Are "part-time" general practitioners workforce idlers or committed professionals?

BACKGROUND: The traditional view of general practice holds that only general practitioners (GPs) in full-time clinical practice can provide quality patient care. Nevertheless, increasing numbers of GPs are choosing to work sessionally, that is, ostensibly “part-time”. There are concerns about the health workforce’s ability to meet demand and also fears that patient care may be compromised. We sought answers to a) what activities do GPs undertake when not consulting patients, b) why do they choose to work sessionally, and c) does sessional general practice reflect a lack of commitment to patients and the profession? METHODS: Semi-structured interviews were conducted with GPs who worked sessionally, (i.e. six or fewer sessions a week in clinical general practice, where a session comprises four consecutive hours of patient care). These data were analysed qualitatively and saturation was reached. RESULTS: The majority of participants were in full-time paid employment, while part-time in clinical general practice. They reported that consultations increasingly required the management of patients with complex, chronic conditions who also required psychological management. Coupled with unrealistic patient expectations, these factors led GPs to be concerned about maintaining the quality patient care they considered professionally desirable. Many diversified their work activities to ensure that they retained their professional standards. CONCLUSIONS: “Part-time” general practice is a misnomer that masks the contribution these GPs make as part of the health workforce. Sessional practice more accurately describes the nature of our participants’ clinical work. Their choice of sessional work is a professional response to the increasing demands within the consultation. It enables GPs to maintain their commitment to quality patient care and their profession, while attenuating the challenges of demanding consultations. Sessional general practitioners demonstrate strong commitment to their patients and the profession

Prevalence of multimorbidity with frailty and associations with socioeconomic position in an adult population : findings from the cross-sectional HUNT Study in Norway

ObjectivesTo explore prevalences and occupational group inequalities of two measures of multimorbidity with frailty.DesignCross-sectional study.SettingThe Nord-TrOndelag Health Study (HUNT), Norway, a total county population health survey, 2006-2008.ParticipantsParticipants older than 25 years, with complete questionnaires, measurements and occupation data were included.Outcomes >= 2 of 51 multimorbid conditions with >= 1 of 4 frailty measures (poor health, mental illness, physical impairment or social impairment) and >= 3 of 51 multimorbid conditions with >= 2 of 4 frailty measures.AnalysisLogistic regression models with age and occupational group were specified for each sex separately.ResultsOf 41 193 adults, 38 027 (55% female; 25-100 years old) were included. Of them, 39% had >= 2 multimorbid conditions with >= 1 frailty measure, and 17% had >= 3 multimorbid conditions with >= 2 frailty measures. Prevalence differences in percentage points (pp) with 95% confidence intervals of those in high versus low occupational group with >= 2 multimorbid conditions and >= 1 frailty measure were largest in women age 30 years, 17 (14 to 20) pp and 55 years, 15 (13 to 17) pp and in men age 55 years, 15 (13 to 17) pp and 80 years, 14 (9 to 18) pp. In those with >= 3 multimorbid conditions and >= 2 frailty measures, prevalence differences were largest in women age 30 years, 8 (6 to 10) pp and 55 years, 10 (8 to 11) ppand in men age 55 years, 9 (8 to 11) pp and 80 years, 6 (95% CI 1 to 10) pp.ConclusionMultimorbidity with frailty is common, and social inequalities persist until age 80 years in women and throughout the lifespan in men. To manage complex multimorbidity, strategies for proportionate universalism in medical education, healthcare, public health prevention and promotion seem necessary

Socioeconomic position, multimorbidity and mortality in a population cohort, the HUNT Study

Multimorbidity and socioeconomic position are independently associated with mortality. We investigated the association of occupational position and several multimorbidity measures with all-cause mortality. A cohort of people aged 35 to 75 years who participated in the Trøndelag Health Study in 2006–2008 and had occupational data was linked to the Norwegian National Population Registry for all-cause mortality from study entry until 1 February 2019. Logistic regression models for each occupational group were used to analyze associations between the number of conditions and 10-year risk of death. Cox regression models were used to examine associations between combinations of multimorbidity, occupational position, and mortality. Analyses were conducted for men and women. Included were 31,132 adults (16,950 women (54.4%)); occupational groups: high, 7501 (24.1%); low, 15,261 (49.0%)). Increased mortality was associated with lower occupational group, more chronic conditions, and all multimorbidity measures. The joint impact of occupational group and multimorbidity on mortality was greater in men than women. All multimorbidity measures are strongly associated with mortality, with varying occupational gradients. Social differences in multimorbidity are a public health challenge and necessitate consideration in health care. Men in lower occupational groups seem to be a particularly vulnerable grouppublishedVersio

Socioeconomic inequalities in the prevalence of complex multimorbidity in a Norwegian population: findings from the cross-sectional HUNT Study

Objectives: Multimorbidity, the co-occurrence of multiple long-term conditions, is common and increasing. Definitions and assessment methods vary, yielding differences in estimates of prevalence and multimorbidity severity. Sociodemographic characteristics are associated with complicating factors of multimorbidity. We aimed to investigate the prevalence of complex multimorbidity by sex and occupational groups throughout adulthood. Design: Cross-sectional study. Setting: The third total county survey of The Nord-Trøndelag Health Study (HUNT), 2006–2008, Norway. Participants: Individuals aged 25–100 years with classifiable occupational data and complete questionnaires and measurements. Outcome measure: Complex multimorbidity defined as ‘the co-occurrence of three or more chronic conditions affecting three or more different body (organ) systems within one person without defining an index chronic condition’. Analysis: Logistic regression models with age and occupational group were specified for each sex separately. Results: 38 027 of 41 193 adults (55% women) were included in our analyses. 54% of the participants were identified as having complex multimorbidity. Prevalence differences in percentage points (pp) of those in the low occupational group (vs the high occupational group (reference)) were 19 (95% CI, 16 to 21) pp in women and 10 (8 to 13) pp in men at 30 years; 12 (10 to 14) pp in women and 13 (11 to 15) pp in men at 55 years; and 2 (−1 to 4) pp in women and 7 (4 to 10) pp in men at 75 years. Conclusion: Complex multimorbidity is common from early adulthood, and social inequalities persist until 75 years in women and 90 years in men in the general population. These findings have policy implications for public health as well as healthcare, organisation, treatment, education and research, as complex multimorbidity breaks with the specialised, fragmented paradigm dominating medicine today.publishedVersio

Sociodemographic and Health Characteristics, Rather Than Primary Care Supply, are Major Drivers of Geographic Variation in Preventable Hospitalizations in Australia

ACKNOWLEDGMENTS: The authors thank the many thousands of people participating in the 45 and Up Study. The authors also thank the Sax Institute, the NSW Ministry of Health, and the NSW Register of Births, Deaths, and Marriages for allowing access to the data, and the Centre for Health Record Linkage for conducting the probabilistic linkage of records.Peer reviewedPublisher PD

Expression of an anti-CD4 single-chain antibody fragment from the donor cornea can prolong corneal allograft survival in inbred rats

To investigate whether expression of an anti-CD4 antibody fragment (scFv) by a lentivector-transduced donor cornea can prolong rat corneal allograft survival. Methods Inbred Fischer 344 rats received penetrating corneal allografts from Wistar-Furth donors after a 3 h transduction of the donor cornea with a lentivector carrying anti-CD4scFv cDNA (Lv-CD4scFv), a lentivector carrying the reporter gene-enhanced yellow fluorescence protein (LV-eYFP), or an adenoviral vector carrying anti-CD4 scFv cDNA (Ad-CD4scFv). Unmodified controls were also performed. Graft survival was assessed by corneal clarity, and rejection was confirmed histologically. Results In organ-cultured corneas, expression of anti-CD4 scFv was detected at 2 days post-transduction with the adenoviral vector, compared with 5 days post-transduction with the lentivector, and was 10-fold higher than the former. More inflammation was observed in Ad-CD4scFv-modified allografts than in Lv-CD4scFv-modified grafts at 15 days postsurgery (p=0.01). The median time to rejection for unmodified, LV-eYFP and Ad-CD4scFv grafts was day 17, compared with day 22 for Lv-CD4scFv grafts (p≤0.018). Conclusion Donor corneas transduced with a lentiviral vector carrying anti-CD4scFv cDNA showed a modest but significant prolongation in graft survival compared with unmodified, Lv-eYFP and Ad-CD4scFv grafts. However, rejection still occurred in all Lv-CD4scFv grafts, indicating that sensitisation may have been delayed but was not prevented.Australian National Health & Medical Research Council and the Ophthalmic Research Institute of Australia

Adaption and validation of the Working Alliance Inventory for General Practice:qualitative review and cross-sectional surveys

Background: Relational aspects of primary care are important, but we have no standard measure for assessment. The ‘working alliance’ incorporates elements of the therapeutic relationship, shared decision-making, goal setting and communication skills. The Working Alliance Inventory (short form) (WAI-SF) has been used in adult psychology, and a high score on the survey is associated with improved outcomes for clients.this work was supported by the Chris Silagy Research Scholarship grant from the Royal Australian College of General Practitioners. MJR is funded by National Institute for Health Research (NIHR) Post-Doctoral Research Fellowship (PDF-2014-07-013)

Electron-doped SiGe Quantum Well Terahertz Emitters pumped by FEL pulses

We explore saturable absorption and terahertz photoluminescence emission in a set of n-doped Ge/SiGe asymmetric coupled quantum wells, designed as three-level systems (i.e., quantum fountain emitter). We generate a non-equilibrium population by optical pumping at the 1→3 transition energy using picosecond pulses from a free-electron laser and characterize this effect by measuring absorption as a function of the pump intensity. In the emission experiment we observe weak emission peaks in the 14–25 meV range (3–6 THz) corresponding to the two intermediate intersubband transition energies. The results represent a step towards silicon-based integrated terahertz emitters

Development of an improved blood-stage malaria vaccine targeting the essential RH5-CyRPA-RIPR invasion complex

Reticulocyte-binding protein homologue 5 (RH5), a leading blood-stage Plasmodium falciparum malaria vaccine target, interacts with cysteine-rich protective antigen (CyRPA) and RH5-interacting protein (RIPR) to form an essential heterotrimeric “RCR-complex”. We investigate whether RCR-complex vaccination can improve upon RH5 alone. Using monoclonal antibodies (mAbs) we show that parasite growth-inhibitory epitopes on each antigen are surface-exposed on the RCR-complex and that mAb pairs targeting different antigens can function additively or synergistically. However, immunisation of female rats with the RCR-complex fails to outperform RH5 alone due to immuno-dominance of RIPR coupled with inferior potency of anti-RIPR polyclonal IgG. We identify that all growth-inhibitory antibody epitopes of RIPR cluster within the C-terminal EGF-like domains and that a fusion of these domains to CyRPA, called “R78C”, combined with RH5, improves the level of in vitro parasite growth inhibition compared to RH5 alone. These preclinical data justify the advancement of the RH5.1 + R78C/Matrix-M™ vaccine candidate to Phase 1 clinical trial

Analysis of the diverse antigenic landscape of the malaria protein RH5 identifies a potent vaccine-induced human public antibody clonotype

The highly conserved and essential Plasmodium falciparum reticulocyte-binding protein homolog 5 (PfRH5) has emerged as the leading target for vaccines against the disease-causing blood stage of malaria. However, the features of the human vaccine-induced antibody response that confer highly potent inhibition of malaria parasite invasion into red blood cells are not well defined. Here, we characterize 236 human IgG monoclonal antibodies, derived from 15 donors, induced by the most advanced PfRH5 vaccine. We define the antigenic landscape of this molecule and establish that epitope specificity, antibody association rate, and intra-PfRH5 antibody interactions are key determinants of functional anti-parasitic potency. In addition, we identify a germline IgG gene combination that results in an exceptionally potent class of antibody and demonstrate its prophylactic potential to protect against P. falciparum parasite challenge in vivo. This comprehensive dataset provides a framework to guide rational design of next-generation vaccines and prophylactic antibodies to protect against blood-stage malaria