Combined horizontal and vertical integration of care: a goal of practice-based commissioning

Practice-based commissioning (PBC) in the UK is intended to improve both the vertical and horizontal integration of health care, in order to avoid escalating costs and enhance population health. Vertical integration involves patient pathways to treat named medical conditions that transcend organisational boundaries and connect communitybased generalists with largely hospital-sited specialists, whereas horizontal integration involves peerbased and cross-sectoral collaboration to improve overall health. Effective mechanisms are now needed to permit ongoing dialogue between the vertical and horizontal dimensions to ensure that medical and nonmedical care are both used to their best advantage. This paper proposes three different models for combining vertical and horizontal integration – each is a hybrid of internationally recognised ideal types of primary care organisation. Leaders of PBC should consider a range of models and apply them in ways that are relevant to the local context. General practitioners, policy makers and others whose job it is to facilitate horizontal and vertical integration must learn to lead such combined approaches to integration if the UK is to avoid the mistakes of the USA in over-medicalising health issues

Effects of a Dispersed and Undispersed Crude Oil on Mangroves, Seagrasses and Corals

The primary objective of this study was to evaluate the application of dispersant to spilled oil as a means of reducing adverse environmental effects of oil spills in nearshore, tropical waters. The results of numerous laboratory and field studies have suggested that dispersants may play a useful role in reducing adverse impacts on sensitive and valued environments such as mangroves, seagrasses, and corals. However, the use of dispersants has not been allowed thus far in most situations because of a lack of direct experimental data on the various effects of dispersants and the environmental trade-offs presumed to occur as a result of their application to crude oils. To accomplish this objective, a 21/2- year field experiment was designed in which detailed, synoptic measurements and assessments were made of representative intertidal and nearshore subtidal habitats and organisms (man-groves, seagrass beds, and coral reefs) before, during, and after exposure to untreated crude oil and chemically dispersed oil. The results were in-tended to give guidance in minimizing the ecological impacts of oil spills through evaluation of trade-offs in the relative impacts of chemical dispersion to tropical marine intertidal and subtidal habitats

Dissipation of vibration in rough contact

The relationship which links the normal vibration occurring during the sliding of rough surfaces and the nominal contact area is investigated. Two regimes are found. In the first one, the vibrational level does not depend on the contact area, while in the second one, it is propor- tional to the contact area. A theoretical model is proposed. It is based on the assumption that the vibrational level results from a competition between two processes of vibration damping, the internal damping of the material and the contact damping occurring at the interface

Key action fields for nearly carbon-neutral districts: Stakeholder-specific strategies and practice

In accordance with the UN Sustainable Development Goals, many countries aim at nearly zero carbon emissions of their building sector by 2050. The research college EnEff.Buildings.2050 is a collaboration of five PhD students and their supervisors to support this goal. In this paper, five key action fields for transformation of urban districts are described, and decisive stakeholders are identified and linked to the action fields. As a case study, the urban district Mierendorff-Island in Berlin is introduced. Three strategies to support transformation are identified: Firstly, new digital planning tools should be applied to assess and improve the energetic performance of new and existing buildings and to illustrate it to decision makers. Secondly, digital processes should be combined throughout the lifecycle of a building by building information modeling (BIM). This can ensure the energetic quality and enable cost-effective construction, servicing and monitoring. Thirdly, start-ups and contractors need support for development of new business models and technical solutions, which can e.g. enable disruptive technologies. Awareness of stakeholders on the transformational state of a district enables them to identify windows of opportunity to spring into action. Framework conditions and support measures determine if they act in favour of the transformation or not

Cold Collision Frequency Shift of the 1S-2S Transition in Hydrogen

We have observed the cold collision frequency shift of the 1S-2S transition in trapped spin-polarized atomic hydrogen. We find $\Delta \nu_{1S-2S} = -3.8(8)\times 10^{-10} n Hz cm^3$, where $n$ is the sample density. From this we derive the 1S-2S s-wave triplet scattering length, $a_{1S-2S}=-1.4(3)$ nm, which is in fair agreement with a recent calculation. The shift provides a valuable probe of the distribution of densities in a trapped sample.Comment: Accepted for publication in PRL, 9 pages, 4 PostScript figures, ReVTeX. Updated connection of our measurement to theoretical wor

Moment of Inertia and Quadrupole Response Function of a Trapped Superfluid

We derive an explicit relationship between the moment of inertia and the quadrupole response function of an interacting gas confined in a harmonic trap. The relationship holds for both Bose and Fermi systems and is well suited to reveal the effects of irrotationality of the superfluid motion. Recent experimental results on the scissors mode are used to extract the value of the moment of inertia of a trapped Bose gas and to point out the deviations from the rigid value due to superfluidity.Comment: 6 page

Three-dimensional FIB-SEM reconstruction of microtubule-organelle interaction in whole primary mouse beta cells

Microtubules play a major role in intracellular trafficking of vesicles in endocrine cells. Detailed knowledge of microtubule organization and their relation to other cell constituents is crucial for understanding cell function. However, their role in insulin transport and secretion is currently under debate. Here, we use Fib-Sem to image islet beta cells in their entirety with unprecedented resolution. We reconstruct mitochondria, Golgi apparati, centrioles, insulin secretory granules and micro-tubules of seven beta cells, and generate a comprehensive spatial map of microtubule-organelle interactions. We find that micro-tubules form non-radial networks that are predominantly not connected to either centrioles or endomembranes. Microtubule number and length, but not microtubule polymer density, vary with glucose stimulation. Furthermore, insulin secretory granules are enriched near the plasma membrane where they associate with microtubules. In summary, we provide the first 3D reconstructions of complete microtubule networks in primary mammalian cells together with evidence regarding their importance for insulin secretory granule positioning and thus supportive role in insulin secretion

Pi±-p total cross sections in the range 450 Mev to 1650 Mev

A series of counter experiments is being carried out at the Berkeley Bevatron and 184-inch cyclotron to measure total and differential scattering cross sections for pions at energies above the first resonance. (1-3) In this Letter we report the results of measurements of the total cross section for positive and negative pions on protons in the energy range from 450-Mev to 1650-Mev pion kinetic energy (lab)

Isomorphs in model molecular liquids

Isomorphs are curves in the phase diagram along which a number of static and dynamic quantities are invariant in reduced units. A liquid has good isomorphs if and only if it is strongly correlating, i.e., the equilibrium virial/potential energy fluctuations are more than 90% correlated in the NVT ensemble. This paper generalizes isomorphs to liquids composed of rigid molecules and study the isomorphs of two systems of small rigid molecules, the asymmetric dumbbell model and the Lewis-Wahnstrom OTP model. In particular, for both systems we find that the isochoric heat capacity, the excess entropy, the reduced molecular center-of-mass self part of the intermediate scattering function, the reduced molecular center-of-mass radial distribution function to a good approximation are invariant along an isomorph. In agreement with theory, we also find that an instantaneous change of temperature and density from an equilibrated state point to another isomorphic state point leads to no relaxation. The isomorphs of the Lewis-Wahnstrom OTP model were found to be more approximative than those of the asymmetric dumbbell model, which is consistent with the OTP model being less strongly correlating. For both models we find "master isomorphs", i.e., isomorphs have identical shape in the virial/potential energy phase diagram.Comment: 20 page

Proliferation and estrogen signaling can distinguish patients at risk for early versus late relapse among estrogen receptor positive breast cancers

Introduction: We examined if a combination of proliferation markers and estrogen receptor (ER) activity could predict early versus late relapses in ER-positive breast cancer and inform the choice and length of adjuvant endocrine therapy. Methods: Baseline affymetrix gene-expression profiles from ER-positive patients who received no systemic therapy (n = 559), adjuvant tamoxifen for 5 years (cohort-1: n = 683, cohort-2: n = 282) and from 58 patients treated with neoadjuvant letrozole for 3 months (gene-expression available at baseline, 14 and 90 days) were analyzed. A proliferation score based on the expression of mitotic kinases (MKS) and an ER-related score (ERS) adopted from Oncotype DX® were calculated. The same analysis was performed using the Genomic Grade Index as proliferation marker and the luminal gene score from the PAM50 classifier as measure of estrogen-related genes. Median values were used to define low and high marker groups and four combinations were created. Relapses were grouped into time cohorts of 0-2.5, 0-5, 5-10 years. Results: In the overall 10 years period, the proportional hazards assumption was violated for several biomarker groups indicating time-dependent effects. In tamoxifen-treated patients Low-MKS/Low-ERS cancers had continuously increasing risk of relapse that was higher after 5 years than Low-MKS/High-ERS cancers [0 to 10 year, HR 3.36; p = 0.013]. High-MKS/High-ERS cancers had low risk of early relapse [0-2.5 years HR 0.13; p = 0.0006], but high risk of late relapse which was higher than in the High-MKS/Low-ERS group [after 5 years HR 3.86; p = 0.007]. The High-MKS/Low-ERS subset had most of the early relapses [0 to 2.5 years, HR 6.53; p < 0.0001] especially in node negative tumors and showed minimal response to neoadjuvant letrozole. These findings were qualitatively confirmed in a smaller independent cohort of tamoxifen-treated patients. Using different biomarkers provided similar results. Conclusions: Early relapses are highest in highly proliferative/low-ERS cancers, in particular in node negative tumors. Relapses occurring after 5 years of adjuvant tamoxifen are highest among the highly-proliferative/high-ERS tumors although their risk of recurrence is modest in the first 5 years on tamoxifen. These tumors could be the best candidates for extended endocrine therapy