E-health and the Universitas 21 organization: 2. Telemedicine and underserved populations

Telemedicine activities in underserved communities were reviewed as part of the Universitas 21 (U21) e-health project. A SWOT analysis (strengths, weaknesses, opportunities, threats) was conducted on 12 articles identified in a literature review, supplemented by expertise from U21 members. The analysis showed that threats include the reluctance of populations to use telemedicine services, and a general absence of infrastructure and resources to sustain them. Opportunities centre around potential research, including cost-effectiveness analyses and quantitative assessments of existing telemedicine services. The great strength of telemedicine is that it can improve access to health services among those most in need. However, its greatest weakness is the lack of evidence supporting its clinical and cost advantages relative to traditional services. This represents an important opportunity for research on telemedicine initiatives among underserved populations.

Tailoring access to high cost, genetically targeted drugs

Assessment of real cost effectiveness, with data linked to individual health outcomes while protecting patient privacy, is an essential challenge we need to meet

Normative influence and rational conflict decisions: Group norms and cost-benefit analyses for intergroup behavior

The present paper articulates a model in which ingroup and outgroup norms inform 'rational' decision-making (cost-benefit analysis) for conflict behaviors. Norms influence perceptions of the consequences of the behavior, and individuals may thus strategically conform to or violate norms in order to acquire benefits and avoid costs. Two studies demonstrate these processes in the context of conflict in Quebec. In the first study, Anglophones' perceptions of Francophone and Anglophone norms for pro-English behaviors predicted evaluations of the benefits and costs of the behaviors, and these cost-benefit evaluations in turn mediated the norm-intention links for both group norms. In the second study, a manipulated focus on supportive versus hostile ingroup and outgroup norms also predicted cost-benefit evaluations, which mediated the norm-intention relationships. The studies support a model of strategic conflict choices in which group norms inform, rather than suppress, rational expectancy value processes. Implications for theories of decision-making and normative influence are discussed.

Intensive case management: A critical re-appraisal of the scientific evidence for effectiveness

Intensive Case Management (ICM) is widely claimed to be an evidence-based and cost effective program for people with high levels of disability as a result of mental illness. However, the findings of recent randomized controlled trials comparing ICM with 'usual services' suggest that both clinical and cost effectiveness of ICM may be weakening. Possible reasons for this, including fidelity of implementation, researcher allegiance effects and changes in the wider service environment within which ICM is provided, are considered. The implications for service delivery and research are discussed.

Monitoring the condition of savanna riparian zones in Northern Australia using high spatial resolution imagery and a field based rapid assessment method

Government agencies responsible for riparian environments are assessing the combined utility of field survey and remote sensing for mapping and monitoring indicators of riparian zone condition. The objective of this work was to compare the Tropical Rapid Appraisal of Riparian Condition (TRARC) method to a satellite image based approach. TRARC was developed for rapid assessment of the environmental condition of savanna riparian zones. The comparison assessed mapping accuracy, representativeness of TRARC assessment, cost-effectiveness, and suitability for multi-temporal analysis. Two multi-spectral QuickBird images captured in 2004 and 2005 and coincident field data covering sections of the Daly River in the Northern Territory, Australia were used in this work. Both field and image data were processed to map riparian health indicators (RHIs) including percentage canopy cover, organic litter, canopy continuity, stream bank stability, and extent of tree clearing. Spectral vegetation indices, image segmentation and supervised classification were used to produce RHI maps. QuickBird image data were used to examine if the spatial distribution of TRARC transects provided a representative sample of ground based RHI measurements. Results showed that TRARC transects were required to cover at least 3% of the study area to obtain a representative sample. The mapping accuracy and costs of the image based approach were compared to those of the ground based TRARC approach. Results proved that TRARC was more cost-effective at smaller scales (1-100km), while image based assessment becomes more feasible at regional scales (100-1000km). Finally, the ability to use both the image and field based approaches for multi-temporal analysis of RHIs was assessed. Change detection analysis demonstrated that image data can provide detailed information on gradual change, while the TRARC method was only able to identify more gross scale changes. In conclusion, results from both methods were considered to complement each other if used at appropriate spatial scales.

An Autonomic Framework for Mobile Cloud Computing

This thesis presents the formal definition of a novel Mobile Cloud Computing (MCC) extension of the Networked Autonomic Machine (NAM) framework, a general-purpose conceptual tool which describes large-scale distributed autonomic systems. The introduction of autonomic policies in the MCC paradigm has proved to be an effective technique to increase the robustness and flexibility of MCC systems. In particular, autonomic policies based on continuous resource and connectivity monitoring help automate context-aware decisions for computation offloading. We have also provided NAM with a formalization in terms of a transformational operational semantics in order to fill the gap between its existing Java implementation NAM4J and its conceptual definition. Moreover, we have extended NAM4J by adding several components with the purpose of managing large scale autonomic distributed environments. In particular, the middleware allows for the implementation of peer-to-peer (P2P) networks of NAM nodes. Moreover, NAM mobility actions have been implemented to enable the migration of code, execution state and data. Within NAM4J, we have designed and developed a component, denoted as context bus, which is particularly useful in collaborative applications in that, if replicated on each peer, it instantiates a virtual shared channel allowing nodes to notify and get notified about context events. Regarding the autonomic policies management, we have provided NAM4J with a rule engine, whose purpose is to allow a system to autonomously determine when offloading is convenient. We have also provided NAM4J with trust and reputation management mechanisms to make the middleware suitable for applications in which such aspects are of great interest. To this purpose, we have designed and implemented a distributed framework, denoted as DARTSense, where no central server is required, as reputation values are stored and updated by participants in a subjective fashion. We have also investigated the literature regarding MCC systems. The analysis pointed out that all MCC models focus on mobile devices, and consider the Cloud as a system with unlimited resources. To contribute in filling this gap, we defined a modeling and simulation framework for the design and analysis of MCC systems, encompassing both their sides. We have also implemented a modular and reusable simulator of the model. We have applied the NAM principles to two different application scenarios. First, we have defined a hybrid P2P/cloud approach where components and protocols are autonomically configured according to specific target goals, such as cost-effectiveness, reliability and availability. Merging P2P and cloud paradigms brings together the advantages of both: high availability, provided by the Cloud presence, and low cost, by exploiting inexpensive peers resources. As an example, we have shown how the proposed approach can be used to design NAM-based collaborative storage systems based on an autonomic policy to decide how to distribute data chunks among peers and Cloud, according to cost minimization and data availability goals. As a second application, we have defined an autonomic architecture for decentralized urban participatory sensing (UPS) which bridges sensor networks and mobile systems to improve effectiveness and efficiency. The developed application allows users to retrieve and publish different types of sensed information by using the features provided by NAM4J's context bus. Trust and reputation is managed through the application of DARTSense mechanisms. Also, the application includes an autonomic policy that detects areas characterized by few contributors, and tries to recruit new providers by migrating code necessary to sensing, through NAM mobility actions.

Drug testing: a way to weed out users?

The aim of this paper is to provide managers and Human Resource executives with the basis for making drug testing policy in their organisations by presenting a critical review of existing literature on Workplace Drug Testing (WDT) and related areas which have been structured into the key areas.The key finding is whilst WDT is becoming more and more widely used, the rationale for this in terms of organizational effectiveness and safety is far from clear. Also there are significant ethical issues associated with WDT which are not always fully considered by organisations. Similarly, a cost/benefit analysis for particular organisations may well show little reason to embark on a testing policy. As a result of our review, we recommend that practitioners take a critical view of proposals introducing WDT since in many cases there is little upside to such a policy and a largely under-researched downside. There are also wider implications for society as a whole since the issue of drug taking as a whole is clearly a matter of great importance to practically every country in the world. The workplace is not at all immune from the impact of drug taking and perhaps a knee-jerk response by managers is to attempt to exclude anyone with any sort of drug habit through the use of WDT. This type of review with a specific HR focus has not been carried out before despite several calls for a more rational approach to the area.

Applying quantitative methods in the assessment of outcomes of pharmacotherapy of psoriasis

Healthcare providers and policy makers are faced with an ever-increasing number of medical publications. Searching for relevant information and keeping up to date with new research findings remains a constant challenge. It has been widely acknowledged that narrative reviews of the literature are susceptible to several types of bias and a systematic approach may protect against these biases. The aim of this thesis was to apply quantitative methods in the assessment of outcomes of topical therapies for psoriasis. In particular, to systematically examine the comparative efficacy, tolerability and cost-effectiveness of topical calcipotriol in the treatment of mild-to-moderate psoriasis. Over the years, a wide range of techniques have been used to evaluate the severity of psoriasis and the outcomes from treatment. This lack of standardisation complicates the direct comparison of results and ultimately the pooling of outcomes from different clinical trials. There is a clear requirement for more comprehensive tools for measuring drug efficacy and disease severity in psoriasis. Ideally, the outcome measures need to be simple, relevant, practical, and widely applicable, and the instruments should be reliable, valid and responsive. The results of the meta-analysis reported herein show that calcipotriol is an effective antipsoriatic agent. In the short-tenn, the pooled data found calcipotriol to be more effective than calcitriol, tacalcitol, coal tar and short-contact dithranol. Only potent corticosteroids appeared to have comparable efficacy, with less short-term side-effects. Potent corticosteroids also added to the antipsoriatic effect of calcipotriol, and appeared to suppress the occurrence of calcipotriol-induced irritation. There was insufficient evidence to support any large effects in favour of improvements in efficacy when calcipotriol is used in combination with systemic therapies in patients with severe psoriasis. However, there was a total absence of long-term morbidity data on the effectiveness of any of the interventions studied. Decision analysis showed that, from the perspective of the NHS as payer, the relatively small differences in efficacy between calcipotriol and short-contact dithranol lead to large differences in the direct cost of treating patients with mildto-moderate plaque psoriasis. Further research is needed to examine the clinical and economic issues affecting patients under treatment for psoriasis in the UK. In particular, the maintenance value and cost/benefit ratio for the various treatment strategies, and the assessment of patient's preferences has not yet been adequately addressed for this chronic recurring disease.

Translation strategies and cross-cultural contraints : a case study of the translation of advertising texts

Since the transfer of a message between two cultures very frequently takes place through the medium of a written text qua communicative event, it would seem useful to attempt to ascertain whether there is any kind of pattern in the use of strategies for the effective interlingual transfer of this message. Awareness of potentially successful strategies, within the constraints of context, text type, intended TL function and TL reader profile will enhance quality and cost-effectiveness (time, effort, financial costs) in the production of the target text. Through contrastive analysis of pairs of advertising texts, SL and TL, French and English, this study will attempt to identify the nature of some recurring choices made by different translators in the attempt to recreate ST information in the TL in such a manner as to reproduce as closely as possible the informative, persuasive and affective functions of the text as advertising material. Whilst recurrence may be seen to be significant in terms of illustrating tendencies with regard to the solution of problems of translation, this would not necessarily be taken as confirmation of the existence of pre-determined or prescriptive rules. These tendencies could, however, be taken as a guide to potential solutions to certain kinds of context-bound and text-type specific problem. Analysis of translated text-pairs taken from the field of advertising should produce examples of constraints posed by the need to select the content, tone and form of the Target Text, in order to ensure maximum efficacy of persuasive effect and to ensure the desired outcome, as determined by the Source Text function. When evaluating the success of a translated advertising text, constraints could be defined in terms of the culture-specific references or assumptions on which a Source Text may build in order to achieve its intended communicative function within the target community.

Enhanced diabetes care to patients of south Asian ethnic origin (the United Kingdom Asian Diabetes Study):a cluster randomised controlled trial

Background - Delivery of high-quality, evidence-based health care to deprived sectors of the community is a major goal for society. We investigated the effectiveness of a culturally sensitive, enhanced care package in UK general practices for improvement of cardiovascular risk factors in patients of south Asian origin with type 2 diabetes. Methods - In this cluster randomised controlled trial, 21 inner-city practices in the UK were assigned by simple randomisation to intervention (enhanced care including additional time with practice nurse and support from a link worker and diabetes-specialist nurse [nine practices; n=868]) or control (standard care [12 practices; n=618]) groups. All adult patients of south Asian origin with type 2 diabetes were eligible. Prescribing algorithms with clearly defined targets were provided for all practices. Primary outcomes were changes in blood pressure, total cholesterol, and glycaemic control (haemoglobin A1c) after 2 years. Analysis was by intention to treat. This trial is registered, number ISRCTN 38297969. Findings - We recorded significant differences between treatment groups in diastolic blood pressure (1·91 [95% CI -2·88 to -0·94] mm?Hg, p=0·0001) and mean arterial pressure (1·36 [-2·49 to -0·23] mm?Hg, p=0·0180), after adjustment for confounders and clustering. We noted no significant differences between groups for total cholesterol (0·03 [-0·04 to 0·11] mmol/L), systolic blood pressure (-0·33 [-2·41 to 1·75] mm?Hg), or HbA1c (-0·15% [-0·33 to 0·03]). Economic analysis suggests that the nurse-led intervention was not cost effective (incremental cost-effectiveness ratio £28?933 per QALY gained). Across the whole study population over the 2 years of the trial, systolic blood pressure, diastolic blood pressure, and cholesterol decreased significantly by 4·9 (95% CI 4·0–5·9) mm?Hg, 3·8 (3·2–4·4) mm?Hg, and 0·45 (0·40–0·51) mmol/L, respectively, and we recorded a small and non-significant increase for haemoglobin A1c (0·04% [-0·04 to 0·13]), p=0·290). Interpretation - We recorded additional, although small, benefits from our culturally tailored care package that were greater than the secular changes achieved in the UK in recent years. Stricter targets in general practice and further measures to motivate patients are needed to achieve best possible health-care outcomes in south Asian patients with diabetes. Funding - Pfizer, Sanofi-Aventis, Servier Laboratories UK, Merck Sharp & Dohme/Schering-Plough, Takeda UK, Roche, Merck Pharma, Daiichi-Sankyo UK, Boehringer Ingelheim, Eli Lilly, Novo Nordisk, Bristol-Myers Squibb, Solvay Health Care, and Assurance Medical Society UK.

Effectiveness and uptake of screening programmes for coronary heart disease and diabetes:a realist review of design components used in interventions

Objective - To evaluate behavioural components and strategies associated with increased uptake and effectiveness of screening for coronary heart disease and diabetes with an implementation science focus. Design - Realist review. Data sources - PubMed, Web of Knowledge, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register and reference chaining. Searches limited to English language studies published since 1990. Eligibility criteria - Eligible studies evaluated interventions designed to increase the uptake of cardiovascular disease (CVD) and diabetes screening and examined behavioural and/or strategic designs. Studies were excluded if they evaluated changes in risk factors or cost-effectiveness only. Results - In 12 eligible studies, several different intervention designs and evidence-based strategies were evaluated. Salient themes were effects of feedback on behaviour change or benefits of health dialogues over simple feedback. Studies provide mixed evidence about the benefits of these intervention constituents, which are suggested to be situation and design specific, broadly supporting their use, but highlighting concerns about the fidelity of intervention delivery, raising implementation science issues. Three studies examined the effects of informed choice or loss versus gain frame invitations, finding no effect on screening uptake but highlighting opportunistic screening as being more successful for recruiting higher CVD and diabetes risk patients than an invitation letter, with no differences in outcomes once recruited. Two studies examined differences between attenders and non-attenders, finding higher risk factors among non-attenders and higher diagnosed CVD and diabetes among those who later dropped out of longitudinal studies. Conclusions - If the risk and prevalence of these diseases are to be reduced, interventions must take into account what we know about effective health behaviour change mechanisms, monitor delivery by trained professionals and examine the possibility of tailoring programmes according to contexts such as risk level to reach those most in need. Further research is needed to determine the best strategies for lifelong approaches to screening.

Neurophysiological investigations for the diagnosis of non-epileptic attack disorder in neuropsychiatry services:from safety standards to improved effectiveness

OBJECTIVE: The discipline of clinical neuropsychiatry currently provides specialised services for a number of conditions that cross the traditional boundaries of neurology and psychiatry, including non-epileptic attack disorder. Neurophysiological investigations have an important role within neuropsychiatry services, with video-electroencephalography (EEG) telemetry being the gold standard investigation for the differential diagnosis between epileptic seizures and non-epileptic attacks. This article reviews existing evidence on best practices for neurophysiology investigations, with focus on safety measures for video-EEG telemetry. METHODS: We conducted a systematic literature review using the PubMed database in order to identify the scientific literature on the best practices when using neurophysiological investigations in patients with suspected epileptic seizures or non-epileptic attacks. RESULTS: Specific measures need to be implemented for video-EEG telemetry to be safely and effectively carried out by neuropsychiatry services. A confirmed diagnosis of non-epileptic attack disorder following video-EEG telemetry carried out within neuropsychiatry units has the inherent advantage of allowing diagnosis communication and implementation of treatment strategies in a timely fashion, potentially improving clinical outcomes and cost-effectiveness significantly. CONCLUSION: The identified recommendations set the stage for the development of standardised guidelines to enable neuropsychiatry services to implement streamlined and evidence-based care pathways.

Three-port DC-DC converter for stand-alone photovoltaic systems

System efficiency and cost effectiveness are of critical importance for photovoltaic (PV) systems. This paper addresses the two issues by developing a novel three-port dc-dc converter for stand-alone PV systems, based on an improved Flyback-Forward topology. It provides a compact single-unit solution with a combined feature of optimized maximum power point tracking (MPPT), high step-up ratio, galvanic isolation, and multiple operating modes for domestic and aerospace applications. A theoretical analysis is conducted to analyze the operating modes followed by simulation and experimental work. This paper is focused on a comprehensive modulation strategy utilizing both PWM and phase-shifted control that satisfies the requirement of PV power systems to achieve MPPT and output voltage regulation. A 250-W converter was designed and prototyped to provide experimental verification in term of system integration and high conversion efficiency.

Optimization of pavement maintenance and rehabilitation programming using shuffled complex evolution algorithm

The major barrier to practical optimization of pavement preservation programming has always been that for formulations where the identity of individual projects is preserved, the solution space grows exponentially with the problem size to an extent where it can become unmanageable by the traditional analytical optimization techniques within reasonable limit. This has been attributed to the problem of combinatorial explosion that is, exponential growth of the number of combinations. The relatively large number of constraints often presents in a real-life pavement preservation programming problems and the trade-off considerations required between preventive maintenance, rehabilitation and reconstruction, present yet another factor that contributes to the solution complexity. In this research study, a new integrated multi-year optimization procedure was developed to solve network level pavement preservation programming problems, through cost-effectiveness based evolutionary programming analysis, using the Shuffled Complex Evolution (SCE) algorithm.^ A case study problem was analyzed to illustrate the robustness and consistency of the SCE technique in solving network level pavement preservation problems. The output from this program is a list of maintenance and rehabilitation treatment (M&R) strategies for each identified segment of the network in each programming year, and the impact on the overall performance of the network, in terms of the performance levels of the recommended optimal M&R strategy. ^ The results show that the SCE is very efficient and consistent in the simultaneous consideration of the trade-off between various pavement preservation strategies, while preserving the identity of the individual network segments. The flexibility of the technique is also demonstrated, in the sense that, by suitably coding the problem parameters, it can be used to solve several forms of pavement management programming problems. It is recommended that for large networks, some sort of decomposition technique should be applied to aggregate sections, which exhibit similar performance characteristics into links, such that whatever M&R alternative is recommended for a link can be applied to all the sections connected to it. In this way the problem size, and hence the solution time, can be greatly reduced to a more manageable solution space. ^ The study concludes that the robust search characteristics of SCE are well suited for solving the combinatorial problems in long-term network level pavement M&R programming and provides a rich area for future research. ^

A Look at Restaurant Commissaries

Restaurant commissaries range the full spectrum from simple storage of food and supplies to multi-million-dollar processing plants. The author discusses the cost effectiveness of commissary units, including their operating costs, quality control, and scope.