When Patient Activation Levels Change, Health Outcomes and Costs Change, Too

Patient engagement has become a major focus of health reform. However, there is limited evidence showing that increases in patient engagement are associated with improved health outcomes or lower costs. This report examined the extent to which a single assessment of engagement, the Patient Activation Measure, was associated with health outcomes and costs over time, and whether changes in assessed activation were related to expected changes in outcomes and costs. The report uses data on adult primary care patients from a single large health care system where the Patient Activation Measure is routinely used. Results indicating higher activation in 2010 were associated with nine out of thirteen better health outcomes -- including better clinical indicators, more healthy behaviors, and greater use of women's preventive screening tests -- as well as with lower costs two years later. Changes in activation level were associated with changes in over half of the health outcomes examined, as well as costs, in the expected directions. These findings suggest that efforts to increase patient activation may help achieve key goals of health reform and that further research is warranted to examine whether the observed associations are causal

Don’t make me laugh: Responsive laughter in (dis)affiliation

This paper examines laughter as a methodical resource for marking a just-prior turn as laughable, even when that turn has not been designed as such by its producer. It focuses in particular on one usage, where laughter targets a prior turn as preposterous and thus laughable: laughter is seen to be but one possible response in such contexts, and, as such, highly disaffiliative. By examining instances of video-taped family interaction and audio recordings of broadcast interviews, I examine the sequential environment both leading up to the production of the laughter – what makes the targeted turn so laughable – and subsequent to it, that is, how the laughter is elaborated verbally. I also examine the features of the laughter itself, and specifically what makes it recognizable as marking a highly negative stance with respect to what it targets. But who exactly produces the responsive laughter is here critical: when the laugh producer is not the ostensible recipient of the prior, laughable turn, the laughter produced is heard both to disaffiliate from that prior but in so doing, to affiliate with its recipient. Such uses show how a single action can be simultaneously both affiliative and disaffiliative

Factors that influence women’s engagement with breastfeeding support:a qualitative evidence synthesis

Breastfeeding is an integral part of early childhood interventions as it can prevent serious childhood and maternal illnesses. For breastfeeding support programmes to be effective, a better understanding of contextual factors that influence women's engagement and satisfaction with these programmes is needed. The aim of this synthesis is to suggest strategies to increase the level of satisfaction with support programmes and to better match the expectations and needs of women. We systematically searched for studies that used qualitative methods for data collection and analysis and that focused on women's experiences and perceptions regarding breastfeeding support programmes. We applied a maximum variation purposive sampling strategy and used thematic analysis. We assessed the methodological quality of the studies using a modified version of the CASP tool and assessed our confidence in the findings using the GRADE‐CERQual approach. We included 51 studies of which we sampled 22 for in‐depth analysis. Our sampled studies described the experiences of women with formal breastfeeding support by health care professionals in a hospital setting and informal support as for instance from community support groups. Our findings illustrate that the current models of breastfeeding support are dependent on a variety of contextual factors encouraging and supporting women to initiate and continue breastfeeding. They further highlight the relevance of providing different forms of support based on socio‐cultural norms and personal backgrounds of women, especially if the support is one‐on‐one. Feeding decisions of women are situated within a woman's personal situation and may require diverse forms of support

Epicardial Adipose Tissue Removal Potentiates Outward Remodeling and Arrests Coronary Atherogenesis

BACKGROUND: Pericoronary epicardial adipose tissue (cEAT) serves as a metabolic and paracrine organ that contributes to inflammation and is associated with macrovascular coronary artery disease (CAD) development. Although there is a strong correlation in humans between cEAT volume and CAD severity, there remains a paucity of experimental data demonstrating a causal link of cEAT to CAD. The current study tested the hypothesis that surgical resection of cEAT attenuates inflammation and CAD progression. METHODS: Female Ossabaw miniature swine (n = 12) were fed an atherogenic diet for 8 months and randomly allocated into sham (n = 5) or adipectomy (n = 7) groups. Both groups underwent a thoracotomy, opening of the pericardial sac, and placement of radioopaque clips to mark the proximal left anterior descending artery. Adipectomy swine underwent removal of 1 to 1.5 cm2 of cEAT from the proximal artery. After sham or adipectomy, CAD severity was assessed with intravascular ultrasonography. Swine recovered for an additional 3 months on an atherogenic diet, and CAD was assessed immediately before euthanasia. Artery sections were processed for histologic and immunohistochemical analysis. RESULTS: Severity of CAD as assessed by percent stenosis was reduced in the adipectomy cohort compared with shams; however, plaque size remained unaltered, whereas larger plaque sizes developed in sham-operated swine. Adipectomy resulted in an expanded arterial diameter, similar to the Glagov phenomenon of positive outward remodeling. No differences in inflammatory marker expression were observed. CONCLUSIONS: These data indicate that cEAT resection did not alter inflammatory marker expression, but arrested CAD progression through increased positive outward remodeling and arrest of atherogenesis

The impact of using computer decision-support software in primary care nurse-led telephone triage:Interactional dilemmas and conversational consequences

Telephone triage represents one strategy to manage demand for face-to-face GP appointments in primary care. Although computer decision-support software (CDSS) is increasingly used by nurses to triage patients, little is understood about how interaction is organized in this setting. Specifically any interactional dilemmas this computer-mediated setting invokes; and how these may be consequential for communication with patients. Using conversation analytic methods we undertook a multi-modal analysis of 22 audio-recorded telephone triage nurse-caller interactions from one GP practice in England, including 10 video-recordings of nurses' use of CDSS during triage. We draw on Goffman's theoretical notion of participation frameworks to make sense of these interactions, presenting 'telling cases' of interactional dilemmas nurses faced in meeting patient's needs and accurately documenting the patient's condition within the CDSS. Our findings highlight troubles in the 'interactional workability' of telephone triage exposing difficulties faced in aligning the proximal and wider distal context that structures CDSS-mediated interactions. Patients present with diverse symptoms, understanding of triage consultations, and communication skills which nurses need to negotiate turn-by-turn with CDSS requirements. Nurses therefore need to have sophisticated communication, technological and clinical skills to ensure patients' presenting problems are accurately captured within the CDSS to determine safe triage outcomes. Dilemmas around how nurses manage and record information, and the issues of professional accountability that may ensue, raise questions about the impact of CDSS and its use in supporting nurses to deliver safe and effective patient care

Transformation and gene editing in the bioenergy grass \u3ci\u3eMiscanthus\u3c/i\u3e

Background: Miscanthus, a C4 member of Poaceae, is a promising perennial crop for bioenergy, renewable bioproducts, and carbon sequestration. Species of interest include nothospecies M. x giganteus and its parental species M. sacchariforus and M. sinensis. Use of biotechnology-based procedures to genetically improve Miscanthus, to date, have only included plant transformation procedures for introduction of exogenous genes into the host genome at random, non-targeted sites. Results: We developed gene editing procedures for Miscanthus using CRISPR/Cas9 that enabled the mutation of a specific (targeted) endogenous gene to knock out its function. Classified as paleo-allopolyploids (duplicated ancient Sorghum-like DNA plus chromosome fusion event), design of guide RNAs (gRNAs) for Miscanthus needed to target both homeologs and their alleles to account for functional redundancy. Prior research in Zea mays demonstrated that editing the lemon white1 (lw1) gene, involved in chlorophyll and carotenoid biosynthesis, via CRISPR/Cas9 yielded pale green/yellow, striped or white leaf phenotypes making lw1 a promising target for visual confirmation of editing in other species. Using sequence information from both Miscanthus and sorghum, orthologs of maize lw1 were identified; a multi-step screening approach was used to select three gRNAs that could target homeologs of lw1. Embryogenic calli of M. sacchariforus, M. sinensis and M. x giganteus were transformed via particle bombardment (biolistics) or Agrobacterium tumefaciens introducing the Cas9 gene and three gRNAs to edit lw1. Leaves on edited Miscanthus plants displayed the same phenotypes noted in maize. Sanger sequencing confirmed editing; deletions in lw1 ranged from 1 to 26 bp in length, and one deletion (433 bp) encompassed two target sites. Confocal microscopy verified lack of autofluorescence (chlorophyll) in edited leaves/sectors. Conclusions: We developed procedures for gene editing via CRISPR/Cas9 in Miscanthus and, to the best of our knowledge, are the first to do so. This included five genotypes representing three Miscanthus species. Designed gRNAs targeted all copies of lw1 (homeologous copies and their alleles); results also confirmed lw1 made a goo

Factors Influencing Dietetic Interns\u27 Dietary Habits During Supervised Practice

Supervised practice is a prerequisite to becoming a registered dietitian. Research suggests that environmental and social factors may affect dietary choices. This focus group research aimed to gather opinions from dietetic interns to understand what factors related to supervised practice, if any, affected their dietary habits. Qualitative data were collected via seven recorded virtual focus groups in which trained moderators facilitated a discussion using a series of controlled questions. Participants, dietetic interns (n = 42) who were currently completing or had completed their supervised practice within the previous six months, attended one of seven virtual focus groups. Each focus group had five to eight participants. Transcripts were separately coded by two trained researchers using a grounded theory approach to identify themes and subthemes. Researchers discussed any disagreements in coding and established a consensus. Elements related to the dietetic internship were observed to influence participants’ dietary choices. Main themes included time, finances, food access and availability, physical and mental effects, non-supervised practice factors, and social factors. Dietetic programs and preceptors should explore ways to raise interns’ awareness and minimize the potential negative impacts of these factors on interns’ dietary habits to improve their overall internship experience

The Florence Statement on Triclosan and Triclocarban

The Florence Statement on Triclosan and Triclocarban documents a consensus of more than 200 scientists and medical professionals on the hazards of and lack of demonstrated benefit from common uses of triclosan and triclocarban. These chemicals may be used in thousands of personal care and consumer products as well as in building materials. Based on extensive peer-reviewed research, this statement concludes that triclosan and triclocarban are environmentally persistent endocrine disruptors that bioaccumulate in and are toxic to aquatic and other organisms. Evidence of other hazards to humans and ecosystems from triclosan and triclocarban is presented along with recommendations intended to prevent future harm from triclosan, triclocarban, and antimicrobial substances with similar properties and effects. Because antimicrobials can have unintended adverse health and environmental impacts, they should only be used when they provide an evidence-based health benefit. Greater transparency is needed in product formulations, and before an antimicrobial is incorporated into a product, the long-term health and ecological impacts should be evaluated

Actions in Practice: On details in collections

Several of the contributions to the Lynch et al. Special issue make the claim that conversation- analytic research into epistemics is ‘routinely crafted at the expense of actual, produced and constitutive detail, and what that detail may show us’. Here, we seek to address the inappositeness of this critique by tracing precisely how it is that recognizable actions emerge from distinct practices of interaction. We begin by reviewing some of the foundational tenets of conversation-analytic theory and method – including the relationship between position and composition, and the making of collections – as these appear to be primary sources of confusion for many of the contributors to the Lynch et al. Special Issue. We then target some of the specific arguments presented in the Special Issue, including the alleged ‘over-hearer’s’ writing of metrics, the provision of so- called ‘alternative’ analyses and the supposed ‘crafting’ of generalizations in epistemics research. In addition, in light of Lynch’s more general assertion that conversation analysis (CA) has recently been experiencing a ‘rapprochement’ with what he disparagingly refers to as the ‘juggernaut’ of linguistics, we discuss the specific expertise that linguists have to offer in analyzing particular sorts of interactional detail. The article as a whole thus illustrates that, rather than being produced ‘at the expense of actual, produced and constitutive detail’, conversation-analytic findings – including its work in epistemics – are unambiguously anchored in such detail. We conclude by offering our comments as to the link between CA and linguistics more generally, arguing that this relationship has long proven to be – and indeed continues to be – a mutually beneficial one