Practice transformations to optimize the delivery of HIV primary care in community healthcare settings in the United States: A program implementation study.

BackgroundThe United States HIV care workforce is shrinking, which could complicate service delivery to people living with HIV (PLWH). In this study, we examined the impact of practice transformations, defined as efficiencies in structures and delivery of care, on demonstration project sites within the Workforce Capacity Building Initiative, a Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program Special Projects of National Significance (SPNS).Methods and findingsData were collected at 14 demonstration project sites in 7 states and the District of Columbia. Organizational assessments were completed at sites once before and 4 times after implementation. They captured 3 transformation approaches: maximizing the HIV care workforce (efforts to increase the number of existing healthcare workforce members involved in the care of PLWH), share-the-care (team-based care giving more responsibility to midlevel providers and staff), and enhancing client engagement in primary HIV care to reduce emergency and inpatient care (e.g., care coordination). We also obtained Ryan White HIV/AIDS Program Services Reports (RSRs) from sites for calendar years (CYs) 2014-2016, corresponding to before, during, and after transformation. The RSR include data on client retention in HIV care, prescription of antiretroviral therapy (ART), and viral suppression. We used generalized estimating equation (GEE) models to analyze changes among sites implementing each practice transformation approach. The demonstration projects had a mean of 18.5 prescribing providers (SD = 23.5). They reported data on more than 13,500 clients per year (mean = 969/site, SD = 1,351). Demographic characteristics remained similar over time. In 2014, a majority of clients were male (71% versus 28% female and 0.2% transgender), with a mean age of 47 (interquartile range [IQR] 37-54). Racial/ethnic characteristics (48% African American, 31% Hispanic/Latino, 14% white) and HIV risk varied (31% men who have sex with men; 31% heterosexual men and women; 7% injection drug use). A substantial minority was on Medicaid (41%). Across sites, there was significant uptake in practices consistent with maximizing the HIV care workforce (18% increase, p < 0.001), share-the-care (25% increase, p < 0.001), and facilitating patient engagement in HIV primary care (13% increase, p < 0.001). There were also significant improvements over time in retention in HIV care (adjusted odds ratio [aOR] = 1.03; 95% confidence interval [CI] 1.02-1.04; p < 0.001), ART prescription levels (aOR = 1.01; 95% CI 1.00-1.01; p < 0.001), and viral suppression (aOR = 1.03; 95% CI 1.02-1.04; p < 0.001). All outcomes improved at sites that implemented transformations to maximize the HIV care workforce or improve client engagement. At sites that implemented share-the-care practices, only retention in care and viral suppression outcomes improved. Study limitations included use of demonstration project sites funded by the Ryan White HIV/AIDS Program (RWHAP), which tend to have better HIV outcomes than other US clinics; varying practice transformation designs; lack of a true control condition; and a potential Hawthorne effect because site teams were aware of the evaluation.ConclusionsIn this study, we found that practice transformations are a potential strategy for addressing anticipated workforce challenges among those providing care to PLWH. They hold the promise of optimizing the use of personnel and ensuring the delivery of care to all in need while potentially enhancing HIV care continuum outcomes

Deep Near-IR Surface Photometry of 57 Galaxies in the Local Sphere of Influence

We present H-band surface photometry of 57 galaxies drawn from the Local Sphere of Influence (LSI) with distances of less than 10 Mpc from the Milky Way. The images with a typical surface brightness limit 4 mag fainter than 2MASS (24.5 mag arcsec^-2 < sb_lim < 26 mag arcsec ^-2) have been obtained with IRIS2 on the 3.9 m Anglo-Australian Telescope. A total of 22 galaxies that remained previously undetected in the near-IR and potentially could have been genuinely young galaxies were found to have an old stellar population with a star density 1-2 magnitudes below the 2MASS detection threshold. The cleaned near-IR images reveal the morphology and extent of many of the galaxies for the first time. For all program galaxies, we derive radial luminosity profiles, ellipticities, and position angles, together with global parameters such as total magnitude, mean effective surface brightness and half-light radius. Our results show that 2MASS underestimates the total magnitude of galaxies with _eff between 18-21 mag arcsec^-2 by up to 2.5 mag. The Sersic parameters best describing the observed surface brightness profiles are also presented. Adopting accurate galaxy distances and a H-band mass-to-light ratio of Upsilon_H=1.0 +/- 0.4, the LSI galaxies are found to cover a stellar mass range of 5.6 < log_10 (M_stars) < 11.1. The results are discussed along with previously obtained optical data. Our sample of low luminosity galaxies is found to follow closely the optical-infrared B versus H luminosity relation defined by brighter galaxies with a slope of 1.14 +/- 0.02 and scatter of 0.3 magnitudes. Finally we analyse the luminosity - surface brightness relation to determine an empirical mass-to-light ratio of Upsilon_H=0.78 +/- 0.08 for late-type galaxies in the H-band.Comment: Accepted by AJ. High resolution version available at http://www.mso.anu.edu.au/~emma/KirbyHband.pd

A multicentre study of the evidence for customized margins in photon breast boost radiotherapy

Objective:To determine if subsets of patients may benefit from smaller or larger margins when using laser setup and bony anatomy verification of breast tumour bed (TB) boost radiotherapy (RT).Methods: Verification imaging data acquired using cone-beam CT, megavoltage CT or two-dimensional kilovoltage imaging on 218 patients were used (1574 images). TB setup errors for laser-only setup (dlaser) and for bony anatomy verification (dbone) were determined using clips implanted into the TB as a gold standard for the TB position. Cases were grouped by centre-, patient- and treatment-related factors, including breast volume, TB position, seroma visibility and surgical technique. Systematic (?) and random (?) TB setup errors were compared between groups, and TB planning target volume margins (MTB) were calculated.Results: For the study population, ?laser was between 2.8 and 3.4?mm, and ?bone was between 2.2 and 2.6?mm, respectively. Females with larger breasts (p?=?0.03), easily visible seroma (p???0.02) and open surgical technique (p???0.04) had larger ?laser. ?bone was larger for females with larger breasts (p?=?0.02) and lateral tumours (p?=?0.04). Females with medial tumours (p?&lt;?0.01) had smaller ?bone.Conclusion:If clips are not used, margins should be 8 and 10?mm for bony anatomy verification and laser setup, respectively. Individualization of TB margins may be considered based on breast volume, TB and seroma visibility.Advances in knowledge:Setup accuracy using lasers and bony anatomy is influenced by patient and treatment factors. Some patients may benefit from clip-based image guidance more than others

In one’s own time: Contesting the temporality and linearity of bereavement

This article explores the experience and meaning of time from the perspective of caregivers who have recently been bereaved following the death of a family member. The study is situated within the broader cultural tendency to understand bereavement within the logic of stages, including the perception of bereavement as a somewhat predictable and certainly time-delimited ascent from a nadir in death to a ‘new normal’ once loss is accepted. Drawing on qualitative data from interviews with 15 bereaved family caregivers we challenge bereavement as a linear, temporally bound process, examining the multiple ways bereavement is experienced and how it variously resists ideas about the timeliness, desirability and even possibility of ‘recovery’. We posit, on the basis of these accounts, that the lived experience of bereavement offers considerable challenges to normative understandings of the social ties between the living and the dead and requires a broader reconceptualization of bereavement as an enduring affective state

The p.M292T NDUFS2 mutation causes complex I-deficient Leigh syndrome in multiple families

Isolated complex I deficiency is the most frequently observed oxidative phosphorylation defect in children with mitochondrial disease, leading to a diverse range of clinical presentations, including Leigh syndrome. For most patients the genetic cause of the biochemical defect remains unknown due to incomplete understanding of the complex I assembly process. Nonetheless, a plethora of pathogenic mutations have been described to date in the seven mitochondrial-encoded subunits of complex I as well as in 12 of the nuclear-encoded subunits and in six assembly factors. Whilst several mitochondrial DNA mutations are recurrent, the majority of these mutations are reported in single families. We have sequenced core structural and functional nuclear-encoded subunits of complex I in a cohort of 34 paediatric patients with isolated complex I deficiency, identifying pathogenic mutations in 6 patients. These included a novel homozygous NDUFS1 mutation in an Asian child with Leigh syndrome, a previously identified NDUFS8 mutation (c.236C>T, p.P79L) in a second Asian child with Leigh-like syndrome and six novel, compound heterozygous NDUFS2 mutations in four white Caucasian patients with Leigh or Leigh-like syndrome. Three of these children harboured an identical NDUFS2 mutation (c.875T>C, p.M292T), which was also identified in conjunction with a novel NDUFS2 splice site mutation (c.866+4A>G) in a fourth Caucasian child who presented to a different diagnostic centre, with microsatellite and single nucleotide polymorphism analyses indicating that this was due to an ancient common founder event. Our results confirm that NDUFS2 is a mutational hotspot in Caucasian children with isolated complex I deficiency and recommend the routine diagnostic investigation of this gene in patients with Leigh or Leigh-like phenotypes

Bidirectional Relations Between Parenting and Behavior Problems From Age 8 to 13 in Nine Countries

This study used data from 12 cultural groups in nine countries (China, Colombia, Italy, Jordan, Kenya, Philippines, Sweden, Thailand, and the United States; N = 1,298) to understand the cross‐cultural generalizability of how parental warmth and control are bidirectionally related to externalizing and internalizing behaviors from childhood to early adolescence. Mothers, fathers, and children completed measures when children were ages 8–13. Multiple‐group autoregressive, cross‐lagged structural equation models revealed that child effects rather than parent effects may better characterize how warmth and control are related to child externalizing and internalizing behaviors over time, and that parent effects may be more characteristic of relations between parental warmth and control and child externalizing and internalizing behavior during childhood than early adolescence

Boys’ and Girls’ Relational and Physical Aggression in Nine Countries

Distinguishing between relational and physical aggression has become a key feature of many developmental studies in North America and Western Europe, but very little information is available on relational aggression in more diverse cultural contexts. This study examined the factor structure of, gender differences in, and associations between relational and physical aggression in China, Colombia, Italy, Jordan, Kenya, the Philippines, Sweden, Thailand, and the United States. Children ages 7 to 10 years (N = 1410) reported on their relationally and physically aggressive behavior. Relational and physical aggression shared a common factor structure across countries. Unsurprisingly, boys reported being more physically aggressive than girls across all nine countries; surprisingly, there were no significant gender differences in relational aggression. In all nine countries, relational and physical aggression were significantly correlated (average r = .49). The countries differed significantly in the mean levels of both relational and physical aggression that children reported using and with respect to whether children reported using more physical than relational aggression or more relational than physical aggression. Despite mean level differences in relational and physical aggression across countries, the findings provided support for cross-country similarities in associations between relational and physical aggression, as well as links between gender and aggression

Parenting, culture, and the development of externalizing behaviors from age 7 to 14 in nine countries

Using multilevel models, we examined mother-, father-, and child-reported (N = 1,336 families) externalizing behavior problem trajectories from age 7 to 14 in nine countries (China, Colombia, Italy, Jordan, Kenya, the Philippines, Sweden, Thailand, and the United States). The intercept and slope of children\u27s externalizing behavior trajectories varied both across individuals within culture and across cultures, and the variance was larger at the individual level than at the culture level. Mothers’ and children\u27s endorsement of aggression as well as mothers’ authoritarian attitudes predicted higher age 8 intercepts of child externalizing behaviors. Furthermore, prediction from individual-level endorsement of aggression and authoritarian attitudes to more child externalizing behaviors was augmented by prediction from cultural-level endorsement of aggression and authoritarian attitudes, respectively. Cultures in which father-reported endorsement of aggression was higher and both mother- and father-reported authoritarian attitudes were higher also reported more child externalizing behavior problems at age 8. Among fathers, greater attributions regarding uncontrollable success in caregiving situations were associated with steeper declines in externalizing over time. Understanding cultural-level as well as individual-level correlates of children\u27s externalizing behavior offers potential insights into prevention and intervention efforts that can be more effectively targeted at individual children and parents as well as targeted at changing cultural norms that increase the risk of children\u27s and adolescents’ externalizing behavior