Primary care-led commissioning and public involvement in the English National Health Service. Lessons from the past.

Background: Patient and Public involvement (PPI) in health care occupies a central place in Western democracies. In England, this theme has been continuously prominent since the introduction of market reforms in the early 1990s. The health care reforms implemented by the current Coalition Government are making primary care practitioners the main commissioners of health care services in the National Health Service, and a duty is placed on them to involve the public in commissioning decisions and strategies. Since implementation of PPI initiatives in primary care commissioning is not new, we asked how likely it is that the new reforms will make a difference. We scanned the main literature related to primary care-led commissioning and found little evidence of effective PPI thus far. We suggest that unless the scope and intended objectives of PPI are clarified and appropriate resources are devoted to it, PPI will continue to remain empty rhetoric and box ticking. Aim: To examine the effect of previous PPI initiatives on health care commissioning and draw lessons for future development. Method: We scanned the literature reporting on previous PPI initiatives in primary careled commissioning since the introduction of the internal market in 1991. In particular, we looked for specific contexts, methods and outcomes of such initiatives. Findings: 1. PPI in commissioning has been constantly encouraged by policy makers in England. 2. Research shows limited evidence of effective methods and outcomes so far. 3. Constant reconfi- guration of health care structures has had a negative impact on PPI. 4. The new structures look hardly better poised to bring about effective public and patient involvement

Ion Beam Sputtered Coatings of Bioglass

The ion beam sputtering technique available at the NASA-Lewis was used to apply coatings of bioglass to ceramic, metallic, and polymeric substrates. Experiments in vivo and in vitro described investigate these coatings. Some degree of substrate masking was obtained in all samples although stability and reactivity equivalent to bulk bioglass was not observed in all coated samples. Some degree of stability was seen in all coated samples that were reacted in vitro. Both metallic and ceramic substrates coated in this manner failed to show significantly improved coatings over those obtained with existing techniques. Implantation of the coated ceramic substrate samples in bone gave no definite bonding as seen with bulk glass; however, partial and patchy bonding was seen. Polymeric substrates in these studies showed promise of success. The coatings applied were sufficient to mask the underlying reactive test surface and tissue adhesion of collagen to bioglass was seen. Hydrophilic, hydrophobic, charged, and uncharged polymeric surfaces were successfully coated

Analysis of ISER 2008-2009 Survey Data

In September 2008, the superintendent of the Anchorage School District and the mayor of Anchorage sent a letter to the governor of Alaska, reporting what they thought might be an influx of students into Anchorage from rural communities. Enrollment in the school district was higher than expected, and it coincided with the largest-ever Alaska Permanent Fund dividend and with a one-time payment of $1,200 the state made per person, to help offset high energy costs. Researchers at the Institute of Social and Economic Research (ISER) at UAA have a longstanding interest in migration patterns in Alaska and the Arctic, and they saw the increased enrollment in Anchorage schools as a potential opportunity to better understand: • If rural Alaskans are moving to Anchorage • Where they are coming from • Why they are moving So with the cooperation of the Anchorage School District, ISER conducted a survey of the parents or guardians of students who had enrolled in Anchorage in the 2007-2008 or 2008-2009 school years and who had transferred in from other Alaska school districts. Besides finding out where students were coming from—and why—another purpose of the study was to provide the Anchorage School District and the Municipality of Anchorage with information about what they could do to help students and families who are new to the city. To our knowledge, this may be the first survey ever conducted to find out why people move to Anchorage from other areas of Alaska.University of Alaska Foundation. BP-Conoco Phillips Charter AgreementExecutive Summary / Introduction / Methods / Where are Alaskan's Moving From? / Organization of Survey Findings / Migration Patterns / Who is Moving? / Challenges and Transitions / Conclusions and Recommendations / References / Appendix A. Survey For

Cómo apoyar al cuidador de un enfermo en el final de la vida

El cuidador de un enfermo en el final de la vida debe ser objeto de una especial protección por parte de la comunidad, no sólo porque es el último eslabón de una cadena de solidaridad sino también porque necesita diversos apoyos para ayudar al que sufre un padecimiento progresivo a sobrellevar mejor esta etapa, a reencontrarse consigo mismo y a afrontar la muerte en paz. Para que ello suceda, el equipo sanitario deberá reconocerle como parte de un triángulo terapéutico – familia– paciente y equipo– y ser sensible a sus problemas, manteniendo una actitud preactiva en todo momento para ayudarle a comunicarse bien con el enfermo, a formarse para su cuidado, a prevenir y resolver sus numerosos problemas, entre ellos el agotamiento, y a darle el apoyo de una red socio-sanitaria que le permita también satisfacer sus propias necesidades físicas y emocionales sin aislarse de sus otros seres queridos.The one who takes care of a patient during the end of his life, must be especially protected by its community, not only as he is the last and stronger link of a chain of solidarity but because will also need social support in order to take care the one who is suffering, this will allow him to endure this process, facing his own reality and enabling to face death in peace. For these objectives to be reached, the health team must recognize the caregiver as a part of a therapeutic triangle in which family– the patient– and physician– are one unit; maintaining all the time a constant proactive attitude to communicate with the patient, through a process of education that improves his caring skills, identifying and resolving potential problems and defining strategies that would satisfy care giver’s needs with the support of a social – sanitary network

Emerging Methods to Objectively Assess Pruritus in Atopic Dermatitis.

INTRODUCTION:Atopic dermatitis (AD) is an inflammatory skin disease with a chronic, relapsing course. Clinical features of AD vary by age, duration, and severity but can include papules, vesicles, erythema, exudate, xerosis, scaling, and lichenification. However, the most defining and universal symptom of AD is pruritus. Pruritus or itch, defined as an unpleasant urge to scratch, is problematic for many reasons, particularly its negative impact on quality of life. Despite the profoundly negative impact of pruritus on patients with AD, clinicians and researchers lack standardized and validated methods to objectively measure pruritus. The purpose of this review is to discuss emerging methods to assess pruritus in AD by describing objective patient-centered tools developed or enhanced over the last decade that can be utilized by clinicians and researchers alike. METHODS:This review is based on a literature search in Medline, Embase, and Web of Science databases. The search was performed in February 2019. The keywords were used "pruritus," "itch," "atopic dermatitis," "eczema," "measurements," "tools," "instruments," "accelerometer," "wrist actigraphy," "smartwatch," "transducer," "vibration," "brain mapping," "magnetic resonance imaging," and "positron emission tomography." Only articles written in English were included, and no restrictions were set on study type. To focus on emerging methods, prioritization was given to results from the last decade (2009-2019). RESULTS:The search yielded 49 results in PubMed, 134 results in Embase, and 85 results in Web of Science. Each result was independently reviewed in a standardized manner by two of the authors (M.S., K.L.), and disagreements between reviewers were resolved by consensus. Relevant findings were categorized into the following sections: video surveillance, acoustic surveillance, wrist actigraphy, smart devices, vibration transducers, and neurological imaging. Examples are provided along with descriptions of how each technology works, instances of use in research or clinical practice, and as applicable, reports of validation studies and correlation with other methods. CONCLUSION:The variety of new and improved methods to evaluate pruritus in AD is welcomed by clinicians, researchers, and patients alike. Future directions include next-generation smart devices as well as exploring new territories, such as identifying biomarkers that correlate to itch and machine-learning programs to identify itch processing in the brain. As these efforts continue, it will be essential to remain patient-centered by developing techniques that minimize discomfort, respect privacy, and provide accurate data that can be used to better manage itch in AD

Acrodermatitis continua of Hallopeau: clinical perspectives.

Acrodermatitis continua of Hallopeau (ACH) is a rare, sterile pustular eruption of one or more digits. The condition presents with tender pustules and underlying erythema on the tip of a digit, more frequently arising on a finger than a toe. As far as classification, ACH is considered a localized form of pustular psoriasis. The eruption typically occurs after local trauma or infection, but such a history is not always present and various other etiologies have been described including infectious, neural, inflammatory, and genetic causes. The natural progression of ACH is chronic and progressive, often resulting in irreversible complications such as onychodystrophy that can result in anonychia, as well as osteitis that can result in osteolysis of the distal phalanges. Because of the rarity of ACH, there have been no randomized controlled studies to evaluate therapies, resulting in an absence of standardized treatment guidelines. In clinical practice, a wide variety of treatments have been attempted, with outcomes ranging from recalcitrance to complete resolution. In recent years, the introduction of biologics has provided a new class of therapy that has revolutionized the treatment of ACH. Specifically, rapid and sustained responses have been reported with the use of anti-tumor necrosis factor agents like infliximab, adalimumab, and etanercept; IL-17 inhibitors like secukinumab; IL-12/23 inhibitors like ustekinumab; and IL-1 inhibitors like anakinra. Nevertheless, there remains a considerable need for more research into treatment for the benefit of individual patients with ACH as well as for the clinical knowledge gained by such efforts. The purpose of this review is to provide a comprehensive overview of the key features of ACH as well as a discussion of clinical management strategies for this unique and debilitating condition

The nursing contribution to chronic disease management: a whole systems approach: Report for the National Institute for Health Research Service Delivery and Organisation programme

Background Transforming the delivery of care for people with Long Term Conditions (LTCs) requires understanding about how health care policies in England and historical patterns of service delivery have led to different models of chronic disease management (CDM). It is also essential in this transformation to analyse and critique the models that have emerged to provide a more detailed evidence base for future decision making and better patient care. Nurses have made, and continue to make, a particular contribution to the management of chronic diseases. In the context of this study, there is a particular focus on the origins of each CDM model examined, the processes by which nursing care is developed, sustained and mainstreamed, and the outcomes of each case study as experienced by service users and carers. Aims To explore, identify and characterise the origins, processes and outcomes of effective CDM models and the nursing contribution to such models using a whole systems approach Methods The study was divided into three phases: Phase 1: Systematic mapping of published and web-based literature. Phase 2: A consensus conference of nurses working within CDM. Sampling criteria were derived from the conference and selected nurses attended a follow up workshop where case study sites were identified. Phase 3: Multiple case study evaluation Sample: 7 case studies representing 4 CDM models. These were: i) public health nursing model; ii) primary care nursing model; iii) condition specific nurse specialist model; iv) community matron model. Methods: Evaluative case study design with the unit of analysis the CDM model (Yin, 2003): • semi-structured interviews with practitioners, patients, their carers, managers and commissioners • documentary analysis • psycho-social and clinical outcome data from specific conditions • children and young people: focus groups, age-specific survey tools. Benchmarking outcomes: Adults benchmarked against the Health Outcomes Data Repository (HODaR) dataset (Currie et al, 2005). Young people were benchmarked against the Health Behaviour of School aged Children Survey (Currie et al, 2008). Cost analysis: Due to limitations in the available data, a simple costing exercise was undertaken to ascertain the per patient cost of the nurse contribution to CDM in each of the models, and to explore patterns of health and social care utilisation. Analysis: A whole system methodology was used to establish the principles of CDM. i) The causal system is a “network of causal relationships” and focuses on long term trends and processes. ii) The data system recognises that for many important areas there is very little data. Where a particular explanatory factor is important but precise data are lacking, a range of methods should be employed to illuminate each factor as much as possible. iii) The organisational whole system emphasises how various parts of the health and social care system function together as a single system rather than as parallel systems. iv) The patient experience recognises that the whole system comes together and is embodied in the experience of each patient. Key findings While all the models strove to be patient centred in their implementation, all were linked at a causal level to disease centric principles of care which dominated the patient experience. Public Health Model • The users (both parents and children) experienced a well organised and coordinated service that is crossing health and education sectors. • The lead school nurse has provided a vision for asthma management in school-aged children. This has led to the implementation of the school asthma strategy, and the ensuing impacts including growing awareness, prevention of hospital admissions, confidence in schools about asthma management and healthier children. Primary Care Model • GP practices are providing planned and routine management of chronic disease, tending to focus on single diseases treated in isolation. Care is geared to the needs of the uncomplicated stable patient. • More complex cases tend to be escalated to secondary care where they may remain even after the patient has stabilised. • Patients with multiple diagnoses continue to experience difficulty in accessing services or practice that is designed to provide a coherent response to the idiosyncratic range of diseases with which they present. This is as true for secondary care as for primary care. • While the QOF system has clearly been instrumental in developing and sustaining a primary care nursing model of CDM, it has also limited the scope of the model to single diseases recordable on a register, rather than focus on patient centred care needs. Nurse Specialist Model • The model works under a disease focused system underpinned by evidence based medicine exemplified by NICE guidelines and NSF’s. • The model follows a template drawn from medicine and sustainability is significantly dependent on the championship and protectionism offered by senior medical clinicians. • A focus on self-management in LTCs gives particular impetus to nurse-led enablement of self-management. • The shift of LTC services from secondary care to primary care has often not been accompanied by a shift in expertise. Community Matron Model • The community matron model was distinctive in that it had been implemented as a top down initiative. • The model has been championed by the community matrons themselves, and the pressure to deliver observable results such as hospital admission reductions has been significant. • This model was the only one that consistently resulted in open access (albeit not 24 hours) and first point of contact for patients for the management of their ongoing condition. Survey Findings Compared to patients from our case studies those within HODaR visited the GP, practice nurse or NHS walk-in centres more, but had less home visits from nurses or social services within the six weeks prior to survey. HODaR patients also took significantly more time off work and away from normal activities, and needed more care from friends/ relatives than patients from our study within the last six weeks. The differences between the HODaR and case study patients in service use cannot easily be explained but it could be speculated when referring to the qualitative data that the case study patients are benefiting from nurse-led care. Cost analysis – The nurse costs per patient are at least ten times higher for community matrons conducting CDM than for nurses working in other CDM models. The pattern of service utilisation is consistent with the focus of the community matron role to provide intensive input to vulnerable patients. Conclusions Nurses are spearheading the kind of approaches at the heart of current health policies (Department of Health, 2008a). However, tensions in health policy and inherent contradictions in the context of health care delivery are hampering the implementation of CDM models and limiting the contribution nurses are able to make to CDM. These include: ? data systems that were incompatible and recorded patients as a disease entity ? QOF reinforced a disease centric approach ? practice based commissioning was resulting in increasing difficulties in cross health sector working in some sites ? the value of the public health model may not be captured in evaluation tools which focus on the individual patient experience. Recommendations Commissioners and providers 1. Disseminate new roles and innovations and articulate how the role or service fits and enhances existing provision. 2. Promote the role of the nurses in LTC management to patients and the wider community. 3. Actively engage with service users in shaping LTC services to meet patients’ needs. 4. Improve the support and supervision for nurses working within new roles. 5. Develop training and skills of nurses working in the community to enable them to take a more central role in LTC management. 6. Develop organisations that are enabling of innovation and actively seek funding for initiatives that provide an environment where nurses can reach their potential in improving LTC services. 7. Work towards data systems that are compatible between sectors and groups of professionals. Explore ways of enabling patients to access data and information systems for test results and latest information. 8. Promote horizontal as well as vertical integration of LTC services. Practitioners 1. Increase awareness of patient identified needs through active engagement with the service user. 2. Work to develop appropriate measures of nursing outcomes in LTC management including not only bureaucratic and physiological outcomes, but patient-identified outcomes. Implications of research findings 1. Investment should be made into changing patient perceptions about the traditional division of labour, the nurses’ role and skills, and the expertise available in primary care for CDM. 2. Development and evaluation of patient accessible websites where patients can access a range of information, their latest test results and ways of interpreting these. 3. Long-term funding of prospective evaluations to enable identification of CDM outcomes. 4. Mapping of patient experience and patient satisfaction so that the conceptual differences between these two related ideas can be demonstrated. 5. Development of appropriate measures of patient experience that can be used as part of the quality outcome measures. 6. Cost evaluation/effectiveness studies carried out over time that includes national quality outcome indicators and valid measures of patient experience. 7. The importance of whole system working needs to be identified in the planning of services. 8. Research into the role of the health visitor in chronic disease management within a public health model

The use of a wearable camera to explore daily functioning of older adults living with persistent pain: Methodological reflections and recommendations

Background: Persistent pain is prevalent within the ageing population and impacts daily functioning. Measuring daily functioning using conventional measures is problematic and novel technologies offer an alternative way of observing these behaviours. Methods: This study aimed to consider the use of a wearable camera as a method of exploring a range of day-to-day patterns of functioning of older adults living with persistent pain. This study followed a mixed methods design. A purposive sample of 13 older adults (65±) with persistent pain (pain >3 months) took part in this study. Two younger adults (<65) with persistent pain and two older adults with no pain also participated. Individuals used a wearable camera (Microsoft SenseCam) for seven days Results: The wearable camera recorded the frequency of body position, movement, and activities of daily living. The wearable camera also presented contextual data of location, social interactions, use of assistive devices, and behavioural adaptations and was used to inform other methods of data collection. Conclusions: The wearable camera allowed insight into patterns and experiences of daily functioning that would not have otherwise been captured. However, not all aspects of functioning were recorded using the wearable camera, including the relationship between functioning and persistent pain

Descripción de los procesos de control para los recursos financieros en el sector público y privado

Los procesos de control financiero y control fiscal son las herramientas de vigilancia y planeación financiera para las organizaciones, sin discriminar si son de índole público o privado, sin embargo, cabe diferenciar que dichos procesos tienen resultados diferentes, los cuales son consecuentes de acuerdo al objeto de la organización. Es así como el control financiero en su desarrollo verifica subprocesos tales como el flujo de caja, el cumplimiento de operaciones, el cierre y la valoración de los portafolios, la administración de pasivos, la planificación, y a su vez influye en elementos tales como las funciones de custodia, los servicios bancarios de la compañía, la inversión del efectivo sobrante, la administración de cuentas por cobrar, la administración del inventario, la gestión del activo fijo entre otros. El control fiscal a diferencia del anterior tiene como objeto garantizar a las entidades de sector público la buena inversión y ejecución de los recursos, orientar las organizaciones a una política de sana austeridad y mesura del gasto, a un equilibrio necesario y conveniente en la inversión, pero sobre todo su inversión va enfocada a la reducción del déficit, control del endeudamiento, descentralización y internalización en la gestión de servicios entro otras