The next phase of healthcare improvement: what can we learn from social movements?

To date, improvement in health care has relied mainly on a "top down" programme by programme approach to service change and development. This has spawned a multitude of different and often impressive improvement schemes and activities. We question whether what has been happening will be sufficient to achieve the desired scale of change within the time scales set. Is it a case of "more of the same" or are there new and different approaches that might now be usefully implemented? Evidence from the social sciences suggests that other perspectives may help to recast large scale organisational change efforts in a new light and offer a different, though complementary, approach to improvement thinking and practice. Particularly prominent is the recognition that such large scale change in organisations relies not only on the "external drivers" but on the ability to connect with and mobilise people?s own "internal" energies and drivers for change, thus creating a "bottom up" locally led "grass roots" movement for improvement and change

Large circulant graphs of fixed diameter and arbitrary degree

We consider the degree-diameter problem for undirected and directed circulant graphs. To date, attempts to generate families of large circulant graphs of arbitrary degree for a given diameter have concentrated mainly on the diameter 2 case. We present a direct product construction yielding improved bounds for small diameters and introduce a new general technique for “stitching” together circulant graphs which enables us to improve the current best known asymptotic orders for every diameter. As an application, we use our constructions in the directed case to obtain upper bounds on the minimum size of a subset A of a cyclic group of order n such that the k-fold sumset kA is equal to the whole group. We also present a revised table of largest known circulant graphs of small degree and diameter

Towards a million change agents. A review of the social movements literature: implications for large scale change in the NHS.

This review explores 'social movements' as a new way of thinking about large-scale systems change and assesses the potential contribution of applying this new perspective to NHS improvement

Staircases, dominoes, and the growth rate of 1324-avoiders

We establish a lower bound of 10.271 for the growth rate of the permutations avoiding 1324, and an upper bound of 13.5. This is done by first finding the precise growth rate of a subclass whose enumeration is related to West-2-stack-sortable permutations, and then combining copies of this subclass in particular ways

A structural characterisation of Av(1324) and new bounds on its growth rate

We establish an improved lower bound of 10.271 for the exponential growth rate of the class of permutations avoiding the pattern 1324, and an improved upper bound of 13.5. These results depend on a new exact structural characterisation of 1324-avoiders as a subclass of an infinite staircase grid class, together with precise asymptotics of a small domino subclass whose enumeration we relate to West-two-stack-sortable permutations and planar maps. The bounds are established by carefully combining copies of the dominoes in particular ways consistent with the structural characterisation. The lower bound depends on concentration results concerning the substructure of a typical domino, the determination of exactly when dominoes can be combined in the fewest distinct ways, and technical analysis of the resulting generating function

The molecular epidemiology of bla-CTX-M antibiotic resistance genes in the faecal microbiome of humans acquiring extended-spectrum beta lactamase-producing escherichia coli

ESBL prevalence is increasing globally and travellers visiting South Asia have high rates of acquisition of CTX-M-producing-E. coli (CTX-M-EC). A prospective observational cohort study of volunteers traveling from the UK to South Asia was undertaken to determine the mechanism of CTX-M-producing E. coli (CTX-M-EC) acquisition. CTX-M-EC was acquired by 16/18 (89%) of volunteers, and polyclonal acquisition of CTX-M-EC was seen in 8/15 volunteers, suggesting multiple acquisition events during travel. CTX-M-EC clones were detectable in faecal samples at six months after travel for 6/6 volunteers. Indistinguishable pre-travel non-CTX-M-EC were found in post-travel faecal samples after CTX-M-EC had been lost in 5/15 cases. Therefore, pre-travel non-CTX-M E. coli remain as a minority population in the gut until the CTX-M-EC are lost. Ten plasmids were sequenced using WGS with short and long reads. Plasmid transfer after filter-mating occurred in CTX-M-EC from 45% of volunteers, suggesting that conjugation also has a role in the human gut. However, in-vivo horizontal transfer of a blaCTX-M plasmid was not detected. Plasmids are closely related to those previously sequenced, isolated from humans, animals and the natural environment. Determining the mechanism of spread of CTX-M-EC will underpin infection prevention and control practices, lay a foundation for future research, and avert excess mortality in the future

Oxidative phosphorylation and lacunar stroke: Genome-wide enrichment analysis of common variants.

OBJECTIVE: We investigated whether oxidative phosphorylation (OXPHOS) abnormalities were associated with lacunar stroke, hypothesizing that these would be more strongly associated in patients with multiple lacunar infarcts and leukoaraiosis (LA). METHODS: In 1,012 MRI-confirmed lacunar stroke cases and 964 age-matched controls recruited from general practice surgeries, we investigated associations between common genetic variants within the OXPHOS pathway and lacunar stroke using a permutation-based enrichment approach. Cases were phenotyped using MRI into those with multiple infarcts or LA (MLI/LA) and those with isolated lacunar infarcts (ILI) based on the number of subcortical infarcts and degree of LA, using the Fazekas grading. Using gene-level association statistics, we tested for enrichment of genes in the OXPHOS pathway with all lacunar stroke and the 2 subtypes. RESULTS: There was a specific association with strong evidence of enrichment in the top 1% of genes in the MLI/LA (subtype p = 0.0017) but not in the ILI subtype (p = 1). Genes in the top percentile for the all lacunar stroke analysis were not significantly enriched (p = 0.07). CONCLUSIONS: Our results implicate the OXPHOS pathway in the pathogenesis of lacunar stroke, and show the association is specific to patients with the MLI/LA subtype. They show that MRI-based subtyping of lacunar stroke can provide insights into disease pathophysiology, and imply that different radiologic subtypes of lacunar stroke subtypes have distinct underlying pathophysiologic processes.Hugh Markus is supported by an NIHR Senior Investigator award. Hugh Markus and Steve Bevan are supported by the NIHR Cambridge University Hospitals Comprehensive Biomedical Research Centre. Collection of the UK Young Lacunar Stroke Resource was primarily supported by a Functional Genomics grant from the Wellcome Trust with additional support from the Stroke Association. Genotyping and MT were supported by a project grant from the Stroke Association (TSA 2013/01). Dr. Anderson is supported by NIH-NINDS K23 NS086873 and a Fellowship in Therapeutic Investigation sponsored by the Massachusetts General Hospital Department of Neurology and Biogen Idec, Inc.This is the final version of the article. It first appeared from Wolters Kluwer via http://dx.doi.org/10.1212/WNL.000000000000226

Oswestry, Hay-on-Wye and Berwick-upon-Tweed: Football fandom, nationalism and national identity across the Celtic borders

Little research has been devoted to studying the interconnections between the ambiguous border identities along the so-called ‘Celtic fringe’ in the UK. It is important to explore whether, in the new context of the devolved Welsh and Scottish states, people resident in the border areas of Wales and Scotland will increasingly come to identify with the Welsh or Scottish “nation” and with its official “nationality”. Using the sociological approach advocated by Robert K. Yin, this thesis draws on ethnographical research to explore the precise nature of the relationship between contemporary national identity, nationalism, borderlands and football fandom. It examines supporters in three border towns: Oswestry (Shropshire), Hay-on-Wye (Powys), and Berwick-upon-Tweed (Northumberland). Focus groups were conducted with match-going supporters of Welsh league champions The New Saints of Oswestry Town, Scottish League Two side Berwick Rangers and Hay St. Mary’s Football Club, who compete in both the Herefordshire and Mid Wales leagues. Examining football fans’ expressions of identity, this study discusses national sentiment and explores identity – local, regional and national – in the England-Wales and England-Scotland border regions from a theoretical and comparative perspective. A detailed and grounded study of national identity and nationalism amongst fans in the borderlands of Wales and Scotland will appeal to academics and students of sports history and with interests in ethnography, the sociology of sport, football fandom, debatable borderlands and contemporary national identities