Chronic condition self-management support: proposed competencies for medical students

Author version made available in accordance with the publisher's policy.Objective Governments and the medical profession are concerned that there continues to be less than optimal health outcomes despite escalating expenditure on health services from the effect of the ageing population with chronic illnesses. In this context, doctors will need to have knowledge and skills in effective Chronic Condition Management (CCM) and Chronic Condition Self-Management (CCSM). Method A national workshop of representatives of eight medical schools from the CCSM Special Interest Group (SIG) of the Australian and New Zealand Association on Medical Education (ANZAME) met in September 2004, to consider curriculum content in CCM and CCSM. Results The workshop recommended that the Committee of Deans of Australian Medical Schools (CDAMS) and the Commonwealth Department of Health and Ageing (DoHA) consider the identification and possible development of a specific curriculum for CCM and CCSM within the curricula of Australian Medical Schools. Discussion Consideration needs to be given to the changing nature of medical practice and that as part of this; doctors of the future will need skills in team participation, continuity of care, self-management support and patient-centered collaborative care planning. Doctors will also need skills to assist patients to better adhere to medical management, lifestyle behaviour change and risk factor reduction, if optimal health outcomes are to be achieved and costs are to be contained

Linking Auxin with Photosynthetic Rate via Leaf Venation

International audienceLand plants lose vast quantities of water to the atmosphere during photosynthetic gas exchange. In angiosperms, a complex network of veins irrigates the leaf, and it is widely held that the density and placement of these veins determines maximum leaf hydraulic capacity and thus maximum photosynthetic rate. This theory is largely based on interspecific comparisons and has never been tested using vein mutants to examine the specific impact of leaf vein morphology on plant water relations. Here we characterize mutants at the Crispoid (Crd) locus in pea (Pisum sativum), which have altered auxin homeostasis and activity in developing leaves, as well as reduced leaf vein density and aberrant placement of free-ending veinlets. This altered vein phenotype in crd mutant plants results in a significant reduction in leaf hydraulic conductance and leaf gas exchange. We find Crispoid to be a member of the YUCCA family of auxin biosynthetic genes. Our results link auxin biosynthesis with maximum photosynthetic rate through leaf venation and substantiate the theory that an increase in the density of leaf veins coupled with their efficient placement can drive increases in leaf photosynthetic capacity

The General Practice Assessment Questionnaire (GPAQ) – Development and psychometric characteristics

<p>Abstract</p> <p>Background</p> <p>Continual quality improvement in primary care is an international priority. In the United Kingdom, the major initiative for improving quality of care is the Quality and Outcomes Framework (QoF) of the 2004 GP contract. Although the primary focus of the QoF is on clinical care, it is acknowledged that a comprehensive assessment of quality also requires valid and reliable measurement of the patient perspective, so financial incentives are included in the contract for general practices to survey patients' views. One questionnaire specified for use in the QoF is the General Practice Assessment Questionnaire (GPAQ). This paper describes the development of the GPAQ (with post-consultation and postal versions) and presents a preliminary examination of the psychometric properties of the questionnaire.</p> <p>Methods</p> <p>Description of scale development and preliminary analysis of psychometric characteristics (internal reliability, factor structure), based on a large dataset of routinely collected GPAQ surveys (n = 190,038 responses to the consultation version of GPAQ and 20,309 responses to the postal version) from practices in the United Kingdom during the 2005–6 contract year.</p> <p>Results</p> <p>Respondents tend to report generally favourable ratings. Responses were particularly skewed on the GP communication scale, though no more so than for other questionnaires in current use in the UK for which data were available. Factor analysis identified 2 factors that clearly relate to core concepts in primary care quality ('access' and 'interpersonal care') that were common to both version of the GPAQ. The other factors related to 'enablement' in the post-consultation version and 'nursing care' in the postal version.</p> <p>Conclusion</p> <p>This preliminary evaluation indicates that the scales of the GPAQ are internally reliable and that the items demonstrate an interpretable factor structure. Issues concerning the distributions of GPAQ responses are discussed. Potential further developments of the item content for the GPAQ are also outlined.</p

Neural correlates of attention-executive dysfunction in lewy body dementia and Alzheimer's disease.

Attentional and executive dysfunction contribute to cognitive impairment in both Lewy body dementia and Alzheimer's disease. Using functional MRI, we examined the neural correlates of three components of attention (alerting, orienting, and executive/conflict function) in 23 patients with Alzheimer's disease, 32 patients with Lewy body dementia (19 with dementia with Lewy bodies and 13 with Parkinson's disease with dementia), and 23 healthy controls using a modified Attention Network Test. Although the functional MRI demonstrated a similar fronto-parieto-occipital network activation in all groups, Alzheimer's disease and Lewy body dementia patients had greater activation of this network for incongruent and more difficult trials, which were also accompanied by slower reaction times. There was no recruitment of additional brain regions or, conversely, regional deficits in brain activation. The default mode network, however, displayed diverging activity patterns in the dementia groups. The Alzheimer's disease group had limited task related deactivations of the default mode network, whereas patients with Lewy body dementia showed heightened deactivation to all trials, which might be an attempt to allocate neural resources to impaired attentional networks. We posit that, despite a common endpoint of attention-executive disturbances in both dementias, the pathophysiological basis of these is very different between these diseases.This work was supported by an Intermediate Clinical Fellowship . Grant Number: (WT088441MA) to John‐Paul Taylor the National Institute for Health Research (NIHR), and Newcastle Biomedical Research Unit (BRU) based at Newcastle upon Tyne Hospitals NHS Trust, Newcastle University

The impact of immediate breast reconstruction on the time to delivery of adjuvant therapy: the iBRA-2 study

Background: Immediate breast reconstruction (IBR) is routinely offered to improve quality-of-life for women requiring mastectomy, but there are concerns that more complex surgery may delay adjuvant oncological treatments and compromise long-term outcomes. High-quality evidence is lacking. The iBRA-2 study aimed to investigate the impact of IBR on time to adjuvant therapy. Methods: Consecutive women undergoing mastectomy ± IBR for breast cancer July–December, 2016 were included. Patient demographics, operative, oncological and complication data were collected. Time from last definitive cancer surgery to first adjuvant treatment for patients undergoing mastectomy ± IBR were compared and risk factors associated with delays explored. Results: A total of 2540 patients were recruited from 76 centres; 1008 (39.7%) underwent IBR (implant-only [n = 675, 26.6%]; pedicled flaps [n = 105,4.1%] and free-flaps [n = 228, 8.9%]). Complications requiring re-admission or re-operation were significantly more common in patients undergoing IBR than those receiving mastectomy. Adjuvant chemotherapy or radiotherapy was required by 1235 (48.6%) patients. No clinically significant differences were seen in time to adjuvant therapy between patient groups but major complications irrespective of surgery received were significantly associated with treatment delays. Conclusions: IBR does not result in clinically significant delays to adjuvant therapy, but post-operative complications are associated with treatment delays. Strategies to minimise complications, including careful patient selection, are required to improve outcomes for patients

Musical works: scored, performed, and recorded

In this thesis, I examine the problem of whether, and under what circumstances, a musical recording can be considered to be a work. Audio recordings were initially conceived as a means of documenting, preserving and transmitting sound events, such as performances of music. The ubiquity of recorded music in recent decades has meant that it has become the dominant mode of music listening for most people (in the developed world, at least), and this has led to a reconsideration of its functions. In addition, serious attention to the aesthetics of rock music—most notably by Theodore Gracyk in Rhythm and Noise[1]—has provided philosophical support for the view that rock music’s primary object of aesthetic attention is the record, thus reinforcing a stance which concords with popular experience. Rather than build directly on Gracyk’s work, I have taken a critical approach to it. The more than 20 years since the publication of Rhythm and Noise have seen music technology and music practice develop in ways which have made it more difficult to delineate clear divisions between performance, recording, and recorded performances. In addition, Gracyk’s partial reliance on the recording being the primary object of aesthetic attention in the rock music tradition seems to invite the question: How can we establish what belongs to that tradition? Music which is on the fringes of the rock music tradition (for example, Country music) sometimes appears to share some but not all the attributes of the rock music style. If we rely on the fact of a recording being in the rock music tradition to establish its status as a musical work in itself, some cases will be ambiguous. On the other hand, the existence of musical works for performance is not in question. If necessary and sufficient conditions for the existence of a work for performance can be unambiguously established, it may point us to the kinds of considerations which will be salient in understanding what a recording as a work might be. Accordingly, the first half of this thesis reviews the literature on works for performance, and consists largely in a discussion of relevant points in Paul Thom’s For an Audience[2] which deals with the performing arts, inclusive of music. Thom’s clear and unambiguous definition of what constitutes a work for performance is useful in deciding whether a work for performance is in any way involved when any particular record is made. Since music is traditionally a performing art, we can expect to find performance in relation to at least some music recordings. At one extreme, an actual complete performance which occurred at a particular time and place might be recorded; at the other extreme, recordings of music exist which involved no performance at any stage of their making (having been, for instance, constructed in a computer). While neither of these circumstances is either a sufficient or a necessary condition to qualify or disqualify a recording as a work, the requirements for something to be a performance of a work for performance will be instructive. Thom identifies the musical work for performance with the performance directive as an abstract type, of which any individual score is a token and a performance is an enactment. This view is at odds with the prevalent conception of the work as an abstract sound structure (defined by the score), of which a performance is an instantiation. Thom’s view naturally accommodates interpretation as a constituent of performance of a work for performance. It also—since the performance directive directs actions to be undertaken—naturally accommodates idiomatic writing for instruments which takes account of the specific physical actions required to produce a certain sequence of sounds. The second half of the thesis analyses the question of musical recordings with a view to establishing their ontological status and whether, and under what conditions, they can be considered to be musical works in themselves. This section engages with the views of authors who have addressed the existence of recordings as works, and also brings points from Thom’s analysis of the ontological status of works for performance to bear on the issue of musical recordings. I conclude that recordings can be works, but that it is neither stylistic tradition nor a particular use of technology in producing the sounds recorded which qualify recordings to be musical works. While sophisticated electronic technology used to manipulate and reproduce sounds has often been conflated with the recording process itself, such technology is frequently in use in live performances today and its use in making a recording does not of itself qualify the recording as a work in itself. On the other hand, some recordings which do not depend on electronic processing (other than what is entailed for the actual recording process) should be considered as works in themselves. Rather, what differentiates recording as a medium for musical works from the medium of notated scores are the ways in which it affects our experience of the music. This amounts to the differences between the experience of a performance from a score, and the experience of a recording. The fundamental property of a recording is that the sounds are fixed; at least in some circumstances, the sound event is exactly repeatable (although in practice there may be artefacts and distortions due to degradation of the media or differences in playback equipment). This fundamental property has further effects. Although there may be some difference in timbre, depending on the playback equipment, the extended sound events to which different playings of a recording give rise exhibit no perceptible variation as regards the sequence of component sound events and their precise timing. The dislocation of playback of a recording from the activity of its production results in a strong tendency for it to be experienced in a decontextualized way, due to the divorce between the immediate circumstances in which the recording was made and the circumstances in which it is heard: small variations in performance—perhaps due to accident or to pragmatic considerations—are both fixed forever and at the same time lacking a perceptible connection to the immediate circumstances in which they were recorded. Further, since a recording can be replayed at will, at different times and in different geographical locations, the listener will frequently be—more or less—unfamiliar with the musical culture in which the recording was produced. The prevalent view of recordings as works holds that the work consists in an ideal sound structure as encoded on the master recording. The master recording contains a sound structure which is the norm-kind of which individual playbacks of copies are instantiations. I argue that the notion of an ideal sound structure is not applicable to recording works but has been carried over from the view of recordings as transmission of an originary sound event. Recordings which are works in themselves, by contrast, should not be thought of as transmitting an originary sound event. Instead, the work is identified with the audio signal encoded in the master, copies from the master are instantiations of a norm-kind, and individual playings provide aspectual access to the work. A central plank of Gracyk’s theorization of recording works in Rhythm and Noise was that rock recordings achieve a representation of a performance. I argue instead that some recordings represent an event of listening, whereby a sense of intentionality is introduced between the listener and any real or imagined performer such that the performance is heard “as though the ears” of a third party. The listeners’ experience is of a sound event “as heard” by someone else, in a similar way that the camera’s view in a photograph conveys a relationship with and stance towards a personage shown in the photograph. This is achieved through manipulation both of cues to the apparent location of the listener relative to what is posited as a recorded sound source, and of cues (such as reverberation) to the apparent physical surroundings of the listening event. While such cues are founded in psycho-acoustic responses to sound, in some cases their meanings are extended through conventions of use. [1] Gracyk, Rhythm and Noise: An Aesthetics of Rock. [2] Thom, For an Audience: A Philosophy of the Performing Arts

Plasma-Enhanced Molecular Layer Deposition of Phosphane-ene Polymer Films

A vapour phase molecular layer deposition (MLD) process generating phosphorus-rich phosphane-ene polymer networks was adapted from known solution phase methods and successfully used in a commercial atomic layer deposition tool. By using plasma-enhanced MLD on Si/SiO2 and Al2O3 substrates, film deposition was carried out with a commercially available primary phosphine, iBuPH2, paired with a known volatile cyclic siloxane precursor, tetramethyltetravinylcyclotetrasiloxane (D4Vinyl). The deposition process used radicals generated by an Ar plasma source to facilitate P-H addition to vinyl functionalities on D4Vinyl which yielded a growth per cycle of 0.6 – 2.0 Å, generating 10-120 nm films as determined by AFM and SEM measurements. Characterization of the films were carried out using X-ray photoelectron spectroscopy and oxygen scavenging capabilities were studied using a quartz crystal microbalance, showing an uptake of oxygen by a 12 nm depth of a freshly deposited polymer film