An exploration of primary care policy and practice for reducing inequalities in mental health

Mental health problems in individuals and in the Scottish population are less well defined by routine data and diagnostic criteria than are physical health problems, but they have similar relationships with social gradients. Primary care in Scotland in recent years has been given an emphasis on health inequalities and on prevention and is also expected to provide frontline services and ongoing support to patients with mental health problems. Addressing health inequalities and inequalities in mental health are thought to require action on social circumstances as well as on biological conditions. However, the health service works within an established biomedical culture influenced by the strong medical workforce system and the broader political emphasis on accelerated economic growth. Policies express a general expectation that all public sector services have addressing health inequalities built in to their functions, but there is evidence to suggest that primary care has not yet found its place in meeting this expectation. To date there have been few concrete proposals for action and no guidelines for primary care to address health inequalities. The study set out to identify the contribution that primary care can make to reducing and preventing inequalities in mental health. Interpretive policy analysis was used as the framework for the study. In contrast to traditional policy analyses, which take an objective approach to comparing policy interventions, interpretive policy analysis can help to synthesise perspectives or reframe debates. It regards stakeholders’ interpretations of policy as drivers for change on the ground rather than the policies themselves. Stakeholders are described as being within three “communities of meaning” of policymakers, implementing agencies and service users, and each grouping can have several internal communities making different interpretations of the same policy. There were four communities of meaning relevant to this study: policymakers; primary care strategic staff; primary care and mental health frontline professionals; and services a patient might encounter. The policymakers’ perspectives on health inequalities and inequalities in mental health were drawn from an appraisal of nine health and social policies current at the time of the main study period (2002 – 2006). The other three communities were identified within one Community Health Partnership in the West of Scotland. Data were collected using document analyses, observation of a primary care mental health needs assessment and interviews with 21 frontline primary care and mental health professional staff from 14 disciplines. Identification of the services a patient might expect in relation to inequalities in mental health was elicited through frontline professionals’ responses to a vignette. All nine policy documents in the appraisal included aims to tackle some aspects of health inequalities, but inequalities in mental health were barely mentioned. The documents presented a disjointed picture of definitions for inequalities that lacked a clear overall interpretation of inequalities in health. They also proposed actions which often did not flow from the definitions and clouded the identification of expectations on primary care for addressing inequalities in mental health. For example, documents suggested that poverty, area deprivation and other social circumstances were linked with health inequalities, but the emphasis for action was skewed towards individual lifestyles and organisational change. The confused policy picture was mirrored by similar disjunctions between definitions and actions among strategic and frontline professional staff. In addition, there were clear differences between definitions identified in policy documents and those given by professionals, suggesting that frontline professional staff appeared to draw information about mental health and inequalities from public media and practice experience rather than from research and policy. Observation of a mental health needs assessment included an appraisal of the local strategic context and additional interviews with key senior staff. The observation found that inequalities were not considered for action in the mental health needs assessment nor in most of the other local strategic processes. This was despite some key strategic staff’s individual perspectives that social inequalities can impact on mental health, and despite information about local social and mental health inequalities being made available. The observation concluded that the culture of the organisation was not conducive to tackling inequalities in mental health. Frontline and strategic staff were generally unclear about identifying a patient’s social circumstances which might put them at most at risk of developing mental health problems. Although some frontline professionals linked mental health and social inequalities in defining health inequalities, most were unlikely to intervene on addressing a patient’s social circumstances. While frontline professionals and strategic staff almost universally defined health inequalities as differential access to services, few indicated that they would take action to ensure access, for example, following a patient’s non-attendance. The culture of the observed primary care organisation was not conducive to driving change on inequalities in mental health, and its contribution to reducing and preventing inequalities in mental health is at an early stage. Interpretive policy analysis identified disjunction and gaps in understanding and leadership to address inequalities in mental health at policy, planning and practice levels, but also identified potential areas for development. The study concluded that some of the building blocks are already in place for the primary care organisation to respond to policy leadership on inequalities in mental health should that time come

A Description of a Public Health Role for Health Visitors

The term "public health nursing" was introduced to the UK before a definition was generally agreed. Consequently, there was confusion over the use of the term "public health" in relation to nursing as a whole and health visiting in particular. SNMAC (1995) believed that health visitors had a particular public health role because of their orientation to health promotion in relation to individual and community need. However, it was not clear whether community-focused health promotion activity could legitimately be described as a current public health role of health visitors. Taking "public health" to mean a population perspective, the purpose of the study was to develop an understanding of health visitors' public health role by examining the practices and processes of community-based health visitors. In addition, the relevance of a community-focused health visiting role was established in relation to current practice and policy in public health, primary care, health promotion and social services. Data were collected from health visitors who worked with community-focused remits in Scotland and England using face-to-face, semi-structured interviews within an ethnographic framework. Transcriptions of interviews were analysed by an inductive process of identifying themes, patterns, concepts, contrasts and irregularities. Reliability and validity were sought through a reflexive process whereby the researcher maintained awareness of her involvement with the data. A model of a health visiting role was proposed that emphasised a population or community approach, and employed a range of methods of working drawn from generic health visiting, public health and community work

Applying Participatory Health Research Elements in Rural End-of-Life Research: Reflections on Conducting In-Depth Interviews With Participants on Sensitive Topics

Gegenstand des Forschungsprojekts "Living Loving Dying" war es, die Versorgung am Lebensende und die Trauerbewältigung für Sterbende und ihre Angehörigen in ländlichen Regionen zu verbessern. Teilnehmende waren Personen, die Sterbende begleitet hatten und in Gebieten mit geringer Einwohner*innenzahl und in relativer geografischer Isolation lebten. Die Datenerhebung zu derart sensitiven Themen mit Menschen, die immer noch von Tod und Trauer betroffen waren, erforderte die Nutzung entsprechen sensitiver Methoden. Wichtig ist auch, dass diese Menschen sicher sein können, dass ihre Stimme gehört wird und dass sie zu positiven Veränderungen für andere beitragen können. Vor diesem Hintergrund haben wir sie gebeten, als Community-Partner*innen an der Studie teilzunehmen, für die wir ein deskriptives qualitatives Design gewählt und partizipative Elemente in die Datenerhebung mittels teilstrukturierter Interviews einbezogen haben. Dabei war die nicht-hierarchische Beziehung zwischen uns Forschenden und den Partner*innen von herausragender Bedeutung gerade angesichts dieser vulnerablen Gruppe. In dem Beitrag reflektieren wird die pragmatischen und ethischen Erwägungen des Methodeneinsatzes für die ländliche Lebensende-Forschung.The "Living Loving Dying" research project aimed to improve end of life and bereavement care for people caring and dying in rural areas. The data were provided by people who had experienced caring for someone until his/her death, while living in an area of low population and geographical isolation. Undertaking data collection on such a sensitive topic, from people still vulnerable from the impacts of death and grief, requires the use of particularly sensitive research methods. It is also important that participants feel their voices are heard and that they are contributing to positive change for others. In view of this we positioned people to participate as community-partners and utilized a descriptive qualitative design with participatory elements in the data collection method of in-depth, semi structured interviewing. The non-hierarchical relationship between researchers and community-partners were key influences for using participatory elements in this research with a vulnerable population. In this article we reflect on the pragmatic and ethical considerations that the application of this method has for rural end-of-life research

Distinct transcriptional roles for Histone H3-K56 acetylation during the cell cycle in Yeast

Dynamic disruption and reassembly of promoter-proximal nucleosomes is a conserved hallmark of transcriptionally active chromatin. Histone H3-K56 acetylation (H3K56Ac) enhances these turnover events and promotes nucleosome assembly during S phase. Here we sequence nascent transcripts to investigate the impact of H3K56Ac on transcription throughout the yeast cell cycle. We find that H3K56Ac is a genome-wide activator of transcription. While H3K56Ac has a major impact on transcription initiation, it also appears to promote elongation and/or termination. In contrast, H3K56Ac represses promiscuous transcription that occurs immediately following replication fork passage, in this case by promoting efficient nucleosome assembly. We also detect a stepwise increase in transcription as cells transit S phase and enter G2, but this response to increased gene dosage does not require H3K56Ac. Thus, a single histone mark can exert both positive and negative impacts on transcription that are coupled to different cell cycle events

Un/Re/Doing Gender in Consumer Research: In Conversation with Pauline Maclaran, Lisa Peñaloza, and Craig Thompson

This article documents a panel conversation with three exceptional scholars in the domain of gender and consumer research— Pauline Maclaran, Lisa Peñaloza, and Craig Thompson. The panel was moderated by Jenna Drenten

Emerging roles for diguanylate cyclase during the evolution of soma in dictyostelia

Background: Cyclic di-guanylate (c-di-GMP), synthesized by diguanylate cyclase, is a major second messenger in prokaryotes, where it triggers biofilm formation. The dictyostelid social amoebas acquired diguanylate cyclase (dgcA) by horizontal gene transfer. Dictyostelium discoideum (Ddis) in taxon group 4 uses c-di-GMP as a secreted signal to induce differentiation of stalk cells, the ancestral somatic cell type that supports the propagating spores. We here investigated how this role for c-di-GMP evolved in Dictyostelia by exploring dgcA function in the group 2 species Polysphondylium pallidum (Ppal) and in Polysphondylium violaceum (Pvio), which resides in a small sister clade to group 4.Results: Similar to Ddis, dgcA is upregulated after aggregation in Ppal and Pvio and predominantly expressed in the anterior region and stalks of emerging fruiting bodies. DgcA null mutants in Ppal and Pvio made fruiting bodies with very long and thin stalks and only few spores and showed delayed aggregation and larger aggregates, respectively. Ddis dgcAˉ cells cannot form stalks at all, but showed no aggregation defects. The long, thin stalks of Ppal and Pvio dgcAˉ mutants were also observed in acaAˉ mutants in these species. AcaA encodes adenylate cyclase A, which mediates the effects of c-di-GMP on stalk induction in Ddis. Other factors that promote stalk formation in Ddis are DIF-1, produced by the polyketide synthase StlB, low ammonia, facilitated by the ammonia transporter AmtC, and high oxygen, detected by the oxygen sensor PhyA (prolyl 4-hydroxylase). We deleted the single stlB, amtC and phyA genes in Pvio wild-type and dgcAˉ cells. Neither of these interventions affected stalk formation in Pvio wild-type and not or very mildly exacerbated the long thin stalk phenotype of Pvio dgcAˉ cells.Conclusions: The study reveals a novel role for c-di-GMP in aggregation, while the reduced spore number in Pvio and Ppal dgcAˉ is likely an indirect effect, due to depletion of the cell pool by the extended stalk formation. The results indicate that in addition to c-di-GMP, Dictyostelia ancestrally used an as yet unknown factor for induction of stalk formation. The activation of AcaA by c-di-GMP is likely conserved throughout Dictyostelia

Temperature controlled high-throughput magnetic tweezers show striking difference in activation energies of replicating viral RNA-dependent RNA polymerases

RNA virus survival depends on efficient viral genome replication, which is performed by the viral RNA dependent RNA polymerase (RdRp). The recent development of high throughput magnetic tweezers has enabled the simultaneous observation of dozens of viral RdRp elongation traces on kilobases long templates, and this has shown that RdRp nucleotide addition kinetics is stochastically interrupted by rare pauses of 1-1000 s duration, of which the short-lived ones (1-10 s) are the temporal signature of a low fidelity catalytic pathway. We present a simple and precise temperature controlled system for magnetic tweezers to characterize the replication kinetics temperature dependence between 25 degrees C and 45 degrees C of RdRps from three RNA viruses, i.e. the double-stranded RNA bacteriophage Phi 6, and the positive-sense single-stranded RNA poliovirus (PV) and human rhinovirus C (HRV-C). We found that Phi 6 RdRp is largely temperature insensitive, while PV and HRV-C RdRps replication kinetics are activated by temperature. Furthermore, the activation energies we measured for PV RdRp catalytic state corroborate previous estimations from ensemble pre-steady state kinetic studies, further confirming the catalytic origin of the short pauses and their link to temperature independent RdRp fidelity. This work will enable future temperature controlled study of biomolecular complex at the single molecule level.Peer reviewe

Reconstruction and validation of arterial geometries for computational fluid dynamics using multiple temporal frames of 4D flow-MRI magnitude Images

Purpose Segmentation and reconstruction of arterial blood vessels is a fundamental step in the translation of computational fluid dynamics (CFD) to the clinical practice. Four-dimensional flow magnetic resonance imaging (4D Flow-MRI) can provide detailed information of blood flow but processing this information to elucidate the underlying anatomical structures is challenging. In this study, we present a novel approach to create high-contrast anatomical images from retrospective 4D Flow-MRI data. Methods For healthy and clinical cases, the 3D instantaneous velocities at multiple cardiac time steps were superimposed directly onto the 4D Flow-MRI magnitude images and combined into a single composite frame. This new Composite Phase-Contrast Magnetic Resonance Angiogram (CPC-MRA) resulted in enhanced and uniform contrast within the lumen. These images were subsequently segmented and reconstructed to generate 3D arterial models for CFD. Using the time-dependent, 3D incompressible Reynolds-averaged Navier–Stokes equations, the transient aortic haemodynamics was computed within a rigid wall model of patient geometries. Results Validation of these models against the gold standard CT-based approach showed no statistically significant inter-modality difference regarding vessel radius or curvature (p > 0.05), and a similar Dice Similarity Coefficient and Hausdorff Distance. CFD-derived near-wall hemodynamics indicated a significant inter-modality difference (p > 0.05), though these absolute errors were small. When compared to the in vivo data, CFD-derived velocities were qualitatively similar. Conclusion This proof-of-concept study demonstrated that functional 4D Flow-MRI information can be utilized to retrospectively generate anatomical information for CFD models in the absence of standard imaging datasets and intravenous contrast

Genetic Variation in an Individual Human Exome

There is much interest in characterizing the variation in a human individual, because this may elucidate what contributes significantly to a person's phenotype, thereby enabling personalized genomics. We focus here on the variants in a person's ‘exome,’ which is the set of exons in a genome, because the exome is believed to harbor much of the functional variation. We provide an analysis of the ∼12,500 variants that affect the protein coding portion of an individual's genome. We identified ∼10,400 nonsynonymous single nucleotide polymorphisms (nsSNPs) in this individual, of which ∼15–20% are rare in the human population. We predict ∼1,500 nsSNPs affect protein function and these tend be heterozygous, rare, or novel. Of the ∼700 coding indels, approximately half tend to have lengths that are a multiple of three, which causes insertions/deletions of amino acids in the corresponding protein, rather than introducing frameshifts. Coding indels also occur frequently at the termini of genes, so even if an indel causes a frameshift, an alternative start or stop site in the gene can still be used to make a functional protein. In summary, we reduced the set of ∼12,500 nonsilent coding variants by ∼8-fold to a set of variants that are most likely to have major effects on their proteins' functions. This is our first glimpse of an individual's exome and a snapshot of the current state of personalized genomics. The majority of coding variants in this individual are common and appear to be functionally neutral. Our results also indicate that some variants can be used to improve the current NCBI human reference genome. As more genomes are sequenced, many rare variants and non-SNP variants will be discovered. We present an approach to analyze the coding variation in humans by proposing multiple bioinformatic methods to hone in on possible functional variation