Improving access for community health and sub-acute outpatient services: protocol for a stepped wedge cluster randomised controlled trial

BACKGROUND: Waiting lists for treatment are common in outpatient and community services, Existing methods for managing access and triage to these services can lead to inequities in service delivery, inefficiencies and divert resources from frontline care. Evidence from two controlled studies indicates that an alternative to the traditional &quot;waitlist and triage&quot; model known as STAT (Specific Timely Appointments for Triage) may be successful in reducing waiting times without adversely affecting other aspects of patient care. This trial aims to test whether the model is cost effective in reducing waiting time across multiple services, and to measure the impact on service provision, health-related quality of life and patient satisfaction. METHODS/DESIGN: A stepped wedge cluster randomised controlled trial has been designed to evaluate the impact of the STAT model in 8 community health and outpatient services. The primary outcome will be waiting time from referral to first appointment. Secondary outcomes will be nature and quantity of service received (collected from all patients attending the service during the study period and health-related quality of life (AQOL-8D), patient satisfaction, health care utilisation and cost data (collected from a subgroup of patients at initial assessment and after 12&nbsp;weeks). Data will be analysed with a multiple multi-level random-effects regression model that allows for cluster effects. An economic evaluation will be undertaken alongside the clinical trial. DISCUSSION: This paper outlines the study protocol for a fully powered prospective stepped wedge cluster randomised controlled trial (SWCRCT) to establish whether the STAT model of access and triage can reduce waiting times applied across multiple settings, without increasing health service costs or adversely impacting on other aspects of patient care. If successful, it will provide evidence for the effectiveness of a practical model of access that can substantially reduce waiting time for outpatient and community services with subsequent benefits for both efficiency of health systems and patient care.<br /

The impact of iodine supplementation and bread fortification on urinary iodine concentrations in a mildly iodine deficient population of pregnant women in South Australia

Mild iodine deficiency during pregnancy can have significant effects on fetal development and future cognitive function. The purpose of this study was to characterise the iodine status of South Australian women during pregnancy and relate it to the use of iodine-containing multivitamins. The impact of fortification of bread with iodized salt was also assessed. Women (n = 196) were recruited prospectively at the beginning of pregnancy and urine collected at 12, 18, 30, 36 weeks gestation and 6 months postpartum. The use of a multivitamin supplement was recorded at each visit. Spot urinary iodine concentrations (UIC) were assessed. Median UICs were within the mildly deficient range in women not taking supplements (<90 μg/L). Among the women taking iodine-containing multivitamins UICs were within WHO recommendations (150–249 μg/L) for sufficiency and showed an increasing trend through gestation. The fortification of bread with iodized salt increased the median UIC from 68 μg/L to 84 μg/L (p = .011) which was still in the deficient range. Pregnant women in this region of Australia were unlikely to reach recommended iodine levels without an iodine supplement, even after the mandatory iodine supplementation of bread was instituted in October 2009.Vicki L Clifton, Nicolette A Hodyl, Paul A Fogarty, David J Torpy, Rachel Roberts, Ted Nettelbeck, Gary Ma and Basil Hetze

Rerandomization and Regression Adjustment

Randomization is a basis for the statistical inference of treatment effects without strong assumptions on the outcome-generating process. Appropriately using covariates further yields more precise estimators in randomized experiments. R. A. Fisher suggested blocking on discrete covariates in the design stage or conducting analysis of covariance (ANCOVA) in the analysis stage. We can embed blocking into a wider class of experimental design called rerandomization, and extend the classical ANCOVA to more general regression adjustment. Rerandomization trumps complete randomization in the design stage, and regression adjustment trumps the simple difference-in-means estimator in the analysis stage. It is then intuitive to use both rerandomization and regression adjustment. Under the randomization-inference framework, we establish a unified theory allowing the designer and analyzer to have access to different sets of covariates. We find that asymptotically (a) for any given estimator with or without regression adjustment, rerandomization never hurts either the sampling precision or the estimated precision, and (b) for any given design with or without rerandomization, our regression-adjusted estimator never hurts the estimated precision. Therefore, combining rerandomization and regression adjustment yields better coverage properties and thus improves statistical inference. To theoretically quantify these statements, we discuss optimal regression-adjusted estimators in terms of the sampling precision and the estimated precision, and then measure the additional gains of the designer and the analyzer. We finally suggest using rerandomization in the design and regression adjustment in the analysis followed by the Huber--White robust standard error

How do enterprises respond to a managerial accounting performance measure mandated by the state?

We study the application of Economic Value Added (EVA®) by Chinese state-owned enterprises (SOEs) following a regulatory requirement to deploy the measure. Our theoretical framing engages conceptual elements of institutional work and public accountability research to consider why key actors vary in their responses to the mandated application of EVA®. Our data derives from thirty interviews with managers in three SOEs and their oversight body (the State-owned Assets Supervision and Administration Commission of the State Council). We identify two relevant dimensions associated with managers: 'accounting centricity' and 'institutional potential' and report that they drive the authenticity of actors' responses in the absence of enforcement of the mandated measure. When accounting centricity and institutional potential align to the dictates of the higher implementing body, accountability remains high notwithstanding the absence of enforcement. When these two factors do not align, accountability fails even when politicization is high and formal accountability claims are high. Where the two factors are partially present, the accountability response is mixed. Our study contributes to a refinement of the perspective advanced by prior investigations of institutionally sanctioned roll outs of accounting systems highlighting in particular, the role of human agency in explaining actor responses

Dendrodendritic synapses in the mouse olfactory bulb external plexiform layer

Odor information relayed by olfactory bulb projection neurons, mitral and tufted cells (M/T), is modulated by pairs of reciprocal dendrodendritic synaptic circuits in the external plexiform layer (EPL). Interneurons, which are accounted for largely by granule cells, receive depolarizing input from M/T dendrites and in turn inhibit current spread in M/T dendrites via hyperpolarizing reciprocal dendrodendritic synapses. Because the location of dendrodendritic synapses may significantly affect the cascade of odor information, we assessed synaptic properties and density within sublaminae of the EPL and along the length of M/T secondary dendrites. In electron micrographs the M/T to granule cell synapse appeared to predominate and was equivalent in both the outer and inner EPL. However, the dendrodendritic synapses from granule cell spines onto M/T dendrites were more prevalent in the outer EPL. In contrast, individual gephyrin-immunoreactive (IR) puncta, a postsynaptic scaffolding protein at inhibitory synapses used here as a proxy for the granule to M/T dendritic synapse was equally distributed throughout the EPL. Of significance to the organization of intrabulbar circuits, gephyrin-IR synapses are not uniformly distributed along M/T secondary dendrites. Synaptic density, expressed as a function of surface area, increases distal to the cell body. Furthermore, the distributions of gephyrin-IR puncta are heterogeneous and appear as clusters along the length of the M/T dendrites. Consistent with computational models, our data suggest that temporal coding in M/T cells is achieved by precisely located inhibitory input and that distance from the soma is compensated for by an increase in synaptic density.Fil: Bartel, Dianna L.. University Of Yale. School Of Medicine; Estados UnidosFil: Rela, Lorena. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Fisiología y Biofísica Bernardo Houssay; Argentina. Universidad de Buenos Aires. Facultad de Medicina; ArgentinaFil: Hsieh, Lawrence. University Of Yale. School Of Medicine; Estados UnidosFil: Greer, Charles A. . University Of Yale. School Of Medicine; Estados Unido

Designing for learning mathematics through programming: A case study of pupils engaging with place value

This paper focuses on a major part of a two-year intervention, ScratchMaths (SM), which seeks to exploit programming for the learning of mathematics. The SM hypothesis is that given the right design of curriculum, pedagogy and digital tools, pupils can engage with and express important mathematical ideas through computer programming. We describe the overall design of SM and as an illustration of the approach, we elaborate a more detailed description of the specific SM activities that seek to harness the programming concept of ‘objects communicating with one another’ for the exploration of the mathematical concept of place value through a syntonic approach to learning. We report a case study of how these activities were implemented in two primary classes. Our findings constitute a kind of existence theorem: that with carefully designed and sequenced learning activities and appropriate teacher support, this approach can allow pupils to engage with difficult mathematical ideas in new, meaningful and generalisable ways. We also point to the challenges which emerged through this process in ensuring pupils encounter these mathematical ideas

Testing the climate intervention potential of ocean afforestation using the Great Atlantic Sargassum Belt

Ensuring that global warming remains 2 emissions reduction. Additionally, 100–900 gigatons CO2 must be removed from the atmosphere by 2100 using a portfolio of CO2 removal (CDR) methods. Ocean afforestation, CDR through basin-scale seaweed farming in the open ocean, is seen as a key component of the marine portfolio. Here, we analyse the CDR potential of recent re-occurring trans-basin belts of the floating seaweed Sargassum in the (sub)tropical North Atlantic as a natural analogue for ocean afforestation. We show that two biogeochemical feedbacks, nutrient reallocation and calcification by encrusting marine life, reduce the CDR efficacy of Sargassum by 20–100%. Atmospheric CO2 influx into the surface seawater, after CO2-fixation by Sargassum, takes 2.5–18 times longer than the CO2-deficient seawater remains in contact with the atmosphere, potentially hindering CDR verification. Furthermore, we estimate that increased ocean albedo, due to floating Sargassum, could influence climate radiative forcing more than Sargassum-CDR. Our analysis shows that multifaceted Earth-system feedbacks determine the efficacy of ocean afforestation

Fishery-Independent Data Reveal Negative Effect of Human Population Density on Caribbean Predatory Fish Communities

BACKGROUND: Understanding the current status of predatory fish communities, and the effects fishing has on them, is vitally important information for management. However, data are often insufficient at region-wide scales to assess the effects of extraction in coral reef ecosystems of developing nations. METHODOLOGY/PRINCIPAL FINDINGS: Here, I overcome this difficulty by using a publicly accessible, fisheries-independent database to provide a broad scale, comprehensive analysis of human impacts on predatory reef fish communities across the greater Caribbean region. Specifically, this study analyzed presence and diversity of predatory reef fishes over a gradient of human population density. Across the region, as human population density increases, presence of large-bodied fishes declines, and fish communities become dominated by a few smaller-bodied species. CONCLUSIONS/SIGNIFICANCE: Complete disappearance of several large-bodied fishes indicates ecological and local extinctions have occurred in some densely populated areas. These findings fill a fundamentally important gap in our knowledge of the ecosystem effects of artisanal fisheries in developing nations, and provide support for multiple approaches to data collection where they are commonly unavailable

Four Regional Marine Biodiversity Studies: Approaches and Contributions to Ecosystem-Based Management

We compare objectives and approaches of four regional studies of marine biodiversity: Gulf of Maine Area Census of Marine Life, Baltic Sea History of Marine Animal Populations, Great Barrier Reef Seabed Biodiversity Project, and Gulf of Mexico Biodiversity Project. Each program was designed as an "ecosystem" scale but was created independently and executed differently. Each lasted 8 to 10 years, including several years to refine program objectives, raise funding, and develop research networks. All resulted in improved baseline data and in new, or revised, data systems. Each contributed to the creation or evolution of interdisciplinary teams, and to regional, national, or international science-management linkages. To date, there have been differing extents of delivery and use of scientific information to and by management, with greatest integration by the program designed around specific management questions. We evaluate each research program's relative emphasis on three principal elements of biodiversity organization: composition, structure, and function. This approach is used to analyze existing ecosystem-wide biodiversity knowledge and to assess what is known and where gaps exist. In all four of these systems and studies, there is a relative paucity of investigation on functional elements of biodiversity, when compared with compositional and structural elements. This is symptomatic of the current state of the science. Substantial investment in understanding one or more biodiversity element(s) will allow issues to be addressed in a timely and more integrative fashion. Evaluating research needs and possible approaches across specific elements of biodiversity organization can facilitate planning of future studies and lead to more effective communication between scientists, managers, and stakeholders. Building a general approach that captures how various studies have focused on different biodiversity elements can also contribute to meta-analyses of worldwide experience in scientific research to support ecosystem-based management