Experiences in developing a micro-payment system for peer-to-peer networks

Micro-payment systems are an important part of peer-to-peer (P2P) networks and address the "free-rider" problem in most existing content sharing systems. To address this issue, the authors have developed a new micro-payment system for content sharing in P2P networks called P2P-Netpay. This is an offline, debit based protocol that provides a secure, flexible, usable and reliable credit service. This article compares micro-payment with non-micro-payment credit systems for file sharing applications and finds that this approach liberates the "free-rider" problem. The authors analyse the heuristic evaluation performed by a set of evaluators and present directions for research aiming to improve the overall satisfaction and efficiency of the proposed model.

An era of governance through performance management - New Labour's National Health Service from 1999 to 2010

In 1997, the New Labour government inherited a ‘crisis’ in the UK National Health Service from the outgoing Conservative government. To address this perceived crisis, New Labour offered investment and, contrary to expectations, further neo-liberal health service reforms. In particular, the government extended the scope of performance management beyond financial numbers to encompass all aspects of managerial and organisational performance. Drawing on an analytics of government framework, this paper demonstrates how reforms were framed and given meaning through a framework of hierarchical accountability and centralised control. These panoptical arrangements relied on performance-management technologies of targets and ratings, which were linked to patient choice and a prospective funding system called ‘Payment by Results’. In turn, these top-down technologies disciplined knowledge, identity, and visibility and control of practice.

Issues in developing e-health systems: an Australian case study

Over the last few years, perceptions of the importance of eHealth have increased rapidly, together with the use of IS&T in the delivery of health and social services. Although “e” approaches to health and social services have much potential, they are not panaceas, and the use of new technologies in improving the efficiency and effectiveness of such systems cannot be considered in isolation from their wider context. eHealth systems remain complex socio-organisational systems and, as we will argue and illustrate through this case study, require that a balanced approach to feasibility and desirability analysis be taken.

The case study in this paper describes a feasibility study into the potential effectiveness of a smartdevice-based electronic data collection and payment system which was proposed for the provision of disability services. A key finding of the study was that the most significant impediment to such a system was the highly diffused, fragmented, interlocking organisational structure of the social service administration itself. Rather than raise issues specific to the implementation or diffusion of new technologies in designing e-health services, it raised issues associated with decision making and control in such an environment, and with the design of the underlying organisational system: for service provision, the level of detail required in the service data, and the locus of decision-making power among the stakeholders.

In our account we illustrate the existence of multiple, incommensurate but valid perceptions of the human service provision problem, and discuss the implications for developers or managers of information systems in the arena of e-health or governance. We examine this environment from sociological and information systems perspectives, and confirm the usefulness of socio-organisational approaches in understanding such contexts.

Serotonin discontinuation syndrome following utero exposure to antidepressant medication : prospective controlled study

Objectives: The aim of the present study was to examine neonatal symptoms previously reported to be associated with exposure to antidepressant medication in late pregnancy in a group of infants exposed to antidepressants, using a prospective and controlled design.

Method: A prospective case-control study recruited 27 pregnant women taking antidepressant medication and 27 matched controls who were not taking antidepressant medication in pregnancy. Of the 27 women taking medication, 25 remained on medication in the third trimester and, of these, 23 women had complete data available. In pregnancy and after delivery women were assessed with the Beck Depression Inventory-II and a purpose-designed questionnaire. After delivery mothers were asked a set of nine questions pertaining to symptoms of discontinuation in their newborn and questions about pregnancy and delivery complications.

Results: There was an increased risk of discontinuation symptoms in neonates exposed to antidepressant medication in late pregnancy and an association with higher dose medication. The study group were found to be significantly more likely to display behaviour such as crying, jitteriness, tremor, feeding, reflux and sneezing and sleep for <3 h after a feed. They also had significantly higher rates of jaundice and admissions to the special care nursery.

Conclusions: Exposure to antidepressants in late pregnancy is associated with a range of symptoms in the neonate that are consistent with the effects of exposure to antidepressants in late pregnancy. The clusters of symptoms most highly correlated are the gastrointestinal and central nervous system symptoms. These finding helps to identify the common symptoms associated with a neonatal serotonin discontinuation syndrome.

Integrity of the circadian time-keeping system in chronic fatigue syndrome

Chronic Fatigue Syndrome (CFS) is a debilitating condition in which severe, ongoing fatigue is the most prominent of a complex of somatic, psychological and neuropsychological symptoms. The aetiology of CFS remains uncertain and, to date, efforts to distinguish a clear pathophysiological profile for the disorder have been unsuccessful. Current evidence suggests that, rather than being a discrete disease entity with a single cause, CFS is a clinical condition resulting from the interaction of a number of pathophysiological factors, including acute infections, stress and psychiatric disorder. Recently, there has been some interest in the proposition that disordered circadian time-keeping may contribute to the development and/or course of the illness. The rationale for the investigation of circadian factors in CFS is based on the fact that disorders known to be associated with circadian dysregulation, such as jet lag and shiftwork related syndromes have a high degree of symptomatological overlap with CFS. Also, the presence of circadian disturbance could account, in part, for other phenomenological aspects of CFS, including the high rates of comorbid affective disturbance, and the reports of low-level immune dyregulation among sufferers. While several recent studies have produced some evidence of chronobiological dysregulation in CFS patients, much work remains before conclusions can be drawn about the presence, nature and clinical significance of circadian disturbance in CFS. This thesis describes a series of studies that were designed to systematically investigate: 1. whether CFS is associated with a state of circadian dysregulation, and 2. whether circadian dysregulation contributes significantly to the symptomatology of CFS. The first of the 5 studies reported here compared the circadian patterns of sleep-activity of CFS sufferers with those of healthy controls. Results indicated that CFS patients' sleep-activity cycles were significantly phase delayed compared to controls, and that some aspects of their circadian profiles of sleep-activity were related to some measures of sleep-disturbance and well-being. Studies 2 and 3 investigated the relationship between rhythms of sleep-wake and core temperature in CFS patients and healthy controls. The major finding from these studies was that sleep-wake and core temperature rhythms appear to be less effectively synchronised. Further evidence was collected that suggested that there was a relationship between circadian parameters and symptom measures in the CFS group. While this indicated that circadian dysregulation is linked in some way to the symptoms of CFS, assessment of the actual clinical significance of circadian disturbances required the use of a prospective methodology. The final two studies, therefore, report on a placebo-controlled trial of clinical interventions that were designed to restore circadian integrity to CFS patients, in order to see whether this would lead to a reduction in symptom number or severity. Results indicated that, although patients experienced improvements across a range of measures of symptoms and functional capacity, these were small in magnitude, of unlikely clinical significance, and no greater, in general, to improvements reported by patients who underwent placebo treatment. These results, along with those of the earlier studies, are discussed with respect to their implications regarding the presence and significance of circadian dysregulation. It is concluded that, while they provide evidence that CFS is associated with a degree of both internal and external circadian desynchrony, these findings suggest that circadian dysregulation is likely to be only a peripheral, contributor to the processes that generate and maintain the symptom complex. These findings are discussed with respect to how they contribute to our overall understanding of this multi-dimensional condition, and the implications they have for the continuing effort to investigate the causes and treatment of CFS.

The role of the medical emergency team in end-of-life care : a multicenter, prospective, observational study

Objective: To investigate the role of medical emergency teams in end-of-life care planning.

Design: One month prospective audit of medical emergency team calls.

Setting: Seven university-affiliated hospitals in Australia, Canada, and Sweden.

Patients: Five hundred eighteen patients who received a medical emergency team call over 1 month.

Interventions: None.

Measurements and Main Results: There were 652 medical emergency team calls in 518 patients, with multiple calls in 99 (19.1%) patients. There were 161 (31.1%) patients with limitations of medical therapy during the study period. The limitation of medical therapy was instituted in 105 (20.3%) and 56 (10.8%) patients before and after the medical emergency team call, respectively. In 78 patients who died with a limitation of medical therapy in place, the last medical emergency team review was on the day of death in 29.5% of patients, and within 2 days in another 28.2%. Compared with patients who did not have a limitation of medical therapy, those with a limitation of medical therapy were older (80 vs. 66 yrs; p < .001), less likely to be male (44.1% vs. 55.7%; p .014), more likely to be medical admissions (70.8% vs. 51.3%; p < .001), and less likely to be admitted from home (74.5% vs. 92.2%, p < .001). In addition, those with a limitation of medical therapy were less likely to be discharged home (22.4% vs. 63.6%; p < .001) and more likely to die in hospital (48.4% vs. 12.3%; p < .001). There was a trend for increased likelihood of calls associated with limitations of medical therapy to occur out of hours (51.0% vs. 43.8%, p .089).

Conclusions: Issues around end-of-life care and limitations of medical therapy arose in approximately one-third of calls, suggesting a mismatch between patient needs for end-of-life care and resources at participating hospitals. These calls frequently occur in elderly medical patients and out of hours. Many such patients do not return home, and half die in hospital. There is a need for improved advanced care planning in our hospitals, and to confirm our findings in other organizations.

Development of an evidence-based scoring system (HF-IS) to assess the quality of heart failure programmes for patients postdischarge from hospital

Aim.  The aim of this study was to develop a potential scoring algorithm for interventions in a chronic heart failure management programme – the Heart Failure Intervention Score – to facilitate quality improvement and programme auditing.

Background.  The overall efficacy of chronic heart failure management programmes has been demonstrated in several meta-analyses. However, meta-analyses did not determine individual interventions in a programme that resulted in beneficial patient outcomes.

Design.  A prospective cross-sectional survey design.

Method.  All chronic heart failure management programmes in Australia (n = 62), identified by a national register, were surveyed to determine programme characteristics and interventions.

Results.  Of the 62 national chronic heart failure management programmes, 48 (77%) completed the survey and 27 individual interventions were identified. Variability in the use of the key interventions was common among the programmes. Each intervention was given an arbitrary weighted score according to the level of supportive evidence available and a total score calculated. Programmes were then categorised into low or high complexity based on several interventions implemented and their weighted score. A total score of ≥190 (median = 178, interquartile range 176–195) was used to divide programmes into two groups. Nine programmes were categorised into high Heart Failure Intervention Score group and majority of these were based in the acute hospital setting (78%). In the low Heart Failure Intervention Score group, there were 39 programmes of which there were a higher proportion of community-based programmes (38%) and programmes in small community hospitals (10%).

Conclusion.  The Heart Failure Intervention Score provides a potential evidence-based quality improvement tool through which a set of minimum standards can be developed. Implementation of the Heart Failure Intervention Score provides guidance to programme coordinators to enable monitoring of standards of heart failure programmes, which may potentially result in better patient outcomes.

Prospective memory in a virtual environment: beneficial effects of cue saliency

Prospective Memory (PM) research focuses on how the cognitive system successfully encodes and retains an intention, before retrieving it at a particular future time or in response to a particular future event. Previous work using 2D text stimuli has shown that increasing the saliency of the retrieval cue can improve performance. In this work, we investigated the effect of increased cue saliency in a more ecologically valid 3D virtual environment. The findings indicate that increased perceptual saliency of the cue does benefit PM in a dynamic and visually rich environment but that the impact of cue saliency does not interact with attentional load.

Association between surgical indications, operative risk, and clinical outcome in infective endocarditis: a prospective study from the International Collaboration on Endocarditis.

Use of surgery for the treatment of infective endocarditis (IE) as related to surgical indications and operative risk for mortality has not been well defined.

Symptoms and distress in children with advanced cancer: prospective patient-reported outcomes from the PediQUEST Study

PURPOSE: Thousands of children are living with advanced cancer; yet patient-reported outcomes (PROs) have rarely been used to describe their experiences. We aimed to describe symptom distress in 104 children age 2 years or older with advanced cancer enrolled onto the Pediatric Quality of Life and Evaluation of Symptoms Technology (PediQUEST) Study (multisite clinical trial evaluating an electronic PRO system).

METHODS: Symptom data were collected using age- and respondent-adapted versions of the PediQUEST Memorial Symptom Assessment Scale (PQ-MSAS) at most once per week. Clinical and treatment data were obtained from medical records. Individual symptom scores were dichotomized into high/low distress. Determinants of PQ-MSAS scores were explored using linear mixed-effects models.

RESULTS: During 9 months of follow-up, PQ-MSAS was administered 920 times: 459 times in teens (99% self-report), 249 times in children ages 7 to 12 years (96% child/parent report), and 212 times in those ages 2 to 6 years (parent reports). Common symptoms included pain (48%), fatigue (46%), drowsiness (39%), and irritability (37%); most scores indicated high distress. Among the 73 PQ-MSAS surveys administered in the last 12 weeks of life, pain was highly prevalent (62%; 58% with high distress). Being female, having a brain tumor, experiencing recent disease progression, and receiving moderate- or high-intensity cancer-directed therapy in the prior 10 days were associated with worse PQ-MSAS scores. In the final 12 weeks of life, receiving mild cancer-directed therapy was associated with improved psychological PQ-MSAS scores.

CONCLUSION: Children with advanced cancer experience high symptom distress. Strategies to promote intensive symptom management are indicated, especially with disease progression or administration of intensive treatments.

Cancer 2015: a longitudinal whole-of-system study of genomic cancer medicine

Genomic cancer medicine promises revolutionary change in oncology. The impacts of 'personalized medicine', based upon a molecular classification of cancer and linked to targeted therapies, will extend from individual patient outcomes to the health economy at large. To address the 'whole-of-system' impact of genomic cancer medicine, we have established a prospective cohort of patients with newly diagnosed cancer in the state of Victoria, Australia, about whom we have collected a broad range of clinical, demographic, molecular, and patient-reported data, as well as data on health resource utilization. Our goal is to create a model for investigating public investment in genomic medicine that maximizes the cost:benefit ratio for the Australian community at large.

A proposed roadmap to optimise the adjudication of complex payment disputes in Australia

In Australia, statutory construction adjudication has recently received a lot of criticism due to the increasing amount of determinations that have been quashed upon judicial review, and anecdotal evidence from some quarters showing dissatisfaction with the quality of adjudication decisions. Such criticism is particularly aimed at adjudications of large and technically and legally complex payment disputes, where adjudicators are under pressure to consider substantial volumes of submissions in very tight timeframes. More specifically, criticisms have been directed at, inter alia, adjudicator’s regulations, procedural fairness, jurisdictional powers and finality of decisions. This paper reviews the measures to improve the quality of adjudications of complex payment disputes then proposes a roadmap by selecting the Qld model as a benchmark but suggesting further improvements identified and explained via specific steps or pit stops. The pit stops include criteria for timeframes of complex claims, appointment, regulation and powers of adjudicators and a review system on the merits to control the quality of adjudication decisions replicating the Singapore model. The findings remain as blunt instruments and deemed as hypotheses to inform subsequent empirical research which the authors are currently undertaking to further investigate, strengthen and validate the findings of this study in order to propose a reliable and useful guide to any parliament seeking to optimise its statutory adjudication to effectively deal with complex payment disputes.