Improved rural health through a collaborative model of care – qualitative findings

INTRODUCTION Health disparity between urban and rural regions in Australia is well-documented. In the Wheatbelt catchments of Western Australia there is higher incidence and rate of avoidable hospitalisation for chronic diseases. Structured care approach to chronic illnesses is not new but the focus has been on single disease state. A recent ARC Discovery Project on general practice nurse-led chronic disease management of diabetes, hypertension and stable ischaemic heart disease reported improved communication and better medical administration.[1] In our study we investigated the sustainability of such a multi-morbidities general practice –led collaborative model of care in rural Australia. METHODS A QUAN(qual) design was utilised. Eight pairs of rural general practices were matched. Inclusion criteria used were >18 years and capable of giving informed consent, at least one identified risk factor or diagnosed with chronic conditions. Patients were excluded if deemed medically unsuitable. A comprehensive care plan was formulated by the respective general practice nurse in consultation with the treating General Practitioner (GP) and patient based on the individual’s readiness to change, and was informed by available local resource. A case management approach was utilised. Shediaz-Rizkallah and Lee’s conceptual framework on sustainability informed our evaluation.[2] Our primary outcome on measures of sustainability was reduction in avoidable hospitalisation. Secondary outcomes were patients and practitioners acceptance and satisfaction, and changes to pre-determined interim clinical and process outcomes. RESULTS The qualitative interviews highlighted the community preference for a ‘sustainable’ local hospital in addition to general practice. Costs, ease of access, low prioritisation of self chronic care, workforce turnover and perception of losing another local resource if underutilised influenced the respondents’ decision to present at local hospital for avoidable chronic diseases regardless. CONCLUSIONS Despite the pragmatic nature of rural general practice in Australia, the sustainability of chronic multi-morbidities management in general practice require efficient integration of primary-secondary health care and consideration of other social determinants of health. What this study adds: What is already known on this subject: Structured approach to chronic disease management is not new and has been shown to be effective for reducing hospitalisation. However, the focus has been on single disease state. What does this study add: Sustainability of collaborative model of multi-morbidities care require better primary-secondary integration and consideration of social determinants of health.

A deconvolution method for deriving the transit time spectrum for ultrasound propagation through cancellous bone replica models

The acceptance of broadband ultrasound attenuation for the assessment of osteoporosis suffers from a limited understanding of ultrasound wave propagation through cancellous bone. It has recently been proposed that the ultrasound wave propagation can be described by a concept of parallel sonic rays. This concept approximates the detected transmission signal to be the superposition of all sonic rays that travel directly from transmitting to receiving transducer. The transit time of each ray is defined by the proportion of bone and marrow propagated. An ultrasound transit time spectrum describes the proportion of sonic rays having a particular transit time, effectively describing lateral inhomogeneity of transit times over the surface of the receiving ultrasound transducer. The aim of this study was to provide a proof of concept that a transit time spectrum may be derived from digital deconvolution of input and output ultrasound signals. We have applied the active-set method deconvolution algorithm to determine the ultrasound transit time spectra in the three orthogonal directions of four cancellous bone replica samples and have compared experimental data with the prediction from the computer simulation. The agreement between experimental and predicted ultrasound transit time spectrum analyses derived from Bland–Altman analysis ranged from 92% to 99%, thereby supporting the concept of parallel sonic rays for ultrasound propagation in cancellous bone. In addition to further validation of the parallel sonic ray concept, this technique offers the opportunity to consider quantitative characterisation of the material and structural properties of cancellous bone, not previously available utilising ultrasound.

Multifunctional agriculture in policy and practice? A comparative analysis of Norway and Australia

Ideals of productivist agriculture in the Western world have faded as the unintended consequences of intensive agriculture and pastoralism have contributed to rural decline and environmental problems. In Norway and Australia, there has been an increasing acceptance of the equal importance of social and environmental sustainability as well as economic sustainability. Alongside this shift is a belief that primary production needs to move away from an intensive, productivist-based agriculture to one that may be defined as post-productivist. In this paper, we argue that the dualism of productivism and post-productivism as concepts on agricultural policy regimes are too simplistic and discuss whether multifunctional agriculture is a better concept for a comparison of rural primary production at two extreme points of the scale, the market-oriented, liberalistic Australian agriculture and the market-protected small-scale Norwegian agriculture. We argue that multifunctionality in Australia rates relatively weakly as an ideology or policy and even less as a discourse or practice and hence is situated toward a ‘weak’ end of a continuum of a level of multifunctional agriculture. In Norwegian agriculture, multifunctional agriculture has thrived within a protectionist setting with the support of the public, the state and agricultural actors. In this sense it is very clearly a policy, practice and discourse that aims to preserve and conserve rural spaces, the cultural landscape, the farming way of life and food safety. Norway is as such situated toward a ‘strong’ end of a continuum of a level of multifunctional agriculture.

The environmental enigma : why do producers professing stewardship continue to practice poor natural resource management?

Despite a wide acceptance that primary producers in Australia subscribe to a stewardship ethic, land and water degradation remains an ongoing problem. Recent calculations suggest that the economic cost of Australia's environmental degradation is amounting to more than $A3.5 billion a year with an estimated cost of managing (not overcoming) problems of salinity, acidification, soil erosion totalling $A60 billion over the next decade. This paper argues that stewardship itself is an unsatisfactory concept when looking to landholders to respond to environmental problems, for rarely does the attitude of stewardship translate into behaviours of improving natural resource management practices on private land. Whilst there is some acceptance of the environmental problem among primary producers, a number of external constraints may also impede the uptake of conservation-orientated practices. In light of the prevailing accounts of poor adoption of sustainable practices a number of policy options are reviewed in this paper, including formal regional partnerships, regulatory frameworks and market-based measures. It is concluded that the contentious nature of some of these new opportunities for change will mean that any moves aimed at reversing environmental degradation in Australia will be slow.

Transfer pricing and multinational financial institutions : the case for replacing arm’s length price with a unitary approach

The international tax system, designed a century ago, has not kept pace with the modern multinational entity rendering it ineffective in taxing many modern businesses according to economic activity. One of those modern multinational entities is the multinational financial institution (MNFI). The recent global financial crisis provides a particularly relevant and significant example of the failure of the current system on a global scale. The modern MNFI is increasingly undertaking more globalised and complex trading operations. A primary reason for the globalisation of financial institutions is that they typically ‘follow-the-customer’ into jurisdictions where international capital and international investors are required. The International Monetary Fund (IMF) recently reported that from 1995-2009, foreign bank presence in developing countries grew by 122 per cent. The same study indicates that foreign banks have a 20 per cent market share in OECD countries and 50 per cent in emerging markets and developing countries. Hence, most significant is that fact that MNFIs are increasingly undertaking an intermediary role in developing economies where they are financing core business activities such as mining and tourism. IMF analysis also suggests that in the future, foreign bank expansion will be greatest in emerging economies. The difficulties for developing countries in applying current international tax rules, especially the current traditional transfer pricing regime, are particularly acute in relation to MNFIs, which are the biggest users of tax havens and offshore finance. This paper investigates whether a unitary taxation approach which reflects economic reality would more easily and effectively ensure that the profits of MNFIs are taxed in the jurisdictions which give rise to those profits. It has previously been argued that the uniqueness of MNFIs results in a failure of the current system to accurately allocate profits and that unitary tax as an alternative could provide a sounder allocation model for international tax purposes. This paper goes a step further, and examines the practicalities of the implementation of unitary taxation for MNFIs in terms of the key components of such a regime, along with their their implications. This paper adopts a two-step approach in considering the implications of unitary taxation as a means of improved corporate tax coordination which requires international acceptance and agreement. First, the definitional issues of the unitary MNFI are examined and second, an appropriate allocation formula for this sector is investigated. To achieve this, the paper asks first, how the financial sector should be defined for the purposes of unitary taxation and what should constitute a unitary business for that sector and second, what is the ‘best practice’ model of an allocation formula for the purposes of the apportionment of the profits of the unitary business of a financial institution.

Processing biases towards gain-framed messages may lead reward sensitive individuals to adopt safer driving behaviours

Using Gray and McNaughton’s revised RST, this study investigated the extent to which the Behavioural Approach System (BAS) and the Fight-Flight-Freeze System (FFFS) influence the processing of gain-framed and loss-framed road safety messages and subsequent message acceptance. It was predicted that stronger BAS sensitivity and FFFS sensitivity would be associated with greater processing and acceptance of the gain-framed messages and loss-framed messages, respectively. Young drivers (N = 80, aged 17–25 years) viewed one of four road safety messages and completed a lexical decision task to assess message processing. Both self-report (e.g., Corr-Cooper RST-PQ) and behavioural measures (i.e., CARROT and Q-Task) were used to assess BAS and FFFS traits. Message acceptance was measured via self-report ratings of message effectiveness, behavioural intentions, attitudes and subsequent driving behaviour. The results are discussed in the context of the effect that differences in reward and punishment sensitivities may have on message processing and message acceptance.

From expert to tasks, expert nursing practice redefined?

Aim The aim of this paper was to explore the concept of expertise in nursing from the perspective of how it relates to current driving forces in health care in which it discusses the potential barriers to acceptance of nursing expertise in a climate in which quantification of value and cost containment run high on agendas. Background Expert nursing practice can be argued to be central to high quality, holistic, individualized patient care. However, changes in government policy which have led to the inception of comprehensive guidelines or protocols of care are in danger of relegating the ‘expert nurse’ to being an icon of the past. Indeed, it could be argued that expert nurses are an expensive commodity within the nursing workforce. Consequently, with this change to the use of clinical guidelines, it calls into question how expert nursing practice will develop within this framework of care. Method The article critically reviews the evidence related to the role of the Expert Nurse in an attempt to identify the key concepts and ideas, and how the inception of care protocols has implications for their role. Conclusion Nursing expertise which focuses on the provision of individualized, holistic care and is based largely on intuitive decision making cannot, should not be reduced to being articulated in positivist terms. However, the dominant power and decision-making focus in health care means that nurses must be confident in articulating the value of a concept which may be outside the scope of knowledge of those with whom they are debating. Relevance to clinical practice The principles of abduction or fuzzy logic may be useful in assisting nurses to explain in terms which others can comprehend, the value of nursing expertise.

Defining the expert ICU nurse

This paper explores the concept of expertise in intensive care nursing practice from the perspective of its relationship to the current driving forces in healthcare. It discusses the potential barriers to acceptance of nursing expertise in a climate in which quantification of value and cost containment run high on agendas. It argues that nursing expertise which focuses on the provision of individualised, holistic care and which is based largely on intuitive decision-making cannot and should not be reduced to being articulated in positivist terms. The principles of abduction or fuzzy logic, derived from computer science, may be useful in assisting nurses to explain in terms, which others can comprehend, the value of nursing expertise.

Producing while consuming: Social interaction around photos shared within private group

User-generated content plays a pivotal role in the current social media. The main focus, however, has been on the explicitly generated user content such as photos, videos and status updates on different social networking sites. In this paper, we explore the potential of implicitly generated user content, based on users’ online consumption behaviors. It is technically feasible to record users’ consumption behaviors on mobile devices and share that with relevant people. Mobile devices with such capabilities could enrich social interactions around the consumed content, but it may also threaten users’ privacy. To understand the potentials of this design direction we created and evaluated a low-fidelity prototype intended for photo sharing within private groups. Our prototype incorporates two design concepts, namely, FingerPrint and MoodPhotos that leverage users’ consumption history and emotional responses. In this paper, we report user values and user acceptance of this prototype from three participatory design workshops.

Safety climate and injury occurrence of repair, maintenance, minor alteration and addition works : a comparison of workers, supervisors and managers

Purpose The repair, maintenance, minor alteration and addition (RMAA) sector has been expanding in many developed cities. Safety problems of the RMAA sector have attracted the attention of many governments. This study has the objectives of comparing the level of safety climate of workers, supervisors and managers in the RMAA sector; and explaining/ predicting the impact of safety climate on injury occurrence of workers, supervisors and managers. Design/methodology/approach A questionnaire survey was administered to RMAA contracting companies in Hong Kong. Findings When comparing the safety climate perception of workers, supervisors and managers in the RMAA sector, the supervisors group had the lowest mean safety climate score. Results showed that a positive workforce safety attitude and acceptance of safety rules and regulations reduced the workers’ likelihood of having injuries. A reasonable production schedule led to a lower probability of supervisors being injured. Management commitment and effective safety management reduced the probability of managers being injured. Originality/value This study revealed variations of safety climate at the different levels in the organizational hierarchy and their varying influence on safety performance of the RMAA sector. Safety of RMAA works could be improved by promulgating specific safety measures at the different hierarchy levels.

A place in the sun : the politics of place, identity and branding

There is no doubt that place branding is a powerful and ubiquitous practice deployed around the globe. Parallel to its acceptance and development as a distinct discipline is an understanding that place branding as responsible practice offers the means to achieve widespread economic, social and cultural benefits. Drawing on work around place and identity in cultural geography and cultural studies, this paper engages critically with this vision. Specifically, it challenges the widely-held assumption that the relationship between place branding and place identity is fundamentally reflective, arguing instead that this relationship is inherently generative. This shift in perspective, explored in relation to current responsible place branding practice, is central to the realisation of place branding as a force for good.

Cloning, expression, characterisation and mutational analysis of l-aspartate oxidase from Pseudomonas putida

L-Amino acid oxidases (LAAOs) are useful catalysts for the deracemisation of racemic amino acid sub-strates when combined with abiotic reductants. The gene nadB encoding the L-aspartate amino acid oxidase from Pseudomonas putida (PpLASPO) has been cloned and expressed in E. coli. The purified PpLASPO enzyme displayed a K M for l-aspartic acid of 2.26 mM and a k cat = 10.6 s −1 , with lower activity also displayed towards L-asparagine, for which pronounced substrate inhibition was also observed. The pH optimum of the enzyme was recorded at pH 7.4. The enzyme was stable for 60 min at up to 40 • C, but rapid losses in activity were observed at 50 • C. A mutational analysis of the enzyme, based on its sequence homology with the LASPO from E. coli of known structure, appeared to confirm roles in substrate binding or catalysis for residues His244, His351, Arg386 and Arg290 and also for Thr259 and Gln242. The high activity of the enzyme, and its promiscuous acceptance of both L-asparagine and L-glutamate as substrates, if with low activity, suggests that PpLASPO may provide a good model enzyme for evolution studies towards AAOs of altered or improved properties in the future.

Apple skin patterning is associated with differential expression of MYb10

Background Some apple (Malus × domestica Borkh.) varieties have attractive striping patterns, a quality attribute that is important for determining apple fruit market acceptance. Most apple cultivars (e.g. 'Royal Gala') produce fruit with a defined fruit pigment pattern, but in the case of 'Honeycrisp' apple, trees can produce fruits of two different kinds: striped and blushed. The causes of this phenomenon are unknown. Results Here we show that striped areas of 'Honeycrisp' and 'Royal Gala' are due to sectorial increases in anthocyanin concentration. Transcript levels of the major biosynthetic genes and MYB10, a transcription factor that upregulates apple anthocyanin production, correlated with increased anthocyanin concentration in stripes. However, nucleotide changes in the promoter and coding sequence of MYB10 do not correlate with skin pattern in 'Honeycrisp' and other cultivars differing in peel pigmentation patterns. A survey of methylation levels throughout the coding region of MYB10 and a 2.5 Kb region 5' of the ATG translation start site indicated that an area 900 bp long, starting 1400 bp upstream of the translation start site, is highly methylated. Cytosine methylation was present in all three contexts, with higher methylation levels observed for CHH and CHG (where H is A, C or T) than for CG. Comparisons of methylation levels of the MYB10 promoter in 'Honeycrisp' red and green stripes indicated that they correlate with peel phenotypes, with an enrichment of methylation observed in green stripes. Conclusions Differences in anthocyanin levels between red and green stripes can be explained by differential transcript accumulation of MYB10. Different levels of MYB10 transcript in red versus green stripes are inversely associated with methylation levels in the promoter region. Although observed methylation differences are modest, trends are consistent across years and differences are statistically significant. Methylation may be associated with the presence of a TRIM retrotransposon within the promoter region, but the presence of the TRIM element alone cannot explain the phenotypic variability observed in 'Honeycrisp'. We suggest that methylation in the MYB10 promoter is more variable in 'Honeycrisp' than in 'Royal Gala', leading to more variable color patterns in the peel of this cultivar.

Alternate healing and medicine : the roles of naturopathy, homeopathy, osteopathy, chiropractic and medical practice in the health system

This thesis is concerned with understanding the roles of four alternate healing systems and medical practice in the community's health behaviour. The four alternate systems are naturopathy, homoeopathy, osteopathy and chiropractic. The research reported developed from work supported by the Committee of Inquiry into Chiropractic, Osteopathy, Homoeopathy and Naturopathy conducted under the chairmanship of Professor E. C. Webb set up by the Australian Government in 1975. The study concentrates on the factors which influence individual clients in their decisions to consult healers for treatment. An underlying assumption is that an analysis of the processes that effect such decisions will lead to further knowledge of the community's attitudes towards the functions of alternate healing and medicine. A review of the historical backgrounds and current status of the four alternate healing systems leads to the conclusion that they differ in a variety of areas. These areas include treatment modalities, historical backgrounds, occupational development and rapprochement with medicine. Homoeopathy, osteopathy and chiropractic emerged as distinct approaches to healing late in the nineteenth century. Naturopathy tends to be a philosophy or style of life as much as a health system in its own right. Their relationships with medicine also vary; osteopathy and naturopathy receive some acceptance, some homoeopaths are tolerated, whilst chiropractic is ostracised and vilified. A common paradigm of treatment underlies all four alternate approaches to healing. They all eschew the use of synthetic pharmaceuticals and invasive treatments and accept an indigenous theory of disease and a belief in the vis medicatrix naturae or the healing power of nature. An inevitable concomitant of this paradigm is that they believe that healing and health must be self-engendered. They rest within the client and his or her actions, not within the hands, skills or power of the healer. It is these characteristics combined with the alternate healers ' claims to espouse a similar scientific rationale for their approaches, and their functioning as parallel healers to medicine, that establishes their special relationship with medicine. This relationship become s more problematic in the face of medicine's hegemony and claim to unique legitimacy as the community's sole healing system. The interaction between these systems and medical practice can be gauged through articles related to the four alternate healing systems that have appeared in the medical literature. Interest has been cyclical but appears to have markedly increased in the past two decades. In this period it has included exploratory and descriptive writing; concern with controlling and/or eradicating the healers; desire to protect an ignorant and vulnerable public and. finally understanding and exploration of what the alternate healers might have to offer. At the same time, the public or institutionalized role has been one of denial and suppression through ostracism and legal constraints. In spite of medicine's position the alternate healing systems have found growing community acceptance so that it is problematical and probably unacceptable now to consider their use as a 'deviant ' health action. Increasing interest in the characteristics of clients has provided a consensus that they are similar to the adult population and are more likely to suffer from musculoskeletal and chronic illnesses. They are no more likely to be neurotic or gullible than the general community, but probably more practical and more oriented towards an active involvement in the healing process. The impact of these issues is explored, through comparing the strategies taken into account when choosing a treatment. These include attending one of the alternate healers exclusively for a condition; attending an alternate healer and a medical practitioner for the same problem; attending a medical practitioner solely or not consulting any healer. Respondents from surveys of alternate healer clients and the general community were classified according to their use of these four strategies, and the influences on their decisions at different stages of the treatment decision making process were compared.

EMT and MET in carcinoma : clinical observations, regulatory pathways and new models

The articles collected here in this special edition Epithelial-Mesenchymal (EMT) and Mesenchymal-Epithelial Transitions (MET) in Cancer provide a snapshot of the very rapidly progressing cinemascope of the involvement of these transitions in carcinoma progression. Pubmed analysis of EMT and cancer shows an exponential increase in the last few years in the number of papers and reviews published under these terms (Fig. 1). The last few years have seen these articles appearing in high calibre journals including Nature, Nature Cell Biology, Cancer Cell, PNAS, JNCI, JCI, and Cell, signaling the acceptance and quality of work in this field.