Do healthcare services behave as complex systems? Analysis of patterns of attendance and implications for service delivery

Background: The science of complex systems has been proposed as a way of understanding health services and the demand for them, but there is little quantitative evidence to support this. We analysed patterns of healthcare use in different urgent care settings to see if they showed two characteristic statistical features of complex systems: heavy-tailed distributions (including the inverse power law) and generative burst patterns. Methods: We conducted three linked studies. In study 1 we analysed the distribution of number of contacts per patient with an urgent care service in two settings: emergency department (ED) and primary care out-of-hours (PCOOH) services. We hypothesised that these distributions should be heavy-tailed (inverse power law or log-normal) in keeping with typical complex systems. In study 2 we analysed the distribution of bursts of contact with urgent care services by individuals: correlated bursts of activity occur in complex systems and represent a mechanism by which overall heavy-tailed distributions arise. In study 3 we replicated the approach of study 1 using data systematically identified from published sources. Results: Study 1 involved data from a PCOOH service in Scotland (725,000) adults, 1.1 million contacts) and an ED in New Zealand (60,000 adults, 98,000 contacts). The total number of contacts per individual in each dataset was statistically indistinguishable from an inverse power law (p &gt; 0.05) above 4 contacts for the PCOOH data and 3 contacts for the ED data. Study 2 found the distribution of contact bursts closely followed a heavy-tailed distribution (p &lt; 0.008), indicating the presence of correlated bursts. Study 3 identified data from 17 studies across 8 countries and found distributions similar to study 1 in all of them. Conclusions: Urgent healthcare use displays characteristic statistical features of large complex systems. These studies provide strong quantitative evidence that healthcare services behave as complex systems and have important implications for urgent care. Interventions to manage demand must address drivers for consultation across the whole system: focusing on only the highest users (in the tail of the distribution) will have limited impact on efficiency. Bursts of attendance - and ways to shorten them - represent promising targets for managing demand.</p

A problem structuring method for ecosystem-based management : the DPSIR modelling process

The purpose of this paper is to learn from Complex Adaptive Systems (CAS) theory to inform the development of Problem Structuring Methods (PSMs) both in general and in the specific context of marine management. The focus on marine management is important because it is concerned with a CAS (formed through the interconnection between natural systems, designed systems and social systems) which exemplifies their particularly ‘wicked' nature. Recognition of this compels us to take seriously the need to develop tools for knowledge elicitation and structuring which meet the demands of CAS. In marine management, chief among those tools is the DPSIR (Drivers - Pressures - State Changes - Impacts - Responses) model and, although widely applied, the extent to which it is appropriate for dealing with the demands of a CAS is questionable. Such questioning is particularly pertinent in the context of the marine environment where there is a need to not only recognise a broad range of stakeholders (a question of boundary critique) but also to manage competing knowledge (economic, local and scientific) and value claims. Hence this paper emphasises how a CAS perspective might add impetus to the development of a critical perspective on DPSIR and PSM theory and practice to promote a more systemic view of decision-making and policy development

Management of the marine environment: Integrating ecosystem services and societal benefits with the DPSIR framework in a systems approach

Ever increasing and diverse use of the marine environment is leading to human-induced changes in marine life, habitats and landscapes, making necessary the development of marine policy that considers all members of the user community and addresses current, multiple, interacting uses. Taking a systems approach incorporating an understanding of The Ecosystem Approach, we integrate the DPSIR framework with ecosystem services and societal benefits, and the focus this gives allows us to create a specific framework for supporting decision making in the marine environment. Based on a linking of these three concepts, we present a set of basic postulates for the management of the marine environment and emphasise that these postulates should hold for marine management to be achieved. We illustrate these concepts using two case studies: the management of marine aggregates extraction in UK waters and the management of marine biodiversity at Flamborough Head, UK. (C) 2010 Elsevier Ltd. All rights reserved

Activation of PKR by Bunyamwera virus is independent of the viral interferon antagonist NSs

Double-stranded RNA (dsRNA) is a by-product of viral RNA polymerase activity, and its recognition is one mechanism by which the innate immune system is activated. Cellular responses to dsRNA include induction of alpha/beta interferon (IFN) synthesis and activation of the enzyme PKR, which exerts its antiviral effect by phosphorylating the eukaryotic initiation factor eIF-2 alpha, thereby inhibiting translation. We have recently identified the nonstructural protein NSs of Bunyamwera virus (BUNV), the prototype of the family Bunyaviridae, as a virulence factor that blocks the induction of IFN by dsRNA. Here, we investigated the potential of NSs to inhibit PKR. We show that wild-type (wt) BUNV that expresses NSs triggered PKR-dependent phosphorylation of eIF-2 alpha to levels similar to those of a recombinant virus that does not express NSs (BUNdelNSs virus). Furthermore, the sensitivity of viruses in cell culture to IFN was independent of PKR and was not determined by NSs. PKR knockout mice, however, succumbed to infection approximately 1 day earlier than wt mice or mice deficient in expression of RNase L, another dsRNA-activated antiviral enzyme. Our data indicate that (i) bunyaviruses activate PKR, but are only marginally sensitive to its antiviral effect, and (ii) NSs is different from other IFN antagonists, since it inhibits dsRNA-dependent IFN induction but has no effect on the dsRNA-activated PKR and RNase L systems

Pharmacist-led management of chronic pain in primary care:results from a randomised controlled exploratory trial

To compare the effectiveness of pharmacist medication review, with or without pharmacist prescribing, with standard care, for patients with chronic pain

T. brucei cathepsin-L increases arrhythmogenic sarcoplasmic reticulum-mediated calcium release in rat cardiomyocytes

Aims: African trypanosomiasis, caused by Trypanosoma brucei species, leads to both neurological and cardiac dysfunction and can be fatal if untreated. While the neurological-related pathogenesis is well studied, the cardiac pathogenesis remains unknown. The current study exposed isolated ventricular cardiomyocytes and adult rat hearts to T. brucei to test whether trypanosomes can alter cardiac function independent of a systemic inflammatory/immune response. Methods and results: Using confocal imaging, T. brucei and T. brucei culture media (supernatant) caused an increased frequency of arrhythmogenic spontaneous diastolic sarcoplasmic reticulum (SR)-mediated Ca2+ release (Ca2+ waves) in isolated adult rat ventricular cardiomyocytes. Studies utilising inhibitors, recombinant protein and RNAi all demonstrated that this altered SR function was due to T. brucei cathepsin-L (TbCatL). Separate experiments revealed that TbCatL induced a 10–15% increase of SERCA activity but reduced SR Ca2+ content, suggesting a concomitant increased SR-mediated Ca2+ leak. This conclusion was supported by data demonstrating that TbCatL increased Ca2+ wave frequency. These effects were abolished by autocamtide-2-related inhibitory peptide, highlighting a role for CaMKII in the TbCatL action on SR function. Isolated Langendorff perfused whole heart experiments confirmed that supernatant caused an increased number of arrhythmic events. Conclusion: These data demonstrate for the first time that African trypanosomes alter cardiac function independent of a systemic immune response, via a mechanism involving extracellular cathepsin-L-mediated changes in SR function

LRP5 Regulates Development of Lung Microvessels and Alveoli through the Angiopoietin-Tie2 Pathway

Angiogenesis is crucial for lung development. Although there has been considerable exploration, the mechanism by which lung vascular and alveolar formation is controlled is still not completely understood. Here we show that low-density lipoprotein receptor-related protein 5 (LRP5), a component of the Wnt ligand-receptor complex, regulates angiogenesis and alveolar formation in the lung by modulating expression of the angiopoietin (Ang) receptor, Tie2, in vascular endothelial cells (ECs). Vascular development in whole mouse lungs and in cultured ECs is controlled by LRP5 signaling, which is, in turn, governed by a balance between the activities of the antagonistic Tie2 ligands, Ang1 and Ang2. Under physiological conditions when Ang1 is dominant, LRP5 knockdown decreases Tie2 expression and thereby, inhibits vascular and alveolar development in the lung. Conversely, when Ang2 dominates under hyperoxia treatment in neonatal mice, high LRP5 and Tie2 expression suppress angiogenesis and lung development. These findings suggest that the LRP5-Tie2-Ang signaling axis plays a central role in control of both angiogenesis and alveolarization during postnatal lung development, and that deregulation of this signaling mechanism might lead to developmental abnormalities of the lung, such as are observed in bronchopulmonary dysplasia (BPD)

A comparative study of factors affecting product quality and customer needs compliance in the new product development process

To succeed and survive in competitive markets, products need to be of the desired quality. Quality is how well the product, in its entirety, satisfies the needs of the intended customers. With products in industrial markets, there are many different types of customers to satisfy. Research has been published that is of general use to help define the New Product Development (NPD) process and the management of its activities and this was useful as a basis for this research study. However, little previous work is available that details the specific aspect of designing for customer needs compliance. An exploratory investigation, using analysis of selected cases and experience surveys, was undertaken to help direct conceptual work. A conceptual model was developed to help describe the NPD process and customer needs compliance. The hypotheses that guided the main study sought to understand the perceptions which the design team has of the product in terms of different customer needs. They also aimed to determine how information management during NPD may affect the final design and, consequently, the quality of the product. With the objective of drawing conclusions across the four companies involved in the main study, collection methods and data analysis provided quantitative results on what is essentially qualitative types of information. The findings conclude that each of the companies do perceive a difference in the needs of the customers between different product types. However, they also imply that specific types of customers have similar needs, no matter what types of products are involved. With a small set of respondents in each company, no evidence was found to suggest that the different perceptions the people involved in the design and development of the product had could be attributed to the functional, managerial or customer involvement groupings under investigation. However, there was some evidence that customer needs compliance may be affected by the way the company handled its information management during the NPD process

Perception of the Effectiveness of a One-Person Compliance Department in Small College Athletics: Division II Compliance Operations

There is a wide scope to the responsibilities reported by compliance officers working in the NCAA Division II landscape. With the varying responsibilities, it is crucial for administrators working at Division II institutions to consider person-organization fit when hiring a compliance officer. Therefore, the purpose of the research presented in this paper is to analyze the current perception of current compliance operations on Division II campuses to gain a better understanding of the person-organization fit requirements that may be imperative for success in the position. The results of this study indicate that compliance professionals feel supported in their role, but it is not effective to have a one-person compliance operation. Participants in this study offer suggestions to improve current compliance operations on Division II campuses. Recommendations include using resources such as The National Association for Athletic Compliance (NAAC) and conference office staff. Additionally, it was recommended to limit roles and responsibilities for compliance personnel that fall outside the scope of compliance tasks

Nocardia kroppenstedtii sp. nov., a novel actinomycete isolated from a lung transplant patient with a pulmonary infection

An actinomycete, strain N1286T, isolated from a lung transplant patient with a pulmonary infection, was provisionally assigned to the genus Nocardia. The strain had chemotaxonomic and morphological properties typical of members of the genus Nocardia and formed a distinct phyletic line in the Nocardia 16S rRNA gene tree. It was most closely related to Nocardia farcinica DSM 43665T (99.8% gene similarity) but was distinguished from the latter by a low level of DNA:DNA relatedness. These strains were also distinguished by a broad range of phenotypic properties. On the basis of these data, it is proposed that isolate N1286T (=DSM 45810T = NCTC 13617T) should be classified as the type strain of a new Nocardia species for which the name Nocardia kroppenstedtii is proposed