Disappearing Vistas

National parks have historically used long distance scenic views, known as vistas, to reveal iconic American landscapes to auto tourists. However, decades of budget constraints and inadequate management have prevented National Parks from maintaining vistas as originally intended. Many important vistas are disappearing due to encroaching vegetation. As a result, numerous complaints and concerns have been expressed by park visitors, especially within Great Smoky Mountains National Park. Vistas still play an intricate role in the visitor experience of national parks – an experience worth protecting. In an effort to conserve this experience, ecologically sustainable vistas must be established that are both aesthetically pleasing to visitors and manageable by limited Park resources. The Great Smoky Mountains National Park is America’s most visited national park, preserving one of the largest, most diverse natural areas in the country. Recent studies showed that 95 percent (approximately 8.5 million) of the Park’s tourists participated in scenic drives. Vistas along Newfound Gap Road – arguably the Park’s most scenic corridor – serve as windows into a variety of forest ecosystems, an experience comparable to a drive from Georgia to Maine. Traditionally, Park vista management has consisted of ad hoc vegetation removal and does not address additional ways to manage future clearing. This thesis suggests that utilizing herbicide and native low growing shrubs that already exist on site to inhibit regrowth is the best way to manage vistas. Once these new low growing ecosystems are established, vista clearings should be nearly self-sustaining, only requiring minimal vegetation removal every seven years. The vista management recommendations made in this document offer a practical, ecological plan that addresses the maintenance needs of the Park and restores memorable views for millions of visitors

Concerns and supports of grandfamilies using formal services: Do they have the help they need?

The objective of this exploratory study was to discover the functional and psychosocial concerns of grandfamilies already receiving support services in their community, and to ask if they had the help they needed. Data were gathered from a convenience sample of 16 grandparents who were raising their grandchildren and were involved with a support group or a grandfamily workshop. Results indicated that grandparents affiliated with formal supports still experience psychosocial concerns (i.e., child’s emotional problems) and functional concerns (i.e., financial strain). Suggestions are included for further development on this measure as derived from the literature, service provider observations, and grandfamily perspectives

Changes in coping behavior and the relationship to personality, health threat communication and illness perceptions from the diagnosis of diabetes: a 2-year prospective longitudinal study

Coping behavior is of critical importance in diabetes because of its impact upon self-care and hence eventual medical outcome. We examined how coping behavior and its relationship to personality, diabetes health threat communication (DHTC) and illness representations changes after diagnosis of diabetes. Newly diagnosed diabetic patients were assessed after diagnosis and at 6, 12 and 24 months using the DHTC, Illness Perceptions and Coping inventory questionnaires. Personality traits were assessed at baseline. Active coping, planning, positive reinterpretation and growth (PRG), seeking emotional and instrumental (social) support decreased over the 2 years from diagnosis while passive acceptance increased. Openness/intellect and conscientiousness traits were associated with active coping and seeking instrumental support. Openness/intellect also associated with planning and PRG. These relationships did not vary over time. Perceived threat and serious consequences were associated with active coping but the effect diminished over time. Illness coherence (understanding of diabetes), personal and treatment control were associated with active coping, planning and seeking instrumental support and did not change over time. The coping strategies most commonly employed by diabetic patients are adaptive. Coping behavior changes over the 2 years from diagnosis. Promoting better understanding of diabetes, perceptions of personal control and treatment effectiveness are more likely than perception of health threat to sustain adaptive problem focused coping behavior

Rasch analysis of a new Patient Reported Outcome Measure for Psoriasis Treatment (PROMPT)

OBJECTIVES A draft patient-reported outcome measure for psoriasis treatment (PROMPT) was developed through patient interviews and comprised 91 items across seven core domains. This study aimed to evaluate the scaling properties and construct validity of the draft measure using the Rasch measurement model. METHODS Patients with chronic plaque psoriasis were identified and recruited according to pre-defined inclusion and exclusion criteria through psoriasis-specific secondary care clinics in the United Kingdom and two national patient organizations. Patients completed the draft measure at two time points, 14 days apart. Respondents with ≥40% of missing data were removed from the final analyses. Data from each sub-scale were analyzed separately using RUMM2030 software to explore Rasch model fit, item difficulty, local dependence, item category thresholds, and differential item functioning (DIF) by age and gender. Where necessary, items were removed individually and the scale iteratively reassessed for fit and unidimensionality. RESULTS A sample of n=209 patients with chronic plaque psoriasis completed the draft measure. Initial fit to the model was poor; disordered category thresholds were identified for items in all scales. Post-hocre-scoring from a 5-point Likert scale to a 3-point Likert scale improved model fit. Items which showed local dependence were removed in context of qualitative findings. Following removal of 11 items, all 7 scales demonstrated acceptable fit with the Rasch model (Chi Sq = 0.09 to 0.2) There was no evidence of DIF by age and gender. CONCLUSIONS The new measure, PROMPT, comprised 80 items in 6 independent, unidimensional scales, free from age or gender bias, with acceptable fit to the Rasch model. As such, the measure is considered to show initial promise for use with patients with chronic plaque psoriasis in a clinical setting. The psychometric properties and scoring of the measure should be explored further and confirmed in future studies

Exploring practice & clinical evidence with pre-manipulative testing for cervical arterial dysfunction amongst musculoskeletal physiotherapists within a Welsh Health Board

Purpose: Debate surrounds cervical arterial dysfunction (CAD) & the risk of catastrophic events associated with Cervical manipulation (CM). A legal duty exists for clinicians to interpret evidence and guidelines effectively to justify clinical reasoning therefore this study investigated how pre-manipulative tests were utilised in practice and how clinical decisions were made based on current evidence. Methods: 12 Musculoskeletal physiotherapists volunteered via purposive sampling for semi-structured interviews to explore the use of pre-manipulative tests, clinical thinking and perception of evidence relating to CM. Data was analysed using literal, interpretive and reflexive methods. Ethical approval was granted by ABHB Research Risk Review Committee and Middlesex University Ethics Subcommittee (Health Studies). Results: No adverse events following CM were reported but insufficient event reporting mechanisms were acknowledged. Frequency of CM was declining due to risk. Pre-manipulative tests were rarely used due to perceived risks; mid-range CM techniques were preferred. Expert opinion was heavily relied upon via literature reviews & guidance subject. Written consent was welcomed to aid clinicians although informed consent was currently practiced. Conclusion(s): Good awareness of haemodynamics associated with CAD existed; accurate reflections of risk factors, sign and symptoms. Implications: This demonstrates the need for clinicians to remain aware of current evidence, clinical guidelines and the risks associated with clinical techniques and to critically reflect on their own practice to minimise risk. Funding acknowledgements: There was considered to be no conflict of interest and no funding was received towards this research from the health board or any other source

Accessing primary health care: A meta-ethnography of the experiences of British South Asian patients with diabetes, coronary heart disease or a mental health problem

Objectives: To develop an explanatory framework of the problems accessing primary care health services experienced by British South Asian patients with a long-term condition or mental health problem. Methods: This study used meta-ethnographic methods. Published qualitative studies were identified from a structured search of six databases and themes synthesized across studies to develop a new explanatory framework. Results: Initial searches identified 951 potentially relevant records from which a total of 27 articles were identified that met inclusion and exclusion criteria. Twelve of these articles were chosen on the basis of their quality and relevance. These 12 articles described themes relating to the cultural, spatial and temporal dimensions of patient experiences of accessing and using health care. Our interpretive synthesis showed that access to primary care among British South Asians with diabetes, coronary heart disease and psychological health problems is co-constructed and negotiated over time and space along the key domains of the candidacy model of access: from help-seeking to interactions at the interface to following treatment advice. In the case of each condition, British South Asians’ claims to candidacy were constrained where their individual as well as broader social and cultural characteristics lacked fit with professionals’ ways of working and cultural typifications. Conclusion: Interventions that positively affect professionals’ capacity to support patient claims to candidacy are likely to help support British South Asians overcome a broad range of barriers to care for physical and mental health problems. </jats:p

Intentional and unintentional medication nonadherence in psoriasis: the role of patients’ medication beliefs and habit strength [abstract only]

The accurate diagnosis of psoriasis has remained a challenge, as no disease-specific biomarkers have yet been identified. Currently, the diagnosis of chronic inflammatory diseases relies mainly on the assessment of visible symptoms or the histological features of the biopsy. This approach is heavily reliant on the experience of the clinician and, therefore, may lead to misdiagnosis as there are numerous different chronic inflammatory skin diseases that may present similar clinical features. Hence, the need for diagnostic biomarkers is clear. Although different investigations have reported the discovery of potential psoriasis biomarkers, still no accurate and reliable biomarker is available. Rather than searching for a single valid biomarker, we propose that applying a multicomponent bio-marker-based approach would result in a higher degree of success and translation into clinical practice. An extensive review of published studies to identify the most relevant psoriasis-specific biomarker candidates was conducted. This led us to conclude that the expression levels of specific genes in the skin hold the most promise as discriminatory biomarkers, resulting in the selection of five genes, the expression levels of which have been demonstrated to be exclusive for psoriasis vulgaris. We first conducted a preliminary validation study applying support vector machine-based classification and principle component analysis on the skin-derived expression data of 12 patients with psoriasis vulgaris and 12 healthy controls, previously produced in our departments. We then confirmed that the expression levels of the five genes in psoriatic lesions indeed present a unique pattern. Encouraged by these results, we continued to develop a quantitative polymerase chain reaction panel to allow the accurate measurement of expression levels for the five genes to be used in the studies to follow. Although we have yet to confirm these results in the context of other chronic inflammatory skin diseases, the results of previously published studies regarding these five genes are promising. Therefore, we are in the process of collecting additional skin samples from patients with chronic inflammatory disease (including different papulosquamous disorders and atopic dermatitis) to validate the discriminatory power of our panel. These results may further be translated to viable clinical diagnostic tests in the near future. This work was supported by the ERA Chair for Translational Genomics and Personalized Medicine at the University of Tartu

Axial Spondyloarthritis: Patient-Reported Impact in Europe

This open access book provides an overview of the International Map of Axial Spondyloarthritis (IMAS) project -focusing on Europe-, a wide-ranging, multi-disciplinary collaboration between academic groups, Health Care Professionals (HCPs), patient organizations and Novartis. IMAS was conceived to improve knowledge of Axial Spondyloarthritis (axSpA) and raise awareness of its heavy burden globally. By asking more than 2,000 patients across Europe about the impact of axSpA on multiple aspects of their life, the full extent of this disease was investigated from a direct patient perspective. This allowed a unique understanding of how living with axSpA affects the daily lives and well-being of patients, and how this varies between European countries. Axial Spondyloarthritis: Patient-Reported Impact in Europe highlights opportunities for progressing quality patient care to be applied to health services globally. HCPs, policy makers and patients will find this book to be an indispensable resource for improving the understanding of this chronic condition, including patients’ clinical outcomes, the protection of those at risk of psychological distress, and the economic burden on patients and society