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.

A framework for experimental determination of localised vertical pedestrian forces on full-scale structures using wireless attitude and heading reference systems

A major weakness among loading models for pedestrians walking on flexible structures proposed in recent years is the various uncorroborated assumptions made in their development. This applies to spatio-temporal characteristics of pedestrian loading and the nature of multi-object interactions. To alleviate this problem, a framework for the determination of localised pedestrian forces on full-scale structures is presented using a wireless attitude and heading reference systems (AHRS). An AHRS comprises a triad of tri-axial accelerometers, gyroscopes and magnetometers managed by a dedicated data processing unit, allowing motion in three-dimensional space to be reconstructed. A pedestrian loading model based on a single point inertial measurement from an AHRS is derived and shown to perform well against benchmark data collected on an instrumented treadmill. Unlike other models, the current model does not take any predefined form nor does it require any extrapolations as to the timing and amplitude of pedestrian loading. In order to assess correctly the influence of the moving pedestrian on behaviour of a structure, an algorithm for tracking the point of application of pedestrian force is developed based on data from a single AHRS attached to a foot. A set of controlled walking tests with a single pedestrian is conducted on a real footbridge for validation purposes. A remarkably good match between the measured and simulated bridge response is found, indeed confirming applicability of the proposed framework.

Development of a Complex Intervention for Secondary Prevention of Coronary Heart Disease in Primary Care Using the UK Medical Research Council Framework

Objective: To apply the UK Medical Research Council (MRC) framework for development and evaluation of trials of complex interventions to a primary healthcare intervention to promote secondary prevention of coronary heart disease. Study Design: Case report of intervention development. Methods: First, literature relating to secondary prevention and lifestyle change was reviewed. Second, a preliminary intervention was modeled, based on literature findings and focus group interviews with patients (n = 23) and staff (n = 29) from 4 general practices. Participants’ experiences of and attitudes toward key intervention components were explored. Third, the preliminary intervention was pilot-tested in 4 general practices. After delivery of the pilot intervention, practitioners evaluated the training sessions, and qualitative data relating to experiences of the intervention were collected using semistructured interviews with staff (n = 10) and patient focus groups (n = 17). Results: Literature review identified 3 intervention components: a structured recall system, practitioner training, and patient information. Initial qualitative data identified variations in recall system design, training requirements (medication prescribing, facilitating behavior change), and information appropriate to the prospective study participants. Identifying detailed structures within intervention components clarified how the intervention could be tailored to individual practice, practitioner, and patient needs while preserving the theoretical functions of the components. Findings from the pilot phase informed further modeling of the intervention, reducing administrative time, increasing practical content of training, and omitting unhelpful patient information. Conclusion: Application of the MRC framework helped to determine the feasibility and development of a complex intervention for primary care research.

Guest sorption and desorption in the metal-organic framework [Co(INA)(2)] (INA = isonicotinate) - evidence of intermediate phases during desorption

The metal-organic framework [Co(INA)(2)].0.5EtOH (INA = isonicotinate, NC5H4-4-CO2-), 1 was synthesised under solvothermal conditions. Its X-ray crystal structure shows channels containing ethanol guests which are hydrogen-bonded to carboxylate oxygens of the framework. The pyridyl rings of the framework alternate between `open' and `closed' positions along the channels resulting in large variation in the channel cross-sectional area from ca. 1.4 by 2.3 at the narrowest point to 4.9 by 5.3 at the widest. Despite the very small windows, the ethanol guests (of van der Waals diameter ca. 4.2-6.1 Angstrom) may be reversibly desorbed and sorbed into the structure quantitatively, as shown by in situ variable-temperture IR spectroscopy and XRPD. The single-crystal structure of the desolvated form [Co(INA)(2)]2 shows that there is no change in the overall connectivity on desolvation, but the rotational positions of the pyridine rings are altered. This suggests that pyridyl rotation may occur to allow guests to pass in and out. When the synthesis was conducted in 1-propanol solvent [Co(INA)(2)].0.5Pr(n)OH.H2O 3, was obtained, and a single-crystal X-ray structure revealed the same overall connectivity as in 1 but with pyridine rings disordered over closed and open positions. There was no evidence of included guests from X-ray crystallography, suggesting that they are also highly disordered. Variable-temperature XRPD performed on bulk samples showed peaks which were unsymmetrical and exhibited shoulders, suggesting that for each pattern obtained the material actually consisted of several closely-related phases. The movements of the peaks during desolvation showed the presence of intermediate phases before the final desolvated product was formed. The peak positions of the intermediate phases matched more closely with the calculated pattern for 3 than with 1 or 2, suggesting that they may have disordered structures similar to 3. The results also suggest that the intermediate phase represents an initial increase in volume before a larger decrease in volume occurs to give the final desolvated material.

In silico prediction of the effects of mutations in the human UDP-galactose 4'-epimerase gene:Towards a predictive framework for type III galactosemia

The enzyme UDP-galactose 4'-epimerase (GALE) catalyses the reversible epimerisation of both UDP-galactose and UDP-N-acetyl-galactosamine. Deficiency of the human enzyme (hGALE) is associated with type III galactosemia. The majority of known mutations in hGALE are missense and private thus making clinical guidance difficult. In this study a bioinformatics approach was employed to analyse the structural effects due to each mutation using both the UDP-glucose and UDP-N-acetylglucosamine bound structures of the wild-type protein. Changes to the enzyme's overall stability, substrate/cofactor binding and propensity to aggregate were also predicted. These predictions were found to be in good agreement with previous in vitro and in vivo studies when data was available and allowed for the differentiation of those mutants that severely impair the enzyme's activity against UDP-galactose. Next this combination of techniques were applied to another twenty-six reported variants from the NCBI dbSNP database that have yet to be studied to predict their effects. This identified p.I14T, p.R184H and p.G302R as likely severely impairing mutations. Although severely impaired mutants were predicted to decrease the protein's stability, overall predicted stability changes only weakly correlated with residual activity against UDP-galactose. This suggests other protein functions such as changes in cofactor and substrate binding may also contribute to the mechanism of impairment. Finally this investigation shows that this combination of different in silico approaches is useful in predicting the effects of mutations and that it could be the basis of an initial prediction of likely clinical severity when new hGALE mutants are discovered.

An application of bi-directional evolutionary structural optimisation for optimising energy absorbing structures using a material damage model

The Bi-directional Evolutionary Structural Optimisation (BESO) method is a numerical topology optimisation method developed for use in finite element analysis. This paper presents a particular application of the BESO method to optimise the energy absorbing capability of metallic structures. The optimisation objective is to evolve a structural geometry of minimum mass while ensuring that the kinetic energy of an impacting projectile is reduced to a level which prevents perforation. Individual elements in a finite element mesh are deleted when a prescribed damage criterion is exceeded. An energy absorbing structure subjected to projectile impact will fail once the level of damage results in a critical perforation size. It is therefore necessary to constrain an optimisation algorithm from producing such candidate solutions. An algorithm to detect perforation was implemented within a BESO framework which incorporated a ductile material damage model.

In pursuit of regulatory compliance: a study of planning enforcement structures in Northern Ireland

As devolution expands across the UK, Northern Ireland (NI) is witnessing the development of new architecture to devolve planning powers. With serious criticism targeted at the legislative provisions for enforcement, this investigation endeavours to assess the robustness of the planning framework through a synergy of theory, law and practice. The paper demonstrates the value of theory in not only supplying a lens that allows both legislative frameworks and praxis to be deconstructed, but also in enabling the identification and scrutiny of underlying problems that pervade the system.

A new statistical framework for the quantification of covariate associations with species distributions

Identifying processes that shape species geographical ranges is a prerequisite for understanding environmental change. Currently, species distribution modelling methods do not offer credible statistical tests of the relative influence of climate factors and typically ignore other processes (e.g. biotic interactions and dispersal limitation). We use a hierarchical model fitted with Markov Chain Monte Carlo to combine ecologically plausible niche structures using regression splines to describe unimodal but potentially skewed response terms. We apply spatially explicit error terms that account for (and may help identify) missing variables. Using three example distributions of European bird species, we map model results to show sensitivity to change in each covariate. We show that the overall strength of climatic association differs between species and that each species has considerable spatial variation in both the strength of the climatic association and the sensitivity to climate change. Our methods are widely applicable to many species distribution modelling problems and enable accurate assessment of the statistical importance of biotic and abiotic influences on distributions.

Local Conventions in Game Play in an Evolving Dual Social Network Framework

People usually perform economic interactions within the social setting of a small group, while they obtain relevant information from a broader source. We capture this feature with a dynamic interaction model based on two separate social networks. Individuals play a coordination game in an interaction network, while updating their strategies using information from a separate influence network through which information is disseminated. In each time period, the interaction and influence networks co-evolve, and the individuals’ strategies are updated through a modified naive learning process. We show that both network structures and players’ strategies always reach a steady state, in which players form fully connected groups and converge to local conventions. We also analyze the influence exerted by a minority group of strongly opinionated players on these outcomes.

A bond model for DEM simulation of cementitious materials and deformable structures

There is an increasing use of the discrete element method (DEM) to study cemented (e.g. concrete and rocks) and sintered particulate materials. The chief advantage of the DEM over continuum based techniques is that it does not make assumptions about how cracking and fragmentation initiate and propagate, since the DEM system is naturally discontinuous. The ability for the DEM to produce a realistic representation of a cemented granular material depends largely on the implementation of an inter-particle bonded contact model. This paper presents a new bonded contact model based on the Timoshenko beam theory which considers axial, shear and bending behaviour of the bond. The bond model was first verified by simulating both the bending and dynamic response of a simply supported beam. The loading response of a concrete cylinder was then investigated and compared with the Eurocode equation prediction. The results show significant potential for the new model to produce satisfactory predictions for cementitious materials. A unique feature of this model is that it can also be used to accurately represent many deformable structures such as frames and shells, so that both particles and structures or deformable boundaries can be described in the same DEM framework. 

The BRUTUS Automatic Cryptanalytic Framework: Testing CAESAR Authenticated Encryption Candidates for Weaknesses

This report summarizes our results from security analysis covering all 57 competitions for authenticated encryption: security, applicability, and robustness (CAESAR) first-round candidates and over 210 implementations. We have manually identified security issues with three candidates, two of which are more serious, and these ciphers have been withdrawn from the competition. We have developed a testing framework, BRUTUS, to facilitate automatic detection of simple security lapses and susceptible statistical structures across all ciphers. From this testing, we have security usage notes on four submissions and statistical notes on a further four. We highlight that some of the CAESAR algorithms pose an elevated risk if employed in real-life protocols due to a class of adaptive-chosen-plaintext attacks. Although authenticated encryption with associated data are often defined (and are best used) as discrete primitives that authenticate and transmit only complete messages, in practice, these algorithms are easily implemented in a fashion that outputs observable ciphertext data when the algorithm has not received all of the (attacker-controlled) plaintext. For an implementor, this strategy appears to offer seemingly harmless and compliant storage and latency advantages. If the algorithm uses the same state for secret keying information, encryption, and integrity protection, and the internal mixing permutation is not cryptographically strong, an attacker can exploit the ciphertext–plaintext feedback loop to reveal secret state information or even keying material. We conclude that the main advantages of exhaustive, automated cryptanalysis are that it acts as a very necessary sanity check for implementations and gives the cryptanalyst insights that can be used to focus more specific attack methods on given candidates.

Localized structures in complex plasmas in the presence of a magnetic field

In this work, the general framework in which fits our investigation is that of modeling the dynamics of dust grains therein dusty plasma (complex plasma) in the presence of electromagnetic fields. The generalized discrete complex Ginzburg-Landau equation (DCGLE) is thus obtained to model discrete dynamical structure in dusty plasma with Epstein friction. In the collisionless limit, the equation reduces to the modified discrete nonlinear Schrödinger equation (MDNLSE). The modulational instability phenomenon is studied and we present the criterion of instability in both cases and it is shown that high values of damping extend the instability region. Equations thus obtained highlight the presence of soliton-like excitation in dusty plasma. We studied the generation of soliton in a dusty plasma taking in account the effects of interaction between dust grains and theirs neighbours. Numerical simulations are carried out to show the validity of analytical approach.