Perceived and reported access to the general practitioner: an international comparison of universal access and mixed private/public systems.

Timely and convenient access to primary healthcare is essential for the health of the population as delays can incur additional health and financial costs. Access to health care is under increasing scrutiny as part of the drive to contain escalating costs, while attempting to maintain equity in service provision. The objective was to compare primary care services in Republic of Ireland and Northern Ireland, and to report on perceived and reported access to GP services in universal access and mixed private/public systems. A questionnaire study was performed in Northern Ireland (NI) and the Republic of Ireland (ROI). Patients of 20 practices in the ROI and NI were contacted (n = 22,796). Main outcome measures were overall satisfaction and the access to GP services. Individual responses and scale scores were derived using the General Practice Assessment Questionnaire (G-PAQ). The response rate was 52% (n = 11,870). Overall satisfaction with GP practices was higher in ROI than in NI (84.2% and 80.9% respectively). Access scores were higher in ROI than in NI (69.2% and 57.0% respectively) Less than 1 in 10 patients in ROI waited two or more working days to see a doctor of choice (8.1%) compared to almost half (45.0%) in NI. In NI overall satisfaction decreased as practice size increased; 82.8%, 80.4%, and 75.8%. In both systems, in large practices, accessibility is reduced when compared to smaller practices. The faster access to GP services in ROI may be due to the deterrent effect of the consultation charge freeing up services although, as it is the poorest and sickest who are deterred by the charge this improved accessibility may come at a significant cost in terms of equity. The underlying concern for policy makers centres around provision of equitable services.

Two-stage mixed discrete-continuous identification of radial basis function (RBF) neural models for nonlinear systems

The identification of nonlinear dynamic systems using radial basis function (RBF) neural models is studied in this paper. Given a model selection criterion, the main objective is to effectively and efficiently build a parsimonious compact neural model that generalizes well over unseen data. This is achieved by simultaneous model structure selection and optimization of the parameters over the continuous parameter space. It is a mixed-integer hard problem, and a unified analytic framework is proposed to enable an effective and efficient two-stage mixed discrete-continuous; identification procedure. This novel framework combines the advantages of an iterative discrete two-stage subset selection technique for model structure determination and the calculus-based continuous optimization of the model parameters. Computational complexity analysis and simulation studies confirm the efficacy of the proposed algorithm.

Secondary prevention of cardiovascular disease in different primary healthcare systems with and without pay-for-performance

Objective: To compare baseline cardiovascular risk management between people recruited from two different healthcare systems, to a research trial of an intervention to optimize secondary prevention. Design: Cross-sectional study. Setting: General practices, randomly selected: 16 in Northern Ireland (NI) (UK NHS, ‘strong’ infrastructure); 32 in Republic of Ireland (RoI) (mixed healthcare economy, less infrastructure). Patients: 903 (mean age 67.5 years; 69.9% male); randomly selected, known coronary heart disease. Main outcome measures: Blood pressure, cholesterol, medications; validated questionnaires for diet (DINE), exercise (Godin), quality of life (SF12); healthcare usage. Results: More RoI than NI participants had systolic BP>140 mmHg (37% v 28%, p=0.01) and cholesterol >5mmol/l (24% v 17%, p=0.02): RoI mean systolic BP was higher (139 v 132 mm Hg). More RoI participants reported a high fibre intake (35% v 23%), higher levels of physical activity (62% v 44%), and better physical and mental health (SF12); they had more GP (5.6 v 4.4) and fewer nurse visits (1.6 v 2.1) in the previous year. Fewer in RoI (55% v 70%) were prescribed B blockers. Both groups’ ACE inhibitor (41%; 48%) prescribing was similar; high proportions were prescribed statins (84%; 85%) and aspirin (83%; 77%). Conclusions Blood pressure and cholesterol are better controlled among patients in a primary healthcare system with a ‘strong’ infrastructure supporting computerization and rewarding measured performance but this is not associated with healthier lifestyle or better quality of life. Further exploration of differences in professionals’ and patients’ engagement in secondary prevention in different healthcare systems is needed.

CsF and alumina: A mixed homogeneous-heterogeneous catalytic system for the transesterification of sunflower oil with methanol

The activity and nature (i e heterogeneous and/or homogeneous) of catalysts based on CsF supported on alpha-Al2O3 were investigated for the transesterification of vegetable oil with methanol. The effect of the activation temperature, CsF loading and the reusability in a recirculating reactor were first studied CsF/alpha-Al2O3 exhibited the highest activity for a CsF loading of 0 6 mmol/g and when activated at 120 degrees C An important aspect of this study is the effect of CsF leaching into the reaction mixture, which is attributed to the high solubility of CsF in methanol, leading to a complete loss of activity after one run It was Identified that the activity of the catalyst resulted from a synergy between alumina and dissolved CsF, the presence of both compounds being absolutely necessary to observe any conversion The use of an alumina with a higher surface area resulted in a far greater reaction rate, showing that the concentration of surface site on the oxide (probably surface hydroxyl) was rate-limiting in the case of the experiments using the low surface area alpha-Al2O3 This work emphasizes that combined homogeneous-heterogeneous catalytic systems made from the blending of the respective catalysts can be used to obtain high conversion of vegetable oil to biodiesel. Despite the homogeneous/heterogeneous dual character, such a catalytic system may prove valuable in developing a simple and cost-effective continuous catalytic process for biodiesel production (C) 2010 Elsevier B V All rights reserved

Physical activity assessment in practice: a mixed methods study of GPPAQ use in primary care

Background: Insufficient physical activity (PA) levels which increase the risk of chronic disease are reported by almost two-thirds of the population. More evidence is needed about how PA promotion can be effectively implemented in general practice (GP), particularly in socio-economically disadvantaged communities. One tool recommended for the assessment of PA in GP and supported by NICE (National Institute for Health and Care Excellence) is The General Practice Physical Activity Questionnaire (GPPAQ) but details of how it may be used and of its acceptability to practitioners and patients are limited. This study aims to examine aspects of GPPAQ administration in non-urgent patient contacts using different primary care electronic recording systems and to explore the views of health professionals regarding its use.

Methods: Four general practices, selected because of their location within socio-economically disadvantaged areas, were invited to administer GPPAQs to patients, aged 35-75 years, attending non-urgent consultations, over two-week periods. They used different methods of administration and different electronic medical record systems (EMIS, Premiere, Vision). Participants’ (general practitioners (GPs), nurses and receptionists) views regarding GPPAQ use were explored via questionnaires and focus groups.

Results: Of 2,154 eligible consultations, 192 (8.9%) completed GPPAQs; of these 83 (43%) were categorised as inactive. All practices were located within areas ranked as being in the tertile of greatest socio-economic deprivation in Northern Ireland. GPs/nurses in two practices invited completion of the GPPAQ, receptionists did so in two. One practice used an electronic template; three used paper copies of the questionnaires. End-of-study questionnaires, completed by 11 GPs, 3 nurses and 2 receptionists and two focus groups, with GPs (n = 8) and nurses (n = 4) indicated that practitioners considered the GPPAQ easy to use but not in every consultation. Its use extended consultation time, particularly for patients with complex problems who could potentially benefit from PA promotion.

Conclusions: GPs and nurses reported that the GPPAQ itself was an easy tool with which to assess PA levels in general practice and feasible to use in a range of electronic record systems but integration within routine practice is constrained by time and complex consultations. Further exploration of ways to facilitate PA promotion into practice is needed.

Distillable entanglement and area laws in spin and harmonic-oscillator systems

We address the presence of nondistillable (bound) entanglement in natural many-body systems. In particular, we consider standard harmonic and spin-1/2 chains, at thermal equilibrium and characterized by few interaction parameters. The existence of bound entanglement is addressed by calculating explicitly the negativity of entanglement for different partitions. This allows us to individuate a range of temperatures for which no entanglement can be distilled by means of local operations, despite the system being globally entangled. We discuss how the appearance of bound entanglement can be linked to entanglement-area laws, typical of these systems. Various types of interactions are explored, showing that the presence of bound entanglement is an intrinsic feature of these systems. In the harmonic case, we analytically prove that thermal bound entanglement persists for systems composed by an arbitrary number of particles. Our results strongly suggest the existence of bound entangled states in the macroscopic limit also for spin-1/2 systems.

Thermal bound entanglement in macroscopic systems and area law

Does bound entanglement naturally appear in quantum many-body systems? We address this question by showing the existence of bound-entangled thermal states for harmonic oscillator systems consisting of an arbitrary number of particles. By explicit calculations of the negativity for different partitions, we find a range of temperatures for which no entanglement can be distilled by means of local operations, despite the system being globally entangled. We offer an interpretation of this result in terms of entanglement-area laws, typical of these systems. Finally, we discuss generalizations of this result to other systems, including spin chains.

Preliminary investigation of mixed adsorbents for the removal of copper and methylene blue from aqueous solutions

With most recent studies being focused on the development of
advanced chemical adsorbents, this paper investigates the possibility of
using two natural low-cost materials for selective adsorption. Multiadsorbent
systems containing tea waste and dolomite have been tested for
their effectiveness in the removal of copper and methylene blue from
aqueous solutions. The effects of contact time, solution pH and
adsorption isotherms on the sorption behaviour were investigated. The
Langmuir and Freundlich isotherms adequately described the adsorption of
copper ions and methylene blue by both materials in different systems.
The highest adsorption capacities for Cu and MB were calculated as 237.7
at pH 4.5 and 150.44 mg.g‒1 at pH 7 for DO and TW+DO respectively. Tea
waste (TW) and dolomite (DO) were characterized by Fourier transform
infrared spectroscopy, scanning electron microscopy and Energy dispersive
X-ray analysis. The removal of Cu and MB by dolomite was mainly via
surface complexation while physisorption was responsible for most of the
Cu and MB adsorption onto tea waste. Identifying the fundamental mechanisms and behaviour is key to the development of practical multi-adsorbent packed columns.

Containing the Nanometer "Pandora-Box": Cross-Layer Design Techniques for Variation Aware Low Power Systems

The demand for richer multimedia services, multifunctional portable devices and high data rates can only been visioned due to the improvement in semiconductor technology. Unfortunately, sub-90 nm process nodes uncover the nanometer Pandora-box exposing the barriers of technology scaling-parameter variations, that threaten the correct operation of circuits, and increased energy consumption, that limits the operational lifetime of today's systems. The contradictory design requirements for low-power and system robustness, is one of the most challenging design problems of today. The design efforts are further complicated due to the heterogeneous types of designs ( logic, memory, mixed-signal) that are included in today's complex systems and are characterized by different design requirements. This paper presents an overview of techniques at various levels of design abstraction that lead to low power and variation aware logic, memory and mixed-signal circuits and can potentially assist in meeting the strict power budgets and yield/quality requirements of future systems.

Pre-charging and DC Fault Ride-Through of Hybri MMC Based HVDC Systems

Compared to half-bridge based MMCs, full-bridge based systems have the advantage of blocking dc fault, but at the expense of increased power semiconductors and power losses. In view of the relationships among ac/dc voltages and currents in full-bridge based MMC with the negative voltage state, this paper provides a detailed analysis on the link between capacitor voltage variation and the maximum modulation index. A hybrid MMC, consisting of mixed half-bridge and full-bridge circuits to combine their respective advantages is investigated in terms of its pre-charging process and transient dc fault ride-through capability. Simulation and experiment results demonstrate the feasibility and validity of the proposed strategy for a full-bridge based MMC and the hybrid MMC.

Computational scheduling methods for integrating plug-in electric vehicles with power systems: a review

Traditional internal combustion engine vehicles are a major contributor to global greenhouse gas emissions and other air pollutants, such as particulate matter and nitrogen oxides. If the tail pipe point emissions could be managed centrally without reducing the commercial and personal user functionalities, then one of the most attractive solutions for achieving a significant reduction of emissions in the transport sector would be the mass deployment of electric vehicles. Though electric vehicle sales are still hindered by battery performance, cost and a few other technological bottlenecks, focused commercialisation and support from government policies are encouraging large scale electric vehicle adoptions. The mass proliferation of plug-in electric vehicles is likely to bring a significant additional electric load onto the grid creating a highly complex operational problem for power system operators. Electric vehicle batteries also have the ability to act as energy storage points on the distribution system. This double charge and storage impact of many uncontrollable small kW loads, as consumers will want maximum flexibility, on a distribution system which was originally not designed for such operations has the potential to be detrimental to grid balancing. Intelligent scheduling methods if established correctly could smoothly integrate electric vehicles onto the grid. Intelligent scheduling methods will help to avoid cycling of large combustion plants, using expensive fossil fuel peaking plant, match renewable generation to electric vehicle charging and not overload the distribution system causing a reduction in power quality. In this paper, a state-of-the-art review of scheduling methods to integrate plug-in electric vehicles are reviewed, examined and categorised based on their computational techniques. Thus, in addition to various existing approaches covering analytical scheduling, conventional optimisation methods (e.g. linear, non-linear mixed integer programming and dynamic programming), and game theory, meta-heuristic algorithms including genetic algorithm and particle swarm optimisation, are all comprehensively surveyed, offering a systematic reference for grid scheduling considering intelligent electric vehicle integration.

Electrochemical promotion of a metal catalyst supported on a mixed-ionic conductor

It has been found that the catalytic activity and selectivity of a metal film deposited on a solid electrolyte could be enhanced dramatically and in a reversible way by applying an electrical current or potential between the metal catalyst and the counter electrode (also deposited on the electrolyte). This phenomenon is know as NEMCA [S. Bebelis, C.G. Vayenas, Journal of Catalysis, 118 (1989) 125-146.] or electrochemical promotion (EP) [J. Prichard, Nature, 343 (1990) 592.] of catalysis. Yttria-doped barium zirconate, BaZr_0.9Y_0.1O_{3 - α} (BZY), a known proton conductor, has been used in this study. It has been reported that proton conducting perovskites can, under the appropriate conditions, act also as oxide ion conductors. In mixed conducting systems the mechanism of conduction depends upon the gas atmosphere that to which the material is exposed. Therefore, the use of a mixed ionic (oxide ion and proton) conducting membrane as a support for a platinum catalyst may facilitate the tuning of the promotional behaviour of the catalyst by allowing the control of the conduction mechanism of the electrolyte. The conductivity of BZY under different atmospheres was measured and the presence of oxide ion conduction under the appropriate conditions was confirmed. Moreover, kinetic experiments on ethylene oxidation corroborated the findings from the conductivity measurements showing that the use of a mixed ionic conductor allows for the tuning of the reaction rate. © 2006 Elsevier B.V. All rights reserved.

Mixed Messages: American Correspondences in Visual and Verbal Practices

Mixed Messages presents and interrogates ten distinct moments from the arts of nineteenth, twentieth and twenty-first century America where visual and verbal forms blend and clash. Charting correspondences concerned with the expression and meaning of human experience, this volume moves beyond standard interdisciplinary theoretical approaches to consider the written and visual artwork in embodied, cognitive, and contextual terms.

Offering a genuinely interdisciplinary contribution to the intersecting fields of art history, avant-garde studies, word-image relations, and literary studies, Mixed Messages takes in architecture, notebooks, poetry, painting, conceptual art, contemporary art, comic books, photographs and installations, ending with a speculative conclusion on the role of the body in the experience of digital mixed media. Each of the ten case studies explores the juxtaposition of visual and verbal forms in a manner that moves away from treating verbal and visual symbols as operating in binary or oppositional systems, and towards a consideration of mixed media, multi-media and intermedia work as brought together in acts of creation, exhibition, reading, viewing, and immersion. The collection advances research into embodiment theory, affect, pragmatist aesthetics, as well as into the continuing legacy of romanticism and of dada, conceptual art and surrealism in an American context.

A realistic evaluation of Early Warning Systems and acute care training in Northern Ireland: findings and recommendations

Statement of purpose The purpose of this concurrent session is to present the main findings and recommendations from a five year study evaluating the implementation of Early Warning Systems (EWS) and the Acute Life-threatening Events: Recognition and Treatment (ALERT) course in Northern Ireland. The presentation will provide delegates with an understanding of those factors that enable and constrain successful implementation of EWS and ALERT in practice in order to provide an impetus for change. Methods The research design was a multiple case study approach of four wards in two hospitals in Northern Ireland. It followed the principles of realist evaluation research which allowed empirical data to be gathered to test and refine RRS programme theory [1]. The stages included identifying the programme theories underpinning EWS and ALERT, generating hypotheses, gathering empirical evidence and refining the programme theories. This approach used a variety of mixed methods including individual and focus group interviews, observation and documentary analysis of EWS compliance data and ALERT training records. A within and across case comparison facilitated the development of mid-range theories from the research evidence. Results The official RRS theories developed from the realist synthesis were critically evaluated and compared with the study findings to develop a mid-range theory to explain what works, for whom in what circumstances. The findings of what works suggests that clinical experience, established working relationships, flexible implementation of protocols, ongoing experiential learning, empowerment and pre-emptive management are key to the success of EWS and ALERT implementation. Each concept is presented as ‘context, mechanism and outcome configurations’ to provide an understanding of how the context impacts on individual reasoning or behaviour to produce certain outcomes. Conclusion These findings highlight the combination of factors that can improve the implementation and sustainability of EWS and ALERT and in light of this evidence several recommendations are made to provide policymakers with guidance and direction for future policy development. References: 1. Pawson R and Tilley N. (1997) Realistic Evaluation. Sage Publications; London Type of submission: Concurrent session Source of funding: Sandra Ryan Fellowship funded by the School of Nursing & Midwifery, Queen’s University of Belfast

Measuring healthcare integration: Operationalization of a framework for a systems evaluation of palliative care structures, processes, and outcomes

BACKGROUND: Healthcare integration is a priority in many countries, yet there remains little direction on how to systematically evaluate this construct to inform further development. The examination of community-based palliative care networks provides an ideal opportunity for the advancement of integration measures, in consideration of how fundamental provider cohesion is to effective care at end of life.

AIM: This article presents a variable-oriented analysis from a theory-based case study of a palliative care network to help bridge the knowledge gap in integration measurement.

DESIGN: Data from a mixed-methods case study were mapped to a conceptual framework for evaluating integrated palliative care and a visual array depicting the extent of key factors in the represented palliative care network was formulated.

SETTING/PARTICIPANTS: The study included data from 21 palliative care network administrators, 86 healthcare professionals, and 111 family caregivers, all from an established palliative care network in Ontario, Canada.

RESULTS: The framework used to guide this research proved useful in assessing qualities of integration and functioning in the palliative care network. The resulting visual array of elements illustrates that while this network performed relatively well at the multiple levels considered, room for improvement exists, particularly in terms of interventions that could facilitate the sharing of information.

CONCLUSION: This study, along with the other evaluative examples mentioned, represents important initial attempts at empirically and comprehensively examining network-integrated palliative care and healthcare integration in general.