Navigating stormy waters in times of fiscal uncertainty: mitigating the challenges

New approaches to resource allocation are providing healthcare managers with ways to meet budget pressures while maximizing benefit to patients and populations. But putting these approaches in place often involves significant organizational change to which some degree of resistance must be expected. The authors have seen seven common objections raised time and again. Here, we offer our best advice on how healthcare leaders can anticipate and respond proactively to these challenges. </jats:p

Exile Vol. XXXIV No. 1

Rock by Cam Martin (cover) New Arrival by Kent Lambert 3 Le Sacre Du Printemps by David Zivan 4 Nightscape by Cam Martin 5 A Cry For Life by Kent Lambert 7-8 Untitled by Grant Young 9 Crazy Circle by Melissa Wellington 10 Untitled by Shelley Dickerson 13 *The Tall Boy by Lauren Williams 15-19 *Untitled by Shelley Dickerson 21 Our Native Images by Cam Martin 23-38 Untitled by Lauran Hannan 39 Psych 100 by David Zivan 41 Routine by Lauren Williams 42-47 Untitled by Shelley Dickerson 49 A Man\u27s Descent to Hell, by Chris Rynd 51-53 Separation by David Zivan 54 Boat by Cynthia Hoag 55 Passage by Rosemary Walsh 57 Whales by Zachary Smith 58 Untitled by Lauren Hannan 59 Contributor Notes 61 Editorial decision is shared equally amoung [sic] the Editorial Board members. - title page * indicates contest winner -2 NOTE: The poem Crazy Circle by Melissa Wellington is listed as page 10 in the published table of contents but actually appears on page 11

A Discrete Class of Intergenic DNA Dictates Meiotic DNA Break Hotspots in Fission Yeast

Meiotic recombination is initiated by DNA double-strand breaks (DSBs) made by Spo11 (Rec12 in fission yeast), which becomes covalently linked to the DSB ends. Like recombination events, DSBs occur at hotspots in the genome, but the genetic factors responsible for most hotspots have remained elusive. Here we describe in fission yeast the genome-wide distribution of meiosis-specific Rec12-DNA linkages, which closely parallel DSBs measured by conventional Southern blot hybridization. Prominent DSB hotspots are located ∼65 kb apart, separated by intervals with little or no detectable breakage. Most hotspots lie within exceptionally large intergenic regions. Thus, the chromosomal architecture responsible for hotspots in fission yeast is markedly different from that of budding yeast, in which DSB hotspots are much more closely spaced and, in many regions of the genome, occur at each promoter. Our analysis in fission yeast reveals a clearly identifiable chromosomal feature that can predict the majority of recombination hotspots across a whole genome and provides a basis for searching for the chromosomal features that dictate hotspots of meiotic recombination in other organisms, including humans

What is the right level of spending needed for health and care in the UK?

The health and care sector plays a valuable role in improving population health and societal wellbeing, protecting people from the financial consequences of illness, reducing health and income inequalities, and supporting economic growth. However, there is much debate regarding the appropriate level of funding for health and care in the UK. In this Health Policy paper, we look at the economic impact of the COVID-19 pandemic and historical spending in the UK and comparable countries, assess the role of private spending, and review spending projections to estimate future needs. Public spending on health has increased by 3·7% a year on average since the National Health Service (NHS) was founded in 1948 and, since then, has continued to assume a larger share of both the economy and government expenditure. In the decade before the ongoing pandemic started, the rate of growth of government spending for the health and care sector slowed. We argue that without average growth in public spending on health of at least 4% per year in real terms, there is a real risk of degradation of the NHS, reductions in coverage of benefits, increased inequalities, and increased reliance on private financing. A similar, if not higher, level of growth in public spending on social care is needed to provide high standards of care and decent terms and conditions for social care staff, alongside an immediate uplift in public spending to implement long-overdue reforms recommended by the Dilnot Commission to improve financial protection. COVID-19 has highlighted major issues in the capacity and resilience of the health and care system. We recommend an independent review to examine the precise amount of additional funds that are required to better equip the UK to withstand further acute shocks and major threats to health

Exile Vol. XXXIV No. 2

ARTWORK The Race and the Load by Rhonwen Churchill (cover) Population 6 by Rory Herbster 5 Untitled by Itar 9 Untitled by Itar 17 Untitled by Itar 25 Floating Nude by Shelley Dicerson 27 Valley of Fire, New Mexico by Pam Schilling 33 Untitled by Rhonwen churchill 39 Merely Players by Rhonwen Churchill 43 Newark at Night by Rob Myers 55 Torso II by Shelley Dickerson 57 Untitled by Don Jacobs 61 Serenade by Jenny Smith 65 FICTION Untitled by Lauren Williams 11-15 A Subtle Change in the Flowers by Zach Smith 30-32 Documenting Secrets by Laura Munson 47-52 POETRY Ars Poetica by David Zivan 3 Jesse James In Wax by Itar 4 Catechism by Jennie Dawes 7 Silent State by Cam Martin 8 Red Rock Mound by Itar 16 Almost There by Chris Hanson 19 In Memory by Kent Lambert 20-23 Driving Cross-Country by David Zivan 24 Yoga At Sunrise by Itar 35-36 His Photograph by Debra Benko 37 Appalachian Spring by Jennie Dawes 38 My Proposal by Liza Jones 41 Spheres of Influence by Zach Smith 42 The Eros Motel by Cam Martin 45 A Sacrificial Science by Jen Druley 46 Bird\u27s-Eye View by Itar 53 Driving by David Zivan 54 Mobile Home In The Sky by Itar 59-60 The Cleaving by Amy Judge 63 She Kent Lambert 64 CONTRIBUTOR NOTES 67 Editorial decision is shared equally among the Editorial Board members. - title pag

Mechanisms of Cognitive Impairment in Cerebral Small Vessel Disease: Multimodal MRI Results from the St George's Cognition and Neuroimaging in Stroke (SCANS) Study.

Cerebral small vessel disease (SVD) is a common cause of vascular cognitive impairment. A number of disease features can be assessed on MRI including lacunar infarcts, T2 lesion volume, brain atrophy, and cerebral microbleeds. In addition, diffusion tensor imaging (DTI) is sensitive to disruption of white matter ultrastructure, and recently it has been suggested that additional information on the pattern of damage may be obtained from axial diffusivity, a proposed marker of axonal damage, and radial diffusivity, an indicator of demyelination. We determined the contribution of these whole brain MRI markers to cognitive impairment in SVD. Consecutive patients with lacunar stroke and confluent leukoaraiosis were recruited into the ongoing SCANS study of cognitive impairment in SVD (n = 115), and underwent neuropsychological assessment and multimodal MRI. SVD subjects displayed poor performance on tests of executive function and processing speed. In the SVD group brain volume was lower, white matter hyperintensity volume higher and all diffusion characteristics differed significantly from control subjects (n = 50). On multi-predictor analysis independent predictors of executive function in SVD were lacunar infarct count and diffusivity of normal appearing white matter on DTI. Independent predictors of processing speed were lacunar infarct count and brain atrophy. Radial diffusivity was a stronger DTI predictor than axial diffusivity, suggesting ischaemic demyelination, seen neuropathologically in SVD, may be an important predictor of cognitive impairment in SVD. Our study provides information on the mechanism of cognitive impairment in SVD

Oseltamivir resistance during treatment of influenza A (H5N1) infection

Influenza A (H5N1) virus with an amino acid substitution in neuraminidase conferring high-level resistance to oseltamivir was isolated from two of eight Vietnamese patients during oseltamivir treatment. Both patients died of influenza A (H5N1) virus infection, despite early initiation of treatment in one patient. Surviving patients had rapid declines in the viral load to undetectable levels during treatment. These observations suggest that resistance can emerge during the currently recommended regimen of oseltamivir therapy and may be associated with clinical deterioration and that the strategy for the treatment of influenza A (H5N1) virus infection should include additional antiviral agents. Copyright © 2005 Massachusetts Medical Society.published_or_final_versio

Learning from contract change in primary care dentistry: a qualitative study of stakeholders in the north of England

The aim of this research was to explore and synthesise learning from stakeholders (NHS dentists, commissioners and patients) approximately five years on from the introduction of a new NHS dental contract in England. The case study involved a purposive sample of stakeholders associated with a former NHS Primary Care Trust (PCT) in the north of England. Semi-structured interviews were conducted with 8 commissioners of NHS dental services and 5 NHS general dental practitioners. Three focus group meetings were held with 14 NHS dental patients. All focus groups and interviews were audio recorded and transcribed verbatim. The data were analysed using a framework approach. Four themes were identified: ‘commissioners’ views of managing local NHS dental services’; ‘the risks of commissioning for patient access’; ‘costs, contract currency and commissioning constraints’; and ‘local decision-making and future priorities’. Commissioners reported that much of their time was spent managing existing contracts rather than commissioning services. Patients were unclear about the NHS dental charge bands and dentists strongly criticised the contract's target-driven approach which was centred upon them generating ‘units of dental activity’. NHS commissioners remained relatively constrained in their abilities to reallocate dental resources amongst contracts. The national focus upon practitioners achieving their units of dental activity appeared to outweigh interest in the quality of dental care provided