Australian home care quality : a political tango

The performance of Australian home care and how it is enacted has been significantly impacted by the economic and political challenges since the announcement of the Aged Care Reforms in July 2012 and the launch of the National Disability Insurance Scheme in July 2013. As a result, the home care business arena has changed, and the effects are being felt as the marketplace shifts, and businesses adapt to new policy directions. The purpose of this research study was to investigate the social context of Australian home care, and to collect information regarding how home care (under the various auspices of government funded and privately funded) service provision is enacted in terms of quality during this time of change. The qualitative research process for this study involved critical reflexive practice and face-to-face semi-structured interviews of 10 home care business leaders from the states of Queensland and Victoria. In listening to the voices of the participants, this research study sought to develop new discursive approaches in order to understand the practice of caring for the Australian community’s most vulnerable people – those who are frail, aged, and for those who have ill-health or a disability. The analytical framework adopted for this study used a post-structural discourse analysis, which was informed by the work of French philosopher Michel Foucault and other contemporary theorists. The philosophical framework of governmentality and discourse analysis helped to situate the voice of the participants at a time when new ideas and the ways of conducting the business of home care are emerging. In using this approach to analyse the data, it became apparent that the discursive practices that had been instituted by government in the home care sector had been constructed to remove progressive inclusionary policies that were contrary to the democratic principles of governing. The research study’s findings reveal the problematic changes that impact on business but more so for consumers as the rules are interpreted. By using the metaphor of ice dancing, the study problematized the leadership of government and the challenges participants faced in maintaining quality service provision in the home care arena. What emerged was the dance of a political tango. These leaders in the arena revealed the importance of knowing when to lead and when to push back. Like the different genres of tango, there are different ways of viewing the world of home care and performing in its different spaces, and there are other ways of viewing quality in caring service provisions. By participating in the research, the participants highlighted the need of being inclusive to hearing and seeing all performers in the arena of home care regardless of social or geographical positioning. This research concludes that hearing and acting on the voices from the wider home care arena continues to be necessary in order to inform future policy direction for quality performance improvements for Australia’s consumers of home care and to move away from home care traditions of governing and ruling. The research additionally advocates for more inclusive governing approaches through more even distribution of power in consultative processes, research, oversight in the marketplace and access to resources for all groups. This thesis is a contribution to creating a new political dance in the space of Australia’s home care politics.Doctor of Philosoph

Risk factors for congenital chondrodystrophy of unknown origin in beef cattle herds in south-eastern Australia

A case control study was conducted on 46 farms in south eastern Australia with a recent history of congenital chondrodystrophy of unknown origin (CCUO) between 2002 and 2007. For each farm data was collected using face-to-face interviews concerning the management of case and control mobs during the gestation period in which affected calves were born. Data concerning the paddocks in which gestating cattle were maintained was also collected for analysis. Three separate multivariable models were constructed using generalised linear mixed models (GLMM). The first model was based on the dichotomous outcome of mob status (affected/not affected) and included explanatory variables for management and environment factors. The second model used a novel approach, taking into account the number of cases in affected mobs in order to utilise available data. The outcome events/ trials was used where the numerator was equal to the number of affected calves in a mob, and the denominator was equal to the total number of calves in the mob. The third model used the dichotomous outcome paddock status and included environmental and soil variables for paddocks involved with case and control mobs. Confounding for dam age and year affected was included in the mob outcome models, and random effects for paddock and farm were incorporated into the models. The birth of CCUO calves was associated with dams grazing native pastures on hilly terrain during gestation. Low levels of pasture were also associated with the outcome. The two models used for the mob outcome were similar in many respects. The events/trial model included the use of supplemental feed and an interaction term. This study demonstrates an association between a maternal nutritional disturbance and the occurrence of CCUO. Keywords: Risk factors, congenital chondrodystrophy, case control study, epidemiology, Australiafunded by Meat and Livestock Australi

Why do Models Overestimate Surface Ozone in the Southeastern United States?

Ozone pollution in the Southeast US involves complex chemistry driven by emissions of anthropogenic nitrogen oxide radicals (NOx = NO + NO2) and biogenic isoprene. Model estimates of surface ozone concentrations tend to be biased high in the region and this is of concern for designing effective emission control strategies to meet air quality standards. We use detailed chemical observations from the SEAC4RS aircraft campaign in August and September 2013, interpreted with the GEOS-Chem chemical transport model at 0.25 deg. x 0.3125 deg. horizontal resolution, to better understand the factors controlling surface ozone in the Southeast US. We find that the National Emission Inventory (NEI) for NOx from the US Environmental Protection Agency (EPA) is too high. This finding is based on SEAC4RS observations of NOx and its oxidation products, surface network observations of nitrate wet deposition fluxes, and OMI satellite observations of tropospheric NO2 columns. Our results indicate that NEI NOx emissions from mobile and industrial sources must be reduced by 30-60%, dependent on the assumption of the contribution by soil NOx emissions. Upper tropospheric NO2 from lightning makes a large contribution to satellite observations of tropospheric NO2 that must be accounted for when using these data to estimate surface NOx emissions. We find that only half of isoprene oxidation proceeds by the high-NOx pathway to produce ozone; this fraction is only moderately sensitive to changes in NOx emissions because isoprene and NOx emissions are spatially segregated. GEOS-Chem with reduced NOx emissions provides an unbiased simulation of ozone observations from the aircraft, and reproduces the observed ozone production efficiency in the boundary layer as derived from a 15 regression of ozone and NOx oxidation products. However, the model is still biased high by 8 +/- 13 ppb relative to observed surface ozone in the Southeast US. Ozonesondes launched during midday hours show a 7 ppb ozone decrease from 1.5 km to the surface that GEOS-Chem does not capture. This bias may reflect a combination of excessive vertical mixing and net ozone production in the model boundary layer

Supporting People With Type 2 Diabetes in the Effective Use of Their Medicine Through Mobile Health Technology Integrated With Clinical Care to Reduce Cardiovascular Risk : Protocol for an Effectiveness and Cost-effectiveness Randomized Controlled Trial

Funding Information: The Support Through Mobile Messaging and Digital Health Technology for Diabetes research team acknowledges the support of the National Institute for Health Research (NIHR) through the Clinical Research Networks. AF, LT, and RR have received support from the NIHR Oxford Biomedical Research Centre. RH received support from the NIHR Collaboration for Leadership in Applied Health Research and Care and North Thames at Bart's Health National Health Service (NHS) Trust. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health. This paper presents independent research funded by the NIHR under its Program Grants for Applied Research as part of a wider program of work (RP-PG-1214-20003). The authors thank the personnel of the University of Oxford Primary Care and Vaccines Clinical Trials Collaborative for providing support in the conduct of the trial.Peer reviewedPublisher PD

An automated software system to promote anticoagulation and reduce stroke risk: cluster-randomized controlled trial

Background and Purpose: Oral anticoagulants (OAC) substantially reduce risk of stroke in atrial fibrillation, but uptake is suboptimal. Electronic health records enable automated identification of people at risk but not receiving treatment. We investigated the effectiveness of a software tool (AURAS-AF [Automated Risk Assessment for Stroke in Atrial Fibrillation]) designed to identify such individuals during routine care through a cluster-randomized trial.Methods: Screen reminders appeared each time the electronic health records of an eligible patient was accessed until a decision had been taken over OAC treatment. Where OAC was not started, clinicians were prompted to indicate a reason. Control practices continued usual care. The primary outcome was the proportion of eligible individuals receiving OAC at 6 months. Secondary outcomes included rates of cardiovascular events and reports of adverse effects of the software on clinical decision-making.Results: Forty-seven practices were randomized. The mean proportion–prescribed OAC at 6 months was 66.3% (SD=9.3) in the intervention arm and 63.9% (9.5) in the control arm (adjusted difference 1.21% [95% confidence interval −0.72 to 3.13]). Incidence of recorded transient ischemic attack was higher in the intervention practices (median 10.0 versus 2.3 per 1000 patients with atrial fibrillation; P=0.027), but at 12 months, we found a lower incidence of both all cause stroke (P=0.06) and hemorrhage (P=0.054). No adverse effects of the software were reported.Conclusions: No significant change in OAC prescribing occurred. A greater rate of diagnosis of transient ischemic attack (possibly because of improved detection or overdiagnosis) was associated with a reduction (of borderline significance) in stroke and hemorrhage over 12 months.Clinical Trial Registration: URL: http://www.isrctn.com. Unique Identifier: ISRCTN55722437.%U http://stroke.ahajournals.org/content/strokeaha/early/2017/01/24/STROKEAHA.116.015468.full.pd

Barriers to a software reminder system for risk assessment of stroke in atrial fibrillation: a process evaluation of a cluster randomised trial in general practice

Background: Oral anticoagulants reduce the risk of stroke in patients with atrial fibrillation (AF), but are underused. AURAS-AF (AUtomated Risk Assessment for Stroke in AF) is a software tool designed to identify eligible patients and promote discussions within consultations about initiating anticoagulants.Aim: To investigate the implementation of the software in UK general practice.Design and setting: Process evaluation involving 23 practices randomly allocated to use AURAS-AF during a cluster randomised trial.Method: An initial invitation to discuss anticoagulation was followed by screen reminders appearing during consultations until a decision had been made. The reminders required responses, giving reasons for cases where an anticoagulant was not initiated. Qualitative interviews with clinicians and patients explored acceptability and usability.Results: In a sample of 476 patients eligible for the invitation letter, only 159 (33.4%) were considered suitable for invitation by their GPs. Reasons given were frequently based on frailty, and risk of falls or haemorrhage. Of those invited, 35 (22%) started an anticoagulant (7.4% of those originally identified). A total of 1695 main-screen reminders occurred in 940 patients. In 883 instances, the decision was taken not to initiate and a range of reasons offered. Interviews with 15 patients and seven clinicians indicated that the intervention was acceptable, though the issue of disruptive screen reminders was raised.Conclusion: Automated risk assessment for stroke in atrial fibrillation and prompting during consultations are feasible and generally acceptable, but did not overcome concerns about frailty and risk of haemorrhage as barriers to anticoagulant uptake

Development of a candidate reference material for adventitious virus detection in vaccine and biologicals manufacturing by deep sequencing.

Unbiased deep sequencing offers the potential for improved adventitious virus screening in vaccines and biotherapeutics. Successful implementation of such assays will require appropriate control materials to confirm assay performance and sensitivity. A common reference material containing 25 target viruses was produced and 16 laboratories were invited to process it using their preferred adventitious virus detection assay. Fifteen laboratories returned results, obtained using a wide range of wet-lab and informatics methods. Six of 25 target viruses were detected by all laboratories, with the remaining viruses detected by 4-14 laboratories. Six non-target viruses were detected by three or more laboratories. The study demonstrated that a wide range of methods are currently used for adventitious virus detection screening in biological products by deep sequencing and that they can yield significantly different results. This underscores the need for common reference materials to ensure satisfactory assay performance and enable comparisons between laboratories

Deeply Inverted Electron-Hole Recombination in a Luminescent Antibody-Stilbene Complex

The blue-emissive antibody EP2-19G2 that has been elicited against trans-stilbene has unprecedented ability to produce bright luminescence and has been used as a biosensor in various applications. We show that the prolonged luminescence is not stilbene fluorescence. Instead, the emissive species is a charge-transfer excited complex of an anionic stilbene and a cationic, parallel π-stacked tryptophan. Upon charge recombination, this complex generates exceptionally bright blue light. Complex formation is enabled by a deeply penetrating ligand-binding pocket, which in turn results from a noncanonical interface between the two variable domains of the antibody

The BRCA2 c.68-7T > A variant is not pathogenic: A model for clinical calibration of spliceogenicity.

Although the spliceogenic nature of the BRCA2 c.68-7T>A variant has been demonstrated, its association with cancer risk remains ontroversial. In this study, we accurately quantified by real-time PCR and digital PCR the BRCA2 isoforms retaining or missing exon 3. In addition, the combined odds ratio for causality of the variant was estimated using genetic and clinical data, and its associated cancer risk was estimated by case-control analysis in 83,636 individuals. Co-occurrence in trans with pathogenic BRCA2 variants was assessed in 5,382 families. Exon 3 exclusion rate was 4.5-fold higher in variant carriers (13%) than controls (3%), indicating an exclusion rate for the c.68-7T>A allele of approximately 20%. The posterior probability of pathogenicity was 7.44 x 10-115. There was neither evidence for increased risk of breast cancer (OR 1.03; 95% CI 0.86-1.24), nor for a deleterious effect of the variant when co-occurring with pathogenic variants. Our data provide for the first time robust evidence of the non-pathogenicity of the BRCA2 c.68-7T>A. Genetic and quantitative transcript analyses together inform the threshold for the ratio between functional and altered BRCA2 isoforms compatible with normal cell function. These findings might be exploited to assess the relevance for cancer risk of other BRCA2 spliceogenic variants