Impact of different health systems on the burden of type 2 diabetes in two populations

Objectives: Health policy directs the management of patients with chronic disease in a country, but evaluating nationwide policies is difficult, not least because of the absence of suitable comparators. This paper examines the management of patients with type 2 diabetes in two demographically comparable populations with different health care systems to see if this represents a viable approach to evaluation.

Methods: A secondary analysis of centralized prescribing databases for 2010 was undertaken to compare the levels and costs of care of patients with type 2 diabetes in Northern Ireland’s National Health Service (NHS) (NI, n = 1.8 million) which has structured care, financial incentives related to diabetes care and an emphasis on generic prescribing, with that of the Republic of Ireland (ROI, n = 4.3 million) where management of diabetes care is guided solely by clinical and other guidelines.

Results: The prevalence of treated type 2 diabetes was 3.59% in NI and 3.09% in ROI, but there were similar and high levels of prescribing of secondary cardiovascular medications. Medication costs per person for anti-diabetic, anti-obesity and cardiovascular medication were 46% higher in ROI than NI, due to differences in levels of generic prescribing.

Conclusions: These different health care systems appear to be producing similar levels of care for patients with type 2 diabetes, although at different levels of cost. The findings question the need for financial incentives in NI and highlight the large cost savings potentially accruing from a greater shift to generic prescribing in ROI. Cross-country comparison, though not without difficulties, may prove a useful adjunct to within-country analysis of policy impact.

Young People and Mental Health, Policy and Research Review

This brief focuses on issues relating to young people’s mental health. It draws on published research evidence and discussion at a Roundtable event organised by YouthAction Northern Ireland (YANI) and ARK and held in December 2012. Roundtable participants included officials from a number of government departments, Health Trusts, representatives from a range of NGOs, academics, and young people from YouthAction Northern Ireland’s Right Here Fermanagh
project and Young Men Talking Project who opened the debate with a contribution on what they think is important for young people’s mental health. The event was conducted under the anonymity of reporting allowed under the Chatham House Rule to encourage open debate.

Promoting Community Renewable Energy in a Corporate Energy World

Small-scale, decentralized and community-owned renewable energy is widely acknowledged to be a desirable feature of low carbon futures, but faces a range of challenges in the context of conventional, centralized energy systems. This paper draws on transition frameworks to investigate why the UK has been an inhospitable context for community-owned renewables and assesses whether anything fundamental is changing in this regard. We give particular attention to whether political devolution, the creation of elected governments for Scotland, Wales and Northern Ireland, has affected the trajectory of community renewables. Our analysis notes that devolution has increased political attention to community renewables, including new policy targets and support schemes. However, these initiatives are arguably less important than the persistence of key features of socio-technical regimes: market support systems for renewable energy and land-use planning arrangements that systemically favour major projects and large corporations, and keep community renewables to the margins. There is scope for rolling out hybrid pathways to community renewables, via joint ownership or through community benefit funds, but this still positions community energy as an adjunct to energy pathways dominated by large, corporate generation facilities

Multi-bubble sonoluminescence: Laboratory curiosity, or real world application?

Sonoluminescence (SL) involves the conversion of mechanical [ultra]sound energy into light. Whilst the phenomenon is invariably inefficient, typically converting just 10^-4 of the incident acoustic energy into photons, it is nonetheless extraordinary, as the resultant energy density of the emergent photons exceeds that of the ultrasonic driving field by a factor of some 10 ¹². Sonoluminescence has specific [as yet untapped] advantages in that it can be effected at remote locations in an essentially wireless format. The only [usual] requirement is energy transduction via the violent oscillation of microscopic bubbles within the propagating medium. The dependence of sonoluminescent output on the generating sound field's parameters, such as pulse duration, duty cycle, and position within the field, have been observed and measured previously, and several relevant aspects are discussed presently. We also extrapolate the logic from a recently published analysis relating to the ensuing dynamics of bubble 'clouds' that have been stimulated by ultrasound. Here, the intention was to develop a relevant [yet computationally simplistic] model that captured the essential physical qualities expected from real sonoluminescent microbubble clouds. We focused on the inferred temporal characteristics of SL light output from a population of such bubbles, subjected to intermediate [0.5-2MPa] ultrasonic pressures. Finally, whilst direct applications for sonoluminescent light output are thought unlikely in the main, we proceed to frame the state-of-the- art against several presently existing technologies that could form adjunct approaches with distinct potential for enhancing present sonoluminescent light output that may prove useful in real world [biomedical] applications.

2011-Application of ultrasound for sonodynamic photocatalysis

Ultrasound has long been recognized as a means of effecting change at the cellular and tissue levels [1-3], which may be enhanced in the presence of photosensitive agents [4-6]. During insonation, the presence of bubbles can also play a role, creating strong microstreaming effects in solution and in more dramatic circumstances leading to the formation of energetic microjets [7], plasmas [8], and the production of other highly reactive species [9]. Such sonodynamic activity has generated particular excitement in the medical community as it Moreover the dual role for microbubbles as both an adjunct to therapy and a diagnostic echogenicity enhancer has seen industry take a proactive role in their development. In the present paper we studied the role of ultrasound driven sonoluminescent light on the degradation of a fluorescent test species (rhodamine) in the presence of an archetypal photocatalyst material, TiO ₂, with a view to exploring its exploitation potential for downstream medical applications. We found that, whilst the efficiency of this process is seen to be low compared with conventional ultra-violet sources, we advocate the further exploration of the sonoluminescent approach given its potential for non-invasive applications. A strategy for enhancing the effect is also suggested. 

Review of Legislation and Policy Guidance relating to Adult Social Care in Northern Ireland

Introduction and Background

This research was undertaken by an international team of academics from Queen’s University, Belfast, Leeds University and Penn State University (USA) who have examined models of adult social care provision across thirteen jurisdictions. The aim of this research is to present the Commissioner for Older People in Northern Ireland (COPNI) with possible options for legal reform to adult social care provision for older people in Northern Ireland.

Project Objectives

The agreed objectives of this research were to provide:
• Identification of gaps and issues surrounding the current legislative framework including policy provision for adult social care in Northern Ireland.
• Comparison of Northern Ireland with best practice in other jurisdictions to include (but not be limited to): England and Wales, Republic of Ireland, Scotland and at least two other international examples; Recommendations, based on the above, as to whether there is a need for legislative reform – provision of suggestions other than legislative change (if applicable).
• Recommendations or options based on the above, on how to best change the current framework in Northern Ireland to provide better support outcomes for older people.
• Stakeholder engagement via roundtable event to discuss outcomes/ recommendations.

Structure of Report

The findings from this research are based on an international review of adult social care in the local, national and international contexts. The report will, therefore, firstly present the key recommendations for Northern Ireland which have emerged from a systematic examination and review of adult social care in diverse jurisdictions. Each jurisdiction is then examined in the context of legislative and policy provision and examples of best practice are provided. The final section of the report then compares Northern Ireland to best practice from each of these aforementioned jurisdictions and the discussion entails the background to the report’s final Recommendations. The recommendations in this report are thus directly linked in with the evidence we have gathered across different countries with contrasting systems of welfare.

Clinical and Cost-Effectiveness of Procalcitonin Test for Prodromal Meningococcal Disease-A Meta-Analysis

BACKGROUND: Despite vaccines and improved medical intensive care, clinicians must continue to be vigilant of possible Meningococcal Disease in children. The objective was to establish if the procalcitonin test was a cost-effective adjunct for prodromal Meningococcal Disease in children presenting at emergency department with fever without source.

METHODS AND FINDINGS: Data to evaluate procalcitonin, C-reactive protein and white cell count tests as indicators of Meningococcal Disease were collected from six independent studies identified through a systematic literature search, applying PRISMA guidelines. The data included 881 children with fever without source in developed countries.The optimal cut-off value for the procalcitonin, C-reactive protein and white cell count tests, each as an indicator of Meningococcal Disease, was determined. Summary Receiver Operator Curve analysis determined the overall diagnostic performance of each test with 95% confidence intervals. A decision analytic model was designed to reflect realistic clinical pathways for a child presenting with fever without source by comparing two diagnostic strategies: standard testing using combined C-reactive protein and white cell count tests compared to standard testing plus procalcitonin test. The costs of each of the four diagnosis groups (true positive, false negative, true negative and false positive) were assessed from a National Health Service payer perspective. The procalcitonin test was more accurate (sensitivity=0.89, 95%CI=0.76-0.96; specificity=0.74, 95%CI=0.4-0.92) for early Meningococcal Disease compared to standard testing alone (sensitivity=0.47, 95%CI=0.32-0.62; specificity=0.8, 95% CI=0.64-0.9). Decision analytic model outcomes indicated that the incremental cost effectiveness ratio for the base case was £-8,137.25 (US $ -13,371.94) per correctly treated patient.

CONCLUSIONS: Procalcitonin plus standard recommended tests, improved the discriminatory ability for fatal Meningococcal Disease and was more cost-effective; it was also a superior biomarker in infants. Further research is recommended for point-of-care procalcitonin testing and Markov modelling to incorporate cost per QALY with a life-time model.

Predicting conversion to dementia in a memory clinic: A standard clinical approach compared with an empirically defined clustering method (latent profile analysis) for mild cognitive impairment subtyping

Introduction
Mild cognitive impairment (MCI) has clinical value in its ability to predict later dementia. A better understanding of cognitive profiles can further help delineate who is most at risk of conversion to dementia. We aimed to (1) examine to what extent the usual MCI subtyping using core criteria corresponds to empirically defined clusters of patients (latent profile analysis [LPA] of continuous neuropsychological data) and (2) compare the two methods of subtyping memory clinic participants in their prediction of conversion to dementia.

Methods
Memory clinic participants (MCI, n = 139) and age-matched controls (n = 98) were recruited. Participants had a full cognitive assessment, and results were grouped (1) according to traditional MCI subtypes and (2) using LPA. MCI participants were followed over approximately 2 years after their initial assessment to monitor for conversion to dementia.

Results
Groups were well matched for age and education. Controls performed significantly better than MCI participants on all cognitive measures. With the traditional analysis, most MCI participants were in the amnestic multidomain subgroup (46.8%) and this group was most at risk of conversion to dementia (63%). From the LPA, a three-profile solution fit the data best. Profile 3 was the largest group (40.3%), the most cognitively impaired, and most at risk of conversion to dementia (68% of the group).

Discussion
LPA provides a useful adjunct in delineating MCI participants most at risk of conversion to dementia and adds confidence to standard categories of clinical inference.

Search filters: mapping the literature using a novel form of content analysis.

Background: Search filters are combinations of words and phrases designed to retrieve an optimal set of records on a particular topic (subject filters) or study design (methodological filters). Information specialists are increasingly turning to reusable filters to focus their searches. However, the extent of the academic literature on search filters is unknown. We provide a broad overview to the academic literature on search filters.
Objectives: To map the academic literature on search filters from 2004 to 2015 using a novel form of content analysis.
Methods: We conducted a comprehensive search for literature between 2004 and 2015 across eight databases using a subjectively derived search strategy. We identified key words from titles, grouped them into categories, and examined their frequency and co-occurrences.
Results: The majority of records were housed in Embase (n = 178) and MEDLINE (n = 154). Over the last decade, both databases appeared to exhibit a bimodal distribution with the number of publications on search filters rising until 2006, before dipping in 2007, and steadily increasing until 2012. Few articles appeared in social science databases over the same time frame (e.g. Social Services Abstracts, n = 3).
Unsurprisingly, the term ‘search’ appeared in most titles, and quite often, was used as a noun adjunct for the word 'filter' and ‘strategy’. Across the papers, the purpose of searches as a means of 'identifying' information and gathering ‘evidence’ from 'databases' emerged quite strongly. Other terms relating to the methodological assessment of search filters, such as precision and validation, also appeared albeit less frequently.
Conclusions: Our findings show surprising commonality across the papers with regard to the literature on search filters. Much of the literature seems to be focused on developing search filters to identify and retrieve information, as opposed to testing or validating such filters. Furthermore, the literature is mostly housed in health-related databases, namely MEDLINE, CINAHL, and Embase, implying that it is medically driven. Relatively few papers focus on the use of search filters in the social sciences.

Non-invasive ventilation for cystic fibrosis.

Non-invasive ventilation may be a means to temporarily reverse or slow the progression of respiratory failure in cystic fibrosis. To compare the effect of non-invasive ventilation versus no non-invasive ventilation in people with cystic fibrosis. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. We searched the reference lists of each trial for additional publications possibly containing other trials.Most recent search: 22 February 2013. Randomised controlled trials comparing a form of pressure preset or volume preset non-invasive ventilation to no non-invasive ventilation in people with acute or chronic respiratory failure in cystic fibrosis. Three reviewers independently assessed trials for inclusion criteria and methodological quality, and extracted data. Fifteen trials were identified; seven trials met the inclusion criteria with a total of 106 participants. Six trials evaluated single treatment sessions and one evaluated a six-week intervention.Four trials (79 participants) evaluated non-invasive ventilation for airway clearance compared with an alternative chest physiotherapy method and showed that airway clearance may be easier with non-invasive ventilation and people with cystic fibrosis may prefer it. We were unable to find any evidence that NIV increases sputum expectoration, but it did improve some lung function parameters.Three trials (27 participants) evaluated non-invasive ventilation for overnight ventilatory support, measuring lung function, validated quality of life scores and nocturnal transcutaneous carbon dioxide. Due to the small numbers of participants and statistical issues, there were discrepancies in the results between the RevMan and the original trial analyses. No clear differences were found between non-invasive ventilation compared with oxygen or room air except for exercise performance, which significantly improved with non-invasive ventilation compared to room air over six weeks. Non-invasive ventilation may be a useful adjunct to other airway clearance techniques, particularly in people with cystic fibrosis who have difficulty expectorating sputum. Non-invasive ventilation, used in addition to oxygen, may improve gas exchange during sleep to a greater extent than oxygen therapy alone in moderate to severe disease. These benefits of non-invasive ventilation have largely been demonstrated in single treatment sessions with small numbers of participants. The impact of this therapy on pulmonary exacerbations and disease progression remain unclear. There is a need for long-term randomised controlled trials which are adequately powered to determine the clinical effects of non-invasive ventilation in cystic fibrosis airway clearance and exercise.

Identification of diagnostic biomarkers for infection in premature neonates

Infection is a leading cause of neonatal morbidity and mortality worldwide. Premature neonates are particularly susceptible to infection because of physiologic immaturity, comorbidity, and extraneous medical interventions. Additionally premature infants are at higher risk of progression to sepsis or severe sepsis, adverse outcomes, and antimicrobial toxicity. Currently initial diagnosis is based upon clinical suspicion accompanied by nonspecific clinical signs and is confirmed upon positive microbiologic culture results several days after institution of empiric therapy. There exists a significant need for rapid, objective, in vitro tests for diagnosis of infection in neonates who are experiencing clinical instability. We used immunoassays multiplexed on microarrays to identify differentially expressed serum proteins in clinically infected and non-infected neonates. Immunoassay arrays were effective for measurement of more than 100 cytokines in small volumes of serum available from neonates. Our analyses revealed significant alterations in levels of eight serum proteins in infected neonates that are associated with inflammation, coagulation, and fibrinolysis. Specifically P- and E-selectins, interleukin 2 soluble receptor alpha, interleukin 18, neutrophil elastase, urokinase plasminogen activator and its cognate receptor, and C-reactive protein were observed at statistically significant increased levels. Multivariate classifiers based on combinations of serum analytes exhibited better diagnostic specificity and sensitivity than single analytes. Multiplexed immunoassays of serum cytokines may have clinical utility as an adjunct for rapid diagnosis of infection and differentiation of etiologic agent in neonates with clinical decompensation.

Authenticity in Scaling the Vision: Defining Boundaries in the Food and Beverage Entrepreneurship Development Cycle

The October 2015 Food and Beverage Entrepreneurship Roundtable brought together over 30 food and beverage industry leaders, entrepreneurs, faculty, and students at the School of Hotel Administration at Cornell University. Discussion topics covered entrepreneurship in the food and beverage industry, including development, intrapreneurship, operational efficiency, beverage product development, and technology. The roundtable began with the presentation of a five-point framework on food and beverage venue development. The first three phases focused on the launch of a venue, including how to define the guest experience; the creation of operational functionality by strategically planning out the design, flow, and efficiency of a defined space; and development capacity. The remaining two points of the framework focused on post-opening considerations, including operating systems and culture development. Participants discussed the importance of culture in the growth of a business. They suggested that intrapreneurship needs to be fostered in the culture of an organization and in an educational curriculum for those who are preparing to enter the industry. Participants also discussed the fine balance between setting expectations for an experience and subsequently being able to maintain this experience in a fast changing environment. In particular they considered what it means to say no to customers. A discussion on the beverage industry focused on how to distribute products in a crowded marketplace. One method to ensure that the product gets into the hands of the consumers is face-to-face sales. Finally, in the technology session, the group discussed technology adoption, specifically focusing on the point at which technology detracts from the guest experience, how to minimize operational risk from technology, and how to maximize consumers’ adoption rates.

Body fat MRS

The increasing levels of obesity, and its associated comorbidities, have prompted a reassessment of the techniques used for assessing body fat, including content, distribution, and composition. Magnetic resonance spectroscopy (MRS) is one among the many invaluable in vivo tools available today to evaluate the role of body fat in health and disease. However, although MRS has become a powerful technique for assessing ectopic fat in vivo, it has had limited use in other areas of research associated with body fat. MRS has found some success as a fast method to determine whole body adiposity in rodent models of disease, as well as a noninvasive method of obtaining an index of the overall composition of body fat in human subjects. Its more significant use has been in the understanding of bone marrow fat content, where important advances have been made, especially in longitudinal studies. In conclusion, in the area of body fat, MRS continues to be an adjunct technique to more precise and versatile MRI methods.

Aspects of the hemes and modulation of hydrogen donors in catalases from bovine liver, yeast, and escherichia coli

Catalase is the enzyme which decomposes hydrogen peroxide to water and oxygen. Escherichia coli contains two catalases. Hydroperoxidase I (HPI) is a bifunctional catalase-peroxidase. Hydroperoxidase II (HPII) is only catalytically active toward H202. Expression of the genes encoding these proteins is controlled by different regimes. HPJI is thought to be a hexamer, having one heme d cis group per enzymatic subunit. HPII wild type protein and heme containing mutant proteins were obtained from the laboratory of P. Loewen (Univ. of Manitoba). Mutants constructed by oligonucleotidedirected mutagenesis were targeted for replacement of either the His128 residue or the Asn201 residue in the vicinity of the HPII heme crevice. His128 is the residue thought to be analogous to the His74 distal axial ligand of the heme in the bovine liver enzyme, and Asn201 is believed to be a residue critical to the function of the enzyme because of its role in orienting and interacting with the substrate molecule. Investigation of the nature of the hemes via absorption spectroscopy of the unmodified catalase proteins and their derived pyridine hemochromes showed that while the bovine and Saccharomyces cerevisiae catalase enzymes are protoheme-containing, the HPII wild type protein contains heme d, and the mutant proteins contain either solely protoheme, or heme d-protoheme mixtures. Cyanide binding studies supported this, as ligand binding was monophasic for the bovine, Saccharomyces cerevisiae, and wild type HPII enzymes, but biphasic for several of the HPII mutant proteins. Several mammalian catalases, and at least two prokaryotic catalases, are known to be NADPH binding. The function of this cofactor appears to be the prevention of inactivation of the enzyme, which occurs via formation of the inactive secondary catalase peroxide compound (compound II). No physiologically plausible scheme has yet been proposed for the NADPH mediation of catalase activity. This study has shown, via fluorescence and affinity chromatography techniques, that NADPH binds to the T (Typical) and A (Atypical) catalases of Saccharomyces cerevisiae, and that wild type HPII apparently does not bind NADPH. This study has also shown that NADPH is unlike any other hydrogen donor to catalase, and addresses its features as a unique donor by proposing a mechanism whereby NADPH is oxidized and catalase is protected from inactivation via the formation of protein radical species. Migration of this radical to a position close to the NADPH is also proposed as an adjunct hypothesis, based on similar electron migrations that are known to occur within metmyoglobin and cytochrome c peroxidase when reacted with H202. Validation of these hypotheses may be obtained in appropriate future experiments.