A Letter of Consequence: Referral Letters from General Practitioners to Secondary Mental Health Services

The referral letter is a key instrument in moving patients from primary to secondary care services. Consequently, the circumstances in which a referral should be made and its contents have been the subject of clinical guidelines. This article is based on a project that demonstrated that physicians do not adhere to clinical guidelines when referring patients to secondary mental health services. This research supports earlier findings into noncompliance with guidelines by general practitioners (GPs). The authors briefly note possible reasons, which have been the subject of some debate. They also present a content analysis of referral letters to demonstrate the important ways in which they differ from guideline criteria. However, their central argument is that the role of the referral letter in relation to the GP’s repertoire of treatments has not been understood fully. Such understanding implies the need for a reexamination of the support available for GPs.

Tackling health inequalities in primary care: an exploration of GPs’ experience at the frontline

In Scotland, life expectancy and health outcomes are strongly tied to socioeconomic status. Specifically, socioeconomically deprived areas suffer disproportionately from high levels of premature multimorbidity and mortality. To tackle these inequalities in health, challenges in the most deprived areas must be addressed. One avenue that merits attention is the potential role of general medical practitioners (GPs) in helping to address health inequalities, particularly due to their long-term presence in deprived communities, their role in improving patient and population health, and their potential advocacy role on behalf of their patients. GPs can be seen as what Lipsky calls ‘street-level bureaucrats’ due to their considerable autonomy in the decisions they make surrounding individual patient needs, yet practising under the bureaucratic structure of the NHS. While previous research has examined the applicability of Lipsky’s framework to the role of GPs, there has been very little research exploring how GPs negotiate between the multiple identities in their work, how GPs ‘socially construct’ their patients, how GPs view their potential role as ‘advocate’, and what this means in terms of the contribution of GPs to addressing existing inequalities in health. Using semi-structured interviews, this study explored the experience and views of 24 GPs working in some of Scotland’s most deprived practices to understand how they might combat this growing health divide via the mitigation (and potential prevention) of existing health inequalities. Participants were selected based on several criteria including practice deprivation level and their individual involvement in the Deep End project, which is an informal network comprising the 100 most deprived general practices in Scotland. The research focused on understanding GPs’ perceptions of their work including its broader implications, within their practice, the communities within which they practise, and the health system as a whole. The concept of street-level bureaucracy proved to be useful in understanding GPs’ frontline work and how they negotiate dilemmas. However, this research demonstrated the need to look beyond Lipsky’s framework in order to understand how GPs reconcile their multiple identities, including advocate and manager. As a result, the term ‘street-level professional’ is offered to capture more fully the multiple identities which GPs inhabit and to explain how GPs’ elite status positions them to engage in political and policy advocacy. This study also provides evidence that GPs’ social constructions of patients are linked not only to how GPs conceptualise the causes of health inequalities, but also to how they view their role in tackling them. In line with this, the interviews established that many GPs felt they could make a difference through advocacy efforts at individual, community and policy/political levels. Furthermore, the study draws attention to the importance of practitioner-led groups—such as the Deep End project—in supporting GPs’ efforts and providing a platform for their advocacy. Within this study, a range of GPs’ views have been explored based on the sample. While it is unclear how common these views are amongst GPs in general, the study revealed that there is considerable scope for ‘political GPs’ who choose to exercise discretion in their communities and beyond. Consequently, GPs working in deprived areas should be encouraged to use their professional status and political clout not only to strengthen local communities, but also to advocate for policy change that might potentially affect the degree of disadvantage of their patients, and levels of social and health inequalities more generally.

Selecting candidate predictor variables for the modelling of post-discharge mortality from sepsis: a protocol development project.

Background: Post-discharge mortality is a frequent but poorly recognized contributor to child mortality in resource limited countries. The identification of children at high risk for post-discharge mortality is a critically important first step in addressing this problem. Objectives: The objective of this project was to determine the variables most likely to be associated with post-discharge mortality which are to be included in a prediction modelling study. Methods: A two-round modified Delphi process was completed for the review of a priori selected variables and selection of new variables. Variables were evaluated on relevance according to (1) prediction (2) availability (3) cost and (4) time required for measurement. Participants included experts in a variety of relevant fields. Results: During the first round of the modified Delphi process, 23 experts evaluated 17 variables. Forty further variables were suggested and were reviewed during the second round by 12 experts. During the second round 16 additional variables were evaluated. Thirty unique variables were compiled for use in the prediction modelling study. Conclusion: A systematic approach was utilized to generate an optimal list of candidate predictor variables for the incorporation into a study on prediction of pediatric post-discharge mortality in a resource poor setting.

Introducing the National Library for Health Skin Conditions Specialist Library

Background: This paper introduces the new National Library for Health Skin Conditions Specialist Library http://www.library.nhs.uk/skin. Description: The aims, scope and audience of the new NLH Skin Conditions Specialist Library, and the composition and functions of its core Project Team, Editorial Team and Stakeholders Group are described. The Library's collection building strategy, resource and information types, editorial policies, quality checklist, taxonomy for content indexing, organisation and navigation, and user interface are all presented in detail. The paper also explores the expected impact and utility of the new Library, as well as some possible future directions for further development. Conclusion: The Skin Conditions Specialist Library is not just another new Web site that dermatologists might want to add to their Internet favourites then forget about it. It is intended to be a practical, "one-stop shop" dermatology information service for everyday practical use, offering high quality, up-to-date resources, and adopting robust evidence-based and knowledge management approaches.

The viability of a tool for fetal health monitoring

Health monitoring has become widespread these past few years. Such applications include from exercise, food intake and weight watching, to specific scenarios like monitoring people who suffer from chronic diseases. More and more we see the need to also monitor the health of new-born babies and even fetuses. Congenital Heart Defects (CHDs) are the main cause of deaths among babies and doctors do not know most of these defects. Hence, there is a need to study what causes these anomalies, and by monitoring the fetus daily there will be a better chance of identifying the defects in earlier stages. By analyzing the data collected, doctors can find patterns and come up with solutions, thus saving peoples’ lives. In many countries, the most common fetal monitor is the ultrasound and the use of it is regulated. In Sweden for normal pregnancies, there is only one ultrasound scan during the pregnancy period. There is no great evidence that ultrasound can harm the fetus, but many doctors suggest to use it as little as possible. Therefore, there is a demand for a new non-ultrasound device that can be as accurate, or even better, on detecting the FHR and not harming the baby. The problems that are discussed in this thesis include how can accurate fetus health be monitored non-invasively at home and how could a fetus health monitoring system for home use be designed. The first part of the research investigates different technologies that are currently being used on fetal monitoring, and techniques and parameters to monitor the fetus. The second part is a qualitative study held in Sweden between April and May 2016. The data for the qualitative study was collected through interviews with 21 people, 10 mothers/mothers-to-be and 11 obstetricians/gynecologists/midwives. The questions were related to the Swedish pregnancy protocol, the use of technology in medicine and in particular during the pregnancy process, and the use of an ECG based monitoring device. The results show that there is still room for improvements on the algorithms to extract the fetal ECG and the survey was very helpful in understanding the need for a fetal home monitor. Parents are open to new technologies especially if it doesn't affect the baby's growth. Doctors are open to use ECG as a great alternative to ultrasound; on the other hand, midwives are happy with the current system. The remote monitoring feature is very desirable to everyone, if such system will be used in the future.

How to optimize the business model for ConsultaClick an innovative startup in the e-health Portuguese sector

Field lab: Entrepreneurial and innovative ventures

A MORE COMPLETE STREET A STREET FOR EVERYONE TO ENJOY, NORTH EAST STREET, FREDERICK, MARYLAND – A DESIGN INVESTIGATION OF DIFFERENT STREET DESIGN THEORIES

This design-research thesis suggests that the improvement of North East Street performances by using Complete Streets, Green Street, Place Making and Context Sensitive Solution principles and practices. Heavily used by a variety of users, often conflicting with one another, University of Maryland Campus Drive would benefit from a major planning and design amelioration to meet the increasing demands of serving as a city main street. The goal of this thesis project is to prioritize the benefits for pedestrians in the right-of-way and improve the pedestrian experience. This goal also responds to the recent North East Street Extension Phrase I of economic renaissances. The goal of this design-research thesis will be achieved focusing on four aspects. First, the plans and designs will suggest to building mixed use blocks, increase the diversity of street economic types and convenience of people’s living. Second, design and plans will propose bike lanes, separate driving lanes from sidewalks and bike lanes by street tree planters, and narrow driving lanes to reduce vehicular traffic volume and speed in order to reduce pedestrian and vehicle conflicts. Third, plans and designs will introduce bioswales, living walls and raingardens to treat and reuse rain water. Finally, the plans and designs will seek to preserve local culture and history by adding murals and farmers market. The outcome of the design-research thesis project is expected to serve as an example of implementing Complete Streets, Green Street, Place Making and Context Sensitive Solution principles and practices in urban landscape, where transportation, environment and social needs interact with each other.

The socioeconomic gradient in health: The role of intra-household resource allocation

This paper aims to analyse the impact of different household financial regimes on the health status of males and females in a number of European countries. Using the EU-SILC 2010 on intra-household sharing of resources, we find that each member of the couple is worse off if his/her partner has most decision-making responsibilities. Additionally, the presence of children in the household plays a role in the effect that household financial regimens exert on individual self-assessed health, especially among females. We conclude that family arrangements regarding resource allocation and decision-making have important consequences and should be given some attention in the task of identifying individuals predisposed to health problems.

Bia’s smile: an health education instrument on cleft lip and palate

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.

Factor structure of the General Health Questionnaire-28 (GHQ-28) from infertile women attending the Yazd Research and Clinical Center for Infertility

Background: Nowadays, infertility problems have become a social concern, and are associated with multiple psychological and social problems. Also, it affects the interpersonal communication between the individual, familial, and social characteristics. Since women are exposed to stressors of physical, mental, social factors, and treatment of infertility, providing a psychometric screening tool is necessary for disorders of this group. Objective: The aim of this study was to determine the factor structure of the general health questionnaire-28 to discover mental disorders in infertile women. Materials and Methods: In this study, 220 infertile women undergoing treatment of infertility were selected from the Yazd Research and Clinical Center for Infertility with convenience sampling in 2011. After completing the general health questionnaire by the project manager, validity and, reliability of the questionnaire were calculated by confirmatory factor structure and Cronbach's alpha, respectively. Results: Four factors, including anxiety and insomnia, social dysfunction, depression, and physical symptoms were extracted from the factor structure. 50.12% of the total variance was explained by four factors. The reliability coefficient of the questionnaire was obtained 0.90. Conclusion: Analysis of the factor structure and reliability of General Health Questionnaire-28 showed that it is suitable as a screening instrument for assessing general health of infertile women.

Mercury in Gas Operations - Occupational Health Risk Assessment

The project goal was to determine plant operations and maintenance worker’s level of exposure to mercury during routine and non-routine (i.e. turnarounds and inspections) maintenance events in eight gas processing plants. The project team prepared sampling and analysis plans designed to each plant’s process design and scheduled maintenance events. Occupational exposure sampling and monitoring efforts were focused on the measurement of mercury vapor concentration in worker breathing zone air during specific maintenance events including: pipe scrapping, process filter replacement, and process vessel inspection. Similar exposure groups were identified and worker breathing zone and ambient air samples were collected and analyzed for total mercury. Occupational exposure measurement techniques included portable field monitoring instruments, standard passive and active monitoring methods and an emerging passive absorption technology. Process sampling campaigns were focused on inlet gas streams, mercury removal unit outlets, treated gas, acid gas and sales gas. The results were used to identify process areas with increased potential for mercury exposure during maintenance events. Sampling methods used for the determination of total mercury in gas phase streams were based on the USEPA Methods 30B and EPA 1631 and EPA 1669. The results of four six-week long sampling campaigns have been evaluated and some conclusions and recommendations have been made. The author’s role in this project included the direction of all field phases of the project and the development and implementation of the sampling strategy. Additionally, the author participated in the development and implementation of the Quality Assurance Project Plan, Data Quality Objectives, and Similar Exposure Groups identification. All field generated data was reviewed by the author along with laboratory reports in order to generate conclusions and recommendations.

THE EFFECT OF EASTERN KENTUCKY COAL FIRES ON LOCAL AIR QUALITY AND PERSONAL HEALTH

The purpose of this project was to investigate student learning in the areas of earth science and environmental responsibility using the subject of coal fires. Eastern Kentucky, where this study was performed, has several coal fires burning that affect the local air quality and may also affect the health of people living near them. This study was conducted during the regular education of 9th grade Earth Science classroom in Russell Independent Schools, located in Russell, Kentucky. Students conducted internet research, read current articles on the subject of coal fire emissions and effect on local ecology, and demonstrated what they learned through summative assessments. There were several aspects of coalmines and coal fires that students studied. Students were able to take this knowledge and information and use it as a learning tool to gain a better understanding of their own environment. Using the local history and geology of coalmines, along with the long tradition of mine production, was a very beneficial starting point, allowing students to learn about environmental impact, stewardship of their local environment, and methods of preserving and protecting the ecosystem.

Application of the UK Foresight Obesity Model in Ireland: The Health and Economic Consequences of Projected Obesity Trends in Ireland

Given the scale of the current obesity epidemic and associated health consequences there has been increasing concern about the economic burden placed on society in terms of direct healthcare costs and indirect societal costs. In the Republic of Ireland these costs were estimated at €1.13 billion for 2009. The total direct healthcare costs for six major obesity related conditions (coronary heart disease & stroke, cancer, hypertension, type 2 diabetes and knee osteoarthritis) in the same year were estimated at €2.55 billion. The aim of this research is to project disease burden and direct healthcare costs for these conditions in Ireland to 2030 using the established model developed by the Health Forum (UK) for the Foresight: Tackling Obesities project.

FOCUS : frailty management optimisation through EIPAHA commitments and utilisation of stakeholders’ input – an innovative European project in elderly care

The goal of FOCUS, which stands for Frailty Management Optimization through EIPAHA Commitments and Utilization of Stakeholders’ Input, is to reduce the burden of frailty in Europe. The partners are working on advancing knowledge of frailty detection, assessment, and management, including biological, clinical, cognitive and psychosocial markers, in order to change the paradigm of frailty care from acute intervention to prevention. FOCUS partners are working on ways to integrate the best available evidence from frailty-related screening tools, epidemiological and interventional studies into the care of frail people and their quality of life. Frail citizens in Italy, Poland and the UK and their caregivers are being called to express their views and their experiences with treatments and interventions aimed at improving quality of life. The FOCUS Consortium is developing pathways to leverage the knowledge available and to put it in the service of frail citizens. In order to reach out to the broadest audience possible, the FOCUS Platform for Knowledge Exchange and the platform for Scaling Up are being developed with the collaboration of stakeholders. The FOCUS project is a development of the work being done by the European Innovation Partnership on Active and Healthy Ageing (EIPAHA), which aims to increase the average healthy lifespan in Europe by 2020 while fostering sustainability of health/social care systems and innovation in Europe. The knowledge and tools developed by the FOCUS project, with input from stakeholders, will be deployed to all EIPAHA participants dealing with frail older citizens to support activities and optimize performance.

Effectiveness of non-pharmacological interventions to prevent falls in older people: a systematic overview. The SENATOR Project ONTOP Series

Background: Falls are common events in older people, which cause considerable morbidity and mortality. Non-pharmacological interventions are an important approach to prevent falls. There are a large number of systematic reviews of non-pharmacological interventions, whose evidence needs to be synthesized in order to facilitate evidence-based clinical decision making. Objectives: To systematically examine reviews and meta-analyses that evaluated non-pharmacological interventions to prevent falls in older adults in the community, care facilities and hospitals. Methods: We searched the electronic databases Pubmed, the Cochrane Database of Systematic Reviews, EMBASE, CINAHL, PsycINFO, PEDRO and TRIP from January 2009 to March 2015, for systematic reviews that included at least one comparative study, evaluating any non-pharmacological intervention, to prevent falls amongst older adults. The quality of the reviews was assessed using AMSTAR and ProFaNE taxonomy was used to organize the interventions. Results: Fifty-nine systematic reviews were identified which consisted of single, multiple and multi-factorial non-pharmacological interventions to prevent falls in older people. The most frequent ProFaNE defined interventions were exercises either alone or combined with other interventions, followed by environment/assistive technology interventions comprising environmental modifications, assistive and protective aids, staff education and vision assessment/correction. Knowledge was the third principle class of interventions as patient education. Exercise and multifactorial interventions were the most effective treatments to reduce falls in older adults, although not all types of exercise were equally effective in all subjects and in all settings. Effective exercise programs combined balance and strength training. Reviews with a higher AMSTAR score were more likely to contain more primary studies, to be updated and to perform meta-analysis. Conclusions: The aim of this overview of reviews of non-pharmacological interventions to prevent falls in older people in different settings, is to support clinicians and other healthcare workers with clinical decision-making by providing a comprehensive perspective of findings.