Health, welfare, and the state — the dangers of forgetting history

Recent public policy in the UK has been dominated by a discourse which asserts that public expenditure on universal health coverage and welfare is a burden on the productive economy and unaffordable in what has been deemed a time of austerity. There is a widely held assumption that universal welfare provision, as offered by most modern welfare states, is a luxury, only afforded since World War 2 by wealthier economies. According to this view, if the productive efficiency of the economy falters, then this luxury should be trimmed back aggressively. Reduction in universal welfare will relieve enterprise, capital, and so-called hard-working families from the burdens of taxation required to fund these unproductive public services and (by implication) those unproductive families—the poor. We argue from history that there should be an end to setting the goal of economic growth against that of welfare provision. A healthy and prospering society needs both. We suggest that they feed each other.The paper arose from discussions in the St John’s College Reading Group on Health Inequalities in Cambridge (http://www.joh.cam.ac.uk/st-john’s-reading-group-health-inequalities), which was supported by the Annual Fund of the College

Acceptability and appropriateness of a clinical pathway for managing anxiety and depression in cancer patients: a mixed methods study of staff perspectives.

BACKGROUND: Clinical pathways (CPs) can improve health outcomes, but to be sustainable, must be deemed acceptable and appropriate by staff. A CP for screening and management of anxiety and depression in cancer patients (the ADAPT CP) was implemented in 12 Australian oncology services for 12 months, within a cluster randomised controlled trial of core versus enhanced implementation strategies. This paper compares staff-perceived acceptability and appropriateness of the ADAPT CP across study arms. METHODS: Multi-disciplinary lead teams at each service tailored, planned, championed and implemented the CP. Staff at participating services, purposively selected for diversity, completed a survey and participated in an interview prior to implementation (T0), and at midpoint (6 months: T1) and end (12 months: T2) of implementation. Interviews were recorded, transcribed and thematically analysed. RESULTS: Seven metropolitan and 5 regional services participated. Questionnaires were completed by 106, 58 and 57 staff at T0, T1 and T2 respectively. Eighty-eight staff consented to be interviewed at T0, with 89 and 76 at T1 and T2 (response rates 70%, 66% and 57%, respectively). Acceptability/appropriateness, on the quantitative measure, was high at T0 (mean of 31/35) and remained at that level throughout the study, with no differences between staff from core versus enhanced services. Perceived burden was relatively low (mean of 11/20) with no change over time. Lowest scores and greatest variability pertained to perceived impact on workload, time and cost. Four major themes were identified: 1) Mental health is an important issue which ADAPT addresses; 2) ADAPT helps staff deliver best care, and reduces staff stress; 3) ADAPT is fit for purpose, for both cancer care services and patients; 4) ADAPT: a catalyst for change. Opposing viewpoints are outlined. CONCLUSIONS: This study demonstrated high staff-perceived acceptability and appropriateness of the ADAPT CP with regards to its focus, evidence-base, utility to staff and patients, and ability to create change. However, concerns remained regarding burden on staff and time commitment. Strategies from a policy and managerial level will likely be required to overcome the latter issues. TRIAL REGISTRATION: The study was registered prospectively with the ANZCTR on 22/3/2017. Trial ID ACTRN12617000411347. https://www.anzctr.org.au/

A discrete genetic locus confers xyloglucan metabolism in select human gut Bacteroidetes

A well-balanced human diet includes a significant intake of non-starch polysaccharides, collectively termed 'dietary fibre', from the cell walls of diverse fruits and vegetables. Owing to the paucity of alimentary enzymes encoded by the human genome, our ability to derive energy from dietary fibre depends on the saccharification and fermentation of complex carbohydrates by the massive microbial community residing in our distal gut. The xyloglucans (XyGs) are a ubiquitous family of highly branched plant cell wall polysaccharides whose mechanism(s) of degradation in the human gut and consequent importance in nutrition have been unclear. Here we demonstrate that a single, complex gene locus in Bacteroides ovatus confers XyG catabolism in this common colonic symbiont. Through targeted gene disruption, biochemical analysis of all predicted glycoside hydrolases and carbohydrate-binding proteins, and three-dimensional structural determination of the vanguard endo-xyloglucanase, we reveal the molecular mechanisms through which XyGs are hydrolysed to component monosaccharides for further metabolism. We also observe that orthologous XyG utilization loci (XyGULs) serve as genetic markers of XyG catabolism in Bacteroidetes, that XyGULs are restricted to a limited number of phylogenetically diverse strains, and that XyGULs are ubiquitous in surveyed human metagenomes. Our findings reveal that the metabolism of even highly abundant components of dietary fibre may be mediated by niche species, which has immediate fundamental and practical implications for gut symbiont population ecology in the context of human diet, nutrition and health

Modeling the transfer of land and water from agricultural to urban uses in the Middle Rio Grande Basin, New Mexico.

Social and ecological scientists emphasize that effective natural resource management depends in part on understanding the dynamic relationship between the physical and non-physical process associated with resource consumption. In this case, the physical processes include hydrological, climatological and ecological dynamics, and the non-physical process include social, economic and cultural dynamics among humans who do the resource consumption. This project represents a case study aimed at modeling coupled social and physical processes in a single decision support system. In central New Mexico, individual land use decisions over the past five decades have resulted in the gradual transformation of the Middle Rio Grande Valley from a primarily rural agricultural landscape to a largely urban one. In the arid southwestern U.S., the aggregate impact of individual decisions about land use is uniquely important to understand, because scarce hydrological resources will likely limit the viability of resulting growth and development trajectories. This decision support tool is intended to help planners in the area look forward in their efforts to create a collectively defined 'desired' social landscape in the Middle Rio Grande. Our research question explored the ways in which socio-cultural values impact decisions regarding that landscape and associated land use. Because of the constraints hydrological resources place on land use, we first assumed that water use, as embodied in water rights, was a reasonable surrogate for land use. We thought that modeling the movement of water rights over time and across water source types (surface and ground) would provide planners with insight into the possibilities for certain types of decisions regarding social landscapes, and the impact those same decisions would have on those landscapes. We found that water rights transfer data in New Mexico is too incomplete and inaccurate to use as the basis for the model. Furthermore, because of its lack of accuracy and completeness, water rights ownership was a poor indicator of water and land usage habits and patterns. We also found that commitment among users in the Middle Rio Grande Valley is to an agricultural lifestyle, not to a community or place. This commitment is conditioned primarily by generational cohort and past experience. If conditions warrant, many would be willing to practice the lifestyle elsewhere. A related finding was that sometimes the pressure to sell was not the putative price of the land, but the taxes on the land. These taxes were, in turn, a function of the level of urbanization of the neighborhood. This urbanization impacted the quality of the agricultural lifestyle. The project also yielded some valuable lessons regarding the model development process. A facilitative and collaborative style (rather than a top-down, directive style) was most productive with the inter-disciplinary , inter-institutional team that worked on the project. This allowed for the emergence of a process model which combined small, discipline- and/or task-specific subgroups with larger, integrating team meetings. The project objective was to develop a model that could be used to run test scenarios in which we explored the potential impact of different policy options. We achieved that objective, although not with the level of success or modeling fidelity which we had hoped for. This report only describes very superficially the results of test scenarios, since more complete analysis of scenarios would require more time and effort. Our greatest obstacle in the successful completion of the project was that required data were sparse, of poor quality, or completely nonexistent. Moreover, we found no similar modeling or research efforts taking place at either the state or local level. This leads to a key finding of this project: that state and local policy decisions regarding land use, development, urbanization, and water resource allocation are being made with minimal data and without the benefit of economic or social policy analysis

Elevated hemostasis markers after pneumonia increases one-year risk of all-cause and cardiovascular deaths

Background: Acceleration of chronic diseases, particularly cardiovascular disease, may increase long-term mortality after community-acquired pneumonia (CAP), but underlying mechanisms are unknown. Persistence of the prothrombotic state that occurs during an acute infection may increase risk of subsequent atherothrombosis in patients with pre-existing cardiovascular disease and increase subsequent risk of death. We hypothesized that circulating hemostasis markers activated during CAP persist at hospital discharge, when patients appear to have recovered clinically, and are associated with higher mortality, particularly due to cardiovascular causes. Methods: In a cohort of survivors of CAP hospitalization from 28 US sites, we measured D-Dimer, thrombin-antithrombin complexes [TAT], Factor IX, antithrombin, and plasminogen activator inhibitor-1 at hospital discharge, and determined 1-year all-cause and cardiovascular mortality. Results: Of 893 subjects, most did not have severe pneumonia (70.6% never developed severe sepsis) and only 13.4% required intensive care unit admission. At discharge, 88.4% of subjects had normal vital signs and appeared to have clinically recovered. D-dimer and TAT levels were elevated at discharge in 78.8% and 30.1% of all subjects, and in 51.3% and 25.3% of those without severe sepsis. Higher D-dimer and TAT levels were associated with higher risk of all-cause mortality (range of hazard ratios were 1.66-1.17, p = 0.0001 and 1.46-1.04, p = 0.001 after adjusting for demographics and comorbid illnesses) and cardiovascular mortality (p = 0.009 and 0.003 in competing risk analyses). Conclusions: Elevations of TAT and D-dimer levels are common at hospital discharge in patients who appeared to have recovered clinically from pneumonia and are associated with higher risk of subsequent deaths, particularly due to cardiovascular disease. © 2011 Yende et al

Comparison of implementation strategies to influence adherence to the clinical pathway for screening, assessment and management of anxiety and depression in adult cancer patients (ADAPT CP): Study protocol of a cluster randomised controlled trial

© 2018 The Author(s). Background: Health service change is difficult to achieve. One strategy to facilitate such change is the clinical pathway, a guide for clinicians containing a defined set of evidence-based interventions for a specific condition. However, optimal strategies for implementing clinical pathways are not well understood. Building on a strong evidence-base, the Psycho-Oncology Co-operative Research Group (PoCoG) in Australia developed an evidence and consensus-based clinical pathway for screening, assessing and managing cancer-related anxiety and depression (ADAPT CP) and web-based resources to support it - staff training, patient education, cognitive-behavioural therapy and a management system (ADAPT Portal). The ADAPT Portal manages patient screening and prompts staff to follow the recommendations of the ADAPT CP. This study compares the clinical and cost effectiveness of two implementation strategies (varying in resource intensiveness), designed to encourage adherence to the ADAPT CP over a 12-month period. Methods: This cluster randomised controlled trial will recruit 12 cancer service sites, stratified by size (large versus small), and randomised at site level to a standard (Core) versus supported (Enhanced) implementation strategy. After a 3-month period of site engagement, staff training and site tailoring of the ADAPT CP and Portal, each site will "Go-live", implementing the ADAPT CP for 12 months. During the implementation phase, all eligible patients will be introduced to the ADAPT CP as routine care. Patient participants will be registered on the ADAPT Portal to complete screening for anxiety and depression. Staff will be responsible for responding to prompts to follow the ADAPT CP. The primary outcome will be adherence to the ADAPT CP. Secondary outcomes include staff attitudes to and experiences of following the ADAPT CP, using the ADAPT Portal and being exposed to ADAPT implementation strategies, collected using quantitative and qualitative methods. Data will be collected at T0 (baseline, after site engagement), T1 (6 months post Go-live) and T2 (12 months post Go-live). Discussion: This will be the first cluster randomised trial to establish optimal levels of implementation effort and associated costs to achieve successful uptake of a clinical pathway within cancer care. Trial registration: The study was registered prospectively with the ANZCTR on 22/3/2017. Trial ID ACTRN1261700041134