The disappearance of the "revolving door" patient in Scottish general practice: successful policies

<b>Background</b> We describe the health of "revolving door" patients in general practice in Scotland, estimate changes in their number over the timescale of the study, and explore reasons for changes, particularly related to NHS and government policy.<p></p> <b>Methods</b> A mixed methods predominantly qualitative study, using a grounded theory approach, set in Scottish general practice. Semi-structured interviews were conducted with professional key informants, 6 Practitioner Services staff who administer the GP registration system and 6 GPs with managerial or clinical experience of working with "revolving door" patients. Descriptive statistical analysis and qualitative analysis of patient removal episodes linked with routine hospital admissions, outpatient appointments, drug misuse treatment episodes and deaths were carried out with cohorts of "revolving door" patients identified from 1999 to 2005 in Scotland.<p></p> <b>Results</b> A "revolving door" patient is removed 4 or more times from GP lists in 7 years. Patients had complex health issues including substance misuse, psychiatric and physical health problems and were at high risk of dying. There was a dramatic reduction in the number of "revolving door" patients during the course of the study.<p></p> <b>Conclusions</b> "Revolving door" patients in general practice had significant health problems. Their numbers have reduced dramatically since 2004 and this probably resulted from improved drug treatment services, pressure from professional bodies to reduce patient removals and the positive ethical regulatory and financial climate of the 2004 GMS GP contract. This is a positive development for the NHS

bcl-2 Transgene Expression Inhibits Apoptosis in the Germinal Center and Reveals Differences in the Selection of Memory B Cells and Bone Marrow Antibody-Forming Cells

Immunization with T cell–dependent antigens generates long-lived memory B cells and antibody-forming cells (AFCs). Both populations originate in germinal centers and, predominantly, produce antibodies with high affinity for antigen. The means by which germinal center B cells are recruited into these populations remains unclear. We have examined affinity maturation of antigen-specific B cells in mice expressing the cell death inhibitor bcl-2 as a transgene. Such mice had reduced apoptosis in germinal centers and an excessive number of memory B cells with a low frequency of V gene somatic mutation, including those mutations encoding amino acid exchanges known to enhance affinity. Despite the frequency of AFCs being increased in bcl-2–transgenic mice, the fraction secreting high-affinity antibody in the bone marrow at day 42 remained unchanged compared with controls. The inability of BCL-2 to alter selection of bone marrow AFCs is consistent with these cells being selected within the germinal center on the basis of their affinity being above some threshold rather than their survival being due to a selective competition for an antigen-based signal. Continuous competition for antigen does, however, explain formation of the memory compartment

Business to digital transformation: a proposed framework for achieving business intelligence alignment

With digital disruption comes an emphasis on the importance of organisation alignment, especially prior to any proposed digital transformation (DT). Analysts project that over 70% of the $1.3trillion annual spend on DT will not succeed as intended. Many enterprise transformations begin with brave ambition, yet many CXOs delay making “go / no-go” decisions due to what the authors term the “Business Intelligence (B.I.) Accessibility Principle”.This refers to the high cost of attaining enterprise-wide understanding, or group-cognition, to sustain the complex changes required. Strategic Management cannot merely plan to implement and deliver on strategic vision. Leadership need more adaptable frameworks to pre-emptively support enterprise engagement and alignment if we are to succeed in transformation. Action Design Research (ADR) can aid our thinking, helping conceptualise and examine alignment frameworks critically. ADR can support Management to quickly ‘sense-categorise-respond’ to both organisational and individual needs prior to transformation decisions. These needs are typically ‘dark-data”, or data hardly being analysed, to improve decision making. The Gap-Map framework helps expose such tacit knowledge, key to enterprise-wide transformation success. It allows management to predict the propensity of the organisation for change, and address change through focused behavioural intervention. This paper’s contribution is a B.I. framework where leaders now invest focused time and resources in DT through earlier understanding of potential impacts. This enables managers to strategically utilise behavioural intervention to enable multilateral group cognition and collaboration earlier. Gap-Map value creation is through flagging potentially costly issues and opportunities earlier, allowing transformation initiatives the propensity to succeed

Observations of storm-induced mixing and Gulf Stream Ring incursion over the southern flank of Georges Bank : winter and summer 1997

Author Posting. © American Geophysical Union, 2010. This article is posted here by permission of American Geophysical Union for personal use, not for redistribution. The definitive version was published in Journal of Geophysical Research 115 (2010): C08008, doi:10.1029/2009JC005706.High-resolution hydrographic measurements collected along the southern edge of Georges Bank during March and June–July 1997 focused on characterizing processes that drive fluxes of material between the slope and bank. Wintertime sampling characterized changes driven by a strong storm. A Scotian Shelf crossover event produced a ribbon of anomalously fresh water along the bank's southern flank that was diluted during the storm. Comparison of prestorm and poststorm sections shows that over the bank changes in heat and salt inventories are consistent with those expected solely from local surface fluxes. In deeper waters, advective effects, likely associated with frontal motion and eddies, are clearly important. Summertime surveys resolve the development of a massive intrusion of Gulf Stream-like waters onto the bank. East of the intrusion, a thin extrusion of bank water is drawn outward by the developing ring, exporting fresher water at a rate of about 7 × 104 m3/s. A large-amplitude Gulf Stream meander appears to initiate the extrusion, but it quickly evolves, near the bank edge, into a warm core ring. Ring water intrudes to approximately the 80 m isobath, 40 km inshore from the bank edge. The intrusion process seems analogous to the development of Gulf Stream shingles (a hydrodynamic instability) in the South Atlantic Bight. It appears that, once the intruded water is established on the bank, it remains there and dissipates in place. Although the intrusion is an extremely dramatic event, it is probably not actually a major contributor to shelf edge exchanges over a seasonal time scale.This work was supported by the National Science Foundation as part of the U.S. Global Ocean Ecosystems Dynamics (GLOBEC) program through grant OCE-9632349. Lee received additional support from OCE-0628379

Upper limits on the strength of periodic gravitational waves from PSR J1939+2134

The first science run of the LIGO and GEO gravitational wave detectors presented the opportunity to test methods of searching for gravitational waves from known pulsars. Here we present new direct upper limits on the strength of waves from the pulsar PSR J1939+2134 using two independent analysis methods, one in the frequency domain using frequentist statistics and one in the time domain using Bayesian inference. Both methods show that the strain amplitude at Earth from this pulsar is less than a few times $10^{-22}$.Comment: 7 pages, 1 figure, to appear in the Proceedings of the 5th Edoardo Amaldi Conference on Gravitational Waves, Tirrenia, Pisa, Italy, 6-11 July 200

Improving the sensitivity to gravitational-wave sources by modifying the input-output optics of advanced interferometers

We study frequency dependent (FD) input-output schemes for signal-recycling interferometers, the baseline design of Advanced LIGO and the current configuration of GEO 600. Complementary to a recent proposal by Harms et al. to use FD input squeezing and ordinary homodyne detection, we explore a scheme which uses ordinary squeezed vacuum, but FD readout. Both schemes, which are sub-optimal among all possible input-output schemes, provide a global noise suppression by the power squeeze factor, while being realizable by using detuned Fabry-Perot cavities as input/output filters. At high frequencies, the two schemes are shown to be equivalent, while at low frequencies our scheme gives better performance than that of Harms et al., and is nearly fully optimal. We then study the sensitivity improvement achievable by these schemes in Advanced LIGO era (with 30-m filter cavities and current estimates of filter-mirror losses and thermal noise), for neutron star binary inspirals, and for narrowband GW sources such as low-mass X-ray binaries and known radio pulsars. Optical losses are shown to be a major obstacle for the actual implementation of these techniques in Advanced LIGO. On time scales of third-generation interferometers, like EURO/LIGO-III (~2012), with kilometer-scale filter cavities, a signal-recycling interferometer with the FD readout scheme explored in this paper can have performances comparable to existing proposals. [abridged]Comment: Figs. 9 and 12 corrected; Appendix added for narrowband data analysi

Search for gravitational wave bursts in LIGO's third science run

We report on a search for gravitational wave bursts in data from the three LIGO interferometric detectors during their third science run. The search targets subsecond bursts in the frequency range 100-1100 Hz for which no waveform model is assumed, and has a sensitivity in terms of the root-sum-square (rss) strain amplitude of hrss ~ 10^{-20} / sqrt(Hz). No gravitational wave signals were detected in the 8 days of analyzed data.Comment: 12 pages, 6 figures. Amaldi-6 conference proceedings to be published in Classical and Quantum Gravit

Quantum state preparation and macroscopic entanglement in gravitational-wave detectors

Long-baseline laser-interferometer gravitational-wave detectors are operating at a factor of 10 (in amplitude) above the standard quantum limit (SQL) within a broad frequency band. Such a low classical noise budget has already allowed the creation of a controlled 2.7 kg macroscopic oscillator with an effective eigenfrequency of 150 Hz and an occupation number of 200. This result, along with the prospect for further improvements, heralds the new possibility of experimentally probing macroscopic quantum mechanics (MQM) - quantum mechanical behavior of objects in the realm of everyday experience - using gravitational-wave detectors. In this paper, we provide the mathematical foundation for the first step of a MQM experiment: the preparation of a macroscopic test mass into a nearly minimum-Heisenberg-limited Gaussian quantum state, which is possible if the interferometer's classical noise beats the SQL in a broad frequency band. Our formalism, based on Wiener filtering, allows a straightforward conversion from the classical noise budget of a laser interferometer, in terms of noise spectra, into the strategy for quantum state preparation, and the quality of the prepared state. Using this formalism, we consider how Gaussian entanglement can be built among two macroscopic test masses, and the performance of the planned Advanced LIGO interferometers in quantum-state preparation

What's wrong with John? A randomised controlled trial of Mental Health First Aid (MHFA) training with nursing students

BACKGROUND: The prevalence of mental health problems have been found to be higher among university students compared to their non-student peers. Nursing students in particular face a range of additional stressors which may impact their undergraduate performance and their careers. Mental Health First Aid (MHFA) aims to increase mental health literacy and to reduce stigma and may positively impact on the student population. This paper describes a MHFA randomised controlled trial targeting nursing students at a large Australian university. This study aimed to measure the impact of the MHFA course on mental health literacy, mental health first aid intentions, confidence in helping someone with a mental health problem and stigmatising attitudes including social distance. METHODS: Participants were first year nursing students (n = 181) randomly allocated to the intervention (n = 92) or control (n = 89) group. Intervention group participants received the standardised MHFA course for nursing students. Online self-report questionnaires were completed at three time intervals: baseline (one week prior to the intervention: T1) (n = 140), post intervention (T2) (n = 120), and two months post intervention (T3) (n = 109). Measures included demographics, mental health knowledge, recognition of depression, confidence in helping, mental health first aid intentions and stigmatising attitudes including social distance. Repeated measures ANOVA was computed to measure if the impact of time (T1, T2, T3) and group (intervention and control) on the outcome variables. RESULTS: There was a significant improvement among intervention compared to control group participants across the three time periods for knowledge scores (p < 0.001), confidence in helping (p < 0.001), mental health first aid intentions (p < 0.001), total personal stigma (p < 0.05), personal dangerous/unpredictable stigma (p < 0.05) and social distance (p < 0.05) scores. CONCLUSION: MHFA is useful training to embed in university courses and has the potential to enhance mental health literacy and reduce stigmatising attitudes and social distance. While this course has particular salience for nursing and other health science students, there are broader benefits to the general university population that should be considered and opportunities accordingly explored for all students to complete the course. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12614000861651 . Retrospectively registered 11 August 2014