Summary care record early adopter programme: an independent evaluation by University College London.

Benefits The main potential benefit of the SCR is considered to be in emergency and unscheduled care settings, especially for people who are unconscious, confused, unsure of their medical details, or unable to communicate effectively in English. Other benefits may include improved efficiency of care and avoidance of hospital admission, but it is too early for potential benefits to be verified or quantified. Progress As of end April 2008, the SCR of 153,188 patients in the first two Early Adopter sites (Bolton and Bury) had been created. A total of 614,052 patients in four Early Adopter sites had been sent a letter informing them of the programme and their choices for opting out of having a SCR. Staff attitudes and usage The evaluation found that many NHS staff in Early Adopter sites (which had been selected partly for their keenness to innovate in ICT) were enthusiastic about the SCR and keen to see it up and running, but a significant minority of GPs had chosen not to participate in the programme and others had deferred participation until data quality improvement work was completed. Whilst 80 per cent of patients interviewed were either positive about the idea of having a SCR or ?did not mind?, others were strongly opposed ?on principle?. Staff who had attempted to use the SCR when caring for patients felt that the current version was technically immature (describing it as ?clunky? and ?complicated?), and were looking forward to a more definitive version of the technology. A comparable technology (the Emergency Care Summary) introduced in Scotland two years ago is now working well, and over a million records have been accessed in emergency and out-of-hours care. Patient attitudes and awareness Having a SCR is optional (people may opt out if they wish, though fewer than one per cent of people in Early Adopter sites have done so) and technical security is said to be high via a system of password protection and strict access controls. Nevertheless, the evaluation showed that recent stories about data loss by government and NHS organisations had raised concerns amongst both staff and patients that human fallibility could potentially jeopardise the operational security of the system. Despite an extensive information programme to inform the public in Early Adopter sites about the SCR, many patients interviewed by the UCL team were not aware of the programme at all. This raises important questions about the ethics of an ?implied consent? model for creating the SCR. The evaluation recommended that the developers of the SCR should consider a model in which the patient is asked for ?consent to view? whenever a member of staff wishes to access their record. Not a single patient interviewed in the evaluation was confident that the SCR would be 100 per cent secure, but they were philosophical about the risks of security breaches. Typically, people said that the potential benefit of a doctor having access to key medical details in an emergency outweighed the small but real risk of data loss due to human or technical error. Even patients whose medical record contained potentially sensitive data such as mental health problems, HIV or drug use were often (though not always) keen to have a SCR and generally trusted NHS staff to treat sensitive data appropriately. However, they and many other NHS patients wanted to be able to control which staff members were allowed to access their record at the point of care. Some doctors, nurses and receptionists, it seems, are trusted to view a person?s SCR, whereas others are not, and this is a decision which patients would like to make in real time

Do Employees From Less-Healthy Communities Use More Care and Cost More? Seeking to Establish a Business Case for Investment in Community Health.

INTRODUCTION: Few studies have examined the impact of community health on employers. We explored whether employed adults and their adult dependents living in less-healthy communities in the greater Philadelphia region used more care and incurred higher costs to employers than employees from healthier communities. METHODS: We used a multi-employer database to identify adult employees and dependents with continuous employment and mapped them to 31 zip code regions. We calculated community health scores at the regional level, by using metrics similar to the Robert Wood Johnson Foundation (RWJF) County Health Rankings but with local data. We used descriptive analyses and multilevel linear modeling to explore relationships between community health and 3 outcome variables: emergency department (ED) use, hospital use, and paid claims. Business leaders reviewed findings and offered insights on preparedness to invest in community health improvement. RESULTS: Poorer community health was associated with high use of ED services, after controlling for age and sex. After including a summary measure of racial composition at the zip code region level, the relationship between community health and ED use became nonsignificant. No significant relationships between community health and hospitalizations or paid claims were identified. Business leaders expressed interest in further understanding health needs of communities where their employees live. CONCLUSION: The health of communities in which adult employees and dependents live was associated with ED use, but similar relationships were not seen for hospitalizations or paid claims. This finding suggests a need for more primary care access. Despite limited quantitative evidence, business leaders expressed interest in guidance on investing in community health improvement

Conformational Entropy as a Means to Control the Behavior of Poly(diketoenamine) Vitrimers In and Out of Equilibrium.

Control of equilibrium and non-equilibrium thermomechanical behavior of poly(diketoenamine) vitrimers is shown by incorporating linear polymer segments varying in molecular weight (MW) and conformational degrees of freedom into the dynamic covalent network. While increasing MW of linear segments yields a lower storage modulus at the rubbery plateau after softening above the glass transition (Tg ), both Tg and the characteristic time of stress relaxation are independently governed by the conformational entropy of the embodied linear segments. Activation energies for bond exchange in the solid state are lower for networks incorporating flexible chains; the network topology freezing temperature decreases with increasing MW of flexible linear segments but increases with increasing MW of stiff segments. Vitrimer reconfigurability is therefore influenced not only by the energetics of bond exchange for a given network density, but also the entropy of polymer chains within the network

Numerical Evidence for Divergent Burnett Coefficients

In previous papers [Phys. Rev. A {\bf 41}, 4501 (1990), Phys. Rev. E {\bf 18}, 3178 (1993)], simple equilibrium expressions were obtained for nonlinear Burnett coefficients. A preliminary calculation of a 32 particle Lennard-Jones fluid was presented in the previous paper. Now, sufficient resources have become available to address the question of whether nonlinear Burnett coefficients are finite for soft spheres. The hard sphere case is known to have infinite nonlinear Burnett coefficients (ie a nonanalytic constitutive relation) from mode coupling theory. This paper reports a molecular dynamics caclulation of the third order nonlinear Burnett coefficient of a Lennard-Jones fluid undergoing colour flow, which indicates that this term is diverges in the thermodynamic limit.Comment: 12 pages, 9 figure

Preparation and characterization of avenin-enriched oat protein by chill precipitation for feeding trials in celiac disease

The safety of oats for people with celiac disease remains unresolved. While oats have attractive nutritional properties that can improve the quality and palatability of the restrictive, low fiber gluten-free diet, rigorous feeding studies to address their safety in celiac disease are needed. Assessing the oat prolamin proteins (avenins) in isolation and controlling for gluten contamination and other oat components such as fiber that can cause non-specific effects and symptoms is crucial. Further, the avenin should contain all reported immunogenic T cell epitopes, and be deliverable at a dose that enables biological responses to be correlated with clinical effects. To date, isolation of a purified food-grade avenin in sufficient quantities for feeding studies has not been feasible. Here, we report a new gluten isolation technique that enabled 2 kg of avenin to be extracted from 400 kg of wheat-free oats under rigorous gluten-free and food grade conditions. The extract consisted of 85% protein of which 96% of the protein was avenin. The concentration of starch (1.8% dry weight), β-glucan (0.2% dry weight), and free sugars (1.8% dry weight) were all low in the final avenin preparation. Other sugars including oligosaccharides, small fructans, and other complex sugars were also low at 2.8% dry weight. Liquid chromatography tandem mass spectrometry (LC-MS/MS) analysis of the proteins in these preparations showed they consisted only of oat proteins and were uncontaminated by gluten containing cereals including wheat, barley or rye. Proteomic analysis of the avenin enriched samples detected more avenin subtypes and fewer other proteins compared to samples obtained using other extraction procedures. The identified proteins represented five main groups, four containing known immune-stimulatory avenin peptides. All five groups were identified in the 50% (v/v) ethanol extract however the group harboring the epitope DQ2.5-ave-1b was less represented. The avenin-enriched protein fractions were quantitatively collected by reversed phase HPLC and analyzed by MALDI-TOF mass spectrometry. Three reverse phase HPLC peaks, representing ~40% of the protein content, were enriched in proteins containing DQ2.5-ave-1a epitope. The resultant high quality avenin will facilitate controlled and definitive feeding studies to establish the safety of oat consumption by people with celiac disease

Are MNCs norm entrepreneurs or followers? The changing relationship between host country institutions and MNC HRM practices

Rooted in the literature on comparative capitalism, we examine the effects of host country institutions on the intra-organizational practices of multinational corporations (MNCs), using transnational level survey data, exploring change over time. We found that the less comprehensive institutional mediation of the Liberal Market Economies correlated with greater diversity and a more pronounced difference between domestic firms and foreign MNCs. However, rather than being the predicted norm entrepreneurs, MNCs tended to follow the lead of local firms in adjusting HRM policies and practices towards liberalization. Those most prone to challenging existing orders were in industries facing particular crises of competitiveness. Finally, we found that single regulatory features rather than complex assemblies of institutions exerted particularly strong effects on the individual firms’ practices encompassed in this study

The global gas and dust budget of the Large Magellanic Cloud: AGB stars and supernovae and the impact on the ISM evolution

‘The definitive version is available at: www3.interscience.wiley.com '. Copyright Blackwell / Royal Astronomical Society. DOI: 10.1111/j.1365-2966.2009.14743.xWe report on an analysis of the gas and dust budget in the interstellar medium (ISM) of the Large Magellanic Cloud (LMC). Recent observations from the Spitzer Space Telescope enable us to study the mid-infrared dust excess of asymptotic giant branch (AGB) stars in the LMC. This is the first time we can quantitatively assess the gas and dust input from AGB stars over a complete galaxy, fully based on observations. The integrated mass-loss rate over all intermediate and high mass-loss rate carbon-rich AGB candidates in the LMC is 8.5 × 10−3 M⊙ yr−1 , up to 2.1 × 10−2 M⊙ yr−1 . This number could be increased up to 2.7 × 10−2 M⊙ yr−1 if oxygen-rich stars are included. This is overall consistent with theoretical expectations, considering the star formation rate (SFR) when these low- and intermediate-mass stars where formed, and the initial mass functions. AGB stars are one of the most important gas sources in the LMC, with supernovae (SNe), which produces about 2–4 × 10−2 M⊙ yr−1 . At the moment, the SFR exceeds the gas feedback from AGB stars and SNe in the LMC, and the current star formation depends on gas already present in the ISM. This suggests that as the gas in the ISM is exhausted, the SFR will eventually decline in the LMC, unless gas is supplied externally. Our estimates suggest 'a missing dust-mass problem' in the LMC, which is similarly found in high-z galaxies: the accumulated dust mass from AGB stars and possibly SNe over the dust lifetime (400–800 Myr) is significant less than the dust mass in the ISM. Another dust source is required, possibly related to star-forming regions.Peer reviewe

An overview of the Lagrangian experiments undertaken during the North Atlantic regional Aerosol Characterisation Experiment (ACE-2)

One of the primary aims of the North Atlantic regional Aerosol Characterisation Experiment (ACE-2) was to quantify the physical and chemical processes affecting the evolution of the major aerosol types over the North Atlantic. The best, practical way of doing this is in a Lagrangian framework where a parcel of air is sampled over several tens of hours and its physical and chemical properties are intensively measured. During the intensive observational phase of ACE-2, between 15 June 1997 and 24 July 1997, 3 cloudy Lagrangian experiments and 3 cloud-free, Lagrangian experiments were undertaken between the south west tip of the Iberian Peninsula and the Canary Islands. This paper gives an overview of the aims and logistics of all of the Lagrangian experiments and compares and contrasts them to provide a framework for the more focused Lagrangian papers in this issue and future process modelling studies and parametrisation development. The characteristics of the cloudy Lagrangian experiments were remarkably different, enabling a wide range of different physical and chemical processes to be studied. In the 1st Lagrangian, a clean maritime air mass was sampled in which salt particle production, due to increased wind speed, dominated the change in the accumulation mode concentrations. In the 2nd Lagrangian, extensive cloud cover resulted in cloud processing of the aerosol in a polluted air mass, and entrainment of air from the free troposphere influenced the overall decrease in aerosol concentrations in the marine boundary layer (MBL). Very little change in aerosol characteristics was measured in the 3rd Lagrangian, where the pollution in the MBL was continually being topped up by entraining air from a residual continental boundary layer (CBL) above. From the analysis of all the Lagrangian experiments, it has been possible to formulate, and present here, a generalised description of a European continental outbreak of pollution over the sub-tropical North Atlantic

Machine learning for comprehensive forecasting of Alzheimer's Disease progression

Most approaches to machine learning from electronic health data can only predict a single endpoint. The ability to simultaneously simulate dozens of patient characteristics is a crucial step towards personalized medicine for Alzheimer’s Disease. Here, we use an unsupervised machine learning model called a Conditional Restricted Boltzmann Machine (CRBM) to simulate detailed patient trajectories. We use data comprising 18-month trajectories of 44 clinical variables from 1909 patients with Mild Cognitive Impairment or Alzheimer’s Disease to train a model for personalized forecasting of disease progression. We simulate synthetic patient data including the evolution of each sub-component of cognitive exams, laboratory tests, and their associations with baseline clinical characteristics. Synthetic patient data generated by the CRBM accurately reflect the means, standard deviations, and correlations of each variable over time to the extent that synthetic data cannot be distinguished from actual data by a logistic regression. Moreover, our unsupervised model predicts changes in total ADAS-Cog scores with the same accuracy as specifically trained supervised models, additionally capturing the correlation structure in the components of ADAS-Cog, and identifies sub-components associated with word recall as predictive of progression