The cornerstone of Labour's 'New NHS': reforming primary care

Two remarkable aspects of the Thatcher ‘internal market’ reforms of the NHS were the focus on creating a market for hospital services and the way in which primary care was treated almost peripherally in the 1989 White Paper (Department of Health 1989a). The 1991 NHS reforms introduced general practitioner (GP) fundholding almost as an afterthought, and the revision of the GP contract in 1990 Paper (Department of Health 1989b) was conducted separately from the implementation of other health care reforms. In contrast the principal focus of Labour’s ‘new NHS’ reform is primary care (Department of Health 1997). The intention of the government is both to improve the efficiency and equity of primary care provision and to develop Primary Care Groups and Primary Care Trusts which both provide care efficiently and act as agents who purchase secondary and tertiary care on behalf of patients. This is an ambitious agenda. This paper explores the policy context of Primary Care Groups in sections 1 and 2, describes and appraises the government proposals in section 3, and identifies major issues involved in the implementation of change in section 4.fundholding, rationing

High Flight - The Poetry of John Magee

John Magee, a young pilot who died at the age of 19 in an air crash in 1941,left an iconic sonnet which has become known to thousands of airmen since his death. This programme explored Magee's short life, and the resonances created by the 14 lines of his famous poem, "High Flight

Recombination in polymer-fullerene bulk heterojunction solar cells

Recombination of photogenerated charge carriers in polymer bulk heterojunction (BHJ) solar cells reduces the short circuit current (Jsc) and the fill factor (FF). Identifying the mechanism of recombination is, therefore, fundamentally important for increasing the power conversion efficiency. Light intensity and temperature dependent current-voltage measurements on polymer BHJ cells made from a variety of different semiconducting polymers and fullerenes show that the recombination kinetics are voltage dependent and evolve from first order recombination at short circuit to bimolecular recombination at open circuit as a result of increasing the voltage-dependent charge carrier density in the cell. The "missing 0.3V" inferred from comparison of the band gaps of the bulk heterojunction materials and the measured open circuit voltage at room temperature results from the temperature dependence of the quasi-Fermi-levels in the polymer and fullerene domains - a conclusion based upon the fundamental statistics of Fermions.Comment: Accepted for publication in Physical Review B. http://prb.aps.org/accepted/B/6b07cO3aHe71bd1b149e1425e58bf2868cda2384d?ajax=1&height=500&width=50

Management of Tuberculosis: a handbook for clinicians

This handbook, a distillation of recommendations from international TB guidelines and the accumulated clinical experience of its authors, provides practical information for clinicians involved in the care of patients with tuberculosis (TB) and other mycobacterial diseases. Topics covered are: management of drug-sensitive and drug-resistant TB; latent TB infection; pregnancy and TB; HIV and TB; nontuberculous mycobacterial infections; BCG vaccination and BCG installation for bladder cancer. The emphasis is on presenting a practical approach to the many clinical issues, common and uncommon, that arise in the day-to-day management of patients with mycobacterial infections. The handbook is primarily intended for specialists and trainee specialists working in the ward and in the outpatient clinic, but it should also appeal to pharmacists and nurses involved with TB care, and to students

The Blackbird - The Life and Legacy of Delia Murphy

Delia Murphy was the first Irish Media Superstar. A singer of traditional songs learned from Irish Tinkers, she became a diplomat's wife and travelled to Australia, Itlay, Canada and the US in the service of her country. Her influence of contemporary Irish music is significant

A predictive model for kidney transplant graft survival using machine learning

Kidney transplantation is the best treatment for end-stage renal failure patients. The predominant method used for kidney quality assessment is the Cox regression-based, kidney donor risk index. A machine learning method may provide improved prediction of transplant outcomes and help decision-making. A popular tree-based machine learning method, random forest, was trained and evaluated with the same data originally used to develop the risk index (70,242 observations from 1995-2005). The random forest successfully predicted an additional 2,148 transplants than the risk index with equal type II error rates of 10%. Predicted results were analyzed with follow-up survival outcomes up to 240 months after transplant using Kaplan-Meier analysis and confirmed that the random forest performed significantly better than the risk index (p<0.05). The random forest predicted significantly more successful and longer-surviving transplants than the risk index. Random forests and other machine learning models may improve transplant decisions.Comment: This work has been published: Pahl ES, Street WN, Johnson HJ, Reed AI. "A Predictive Model for Kidney Transplant Graft Survival Using Machine Learning." 4th International Conference on Computer Science and Information Technology (COMIT 2020), November 28-29, 2020, Dubai, UAE. ISBN: 978-1-925953-30-5. Volume 10, Number 16.10.5121/csit.2020.10160

Spectrum of Sizes for Perfect Deletion-Correcting Codes

One peculiarity with deletion-correcting codes is that perfect $t$-deletion-correcting codes of the same length over the same alphabet can have different numbers of codewords, because the balls of radius $t$ with respect to the Levenshte\u{\i}n distance may be of different sizes. There is interest, therefore, in determining all possible sizes of a perfect $t$-deletion-correcting code, given the length $n$ and the alphabet size~$q$. In this paper, we determine completely the spectrum of possible sizes for perfect $q$-ary 1-deletion-correcting codes of length three for all $q$, and perfect $q$-ary 2-deletion-correcting codes of length four for almost all $q$, leaving only a small finite number of cases in doubt.Comment: 23 page

Detection of (1,3)-β-d-Glucan in Cerebrospinal Fluid in Histoplasma Meningitis

The diagnosis of central nervous system (CNS) histoplasmosis is often difficult. Although cerebrospinal fluid (CSF) (1,3)-β-d-glucan (BDG) is available as a biological marker for the diagnosis of fungal meningitis, there are limited data on its use for the diagnosis of Histoplasma meningitis. We evaluated CSF BDG detection, using the Fungitell assay, in patients with CNS histoplasmosis and controls. A total of 47 cases and 153 controls were identified. The control group included 13 patients with a CNS fungal infection other than histoplasmosis. Forty-nine percent of patients with CNS histoplasmosis and 43.8% of controls were immunocompromised. The median CSF BDG level was 85 pg/ml for cases, compared to <31 pg/ml for all controls (P < 0.05) and 82 pg/ml for controls with other causes of fungal meningitis (P = 0.27). The sensitivity for detection of BDG in CSF was 53.2%, whereas the specificity was 86.9% versus all controls and 46% versus other CNS fungal infections. CSF BDG levels of ≥80 pg/ml are neither sensitive nor specific to support a diagnosis of Histoplasma meningitis

Complex PrEP: the factors requiring consultant-led review of PrEP users

INTRODUCTION: HIV-1 pre-exposure prophylaxis (PrEP) has been available in England since March 2020 on the National Health Service using generic emtricitabine and tenofovir disoproxil. 56 Dean Street (56DS) provided PrEP through (1) additional private care from September 2015, estimated to be providing 11% of England's PrEP in 2019; and (2) the IMPACT trial, as well as monitoring those self-sourcing PrEP. Providing PrEP at scale through a nurse-led service required a safety net for complex individuals. 56DS introduced a consultant-led PrEP outpatient service, the PrEP review clinic, in January 2018 and we report the outcomes of this service. METHODS: We present a retrospective case note review of the PrEP review clinic with descriptive outcomes from 26 January 2018 to 20 December 2019. Reason for referral, demographics, PrEP management and PrEP discontinuations were recorded. RESULTS: 13 980 unique users accessed PrEP from 56DS during the two year evaluation period. 220 individuals were seen in the PrEP review clinic. Majority of patients were referred for renal issues (114 of 220, 51.8%), followed by side effects (59 of 220, 26.8%) and comorbidities (38 of 220, 17.2%). Of those with renal issues, 89 (out of 114, 78.1%) users were referred for an abnormal estimated glomerular filtration rate (eGFR). 35 (out of 114, 30.7%) PrEP users had an eGFR between 45 and 59 mL/min/1.73 m2, of whom 2 (5.7%) discontinued PrEP. Majority of users were advised to stop supplements±switch to event-based dosing (24 of 35, 68.6%). Ten PrEP users were referred with an eGFR between 30 and 44 mL/min/1.73 m2; 4 (40%) stopped or did not start PrEP and 6 (60%) were asked to stop supplements±switch to event-based dosing. DISCUSSION: A small proportion of PrEP users have complex PrEP issues. Methods to manage renal dysfunction with PrEP included stopping supplements and switching to event-based dosing. Those with side effects were managed with an array of options, with only modest effectiveness. Other PrEP options are needed to support those with toxicities or intolerances

Monitoring the Effects of Tenofovir Disoproxil Fumarate to Tenofovir Alafenamide Switch for Tubulotoxicity in Highly Treatment-Experienced or in Very Sick Individuals Infected with HIV

Tenofovir disoproxil fumarate (TDF) is a common antiretroviral utilised in the treatment of human immunodeficiency virus (HIV) and hepatitis B infections. It is associated with the development of tubulotoxicity and tubulopathies, and is not recommended in the treatment of patients with baseline chronic kidney disease. Until now, guidelines have suggested frequent monitoring of serum biochemistry to detect the development of such complications. In recent trials, a new prodrug formulation of tenofovir alafenamide (TAF) has been shown to exhibit less tubular toxicity than its counterpart due to a lower serum concentration of its metabolites. In this article, we share our experience with two patients who developed tubulotoxicity following the commencement of TDF-based regimens in HIV, and its improvement following its change to TAF, and review the available literature regarding tenofovir-based nephrotoxicity