Nurse telephone triage for same day appointments in general practice: multiple interrupted time series trial of effect on workload and costs

OBJECTIVE: To compare the workloads of general practitioners and nurses and costs of patient care for nurse telephone triage and standard management of requests for same day appointments in routine primary care. DESIGN: Multiple interrupted time series using sequential introduction of experimental triage system in different sites with repeated measures taken one week in every month for 12 months. SETTING: Three primary care sites in York. Participants: 4685 patients: 1233 in standard management, 3452 in the triage system. All patients requesting same day appointments during study weeks were included in the trial. MAIN OUTCOME MEASURES: Type of consultation (telephone, appointment, or visit), time taken for consultation, presenting complaints, use of services during the month after same day contact, and costs of drugs and same day, follow up, and emergency care. RESULTS: The triage system reduced appointments with general practitioner by 29-44%. Compared with standard management, the triage system had a relative risk (95% confidence interval) of 0.85 (0.72 to 1.00) for home visits, 2.41 (2.08 to 2.80) for telephone care, and 3.79 (3.21 to 4.48) for nurse care. Mean overall time in the triage system was 1.70 minutes longer, but mean general practitioner time was reduced by 2.45 minutes. Routine appointments and nursing time increased, as did out of hours and accident and emergency attendance. Costs did not differ significantly between standard management and triage: mean difference £1.48 more per patient for triage (95% confidence interval -0.19 to 3.15). CONCLUSIONS: Triage reduced the number of same day appointments with general practitioners but resulted in busier routine surgeries, increased nursing time, and a small but significant increase in out of hours and accident and emergency attendance. Consequently, triage does not reduce overall costs per patient for managing same day appointments

Sameness and difference in therapy

There has been much anecdotal and theoretical material concerning the impact of `race' on therapy in Britain, especially with regards to therapeutic outcomes. The three studies presented in this thesis empirically investigated the notion that premature termination in counselling, and apparently shorter duration of therapeutic treatment, amongst British Black clients is a function of lack of ethnic matching with a Black counsellor; and that racial identity attitudes may help provide some light on this attendance pattern of Black people. Results from SGlindicated that Black people had an appropriate appreciation of the uses and benefits of counselling; that over two-thirds of Black individuals would consider receiving counselling for their problems; and, when asked directly, a statistically significant amount of Black respondents stated that if they were to see a counsellor, they would prefer to see a racially similar counsellor. However, when `race' was not mentioned, this preference was not significant. Analysis of archival material of former clients ('SG2'), did not find a significant difference between Black and White samples in teens of premature termination of counselling or with regards to length of treatment. Similarly, no significant difference was found in terms of dropout rates between those Black clients who were ethnically matched with a Black counsellor and those who were not. The RIAS revealed low item reliability for the British sample in SG3. It was concluded that counsellors should take account of the heterogeneous nature of `Black' people as a group and not automatically presume that a Black client will prefer a Black counsellor, but to explore this with each Black client. Other implications for therapists are considered and recommendations for further research are made

High-resolution radiation mapping to investigate FDNPP derived contaminant migration

AbstractAs of March 2016, five years will have passed since the earthquake and ensuing tsunami that crippled the Fukushima Daiichi Nuclear Power Plant on Japan’s eastern coast, resulting in the explosive release of significant quantities of radioactive material. Over this period, significant time and resource has been expended on both the study of the contamination as well as its remediation from the affected environments. Presented in this work is a high-spatial resolution foot-based radiation mapping study using gamma-spectrometry at a site in the contaminated Iitate Village; conducted at different times, seventeen months apart. The specific site selected for this work was one in which consistent uniform agriculture was observed across its entire extent. From these surveys, obtained from along the main northwest trending line of the fallout plume, it was possible to determine the rate of reduction in the levels of contamination around the site attributable to the natural decay of the radiocesium, remediation efforts or material transport. Results from the work suggest that neither the natural decay of radiocesium nor its downward migration through the soil horizons were responsible for the decline in measured activity levels across the site, with the mobilisation of contaminant species likely adhered to soil particulate and the subsequent fluvial transport responsible for the measurable reduction in activity. This transport of contaminant via fluvial methods has already well studied implications for the input of contaminant material entering the neighbouring Pacific Ocean, as well as the deposition of material along rivers within previously decontaminated areas

On the absence of appreciable half-life changes in alpha emitters cooled in metals to 1 Kelvin and below

The recent suggestion that dramatic changes may occur in the lifetime of alpha and beta decay when the activity, in a pure metal host, is cooled to a few Kelvin, is examined in the light of published low temperature nuclear orientation (LTNO) experiments, with emphasis here on alpha decay. In LTNO observations are made of the anisotropy of radioactive emissions with respect to an axis of orientation. Correction of data for decay of metallic samples held at temperatures at and below 1 Kelvin for periods of days and longer has been a routine element of LTNO experiments for many years. No evidence for any change of half life on cooling, with an upper level of less than 1%, has been found, in striking contrast to the predicted changes, for alpha decay, of several orders of magnitude. The proposal that such dramatic changes might alleviate problems of disposal of long-lived radioactive waste is shown to be unrealistic.Comment: 27 pages, 12 figures, accepted for publication in Nucl.Phys.A. Revised version, including quantitative analysis of the sensitivity of nuclear orientation experiments, discussed in this work, to changes of alpha-decay lifetimes in metals at low temperatures. Conclusions remain unchange

Mass spectrometry based metabolomics comparison of liver grafts from donors after circulatory death (DCD) and donors after brain death (DBD) used in human orthotopic liver transplantation

Use of marginal liver grafts, especially those from donors after circulatory death (DCD), has been considered as a solution to organ shortage. Inferior outcomes have been attributed to donor warm ischaemic damage in these DCD organs. Here we sought to profile the metabolic mechanisms underpinning donor warm ischaemia. Non-targeted Fourier transform ion cyclotron resonance (FT-ICR) mass spectrometry metabolomics was applied to biopsies of liver grafts from donors after brain death (DBD; n = 27) and DCD (n = 10), both during static cold storage (T1) as well as post-reperfusion (T2). Furthermore 6 biopsies from DBD donors prior to the organ donation (T0) were also profiled. Considering DBD and DCD together, significant metabolic differences were discovered between T1 and T2 (688 peaks) that were primarily related to amino acid metabolism, meanwhile T0 biopsies grouped together with T2, denoting the distinctively different metabolic activity of the perfused state. Major metabolic differences were discovered between DCD and DBD during cold-phase (T1) primarily related to glucose, tryptophan and kynurenine metabolism, and in the post-reperfusion phase (T2) related to amino acid and glutathione metabolism. We propose tryptophan/kynurenine and S-adenosylmethionine as possible biomarkers for the previously established higher graft failure of DCD livers, and conclude that the associated pathways should be targeted in more exhaustive and quantitative investigations

Genetic partitioning of interleukin-6 signalling in mice dissociates Stat3 from Smad3-mediated lung fibrosis

Idiopathic pulmonary fibrosis (IPF) is a fatal disease that is unresponsive to current therapies and characterized by excessive collagen deposition and subsequent fibrosis. While inflammatory cytokines, including interleukin (IL)-6, are elevated in IPF, the molecular mechanisms that underlie this disease are incompletely understood, although the development of fibrosis is believed to depend on canonical transforming growth factor (TGF)-β signalling. We examined bleomycin-induced inflammation and fibrosis in mice carrying a mutation in the shared IL-6 family receptor gp130. Using genetic complementation, we directly correlate the extent of IL-6-mediated, excessive Stat3 activity with inflammatory infiltrates in the lung and the severity of fibrosis in corresponding gp130757F mice. The extent of fibrosis was attenuated in B lymphocyte-deficient gp130757F;µMT−/− compound mutant mice, but fibrosis still occurred in their Smad3−/− counterparts consistent with the capacity of excessive Stat3 activity to induce collagen 1α1 gene transcription independently of canonical TGF-β/Smad3 signalling. These findings are of therapeutic relevance, since we confirmed abundant STAT3 activation in fibrotic lungs from IPF patients and showed that genetic reduction of Stat3 protected mice from bleomycin-induced lung fibrosis

The institutional shaping of management: in the tracks of English individualism

Globalisation raises important questions about the shaping of economic action by cultural factors. This article explores the formation of what is seen by some as a prime influence on the formation of British management: individualism. Drawing on a range of historical sources, it argues for a comparative approach. In this case, the primary comparison drawn is between England and Scotland. The contention is that there is a systemic approach to authority in Scotland that can be contrasted to a personal approach in England. An examination of the careers of a number of Scottish pioneers of management suggests the roots of this systemic approach in practices of church governance. Ultimately this systemic approach was to take a secondary role to the personal approach engendered by institutions like the universities of Oxford and Cambridge, but it found more success in the different institutional context of the USA. The complexities of dealing with historical evidence are stressed, as is the value of taking a comparative approach. In this case this indicates a need to take religious practice as seriously as religious belief as a source of transferable practice. The article suggests that management should not be seen as a simple response to economic imperatives, but as shaped by the social and cultural context from which it emerges

BB Intermeson Potentials in the Quark Model

In this paper we derive quark model results for scattering amplitudes and equivalent low energy potentials for heavy meson pairs, in which each meson contains a heavy quark. This "BB" system is an attractive theoretical laboratory for the study of the nuclear force between color singlets; the hadronic system is relatively simple, and there are lattice gauge theory (LGT) results for V_BB(r) which may be compared to phenomenological models. We find that the quark model potential (after lattice smearing) has qualitative similarities to the LGT potential in the two B*B* channels in which direct comparison is possible, although there is evidence of a difference in length scales. The quark model prediction of equal magnitude but opposite sign for I=0 and I=1 potentials also appears similar to LGT results at intermediate r. There may however be a discrepancy between the LGT and quark model I=1 BB potentials. A numerical study of the two-meson Schrodinger equations in the (bqbar)(bqbar) and (cqbar)(cqbar) sectors with the quark model potentials finds a single "molecule", in the I=0 BB* sector. Binding in other channels might occur if the quark model forces are augmented by pion exchange.Comment: 30 pages, 5 figures, revtex and epsfig. Submitted to Phys. Rev.