Characteristics of primary care office visits to nurse practitioners, physician assistants and physicians in United States Veterans Health Administration facilities, 2005 to 2010: a retrospective cross-sectional analysis.

UNLABELLED: BACKGROUND: Primary care, an essential determinant of health system equity, efficiency, and effectiveness, is threatened by inadequate supply and distribution of the provider workforce. The Veterans Health Administration (VHA) has been a frontrunner in the use of nurse practitioners (NPs) and physician assistants (PAs). Evaluation of the roles and impact of NPs and PAs in the VHA is critical to ensuring optimal care for veterans and may inform best practices for use of PAs and NPs in other settings around the world. The purpose of this study was to characterize the use of NPs and PAs in VHA primary care and to examine whether their patients and patient care activities were, on average, less medically complex than those of physicians. METHODS: This is a retrospective cross-sectional analysis of administrative data from VHA primary care encounters between 2005 and 2010. Patient and patient encounter characteristics were compared across provider types (PA, NP, and physician). RESULTS: NPs and PAs attend about 30% of all VHA primary care encounters. NPs, PAs, and physicians fill similar roles in VHA primary care, but patients of PAs and NPs are slightly less complex than those of physicians, and PAs attend a higher proportion of visits for the purpose of determining eligibility for benefits. CONCLUSIONS: This study demonstrates that a highly successful nationwide primary care system relies on NPs and PAs to provide over one quarter of primary care visits, and that these visits are similar to those of physicians with regard to patient and encounter characteristics. These findings can inform health workforce solutions to physician shortages in the USA and around the world. Future research should compare the quality and costs associated with various combinations of providers and allocations of patient care work, and should elucidate the approaches that maximize quality and efficiency.

Caring for Alaska Native prostate cancer survivors in primary care: a survey of Alaska Tribal Health System providers.

BACKGROUND: Little is known about the constraints of optimizing health care for prostate cancer survivors in Alaska primary care. OBJECTIVE: To describe the experiences and attitudes of primary care providers within the Alaska Tribal Health System (ATHS) regarding the care of prostate cancer survivors. DESIGN: In late October 2011, we emailed a 22-item electronic survey to 268 ATHS primary care providers regarding the frequency of Prostate Specific Antigen (PSA) monitoring for a hypothetical prostate cancer survivor; who should be responsible for the patient's life-long prostate cancer surveillance; who should support the patient's emotional and medical needs as a survivor; and providers' level of comfort addressing recurrence monitoring, erectile dysfunction, urinary incontinence, androgen deprivation therapy, and emotional needs. We used simple logistic regression to examine the association between provider characteristics and their responses to the survivorship survey items. RESULTS: Of 221 individuals who were successfully contacted, a total of 114 responded (52% response rate). Most ATHS providers indicated they would order a PSA test every 12 months (69%) and believed that, ideally, the hypothetical patient's primary care provider should be responsible for his life-long prostate cancer surveillance (60%). Most providers reported feeling either "moderately" or "very" comfortable addressing topics such as prostate cancer recurrence (59%), erectile dysfunction (64%), urinary incontinence (63%), and emotional needs (61%) with prostate cancer survivors. These results varied somewhat by provider characteristics including female sex, years in practice, and the number of prostate cancer survivors seen in their practice. CONCLUSIONS: These data suggest that most primary care providers in Alaska are poised to assume the care of prostate cancer survivors locally. However, we also found that large minorities of providers do not feel confident in their ability to manage common issues in prostate cancer survivorship, implying that continued access to specialists with more expert knowledge would be beneficial.

Primary vascularization of the graft determines the immunodominance of murine minor H antigens during organ transplantation.

Grafts can be rejected even when matched for MHC because of differences in the minor histocompatibility Ags (mH-Ags). H4- and H60-derived epitopes are known as immunodominant mH-Ags in H2(b)-compatible BALB.B to C57BL/6 transplantation settings. Although multiple explanations have been provided to explain immunodominance of Ags, the role of vascularization of the graft is yet to be determined. In this study, we used heart (vascularized) and skin (nonvascularized) transplantations to determine the role of primary vascularization of the graft. A higher IFN-γ response toward H60 peptide occurs in heart recipients. In contrast, a higher IFN-γ response was generated against H4 peptide in skin transplant recipients. Peptide-loaded tetramer staining revealed a distinct antigenic hierarchy between heart and skin transplantation: H60-specific CD8(+) T cells were the most abundant after heart transplantation, whereas H4-specific CD8(+) T cells were more abundant after skin graft. Neither the tissue-specific distribution of mH-Ags nor the draining lymph node-derived dendritic cells correlated with the observed immunodominance. Interestingly, non-primarily vascularized cardiac allografts mimicked skin grafts in the observed immunodominance, and H60 immunodominance was observed in primarily vascularized skin grafts. However, T cell depletion from the BALB.B donor prior to cardiac allograft induces H4 immunodominance in vascularized cardiac allograft. Collectively, our data suggest that immediate transmigration of donor T cells via primary vascularization is responsible for the immunodominance of H60 mH-Ag in organ and tissue transplantation.

Specialist and primary care physicians' views on barriers to adequate preparation of patients for renal replacement therapy: a qualitative study.

BACKGROUND: Early preparation for renal replacement therapy (RRT) is recommended for patients with advanced chronic kidney disease (CKD), yet many patients initiate RRT urgently and/or are inadequately prepared. METHODS: We conducted audio-recorded, qualitative, directed telephone interviews of nephrology health care providers (n = 10, nephrologists, physician assistants, and nurses) and primary care physicians (PCPs, n = 4) to identify modifiable challenges to optimal RRT preparation to inform future interventions. We recruited providers from public safety-net hospital-based and community-based nephrology and primary care practices. We asked providers open-ended questions to assess their perceived challenges and their views on the role of PCPs and nephrologist-PCP collaboration in patients' RRT preparation. Two independent and trained abstractors coded transcribed audio-recorded interviews and identified major themes. RESULTS: Nephrology providers identified several factors contributing to patients' suboptimal RRT preparation, including health system resources (e.g., limited time for preparation, referral process delays, and poorly integrated nephrology and primary care), provider skills (e.g., their difficulty explaining CKD to patients), and patient attitudes and cultural differences (e.g., their poor understanding and acceptance of their CKD and its treatment options, their low perceived urgency for RRT preparation; their negative perceptions about RRT, lack of trust, or language differences). PCPs desired more involvement in preparation to ensure RRT transitions could be as "smooth as possible", including providing patients with emotional support, helping patients weigh RRT options, and affirming nephrologist recommendations. Both nephrology providers and PCPs desired improved collaboration, including better information exchange and delineation of roles during the RRT preparation process. CONCLUSIONS: Nephrology and primary care providers identified health system resources, provider skills, and patient attitudes and cultural differences as challenges to patients' optimal RRT preparation. Interventions to improve these factors may improve patients' preparation and initiation of optimal RRTs.

Patient expectation is the most important predictor of discharge destination after primary total joint arthroplasty.

The purpose of this study was to identify preoperative predictors of discharge destination after total joint arthroplasty. A retrospective study of three hundred and seventy-two consecutive patients who underwent primary total hip and knee arthroplasty was performed. The mean length of stay was 2.9 days and 29.0% of patients were discharged to extended care facilities. Age, caregiver support at home, and patient expectation of discharge destination were the only significant multivariable predictors regardless of the type of surgery (total knee versus total hip arthroplasty). Among those variables, patient expectation was the most important predictor (P < 0.001; OR 169.53). The study was adequately powered to analyze the variables in the multivariable logistic regression model, which had a high concordance index of 0.969.

IMPROVISATION AND THE CONCERT SAXOPHONIST: A SURVEY OF COMPOSITIONAL AND PERFORMANCE TECHNIQUES

Much of the contemporary concert (i.e. “classical”) saxophone literature has connections to compositional styles found in other genres like jazz, rock, or pop. Although improvisation exists as a dominant compositional device in jazz, improvisation as a performance technique is not confined to a single genre. This study looks at twelve concert saxophone pieces that are grouped into three primary categories of compositional techniques: 1) those containing unmeasured phrases, 2) those containing limited relation to improvisation but a close relationship to jazz styles, and 3) those containing jazz improvisation. In concert saxophone music, specific crossover pieces use the compositional technique of jazz improvisation. Four examples of such jazz works were composed by Dexter Morrill, Phil Woods, Bill Dobbins, and Ramon Ricker, all of which provide a foundation for this study. In addition, pieces containing varying degrees of unmeasured phrases are highlighted. As this dissertation project is based in performance, the twelve pieces were divided into three recitals that summarize a pedagogical sequence. Any concert saxophonist interested in developing jazz improvisational skills can use the pieces in this study as a method to progress toward the performance of pieces that merge jazz improvisation with the concert format. The three compositional techniques examined here will provide the performer with the necessary material to develop this individualized approach to improvisation. Specific compositional and performance techniques vary depending on the stylistic content: this study examines improvisation in the context of concert saxophone repertoire.

The primary cellular immune responses to B. pertussis antigens in infants

info:eu-repo/semantics/nonPublished

Recent input for flow cytometry in the diagnosis of primary immune deficiencies

info:eu-repo/semantics/nonPublished

Incidence of febrile neutropenia and neutropenic infections in elderly patients receiving anthracycline-based chemotherapy for breast cancer without primary prophylaxis with colony-stimulating factors

There is concern about the potential increase of hematological toxicity in elderly patients treated with chemotherapy. Recently, primary prophylaxis with colony-stimulating factors (CSFs) was proposed for elderly patients receiving moderately toxic chemotherapy. However, evidence for the benefits of this primary prophylaxis for elderly breast cancer patients is currently lacking. We retrospectively analyzed the incidence of febrile neutropenia (FN) and neutropenic infections in elderly breast cancer patients receiving anthracycline-based chemotherapy without primary prophylaxis with colony-stimulating factors. In addition, we assessed the direct costs of hospitalization for these complications. Febrile neutropenia or neutropenic infection occurred in 13% of the 46 patients. Further studies are needed to adequately evaluate the risk of neutropenic complications (NC) in elderly patients receiving standard-dose chemotherapy for breast cancer and the potential benefits of primary prophylaxis with colony-stimulating factors. © 2004 Elsevier Ireland Ltd. All rights reserved.

A study of in vitro primary responses from rabbit peripheral blood lymphocytes

SCOPUS: ar.j

Role of the IL-10/IL-12 balance in the primary cellular immune response of infants to pertussis vaccines

info:eu-repo/semantics/nonPublished

The primary cellular immune responses to B. pertussis antigens in infants

info:eu-repo/semantics/nonPublished

The use of a biased heuristic by a genetic algorithm applied to the design of multipoint connections in a local access network

This paper presents a genetic algorithm for finding a constrained minimum spanning tree. The problem is of relevance in the design of minimum cost communication networks, where there is a need to connect all the terminals at a user site to a terminal concentrator in a multipoint (tree) configuration, while ensuring that link capacity constraints are not violated. The approach used maintains a distinction between genotype and phenotype, which produces superior results to those found using a direct representation in a previous study.

Effect of reflow profile and thermal cycle ageing on the intermetallic formation and growth in lead-free soldering

The formation and growth of intermetallic compound layer thickness is one of the important issues in search for reliable electronic and electrical connections. Intermetallic compounds (IMCs) are an essential part of solder joints. At low levels, they have a strengthening effect on the joint; but at higher levels, they tend to make solder joints more brittle. If the solder joint is subjected to long-standing exposure of high temperature, this could result in continuous growth of intermetallic compound layer. The brittle intermetallic compound layer formed in this way is very much prone to fracture and cold therefore lead to mechanical and electrical failure of the joint. Therefore, the primary aim of this study is to investigate the growth of intermetallic compound layer thickness subjected to five different reflow profiles. The study also looks at the effect of three different temperature cycles (with maximum cycle temperature of 25 0C, 40 0C and 60 0C) on intermetallic compound formation and their growth behaviour.. Two different Sn-Ag-Cu solder pastes (namely paste P1 and paste P2) which were different in flux medium, were used for the study. The result showed that the growth of intermetallic compound layer thickness was a function of ageing temperature. It was found that the rate of growth of intermetallic compound layer thickness of paste P1 was higher than paste P2 at the same temperature condition. This behaviour could be related to the differences in flux mediums of solder paste samples used.

Education and climate change – some systemic connections

Unlike most papers on education and ecology, this one is not concerned with the content of education but its organisation as a system and hence its purpose or finality. The central contention of the paper, which takes English education and training (or ‘learning’) as a case in point, is that in a new market-state formation the pursuit of short-term goals is tied to the global free-market economy over which any attempt at democratic control has been relinquished. At a time when humanity worldwide faces increasing change in the ecology that sustains it, this is considered to be ‘ecocidally insane’ and the opposite of any sort of learning from experience to alter behaviour in the future. The re-regulated new global market is seen in conclusion as a crisis response to the end of the previous Keynesian welfare nation-state formation. As such, it is argued to be unsustainable in any sense.