Primary health care case management through the lens of complexity: an exploratory study of naturopathic practice using complexity science principles.

BACKGROUND: Advances in systems science creates an opportunity to bring a complexity perspective to health care practices and research. While medical knowledge has greatly progressed using a reductionist and mechanistic philosophy, this approach may be limited in its capacity to manage chronic and complex illness. With its holistic foundation, naturopathy is a primary health profession with a purported alignment with a complexity perspective. As such this pilot study aimed to investigate the application of complexity science principles, strategies, and tools to primary health care using naturopathy as a case study. METHODS: A network mapping and analysis of the naturopathic case management process was conducted. Mind maps were created by naturopathic practitioners to reflect their clinical conceptualisation of a common paper clinical case. These mind maps were inputed into Gephi, a network mapping, exploration, and analysis software. Various layouts of the data were produced, and these were analysed using exploratory data analysis and computational network analysis. RESULTS: Seven naturopathic practitioners participated in the study. In the combined network mapping, 133 unique elements and 399 links were identified. Obesity, the presenting issue in the case, was centrally located. Along with obesity, other keystone elements included: systemic inflammation, dysbiosis, diet, the liver, and mood. Each element was connected on average to 3.05 other elements, with a degree variation between one and 36. Six communities within the dataset were identified, comprising: the nervous system and mood, gastroinstetinal and dietary factors, systemic inflammation and obesity, the endocrine system and metabolism. CONCLUSIONS: This pilot study demonstrates that it is feasible to apply a complexity science perspective to investigating primary health care case management. This supports a shift to viewing the human organism as a complex adaptive system within primary health care settings, with implications for health care practices that are more cognisant with the treatment of chronic and complex conditions and research opportunities to capture the complex clinical reasoning processes of practitioners

The converging paradigms of holism and complexity: An exploration of naturopathic clinical case management using complexity science principles.

RATIONALE: Traditional whole systems of medicine, such as naturopathy, are founded upon holism; a philosophical paradigm consistent with contemporary complexity science. Naturopathic case management is predicated upon the understanding of an intimately interconnected internal physiological and external context of the human organism-potentially indicating a worldview aligned with a complexity perspective. In this study we investigate naturopathic clinical reasoning using a complexity lens with the aim of ascertaining the extent of correspondence between the two. METHOD: Mind maps depicting case presentations were sought from Australian degree qualified naturopaths. A network mapping was undertaken, which was then analysed in accordance with a complexity science framework using exploratory data analysis and network analysis processes and tools. RESULTS: Naturopathic case schematics, in the form of mind maps (n = 70), were collected, network mapped, and analysed. A total of 739 unique elements and 2724 links were identified across the network. Integral elements across the network were: stress, fatigue, general anxiety, systemic inflammation, gut dysbiosis, and diet. A modularity algorithm detected 11 communities, the primary ones of these representing the nervous system and mood; the gastrointestinal tract, liver, and nutrition; immune function and the immune system; and diet and nutrients. CONCLUSIONS: Naturopathic case management is holistic and based on a perspective of an integrated physiology and external context of the human organism. The traditional concept of holism, when subjected to a complexity lens, leads to the emergence of a contemporary holistic paradigm cognisant of the human organism being a complex system. The application of complexity science to investigate naturopathic case management as employed in this study, demonstrates that it is possible to investigate traditional philosophies and principles in a scientific and critical manner. A complexity science research approach may offer a suitable scientific paradigm to develop our understanding of traditional whole systems of medicine

Development of dilated cardiomyopathy and impaired calcium homeostasis with cardiac-specific deletion of ESRRβ.

Mechanisms underlying the development of idiopathic dilated cardiomyopathy (DCM) remain poorly understood. Using transcription factor expression profiling, we identified estrogen-related receptor-β (ESRRβ), a member of the nuclear receptor family of transcription factors, as highly expressed in murine hearts and other highly oxidative striated muscle beds. Mice bearing cardiac-specific deletion of ESRRβ (MHC-ERRB KO) develop DCM and sudden death at ~10 mo of age. Isolated adult cardiomyocytes from the MHC-ERRB KO mice showed an increase in calcium sensitivity and impaired cardiomyocyte contractility, which preceded echocardiographic cardiac remodeling and dysfunction by several months. Histological analyses of myocardial biopsies from patients with various cardiomyopathies revealed that ESRRβ protein is absent from the nucleus of cardiomyocytes from patients with DCM but not other forms of cardiomyopathy (ischemic, hypertrophic, and arrhythmogenic right ventricular cardiomyopathy). Taken together these observations suggest that ESRRβ is a critical component in the onset of DCM by affecting contractility and calcium balance.NEW & NOTEWORTHY Estrogen-related receptor-β (ESRRβ) is highly expressed in the heart and cardiac-specific deletion results in the development of a dilated cardiomyopathy (DCM). ESRRβ is mislocalized in human myocardium samples with DCM, suggesting a possible role for ESRRβ in the pathogenesis of DCM in humans

CHARGE syndrome

CHARGE syndrome was initially defined as a non-random association of anomalies (Coloboma, Heart defect, Atresia choanae, Retarded growth and development, Genital hypoplasia, Ear anomalies/deafness). In 1998, an expert group defined the major (the classical 4C's: Choanal atresia, Coloboma, Characteristic ears and Cranial nerve anomalies) and minor criteria of CHARGE syndrome. Individuals with all four major characteristics or three major and three minor characteristics are highly likely to have CHARGE syndrome. However, there have been individuals genetically identified with CHARGE syndrome without the classical choanal atresia and coloboma. The reported incidence of CHARGE syndrome ranges from 0.1–1.2/10,000 and depends on professional recognition. Coloboma mainly affects the retina. Major and minor congenital heart defects (the commonest cyanotic heart defect is tetralogy of Fallot) occur in 75–80% of patients. Choanal atresia may be membranous or bony; bilateral or unilateral. Mental retardation is variable with intelligence quotients (IQ) ranging from normal to profound retardation. Under-development of the external genitalia is a common finding in males but it is less apparent in females. Ear abnormalities include a classical finding of unusually shaped ears and hearing loss (conductive and/or nerve deafness that ranges from mild to severe deafness). Multiple cranial nerve dysfunctions are common. A behavioral phenotype for CHARGE syndrome is emerging. Mutations in the CHD7 gene (member of the chromodomain helicase DNA protein family) are detected in over 75% of patients with CHARGE syndrome. Children with CHARGE syndrome require intensive medical management as well as numerous surgical interventions. They also need multidisciplinary follow up. Some of the hidden issues of CHARGE syndrome are often forgotten, one being the feeding adaptation of these children, which needs an early aggressive approach from a feeding team. As the child develops, challenging behaviors become more common and require adaptation of educational and therapeutic services, including behavioral and pharmacological interventions

Good Gig, Bad Gig: Autonomy and Algorithmic Control in the Global Gig Economy

This article evaluates the job quality of work in the remote gig economy. Such work consists of the remote provision of a wide variety of digital services mediated by online labour platforms. Focusing on workers in Southeast Asia and Sub-Saharan Africa, the article draws on semi-structured interviews in six countries (N = 107) and a cross-regional survey (N = 679) to detail the manner in which remote gig work is shaped by platform-based algorithmic control. Despite varying country contexts and types of work, we show that algorithmic control is central to the operation of online labour platforms. Algorithmic management techniques tend to offer workers high levels of flexibility, autonomy, task variety and complexity. However, these mechanisms of control can also result in low pay, social isolation, working unsocial and irregular hours, overwork, sleep deprivation and exhaustion

Violence and vulnerability:Children’s strategies and the logic of violence in Burundi

This study explores how children in conflict-affected Burundi deal with violence in their everyday lives. Focusing on schools as a context in which children are prepared for further roles in society, child-centred, qualitative and mixed-methods research was conducted at 36 primary schools throughout Burundi. Findings reveal that children use a variety of strategies to deal with violence they encounter. These strategies reflect a learned 'logic of violence', matching dynamics of violence and vulnerability in society at large. Children's strategies are ultimately aimed at reducing vulnerability to (future) violence and indicative of the omnipresence of violence and uncertainty in Burundi. (C) 2019 The Authors. Children & Society published by National Children's Bureau and John Wiley & Sons LtdPublic Health and primary car

An improved methodology for the recovery of Zea mays and other large crop pollen, with implications for environmental archaeology in the Neotropics

We present a simple sieving methodology to aid the recovery of large cultigen pollen grains, such as maize (Zea mays L.), manioc (Manihot esculenta Crantz), and sweet potato (Ipomoea batatas L.), among others, for the detection of food production using fossil pollen analysis of lake sediments in the tropical Americas. The new methodology was tested on three large study lakes located next to known and/or excavated pre-Columbian archaeological sites in South and Central America. Five paired samples, one treated by sieving, the other prepared using standard methodology, were compared for each of the three sites. Using the new methodology, chemically digested sediment samples were passed through a 53 µm sieve, and the residue was retained, mounted in silicone oil, and counted for large cultigen pollen grains. The filtrate was mounted and analysed for pollen according to standard palynological procedures. Zea mays (L.) was recovered from the sediments of all three study lakes using the sieving technique, where no cultigen pollen had been previously recorded using the standard methodology. Confidence intervals demonstrate there is no significant difference in pollen assemblages between the sieved versus unsieved samples. Equal numbers of exotic Lycopodium spores added to both the filtrate and residue of the sieved samples allow for direct comparison of cultigen pollen abundance with the standard terrestrial pollen count. Our technique enables the isolation and rapid scanning for maize and other cultigen pollen in lake sediments, which, in conjunction with charcoal and pollen records, is key to determining land-use patterns and the environmental impact of pre-Columbian societies

Nitrogen fixation in a landrace of maize is supported by a mucilage-associated diazotrophic microbiota

© 2018 Van Deynze et al. http://creativecommons.org/licenses/by/4.0/. Plants are associated with a complex microbiota that contributes to nutrient acquisition, plant growth, and plant defense. Nitrogen-fixing microbial associations are efficient and well characterized in legumes but are limited in cereals, including maize. We studied an indigenous landrace of maize grown in nitrogen-depleted soils in the Sierra Mixe region of Oaxaca, Mexico. This landrace is characterized by the extensive development of aerial roots that secrete a carbohydrate-rich mucilage. Analysis of the mucilage microbiota indicated that it was enriched in taxa for which many known species are diazotrophic, was enriched for homologs of genes encoding nitrogenase subunits, and harbored active nitrogenase activity as assessed by acetylene reduction and 15 N 2 incorporation assays. Field experiments in Sierra Mixe using 15 N natural abundance or 15 N-enrichment assessments over 5 years indicated that atmospheric nitrogen fixation contributed 29%–82% of the nitrogen nutrition of Sierra Mixe maize