Implementing collaborative care for major depression in a cancer center: An observational study using mixed-methods.

OBJECTIVES: To describe the implementation of a collaborative care (CC) screening and treatment program for major depression in people with cancer, found to be effective in clinical trials, into routine outpatient care of a cancer center. METHOD: A mixed-methods observational study guided by the RE-AIM implementation framework using quantitative and qualitative data collected over five years. RESULTS: Program set-up took three years and required more involvement of CC experts than anticipated. Barriers to implementation were uncertainty about whether oncology or psychiatry owned the program and the hospital's organizational complexity. Selecting and training CC team members was a major task. 90% (14,412/16,074) of patients participated in depression screening and 61% (136/224) of those offered treatment attended at least one session. Depression outcomes were similar to trial benchmarks (61%; 78/127 patients had a treatment response). After two years the program obtained long-term funding. Facilitators of implementation were strong trial evidence, effective integration into cancer care and ongoing clinical and managerial support. CONCLUSION: A CC program for major depression, designed for the cancer setting, can be successfully implemented into routine care, but requires time, persistence and involvement of CC experts. Once operating it can be an effective and valued component of medical care

Proactive and integrated consultation-liaison psychiatry for older medical inpatients: a mixed methods description of training, care provided and clinician experience in the HOME study

Objectives: To describe the practical experience of delivering a proactive and integrated consultation-liaison (C-L) psychiatry service model (PICLP). PICLP is designed for older medical inpatients and is explicitly biopsychosocial and discharge-focused. In this paper we report: (a) observations on the training of 15 clinicians (seven senior C-L psychiatrists and eight assisting clinicians) to deliver PICLP; (b) the care they provided to 1359 patients; (c) their experiences of working in this new way. Method: A mixed methods observational study using quantitative and qualitative data, collected prospectively over two years as part of The HOME Study (a randomized trial comparing PICLP with usual care). Results: The clinicians were successfully trained to deliver PICLP according to the service manual. They proactively assessed all patients and found that most had multiple biopsychosocial problems impeding their timely discharge from hospital. They integrated with ward teams to provide a range of interventions aimed at addressing these problems. Delivering PICLP took a modest amount of clinical time, and the clinicians experienced it as both clinically valuable and professionally rewarding. Conclusion: The experience of delivering PICLP highlights the special role that C-L psychiatry clinicians, working in a proactive and integrated way, can play in medical care

Density growth in Kantowski-Sachs cosmologies with cosmological constant

In this work the growth of density perturbations in Kantowski-Sachs cosmologies with a positive cosmological constant is studied, using the 1+3 and 1+1+2 covariant formalisms. For each wave number we obtain a closed system for scalars formed from quantities that are zero on the background and hence are gauge-invariant. The solutions to this system are then analyzed both analytically and numerically. In particular the effects of anisotropy and the behaviour close to a bounce in the cosmic scale factor are considered. We find that typically the density gradient in the bouncing directions experiences a local maximum at or slightly after the bounce.Comment: 33 pages, 17 picture

A spiral scaffold underlies cytoadherent knobs in Plasmodium falciparum-infected erythrocytes

Much of the virulence of Plasmodium falciparum malaria is caused by cytoadherence of infected erythrocytes, which promotes parasite survival by preventing clearance in the spleen. Adherence is mediated by membrane protrusions known as knobs, whose formation depends on the parasite-derived, knob-associated histidine-rich protein (KAHRP). Knobs are required for cytoadherence under flow conditions, and they contain both KAHRP and the parasite-derived erythrocyte membrane protein PfEMP1. Using electron tomography, we have examined the three-dimensional structure of knobs in detergent-insoluble skeletons of P. falciparum 3D7 schizonts. We describe a highly organised knob skeleton composed of a spiral structure coated by an electron dense layer underlying the knob membrane. This knob skeleton is connected by multiple links to the erythrocyte cytoskeleton. We used immuno-electron microscopy to locate KAHRP in these structures. The arrangement of membrane proteins in the knobs, visualised by high resolution freeze fracture scanning electron microscopy, is distinct from that in the surrounding erythrocyte membrane, with a structure at the apex that likely represents the adhesion site. Thus, erythrocyte knobs in P. falciparum infection contain a highly organised skeleton structure underlying a specialised region of membrane. We propose that the spiral and dense coat organise the cytoadherence structures in the knob, and anchor them into the erythrocyte cytoskeleton. The high density of knobs and their extensive mechanical linkage suggest an explanation for the rigidification of the cytoskeleton in infected cells, and for the transmission to the cytoskeleton of shear forces experienced by adhering cells

Gluteus minimus: observations on its insertion

In 17 adult and 3 full term fetuses the hip joints were dissected to expose the insertion of gluteus minimus. An attachment of the deep surface of the tendon as it passes over the hip joint capsule was found in every case. Histological examination of this insertion confirmed the presence of short intramuscular tendons firmly anchoring the tendon to the capsule. It is suggested that this attachment retracts the capsule during hip joint motion, thereby preventing capsular entrapment