How do healthcare professionals working in accountable care organisations understand patient activation and engagement? Qualitative interviews across two time points.

ObjectiveIf patient engagement is the new 'blockbuster drug' why are we not seeing spectacular effects? Studies have shown that activated patients have improved health outcomes, and patient engagement has become an integral component of value-based payment and delivery models, including accountable care organisations (ACO). Yet the extent to which clinicians and managers at ACOs understand and reliably execute patient engagement in clinical encounters remains unknown. We assessed the use and understanding of patient engagement approaches among frontline clinicians and managers at ACO-affiliated practices.DesignQualitative study; 103 in-depth, semi-structured interviews.ParticipantsSixty clinicians and eight managers were interviewed at two established ACOs.ApproachWe interviewed healthcare professionals about their awareness, attitudes, understanding and experiences of implementing three key approaches to patient engagement and activation: 1) goal-setting, 2) motivational interviewing and 3) shared decision making. Of the 60 clinicians, 33 were interviewed twice leading to 93 clinician interviews. Of the 8 managers, 2 were interviewed twice leading to 10 manager interviews. We used a thematic analysis approach to the data.Key resultsInterviewees recognised the term 'patient activation and engagement' and had favourable attitudes about the utility of the associated skills. However, in-depth probing revealed that although interviewees reported that they used these patient activation and engagement approaches, they have limited understanding of these approaches.ConclusionsWithout understanding the concept of patient activation and the associated approaches of shared decision making and motivational interviewing, effective implementation in routine care seems like a distant goal. Clinical teams in the ACO model would benefit from specificity defining key terms pertaining to the principles of patient activation and engagement. Measuring the degree of understanding with reward that are better-aligned for behaviour change will minimise the notion that these techniques are already being used and help fulfil the potential of patient-centred care

Decline in coral cover and flattening of the reefs around Mauritius (1998–2010)

© The Author(s), 2018. This article is distributed under the terms of the Creative Commons Attribution License. The definitive version was published in Elliott JA, Patterson MR, Staub CG, Koonjul M, Elliott SM. 2018. Decline in coral cover and flattening of the reefs around Mauritius (1998–2010) PeerJ 6:e6014, doi: 10.7717/peerj.6014 .Coral reefs are degrading through the impacts of multiple anthropogenic stressors. How are coral reef communities going to change and how to protect them for future generations are important conservation questions. Using coral reef data from Mauritius, we examined changes in cover in 23 benthic groups for a 13-yr period and at 15 sites. Moreover, we determined which land-based stressor out of four (human population, agriculture, tourism, rainfall) correlated the most with the observed changes in coral reef cover. Among the stony corals, Acropora corals appeared to be the most impacted, decreasing in cover at many sites. However, the non-Acropora encrusting group increased in cover at several sites. The increase in abundance of dead corals and rubble at some sites also supported the observations of stony coral decline during the study period. Additionally, the decline in stony corals appeared to be more pronounced in second half of the study period for all sites suggesting that a global factor rather than a local factor was responsible for this decline. There was little change in cover for the other benthic groups, some of which were quite rare. Human population was significantly correlated with changes in coral reef cover for 11 sites, followed by tourism and agriculture. Rainfall, a proxy for runoff, did not appear to affect coral reef cover. Overall, our results showed that there has been a decline of stony coral cover especially the ones with complex morphologies, which in turn suggest that coral reefs around Mauritius have experienced a decline in habitat complexity during the study period. Our study also suggests that humans are an important factor contributing to the demise of coral reefs around the island.We would like to thank the Albion Fisheries Research Centre, Ministry of Fisheries, Government of Mauritius for providing the long-term benthic community dataset without which this work would not have been possible. Jennifer Elliott expresses her deepest gratitude to the members of her advisory committee, Peter Edmunds, Tarik Gouhier, Brian Helmuth and Steve Vollmer for their thoughtful inputs during the execution of this work. This is contribution number 384 from the Marine Science Center at Northeastern University

Physical control of the distributions of a key Arctic copepod in the northeast Chukchi Sea

Submitted in partial fulfillment of the requirements for the degree of Master of Science at the Massachusetts Institute of Technology and the Woods Hole Oceanographic Institution June 2015The copepod Calanus glacialis is one of the most important zooplankton taxa in the Arctic shelf seas where it serves as a key grazer, predator, and food source. Its summer distribution and abundance have direct effects on much of the food web, from blooming phytoplankton to migrating bowhead whales. The Chukchi Sea represents a highly advective regime dominated by a barotropicly driven northward flow modulated by wind driven currents that reach the bottom boundary layer of this shallow environment. In addition, a general northward gradient of decreasing temperature and food concentration leads to geographically divergent copepod growth and development rates. The physics of this system establish the connection potential between specific regions. Unless biological factors are uniform and ideal the true connections will be an uneven subset of this physically derived connection potential. In August 2012 and 2013, C. glacialis distributions were observed over Hanna Shoal in the northeast Chukchi Sea. Here we used the Finite Volume Community Ocean Model i-State Configuration Model to advect these distributions forward and back in time to determine the source and sink regions of the transient Hanna Shoal C. glacialis population. We found that Hanna Shoal supplies diapause competent C. glacialis to both the Beaufort Slope and the Chukchi Cap, mainly receives juveniles from the broad slope between Hanna Shoal and Herald Canyon and receives second year adults from as far as the Anadyr Gulf and as close as the broad slope between Hanna Shoal and Herald Canyon. These connection potentials were not sensitive to precise times and locations of release, but were quite sensitive to depth of release. Deeper particles often traveled further than shallow particles due to strong vertical shear in the shallow Chukchi. The 2013 sink region was shifted west relative to the 2012 region and the 2013 adult source region was shifted north relative to the 2012 region.The U.S. Department of Interior, Bureau of Ocean Energy and Management (BOEM), Alaska Outer Continental Shelf Region, Anchorage, Alaska provided funding for the fieldwork and plankton sample enumeration as part of the Chukchi Sea Offshore Monitoring in Drilling Area (COMIDA) Project and the BOEM Alaska Environmental Studies Program under contract Number M11AC00007 to the University of Texas and a subcontract to the Woods Hole Oceanographic Institution

Post-immunization leucocytosis and its implications for the management of febrile infants.

AIMS: Clinical guidelines for management of infants with fever but no evident focus of infection recommend that those aged 1-3 months with a white cell count >15 × 109/l have a full septic screen and be admitted for parenteral antibiotics. However, there is limited information about leucocyte changes following routine immunization, a common cause of fever. We investigated white cell counts shortly after routine immunization in Ugandan infants under 3 months of age. METHODS: White cell counts were measured in 212 healthy infants following routine immunizations (DTwP-HepB-Hib, oral polio and pneumococcal conjugate 7 vaccines) received prior to 3 months of age. RESULTS: Mean leucocyte counts increased from 9.03 × 109/l (95% confidence interval 8.59-9.47 × 109/l) pre-immunizations to 16.46 × 109/l (15.4-17.52 × 109/l) at one-day post-immunizations at 6 weeks of age, and 15.21 × 109/l (14.07-16.36 × 109/l) at one-day post-immunizations at 10 weeks of age. The leucocytosis was primarily a neutrophilia, with neutrophil percentages one-day post-immunization of 49% at 6 weeks of age and 46% at 10 weeks of age. White cell parameters returned to baseline by two-days post-immunization. No participant received antibiotics when presenting with isolated fever post-immunization and all remained well at follow-up. CONCLUSIONS: In our study almost half the children <3 months old presenting with fever but no evident focus of infection at one-day post-immunization met commonly used criteria for full septic screen and admission for parenteral antibiotics, despite having no serious bacterial infection. These findings add to the growing body of literature that questions the utility of white blood cell measurement in identification of young infants at risk of serious bacterial infections, particularly in the context of recent immunizations, and suggest that further exploration of the effect of different immunization regimes on white cell counts is needed. This observational work was nested within a clinical trial, registration number ISRCTN59683017

Exclusion of Stellar Companions to Exoplanet Host Stars

Given the frequency of stellar multiplicity in the solar neighborhood, it is important to study the impacts this can have on exoplanet properties and orbital dynamics. There have been numerous imaging survey projects established to detect possible low-mass stellar companions to exoplanet host stars. Here we provide the results from a systematic speckle imaging survey of known exoplanet host stars. In total, 71 stars were observed at 692~nm and 880~nm bands using the Differential Speckle Survey Instrument (DSSI) at the Gemini-North Observatory. Our results show that all but 2 of the stars included in this sample have no evidence of stellar companions with luminosities down to the detection and projected separation limits of our instrumentation. The mass-luminosity relationship is used to estimate the maximum mass a stellar companion can have without being detected. These results are used to discuss the potential for further radial velocity follow-up and interpretation of companion signals.Comment: 11 pages, 4 figures, 3 tables, accepted for publication in A

Effect of praziquantel treatment of Schistosoma mansoni during pregnancy on immune responses to schistosome antigens among the offspring: results of a randomised, placebo-controlled trial.

BACKGROUND: Offspring of women with schistosomiasis may exhibit immune responsiveness to schistosomes due to in utero sensitisation or trans-placental transfer of antibodies. Praziquantel treatment during pregnancy boosts maternal immune responses to schistosome antigens and reduces worm burden. Effects of praziquantel treatment during pregnancy on responses among offspring are unknown. METHODS: In a trial of anthelminthic treatment during pregnancy in Uganda (ISRCTN32849447; http://www.controlled-trials.com/ISRCTN32849447/elliott), offspring of women with Schistosoma mansoni were examined for cytokine and antibody responses to schistosome worm (SWA) and egg (SEA) antigen, in cord blood and at age one year. Relationships to maternal responses and pre-treatment infection intensities were examined, and responses were compared between the offspring of women who did, or did not receive praziquantel treatment during pregnancy. RESULTS: Of 388 S. mansoni-infected women studied, samples were obtained at age one year from 215 of their infants. Stool examination for S. mansoni eggs was negative for all infants. Cord and infant samples were characterised by very low cytokine production in response to schistosome antigens with the exception of cord IL-10 responses, which were substantial. Cord and infant cytokine responses showed no association with maternal responses. As expected, cord blood levels of immunoglobulin (Ig) G to SWA and SEA were high and correlated with maternal antibodies. However, by age one year IgG levels had waned and were hardly detectable. Praziquantel treatment during pregnancy showed no effect on cytokine responses or antibodies levels to SWA or SEA either in cord blood or at age one year, except for IgG1 to SWA, which was elevated in infants of treated mothers, reflecting maternal levels. There was some evidence that maternal infection intensity was positively associated with cord blood IL-5 and IL-13 responses to SWA, and IL-5 responses to SEA, and that this association was modified by treatment with praziquantel. CONCLUSIONS: Despite strong effects on maternal infection intensity and maternal immune responses, praziquantel treatment of infected women during pregnancy had no effect on anti-schistosome immune responses among offspring by age one year. Whether the treatment will impact upon the offspring's responses on exposure to primary schistosome infection remains to be elucidated. TRIAL REGISTRATION: ISRCTN: ISRCTN32849447

HealthCare Partners: Building on a Foundation of Global Risk Management to Achieve Accountable Care

Describes the progress of a medical group and independent practice association in forming an accountable care organization by working with insurers as part of the Brookings-Dartmouth ACO Pilot Program. Lists lessons learned and elements of success

Circulating B-lymphocytes as potential biomarkers of tuberculosis infection activity.

Accurate biomarkers of Mycobacterium tuberculosis infection activity would significantly improve early diagnosis, treatment and management of M. tuberculosis infection. We hypothesised that circulating B-lymphocytes may be useful biomarkers of tuberculosis (TB) infection status in highly TB-endemic settings. Ex-vivo and in-vitro mycobacteria-specific B-cell ELISPOT assays were used to examine the plasmablast (PB) and memory B-cell (MBC) responses in the peripheral blood of adult, healthy, community controls (n = 151) and of active TB patients (n = 48) living in Uganda. Frequencies of mycobacteria-specific PBs were markedly higher in active TB patients compared to healthy controls, and, conversely, MBCs were markedly higher in the healthy controls compared to active TB patients. In addition, the community controls with evidence of latent TB infection had higher peripheral blood PB and MBC responses than those without evidence of TB infection. These data demonstrate that peripheral blood B-cell responses are differentially modulated during latent and active M. tuberculosis infection, and suggest that the PB to MBC ratio may be a useful biomarker of TB infection activity

Probabilistic modelling of a rotational energy harvester

Relatively recently, many researchers in the field of energy harvesting have focused on the concept of harvesting electrical energy from relatively large-amplitude, low-frequency vibrations (such as the movement caused by walking motion or ocean waves). This has led to the development of ‘rotational energy harvesters’ which, through the use of a rackand-pinion or a ball-screw, are able to convert low-frequency translational motion into high-frequency rotational motion. A disadvantage of many rotational energy harvesters is that, as a result of friction effects in the motion transfer mechanism, they can exhibit large parasitic losses. This results in nonlinear behaviour, which can be difficult to predict using physical-law-based models. In the current article a rotational energy harvester is built and, through using experimental data in combination with a Bayesian approach to system identification, is modelled in a probabilistic manner. It is then shown that the model can be used to make predictions which are both accurate and robust against modelling uncertainties