Persistent frequent attenders in primary care: costs, reasons for attendance, organisation of care and potential for cognitive behavioural therapeutic intervention

<p><b>Abstract</b></p> <p>Background</p> <p>The top 3% of frequent attendance in primary care is associated with 15% of all appointments in primary care, a fivefold increase in hospital expenditure, and more mental disorder and functional somatic symptoms compared to normal attendance. Although often temporary if these rates of attendance last more than two years, they may become persistent (persistent frequent or regular attendance). However, there is no long-term study of the economic impact or clinical characteristics of regular attendance in primary care. Cognitive behaviour formulation and treatment (CBT) for regular attendance as a motivated behaviour may offer an understanding of the development, maintenance and treatment of regular attendance in the context of their health problems, cognitive processes and social context.</p> <p>Methods/design</p> <p>A case control design will compare the clinical characteristics, patterns of health care use and economic costs over the last 10 years of 100 regular attenders (≥30 appointments with general practitioner [GP] over 2 years) with 100 normal attenders (6–22 appointments with GP over 2 years), from purposefully selected primary care practices with differing organisation of care and patient demographics. Qualitative interviews with regular attending patients and practice staff will explore patient barriers, drivers and experiences of consultation, and organisation of care by practices with its challenges. Cognitive behaviour formulation analysed thematically will explore the development, maintenance and therapeutic opportunities for management in regular attenders. The feasibility, acceptability and utility of CBT for regular attendance will be examined.</p> <p>Discussion</p> <p>The health care costs, clinical needs, patient motivation for consultation and organisation of care for persistent frequent or regular attendance in primary care will be explored to develop training and policies for service providers. CBT for regular attendance will be piloted with a view to developing this approach as part of a multifaceted intervention.</p

Guidelines for Analysis of Music for Student Performers

The guidelines included in this volume were systematically developed for use in analytical studies of Canadian repertoire suitable for student performers. These guidelines may be used in a variety of contexts: for example, by researchers analyzing Canadian or non-Canadian repertoire in terms of its suitability for educational use, by teachers selecting music for their students, and by composers writing music for student performers

Pickering emulsions co-stabilized by composite protein/ polysaccharide particle-particle interfaces: Impact on in vitro gastric stability

The objective of this study was to delay the rate and extent of gastric destabilization of emulsions using composite particle-particle layers at the O/W interface. Pickering emulsions (20 wt% oil) were prepared using lactoferrin nanogel particles (LFN, Dh = 100 nm) (1 wt%) or a composite layer of LFN and inulin nanoparticles, latter was enzymatically synthetized by inulosucrase IslA from Leuconostoc citreum (INP) (Dh = 116 ± 1 nm) (1 wt% LFN 3 wt% INP). The hypothesis was that creating a secondary layer of biopolymeric particles might act as a barrier to pepsin to access the underlying proteinaceous particles. Droplet size, microscopy (optical and transmission electron microscopy (TEM)), ζ-potential and sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) were used to understand the colloidal fate of these Pickering emulsions in an in vitro gastric model (pH 3, 37 ○C, pepsin). The ζ-potential measurements and TEM images confirmed that LFN and INP were at the O/W interface, owing to the electrostatic attraction between oppositely charged LFN (+29.3 ± 0.7 mV) and INP (−10 ± 1.8 mV) at both neutral and gastric pH. The SDS-PAGE results revealed that adsorbed LFN was less prone to pepsinolysis as compared to a typical protein monolayer at the interface. Presence of INP further decreased the rate and degree of hydrolysis of the LFN (>65% intact protein remaining after 60 min of digestion) by acting as a steric barrier to the diffusion of pepsin and inhibited droplet coalescence. Thus, composite particle-particle layers (LFN + INP) at droplet surface shows potential for rational designing of gastric-stable food and pharmaceutical applications

Evaluation of B-type Natriuretic Peptide for validation of a heart failure register in primary care

Abstract Background Diagnosing heart failure and left ventricular systolic dysfunction is difficult on clinical grounds alone. We sought to determine the accuracy of a heart failure register in a single primary care practice, and to examine the usefulness of b-type (or brain) natriuretic peptide (BNP) assay for this purpose. Methods A register validation audit in a single general practice in the UK was carried out. Of 217 patients on the heart failure register, 56 of 61 patients who had not been previously investigated underwent 12-lead electrocardiography and echocardiography within the practice site. Plasma was obtained for BNP assay from 45 subjects, and its performance in identifying echocardiographic abnormalities consistent with heart failure was assessed by analysing area under receiver operator characteristic (ROC) curves. Results 30/217 were found to have no evidence to suggest heart failure on notes review and were probably incorrectly coded. 70/112 who were previously investigated were confirmed to have heart failure. Of those not previously investigated, 24/56 (42.9%) who attended for the study had echocardiographic left ventricular systolic dysfunction. A further 8 (14.3%) had normal systolic function, but had left ventricular hypertrophy or significant valve disease. Overall, echocardiographic features consistent with heart failure were found in only 102/203 (50.2%). BNP was poor at discriminating those with and without systolic dysfunction (area under ROC curve 0.612), and those with and without any significant echocardiographic abnormality (area under ROC curve 0.723). Conclusion In this practice, half of the registered patients did not have significant cardiac dysfunction. On-site echocardiography identifies patients who can be removed from the heart failure register. The use of BNP assay to determine which patients require echocardiography is not supported by these data.</p

All together now: A symphony orchestra audience as a consuming community

This study examines the nature of communal consumption in the context of audience experience of the performing arts. Building on existing literature on consumption communities and ritualistic perspectives on shared event-based consumption, it uses focus groups and participant observation to investigate the experience of members of a UK symphony orchestra's audience as a consuming community (a 'consumity' in short). It finds tensions between respondents' perceptions of their individual and collective experience, framed within a pervasive anxiety about the sustainability of both audience and art form. It concludes that the communal aspect of audience experience is more complex and inflected than current notions of shared consumption acknowledge, in particular with respect to the audience's sense of itself over time. It concludes by questioning the absence from current arts marketing discourse of a more integrated view of the experience of customers in a temporal context