SDN enabled dynamically reconfigurable high capacity optical access architecture for converged services

Dynamically reconfigurable time-division multiplexing (TDM) dense wavelength division multiplexing (DWDM) long-reach passive optical networks (PONs) can support the reduction of nodes and network interfaces by enabling a fully meshed flat optical core. In this paper we demonstrate the flexibility of the TDM-DWDM PON architecture, which can enable the convergence of multiple service types on a single physical layer. Heterogeneous services and modulation formats, i.e. residential 10G PON channels, business 100G dedicated channel and wireless fronthaul, are demonstrated co-existing on the same long reach TDM-DWDM PON system, with up to 100km reach, 512 users and emulated system load of 40 channels, employing amplifier nodes with either erbium doped fiber amplifiers (EDFAs) or semiconductor optical amplifiers (SOAs). For the first time end-to-end software defined networking (SDN) management of the access and core network elements is also implemented and integrated with the PON physical layer in order to demonstrate two service use cases: a fast protection mechanism with end-to-end service restoration in the case of a primary link failure; and dynamic wavelength allocation (DWA) in response to an increased traffic demand.

La place de la relation conjugale dans la réinsertion sociale des délinquants sous l’autorité des Services correctionnels du Québec

Rapport de stage présenté à la Faculté des arts et des sciences en vue de l’obtention du grade de Maître ès sciences (M.Sc.) en criminologie, option intervention

Graded Exercise Therapy Guided Self-Help Trial for Patients with Chronic Fatigue Syndrome (GETSET): Protocol for a Randomized Controlled Trial and Interview Study

Background: Chronic fatigue syndrome, also known as myalgic encephalomyelitis (CFS/ME), is characterized by chronic disabling fatigue and other symptoms, which are not explained by an alternative diagnosis. Previous trials have suggested that graded exercise therapy (GET) is an effective and safe treatment. GET itself is therapist-intensive with limited availability. Objective: While guided self-help based on cognitive behavior therapy appears helpful to patients, Guided graded Exercise Self-help (GES) is yet to be tested. Methods: This pragmatic randomized controlled trial is set within 2 specialist CFS/ME services in the South of England. Adults attending secondary care clinics with National Institute for Health and Clinical Excellence (NICE)-defined CFS/ME (N=218) will be randomly allocated to specialist medical care (SMC) or SMC plus GES while on a waiting list for therapist-delivered rehabilitation. GES will consist of a structured booklet describing a 6-step graded exercise program, supported by up to 4 face-to-face/telephone/Skype™ consultations with a GES-trained physiotherapist (no more than 90 minutes in total) over 8 weeks. The primary outcomes at 12-weeks after randomization will be physical function (SF-36 physical functioning subscale) and fatigue (Chalder Fatigue Questionnaire). Secondary outcomes will include healthcare costs, adverse outcomes, and self-rated global impression change scores. We will follow up all participants until 1 year after randomization. We will also undertake qualitative interviews of a sample of participants who received GES, looking at perceptions and experiences of those who improved and worsened. Results: The project was funded in 2011 and enrolment was completed in December 2014, with follow-up completed in March 2016. Data analysis is currently underway and the first results are expected to be submitted soon. Conclusions: This study will indicate whether adding GES to SMC will benefit patients who often spend many months waiting for rehabilitative therapy with little or no improvement being made during that time. The study will indicate whether this type of guided self-management is cost-effective and safe. If this trial shows GES to be acceptable, safe, and comparatively effective, the GES booklet could be made available on the Internet as a practitioner and therapist resource for clinics to recommend, with the caveat that patients also be supported with guidance from a trained physiotherapist. The pragmatic approach in this trial means that GES findings will be generalizable to usual National Health Service (NHS) practice.

Measuring Scope of Practice Enactment among Primary Care Registered Nurses in Ontario

Background: Primary care is the sector of health care in which patients first establish contact with the health system, are provided person-focused care over time for all new or common needs, and receive coordinated integrated health services provided elsewhere by other members of the health care team. Registered Nurses (RNs) in Canada provide care within this sector in varying roles. The extent to which RNs enact their full scope of practice in primary care settings in Canada is not known. The Actual Scope of Practice questionnaire (ASCOP) is a 26 item Likert scale questionnaire developed by researchers in Canada and validated in the acute care setting to measure the extent to which RNs apply the knowledge, skills and competencies of the professional full scope of practice. Similar to the acute care setting, there is a need to measure scope of practice enactment in the primary care setting. Objectives: The overall aim of this thesis was to measure scope of practice enactment in the primary care setting. Two research objectives were addressed: (1) to revise and adapt the ASCOP questionnaire for use in the primary care setting, and (2) to determine internal consistency, construct validity, and sensitivity of the modified instrument, the ASCOP-PC. Methods: To address the first objective, a narrative literature review and synthesis and an expert panel review was conducted. To address the second objective a cross-sectional survey of 178 RNs working in primary care organizations in Ontario was conducted Results: The ASCOP, with few modifications, addressed key attributes of nursing scope of practice in the primary care setting. The ASCOP-PC yielded acceptable alpha coefficients ranging from 0.66 to 0.91 and explained variances from 44.2 to 62.6. Total mean score of 5.16 suggests that RNs within these models of care almost always engage in activities reflected in the ASCOP-PC. Interpretation: Findings from this study support the use of a the modified ASCOP questionnaire as a reliable and valid measure of scope of practice enactment among primary care nurses in the primary care setting.

Economic crisis and national health system

The text analyzes the impact of the economic crisis in some critical aspects of the National Health System: outcomes, health expenditure, remuneration policy and privatization through Private Public Partnership models. Some health outcomes related to social inequalities are worrying. Reducing public health spending has increased the fragility of the health system, reduced wage income of workers in the sector and increased heterogeneity between regions. Finally, the evidence indicates that privatization does not mean more efficiency and better governance. Deep reforms are needed to strengthen the National Health System.

Chemotherapy patient perception regarding communication with the healthcare staff

Purpose: To qualitatively explore the communication between healthcare professionals and oncology patients based on the perception of patients undergoing chemotherapy.Method: Qualitative and exploratory design. Participants were 14 adult patients undergoing chemotherapy at different stages of the disease. A socio-demographic and clinical data form was utilized along with semi-structured interviews. The interviews were audio-recorded, transcribed and content analysis was performed. Two independent judges evaluated the interview content in regards to emerging categories and obtained a Kappa index of 0.834.Results: Three categories emerged from the data: 1) Technical communication without emotional support, in which the information provided is composed of strictly technical information regarding the diagnosis, treatment and/or prognosis; 2) Technical communication, in which the information provided is oriented towards the technical aspects of the patient’s physical condition, while also providing psychological support for the patients’ subjective needs; and 3) Insufficient technical communication, win which there are gaps in the information provided causing confusion and suffering to the patient.Conclusions: Communication with emotional support contributes to greater satisfaction of chemotherapy patients. Practical implications: the results provide elements for the training of healthcare professionals regarding the importance of the emotional support that can be offered to cancer patients during their treatment.

Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial

Background
Primary angle-closure glaucoma is a leading cause of irreversible blindness worldwide. In early-stage disease, intraocular pressure is raised without visual loss. Because the crystalline lens has a major mechanistic role, lens extraction might be a useful initial treatment.

Methods
From Jan 8, 2009, to Dec 28, 2011, we enrolled patients from 30 hospital eye services in five countries. Randomisation was done by a web-based application. Patients were assigned to undergo clear-lens extraction or receive standard care with laser peripheral iridotomy and topical medical treatment. Eligible patients were aged 50 years or older, did not have cataracts, and had newly diagnosed primary angle closure with intraocular pressure 30 mm Hg or greater or primary angle-closure glaucoma. The co-primary endpoints were patient-reported health status, intraocular pressure, and incremental cost-effectiveness ratio per quality-adjusted life-year gained 36 months after treatment. Analysis was by intention to treat. This study is registered, number ISRCTN44464607.

Findings
Of 419 participants enrolled, 155 had primary angle closure and 263 primary angle-closure glaucoma. 208 were assigned to clear-lens extraction and 211 to standard care, of whom 351 (84%) had complete data on health status and 366 (87%) on intraocular pressure. The mean health status score (0·87 [SD 0·12]), assessed with the European Quality of Life-5 Dimensions questionnaire, was 0·052 higher (95% CI 0·015–0·088, p=0·005) and mean intraocular pressure (16·6 [SD 3·5] mm Hg) 1·18 mm Hg lower (95% CI –1·99 to –0·38, p=0·004) after clear-lens extraction than after standard care. The incremental cost-effectiveness ratio was £14 284 for initial lens extraction versus standard care. Irreversible loss of vision occurred in one participant who underwent clear-lens extraction and three who received standard care. No patients had serious adverse events.

Interpretation
Clear-lens extraction showed greater efficacy and was more cost-effective than laser peripheral iridotomy, and should be considered as an option for first-line treatment.

UK consensus project on quality in palliative day services: developing a quality indicator set using the RAND/UCLA appropriateness method

Introduction
Evaluating quality of palliative day services is essential for assessing care across diverse settings, and for monitoring quality improvement approaches.

Aim
To develop a set of quality indicators for assessment of all aspects (structure, process and outcome) of care in palliative day services.

Methods
Using a modified version of the RAND/UCLA appropriateness method (Fitch et al., 2001), a multidisciplinary panel of 16 experts independently completed a survey rating the appropriateness of 182 potential quality indicators previously identified during a systematic evidence review. Panel members then attended a one day, face-to-face meeting where indicators were discussed and subsequently re-rated. Panel members were also asked to rate the feasibility and necessity of measuring each indicator.

Results
71 indicators classified as inappropriate during the survey were removed based on median appropriateness ratings and level of agreement. Following the panel discussions, a further 60 were removed based on appropriateness and feasibility ratings, level of agreement and assessment of necessity. Themes identified during the panel discussion and findings of the evidence review were used to translate the remaining 51 indicators into a final set of 27.

Conclusion
The final indicator set included information on rationale and supporting evidence, methods of assessment, risk adjustment, and recommended performance levels. Further implementation work will test the suitability of this ‘toolkit’ for measurement and benchmarking. The final indicator set provides the basis for standardised assessment of quality across services, including care delivered in community and primary care settings.

Reference

• Fitch K, Bernstein SJ, Aguilar MD, et al. The RAND/UCLA Appropriateness Method User’s Manual. Santa Monica, CA: RAND Corporation; 2001. http://www.rand.org/pubs/monograph_reports/MR1269

An Assessment of How Nurse Practitioners Create Access to Primary Care in Canadian Residential Long-Term Care Settings

The aim of this paper is to explore the role and activities of nurse practitioners (NPs) working in long-term care (LTC) to understand concepts of access to primary care for residents. Utilizing the "FIT" framework developed by Penchanksy and Thomas, we used a directed content analysis method to analyze data from a pan-Canadian study of NPs in LTC. Individual and focus group interviews were conducted at four sites in western, central and eastern regions of Canada with 143 participants, including NPs, RNs, regulated and unregulated nursing staff, allied health professionals, physicians, administrators and directors and residents and family members. Participants emphasized how the availability and accessibility of the NP had an impact on access to primary and urgent care for residents. Understanding more about how NPs affect access in Canadian LTC will be valuable for nursing practice and healthcare planning and policy and may assist other countries in planning for the introduction of NPs in LTC settings to increase access to primary care.

A cross-sectional evaluation of community pharmacists’ perceptions of intermediate care and medicines management across the healthcare interface

Background Despite the importance placed on the concept of the multidisciplinary team in relation to intermediate care (IC), little is known about community pharmacists’ (CPs) involvement. 
Objective To determine CPs’ awareness of and involvement with IC services, perceptions of the transfer of patients’ medication information between healthcare settings and views of the development of a CP–IC service. 
Setting Community pharmacies in Northern Ireland. 
Methods A postal questionnaire, informed by previous qualitative work was developed and piloted. 
Main outcome measure CPs’ awareness of and involvement with IC. Results The response rate was 35.3 % (190/539). Under half (47.4 %) of CPs ‘agreed/strongly agreed’ that they understood the term ‘intermediate care’. Three quarters of respondents were either not involved or unsure if they were involved with providing services to IC. A small minority (1.2 %) of CPs reported that they received communication regarding medication changes made in hospital or IC settings ‘all of the time’. Only 9.5 and 0.5 % of respondents ‘strongly agreed’ that communication from hospital and IC, respectively, was sufficiently detailed. In total, 155 (81.6 %) CPs indicated that they would like to have greater involvement with IC services. ‘Current workload’ was ranked as the most important barrier to service development.
Conclusion It was revealed that CPs had little awareness of, or involvement with, IC. Communication of information relating to patients’ medicines between settings was perceived as insufficient, especially between IC and community pharmacy settings. CPs demonstrated willingness to be involved with IC and services aimed at bridging the communication gap between healthcare settings.

Time-limited home-care reablement services for maintaining and improving the functional independence of older adults

Background: Reablement, also known as restorative care, is one possible approach to home-care services for older adults at risk of functional decline. Unlike traditional home-care services, reablement is frequently time-limited (usually six to 12 weeks) and aims to maximise independence by offering an intensive multidisciplinary, person-centred and goal-directed intervention. Objectives:Objectives To assess the effects of time-limited home-care reablement services (up to 12 weeks) for maintaining and improving the functional independence of older adults (aged 65 years or more) when compared to usual home-care or wait-list control group. Search methods:We searched the following databases with no language restrictions during April to June 2015: the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (OvidSP); Embase (OvidSP); PsycINFO (OvidSP); ERIC; Sociological Abstracts; ProQuest Dissertations and Theses; CINAHL (EBSCOhost); SIGLE (OpenGrey); AgeLine and Social Care Online. We also searched the reference lists of relevant studies and reviews as well as contacting authors in the field.Selection criteria:We included randomised controlled trials (RCTs), cluster randomised or quasi-randomised trials of time-limited reablement services for older adults (aged 65 years or more) delivered in their home; and incorporated a usual home-care or wait-list control group. Data collection and analysis:Two authors independently assessed studies for inclusion, extracted data, assessed the risk of bias of individual studies and considered quality of the evidence using GRADE. We contacted study authors for additional information where needed.Main results:Two studies, comparing reablement with usual home-care services with 811 participants, met our eligibility criteria for inclusion; we also identified three potentially eligible studies, but findings were not yet available. One included study was conducted in Western Australia with 750 participants (mean age 82.29 years). The second study was conducted in Norway (61 participants; mean age 79 years). We are very uncertain as to the effects of reablement compared with usual care as the evidence was of very low quality for all of the outcomes reported. The main findings were as follows. Functional status: very low quality evidence suggested that reablement may be slightly more effective than usual care in improving function at nine to 12 months (lower scores reflect greater independence; standardised mean difference (SMD) -0.30; 95% confidence interval (CI) -0.53 to -0.06; 2 studies with 249 participants). Adverse events: reablement may make little or no difference to mortality at 12 months’ follow-up (RR 0.97; 95% CI 0.74 to 1.29; 2 studies with 811 participants) or rates of unplanned hospital admission at 24 months (RR 0.94; 95% CI 0.85 to 1.03; 1 study with 750 participants). The very low quality evidence also means we are uncertain whether reablement may influence quality of life (SMD -0.23; 95% CI -0.48 to 0.02; 2 trials with 249 participants) or living arrangements (RR 0.92, 95% CI 0.62 to 1.34; 1 study with 750 participants) at time points up to 12 months. People receiving reablement may be slightly less likely to have been approved for a higher level of personal care than people receiving usual care over the 24 months’ follow-up (RR 0.87; 95% CI 0.77 to 0.98; 1 trial, 750 participants). Similarly, although there may be a small reduction in total aggregated home and healthcare costs over the 24-month follow-up (reablement: AUD 19,888; usual care: AUD 22,757; 1 trial with 750 participants), we are uncertain about the size and importance of these effects as the results were based on very low quality evidence. Neither study reported user satisfaction with the serviceAuthors’ conclusions:There is considerable uncertainty regarding the effects of reablement as the evidence was of very low quality according to our GRADE ratings. Therefore, the effectiveness of reablement services cannot be supported or refuted until more robust evidence becomes available. There is an urgent need for high quality trials across different health and social care systems due to the increasingly high profile of reablement services in policy and practice in several countries. 

Policy for the Provision and Management of Cleaning Services (PDF 464KB)

This policy sets out the Department’s commitment to maintaining and improving environmental cleanliness in Northern Ireland (NI). It has been developed with the aim that best management practice, staff training and continued monitoring of performance will lead to services being maintained and improved in a challenging financial climate. The detail of the policy is presented in the three sections which follow this executive summary. Section 1 – Introduction and Background. This section sets out the aims, objectives and scope of the policy. It also sets out the key principles which should apply to cleaning services. Section 2 - Developments since the launch of Cleanliness Matters Strategy in October 2005. This outlines events and progress since 2005 and indicates how these are shaping the proposed strategic direction. Section 3 - The Way Forward. This section sets out the areas for attention over the coming years.  

Health in Ireland: Key Trends 2015

Health in Ireland Key Trends gives us insights into trends in demographics, population health, hospital and primary care and health service employment and expenditure. The presentation of trend data over the last decade in the 2015 report highlights the many significant achievements that Ireland has made in terms of key outcomes relating to the health and wellbeing of the population. However, it also highlights the challenges that persist in terms of the accessibility of timely healthcare and in the context of financial constraints. In the last decade alone, there has been an increase of two and a half years in life expectancy. These gains are driven largely by reductions in mortality rates from principal causes of deaths such as those from heart disease and cancer. Another striking feature is the growth in the number of people aged over 65. Each year this cohort increases by 20,000 people. This trend is set to continue into the future and will have implications for future planning and health service delivery. Ireland will see the largest proportional increases in the population aged 85 years and older. Ageing of the population in conjunction with lifestyle-related health threats continue to present major challenges now and into the future in sustaining and further improving health and health services in Ireland. Although difficult to quantify, the contribution of modern health services to these improvements in health outcomes and in life expectancy have been significant. Ireland’s fertility rates are still among the highest in Europe but the birth rate has fallen to its lowest rate for the last decade.  However, Ireland currently has the highest proportion of children and young people in our population among EU countries.  

Evaluating the efficiency of community-based HIV testing and counseling strategies in sub-Saharan Africa

Thesis (Ph.D.)--University of Washington, 2016-08

Healthcare Staffs’ Experiences and Perceptions of Caring for People with Dementia in the Acute Setting: Qualitative Evidence Synthesis

Background Dementia is a global issue, with increasing prevalence rates impacting on health services internationally. People with dementia are frequently admitted to hospital, an environment that may not be suited to their needs. While many initiatives have been developed to improve their care in the acute setting, there is a lack of cohesive understanding of how staff experience and perceive the care they give to people with dementia in the acute setting. Objectives The aim of this qualitative synthesis was to explore health care staffs’ experiences and perceptions of caring for people with dementia in the acute setting. Qualitative synthesis can bring together isolated findings in a meaningful way that can inform policy development. Settings A screening process, using inclusion/exclusion criteria, identified qualitative studies that focused on health care staff caring for people with dementia in acute settings. Participants Twelve reports of nine studies were included for synthesis. Data extraction was conducted on each report by two researchers. Methods Framework synthesis was employed using VIPS framework, using Values, Individualised, Perspective and Social and psychological as concepts to guide synthesis. The VIPS framework has previously been used for exploring approaches to caring for people with dementia. Quality appraisal was conducted using Critical Appraisal Skills Programme (CASP) and NVivo facilitated sensitivity analysis to ensure confidence in the findings. Results Key themes, derived from VIPS, included a number of specific subthemes that examined: infrastructure and care pathways, person-centred approaches to care, how the person interacts with their environment and other patients, and family involvement in care decisions. The synthesis identified barriers to appropriate care for the person with dementia. These include ineffective pathways of care, unsuitable environments, inadequate resources and staffing levels and lack of emphasis on education and training for staff caring for people with dementia. Conclusions This review has identified key issues in the care of people with dementia in the acute setting: improving pathways of care, creating suitable environments, addressing resources and staffing levels and placing emphasis on the education for staff caring for people with dementia. Recommendations are made for practice consideration, policy development and future research. Leadership is required to instil the values needed to care for this client group in an effective and personcentred way. Qualitative evidence synthesis can inform policy and in this case, recommends VIPS as a suitable framework for guiding decisions around care for people with dementia in acute settings.