Contextual barriers to implementation in primary care:an ethnographic study of a program to improve chronic kidney disease care

Background. Context is important in implementation—we know that what works in one setting may not work in the same way elsewhere. Primary care has been described as a unique context both in relation to the care delivered and efforts to carry out research and implementation of new evidence. Objective. To explore some of the distinctive features of the primary care environment that may influence implementation. Methods. We conducted an ethnographic study involving observations, interviews and documentary analysis of the ENABLE-CKD project, which involved general practices implementing a chronic kidney disease care bundle and offering self-management support tools to patients. Analysis was based on the constant comparative method. Results. Four elements of the primary care environment emerged as important influences on the extent to which implementation was successful. First, the nature of delivering care in this setting meant that prioritizing one condition over others was problematic. Second, the lack of alignment with financial and other incentives affected engagement. Third, the project team lacked mechanisms through which engagement could be mandated. Fourth, working relationships within practices impacted on engagement. Conclusions. Those seeking to implement interventions in primary care need to consider the particular context if they are to secure successful implementation. We suggest that there are particular kinds of interventions, which may be best suited to the primary care context

Covering Scientific Uncertainty In Ongoing Research

What should experts say to inform public health decision making when the available scientific evidence is uncertain? In this dissertation, I focus on this question through the lens of electronic cigarettes (e-cigarettes), a topic of ongoing conversations in public health around risk reduction despite uncertain long-term health effects. This dissertation measures two kinds of messages about scientific uncertainty in public dialogue: 1) conflict messages, which present contradictory conclusions from experts and emphasize disagreement, and 2) limited evidence messages, those presenting uncertainty in terms of what scientists are still investigating without emphasizing disagreement. Study 1 demonstrates the prevalence of these distinct uncertainty messages in a population of newspaper articles about e-cigarettes (N=376 articles from 2017 through mid-2018). The results of this content analysis compose the stimuli of the subsequent experimental study (Study 2, N=457 current and former smokers, 4 condition mixed design). Results demonstrates these two kinds of uncertainty messages produce divergent perceptions of experts as hypothesized: conflict increases perceptions of expert disagreement, and limited evidence increases perceptions of expert uncertainty. Based on this validation, a final experimental study was undertaken to examine the hypothesis that exposure to high levels of disagreement about e-cigarettes will spillover to decrease intentions to perform recommended healthy behaviors—a so-called “spillover” hypothesized in the previous literature. Study 3 focused on N=765 current and former smokers in 5 conditions: 2 (perceived disagreement: high or low) x 2 (perceived uncertainty: high or low) + 1 (no message). Results do not reveal spillover towards more distantly related recommended health behaviors (e.g., exercise, nutrition). Results do support backlash effects after exposure to conflict, including decreased intentions to try e-cigarettes for smoking cessation (among current smokers). Conclusions from this series of studies merit further investigation of the messages available to experts communicating about scientific uncertainty, especially preceding public health crisis. Results of this work support further inquiry evaluating the cumulative impact of exposure to conflict messages over time, particularly as these cumulative effects may diverge from other ways of presenting scientific uncertainty

Effects on elastic constants of technical membranes applying the evaluation methods of MSAJ/M-02-1995

The non-linear load-deform ation behaviour of textile m embranes highly depends on the ratio of the applied m embrane forces in warp and weft direct ion (called load ratio hereafter). In practice, usually for each membrane structure the biaxial material behaviour is determined experimentally. The Japane se Standard MSAJ/M-02-1995 describes a standardized biaxial testing procedure. To achie ve input parameters for the structural design process, the commentary to this standard expl ains some methods how to evaluate one set of fictitious elastic constants based on the expe rimental results which, sim ultaneously, envelop different load ratios and do not reflect the non -linear material behaviour anymore. Different approaches of determining such simplified, fictit ious elastic constants have been investigated in the present contribution, with m ainly two co nclusions: firstly, to have one set of elastic constants by means of which all types of structures under all types of loading can be treated is a highly disputable objective a nd secondly, the values of the determined elastic constants react quite sensitively on the underlying determination option, which should be defined by the users themselves

Simulations of stellar convection, pulsation and semiconvection

We report on modelling in stellar astrophysics with the ANTARES code. First, we describe properties of turbulence in solar granulation as seen in high-resolution calculations. Then, we turn to the first 2D model of pulsation-convection interaction in a cepheid. We discuss properties of the outer and the HEII ionization zone. Thirdly, we report on our work regarding models of semiconvection in the context of stellar physics.Comment: Astrophysical Dynamics: From Stars to Galaxies. IAU Symposium 27

Components and principles of a pediatric palliative care consultation: results of a Delphi study

Background: Pediatric palliative care is a distinct specialty that requires input from pediatric and palliative medicine specialists to provide comprehensive high-quality care. Consultations undertaken early in a child's illness trajectory, when end-of-life care is not anticipated to be required, enables relationships to be established and may enhance the quality of care provided

Support or Competition? How Online Social Networks Increase Physical Activity: A Randomized Controlled Trial

To identify what features of online social networks can increase physical activity, we conducted a 4-arm randomized controlled trial in 2014 in Philadelphia, PA. Students (n = 790, mean age = 25.2) at an university were randomly assigned to one of four conditions composed of either supportive or competitive relationships and either with individual or team incentives for attending exercise classes. The social comparison condition placed participants into 6-person competitive networks with individual incentives. The social support condition placed participants into 6-person teams with team incentives. The combined condition with both supportive and competitive relationships placed participants into 6-person teams, where participants could compare their team\u27s performance to 5 other teams\u27 performances. The control condition only allowed participants to attend classes with individual incentives. Rewards were based on the total number of classes attended by an individual, or the average number of classes attended by the members of a team. The outcome was the number of classes that participants attended. Data were analyzed using multilevel models in 2014. The mean attendance numbers per week were 35.7, 38.5, 20.3, and 16.8 in the social comparison, the combined, the control, and the social support conditions. Attendance numbers were 90% higher in the social comparison and the combined conditions (mean = 1.9, SE = 0.2) in contrast to the two conditions without comparison (mean = 1.0, SE = 0.2) (p = 0.003). Social comparison was more effective for increasing physical activity than social support and its effects did not depend on individual or team incentives

Home telehealth and paediatric palliative care: clinician perceptions of what is stopping us?

Background: Advances in technology have made the use of telehealth in the home setting a feasible option for palliative care clinicians to provide clinical care and support. However, despite being widely available and accessible, telehealth has still not been widely adopted either in Australia or internationally. The study aim was to investigate the barriers, enablers and perceived usefulness for an established home telehealth program in paediatric palliative care from the perspective of clinicians

Identification of Universally Applicable and Species-Specific Marker Peptides for Bacillus anthracis

Anthrax is a zoonotic infection caused by the bacterium Bacillus anthracis (BA). Specific identification of this pathogen often relies on targeting genes located on two extrachromosomal plasmids, which represent the major pathogenicity factors of BA. However, more recent findings show that these plasmids have also been found in other closely related Bacillus species. In this study, we investigated the possibility of identifying species-specific and universally applicable marker peptides for BA. For this purpose, we applied a high-resolution mass spectrometry-based approach for 42 BA isolates. Along with the genomic sequencing data and by developing a bioinformatics data evaluation pipeline, which uses a database containing most of the publicly available protein sequences worldwide (UniParc), we were able to identify eleven universal marker peptides unique to BA. These markers are located on the chromosome and therefore, might overcome known problems, such as observable loss of plasmids in environmental species, plasmid loss during cultivation in the lab, and the fact that the virulence plasmids are not necessarily a unique feature of BA. The identified chromosomally encoded markers in this study could extend the small panel of already existing chromosomal targets and along with targets for the virulence plasmids, may pave the way to an even more reliable identification of BA using genomics- as well as proteomics-based techniques

What are the predictors of change in multimorbidity among people with HIV? : a longitudinal observational cohort study

Introduction: Multimorbidity is common among people living with HIV (PLWH), with numerous cross-sectional studies demonstrating associations with older age and past immunosuppression. Little is known about the progression of multimorbidity, particularly in the setting of long-term access to antiretrovirals. This study aims to determine factors predictive of change in multimorbidity in PLWH. Methods: People living with HIV who attended a regional HIV service were recruited to a consented observational cohort between September 2016 and March 2020. Demographic data, laboratory results and a Cumulative Illness Rating Scale (CIRS) were collected at enrolment and first clinical review of every subsequent year. Change in CIRS score was calculated from enrolment to February 2021. Associations with change were determined through univariate and multivariate linear regression. Results: Of 253 people, median age was 58.9 [interquartile range (IQR): 51.9–64.4] years, 91.3% were male, and HIV was diagnosed a median of 22.16 years (IQR: 12.1–30.9) beforehand. Length of time in the study was a median of 134 weeks (IQR: 89.0–179.0), in which a mean CIRS score change of 1.21 (SD 2.60) was observed. Being older (p < 0.001) and having a higher body mass index (p = 0.008) and diabetes (p = 0.014) were associated with an increased likelihood of worsening multimorbidity. PLWH with a higher level of multimorbidity at baseline were less likely to worsen over time (p < 0.001). Conclusion: As diabetes and weight predict worsening multimorbidity, routine diabetes screening, body mass index measurement, and multimorbidity status awareness are recommended