Using care plans to better manage multimorbidity

BACKGROUND: The health care for patients having two or more long-term medical conditions is fragmented between specialists, allied health professionals, and general practitioners (GPs), each keeping separate medical records. There are separate guidelines for each disease, making it difficult for the GP to coordinate care. The TrueBlue model of collaborative care to address key problems in managing patients with multimorbidity in general practice previously reported outcomes on the management of multimorbidities. We report on the care plan for patients with depression, diabetes, and/or coronary heart disease that was embedded in the TrueBlue study. METHODS: A care plan was designed around diabetes, coronary heart disease, and depression management guidelines to prompt implementation of best practices and to provide a single document for information from multiple sources. It was used in the TrueBlue trial undertaken by 400 patients (206 intervention and 194 control) from 11 Australian general practices in regional and metropolitan areas. RESULTS: Practice nurses and GPs successfully used the care plan to achieve the guideline-recommended checks for almost all patients, and successfully monitored depression scores and risk factors, kept pathology results up to date, and identified patient priorities and goals. Clinical outcomes improved compared with usual care. CONCLUSION: The care plan was used successfully to manage and prioritise multimorbidity. Downstream implications include improving efficiency in patient management, and better health outcomes for patients with complex multimorbidities

Two-photon-induced photoconductivity enhancement in semiconductor microcavities: a theoretical investigation

We describe a detailed theoretical investigation of two-photon absorption photoconductivity in semiconductor microcavities. We show that high enhancement (by a factor of >10, 000) of the nonlinear response can be obtained as a result of the microcavity effect. We discuss in detail the design and performance (dynamic range, speed) of such a device with the help of the example of an AlGaAs/GaAs microcavity operating at 900 nm. This device shows promise for low-intensity, fast autocorrelation and demultiplexing applications

Climate and basin drivers of seasonal river water temperature dynamics

Stream water temperature is a key control of many river processes (e.g. ecology, biogeochemistry, hydraulics) and services (e.g. power plant cooling, recreational use). Consequently, the effect of climate change and variability on stream temperature is a major scientific and practical concern. This paper aims (1) to improve the understanding of large-scale spatial and temporal variability in climate–water temperature associations, and (2) to assess explicitly the influence of basin properties as modifiers of these relationships. A dataset was assembled including six distinct modelled climatic variables (air temperature, downward short-wave and long-wave radiation, wind speed, specific humidity, and precipitation) and observed stream temperatures for the period 1984–2007 at 35 sites located on 21 rivers within 16 basins (Great Britain geographical extent); the study focuses on broad spatio-temporal patterns, and hence was based on 3-month-averaged data (i.e. seasonal). A wide range of basin properties was derived. Five models were fitted (all seasons, winter, spring, summer, and autumn). Both site and national spatial scales were investigated at once by using multi-level modelling with linear multiple regressions. Model selection used multi-model inference, which provides more robust models, based on sets of good models, rather than a single best model. Broad climate–water temperature associations common to all sites were obtained from the analysis of the fixed coefficients, while site-specific responses, i.e. random coefficients, were assessed against basin properties with analysis of variance (ANOVA). All six climate predictors investigated play a role as a control of water temperature. Air temperature and short-wave radiation are important for all models/seasons, while the other predictors are important for some models/seasons only. The form and strength of the climate–stream temperature association vary depending on season and on water temperature. The dominating climate drivers and physical processes may change across seasons and across the stream temperature range. The role of basin permeability, size, and elevation as modifiers of the climate–water temperature associations was confirmed; permeability has the primary influence, followed by size and elevation. Smaller, upland, and/or impermeable basins are the most influenced by atmospheric heat exchanges, while larger, lowland and permeable basins are the least influenced. The study showed the importance of accounting properly for the spatial and temporal variability of climate–stream temperature associations and their modification by basin properties

The Canadian Joint Replacement Registry—what have we learned?

The Canadian Joint Replacement Registry (CJRR) was launched in 2000 through the collaborative efforts of the Canadian Orthopedic Association and the Canadian Institutes for Health Information. Participation is voluntary, and data collected by participating surgeons in the operating room is linked to hospital stay information from administrative databases to compile yearly reports. In the fiscal year 2006–2007, there were 62,196 hospitalizations for hip and knee replacements in Canada, excluding Quebec. This represents a 10-year increase of 101% and a 1-year increase of 6%. Compared to men, Canadian women have higher age-adjusted rates per 105 for both TKA (148 vs. 110) and THA (86 vs. 76). There also exist substantial inter-provincial variations in both age-adjusted rates of arthroplasty and implant utilization that cannot be explained entirely on the basis of differing patient demographics. The reasons for these variations are unclear, but probably represent such factors as differences in provincial health expenditure, efforts to reduce waiting lists, and surgeon preference. The main challenge currently facing the CJRR is to increase procedure capture to > 90%. This is being pursued through a combination of efforts including simplification of the consent process, streamlining of the data collection form, and the production of customized reports with information that has direct clinical relevance for surgeons and administrators. As the CJRR continues to mature, we are optimistic that it will provide clinically important information on the wide range of factors that affect arthroplasty outcome

Using care plans to better manage multimorbidity

Background The health care for patients having two or more long-term medical conditions is fragmented between specialists, allied health professionals, and general practitioners (GPs), each keeping separate medical records. There are separate guidelines for each disease, making it difficult for the GP to coordinate care. The TrueBlue model of collaborative care to address key problems in managing patients with multimorbidity in general practice previously reported outcomes on the management of multimorbidities. We report on the care plan for patients with depression, diabetes, and/or coronary heart disease that was embedded in the TrueBlue study. Methods A care plan was designed around diabetes, coronary heart disease, and depression management guidelines to prompt implementation of best practices and to provide a single document for information from multiple sources. It was used in the TrueBlue trial undertaken by 400 patients (206 intervention and 194 control) from 11 Australian general practices in regional and metropolitan areas. Results Practice nurses and GPs successfully used the care plan to achieve the guideline-recommended checks for almost all patients, and successfully monitored depression scores and risk factors, kept pathology results up to date, and identified patient priorities and goals. Clinical outcomes improved compared with usual care. Conclusion The care plan was used successfully to manage and prioritise multimorbidity. Downstream implications include improving efficiency in patient management, and better health outcomes for patients with complex multimorbidities

Macroinvertebrate and diatom community responses to thermal alterations below water supply reservoirs

River impoundments have transformed river ecosystems globally due to the modification of various abiotic and biotic factors. This study provides rare evidence quantifying how water supply reservoirs alter water temperature regimes and its effects on macroinvertebrate and diatom communities over a 4-year period. We obtained near-continuous water temperature measurements upstream and downstream of three reservoirs and analysed thermal variables in association with macroinvertebrate and diatom community indices (including taxonomic richness, proportion of Ephemeroptera, Plecoptera and Trichoptera taxa [%EPT] and diatom ecological guilds). Reservoirs typically decreased downstream thermal variability, with reduced summer temperatures and increased winter temperatures, and a delayed timing of annual temperature extremes. Marked differences in thermal regime modifications between reservoirs were observed, including evidence of inter-annual variation associated with inter-basin water transfers downstream of one reservoir. Biomonitoring indices showed associations with thermal indices that differed between site types (regulated versus non-regulated) and seasons (spring vs. autumn). Various macroinvertebrate and diatom indices capturing community diversity elements and sensitivities to different environmental pressures were associated with higher maximum summer temperatures and lower minimum winter temperatures, suggesting ecological effects of reduced thermal variation downstream of reservoirs. Different ecological responses to thermal indices were observed between seasons, likely due to organism life-cycle effects and intra-annual thermal variations. Contrasting macroinvertebrate and diatom communities were observed between regulated and non-regulated sites, which may be driven by differences in the thermal regime and other abiotic factors at regulated sites, including nutrient, sediment and flow regimes. Long-term continuous water temperature monitoring of both multiple regulated and non-regulated river systems is necessary to better understand the environmental and ecological effects of river impoundments. Given the extent to which river impoundment has modified stream temperatures globally, the inclusion of thermal regime data in environmental flow studies alongside hydrological information may guide the implementation of mitigation measures on impounded waterbodies.Natural Environment Research Council (NERC): NE/L002493/

Evaluation of AUSDRISK as a screening tool for lifestyle modification programs: international implications for policy and cost-effectiveness

OBJECTIVE: To evaluate the current use of Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK) as a screening tool to identify individuals at high risk of developing type 2 diabetes for entry into lifestyle modification programs. RESEARCH DESIGN AND METHODS: AUSDRISK scores were calculated from participants aged 40-74 years in the Greater Green Triangle Risk Factor Study, a cross-sectional population survey in 3 regions of Southwest Victoria, Australia, 2004-2006. Biomedical profiles of AUSDRISK risk categories were determined along with estimates of the Victorian population included at various cut-off scores. Sensitivity, specificity, positive predictive value (PPV), negative predictive value, and receiver operating characteristics were calculated for AUSDRISK in determining fasting plasma glucose (FPG) ≥6.1 mmol/L. RESULTS: Increasing AUSDRISK scores were associated with an increase in weight, body mass index, FPG, and metabolic syndrome. Increasing the minimum cut-off score also increased the proportion of individuals who were obese and centrally obese, had impaired fasting glucose (IFG) and metabolic syndrome. An AUSDRISK score of ≥12 was estimated to include 39.5% of the Victorian population aged 40-74 (916 000), while a score of ≥20 would include only 5.2% of the same population (120 000). At AUSDRISK≥20, the PPV for detecting FPG≥6.1 mmol/L was 28.4%. CONCLUSIONS: AUSDRISK is powered to predict those with IFG and undiagnosed type 2 diabetes, but its effectiveness as the sole determinant for entry into a lifestyle modification program is questionable given the large proportion of the population screened-in using the current minimum cut-off of ≥12. AUSDRISK should be used in conjunction with oral glucose tolerance testing, fasting glucose, or glycated hemoglobin to identify those individuals at highest risk of progression to type 2 diabetes, who should be the primary targets for lifestyle modification

Two-photon absorption photocurrent enhancement in bulk AlGaAs semiconductor microcavities

We report on two-photon absorption (TPA) photocurrent in semiconductor microcavities. We experimentally show a substantial increase in the TPA photocurrent generated, at resonance, in a GaAlAs/GaAs microcavity designed for TPA operation at ~890 nm. An enhancement factor of ~12 000 of the photocurrent is obtained via the microcavity effect, which could have an important impact on the use of TPA devices for high speed switching and sampling applications. Our results also show the implications of the cavity photon lifetime on autocorrelation traces measured using TPA in semiconductor microcavities