Evaluating the Programme for Integrated Child Health

1.1 Background, aims and research questions Improving child health depends on a rounded understanding of what constitutes good child health. Improving child health is not simply a matter of responding to clinical needs, but must involve the psychosocial dimension of care, and the ability to ensure not only that ill-health is treated, but that good health is maintained which includes attention to prevention. Delivering this holistic care depends on effective collaborative practices between hospital-based and community-based settings which have person-centred care as the driving force behind service design. Integration of child health services should offer an efficient approach which is better designed to improve child health, and a crucial aspect of this is effective communication between general practitioners and paediatricians. The Programme for Integrated Child Health (PICH) has been developed in anticipation of a continuing move towards integrating high quality holistic paediatric care and with the aim of preparing paediatric and general practice trainees for new ways of working in the delivery of child health in the community. The aim of this evaluation was firstly to provide a synthesis of current research and perspectives about integrated care through a rapid review of the literature review. Then, subsequently to evaluate participants’ and mentors’ experiences of being involved in the PICH programme, to explore the following research questions: 1. How do course participants evaluate the PICH programme, in particular? a) What are the participants’ views about the structure of the programme? b) What did the participants learn from the programme? 2. What are participants’ views about integrated care and its impact on healthcare, in particular? a) How do participants understand the concept of integrated care, its aims, and its importance? b) What do participants say are the structural issues relevant to delivering integrated care? 3. How does the intraprofessional nature of the programme influence the participants? 1.2 Methodology A rapid review of the literature was followed by a mixed methods empirical study in which 1:1 interviews and ethnographic observations were used to explore the experiences and perceptions of mentors, GPs and paediatric trainees involved in the programme. 1.2.1 Participant sampling framework and recruitment The study population comprised trainees and mentors from Cohorts 1 and 2 of the PICH programme, which corresponded to the first and second years that the programme had run. All participants volunteered to take part in the study. The induction session from Cohort 3 was observed further research with that cohort was outside of the scope of this evaluation. 1.2.2 Data gathering Three PICH programme sessions were observed and 23 one-to-one participant interviews took place. A semi-structured interview schedule guided all interviews and they were audio-recorded and subsequently transcribed verbatim by a professional stenographer. 1.2.3 Data analysis Observation data and interview transcripts were subjected to thematic analysis. QSR NVivo 11© software was used to assist in the analysis and ensure inter-coder reliability. Data was analysed inductively from themes arising from the data but also deductively in response to the research questions. 1.2.4 Ethics Ethical approval was granted by UCL Research ethics committee (Ref: 8949/001). Participants gave their consent verbally at the start of the interviews. 1.3 Results 1.3.1 Participants Four teaching sessions were observed, three from cohort 2 and the induction session from cohort 3. One-to-one interviews were conducted with 23 participants. 1.3.2 Main findings 1.3.2.1 Programme evaluation The PICH programme was perceived to be well run, worthwhile, and provided the desired benefits in terms of education and learning about how integrated care can be delivered. The observations and interviews both revealed the enthusiasm of participants, mentors and programme leads and this undoubtedly contributed to the supportive yet ‘buzzing’ atmosphere described by many of the course participants. The induction session, the project website, the mentoring scheme, and the monthly seminars were all largely evaluated positively. There were some complications, for example, it was difficult for all trainees to attend all seminars due to busy work schedules. The induction was felt to be rather long and presentations, whilst of immense high quality, were perceived to be ‘too good’ and somewhat intimidating. Mentorship and support was appreciated by many of the trainees, both peers and mentors provided sources of influential advice. Some trainees felt that the mentoring was too open-ended and those who were unable to finalise their projects at the end of the year missed out on guidance. One critical component of the programme was the project. It caused both frustration and pleasure. Where barriers and delays were encountered, which derailed participants from submitting in a timely fashion, they often felt disappointment. However, many reflected later on the generic learning and the importance of the process. The projects gave participants a deep understanding of how using real data could influence traditional systems: an authentic problem-based approach. It also provided a sense of autonomy, enabling them to craft something of personal and professional relevance, to innovate and shape their own clinical environment. There was a widespread and positive perception of the style of learning delivered by the PICH programme. The aims of the project were clearly and spontaneously articulated in the interviews, demonstrating the success in delivering the PICH programme. Whilst participants did talk about learning clinical knowledge and skills in a speciality to which they would not necessarily have exposure, the vast majority of their talk was directed towards their own personal development: gaining confidence, independence, forming networks, tools for individual reflection and application. An important finding from the interviews, with both trainees and mentors, was that the course appeared to be successful in delivering tools for leadership too. Participants acquired skills to take forward integrated care initiatives; ready to enact change as ‘leaders’ of integrated care for the future. 1.3.2.2 Integrated care Trainees and mentors on the PICH programme were all integrated care enthusiasts, having been involved in other educational initiatives, in particular the ‘Learning Together’ clinics or having prior interest in the area. The rationale for integrating care was well understood and articulated by participants. All participants perceived a drive towards integration as rational, since they specified the patient must always be at the centre of care and it is in the patient’s interest that care is seamless, which integrated care enables. Moreover, there was a widespread feeling that integrated care is an idea whose time has come, not only because of the growing prominence of ‘patient-centred care’ as an ideal, but also given the need to increase efficiency in view of increasing economic pressures on healthcare. Participants were hopeful that integrated care was a driver for positive health systems change and believed that more integration was inevitable. However, they were mindful of significant barriers to implementation, including financial and territorial issues. Integrated care was reported to impact on patient care positively. Specific examples of overcoming current voids in the system were smoother referral processes and getting timely specialist advice. Integrated care was also felt to improve efficiency by preventing work from being duplicated. Integration was seen as an important concept centralizing the patient in systems-based re-organisation of health care which was likely to have tangible positive impacts for children and their families. 1.3.2.3 Integrated professions One of the most influential aspects of the programme was the creation of a shared spare for participants to talk about providing care by sharing stories. These narratives became fuller and more nuanced as the diversity of the participants increased. There were frequent stories about how responsibilities are shared within child health care and this provided the impetus for them to start thinking critically about how professional boundaries interlock and / or cross over between paediatrics and general practice. They talked about the vital role of effective communication in both the intra as well as interprofessional context, although the vast majority of the dialogue related to the latter. Communication was seen as a means of establishing effective relationships and reciprocally, building relationships resulted in improved communication and improved sharing of information. During the PICH programme participants’ learnt about seeing the other side of things, others working environment, the burden of paediatric clinical work, service pressures and affiliated health care networks which supported or undermined clinical practice. It was clear that their close perceived professional alignment – paediatricians and GP – was a natural one. However, alignment was not reported as universal. Certain specialities were not seen to align as similarly, which may be problematic for implementing future integrated care pathways. Participants gained a deeper understanding of the differences and similarities in each other’s clinical roles and how, crucially, they would now alter their own professional practice to take these into account. They became a more ‘blended professional’; one who adapts their own practice mindful of the others. This emergence of a blended professional raises the concept of professional identity, how they thought about themselves in their clinical capacity and how stepping out of traditional identities and thus roles aided the development of them as integrated professionals. 1.4 Conclusions The PICH programme was highly evaluated by participants and mentors. The overall feeling was that of a generally well-run course, which was populated by enthusiastic mentors and trainees, and which led to significant learning for everyone involved. Fundamental to its success were two key ingredients. Firstly, the learning environment established at the seminars provided both support and challenge from peers and senior colleagues and secondly, the project which allowed participants to engage with data, work with authentic problems and innovate. Whilst there were logistic issues with attendance and some frustration about project completion participant’s reported developing clinical, professional and transferable skills including leadership. Participants were all enthusiastic adopters of the concept of integrated care. However, they were aware of the practical realities of implementation, often significant structural barriers, but considered integrated care to be an effective patient-centred model for health service development. Alongside organisational systems participants learnt, through the PICH programme, the importance of the interpersonal. They articulated the value of understanding and adapting roles and identities to change professional behaviours and how to work as ‘integrated professionals’

Does the structure of the medical consultation align with an educational model of clinical communication? A study of physicians’ consultations from a postgraduate examination

OBJECTIVE: This study examined whether the structure of consultations in which physicians were tasked with sharing information corresponded to the chronological stages proposed by an established educational model of clinical communication. METHOD: Seventy six simulated consultations from a postgraduate examination for general medical hospital physicians were transcribed verbatim and converted into diagrams showing consultation structure. All doctor-patient/relative talk was allocated into six phases: Initiating, Gathering information, Summary, Explanation, Planning and Closing, using the ‘communication process skills’ from the Calgary-Cambridge Guide to the Medical Interview. RESULTS: The majority of consultations included four or five of the expected phases, with most talk (41-92%) in Explanation and Planning. There was no discernible consistency of structure across the consultations or in consultations from the same scenario. Consultations varied in the presence, sequential order, size, location and reappearance of phases. CONCLUSIONS: The structure of consultations in this standardised setting bore little resemblance to the chronological order of phases predicted by an educational model. PRACTICE IMPLICATIONS: Educational guidance and interventions to support patients in preparing for consultations need to take account of doctors’ behaviour in practice. Assumptions about the organisation of medical consultations should be queried in the absence of an evidence base

Development of microdialysis methodology for interstitial insulin measurement in rodents.

INTRODUCTION: Accurate assessment of muscle insulin sensitivity requires measurement of insulin concentration in interstitial fluid (ISF), but has proved difficult. We aimed to optimise measurement of ISF insulin concentrations in rat muscles in vivo using microdialysis. METHODS: Factorial experimental design experiments were performed in vitro to determine optimal conditions for insulin recovery with microdialysis probes. These conditions were tested in vivo, adjusted appropriately and used in lean and obese Zucker rats to compare ISF insulin concentrations basally and during hyperinsulinaemic-euglycaemic (HE) clamp. RESULTS: Optimal conditions in vivo were: a 100kDa microdialysis probe inserted in muscle, perfused with 1% BSA, 1.5mM glucose in 0.9% sodium chloride at 1μl/min. Samples were collected into siliconised glass microvials. As a reference for insulin, we established a protocol of inulin infusion, beginning at -80min and reaching equilibrium within 60min. HE clamp, beginning at 0min, increased ISF insulin concentration from 122±56 basally to 429±180pmol/l (P<0.05) in lean rats and from 643±165 to 1087±243pmol/l (P=0.07) in obese rats; ISF insulin concentrations were significantly higher throughout in obese rats. The difference between ISF and plasma insulin concentration (ISF:plasma ratio) was substantially higher in obese rats, but fell to similar values in obese and lean rats during HE clamp. DISCUSSION: Optimising insulin recovery with microdialysis allowed accurate measurement of basal ISF insulin in muscle of lean and obese Zucker rats and indicates insulin transport across capillaries is impaired in obese rats, basally and during hyperinsulinaemia

Why Are Male Social Relationships Complex in the Doubtful Sound Bottlenose Dolphin Population?

Copyright 2008 Elsevier B.V., All rights reserved.Peer reviewedPublisher PD

Unrelated Helpers in a Primitively Eusocial Wasp: Is Helping Tailored Towards Direct Fitness?

The paper wasp Polistes dominulus is unique among the social insects in that nearly one-third of co-foundresses are completely unrelated to the dominant individual whose offspring they help to rear and yet reproductive skew is high. These unrelated subordinates stand to gain direct fitness through nest inheritance, raising the question of whether their behaviour is adaptively tailored towards maximizing inheritance prospects. Unusually, in this species, a wealth of theory and empirical data allows us to predict how unrelated subordinates should behave. Based on these predictions, here we compare helping in subordinates that are unrelated or related to the dominant wasp across an extensive range of field-based behavioural contexts. We find no differences in foraging effort, defense behaviour, aggression or inheritance rank between unrelated helpers and their related counterparts. Our study provides no evidence, across a number of behavioural scenarios, that the behaviour of unrelated subordinates is adaptively modified to promote direct fitness interests

Effects of water potential on spore germination and viability of Fusarium species

Germination of macroconidia and/or microconidia of 24 strains of Fusarium solani, F. chlamydosporum, F. culmorum, F. equiseti, F. verticillioides, F. sambucinum, F. oxysporum and F. proliferatum isolated from fluvial channels and sea beds of the south-eastern coast of Spain, and three control strains (F. oxysporum isolated from affected cultures) was studied in distilled water in response to a range of water potentials adjusted with NaCI. (0, -13.79, -41.79, -70.37, -99.56 and -144.54 bars). The vialibility (UFC/ml) of suspension was also tested in three time periods (0,24 and 48h). Conidia always germinated in distilled water. The pattern of conidial germination obseved of F. verticillioides, F. oxysporum, F. proliferatum, F. chlamydosporum and F. culmorum was similar. A great diminution of spore germination was found in -13.79 bars solutions. Spore germination percentage for F. solani isolates was maximal at 48 h. and -13.79 bars with 21.33% spore germination, 16% higher than germination in distilled water. F. equiseti shows the maximum germination percentage in -144.54 bars solution in 24 h time with 12.36% germination. These results did not agree with those obtained in the viability test where maximum germination was found in distilled water. The viability analysis showed the great capacity of F. verticilloides strains to form viable colonies, even in such extreme conditions as -144,54 bars after 24 h F. proliferatum colony formation was prevented in the range of -70.37 bars. These results show the clear affectation of water potential to conidia germination of Fusaria. The ability of certain species of Fusarium to develop a saprophytic life in the salt water of the Mediterraneam Sea could be certain. Successful germination, even under high salty media conditions, suggests taht Fusarium spp. could have a competitive advantage over other soil fungi in crops irrigated with saline water. In the specific case of F. solani, water potential of -13.79 bars affected germination positively. It could indicate that F. solani has an special physiological mechanism of survival in low water potential environments

Flat Clathrin Lattices: stable features of the plasma membrane

Clathrin-mediated endocytosis (CME) is a fundamental property of eukaryotic cells. Classical CME proceeds via the formation of clathrin-coated pits (CCP) at the plasma membrane that invaginate to form clathrin-coated vesicles; a process that is well understood. However, clathrin also assembles into flat clathrin lattices (FCL); these structures remain poorly described and their contribution to cell biology is unclear. We have used quantitative imaging to provide the first comprehensive description of FCL and explore their influence on plasma membrane organization. Ultrastructural analysis by electron and super-resolution microscopy revealed two discrete populations of clathrin structures. CCP were typified by their sphericity, small size and homogeneity. FCL were planar, large and heterogeneous, and present on both the dorsal and ventral surfaces of cells. Live microscopy demonstrated that CCP are short-lived and culminate in a peak of dynamin recruitment, consistent with classical CME. In contrast, FCL were long-lived with sustained association with dynamin. We investigated the biological relevance of FCL using the chemokine receptor CCR5 as a model system. Agonist activation leads to sustained recruitment of CCR5 to FCL. Quantitative molecular imaging indicated that FCL partitioned receptors at the cell surface. Our observations suggest that FCL provide stable platforms for the recruitment of endocytic cargo

Bright ligand-activatable fluorescent protein for high-quality multicolor live-cell super-resolution microscopy

We introduce UnaG as a green-to-dark photoswitching fluorescent protein capable of high-quality super-resolution imaging with photon numbers equivalent to the brightest photoswitchable red protein. UnaG only fluoresces upon binding of a fluorogenic metabolite, bilirubin, enabling UV-free reversible photoswitching with easily controllable kinetics and low background under Epi illumination. The on- and off-switching rates are controlled by the concentration of the ligand and the excitation light intensity, respectively, where the dissolved oxygen also promotes the off-switching. The photo-oxidation reaction mechanism of bilirubin in UnaG suggests that the lack of ligand-protein covalent bond allows the oxidized ligand to detach from the protein, emptying the binding cavity for rebinding to a fresh ligand molecule. We demonstrate super-resolution single-molecule localization imaging of various subcellular structures genetically encoded with UnaG, which enables facile labeling and simultaneous multicolor imaging of live cells. UnaG has the promise of becoming a default protein for high-performance super-resolution imaging. Photoconvertible proteins occupy two color channels thereby limiting multicolour localisation microscopy applications. Here the authors present UnaG, a new green-to-dark photoswitching fluorescent protein for super-resolution imaging, whose activation is based on a noncovalent binding with bilirubin

A scoping review of the implications of adult obesity in the delivery and acceptance of dental care.

Background Due to the increasing prevalence of obesity within the general population it is presumed that the prevalence of overweight and obese adults accessing dental services will also increase. For this reason dentists need to be aware of implications of managing such patients.Methods A scoping review was carried out. Both Medline via OVID and Scopus databases were searched along with grey literature databases and the websites of key organizations. Inclusion and exclusion criteria were established. The data were collected on a purpose-made data collection form and analysed descriptively.Results The review identified 28 relevant published articles and two relevant items of grey literature. Following review of this literature three themes relating to adult obesity in the delivery and acceptance of dental care emerged; clinical, service delivery and patient implications. The majority of the papers focused on the clinical implications.Conclusion On the topic of adult obesity and dental care, the majority of published and grey literature focuses on the clinical implications. Further research is needed on both the patients' perspectives of being overweight or obese and the delivery and acceptance of dental care and the service delivery implications

Diagnosis and monitoring for light chain only and oligosecretory myeloma using serum free light chain tests

This study aims to guide the integration of serum free light chain (sFLC) tests into clinical practice, including a new rapid test (Seralite®). Blood and urine analysis from 5573 newly diagnosed myeloma patients identified 576 light chain only (LCO) and 60 non-secretory (NS) cases. Serum was tested by Freelite® and Seralite® at diagnosis, maximum response and relapse. 20% of LCO patients had urine FLC levels below that recommended for measuring response but >97% of these had adequate sFLC levels (oligosecretory). The recommended Freelite® sFLC ≥100 mg/l for measuring response was confirmed and the equivalent Seralite® FLC difference (dFLC) >20 mg/l identified. By both methods, ≥38% of NS patients had measurable disease (oligosecretory). Higher sFLC levels were observed on Freelite® at all time points. However, good clinical concordance was observed at diagnosis and in response to therapy. Achieving at least a very good partial response according to either sFLC method was associated with better patient survival. Relapse was identified using a Freelite® sFLC increase >200 mg/l and found 100% concordance with a corresponding Seralite® dFLC increase >30 mg/l. Both Freelite® and Seralite® sensitively diagnose and monitor LCO/oligosecretory myeloma. Rapid testing by Seralite® could fast-track FLC screening and monitoring. Response by sFLC assessment was prognostic for survival and demonstrates the clinical value of routine sFLC testing