidity of self-categories and resultant identities, in line with the original specifications of the social identity approach.</p

Mouth Opening A New Angle

Background: The authors hypothesized that craniocervical extension occurs during normal mouth opening. Methods: Twenty volunteers were studied. Interdental distance was measured at four different degrees of craniocervical extension. Results: Interdental distance increased from 28 mm (95% confidence interval, 25-30) in slight flexion to 46 mm (95% confidence interval, 42-49) at full extension. Nearly maximal mouth opening was obtained with 26°(95% confidence interval, 22-30) of craniocervical extension from neutral. Conclusion: Craniocervical extension is an integral part of complete mouth opening in conscious subjects. Fixation of the craniocervical junction by disease, an internal or external fixation device, or technique may restrict mouth opening, with consequences for airway management