Evaluation of the primary/secondary care interface in relation to a primary care rheumatology service

Objective The rheumatology department at The Royal Oldham Hospital developed a primary care service aimed at bridging the gap between primary and secondary care for patients with potential rheumatological conditions, and this was given the name rheumatology Tier 2. The objective of this study was to evaluate this primary care rheumatology service (Tier 2)in order to assess its validity, patient satisfaction and effectiveness. Design Ten patients participated in individual semi-structured interviews. Three GPs were interviewed individually, and two GPs formed a focus group. Thematic analysis was used to interpret the findings. Setting Patients were recruited from seven consecutive rheumatology Tier 2 clinics. GPs were recruited from Oldham Primary Care Trust (PCT) as this was the main source of patient referrals for the service. Results The key findings were in relation to the integration of primary healthcare and hospital services, i.e. the primary/secondary care interface. This highlighted the importance of early assessment, diagnosis and treatment of patients with suspected inflammatory arthritis. Conclusion Early diagnosis and treatment with disease-modifying anti-rheumatic drugs improves patients’ outcomes. The rheumatology Tier 2 service built on this evidence and provided a rapid assessment and referral to secondary care for those patients with suspected inflammatory arthritis

Patient and practitioner views of a new rheumatology (Tier 2) primary care service

The rheumatology Tier 2 service in Oldham was implemented to see patients in a primary care setting for their initial assessment. They were treated and discharged within the service, or referred on to secondary care in order to limit inappropriate attendance in secondary care and fast-track patients with inflammatory disease to the rheumatology consultant. The aim of this study was to evaluate patients’ and general practitioners’ (GPs’) views about the transfer of rheumatological services from secondary to primary care. Patients and GPs were from a single primary care trust in Oldham, north west England. A thematic analysis of interview data was taken, and findings showed high patient satisfaction with the service, favouring the primary care environment to a hospital setting. GPs reported on cost-effectiveness of the service and better management of the disease. The Tier 2 service has the potential to set a new direction for multiagency care within a primary care setting

Comparing primary prevention with secondary prevention to explain decreasing Coronary Heart Disease death rates in Ireland, 1985-2000.

BACKGROUND: To investigate whether primary prevention might be more favourable than secondary prevention (risk factor reduction in patients with coronary heart disease(CHD)). METHODS: The cell-based IMPACT CHD mortality model was used to integrate data for Ireland describing CHD patient numbers, uptake of specific treatments, trends in major cardiovascular risk factors, and the mortality benefits of these specific risk factor changes in CHD patients and in healthy people without recognised CHD. RESULTS: Between 1985 and 2000, approximately 2,530 fewer deaths were attributable to reductions in the three major risk factors in Ireland. Overall smoking prevalence declined by 14% between 1985 and 2000, resulting in about 685 fewer deaths (minimum estimate 330, maximum estimate 1,285) attributable to smoking cessation: about 275 in healthy people and 410 in known CHD patients. Population total cholesterol concentrations fell by 4.6%, resulting in approximately 1,300 (minimum estimate 1,115, maximum estimate 1,660) fewer deaths attributable to dietary changes(1,185 in healthy people and 115 in CHD patients) plus 305 fewer deaths attributable to statin treatment (45 in people without CHD and 260 in CHD patients). Mean population diastolic blood pressure fell by 7.2%, resulting in approximately 170 (minimum estimate 105, maximum estimate 300) fewer deaths attributable to secular falls in blood pressure (140 in healthy people and 30 in CHD patients), plus approximately 70 fewer deaths attributable to antihypertensive treatments in people without CHD. Of all the deaths attributable to risk factor falls, some 1,715 (68%) occurred in people without recognized CHD and 815(32%) in CHD patients. CONCLUSION: Compared with secondary prevention, primary prevention achieved a two-fold larger reduction in CHD deaths. Future national CHD policies should therefore prioritize nationwide interventions to promote healthy diets and reduce smoking

AdS Taub-Nut Space and the O(N) Vector Model on a Squashed 3-Sphere

In this note, motivated by the Klebanov-Polyakov conjecture we investigate the strongly coupled O(N) vector model at large $N$ on a squashed three-sphere and its holographic relation to bulk gravity on asymptotically locally $AdS_4$ spaces. We present analytical results for the action of the field theory as the squashing parameter $\alpha\to-1$, when the boundary becomes effectively one dimensional. The dual bulk geometry is AdS-Taub-NUT space in the corresponding limit. In this limit we solve the theory exactly and show that the action of the strongly coupled boundary theory scales as $\ln(1+\alpha)/ (1+\alpha)^2$. This result is remarkably close to the $-1/(1+\alpha)^2$ scaling of the Einstein gravity action for AdS-Taub-NUT space. These results explain the numerical agreement presented in hep-th/0503238, and the soft logarithmic departure is interpreted as a prediction for the contribution due to higher spin fields in the bulk $AdS_4$ geometry.Comment: 11 pages, 3 figures. References adde

Effective actions on the squashed three-sphere

The effective actions of a scalar and massless spin-half field are determined as functions of the deformation of a symmetrically squashed three-sphere. The extreme oblate case is particularly examined as pertinant to a high temperature statistical mechanical interpretation that may be relevant for the holographic principle. Interpreting the squashing parameter as a temperature, we find that the effective `free energies' on the three-sphere are mixtures of thermal two-sphere scalars and spinors which, in the case of the spinor on the three-sphere, have the `wrong' thermal periodicities. However the free energies do have the same leading high temperature forms as the standard free energies on the two-sphere. The next few terms in the high-temperature expansion are also explicitly calculated and briefly compared with the Taub-Bolt-AdS bulk result.Comment: 23 pages, JyTeX. Conclusion slightly amended, one equation and minor misprints correcte

Casimir energy of a massive field in a genus-1 surface

We review the definition of the Casimir energy steming naturally from the concept of functional determinant through the zeta function prescription. This is done by considering the theory at finite temperature and by defining then the Casimir energy as its energy in the limit $T\to 0$. The ambiguity in the coefficient $C_{d/2}$ is understood to be a result of the necessary renormalization of the free energy of the system. Then, as an exact, explicit example never calculated before, the Casimir energy for a massive scalar field living in a general $(1+2)$-dimensional toroidal spacetime (i.e., a general surface of genus one) with flat spatial geometry ---parametrized by the corresponding Teichm\"uller parameters--- and its precise dependence on these parameters and on the mass of the field is obtained under the form of an analytic function.Comment: Changes everywhere: title, abstract, contents and figures. Version to appear in Physics Letters

The O(N) model on a squashed S^3 and the Klebanov-Polyakov correspondence

We solve the O(N) vector model at large N on a squashed three-sphere with a conformal mass term. Using the Klebanov-Polyakov version of the AdS_4/CFT_3 correspondence we match various aspects of the strongly coupled theory with the physics of the bulk AdS Taub-NUT and AdS Taub-Bolt geometries. Remarkably, we find that the field theory reproduces the behaviour of the bulk free energy as a function of the squashing parameter. The O(N) model is realised in a symmetric phase for all finite values of the coupling and squashing parameter, including when the boundary scalar curvature is negative.Comment: 1+27 pages. 6 figures. LaTeX. References adde

Orthogonalization of vectors with minimal adjustment

Two transformations are proposed that give orthogonal components with a one-to-one correspondence between the original vectors and the components. The aim is that each component should be close to the vector with which it is paired, orthogonality imposing a constraint. The transformations lead to a variety of new statistical methods, including a unified approach to the identification and diagnosis of collinearities, a method of setting prior weights for Bayesian model averaging, and a means of calculating an upper bound for a multivariate Chebychev inequality. One transformation has the property that duplicating a vector has no effect on the orthogonal components that correspond to nonduplicated vectors, and is determined using a new algorithm that also provides the decomposition of a positive-definite matrix in terms of a diagonal matrix and a correlation matrix. The algorithm is shown to converge to a global optimum

Critical Thinking Activities and the Enhancement of Ethical Awareness: An application of a ‘Rhetoric of Disruption’ to the undergraduate general education classroom

This article explores how critical thinking activities and assignments can function to enhance students’ ethical awareness and sense of civic responsibility. Employing Levinas’s Othercentered theory of ethics, Burke’s notion of ‘the paradox of substance’, and Murray’s concept of ‘a rhetoric of disruption’, this article explores the nature of critical thinking activities designed to have students question their (often taken-for-granted) moral assumptions and interrogate their (often unexamined) moral identities. This article argues that such critical thinking activities can trigger a metacognitive destabilization of subjectivity, understood as a dialectical prerequisite (along with exposure to otherness) for increased ethical awareness. This theoretical model is illustrated through a discussion of three sample classroom activities designed to destabilize moral assumptions and identity, thereby clearing the way for a heightened acknowledgment of otherness. In so doing, this article provides an alternative (and dialectically inverted) strategy for addressing one of the central goals of many General Education curricula: the development of ethical awareness and civic responsibility. Rather than introducing students to alternative perspectives and divergent cultures with the expectation that heightened moral awareness will follow, this article suggests classroom activities and course assignments aimed at disrupting moral subjectivity and creating an opening in which otherness can be more fully acknowledged and the diversity of our world more fully appreciated